Microsoft Word - 11394 NSB Saioc 2023.03.27.docx Received: 01 Dec 2022. Received in revised form: 20 Mar 2023. Accepted: 22 Mar 2023. Published online: 27 Mar 2023. From Volume 13, Issue 1, 2021, Notulae Scientia Biologicae journal uses article numbers in place of the traditional method of continuous pagination through the volume. The journal will continue to appear quarterly, as before, with four annual numbers. SHSTSHSTSHSTSHST Horticulture and ForestryHorticulture and ForestryHorticulture and ForestryHorticulture and Forestry Society of TransylvaniaSociety of TransylvaniaSociety of TransylvaniaSociety of Transylvania Saioc A et al. (2023) Notulae Scientia BiologicaeNotulae Scientia BiologicaeNotulae Scientia BiologicaeNotulae Scientia Biologicae Volume 15, Issue 1, Article number 11394 DOI:10.15835/nsb15111394 Research ArticleResearch ArticleResearch ArticleResearch Article.... NSBNSBNSBNSB Notulae Scientia Notulae Scientia Notulae Scientia Notulae Scientia BiologicaeBiologicaeBiologicaeBiologicae A shortA shortA shortA short----term survival analysis of severe patients with acute vascular term survival analysis of severe patients with acute vascular term survival analysis of severe patients with acute vascular term survival analysis of severe patients with acute vascular event admitted on event admitted on event admitted on event admitted on intensive care unit departmentintensive care unit departmentintensive care unit departmentintensive care unit department Alexandra SAIOC1,2, Vlad-Ionuţ NECHITA3,4*, Cosmin I. PUIA4,5,6 1Clinical Emergency Hospital of Oradea, 65 Gheorghe Doja, 410169 Oradea, Romania; alexandrangelas@gmail.com 2Oradea University, Faculty of Medicine and Pharmacy, Department of Medical Disciplines, Doctoral School of Biomedical Sciences, Oradea, Romania 3“Iuliu Hațieganu” University of Medicine and Pharmacy, Department of Medical Informatics and Biostatistics, 6 Louis Pasteur Str., 400349 Cluj-Napoca, Romania; nechita.vlad@umfcluj.ro (*corresponding author) 4Third Surgery Clinic, Prof. Dr. “Octavian Fodor” Regional Institute of Gastroenterology - Hepatology, 19-21 Croitorilor Street, 400162 Cluj-Napoca, Romania; drpuia@yahoo.fr 5Oradea University, Faculty of Medicine and Pharmacy, Doctoral School of Biomedical Sciences, Oradea, Romania 6“Iuliu Haţieganu” University of Medicine and Pharmacy, Faculty of Medicine, Department of Surgery, 19-21 Croitorilor Street, Cluj- Napoca, Romania AbstractAbstractAbstractAbstract The study evaluated the short-term survival during hospitalization period of the patients admitted on the intensive care unit department with an acute vascular event in comparison with other pathologies. We developed a retrospective cohort study with longitudinal design on 178 subjects admitted in an intensive care unit department. The patients were divided according the presence (33 patients) or absence (145 patients) of an acute vascular event (myocardial infarction or stroke). The survival during the hospitalization period was evaluated also considering the presence of diabetes (58 patients) or diabetes with complications (54 patients). The survival was presented as probability to survive during hospitalization period and median survival time. Logrank test was used to compare the groups. Patients with myocardial infarction had the average age of 60.57±7.97 years old, with 100% mortality during the hospitalisation period and a median survival time of 16 days. The patients with stroke were 66.34±14.12 years old with 46.15% survival probability and median survival time of 26 days; respectively patients without vascular event were 65.52±15.81 years old, had a survival probability of 46.89% and a median survival time of 28 days. Considering all the patients with vascular events, survival probability was 36.36%. Diabetes, the presence of arterial hypertension or diabetic complications does not influence significantly the survival in this sample (Logrank test, p>0.05). Survival of patients with acute vascular event is comparable with that of the patients admitted on intensive care unit for other health condition. A poor prognostic was observed for myocardial infarction. Keywords:Keywords:Keywords:Keywords: intensive care unit; myocardial infarction; stroke; survival; vascular event https://www.notulaebiologicae.ro/index.php/nsb/index Saioc A et al. (2023). Not Sci Biol 15(1):11394 2 IntroductionIntroductionIntroductionIntroduction Type 2 diabetes is a very important metabolic disorder characterized by chronic hyperglycemia, a burden for the healthcare system worldwide (Reed et al., 2021). This disease was mentioned for the first time in a manuscript, about three thousand years ago (Hegazi et al., 2015). The highest prevalence in the population have type 2 diabetes (90%), followed by type 1 diabetes (less than 10%) and other rare types. The increase in prevalence for type 2 diabetes is related with bad eating habits and increase body weight (Haslam, 2010; Maahs et al., 2010; Ozougwu et al., 2013). The molecular cause for type 2 diabetes seems to be inappropriate insulin production or secretion in the pancreatic beta cells or the resistance to insulin (Thompson and Kanamarlapudi, 2013). Long-term complications are important in this pathology, considering that is the first cause of blindness, end-stage kidney disease, cardiovascular disease and leg amputation worldwide (Thompson and Kanamarlapudi, 2013). Myocardial infarction is characterized by the death of myocardial cell due to ischemia (Thygesesn et al., 2010). Mortality decreased in the past years (Mozaffarian et al., 2010). Dispensarisation on intensive care unit after an acute myocardial infarction is accepted in the standard practice (Halpern and Pastores, 2013). Stroke is another important acute vascular event caused by hemorrhage or ischemia that can require management in the intensive care unit (Khassawneh et al., 2012). According to Ho et al. (2015) the in-hospital mortality after hemorrhagic and ischemic stroke is 20.4% respectively 15%. For patients with myocardial infarction who developed cardiogenic shock a mortality of at least 40% is described in the literature (Saleh and Ambrose, 2010). The aim of our study was to evaluate the short-term survival of patients with a major vascular event that needed intensive care management considering associated diabetes in comparison with other cases from intensive care unit department. Materials and MethodsMaterials and MethodsMaterials and MethodsMaterials and Methods Setting and study design A cohort study with longitudinal retrospective design was conducted on patients admitted in the intensive care unit from Oradea Regional Emergency Hospital. Participants All patients admitted in the intensive care unit department were eligible for the study. Patients who were in the direct care of the main author, with a complete medical history and without missing data were included for analysis. The cohort was divided according the presence and the type of vascular event (myocardial infarction or stroke). Data source and collection Patient’s information was collected from hospital database and patient observation sheets. Qualitative data (gender and comorbidities), quantitative (age) and survival information (survival time in days) were collected. Statistical analysis The statistics were computed on R Commander Version 2.8.0 and for survival graphs the KMggplot2 package was used. Qualitative data were evaluated as relative frequencies, quantitative data were presented as averages and standard deviations respectively median and interquartile range. The survival time was presented Saioc A et al. (2023). Not Sci Biol 15(1):11394 3 as median and 95% confidence intervals. To compare the survival time, we used the Logrank test and Kaplan Meyer curves. The p value lower than 0.05 was considered statistically significant. Ethical issues This study received approval no. 33441/07.10.2022 from the Ethics Committee of the Oradea Regional Emergency Hospital. Results Results Results Results One hundred seventy-eight patients admitted in the intensive care unit department were evaluated. The groups were built according to the presence of cardiovascular event: twenty-six patients after a stroke (14.61%), seven patients after myocardial infarction (3.93%) and one hundred forty-five subjects without vascular events (81.46%). The main characteristics of the patients and associated comorbidities are presented in Table 1. Table 1.Table 1.Table 1.Table 1. The main characteristics of the sample (n=178) All subjects All subjects All subjects All subjects (n=178)(n=178)(n=178)(n=178) Myocardial Myocardial Myocardial Myocardial infarction (n=7)infarction (n=7)infarction (n=7)infarction (n=7) Stroke Stroke Stroke Stroke (n=26)(n=26)(n=26)(n=26) No vascular event No vascular event No vascular event No vascular event (n=145)(n=145)(n=145)(n=145) CharacteristicsCharacteristicsCharacteristicsCharacteristics Age* (years) mean± SD 65.44±15.32 60.57±7.97 66.34±14.12 65.52±15.81 Gender, male – no. (%) 101 (56.74%) 5 (7.14%) 16 (61.53%) 80 (55.17%) Diabetes - no. (%) 58 (32.58) 4 (57.14%) 6 (23.07%) 48 (33.1%) Diabetes with hypertension - no. (%) 13 (7.3%) 0 1 (3.84%) 12 (8.27%) Diabetes with complications - no. (%) 54 (30.33%) 4 (57.14) 6 (23.07%) 44 (30.34%) SurvivalSurvivalSurvivalSurvival Death during hospitalization period - no. (%) 98 (55.05%) 7 (100%) 14 (53.84%) 77 (53.1%) Death on the intensive care unit - no. (%) 89 (50%) 7 (100%) 14 68 (46.89%) Death after they were transferred to another department - no. (%) 9 (5.05%) 0 0 9 (6.2%) Median survival time * 27 (95% CI 24- 33) 16 (95% CI 1- NA) 26 (95% CI 20- NA) 28 (95% CI 24- 35) *Presented as median and 95% confidence intervals; NA, not applicable. No statistically significant difference in survival (p=0.25 –Log-rank test) was observed for diabetic patients that had a survival probability of 48.27% and a median survival time of 27 days (95% CI 19-45) in comparison with the median survival time for those without diabetes with a survival probability of 46.66% and median survival of 27 days (95% CI 24-34). Patients with diabetes and associated hypertension have a survival probability of 46.15% with a median survival time of 28 days (95% CI 5-NA), and the difference was not statistically significant in comparison to those without hypertension (Figure 1). For those with diabetes and specific diabetic complications, the survival probability was 50% and the median survival time on intensive care unit was 28 days (95% CI 18-45). For patients with diabetes and an acute vascular event, the survival probability was 50% with a median survival time of 32.5 days (95% CI 17-NA), but the differences with the other patients admitted on intensive care unit were not statistically significant (Figure 1). Saioc A et al. (2023). Not Sci Biol 15(1):11394 4 (A) (B) (C) (D) Figure 1.Figure 1.Figure 1.Figure 1. Survival during hospitalization period regarding the presence of diabetes (A), hypertension (B), diabetic complications (C) and vascular events (D) The survival probability for the subjects with stroke admitted in the intensive care unit was 46.15% with a median survival time of 26 days (95% CI 20-NA) while none of the subjects admitted with myocardial infarction managed to survive. The median survival time for myocardial infarction was 16 days (95% CI 1- NA). The overall survival probability for subjects with vascular events admitted in the intensive care unit was 36.36%. For the subjects without vascular event the survival probability was 46.89% and the median survival time of 28 days (95% CI 24-35) (Figure 2). The survival probability was significantly inferior for the subjects with myocardial infarction. Saioc A et al. (2023). Not Sci Biol 15(1):11394 5 (A) (B) Figure 2.Figure 2.Figure 2.Figure 2. Survival during hospitalization period regarding the presence (A) and the type (B) of vascular event DiscussionDiscussionDiscussionDiscussion The myocardial infarction and stroke are considered diseases with golden hour (Cho et al., 2019). This study evaluated the short-term survival in case of a major vascular event (myocardial infarction or stroke) in comparison with other subjects admitted in a mixed intensive care unit. Myocardial infarction that needed intensive care management proved to have a significantly poor prognostic in comparison with the other subjects, despite a slightly lower average age (Table 1 and Figure 2). Kristoffersen et al. (2012) described a close overall relative frequency of death among the patients after acute myocardial infarction (19.1%) to those that had an acute stroke event (17.6%) during the first 30 days hospitalization period. The rates were higher in our study, considering also the severity of the cases that needed intensive care management. An important factor for survival was also the time and the distance before the patients firstly arrived in the hospital, as Berlin et al. (2016) mentioned. Driving time to the hospital was less important for stroke patients in comparison with myocardial infarction regarding the prognostic (Berlin et al., 2016). Myocardial infarction seems to have a poor short –term survival especially STEMI in comparison with the stroke where mortality is increased later, after the first approach due to secondary sequelae, hemodynamic instability or pulmonary complications (Berlin et al., 2016). A meta-analysis over 141 studies regarding the mortality in the intensive care unit for subjects with diabetes in comparison to those without diabetes, a significant disadvantage for diabetes was observed only for subjects admitted after surgery (OR= 1.48 [1.04 to 2.11]), but not for those from the medical or mixed intensive care units (Siegelaar et al., 2011). The results were similar with the situation described in our study. The diabetes was not associated with increased mortality (Figure 1). The presence of diabetic complications did not make differences on short-term outcome, and this can be explained by a different treatment approach adapted to their needs, and a good care they receive, to have a similar survival chance. Also, regarding the chronic pathology and complications, they seem to be managed efficiently (Figure 1). Krinsley (2003) suggested that hyperglycemia is a common condition for the critically ill patient, being associated with an increased in- hospital mortality. Patients with high glucose levels due to diabetes seems to be less affected by hyperglycemia in critical situations (Rady et al., 2005; Egi et al., 2008; Falciglia et al., 2009; Graham et al., 2010). This can also explain the similarities for the short-term prognostic (Figure 1). Saioc A et al. (2023). Not Sci Biol 15(1):11394 6 Our single-center experience can be valuable to assess the short-term prognostic for severe subjects after an acute vascular event admitted for intensive care. Possible drawback for this study is the retrospective design; the small sample size, and the low number of of subjects in the group with vascular event; especially for those with myocardial infarction. A larger sample with prospective follow-up is recommended for further research on this domain. ConclusionsConclusionsConclusionsConclusions Survival of patients admitted after an acute stroke on a mixed intensive care unit is comparable with that of the patients admitted for other non-vascular conditions. A poor prognostic was observed for myocardial infarction in comparison with stroke or non-vascular subjects. For patients with diabetes or with diabetic complications no differences in survival were observed during short-term prognostic on a mixed intensive care unit department. Authors’ ContributionsAuthors’ ContributionsAuthors’ ContributionsAuthors’ Contributions SA was responsible for data collection and manuscript writing. NVI was involved in statistical analysis, interpretation, review and editing of final manuscript. PCI provided conceptualization, supervision, study design, final review and correction. All authors read and approved the final manuscript. Ethical approvalEthical approvalEthical approvalEthical approval (for researches involving animals or humans) This study received approval no. 33441/07.10.2022 from the Ethics Committee of the Oradea Regional Emergency Hospital. AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements We thankfully acknowledge the support we received from University of Oradea Faculty of Medicine and Pharmacy for this study. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflict of InterestsConflict of InterestsConflict of InterestsConflict of Interests The authors declare that there are no conflicts of interest related to this article. ReferencesReferencesReferencesReferences Berlin C, Panczak R, Hasler R, Zwahlen M (2016). Do acute myocardial infarction and stroke mortality vary by distance to hospitals in Switzerland? Results from the Swiss National Cohort Study. British Medical Journal 6(11):e013090. https://doi.org/10.1136/bmjopen-2016-013090 Saioc A et al. (2023). Not Sci Biol 15(1):11394 7 Cho KH, Nam CM, Lee SG, Kim TH, Lee SH, Park EC (2019). 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