Rates, patterns, and predictors of specialty palliative care consultation among patients with acute-on-chronic liver failure.

BACKGROUND & AIMS: There is growing acceptance that principles of palliative care should be integrated into the management of serious illnesses affecting the liver, such as acute-on-chronic liver failure (ACLF). However, rates, patterns, and predictors of specialty palliative care consultation among patients with ACLF have not been well-described. METHODS: We performed a retrospective cohort study of patients hospitalized with ACLF between 1/1/2008 and 12/31/2018 using the VOCAL cohort. Patients were followed until 6/2021. We used mixed-effects regression analyses to identify significant patient and facility factors associated with palliative care consultation. We examined timing of consultation, the influence of ACLF characteristics, and facility-level variation on receipt of palliative care consultation. RESULTS: We identified 21,987 patients hospitalized with ACLF, of whom 30.5% received specialty palliative care consultation. Higher ACLF grade (ACLF-2 [odds ratio (OR) 1.82, 95% CI 1.67-1.99], ACLF-3 [OR 3.06, 95% CI 2.76-3.40]), prior specialty palliative care consultation (OR 2.62, 95% CI 2.36-2.91), and hepatocellular carcinoma (OR 2.10, 95% CI 1.89-2.33) were associated with consultation. Consultation occurred latest and closest to the time of death for patients with ACLF-3 compared to ACLF-1 and ACLF-2. Significant facility-level variation in consultation persisted among patients with ACLF-3, despite adjusting for multiple patient and facility factors. CONCLUSION: In this large cohort of hospitalized patients with ACLF, specialty palliative care consultation was rare, more common in patients with higher grade ACLF, and tended to occur closer to the time of death for the sickest patients. Greater attention should be placed on earlier integration of palliative care during acute hospitalizations in patients with ACLF. IMPACT AND IMPLICATIONS: Though palliative care consultation is recommended for patients with acute-on-chronic liver failure, there is no data demonstrating how often this occurs during hospitalizations, on a population level. We found that consultation occurs in only 30.5% of patients and occurs later for patients with grade 3 acute-on-chronic liver failure. Our data should provoke clinicians to urgently consider quality improvement efforts to integrate palliative care into the management of these seriously ill patients

Comparative Analysis of Electric Field Strength, Magnetic Field Strength and Power Density around the Cell Phone Towers of Varying Characteristics with a Proposed Classification Facilitating Research on Human Population

The continuous exposure of electromagnetic field (EMF) radiation from cell phone towers may possibly have an influence on public health. Each cell phone tower is unique in terms of number of antennas and its associated attributes; thus, the radiation exposure varies from one tower to another. Hence, a standardized method for quantifying the exposure is beneficial while studying the effects of radiation on the human population residing around the cell phone towers. A mere collection of data or human samples without understanding the cell phone tower differences may show study results such as an increase or decrease in biological parameters. Those changes may not be due to the effects of EMF radiation from cell phone towers but could be due to any other cause. Therefore, a comparative study was designed with the aim of quantifying and comparing the electric field strength (EF), magnetic field strength (MF) and power density (PD) on four sides of cell phone towers with varying numbers of antennas at 50 m and 100 m. Further, an attempt was made to develop a PD-based classification for facilitating research involving human biological samples. Through convenience sampling, sixteen cell phone towers were selected. With the use of coordinates, the geographic mapping of selected towers was performed to measure the distance between the towers. Based on the number of antennas, the cell phone towers were categorized into four groups which are described as group I with 1–5 antennas, group II comprising of 6–10 antennas, group III consisting of 11–15 antennas and group IV comprised of towers clustered with more than 15 antennas. The study parameters, namely the EF, MF and PD, were recorded on all four sides of the cell phone towers at 50 m and 100 m. One-way ANOVA was performed to compare the study parameters among study groups and different sides using the Statistical Package for the Social Sciences (SPSS) version 25.0. The mean MF in Group IV was 2221.288 ± 884.885 μA/m and 1616.913 ± 745.039 μA/m at 50 m and 100 m respectively. The mean PD in Group IV at 50 m was 0.129 ± 0.094 μW/cm2 and 0.072 ± 0.061 μW/cm2 at 100 m. There was a statistically significant (p < 0.05) increase in the MF and PD at 50 m compared to 100 m among cell phone tower clusters with more than 15 antennas (Group IV). On the other hand, a non-significant increase in EF was observed at 50 m compared to 100 m in Group II and IV. The EF, MF and PD on all four sides around cell phone towers are not consistent with distance at 50 m and 100 m due to variation in the number of antennas. Accordingly, a PD-based classification was developed as low, medium and high for conducting research involving any biological sample based on quantile. The low PD corresponds to 0.001–0.029, medium to 0.03–0.099 and high to 0.1–0.355 (μW/cm2). The PD-based classification is a preferred method over the sole criteria of distance for conducting human research as it measures the true effects of EMF radiation from the cell phone towers

The novel SALT-M score predicts 1-year post-transplant mortality in patients with severe acute-on-chronic liver failure

BACKGROUND & AIMS: Patients with acute-on-chronic liver failure grades 2/3 (severe ACLF) have 28-day mortality ranging from 30-90%. Though liver transplantation (LT) has demonstrated a survival benefit, the scarcity of donor organs and uncertainty regarding post-LT mortality among patients with severe ACLF may cause provider hesitation to proceed with LT. We developed and externally validated a model to predict 1-year post-LT mortality in severe ACLF, called the Sundaram ACLF-LT-M probability score, and estimated the median length of stay (LoS) after LT (ACLF-LT-LoS). METHODS: In 15 LT centers in the USA, we retrospectively identified a cohort of severe ACLF patients transplanted between 2014-2019, followed up to Jan'2022. Candidate predictors included demographics, clinical, laboratory values, and organ failures. We selected predictors in the final model using clinical criteria and externally validated them in two French cohorts. We provided measures of overall performance, discrimination, and calibration. We used multivariable median regression to estimate LoS after adjusting for clinically relevant factors. RESULTS: We included 735 patients, of whom 521 (70.8%) had severe ACLF (120 ACLF3,external cohort). The median age was 55 years, and 104 with severe ACLF (19.9%) died within 1-year post-LT. Our final model included age > 50 years, use of 1/2+ inotropes, presence of respiratory failure, diabetes mellitus, and body mass index (BMI, continuous). The c-statistic was 0.72 (derivation) and 0.80 (validation), indicating adequate discrimination and calibration based on the observed/expected probability plots. Age, respiratory failure, BMI, and presence of infection independently predicted median LoS. CONCLUSIONS: The ACLF-LT-M score predicts mortality within 1-year after LT in patients with ACLF.The ACLF-LT-LoS score predicted median post-LT stay. Future studies using the ACLF-LT scores could assist in determining transplant benefits. IMPACT AND IMPLICATIONS: Acute-on-chronic liver failure (ACLF) is a common syndrome, characterized by multi-organ failure in patients with cirrhosis associated with high-short term mortality. Liver transplantation (LT) may be the only life-saving procedure available to these patients but clinically unstability can augment the perceived risk of post-transplant mortality at one year. We provided a parsinominous score with clinically, and readily available parameters to objectively assess 1-year post LT survival and predict median length of stay after LT. Using modern estimation techniques, we developed and externally validated a clinical score model called the Sundaram ACLF-LT-Mortality score in 521 U.S. patients with ACLF with 2 or 3+ organ failure (s) and 120 French patients with grade ACLF-3. The area under the receiver operating characteristics curve was 0.72 in the development cohort and 0.80 in the validation cohort. We also provided an estimation of the median length of stay after LT in these patients. Our models can be incorporated in the discussion of risks/benefits in patients with severe ACLF listed for LT. Nevertheless, the score is far from perfect and other factors, such as patient's preference and center-specific factors, need to be considered whe using these tools