Background: Fibrinogen (FIB) levels less than 150 mg/dL have been associated with increased rates of bleeding and lower survival in critically ill cirrhosis patients. Objective: We aimed to determine if treatment with cryoprecipitate (CRYO) for low FIB levels were associated with bleeding complications or survival. Patients / Methods: 237 cirrhosis patients admitted to an intensive care unit at a tertiary care liver transplant center with initial FIB levels less than 150 mg/dL were retrospectively assessed for CRYO transfusion, bleeding events, and survival outcomes. Results: The mean MELD score was 27.2 (95% CI 26.0 - 28.3) and CLIF-C Acute on Chronic Liver Failure (ACLF) score was 53.4 (51.9 - 54.8). Ninety-nine (41.8%) were admitted for acute bleeding and the remainder were admitted for non-bleeding illnesses. FIB level on admission correlated strongly with disease severity. After adjusting for disease severity, FIB on admission was not an independent predictor of 30-day survival (HR 0.99, 95% CI 0.99 - 1.01, p = 0.68). CRYO transfusion increased FIB levels but had no independent effect on mortality or bleeding complications (HR 1.10, 95% CI 0.72 - 1.70, p = 0.65). Conclusions: In cirrhosis patients with critical illness, low FIB levels on presentation reflect severity of illness but are not independently associated with 30-day mortality. Treatment of low FIB with CRYO also does not affect survival or bleeding complications suggesting FIB is an additional marker of severity of illness but is not itself a direct factor in the pathophysiology of bleeding in critically ill cirrhosis patients.
Introduction: Up to 30% of acute stroke evaluations are deemed stroke mimics, and these are common in telestroke as well. We recently published a risk prediction score, derived from the Partners TeleStroke Network, for use during telestroke encounters to differentiate stroke mimics (SM) from ischemic cerebrovascular disease (iCVD). Using data from 3 distinct US and European telestroke networks, we sought to externally validate the TM score in a broader population. Methods: We evaluated the TM score in 1,985 telestroke consults from the University of Utah Telestroke Program (n=190), Georgia Regents University Telestroke Network (n=719) and the Bavarian TeleMedical Project for integrative Stroke Care (TEMPiS) in Germany (n=1076). We report the AUC in ROC curve analysis with 95% CI. The TM score = 0.2*(Age in years) + 6*(Hx of atrial fib) + 3*(Hx of HTN) + 9*(facial weakness) + 5*(NIHSS > 14) - 6*(Hx of seizure). Lower TM scores correspond with a higher likelihood of being a stroke mimic. Results: Based on final diagnosis at the end of the telestroke consultation, there were 691/1985 (34.8%) SM in the external validation cohort. We tested the association between the TM score and the diagnosis of stroke mimic (Table). The TM score performed well at the external centers on ROC curve analysis with an AUC of 0.70 (0.67 - 0.73; p<0.001), similar to what we observed during the development of the score at our center. Conclusion: As telestroke consultation expands, increasing numbers of SM patients are being evaluated. The TM score correctly predicted the presence of a SM in these diverse cohorts just as well as in our original cohort. Decision-support tools based on predictive models, like the TM score, may help highlight key clinical differences during complex, time-critical telestroke evaluations.
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