Kumar, Gagan

Background: Recent case series and smaller registries from around the world have reported higher frequency of Takotsubo Cardiomyopathy (TTC) in females.The aim of this study was to look for gender difference and age - gender interactions for TTC across the nation. Methods: This was a cross sectional study using the Nationwide Inpatient Sample (NIS) 2007 database. TTC or Broken heart syndrome or Reversible left ventricular dysfunction following sudden emotional stress or Stress induced Cardiomyopathy or Transient left ventricular apical ballooning syndrome was defined as patients discharged with any ICD code of 429.83 ( http://www.cdc.gov/nchs/data/icd9/agendasept05.pdf ). Multivariate logistic regression with interaction variable between age and sex was performed. Results: There were 6229 estimated discharges in 2007 NIS. Of these, 5558 (89.2 %) were females and 671 (10.8%) were males. 11.1 % were between 18-50 years, 32% between 50-65 years,58% were more than 65 years. Overall females had significantly higher odds of developing TTC (OR, 7.5; 95% CI, 6.31-9.13). In age group > 55yrs, the odds of developing TTC was 9.5 times higher in females than in males, while in age 55yrs had 2.9 times higher odds of developing TTC while there was no such age difference in males. Conclusions: We conclude that women have 7.5 times higher odds of developing TTC than males. Females with age > 55 years have 2.9 times higher odds of developing TTC than females with age < 55 years. Further research needs to be done on hormonal influence and its effect on TTC.

Background: Takotsubo cardiomyopathy (TTC) has emerged as a new clinical entity which has not been fully understood. Numerous case reports exist regarding association of TTC with high adrenergic state conditions like Pheochromocytoma. Our aim was to explore the association of common medical conditions with TTC. Methods: This was a cross sectional study using the National Inpatient Sample (NIS) 2007 database.TTC or Broken heart syndrome or Reversible left ventricular dysfunction following sudden emotional stress or Stress induced cardiomyopathy or Transient left ventricular apical ballooning syndrome was defined as patients discharged with any ICD code of 429.83 ( http://www.cdc.gov/nchs/data/icd9/agendasept05.pdf ). The common medical conditions were identified by appropriate ICD 9 codes Results: We indentified total 6229 discharges with any discharge diagnosis of TTC. The likelihood of common medical conditions with TTC is shown in Table 1. Conclusions: This is the first study to explore the association of common medical conditions associated with TTC on a nationwide basis. We conclude that the patient with hyperlipidemia, smoking, pulmonary hypertension, sub arachnoid hemorrhage, migraine, hyperthyroidism, collagen vascular diseases, anxiety state, and stress have higher odds of developing TTC. Further research needs to be done for better understanding the causes and pathophysiology of TTC which in turn will help risk stratification and define optimal therapy.

OBJECTIVES: To develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU. DESIGN: The guideline panel comprised 27 members with expertise in aspects of care of the critically ill patient with liver failure or methodology. We adhered to the Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. INTERVENTIONS: In part 2 of this guideline, the panel was divided into four subgroups: neurology, peri-transplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements. MEASUREMENTS AND MAIN RESULTS: We report 28 recommendations (from 31 PICO questions) on the management ALF and ACLF in the ICU. Overall, five were strong recommendations, 21 were conditional recommendations, two were best-practice statements, and we were unable to issue a recommendation for five questions due to insufficient evidence. CONCLUSIONS: Multidisciplinary, international experts formulated evidence-based recommendations for the management ALF and ACLF patients in the ICU, acknowledging that most recommendations were based on low quality and indirect evidence.

Objectives: To develop evidence-based recommendations for clinicians caring for adults with acute or acute on chronic liver failure in the ICU. Design: The guideline panel comprised 29 members with expertise in aspects of care of the critically ill patient with liver failure and/or methodology. The Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy were followed throughout. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. Setting: The panel was divided into nine subgroups: cardiovascular, hematology, pulmonary, renal, endocrine and nutrition, gastrointestinal, infection, perioperative, and neurology. Interventions: We developed and selected population, intervention, comparison, and outcomes questions according to importance to patients and practicing clinicians. For each population, intervention, comparison, and outcomes question, we conducted a systematic review aiming to identify the best available evidence, statistically summarized the evidence whenever applicable, and assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements. Measurements and Main Results: In this article, we report 29 recommendations (from 30 population, intervention, comparison, and outcomes questions) on the management acute or acute on chronic liver failure in the ICU, related to five groups (cardiovascular, hematology, pulmonary, renal, and endocrine). Overall, six were strong recommendations, 19 were conditional recommendations, four were best-practice statements, and in two instances, the panel did not issue a recommendation due to insufficient evidence. Conclusions: Multidisciplinary international experts were able to formulate evidence-based recommendations for the management acute or acute on chronic liver failure in the ICU, acknowledging that most recommendations were based on low-quality indirect evidence.