Acute Coagulopathy Research Articles

Study on immune status alterations in patients with sepsis

Sepsis, characterized by cytokine-mediated hyper-inflammation and a consistent decline in immune responsiveness, is associated with a high risk of death in the intensive care unit (ICU). Here, we for the first time investigated the changes in immune and inflammatory responses to understand the interactions between immune and inflammatory biomarkers and their association with patient outcomes. The cytokine and lymphocyte subset levels were analyzed in healthy donors (HD) and patients with sepsis upon admission to the ICU (D0), D3, D7, D14, and D28 using flow cytometry. The primary endpoint was mortality on day 90. The trends in lymphocyte subsets and cytokine levels in all patients (n=47), HD (n=27), and patient subgroups (surviving, n=30; dead, n=17) were analyzed using an independent sample t-test and principal component analysis. Age, steroids (steroids used>48h), secondary infection, acute heart failure, acute kidney injury, coagulopathy, hypohepatia, organ transplant and septic shock (when transferred to the ICU) were associated with mortality. Absolute lymphocyte counts and lymphocyte subsets levels were reduced in most patients with sepsis. The proportion of Tregs in the patients increased with disease progression and was associated with immunosuppression. In conclusion, sepsis downregulated adaptive immunity, and induced the transition of the patients to prolonged immune suppression. The study suggests that while cellular immunity recovered within 2weeks of admission, humoral and innate immunity recovery takes longer. These findings may assist in developing appropriate therapeutic approaches to improve the immune responses in patients with sepsis.

Managing the coagulopathy of postpartum hemorrhage: an evolving role for viscoelastic hemostatic assays

Postpartum hemorrhage (PPH) is usually caused by obstetrical complications but may be exacerbated by hemostatic impairment. Standard laboratory tests of coagulation often take too long to become available to inform treatment in a rapidly changing clinical situation. The role of point-of-care viscoelastic hemostatic assays (VHAs) in monitoring hemostatic impairment and guiding procoagulant blood product replacement during PPH is evolving, although these technologies are not available in most maternity units. We have used VHAs during PPH in our institution for the last 8 years and have developed a simple algorithm to direct blood component replacement. VHAs are useful for reassuring clinicians that hemostasis is adequate and that procoagulant blood products are not required and an obstetrical cause for bleeding needs to be sought. VHAs can be used to detect hypofibrinogenemia due to dilution or acute obstetrical coagulopathy and to guide fibrinogen replacement. The role of VHAs in guiding fresh frozen plasma infusion is less clear, but normal results suggest that fresh frozen plasma is not required. In this review, we describe 3 cases of postpartum hemorrhage to illustrate different hemostatic scenarios and discuss the controversies and evidence gaps related to each case.

Crucial new insights into the understanding and treatment of acute obstetric coagulopathy

Crucial new insights into the understanding and treatment of acute obstetric coagulopathy

Left atrial appendage closure device outcomes among cirrhosis patients with atrial fibrillation: a United States National Cohort Study.

Literature regarding outcomes associated with atrial fibrillation among cirrhosis patients who had left atrial appendage occlusion (LAAO) device procedure is limited. We aim to evaluate the in-hospital clinical outcomes and 30-day readmissions among LAAO with and without cirrhosis. We performed a retrospective study of all hospitalizations associated with the LAAO procedure, using the Nationwide Readmissions Database for the years 2016-19. Primary outcomes were in-hospital clinical outcomes and 30-day readmissions. A total of 54 897 index hospitalizations for LAAO (female 41.8%) were reported. Of these, 905(1.65%) had cirrhosis. Gastrointestinal (GI) bleeding was reported in 44 (4.9%) vs. 1606 (2.97%) and coagulopathy in 21 (2.3%) vs. 521 (0.96%) in cirrhosis and without-cirrhosis groups, respectively. A total of 872 (1.59%) patients needed blood transfusion, 24 (2.7%) vs. 848(1.57%) in cirrhosis vs. without-cirrhosis groups (P = 0.047). Fresh frozen plasma (FFP) transfusion was reported among 888 (1.62%), with cirrhosis 26 (3%) vs. without cirrhosis 862 (1.6%) (P = 0.05). On adjusted multivariate logistic regression analysis, acute kidney injury, coagulopathy, FFP transfusion, and blood transfusion were strongly associated with cirrhosis, and GI bleeding, ischaemic stroke, and intracranial haemorrhage were not associated with cirrhosis. Readmissions in 30 days were 5028 (9.18%), 167 (18.5%) in the cirrhosis group and 4861 (9%) without-cirrhosis group (P = 0.01). On multivariate Cox regression, CHA2DS2-Vasc score of six was significantly associated with 30-day readmission compared with other scores [hazard ratio 2.24; 95% confidence interval (1.58-3.16); P < 0.001]. Left atrial appendage occlusion procedure in patients with cirrhosis had relatively similar GI bleeding and stroke rates, however, had higher rates of 30-day readmission. A higher CHA2DS2-Vasc score was more likely to be associated with 30-day readmissions and hence would help in discharge planning. The long-term safety and efficacy of LAAO in the cirrhosis population need to be demonstrated.

Clinical, anatomopathological manifestations and laboratory findings of Covid-19 in adults: a narative review

Introduction: SARS-CoV-2, the causative agent of the COVID-19 pandemics can cause anything from asymptomatic infections to several clinical manifestations. This study aims to present signs, symptoms, anatomopathological diagnosis, clinical diagnosis and laboratory findings in patients with COVID-19 in a narrative review. Methods: Narrative review of studies available in PubMed/Medline database about clinical manifestations in adult patients which were published in English, Portuguese and Spanish. Results: 547 articles were found, out of which 450 were excluded and 3 studies were added to the existing ones, totalizing 100 articles that composed the analyzed data. The main signs and symptoms were fever, dry cough, fatigue, dyspnea, pneumonia, headache, myalgia, vomiting, diarrhea, productive cough, acute myocardial injury, coagulopathy and olfactory and taste disorders. Conclusions: The findings suggest a great variety and complexity of Covid-19 clinical presentations indicating that, many differential diagnoses must be considered.

Spontaneous intracerebral haemorrhage secondary to 5-ALA-induced thrombocytopaenia in a paediatric patient: case report and literature review

IntroductionThe primary objective of neurosurgical management of malignant gliomas is maximal safe resection of the tumour. One of the main obstacles in achieving this is the ability to accurately discriminate between tumour edges and the surrounding healthy brain tissue. The use of fluorescence-guided surgery utilising 5-aminolevulinic acid (5-ALA), first introduced more than 20 years ago, has become an invaluable adjunct in high-grade glioma surgery in adults. However, as 5-ALA is not licensed for use in paediatric patients, the safety profile for such use remains undetermined.Case reportWe describe the case of a 4-year-old boy who underwent 5-ALA-guided resection of a fourth ventricle anaplastic ependymoma. Although complete resection was achieved and the patient awoke from surgery well with no neurological deficits, the patient developed acute transaminitis, anaemia, thrombocytopaenia and coagulopathy postoperatively. The patient had a sudden neurological deterioration on postoperative day 2; imaging revealed that he had suffered a spontaneous right frontal intracerebral haemorrhage. The patient returned to theatre for surgical decompression and evacuation of the haematoma, and ultimately went on to make a full recovery.ConclusionThe use of 5-ALA in paediatric patients can be helpful in maximising surgical resection, but the associated safety profile remains undefined. Further research is urgently warranted in order to characterise the efficacy and risk of the use of 5-ALA in the paediatric population.

Correlation Between Degrees of Trauma and Volume of Rescission Fluids with Acute Coagulopathy in Multiple Trauma Patients at Prof. Dr. I.G.N.G Ngoerah Denpasar Hospital

Background: Coagulopathy that occurs in trauma is known as Trauma Induced Coagulopathy (TIC). 1 in 7 deaths caused trauma, and 30% of all trauma patients who came to the hospital were in TIC condition. Prof. Dr IGNG Ngoerah Denpasar Hospital reported that coagulopathy occurred in 24 (39.3%) of 61 multiple trauma patients. Objective: Proving the correlation between the degree of trauma and volume of resuscitation fluid with the incidence of acute coagulopathy due to multiple trauma. Method: A retrospective cohort study conducted at Prof. Dr IGNG Ngoerah Denpasar Hospital with secondary data in a medical record from January 2020-December 2021. This study’s data analysis consisted of univariate, bivariate, and multivariate analysis using SPSS IBM version 23. Results: There were 100 subjects where 40 respondents had coagulopathy, the median age was 33.5 years, the male gender was 80%, and the most type of trauma was a head injury. The results of the degrees of trauma with a NISS score (New Injury Severity Score) ≥ 41 increases the incidence of coagulopathy 17.7 times with p&lt;0.001 of resuscitation fluid is more than 2 litres increases the risk of developing coagulopathy 27 times in multiple trauma patients with p&lt;0.001. In addition, class 3-4 bleeding classification ATLS is known to be 17 times at risk of coagulopathy with p&lt;0.001. Conclusion: There is a statistically significant correlation between an increase in the degree of trauma and NISS️≥ 41 and the volume of resuscitation

Fulminant hepatitis due to spontaneous reactivation of virus B in an immunocompetent patient.

We present the case of a 52-year-old woman with a history of HBeAg-negative chronic hepatitis B virus (HBV) infection, viral load (VL) Z+<20,000U.l/ml with no evidence of liver fibrosis and, therefore, untreated. She presented to the emergency department with jaundice, epigastric pain, nausea, and vomiting. On admission, blood analysis revealed ALT 3982U/l, AST 3221U/l, Gamma-GT 80U/l, alkaline phosphatase 252U/l, LDH 960U/l, bilirrubin12.5mg/dl; no elevation of acute phase reactants, 141,000 platelets and coagulopathy with a prothrombin activity of 29%. Abdominal ultrasound showed no relevant findings. The serological profile revealed AgHBs+, anti-HBe+ y anti-HBc IgM+ and VL VHB>100 mills. Ul/ml, the remaining serology was negative and other causes of liver disease were ruled out. With the diagnosis of severe acute hepatitis (SAH) due to HBV reactivation (HBVR) treatment with entecavir was initiated. Given the analytical evolution (Table 1) and the appearance of encephalopathy grade I-II/IV, an urgent liver transplant was performed. The histological result of the explant was conclusive with intense interphase and lobular hepatitis with extensive areas of massive necrosis in both lobes, without hepatic fibrosis compatible with fulminant hepatitis (FH).

Possibility of Red Blood Cell Changes after COVID-19 Pandemic

Dear editor,&#x0D; &#x0D; The COVID-19 pandemic caused a lot of changes in society and the economy as well as individual, physical, and mental health. COVID-19 might cause acute respiratory syndrome, coagulopathy, vascular failure, and organ damage1-3. In the study by Huang L et al., 2469 patients who recovered from severe COVID-19 were followed up for two years, the longest follow-up until now. They demonstrated that COVID-19 survivors had remarkably lower health status than the general population after two years and suggested urgent exploration into the pathogenesis of the disease4. Otherwise, there were some important issues with this study. First, it was not an international study that included different geographic regions, ethnicities, races, and countries. Another important point was that 80 percent of patients experienced mild or no symptoms of this disease which were excluded from this study. However, COVID -19 affected their health conditions as well as severe patients. It is clear that exposure to the virus in the recent pandemic is unavoidable and no one can be sure about the previous infection of the studied cases.Furthermore, many people were reluctant to take a PCR test despite mild symptoms and also, the PCR test has a high false-negative rate, which is affected by the sampling method and the time of interval5, 6. It is suggested researchers investigate the COVID-19 effects on the general population.&#x0D; Most COVID-19 patients reported breathlessness and reduced fitness, which might be related to pulmonary damage and altered oxygen uptake into the red blood cells (RBC), leading to hypoxemia.&#x0D; Some studies demonstrated that COVID-19 altered RBC morphology and revealed a higher percentage of elongated RBC(7). The RBC deformability was significantly increased in COVID-19 patients7. Nader et al. showed that RBC aggregation increased in COVID-19 patients and correlated positively with the hospitalization length8. In a recent study, it was found that oxidation and fragmentation of ankyrin, spectrin beta, and the N-terminal cytosolic domain of band 3 (AE1) may cause RBCs disability in COVID- 19 patients, who could respond to environmental changes in hemoglobin oxygen saturation/oxidant stress. Nonetheless, there were no alterations in hematological parameters, such as RBC count, hematocrit, or mean corpuscular hemoglobin concentration9. Based on these reports, the count of normal RBC is admissible, but maybe the function of RBCs in oxygen transfer have changes.&#x0D; The above-mentioned studies indicated the temporary effects of COVID-19 on RBCS, but COVID-19 may cause some long-term effects on RBCs10. There is enough evidence indicating that the numbers of RBC and hematocrit (HCT) increase significantly in response to hypoxic environments, similar to changes that occur by living in high-altitude places11. With the large-scale outbreak of the COVID epidemic worldwide, the number of people using protective masks has increased rapidly. Using masks can cause problems, such as hypoxia symptoms, which increase RBC mass and HCT for a long time12,13. According to recent studies, wearing a mask can alter peripheral Spo2 after two hours, and it can cause small but significant changes in cerebral blood flow (CBF) and cerebral blood oxygen saturation (StO2) while wearing diffrent types of masks (surgical and FFP2)14,15.&#x0D; Based on the above-mentioned studies, the significant changes in RBC functions after the COVID-19 pandemic can be concluded, however the definitive diagnosis is not possible using routine laboratory tests. According to long-term changes in RBC count, the lack of any population-based studies on RBC changes before and after the COVID-19 pandemic, and the key role of RBC count in diagnosing disease, especially in anemia, more investigations seem to be necessary. Reference intervals need to be re-examined in the new health conditions after the COVID-19 pandemic.

Acute obstetric coagulopathy during postpartum hemorrhage is caused by hyperfibrinolysis and dysfibrinogenemia: an observational cohort study

BackgroundPostpartum hemorrhage (PPH) may be exacerbated by hemostatic impairment. Information about PPH-associated coagulopathy is limited, often resulting in treatment strategies based on data derived from trauma studies. ObjectivesTo investigate hemostatic changes associated with PPH. Patients/MethodsFrom a population of 11 279 maternities, 518 (4.6%) women were recruited with PPH ≥ 1000 mL or placental abruption, amniotic fluid embolism, or concealed bleeding. Routine coagulation and viscoelastometric results were collated. Stored plasma samples were used to investigate women with bleeds > 2000 mL or those at increased risk of coagulopathy defined as placenta abruption, amniotic fluid embolism, or need for blood components. Procoagulant factors were assayed and global hemostasis was assessed using thrombin generation. Fibrinolysis was investigated with D-dimer and plasmin/antiplasmin complexes. Dysfibrinogenemia was assessed using the Clauss/antigen ratio. ResultsAt 1000 mL blood loss, Clauss fibrinogen was ≤2 g/L in 2.4% of women and 6/27 (22.2%) cases of abruption. Women with very large bleeds (>3000 mL) had evidence of a dilutional coagulopathy, although hemostatic impairment was uncommon. A subgroup of 12 women (1.06/1000 maternities) had a distinct coagulopathy characterized by massive fibrinolysis (plasmin/antiplasmin > 40 000 ng/mL), increased D-dimer, hypofibrinogenemia, dysfibrinogenemia, reduced factor V and factor VIII, and increased activated protein C, termed acute obstetric coagulopathy. It was associated with fetal or neonatal death in 50% of cases and increased maternal morbidity. ConclusionsClinically significant hemostatic impairment is uncommon during PPH, but a subgroup of women have a distinct and severe coagulopathy characterized by hyperfibrinolysis, low fibrinogen, and dysfibrinogenemia associated with poor fetal outcomes.

Epidemiological and clinical features of hump-nosed pit viper (Hypnale hypnale and Hypnale zara) envenoming in children.

Bites by the hump-nosed pit vipers (HNPV) of the genus Hypnale are the commonest type of venomous snakebites in Sri Lanka. Their bites frequently cause local effects while rarely causing systemic envenoming, that may include acute kidney injury and coagulopathy. There are 3 species of genus Hypnale including H. hypnale, H. zara and H. nepa from which latter two are endemic to Sri Lanka. Virtually all studies on HNPV bites in Sri Lanka are focused on adults except two studies in paediatric group. The aims of this study were to describe the epidemiology and clinical manifestations of HNPV bites in a group of children admitted to a tertiary care hospital in Sri Lanka. This was a prospective observational study carried out in Teaching Hospital Ratnapura, Sri Lanka over 27 months commencing from May 2020 including all children aged up to 14 years with the history of HNPV bites. There were 40 (56%) HNPV bites, of them 28 (70%) were males. The age was 84 months (50.2-120 months). Majority (n = 21;52.5%) were bitten during day-time (06:00-17:59) in home gardens (n = 20; 50%) on lower limbs (n = 24;60%). Most children (n = 30;75%) were admitted to the medical facility < 4 hours after the snakebite [90 min (40-210 min)] and the hospital stay was 4 days (3-5 days). Local envenoming was observed in 38 patients (95%) and systemic effects developed in 4 patients (10%) as mild coagulopathy. Local effects include local pain (n = 30; 94%), swelling (n = 38;95%), blistering (n = 11;27.5%), necrosis at the site of bite (n = 11; 27.5%), regional lymph node enlargement (n = 8;20%) and local bleeding (n = 4;10%). For the local effects, surgical interventions were needed in 10 children (25%) and 3 (7.5%) of them developed acute compartment syndrome leading to fasciotomy. Leucocytosis (n = 28;78%) and eosinophilia (n = 9;27%) were the prominent laboratory findings. All got recovered except in patients with fasciotomy who got permanent scar. Hump-nosed pit viper bites mostly cause local effects and rarely systemic envenoming in children. Compartment syndrome is common in children following their bites.

1246: CALCIUM CHANNEL BLOCKER TOXICITY TREATED WITH METHYLENE BLUE AND LIPID EMULSION: A RARE SURVIVOR

Introduction: Calcium channel blocker (CCB) toxicity due to intentional overdose (OD) is associated with high morbidity and mortality. Depending on the CCB subclass, symptoms can include altered mentation, hypotension, and bradycardia. The lack of formally recognized guidelines in the treatment of CCB toxicity can complicate management. Description: A 67-year-old female with history of depression was admitted to the ICU after suicidal ingestion of thirty amlodipine 5 mg tablets for shock refractory to volume resuscitation and vasopressor support. Initial vitals were reported as blood pressure 55/29, pulse 86, respirations 18, pulse oximeter 94% on room air, Glascow coma scale of 13 with stuporous mentation. Despite fluids, initiation of norepinephrine, intravenous (iv) calcium and glucagon, her shock persisted. Toxicology was contacted and recommended high dose iv insulin and dextrose which transiently improved blood pressures, however low mean arterial pressures (MAP) necessitated initiation of vasopressin and epinephrine drips. Methylene blue was started, followed by escalation to iv lipid emulsion (ILE) therapy. With this regimen, distributive shock and mentation improved. With time, vasopressor support was weaned and the patient made a complete recovery from severe CCB toxicity. Discussion: Conventional treatment with iv calcium, glucagon, atropine, cardiac pacing and pressors often fail to improve the hemodynamics associated with intentional CCB OD. Adjunct therapy with insulin may improve cardiac myocyte contractility and methylene blue is postulated to improve distributive shock via inhibition of nitric oxide synthase but current literature lacks case control data. ILE therapy should also be considered early in the treatment course and utilized with the guidance of a toxicologist as ILE is not without risk of complications including but not limited to acute pancreatitis, fat embolism, cardiac arrest, kidney injury, ARDS, seizure, and coagulopathy. Despite its growing utility in the treatment of lipophilic drug toxicity, most studies with CCB OD are case reports and based on animal studies rather than clinical trials. This case demonstrates the potential benefits of adjunct treatment with methylene blue and iv lipid emulsion to improve refractory distributive shock.

Perioperative Gelatin Use Is Associated With Increased Complication Rates and Does Not Prevent Postoperative Fluid Overload in Patients Undergoing Elective Cardiac Surgery

The benefit of using gelatin solution in cardiac surgery is still controversial. Previous data suggested adverse interactions of gelatin infusion with acute kidney injury (AKI) or coagulopathy. The purpose of this study was to evaluate the association between perioperative gelatin use and fluid overload (FO), hemodynamic stability, and outcomes compared to crystalloid-based fluid management. A retrospective study design. At a single-center tertiary university setting. Propensity score-matched cohort study of 191 pairs of patients scheduled for cardiac surgery. Patients received either gelatin+crystalloid or pure crystalloid-based perioperative fluid management. The primary outcomes were the frequency of FO and hemodynamic stability defined by the vasoactive-inotropic score. Postoperative complications and 3-year survival were analyzed also. Patients who received gelatin experienced more frequent postoperative FO than controls (11.0% v 3.1%, p=0.006) despite comparable hemodynamic stability in both groups. Gelatin administration was linked with a higher rate of postoperative complications, including blood loss, AKI, and new-onset postoperative atrial fibrillation. Use of gelatin infusion resulted in an adjusted odds ratio of 1.982 (95% CI 1.051-3.736, p=0.035) for developing early postoperative AKI. This study confirmed a dose-dependent relationship between gelatin infusion and AKI. Thirty-day mortality and 3-year survival were similar in the groups. Gelatin administration versus crystalloid fluid management showed a significant association with a higher rate of FO and an increased risk for early postoperative AKI in a dose-dependent manner.

281 Out-of-Hospital TXA Administration Opportunities in Trauma Patients Transported by ALS Ground EMS - A Descriptive Study

As many as 30% of severely injured trauma patients demonstrate evidence of acute coagulopathy of trauma (ACOT) at the time of ED admission. Early administration of tranexamic acid (TXA) may improve patient outcomes with ACOT. Within our system, TXA is currently available only to helicopter EMS (HEMS) units. The purpose of the current study was to determine whether there was a cohort of trauma patients transported by ground EMS (GEMS) who might benefit from out-of-hospital TXA administration.

The Applicability of Thromboelastography in Acute Ischemic Stroke: A Literature Review

Acute ischemic stroke (AIS) due to cerebral artery occlusion is often treated by thrombolytics or antithrombotic drugs. Thromboelastography (TEG) is a noninvasive test that provides a dynamic overview of the coagulation process. TEG may help guide thrombolytic and antithrombotic therapy in AIS. This article aims to highlight the potential use of TEG in AIS patients by reviewing available studies. We conducted a literature review, including PubMed and Cochrane library databases. The following keywords were used to find relevant studies: thromboelastography, TEG, acute ischemic stroke, stroke, coagulopathy, antiplatelet, and anticoagulant treatment. We identified 142 papers and after abstract review, we included 24 studies in this report. TEG identified a hypercoagulable state in AIS patients represented by short R, K, and greater α: angle in all papers included. Modification of TEG parameters induced by intravenous thrombolysis was inconsistent but prolonged lysis (increased LY30) and weaker clots (lower maximum amplitude) were most frequent. TEG detected hypo-coagulopathy induced by dual antiplatelet therapy as well as antiplatelet drug resistance, with ticagrelor and aspirin having greater inhibition of platelet activity. A prolonged R-value seems to be the most reliable TEG parameter in detecting the anticoagulant effect of factor Xa inhibitor treatment. TEG might represent a useful point-of-care test for emergency decision-making in AIS patients and a tool for individualized treatment options. This hypothesis needs validation in a large cohort of prospectively studied AIS patients.

The Role of Echocardiography in Amniotic Fluid Embolism: A Case Series and Review of the Literature

(Can J Anesth/J Can Anesth. 2021;68:1541–1548) Amniotic fluid embolism (AFE) is not completely understood and can be difficult to diagnose, as it shares characteristics with other obstetric complications. AFE occurs during labor or soon after delivery and is characterized by acute hypotension, hypoxia, and coagulopathy. The Clark diagnostic criteria for diagnosis of AFE is as follows: sudden cardiorespiratory arrest or both hypotension and respiratory compromise; disseminated intravascular coagulation; clinical onset during labor or within 30 minutes of delivery of the placenta; and absence of fever. Situations that may lead to the exchange of maternal and fetal fluid, such as cesarean delivery or cervical trauma, have been reported as risk factors. Point-of-care echocardiography has recently been used to diagnose and manage maternal shock. This report details three cases of AFE that utilized point-of-care echocardiography.

Inflammation and vascular dysfunction: The negative synergistic combination of diabetes and COVID-19.

AimsSeveral reports indicate that diabetes determines an increased mortality risk in patients with coronavirus disease 19 (COVID‐19) and a good glycaemic control appears to be associated with more favourable outcomes. Evidence also supports that COVID‐19 pneumonia only accounts for a part of COVID‐19 related deaths. This disease is indeed characterised by abnormal inflammatory response and vascular dysfunction, leading to the involvement and failure of different systems, including severe acute respiratory distress syndrome, coagulopathy, myocardial damage and renal failure. Inflammation and vascular dysfunction are also well‐known features of hyperglycemia and diabetes, making up the ground for a detrimental synergistic combination that could explain the increased mortality observed in hyperglycaemic patients.Materials and methodsIn this work, we conduct a narrative review on this intriguing connection. Together with this, we also present the clinical characteristics, outcomes, laboratory and histopathological findings related to this topic of a cohort of nearly 1000 subjects with COVID‐19 admitted to a third‐level Hospital in Milan.ResultsWe found an increased mortality in subjects with COVID‐19 and diabetes, together with an altered inflammatory profile.ConclusionsThis may support the hypothesis that diabetes and COVID‐19 meet at the crossroads of inflammation and vascular dysfunction. (ClinicalTrials.gov NCT04463849 and NCT04382794).

Acute ischemic stroke: a rare complication of hump-nosed pit viper (Hypnale spp.) bite: a case report

BackgroundHump-nosed pit viper is a medically important deadly venomous snake in Sri Lanka and is the commonest cause of venomous snakebites in the country. It frequently causes local effects and systemic manifestations such as acute kidney injury and coagulopathy that occur in less than 10% of all bites. This also includes some atypical presentations such as thrombotic microangiopathy and myocardial infarction. Currently, no antivenom is available for hump-nosed pit viper bites in Sri Lanka, and patients are managed with supportive treatment. This case illustrates an acute ischemic stroke following a hump-nosed viper bite, which is the second case in the literature.Case presentationA 71-year-old a Sinhalese male patient presented with left-sided hemiparesis with mouth deviation on day 2 of hump-nosed viper (Hypnale spp.) bite on the right foot. Non-contrast computed tomography of brain showed right ischemic stroke in internal capsule. He was given antiplatelets and statins and continued supportive treatment including limb physiotherapy and speech therapy. He recovered completely and was discharged on day 4 with clinic follow-up.ConclusionsPhysicians should be aware that ischemic cerebral infarcts may occur following hump-nosed pit viper bites.

Outcomes of Hospitalized Acute Alcoholic Hepatitis (AH) in Patients With Bipolar 1 Disorder (B1D).

Introduction: Alcoholic hepatitis (AH) is a common cause of hospital admissions and is associated with a high mortality rate. AH occurs frequently in patients with heavy alcohol use. Alcohol use disorder (AUD) commonly presents with comorbid psychiatric disorders such as bipolar disorder. Bipolar disorder patients are also known to be at an increased risk for chronic liver diseases. Bipolar 1 disorder (B1D) is often considered the most severe presentation among different types of bipolar disorder. This study assesses the clinical outcomes of patients admitted for AH with concomitant B1D.Methods: Adult patients with AH were identified within the 2014 National Inpatient Sample (NIS) database. International Classification of Diseases, Ninth Edition Revision, Clinical Modification (ICD-9 CM) codes were used to select for all of the diagnoses for this study. AH patients were subdivided into those with and without B1D. The outcomes of interest were sepsis, hepatic encephalopathy, acute respiratory failure, acute kidney injury, ischemic stroke, hepatic failure, coagulopathy, and inpatient mortality. A multivariate logistic regression analysis was performed to explore whether B1D is an independent predictor for the outcomes.Results: Among 4,453 patients with AH identified, 166 patients also had B1D. AH patients with comorbid B1D were seen to be younger (42.9 years old vs. 46.2 years old, p < 0.05) and more commonly female (55.4% vs. 36.5%, p < 0.05). The B1D subgroup of AH patients were found to less likely develop acute hepatic failure (adjusted odds ratio (aOR) 0.13, 95% confidence interval (CI): 0.02-0.97, p < 0.05). The adjusted odds ratios for the remaining outcomes were not statistically significant.Conclusions: Our study indicates that B1D may be an independent protective factor against acute hepatic failure in patients hospitalized with AH. This finding can be explained by frequent laboratory monitoring and psychiatric assessments performed by psychiatrists treating B1D patients, as well as the impact B1D has on cortisol release induced by hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis.

MO314: Oliguria as a Strong Predictor of Mortality in Leptospirosis

Abstract BACKGROUND AND AIMS Leptospirosis is an endemic, globally widespread zoonotic disease caused by pathogenic spirochetes of the genus Leptospira. It presents with high clinical variability, with a constellation of symptoms ranging from a mild, nonspecific, self-limiting febrile syndrome to acute liver failure, acute kidney injury, coagulopathy and respiratory involvement. Acute kidney injury (AKI) is a common complication and generally presents as nonoliguric and hypokalemic. The aim of this study was to delineate potential predictors of mortality in Leptospirosis. METHOD We conducted a prospective, observational, single-center study in the span of 5 years, from 2010 to 2015. Patients enrolled in the study had an age at presentation &amp;gt;14 years and were hospitalized for longer than 24 h with a conclusive diagnosis of Leptospirosis. Baseline patient characteristics, including demographic, clinical and laboratory data were collected. Definitive diagnosis was established through serology assay, using the indirect-ELISA test to detect positive Leptospira IgM and IgG. Fisher's exact test was used to identify predictors of mortality during the course of the infection. RESULTS A total of 119 consecutive patients diagnosed with Leptospirosis were enrolled during a 5-year period, 92% were males. Mean age at presentation was 48.8 ± 14.9 and 41.5 ± 19.8 years for males and females, respectively. Mortality in our cohort was estimated to be 9% (10 patients). Urine output and bilirubin levels were found to be the most significant predictors of mortality. Fischer's exact test determined urine output at a cut-off value of 400 mL/24 h as the strongest predictor of mortality (P &amp;lt; 0.001) in Leptospirosis. Bilirubin levels showed an equivalent statistical significance at a cut-off value of 19 mg/dL (P &amp;lt; .001). Creatinine levels on admission, at a cut-off value of 3 mg/dL, proved to be the third strongest predictor of mortality, followed by nadir platelet count and age at a cut-off value of 70 × 103/µL and 49 years, respectively. CONCLUSION Our study defined oliguria as the most significant predictor of mortality in patients with severe Leptospirosis, closely followed by bilirubin levels on admission. Other predictors to consider include creatinine levels on admission, nadir platelet count and age at presentation. Incorporating predictors of mortality, from the outset, in treatment algorithms of Leptospirosis, will promote a more timely diagnosis and the development of more specific management guidelines, enabling clinicians to provide personalized treatment plans, potentially impacting the prognosis, morbidity and mortality rates in these patients.