Abnormal White Blood Cell Count Research Articles

Hematologic abnormalities and pregnancy outcomes in pregnant women with COVID-19

Background: Since declaring coronavirus disease 19 as a pandemic by the World Health Organization, a great concern was directed toward pregnant women and their fetuses. Despite the substantial impact of COVID-19 disease on pregnancy, there is a scarcity of national researches discussing this important issue. Objectives: To study the relationship between peripheral blood abnormalities and COVID-19 in pregnant women. Patients and methods: A case control study was conducted in the labour wards of Baghdad Teaching Hospital in the Medical complex / Baghdad /Iraq during the period from 1st of February till 31st of July, 2021. Fifty pregnant women diagnosed with COVID-19 disease were compared to 50 healthy pregnant women as controls. The pregnant women enrolled in the study were tested by COVID-19-Reverse transcription RT-PCR test upon admission to hospital. The confirmation of COVID-19 diagnosis was done according to the Iraqi guidelines approved by the Iraqi Ministry of Health. Results: Dyspnea was a significant clinical presentation of pregnant women with COVID-19 disease. Those women had abnormal white blood cell count, lymphocytopenia, high neutrophil to lymphocyte ratio, high platelets to lymphocyte ratio and mild to moderate anemia which were significant when compared to controls. The maternal and neonatal morbidity and mortality rates were higher among pregnant women with COVID-19 disease. Abnormalities in peripheral blood system parameters like lymphocyte count, neutrophils count, platelets count and hemoglobin level were predictors of maternal morbidity and mortality. Conclusions: The clinical presentations and hematological abnormalities are useful in the diagnosis of COVID-19 disease in pregnant women and may be used as predictors of maternal and neonatal morbidity and mortality.

Dengue Fever with Corona Virus Disease 2019: Is it a “Double Trouble” with Concurrent Both Diseases or Single Disease with “Polyhedron” Nature and Antigenic Cross Reactivity?

Introduction: Corona virus disease 2019 (COVID-2019) disease caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2, is having propensity of pulmonary and extrapulmonary involvement. Although dengue virus has a predominant extrapulmonary effect, pulmonary involvement is less common. COVID-19–dengue overlap is a mixture of both diseases sharing few similarities. Methods: A multicentric observational study conducted from May 2021 to October 2021, in MIMSR Medical College and Venkatesh Hospital, Latur, India, included 300 COVID-19 cases with dengue NS1 or dengue immunoglobulin M (IgM) positive, with lung involvement documented and categorized on high-resolution computerized tomography (CT) thorax at the entry point. We have recorded demographic parameters as age, gender, comorbidity, and laboratory parameters such as total white blood cell count, platelet count, lactate dehydrogenase (LDH), C-reactive protein (CRP), interleukin-6 (IL-6), dengue serology, and use of BIPAP/NIV in COVID-19 cases in critical care settings in all study cases. CT severity scoring was done as per universally accepted standard mild if score < 7, moderated if score 8–15, and severe if score > 15. The final radiological outcome as presence or absence of fibrosis with clinical recovery was documented. All cases were subjected to dengue immunoglobulin G (IgG) antibody titers and dengue IgM/IgG antibody titer analysis after 12 weeks of discharge from the hospital after clinical recovery. Statistical analysis is done by using Chi-square test. Results: In a study of 300 COVID-19 pneumonia cases, COVID-19–dengue overlap was documented in 16.3% (49/300) of cases. Predominant age groups between 18–95 years and age ≥ 50 years were 60% (180/300), age < 50 were 40% (120/300). In the gender distribution in the study group, male population was 70.3% (211/300) and females were 29.7% (89/300). The main symptoms in the study group were shortness of breath in 79% of cases, fever in 71%, cough especially dry in 48%, and fatigability in 79%, tachycardia in 72%, tachypnea in 24%, and oxygen desaturation on 6 minutes walk in 29%. Positive dengue serology was documented as per CT severity scoring in 26/42 mild CT severity cases, 16/92 in moderate CT severity cases, and 7/166 in severe CT severity cases (P < 0.00001). Hematological parameters were having a significant association in COVID-19 cases with and without dengue overlap such as abnormal white blood cell count (P < 0.0076) and abnormal platelet count (P < 0.00001). Clinical parameters like hypoxia have a significant association in COVID-19 cases with and without dengue overlap (P < 0.00001). “Inflammatory markers” analysis such as interleukin 6 (IL-6) (P < 0.00001), CRP (P < 0.00001), and LDH (P < 0.00001) has documented significant association in COVID-19 cases with and without dengue overlap. In a study of 49 cases of COVID-19–dengue overlap, post-COVID lung fibrosis was documented in 1 case while 251 COVID-19 patients with negative dengue serology documented post-COVID lung fibrosis in 45 cases (P < 0.004). In a study of 49 cases of COVID-19–dengue overlap, actual serological assessment in dengue IgM/IgG and COVID-19 antibody titers was documented in significant association (P < 0.00001). Conclusion: COVID-19–dengue overlap is very frequently documented in tropical settings and disease of concern in critical care settings as the natural trend of this entity is different and has an impact on clinical outcome if diagnosis is delayed. COVID-19 pneumonia with dengue fever behaves like “two sides of the same coin” or the “polyhedron” nature of COVID-19 due to antigenic cross reactivity. Rationality for coexistent pathology is still undetermined.

Predictive factors for stone management timing after emergency percutaneous nephrostomy drainage in patients with infection and hydronephrosis secondary to ureteral calculi.

This study examined the interval between stone management and emergency percutaneous nephrostomy drainage in patients with infection and hydronephrosis secondary to ureteral calculi. A retrospective chart review was conducted for 88 patients treated for 94 stones enrolled in this study from 2005 to 2020. The mean age was 60.7 ± 15.2years (range: 2-87years). The average stone size was 1.51 ± 0.8cm (range: 0.4-4cm). The most common location was the upper ureter (n = 71, 75.5%), followed by the lower (n = 17, 18.1%) and middle (n = 6, 6.4%) ureter. The mean interval between percutaneous nephrostomy drainage and secondary stone management was 8.17 ± 11.6days (range: 1-76days). Most patients underwent operations within 1week (n = 72, 81.8%). Abnormal white blood cell counts were found in most patients (58, 65.9%). Tachycardia was detected in 40 (45.5%) patients. Only 11 (12.5%) patients had fever upon emergency department arrival. Severe shock was reported in 6 (6.8%) patients. More than half of all patients (45, 51.1%) experienced acute kidney injury, and 37 (42%) patients had elevated C-reactive protein levels. Most patients (69, 73.4%) received ureteroscopic lithotripsy as stone management. Mean arterial pressure (MAP) was the only significant parameter (p = 0.016) affecting the operation interval, with MAP < 60mmHg associated with longer operation intervals (16.2days). The timing of stone surgery depends on clinician discretion and patient recovery.

Long-Term Outcome of a “Mother-Child” Coaxial Dual-Catheter Technique for Percutaneous Transluminal Angioplasty of Central Vein Stenosis or Occlusion in Hemodialysis Patients

Purpose: This study aims to evaluate the long-term outcome and prognostic factors of a “mother-child” coaxial dual-catheter technique for percutaneous transluminal angioplasty (PTA) in the treatment of central vein stenosis (CVS) or central vein occlusion (CVO). Materials and Methods: During September 2017 to August 2020, totally, 76 hemodialysis patients with symptomatic CVS or CVO were treated with PTA using the mother-child technique. The success rate, complications, and follow-up information were collected. Cox proportional hazard analysis was used to explore the predicting factors of primary patency. Primary patency rates of different subgroups were generated with the Kaplan-Meier analysis and compared using the log-rank (Mantel-Cox) test. Results: There were 31 CVS patients and 45 CVO patients who presented with 114 PTAs. The initial procedure success rate was 98.25%. By the end of the follow-up, 57 patients (75%) had maintained functioning fistula after initial or repeated PTAs. The primary patency rates were 88.75% at 3 months, 73.36% at 6 months, 55.83% at 12 months, and 50.75% at 18 months. The secondary patency rates were 97.14% at 6 months, 87.66% at 12 months, and 82.18% at 24 months. The predictors for primary patency were history diabetes mellitus (hazard ratio [HR] = 3.1, 95% confidence interval [CI]: 1.31-7.30, P = .010), abnormal white blood cell count (HR = 1.44, 95% CI: 1.18-1.75, P < .001), lesion at subclavian-innominate vein (HR=2.75, 95% CI: 1.34-5.63, P = .006), and occlusion (HR=0.33, 95% CI: 0.14-0.76, P = .010). The primary patency was significantly lower in the subclavian-innominate vein subgroup, with a median primary patency of 4.5 (3-12.75) months, than in the nonsubclavian-innominate vein subgroup (8.5 [5-13] months; P = .005). The median duration of each PTA was 8 months for the first PTA, 7.5 months for the second PTA, and 5 months for the third PTA. There was no significant difference in the patency duration of repeated PTAs and the primary PTA (P = .389). Conclusions: The mother-child coaxial dual-catheter technique has a good success rate and acceptable primary patency in the treatment of hemodialysis patients with CVS or CVO. Repeated PTA is as effective as the primary PTA. Clinical Impact This is the follow up report on the “Mother-Child” coaxial dual-catheter technique for percutaneous transluminal angioplasty of central vein stenosis or occlusion in hemodialysis patients since we first presented it in 2019. In this paper, we can see that the long-term patency rate of this technique for central venous disease is satisfactory, and repeated use of this technique does not affect the patency time. Compared with other literature reports, the surgical success rate of this technique is significantly improved. Therefore, this technique is worth popularizing in the treatment of central venous disease.

Isolated Thrombocytopenia in Older Adults Is Associated with the Diagnosis of Hematologic Malignancy: A Population-Based Study

Background: In older patients, performing a bone marrow aspirate/biopsy (BM) during consideration of the diagnosis of immune thrombocytopenia (ITP) is controversial, and international hematology societies conflict in their recommendations due to limited evidence. Although ITP is more common in patients older than 60 years, the prevalence of hematologic malignancy also rises with age. The objective of this study was to determine whether isolated thrombocytopenia in patients aged 60 years and older is associated with the diagnosis of a hematologic malignancy, compared to matched patients without thrombocytopenia. Methods: We performed a retrospective population-based propensity-matched cohort study using linked health administrative data in Ontario, Canada. We included patients aged 60 years and older. Exposed patients were those with an internist or hematologist billing a consultation for thrombocytopenia, with laboratory-documented thrombocytopenia (platelet count <100x109/L) within 6 months prior to the consultation date (index date). Unexposed patients were those who never had specialist consultation for thrombocytopenia, who had all platelet counts >100x109/L within 6 months prior to index date. Patients were excluded if they had an abnormal hemoglobin or white blood cell count at index date, or a history of cancer, cirrhosis, or inherited bleeding or coagulation disorder. Exposed and unexposed patients were matched 1:4 on age at index (within 1 year), sex, and a propensity-score (within 0.2 standard deviations). The primary outcome was diagnosis of hematologic malignancy using a competing-risk of death model. The secondary outcome was all-cause death. We performed pre-specified stratified analyses on the primary outcome by age (<80; >80 years), sex, duration of thrombocytopenia prior to specialist consultation (<1; >1 year), severity of thrombocytopenia at index date or closest laboratory test prior to index date (<30x109/L; >30x109/L), and patients treated with corticosteroids (prednisone or dexamethasone) within 2 weeks of index date versus patients not treated with corticosteroids. We also performed pre-specified sensitivity analyses on the primary and secondary outcome to compare hazard ratios (HR) among exposed patients stratified by platelet count on index date or closest platelet count prior to index date (<10x109/L, 10-29x109/L, 30-49x109/L, 50-99x109/L). Results: We matched 4,390 exposed to 17,556 unexposed patients from January 1, 2009 to December 31, 2019. Among exposed patients, 378 (8.6%, 95% CI 7.8-9.5; 19.1/1000 person years (PY), 95% CI 17.1-21.0) were diagnosed with hematologic malignancy over 3.91 years of follow-up, compared to 204 unexposed patients (1.2%, 95% CI 1.0-1.3; 2.5/1000PY, 95% CI 2.2-2.8) over 4.05 years of follow-up. In the first year after consultation, the HR for being diagnosed with a hematologic malignancy was 15.5 (95% CI 11.3-21.4, p<0.0001, Figure 1) in exposed patients compared to unexposed. In subsequent years the HR was 5.3 (95% CI 4.4-6.6, p<0.0001, Figure 1). This relationship persisted in stratified analyses by sex, age, severity or duration of thrombocytopenia, and patients treated with corticosteroids within 2 weeks of consultation. Among exposed patients, the majority of hematologic malignancy diagnoses in the first year after index date were registered within 6 weeks of a BM (88%), while in subsequent years 45% of diagnoses were registered within 6 weeks of a BM. The most common hematologic cancer diagnosed in exposed patients was MDS (31%) (Table 1). Over half of cases of hematologic malignancy found in the exposed cohort would have been immediately actionable with disease-specific therapy. In terms of overall survival, 1,277 exposed patients (29.1%, 95% CI 27.8-30.5; 61.1/1000PY, 95% CI 57.8-64.5) and 3,663 unexposed patients (20.9%, 95% CI 20.3-21.5; 44.7/1000PY, 95% CI 43.3-46.2) died during the follow-up period (HR 1.4; 95% CI 1.3-1.5, p<0.0001). In a sensitivity analysis, there was no difference in the rate of hematologic malignancy diagnosis or rate of death based on severity of thrombocytopenia. Conclusions and Relevance: This population-based study demonstrates a strong association between thrombocytopenia and hematologic malignancy in patients aged 60 years and older. These data support the use of BM upfront in outpatient specialist consultation for isolated thrombocytopenia in older patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Factors influencing the hematological parameters among laborers at a gas service station in Rayong Province, Thailand

The purpose of this cross-sectional study was to investigate the factors that influenced the hematological parameters among gasoline station service workers. The sample comprised a total of 200 people split between those working at a fuel dispenser and those working outside the fuel dispenser. Interview forms, urine sample collection devices, and blood analysis samples were used to analyze Benzene, Toluene, Ethylbenzene, and Xylene (BTEX) metabolites and hematological parameters. The study showed that the employees had been exposed to metabolites of benzene (t,t-MA) exceeding the standard, which was 29.5 percent. The metabolites of toluene, ethylbenzene, and xylene were all within the standard limit. Information concerning hematology found that MCV was below the standard level, which was 37.5 percent, while the mean cell hemoglobin (MCH) and hematocrit (HCT) were also below the standard limit (36.5 and 32.0 percent, respectively). The results of the logistic regression analysis revealed that the factors influencing hematology parameters were statistically significant (p&lt;0.05). Affected females were reported as having abnormal MCH (OR=2.94; 95% CI=1.58, 5, 47), mean cell hemoglobin concentration (MCHC) (OR=2.68; 95% CI= 1.03, 6.98) and red cell distribution width (RDW) (OR=2.16; 95% CI=1.04, 4.49). Body mass index (BMI) affected MCH (OR=1.86; 95% CI=1.03, 3.35) and MCHC (OR=1.89; 95%CI=1.04, 3.43). Gasohol refueling affected red blood cells (RBC) (OR=2.35; 95% CI=1.19, 4.67) and hemoglobin (HB) (OR=1.95; 95% CI =1.01, 3.79). White blood cell count (WBC) was also affected by the refueling of more than 11 vans per day (OR=3.59; 95% CI=1.25, 12.48). In conclusion, personal factors as well as employment at gas stations put workers at risk for RBC, HB, and WBC abnormalities. This study identified groups of workers who were at high risk of hematology effects, particularly female workers and those with a BMI greater than the average. Furthermore, gasohol refueling should be carried out carefully to minimize any potentially negative effects on the blood system when exposed to vapors.

The Analysis of the Effect of Blood Transfusion on Changes of Blood Platelet Parameters in Patients with Leukemia Treated with Chemotherapy.

Objective To study and analyze the effect of blood transfusion on the change of blood platelet parameters in patients with leukemia treated with chemotherapy. Methods Ninety-eight patients with leukemia treated with chemotherapy in the First Affiliated Hospital of Xi'an Jiaotong University from January 2021 to January 2022 were selected to observe the changes of platelet parameters before and after blood transfusion. Results There was significant difference between pre-transfusion and post-transfusion indexes (platelet count, mean platelet volume, and hematocrit) (P < 0.05). After binary logistic regression analysis, the use of antibiotics (OR = 2.235), blood transfusion history (OR = 3.086), abnormal white blood cell count (OR = 1.134), and frozen plasma transfusion (OR = 3.121) were the main factors of blood platelet parameters after transfusion in leukemia patients (P < 0.05). Conclusion Blood transfusion is beneficial to improve blood platelet parameters and prevent bleeding in patients with leukemia treated with chemotherapy. Attention should be paid to patients with risk factors for poor response to blood platelet transfusion and early intervention.

Optimal timing of biliary drainage based on the severity of acute cholangitis: A single-center retrospective cohort study.

BACKGROUNDBiliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis (AC). Although early biliary drainage is recommended by the treatment guidelines for AC, the best time for performing this procedure is yet to be established. Furthermore, since the clinical outcomes of patients with severe AC vary dramatically, screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria.AIMTo investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.METHODSIn this retrospective monocenter cohort analysis, we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020. Demographic characteristics including age and sex, clinical and laboratory characteristics, and imaging findings of each patient were obtained from electronic medical records. We investigated the all-cause in-hospital mortality (IHM), hospital length of stay (LOS), and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors [age, white blood cell (WBC) count, total bilirubin, albumin, lactate, malignant obstruction, and Charlton comorbidity index (CCI)]. RESULTSBiliary drainage within 24 or 48 h in Grade III AC patients could dramatically decrease IHM (3.9% vs 9.0%, P = 0.041; 4% vs 9.9%, P = 0.018, respectively), while increasing LOS and hospitalization costs. Multivariate logistic analysis revealed that neurological, respiratory, renal, and cardiovascular dysfunctions, hypoalbuminemia, and malignant obstruction were significantly associated with IHM (odds ratio = 5.32, 2.541, 6.356, 4.021, 5.655, and 7.522; P < 0.001, P = 0.016, P < 0.001, P = 0.012, P < 0.001, and P < 0.001; respectively). Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction (0% vs 17.3%, P = 0.041) or with serum lactate > 2 mmol/L (0% vs 5.4%, P = 0.016). In the subgroup of AC patients with renal dysfunction, abnormal WBC count, hyperbilirubinemia, or hypoalbuminemia, early drainage (< 24 h) reduced the IHM (3.6% vs 33.3%, P = 0.004; 1.9% vs 5.8%, P = 0.031; 1.7% vs 5.0%, P = 0.019; 0% vs 27%, P = 0.026; respectively). The IHM was lower in patients with AC combined with hepatic dysfunction, malignant obstruction, or a CCI > 3 who had undergone biliary drainage within 48 h (2.6% vs 20.5%, P = 0.016; 3.0% vs 13.5%, P = 0.006; 3.4% vs 9.6%, P = 0.021; respectively).CONCLUSIONBiliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction, while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade III AC.

Occurrence and recovery of adverse drug reactions of preventive treatment in elderly population with latent tuberculosis infection

Objective: To evaluate the occurrence and recovery of adverse drug reactions (ADRs) of preventive treatment in the elderly population with latent tuberculosis infection (LTBI). Methods: A total of 2 583 elderly patients with LTBI were recruited in Zhongmu, Henan Province from July 1 to October 17, 2015. Face-to-face surveys and physical examinations were used to obtain the basic information of the participants, and the body mass index (BMI) was calculated. Fasting venous blood was collected from the participants for blood biochemical and routine blood tests. The random numbers were generated by Excel 2010, and the participants were divided into group A (1 284 cases) and group B (1 299 cases) by simple randomization. Both group A and group B received combination treatment of isoniazid and rifapentine. Group A was treated for 8 weeks with weekly doses of isoniazid at 15 mg/kg and 900 mg for those with body weight ≤50 and>50 kg, respectively, and the doses of rifapentin were 750 and 900 mg, respectively. Group B was treated twice a week for 6 weeks, the doses of isoniazid in patients with body weight ≤50 and>50 kg were [600-(50-body weight)×15] (rounded up) and 600 mg, respectively, and the doses of rifapentin were 600 and 450 mg, respectively. During the treatment period, doctors observed, inquired about and recorded symptoms related to ADRs, and blood biochemical and routine blood tests were performed at 4 weeks after taking the drug, the end of the treatment, and 3 months after the end of the treatment. The patients with ADRs were treated accordingly by severity. The ADRs and graded treatment outcomes of LTBI patients in group A and group B were compared. Results: The age［M（Q1，Q3）］of the participants was 60 (55,65) years old, and 54.7% (1 412/2 583) were males. There were no statistical differences in age, gender, BMI and baseline biochemical indexes between groups A and B (all P values>0.05). The incidence of ADRs in group A and group B were 18.5% (237/1 279) and 16.3% (209/1 279), respectively, and those with alanine aminotransferase (ALT)≥5 ULN accounted for 0.8% (7/931) and 1.1% (11/987), aspartate aminotransferase (AST)≥5 ULN accounted for 0.3% (3/931) and 0.3% (3/987), respectively, and there were no statistically significant differences (all P values>0.05). There were 7 and 11 patients with ALT≥5 ULN in group A and group B, respectively, and 3 patients with AST≥5 ULN for each group, respectively. After treatment, except for 2 patients with ALT≥5 ULN in group B, ALT and AST levels in all the other patients returned to normal. There were 15 and 10 patients with abnormal white blood cell count in group A and group B, respectively, and 10 and 9 patients returned to normal after treatment. Conclusion: LTBI preventive treatment has a high incidence of adverse drug reactions, but it can be effectively controlled through active monitoring and graded management.

Ceftriaxone resistance and adequacy of initial antibiotic therapy in community onset bacterial pneumonia.

Much remains unknown about the impact of initial antibiotic adequacy on mortality in community onset bacterial pneumonia (COBP). Therefore, we performed a study to determine how the adequacy of initial antibiotic therapy affects in-hospital mortality for patients with COBP.We carried out a retrospective cohort study among the 11 BJC Healthcare community and academic hospitals in Missouri and Illinois. The electronic medical records for BJC Healthcare were queried to obtain a set of patient admissions with culture positive (respiratory or blood) COBP admitted from January 1, 2016 through December 31, 2019. Patients with COBP required an International Classification of Diseases (ICD)-10 diagnostic code for pneumonia, admission to the hospital through an emergency department, a chest radiograph with an infiltrate, an abnormal white blood cell count or temperature, an order for 1 or more new antibiotics, and a positive respiratory or blood culture. Antibiotic selection was deemed adequate if the patient had organisms susceptible to at least one of the antibiotics received according to in vitro testing using standard laboratory breakpoints.Among 36,645 screened pneumonia admissions, 1843 met criteria for culture positive COBP. Eight hundred nineteen (44.4%) had ceftriaxone-resistant (CTX-R) organisms and 1024 had ceftriaxone-sensitive (CTX-S) organisms. The most common CTX-R pathogens were methicillin resistant Staphylococcus aureus (46.9%), Pseudomonas species (38.4%), and Escherichia coli (4.5%). On the day of admission 71% of all patients were given adequate antibiotic treatment (62.2% of CTX-R and 77.9% of CTX-S). Unnecessarily broad initial treatment was administered to 57.1% of CTX-S patients. In a logistic regression model accounting for comorbidities and severity of illness, inadequate therapy on the day of admission was associated with higher in-hospital mortality (P = .005). Among CTX-S patients who were adequately treated, initial use of unnecessarily broad antibiotics was associated with increased in-hospital mortality (P = .003).Ceftriaxone resistance was common in this cohort of culture positive COBP patients. Inappropriate coverage on day of admission was associated with greater likelihood of in-hospital mortality.

Rethinking the “Pan-Culture”: Clinical Impact of Respiratory Culturing in Patients With Low Pretest Probability of Ventilator-Associated Pneumonia

BackgroundRespiratory cultures are often obtained as part of a “pan-culture” in mechanically ventilated patients in response to new fevers or leukocytosis, despite an absence of clinical or radiographic evidence suggestive of pneumonia.MethodsThis was a propensity score–stratified cohort study of hospitalized mechanically ventilated adult patients between 2014 and 2019, with a new abnormal temperature or serum white blood cell count (NATW), but without radiographic evidence of pneumonia, change in ventilator requirements, or documentation of purulent secretions. Two patient groups were compared: those with respiratory cultures performed within 36 hours after NATW and those without respiratory cultures performed. The co-primary outcomes were the proportion of patients receiving >2 days of total antibiotic therapy and >2 days of broad-spectrum antibiotic therapy within 1 week after NATW.ResultsOf 534 included patients, 113 (21.2%) had respiratory cultures obtained and 421 (78.8%) did not. Patients with respiratory cultures performed were significantly more likely to receive antibiotics for >2 days within 1 week after NATW than those without respiratory cultures performed (total antibiotic: adjusted odds ratio [OR], 2.57; 95% CI, 1.39–4.75; broad-spectrum antibiotic: adjusted OR, 2.47, 95% CI, 1.46–4.20).ConclusionsPerformance of respiratory cultures for fever/leukocytosis in mechanically ventilated patients without increasing ventilator requirements, secretion burden, or radiographic evidence of pneumonia was associated with increased antibiotic use within 1 week after incident abnormal temperature and/or white blood cell count. Diagnostic stewardship interventions targeting performance of unnecessary respiratory cultures in mechanically ventilated patients may reduce antibiotic overuse within intensive care units.

Platelet to white blood cell ratio was an independent prognostic predictor in acute myeloid leukemia

ABSTRACT Background Recently, platelet to white blood cell ratio (PWR) was reported as an independent prognostic predictor in acute promyelocytic leukemia. Acute myeloid leukemia (AML) often presents with abnormal platelet counts and white blood cell counts (WBC) at disease diagnosis. However, the clinical impact of PWR on cytogenetically normal AML (CN-AML) is still unclear. Therefore, we evaluate its prognostic impact on CN-AML patients. Methods We recorded the clinical information at the time of disease diagnosis, and calculated the ratio of platelet counts to WBC in 338 patients with CN-AML. To assess the prognostic value of PWR, we divided patients into low, intermediate and high group based on the values of PWR. The independent prognostic value of PWR was investigated in the context of the well-established predictors including white blood cell counts, age, and genes of NPM1, FLT3-ITD, CEBPA, and DNMT3A mutations. Receiver operating characteristic (ROC) curve was used to assess the performance of its prognostic prediction. Results Higher PWR have the higher levels of platelet counts, but lower levels of white blood cell counts, percentage of bone marrow blasts, FLT3-ITD and NPM1 mutations. The performance of survival prediction was comparable between PWR alone and combined molecular biomarkers. Moreover, PWR had the additional prognostic information to the molecular biomarkers. Finally, PWR was associated with favorable overall survival and event free survival in CN-AML patients independent of genetic subtypes and clinical parameters. Conclusion We found PWR was an independent prognostic predictor in CN-AML.

Risk Factors and Interventions: Fournier Gangrene in a Tertiary Hospital: A 10-year Experience

Objective. The study aimed to describe the patient demographic characteristics, clinical factors, surgical interventions, and quality of care parameters in non-survivors and survivors of Fournier’s gangrene (FG).&#x0D; Methods. A total of 131 cases of Fournier’s gangrene (FG) were included in a retrospective chart review in the Philippine General Hospital over 10 years using the Department of Surgery research database. We collected data for various direct and derived variables from the identified population. The primary outcome was mortality rate, while other factors studied were genital and colorectal manipulation, bowel diversion, laboratory parameters (white blood cell count, creatinine, hemoglobin).&#x0D; Results. The mortality rate was 15%. Diabetes mellitus was common comorbidity among patients with Fournier’s disease. The following were statistically more common in the non-survivor group: female sex, concomitant bowel diversion surgery. Admission data in the non-survivor group showed a lower serum hemoglobin, a higher serum creatinine, and an increased percentage of patients with an abnormal white blood cell count; these did not statistically differ between cohorts, however. The median time to first antibiotic infusion was six hours. The median time to surgery was 13 hours.&#x0D; Conclusions. Among patients with Fournier’s gangrene, the proportion of women and those undergoing bowel diversion was higher in those who did not survive. The time of infusion of antibiotics or time to surgery did not differ significantly between survivors and non-survivors.

Lymphocytes ≥ 2.9 (109/L) in Newly Diagnosed Diabetes Are A Predictor of Future CVD Events.

Atherosclerosis is considered a chronic inflammatory condition. The immune system is a key mediator in the initiation and progression of atherosclerosis. In a previous study, we found that the immune system was activated in diabetes and that total white blood cell (WBC) counts were elevated significantly in diabetic patients. To investigate whether WBC subtype counts in newly diagnosed diabetes are risk factors for future cardiovascular disease (CVD) events, we conducted a prospective population-based cohort study. A total of 1498 newly diagnosed diabetic patients aged 40 to 70 years old were followed up for three years. Participants with previous CVD history and abnormal WBC counts were excluded. CVD events were recorded during follow-up. We found that the baseline lymphocyte counts were independently associated with cardiovascular events during follow-up, with the Exp (β) (95% CI) at 1.749 (1.084-2.821). Lymphocyte count ≥2.9 (109/L) was significantly associated with the development of CVD (HR, 2.29; 95% CI, 1.12-4.67). The corresponding incidence of CVD per 1000 person-year for the lymphocyte count ≤2.8 (109/L) and lymphocyte count ≥2.9 (109/L) groups were 11.26 and 26.38, respectively. We concluded that even in a normal range, higher lymphocyte levels may result in a significantly higher CVD risk among diabetic patients. Lymphocyte count ≥2.9 (109/L) is an independent predictor of developing future CVD events.

Comparison of the diagnostic accuracy of monocyte distribution width and procalcitonin in sepsis cases in the emergency department: a prospective cohort study

BackgroundEarly diagnosis and treatment of patients with sepsis reduce mortality significantly. In terms of exploring new diagnostic tools of sepsis, monocyte distribution width (MDW), as part of the white blood cell (WBC) differential count, was first reported in 2017. MDW greater than 20 and abnormal WBC count together provided a satisfactory accuracy and was proposed as a novel diagnostic tool of sepsis. This study aimed to compare MDW and procalcitonin (PCT)’s diagnostic accuracy on sepsis in the emergency department.MethodsThis was a single-center prospective cohort study. Laboratory examinations including complete blood cell and differentiation count (CBC/DC), MDW, PCT were obtained while arriving at the ED. We divided patients into non-infection, infection without systemic inflammatory response syndrome (SIRS), infection with SIRS, and sepsis-3 groups. This study’s primary outcome is the sensitivity and specificity of MDW, PCT, and MDW + WBC in differentiating septic and non-septic patients. In addition, the cut-off value for MDW was established to maximize sensitivity at an optimal level of specificity.ResultsFrom May 2019 to September 2020, 402 patients were enrolled for data analysis. Patient number in each group was: non-infection 64 (15.9%), infection without SIRS 82 (20.4%), infection with SIRS 202 (50.2%), sepsis-3 15 (7.6%). The AUC of MDW, PCT, and MDW + WBC to predict infection with SIRS was 0.753, 0.704, and 0.784, respectively (p < 0.01). The sensitivity, specificity, PPV, and NPV of MDW using 20 as the cutoff were 86.4%, 54.2%, 76.4%, and 70%, compared to 32.9%, 88%, 82.5%, and 43.4% using 0.5 ng/mL as the PCT cutoff value. On combing MDW and WBC count, the sensitivity and NPV further increased to 93.4% and 80.3%, respectively. In terms of predicting sepsis-3, the AUC of MDW, PCT, and MDW + WBC was 0.72, 0.73, and 0.70, respectively. MDW, using 20 as cutoff, exhibited sensitivity, specificity, PPV, and NPV of 90.6%, 37.1%, 18.7%, and 96.1%, respectively, compared to 49.1%, 78.6%, 26.8%, and 90.6% when 0.5 ng/mL PCT was used as cutoff.ConclusionsIn conclusion, MDW is a more sensitive biomarker than PCT in predicting infection-related SIRS and sepsis-3 in the ED. MDW < 20 shows a higher NPV to exclude sepsis-3. Combining MDW and WBC count further improves the accuracy in predicting infection with SIRS but not sepsis-3.Trial registration The study was retrospectively registered to the ClinicalTrial.gov (NCT04322942) on March 26th, 2020.

Prediction model for cardiovascular disease risk in hemodialysis patients.

To derive and validate a prediction score for cardiovascular disease (CVD) risk in hemodialysis patients in China. Three hundred and eighty-eight patients with regular hemodialysis for more than 3months were recruited from January 1, 2015 to September 30, 2019 and followed up till May 31, 2020. We derived a prediction score using all participants as a training data set and validated using a bootstrap validation data set. Discriminatory ability of the prediction score was assessed by the area under the receiver operating characteristic curve (AUC). Of 388 patients without CVD at baseline, 132 developed first CVD events during an average follow-up of 3.27 (inter-quartile range = 3.08) years. Of 26 clinical parameters, age, hypertension, diabetes and abnormal white blood cell (WBC) count were identified as significant predictors and included in the prediction model. Compared to those without any of these risk factors, those with one, two, and three to four points showed increased risks of CVD, with the adjusted hazards ratio and 95% confidence interval (CI) being 3.29 (1.17-9.26), 7.42 (2.68-20.51) and 15.43 (5.44-43.75), respectively. The score showed satisfactory discriminatory ability in both training and validation data set (AUC = 0.7025, 95% CI 0.6520-0.7530, and 0.6876, 95% CI 0.6553-0.7200, respectively). We derived and validated a prediction score for CVD risk in hemodialysis patients in China. Given there is a rapid increase in the number of hemodialysis patients, this simple point score can be used to identify high-risk individuals in clinical practice for more precise and efficient personalized treatment.

Clinical investigation on acute pyelonephritis without pyuria: a retrospective observational study.

BackgroundThe current guidelines for the diagnosis of acute pyelonephritis (APN) recommend that APN be diagnosed based on the clinical features and the presence of pyuria. However, we observed that some of the patients who are diagnosed with APN do not have characteristic clinical features or pyuria at the initial examination. We performed this study to investigate the characteristics of APN without pyuria.MethodsA retrospective, cross-sectional study was conducted on 391 patients diagnosed with APN based on clinical and radiologic findings, between 2015 and 2019. The clinical features, laboratory results, and computed tomography (CT) findings were compared between patients with normal white blood cell (WBC) counts and those with abnormal WBC counts (WBC of 0–5/high power field [HPF] vs. >5/HPF) in urine. ResultsMore than 50% of patients with APN had no typical urinary tract symptoms and one-third of them had no costovertebral angle (CVA) tenderness. Eighty-eight patients (22.5%) had normal WBC counts (0–5/HPF) on urine microscopy. There was a negative correlation between pyuria (WBC of >5/HPF) and previous antibiotic use (odds ratio, 0.249; 95% confidence interval, 0.140–0.441; p<0.001), and the probability of pyuria was reduced by 75.1% in patients who took antibiotics before visiting the emergency room. ConclusionThe diagnosis of APN should not be overlooked even if there are no typical clinical features, or urine microscopic examination is normal. If a patient has already taken antibiotics at the time of diagnosis, imaging studies such as CT should be performed more actively, regardless of the urinalysis results.

Emergency surgery for hemobilia due to hepatic artery pseudoaneurysm rupture complicated by Mirizzi syndrome type II: a case report

BackgroundHemobilia refers to bleeding into the biliary tract. Hepatic artery pseudoaneurysm (HAP) rupture is an uncommon cause of hemobilia, and cases of HAP associated with Mirizzi syndrome are extremely rare. Although transarterial embolization is recommended as the first-line treatment for hemobilia, surgery is sometimes required.Case presentationA 76-year-old woman was referred to our hospital with epigastric pain. She was febrile and had conjunctival icterus and epigastric tenderness. Laboratory tests revealed abnormal white blood cell count and liver function. An abdominal computed tomography (CT) revealed multiple calculi in the gallbladder, an incarcerated calculus in the cystic duct, and a slightly dilated common hepatic duct. Based on examination findings, she was diagnosed with Mirizzi syndrome type I, complicated by cholangitis. Intravenous antibiotics were administered, and we performed endoscopic retrograde cholangiopancreatography (ERCP) to place a drainage tube. The fever persisted; therefore, contrast-enhanced CT (CECT) was performed. This revealed portal vein thrombosis and hepatic abscesses; therefore, heparin infusion was administered. The following day, she complained of melena, and laboratory tests showed that she was anemic. ERCP was performed to change the drainage tube in the bile duct; however, bleeding from the papilla of Vater was observed. CECT demonstrated a right HAP with high-density fluid in the gallbladder and gallbladder perforation. Finally, she was diagnosed with hemobilia caused by HAP rupture, and emergency surgery was performed to secure hemostasis and control the infection. During laparotomy, we found that a right HAP had ruptured into the gallbladder. The gallbladder made a cholecystobiliary fistula, which indicated Mirizzi syndrome type II. Although we tried to repair the right hepatic artery, we later ligated it due to arterial wall vulnerability. Then, we performed subtotal cholecystectomy and inserted a T-tube into the common bile duct. There were no postoperative complications except for minor leakage from the T-tube insertion site. The patient was discharged after a total hospital stay of 7 weeks.ConclusionsWe experienced an extremely rare case of emergency definitive surgery for hemobilia due to HAP rupture complicated by Mirizzi syndrome type II. Surgery might be indicated when controlling underlying infections was required.

Predictors of in-hospital mortality by logistic regression analysis among melioidosis patients in Northern Malaysia

Objective: To identify the predictors of mortality among in-hospital melioidosis patients. Methods: A total of 453 patients in Hospital Sultanah Bahiyah, Kedah, and Hospital Tuanku Fauziah, Perlis with culture-confirmed melioidosis were retrospectively included in the study. Advanced multiple logistic regression was used to obtain the final model of predictors of mortality from melioidosis. The analysis was performed using STATA/SE 14.0. Results: A total of 50.11% (227/453) of the patients died at the hospital, and a majority (86.75%, 393/453) of cases were bacteremic. The logistic regression estimated that the bacteremic type of melioidosis, low platelet count, abnormal white blood cell counts, and increased urea value were predictors of mortality. The results showed that bacteremic melioidosis increased the risk of death by 4.39 times (OR 4.39, 95% CI 1.83-10.55, P=0.001) compared to non-bacteremic melioidosis. Based on laboratory test, the adjusted ORs from the final model showed that all three blood investigations were included as the associated factors of mortality for the disease [high white blood cell (&gt;10×109/L): OR 2.43, 95% CI 1.41-4.17, P&lt;0.001; low white blood cell (&lt;4×109/L): OR 3.82, 95% CI 1.09-13.34, P=0.036; low platelet (&lt;100×109/L): OR 4.19, 95% CI 1.89-9.30, P&lt;0.001; high urea (&gt;7 800 μmol/L): OR 5.53, 95% CI 2.50-12.30, P&lt;0.001; and low level of urea (&lt;2 500 μmol/L): OR 3.52, 95% CI 1.71-7.23, P=0.001). Conclusions: Routine blood investigations during a hospital admission can early identify predictors of mortality in melioidosis patients.

Prognostic Factors and Survival Outcomes in Phase I Patients with Hematologic Malignancies

Introduction: Patient selection is a challenge in designing effective phase I clinical trials in hematologic malignancies. Potential candidates typically have relapsed or refractory disease, and have had poor response to multiple prior lines of therapy. Such patients are at risk for early death, which reduces both the scientific yield and the therapeutic value of clinical trials: patients whose disease has already entered a terminal phase, and who subsequently die within a few months, provide little meaningful data to advance the understanding of an experimental treatment, and likely derive little clinical benefit from that treatment.Currently, eligibility criteria for most trials rely on ad hoc laboratory thresholds, and on subjective assessments of performance status and life expectancy. It is desirable to have an objective, statistically validated means of predicting survival, to optimize patient selection for phase I clinical trials. A prognostic scoring system for this purpose has been developed and validated for patients with solid tumors (Garrido-Laguna et al. Cancer . 2012;118(5):1422-1428); this model incorporates variables on tumor type and number of metastatic sites, which are not directly applicable outside of solid tumors. Similar work has recently been reported in hematologic malignancies (Benajiba et al. Anti-cancer drugs . 2017;28(5):540-545), using only three variables: performance status, serum albumin, and disease class. We developed a novel prognostic scoring system to estimate progression free (PFS) and overall (OS) survival for patients enrolled in phase I clinical trials for treatment of hematologic malignancy.Methods: We retrospectively reviewed the electronic medical records of 106 patients enrolled in phase I clinical trials for treatment of hematologic malignancies at the UT Health San Antonio Cancer Center between 2000 and 2014. Descriptive, univariate, and multivariate analyses were performed to determine the parameters that carry prognostic significance. Cox proportional hazards regression models of Progression Free and Overall Survival (PFS, OS) were used for multivariate analyses. A backward elimination process with a relaxed P-value (0.2) threshold was used to select variables for adjustment.Results: Our analysis identified Hispanic ethnicity (P=0.03), low albumin level (<3.5 g/dL), low hemoglobin (<10 g/dL, P=0.02), hyperbilirubinemia (>1.0 mg/dL, P=0.03), abnormal white blood cell count (<4 k/µL or >10 k/µL, P<0.01), elevated lactate dehydrogenase (LDH) (>240 IU/L, P<0.01), and diagnosis of acute leukemia (P<0.01) as independent predictors of poor overall survival. The patient cohort was stratified by risk score into good (0-1), intermediate (2-4), and poor (5-7) risk categories, which were compared with respect to PFS and OS using Kaplan-Meier curves and log rank testing (see figures 1 and 2).Conclusion: A simple score incorporating diagnosis, ethnicity, albumin, hemoglobin, bilirubin, white blood count, and LDH can identify patients with advanced hematologic malignancy who are likely to have short OS and PFS. Efforts are underway to validate this score against a separate cohort of phase I patients. Once validated, it could be incorporated in phase I trial design, potentially making these trials easier, faster, and more cost-effective to conduct, while allocating experimental treatments to those patients most likely to derive benefit. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.