BACKGROUND
Red blood cell distribution width (RDW), a component of an electronic complete blood count, is a measure of heterogeneity in the size of circulating erythrocytes. In patients with symptomatic cardiovascular disease (CVD), RDW is associated with mortality. However, it has not been demonstrated that RDW is a predictor of mortality independent of nutritional deficiencies or in the general population.


METHODS
Red blood cell distribution width was measured in a national sample of 8175 community-dwelling adults 45 years or older who participated in the 1988-1994 National Health and Nutrition Examination Survey; mortality follow-up occurred through December 31, 2000. Deaths from all causes, CVD, cancer, and other causes were examined as a function of RDW.


RESULTS
Higher RDW values were strongly associated with an increased risk of death. Compared with the lowest quintile of RDW, the following were adjusted hazard ratios (HRs) for all-cause mortality (and 95% confidence intervals [CIs]): second quintile, HR, 1.1 (95% CI, 0.9-1.3); third quintile, HR, 1.2 (95% CI, 1.0-1.4); fourth quintile, HR, 1.4 (95% CI, 1.2-1.8); and fifth quintile, HR, 2.1 (95% CI, 1.7-2.6). For every 1% increment in RDW, all-cause mortality risk increased by 22% (HR, 1.22; 95% CI, 1.15-1.30; P < .001). Even when analyses were restricted to nonanemic participants or to those in the reference range of RDW (11%-15%) without iron, folate, or vitamin B(12) deficiency, RDW remained strongly associated with mortality. The prognostic effect of RDW was observed in both middle-aged and older adults for multiple causes of death.


CONCLUSION
Red blood cell distribution width is a widely available test that is a strong predictor of mortality in the general population of adults 45 years or older.

Red Blood Cell Distribution Width and the Risk of Death in Middle-aged and Older Adults.

Atemfrequenz vernachlässigt Im Vergleich zu Blutdruck, Herzfrequenz und Temperatur muss die Atemfrequenz als eine im klinischen Alltag vernachlässigte Größe angesehen werden [1]. Obwohl die prognostische Bedeutung der Atemfrequenz zur Einschätzung der Schwere von akuten kardiorespiratorischen Erkrankungen mittlerweile vielfach bestätigt wurde, wird sie in der Notaufnahme oder auf der Normalstation immer noch vergleichsweise selten gemessen. Erscheint uns der Aufwand der Messung zu hoch oder wird die klinische Bedeutung der Atemfrequenz weiterhin unterschätzt bzw. nicht erkannt?

[Respiratory Rate - a Neglected Vital Sign].

The disease course of COVID-19 varies from asymptomatic infection to critical condition leading to mortality. Identification of prognostic factors is important for prevention and early treatment. We aimed to examine whether obesity is a risk factor for the critical condition in COVID-19 patients by performing a meta-analysis. The review protocol was registered onto PROSPERO (CRD42020185980). A systematic search was performed in five scientific databases between 1 January and 11 May 2020. After selection, 24 retrospective cohort studies were included in the qualitative and quantitative analyses. We calculated pooled odds ratios (OR) with 95% confidence intervals (CIs) in meta-analysis. Obesity was a significant risk factor for intensive care unit (ICU) admission in a homogenous dataset (OR = 1.21, CI: 1.002-1.46; I2 = 0.0%) as well as for invasive mechanical ventilation (IMV) (OR = 2.05, CI: 1.16-3.64; I2 = 34.86%) in COVID-19. Comparing body mass index (BMI) classes with each other, we found that a higher BMI always carries a higher risk. Obesity may serve as a clinical predictor for adverse outcomes; therefore, the inclusion of BMI in prognostic scores and improvement of guidelines for the intensive care of patients with elevated BMI are highly recommended.

Obesity is a risk factor for developing critical condition in COVID-19 patients: A systematic review and meta-analysis.

C-reactive protein (CRP) is an acute-phase protein synthesized by hepatocytes in response to pro-inflammatory cytokines and the action of interleukin-6 on the gene responsible for the transcription of CRP during inflammatory/infectious processes. CRP exists in conformationally distinct forms such as the native pentameric CRP (pCRP) and modified/monomeric CRP (mCRP) and may bind to distinct receptors and lipid rafts and exhibit different functional properties. It is known as a biomarker of acute inflammation, and many large-scale prospective studies demonstrate that CRP is both a predictor and participant in the development of cardiovascular diseases and known to be associated with chronic inflammation. In this review, we summarize and critically discuss the different functions and clinical significance of CRP in chronic inflammation and neurodegeneration. In addition, we highlight the advances in these areas that may be translated into promising measures for the diagnosis and treatment of inflammatory diseases.

The Clinical Significance and Potential Role of C-Reactive Protein in Chronic Inflammatory and Neurodegenerative Diseases.

Purpose of review To describe portal vein thrombosis (PVT) in the setting of cirrhosis especially in relation to its potential impact on liver transplantation. In addition, the safety and efficacy of anticoagulation is reviewed. Recent findings PVT in cirrhosis occurs in up to 26% of patients awaiting liver transplantation. Different studies have suggested that PVT impacts negatively post-liver transplantation survival, particularly in first year post-liver transplantation and when PVT is complete involving the porto-mesenteric confluence and not allowing physiological anastomosis. Anticoagulation is effective in preventing PVT progression and may achieve partial or complete PVT recanalization. Its use in patients with cirrhosis seems not to be associated with increased bleeding risk. Summary The goal of anticoagulation is to prevent thrombus extension to the superior mesenteric vein and/or favor recanalization if previously affected, allowing physiological anastomosis during liver transplantation and therefore improving outcome. Low-molecular-weight heparin and vitamin K antagonist have a similar safety profile without specific data in favor of any of them. Treatment with direct anticoagulants cannot be recommended yet because of limited experience in cirrhosis. Transjugular intrahepatic portosystemic shunt could be an alternative particularly if thrombosis progresses despite satisfactory anticoagulation and/or when PVT is associated with severe portal hypertension complications. However, careful consideration of potential risks and benefits of anticoagulation is recommended until further studies are conducted.

Portal vein thrombosis: yes or no on anticoagulation therapy.

Purpose of review To review the surgical and critical care management of liver trauma; one of the most common abdominal injuries sustained due to its size and location. Recent findings Hepatic injuries range from negligible to life threatening: in the acute phase, the most common cause of morbidity and mortality is hemorrhage; however, severe traumatic hepatic injuries can also lead to biochemical abnormalities, altered coagulation, and ultimately liver failure. This brief review will review the classification of traumatic liver injuries by mechanism, grade, and severity. Most Grades I–III injuries can be managed nonoperatively, whereas the majority of Grades IV–VI injuries require operative management. Therapeutic strategies for traumatic liver injury including nonoperative, operative, radiologic will be described. The primary goal of liver trauma management in the acute setting is hemorrhage control, then the management of secondary factors such as bile leaks. The rapid restoration of homeostasis may prevent further damage to the liver and allow for deferred nonoperative management, which has been shown to be associated with good clinical outcomes. Summary A multidisciplinary approach to the care of these patients at an experienced liver surgery center is warranted.

Liver trauma in the intensive care unit

Melanoma maligno metastizado no estômago

BACKGROUND
Serum ammonia variation in critically ill patients with cirrhosis has been poorly studied.


AIM
To describe and assess the impact of serum ammonia variation in these patients' outcomes.


METHODS
We studied patients ≥18 years old admitted to the intensive care units (ICUs) at University of Alberta Hospital (Edmonton, Canada) and Curry Cabral Hospital (Lisbon, Portugal; derivation cohort, n = 492) and Northwestern University Hospital (Chicago, USA; validation cohort, n = 600) between January 2010 and December 2021. Primary exposure was ICU days 1-3 serum ammonia. Primary endpoint was all-cause hospital mortality.


RESULTS
In the derivation cohort, 330 (67.1%) patients were male and median (IQR) age was 57 (50-63) years. On ICU day 1, median ammonia was higher in patients with grade 3/4 hepatic encephalopathy (HE) than those with grade 2 HE or grade 0/1 HE (112 vs. 88 vs. 77 μmoL/L, respectively; p < 0.001). Furthermore, medium ammonia was higher in hospital non-survivors than survivors (99 vs. 86 μmol/L; p < 0.030). Following adjustment for significant confounders (age, HE, vasopressor use and renal replacement therapy delivery), higher ICU day 2 ammonia was independently associated with higher hospital mortality (adjusted OR per each 10 μmoL/L increment [95% CI] = 1.11 [1.01-1.21]; p = 0.024). In the validation cohort, this model with serial ammonia (ICU days 1 and 3) predicted hospital mortality with reasonably good discrimination (c-statistic = 0.73) and calibration (R2  = 0.19 and Brier score = 0.17).


CONCLUSIONS
Among patients with cirrhosis in the ICU, early serum ammonia variation was independently associated with hospital mortality. In this context, serial serum ammonia may have prognostic value.

Early serum ammonia variation in critically ill patients with cirrhosis: A multicentre cohort study.

Abstract In critical patients, abdominal perfusion pressure (APP) has been shown to correlate with outcome. However, data from cirrhotic patients is scarce. We aimed to characterize APP in critically ill cirrhotic patients, analyze the prevalence and risk factors of abdominal hypoperfusion (AhP) and outcomes. A prospective cohort study in a general ICU specialized in liver disease at a tertiary hospital center recruited consecutive cirrhotic patients between October 2016 and December 2021. The study included 101 patients, with a mean age of 57.2 (± 10.4) years and a female gender proportion of 23.5%. The most frequent etiology of cirrhosis was alcohol (51.0%), and the precipitant event was infection (37.3%). ACLF grade (1–3) distribution was 8.9%, 26.7% and 52.5%, respectively. A total of 1274 measurements presented a mean APP of 63 (± 15) mmHg. Baseline AhP prevalence was 47%, independently associated with paracentesis (aOR 4.81, CI 95% 1.46–15.8, p = 0.01) and ACLF grade (aOR 2.41, CI 95% 1.20–4.85, p = 0.01). Similarly, AhP during the first week (64%) had baseline ACLF grade (aOR 2.09, CI 95% 1.29–3.39, p = 0.003) as a risk factor. Independent risk factors for 28-day mortality were bilirubin (aOR 1.10, CI 95% 1.04–1.16, p &lt; 0.001) and SAPS II score (aOR 1.07, CI 95% 1.03–1.11, p = 0.001). There was a high prevalence of AhP in critical cirrhotic patients. Abdominal hypoperfusion was independently associated with higher ACLF grade and baseline paracentesis. Risk factors for 28-day mortality included clinical severity and total bilirubin. The prevention and treatment of AhP in the high-risk cirrhotic patient is prudential. 

/pdf/abdominal-perfusion-pressure-in-critically-ill-cirrhotic-12tnjhpv.pdf

Abdominal perfusion pressure in critically ill cirrhotic patients: a prospective observational study

Uma doente com 60 anos de idade e história de melanoma maligno do seio maxilar esquerdo, diagnosticado 10 meses antes e tratado com cirurgia ablativa e radioterapia, foi admitida no serviço de urgência por fadiga incapacitante e epigastralgia persistente. Negou vómitos, alteração do hábito intestinal, febre, suores noturnos, perda ponderal ou outras queixas. Ao exame físico identificou-se uma tumefação epigástrica elástica, indolor, com cerca de 12 cm de maior diâmetro, não se palpando hepatomegalia, esplenomegalia ou adenomegalias. A avaliação laboratorial revelou anemia com hemoglobina de 5 g/dl e perfil de doença crónica. A tomografia computorizada abdominal identificou uma tumefação heterogénea, localizada entre o pilar esquerdo do diafragma, a cauda do pâncreas, e a parede gástrica, e com cerca de 12 cm de maior diâmetro. A esofagogastroduodenoscopia observou no fundo e corpo gástricos múltiplas lesões polipóides ulceradas, de fundo com pigmentação escura, e com cerca de 1-4 cm de maior diâmetro (figs. 1 e 2). O resultado anátomo-patológico das biopsias gástricas foi de melanoma maligno. A doente foi referenciada para uma unidade de cuidados paliativos, tendo falecido cerca de 3 meses depois. O envolvimento do estômago por metástases com origem num tumor extragástrico é incomum1. O melanoma maligno constitui uma das neoplasias malignas que mais frequentemente metastiza para o trato gastrointestinal2. Nestes

Filipe S. Cardoso

Papers

Liver trauma in the intensive care unit

Melanoma maligno metastizado no estômago

Early serum ammonia variation in critically ill patients with cirrhosis: A multicentre cohort study.

Abdominal perfusion pressure in critically ill cirrhotic patients: a prospective observational study

Melanoma maligno metastizado no estômago Metastatic malignant melanoma of the stomach