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Outcomes in Adults With Acute Liver Failure Between 1998 and 2013: An Observational Cohort Study.

ABSTRACT: BACKGROUND:Acute liver failure (ALF) is a rare syndrome of severe, rapid-onset hepatic dysfunction-without prior advanced liver disease-that is associated with high morbidity and mortality. Intensive care and liver transplantation provide support and rescue, respectively. OBJECTIVE:To determine whether changes in causes, disease severity, treatment, or 21-day outcomes have occurred in recent years among adult patients with ALF referred to U.S. tertiary care centers. DESIGN:Prospective observational cohort study. (ClinicalTrials .gov: NCT00518440). SETTING:31 liver disease and transplant centers in the United States. PATIENTS:Consecutively enrolled patients-without prior advanced liver disease-with ALF (n = 2070). MEASUREMENTS:Clinical features, treatment, and 21-day outcomes were compared over time annually for trends and were also stratified into two 8-year periods (1998 to 2005 and 2006 to 2013). RESULTS:Overall clinical characteristics, disease severity, and distribution of causes remained similar throughout the study period. The 21-day survival rates increased between the two 8-year periods (overall, 67.1% vs. 75.3%; transplant-free survival [TFS], 45.1% vs. 56.2%; posttransplantation survival, 88.3% vs. 96.3% [P < 0.010 for each]). Reductions in red blood cell infusions (44.3% vs. 27.6%), plasma infusions (65.2% vs. 47.1%), mechanical ventilation (65.7% vs. 56.1%), and vasopressors (34.9% vs. 27.8%) were observed, as well as increased use of N-acetylcysteine (48.9% vs. 69.3% overall; 15.8% vs. 49.4% [P < 0.001] in patients with ALF not due to acetaminophen toxicity). When examined longitudinally, overall survival and TFS increased throughout the 16-year period. LIMITATIONS:The duration of enrollment, the number of patients enrolled, and possibly the approaches to care varied among participating sites. The results may not be generalizable beyond such specialized centers. CONCLUSION:Although characteristics and severity of ALF changed little over 16 years, overall survival and TFS improved significantly. The effects of specific changes in intensive care practice on survival warrant further study. PRIMARY FUNDING SOURCE:National Institutes of Health.

SUBMITTER: Reuben A

PROVIDER: S-EPMC5526039 | biostudies-literature | 2016 Jun

REPOSITORIES: biostudies-literature

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Outcomes in Adults With Acute Liver Failure Between 1998 and 2013: An Observational Cohort Study.

Reuben Adrian A Tillman Holly H Fontana Robert J RJ Davern Timothy T McGuire Brendan B Stravitz R Todd RT Durkalski Valerie V Larson Anne M AM Liou Iris I Fix Oren O Schilsky Michael M McCashland Timothy T Hay J Eileen JE Murray Natalie N Shaikh Obaid S OS Ganger Daniel D Zaman Atif A Han Steven B SB Chung Raymond T RT Smith Alastair A Brown Robert R Crippin Jeffrey J Harrison M Edwyn ME Koch David D Munoz Santiago S Reddy K Rajender KR Rossaro Lorenzo L Satyanarayana Raj R Hassanein Tarek T Hanje A James AJ Olson Jody J Subramanian Ram R Karvellas Constantine C Hameed Bilal B Sherker Averell H AH Robuck Patricia P Lee William M WM

Annals of internal medicine 20160405 11

<h4>Background</h4>Acute liver failure (ALF) is a rare syndrome of severe, rapid-onset hepatic dysfunction-without prior advanced liver disease-that is associated with high morbidity and mortality. Intensive care and liver transplantation provide support and rescue, respectively.<h4>Objective</h4>To determine whether changes in causes, disease severity, treatment, or 21-day outcomes have occurred in recent years among adult patients with ALF referred to U.S. tertiary care centers.<h4>Design</h4> ...[more]

PMID: 27043883

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Project description:ObjectivesTo study circadian rhythm aspects, national holidays, and major sports events as triggers of myocardial infarction.DesignRetrospective observational study using the nationwide coronary care unit registry, SWEDEHEART.SettingSweden.Participants283?014 cases of myocardial infarction reported to SWEDEHEART between 1998 and 2013. Symptom onset date was documented for all cases, and time to the nearest minute for 88%.InterventionsMyocardial infarctions with symptom onset on Christmas/New Year, Easter, and Midsummer holiday were identified. Similarly, myocardial infarctions that occurred during a FIFA World Cup, UEFA European Championship, and winter and summer Olympic Games were identified. The two weeks before and after a holiday were set as a control period, and for sports events the control period was set to the same time one year before and after the tournament. Circadian and circaseptan analyses were performed with Sunday and 24:00 as the reference day and hour with which all other days and hours were compared. Incidence rate ratios were calculated using a count regression model.Main outcome measuresDaily count of myocardial infarction.ResultsChristmas and Midsummer holidays were associated with a higher risk of myocardial infarction (incidence rate ratio 1.15, 95% confidence interval 1.12 to 1.19, P<0.001, and 1.12, 1.07 to 1.18, P<0.001, respectively). The highest associated risk was observed for Christmas Eve (1.37, 1.29 to 1.46, P<0.001). No increased risk was observed during Easter holiday or sports events. A circaseptan and circadian variation in the risk of myocardial infarction was observed, with higher risk during early mornings and on Mondays. Results were more pronounced in patients aged over 75 and those with diabetes and a history of coronary artery disease.ConclusionsIn this nationwide real world study covering 16 years of hospital admissions for myocardial infarction with symptom onset documented to the nearest minute, Christmas, and Midsummer holidays were associated with higher risk of myocardial infarction, particularly in older and sicker patients, suggesting a role of external triggers in vulnerable individuals.

Project description:BackgroundPatients aged ≥ 65 years are vulnerable to readmissions due to a transient period of generalized risk after hospitalization. However, whether young and middle-aged adults share a similar risk pattern is uncertain. We compared the rate, timing, and readmission diagnoses following hospitalization for heart failure (HF), acute myocardial infarction (AMI), and pneumonia among patients aged 18-64 years with patients aged ≥ 65 years.Methods and findingsWe used an all-payer administrative dataset from California consisting of all hospitalizations for HF (n=206,141), AMI (n=107,256), and pneumonia (n=199,620) from 2007-2009. The primary outcomes were unplanned 30-day readmission rate, timing of readmission, and readmission diagnoses. Our findings show that the readmission rate among patients aged 18-64 years exceeded the readmission rate in patients aged ≥ 65 years in the HF cohort (23.4% vs. 22.0%, p<0.001), but was lower in the AMI (11.2% vs. 17.5%, p<0.001) and pneumonia (14.4% vs. 17.3%, p<0.001) cohorts. When adjusted for sex, race, comorbidities, and payer status, the 30-day readmission risk in patients aged 18-64 years was similar to patients ≥ 65 years in the HF (HR 0.99; 95%CI 0.97-1.02) and pneumonia (HR 0.97; 95%CI 0.94-1.01) cohorts and was marginally lower in the AMI cohort (HR 0.92; 95%CI 0.87-0.96). For all cohorts, the timing of readmission was similar; readmission risks were highest between days 2 and 5 and declined thereafter across all age groups. Diagnoses other than the index admission diagnosis accounted for a substantial proportion of readmissions among age groups <65 years; a non-cardiac diagnosis represented 39-44% of readmissions in the HF cohort and 37-45% of readmissions in the AMI cohort, while a non-pulmonary diagnosis represented 61-64% of patients in the pneumonia cohort.ConclusionWhen adjusted for differences in patient characteristics, young and middle-aged adults have 30-day readmission rates that are similar to elderly patients for HF, AMI, and pneumonia. A generalized risk after hospitalization is present regardless of age. Please see later in the article for the Editors' Summary.

Dataset Information

Outcomes in Adults With Acute Liver Failure Between 1998 and 2013: An Observational Cohort Study.

Publications

Outcomes in Adults With Acute Liver Failure Between 1998 and 2013: An Observational Cohort Study.

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