First 24h Of Admission Research Articles

Effectiveness of early treatment with plasma exchange in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis.

Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are potentially fatal medical conditions that lack established treatment. Therapeutic plasma exchange (PE) is a potential treatment option; however, its effectiveness is unclear. We aimed to evaluate the effectiveness of PE in patients with SJS/TEN. A retrospective cohort study was conducted using data from the Japanese National Administrative Claims database from 2016 to 2021. The analysis included 256 patients diagnosed with SJS/TEN who were admitted to the intensive care unit, of whom 38 received PE and 218 did not. The outcomes of patients who did and did not receive PE within the first 24h of admission were compared. The risk ratios and 95% confidence intervals of the PE group compared with those of the no-PE group were as follows: in-hospital mortality, 0.983 (0.870-1.155); 30-day mortality rate, 1.057 (0.954-1.217); 50-day mortality rate, 1.023 (0.916-1.186); and length of hospital stay, 1.163 (0.762-1.365). This study does not provide evidence of a benefit of PE in reducing mortality or length of hospital stay in patients with severe SJS/TEN.

Prognostic Value of Diaphragmatic Ultrasound in Patients Admitted for COVID-19 Pneumonia

IntroductionCOVID-19 pneumonia results in an impairment of the diaphragmatic musculature that influences the development of respiratory failure during the patient's hospitalization. Diaphragmatic ultrasound is a useful, non-invasive, and accessible tool for measuring the function of this muscle. ObjectiveAssessing the morphological and functional ultrasound status of the diaphragm in patients admitted within the first 24h for COVID-related pneumonia and its association with hospital morbidity and mortality (NCT05805579). Material and methodsObservational, prospective cohort study that included 68 patients admitted for COVID-19 pneumonia with respiratory failure. Diaphragmatic ultrasound was performed within the first 24h of admission to the pulmonology ward. Clinical, analytical, and ultrasound variables were collected: excursion, thickness, and diaphragmatic shortening fraction (DSF). DSF<20% was used to define diaphragmatic dysfunction (DD). Patients who showed favorable progression and were managed on the ward (HCONV) were compared to those who required admission to the respiratory monitoring unit (RMU). ResultsA total of 68 patients were included, of which 22 (32.35%) were admitted to the RMU. Diaphragmatic excursion at maximum volume was higher in the HCONV group compared to the RMU group (58.41±17.83 vs. 50.03±16.23; p=0.123). Diaphragmatic dysfunction (DD) was observed in 21 (30.88%) patients, with a higher prevalence in the RMU group than in the HCONV group (15 (68.18%) vs. 6 (13.04%); p=0.0001). In the multivariate analysis, age and DSF at admission were the best predictors of failure to discharge. ConclusionsPerforming diaphragmatic ultrasound to assess mobility and DSF within the first 24h of admission for COVID-19 pneumonia proves valuable in determining short-term progression and the need for admission to a respiratory monitoring unit.

SCAI classification, the importance of its dynamic reclassification in the first 24 hours and the impact of risk modifiers in cardiogenic shock admissions

Abstract Introduction The Society for Cardiovascular Angiography and Interventions (SCAI) shock stage classification has been proposed as a simple, easily applied framework to stratify mortality risk across the spectrum of cardiogenic shock (CS) severity. This categorization has been recently refined (2022) to incorporate the continuum dynamic trajectory of the disease, as well as other risk modifiers. The aims of this study were: 1) to validate the SCAI classification at admission in a cohort of patients admitted to the cardiac intensive care unit (CICU) due to CS; 2) evaluate the prognostic impact of SCAI stage variation during the first 24h of admission; 3) evaluate the prognostic impact of other risk modifiers. Methods We retrospectively analyzed patients consecutively admitted to the CICU with established CS (SCAI C and above) from all causes, from January 2017 to November 2022. SCAI staging was assessed at diagnosis and after 24 hours. The primary outcome was 30-day mortality. Results A total of 208 patients (66±16 years, 67% male) were included. Overall, 53% had an acute myocardial infarction, 34% were admitted due to decompensation of chronic heart failure, and 29.1% had a cardiac arrest. The proportion of patients in SCAI stage C to E at the time of diagnosis was 69% (n=143), 25% (n=52), and 6% (n=13), respectively. 30-day mortality increased across SCAI categories (p&amp;lt;0.001 – figure 1.1). After the first 24 hours, 34 (%) of patients improved SCAI category, 113 (%) remained in the same class, and 45 (%) worsened, with a 30-day mortality of 18%, 34%, and 62%, respectively (p&amp;lt;0.001 – figure 1.2). Risk modifiers also carried prognostic significance (figure 1.3). 30-day mortality was significantly higher in patients with acute myocardial infarction vs. other etiologies (52% vs. 32%; p=0.002), acute CS vs. acute-on-chronic CS (47% vs. 33%; p=0.034), and cardiac arrest (56% vs. 37%; p=0.005). Conclusion Early changes in SCAI classification reflect the dynamic nature of CS patients while retaining significant prognostic discrimination. 24h SCAI re-staging together with risk modifiers may be valuable in readjusting therapeutic strategies aiming at shock reversal.

Decreased Heart Rate Variability in Children with Acute Decompensated Heart Failure is Associated with Poor Outcomes.

Heart rate variability (HRV) is a noninvasive indicator of the health of neurocardiac interactions of the autonomic nervous system. In adults, decreased HRV correlates with increased cardiovascular mortality. However, the relationship between HRV and outcomes in children with acute decompensated heart failure (ADHF) has not been described. Patients < 21years old hospitalized with ADHF from 2013 to 2019 were included (N = 79). Primary outcome was defined as death, heart transplant, or mechanical circulatory support (MCS). The median standard deviation of the R-to-R interval in 5-min intervals (SDNN) was calculated from telemetry data obtained across the first 24h of admission. Patients who met the primary outcome had significantly lower median SDNN (13.8 [7.8, 29.1]) compared to those who did not (24.6 [15.3, 84.4]; p = 0.004). A median SDNN of 20ms resulted in a sensitivity of 68% and specificity of 69%. Median SDNN < 20ms represented decreased freedom from primary outcome (p = 0.043) and a hazard ratio of 2.2 in multivariate analysis (p = 0.016). Pediatric patients with ADHF who died, underwent heart transplant, or required MCS had significantly decreased HRV at presentation compared to those that did not. This supports HRV as a noninvasive tool to improve prognostication in children in ADHF.

Retrospective study of the effect of vaccination against SARS-CoV-2 in seriously ill patients admitted to an intensive care unit

Background and objectiveOur study aims to compare the clinical and epidemiological characteristics, length of stay in the ICU, and mortality rates of COVID-19 patients admitted to the ICU who are fully vaccinated, partially vaccinated, or unvaccinated. Patients and methodsRetrospective cohort study (March 2020–March 2022). Patients were classified into unvaccinated, fully vaccinated, and partially vaccinated groups. We initially performed a descriptive analysis of the sample, a multivariable survival analysis adjusting for a Cox regression model, and a 90-day survival analysis using the Kaplan-Meier method for the death time variable. ResultsA total of 894 patients were analyzed: 179 with full vaccination, 32 with incomplete vaccination, and 683 were unvaccinated. Vaccinated patients had a lower incidence (10% vs. 21% and 18%) of severe ARDS. The survival curve did not show any differences in the probability of surviving for 90 days among the studied groups (P=.898). In the Cox regression analysis, only the need for mechanical ventilation during admission and the value of LDH (per unit of measurement) in the first 24h of admission were significantly associated with mortality at 90 days (HR: 5.78; 95% CI: 1.36–24.48); P=.01 and HR: 1.01; 95% CI: 1.00–1.02; P=.03, respectively. ConclusionsPatients with severe SARS-CoV-2 disease who are vaccinated against COVID-19 have a lower incidence of severe ARDS and mechanical ventilation than unvaccinated patients.

Early Expected Discharge Date Accuracy During Hospitalization: A Multivariable Analysis.

Accurate estimation of an expected discharge date (EDD) early during hospitalization impacts clinical operations and discharge planning. We conducted a retrospective study of patients discharged from six general medicine units at an academic medical center in Boston, MA from January 2017 to June 2018. We retrieved all EDD entries and patient, encounter, unit, and provider data from the electronic health record (EHR), and public weather data. We excluded patients who expired, discharged against medical advice, or lacked an EDD within the first 24h of hospitalization. We used generalized estimating equations in a multivariable logistic regression analysis to model early EDD accuracy (an accurate EDD entered within 24h of admission), adjusting for all covariates and clustering by patient. We similarly constructed a secondary multivariable model using covariates present upon admission alone. Of 3917 eligible hospitalizations, 890 (22.7%) had at least one accurate early EDD entry. Factors significantly positively associated (OR > 1) with an accurate early EDD included clinician-entered EDD, admit day and discharge day during the work week, and teaching clinical units. Factors significantly negatively associated (OR < 1) with an accurate early EDD included Elixhauser Comorbidity Index ≥ 11 and length of stay of two or more days. C-statistics for the primary and secondary multivariable models were 0.75 and 0.60, respectively. EDDs entered within the first 24h of admission were often inaccurate. While several variables from the EHR were associated with accurate early EDD entries, few would be useful for prospective prediction.

Predicting delirium in older non-intensive care unit inpatients: development and validation of the DELIrium risK Tool (DELIKT).

Effective delirium prevention could benefit from automatic risk stratification of older inpatients using routinely collected clinical data. Primary aim was to develop and validate a delirium prediction model (DELIKT) suitable for implementation in hospitals. Secondary aim was to select an anticholinergic burden scale as a predictor. We used one cohort for model development and another for validation with electronically available data collected within the first 24h of admission. Included were patients aged ≥ 65, hospitalised ≥ 48h with no stay > 24h in an intensive care unit. Predictors, such as administrative and laboratory variables or an anticholinergic burden scale, were selected using a combination of feature selection filter method and forward/backward selection. The final model was based on logistic regression and the DELIKT was derived from the β-coefficients. We report the following performance measures: area under the curve, sensitivity, specificity and odds ratio. Both cohorts were similar and included over 10,000 patients each (mean age 77.6 ± 7.6years) with 11% experiencing delirium. The model included nine variables: age, medical department, dementia, hemi-/paraplegia, catheterisation, potassium, creatinine, polypharmacy and the anticholinergic burden measured with the Clinician-rated Anticholinergic Scale (CrAS). The external validation yielded an AUC of 0.795. With a cut-off at 20 points in the DELIKT, we received a sensitivity of 79.7%, specificity of 62.3% and an odds ratio of 5.9 (95% CI 5.2,6.7). The DELIKT is a potentially automatic tool with predictors from standard care including the CrAS to identify patients at high risk for delirium.

Risk factors, clinical characteristics and prognostic value of acute kidney injury in COVID-19 compared with influenza virus and respiratory syncytial virus.

Acute Kidney Injury (AKI) complicates a substantial part of patients withCOVID-19. Direct viral penetration of renal cells through the Angiotensin Converting Enzyme 2 receptor, and indirect damage by the aberrant inflammatory response characteristic of COVID-19 are likely mechanisms. Nevertheless, other common respiratory viruses such as Influenza and Respiratory Syncytial Virus (RSV) are also associated with AKI. We retrospectively compared the incidence, risk factors and outcomes of AKI among patients who were admitted to a tertiary hospital because of infection withCOVID-19, influenza (A + B) or RSV. We collected data of 2593 patients hospitalized withCOVID-19, 2041patients with influenza and 429 withRSV. Patients affected byRSV were older, had more comorbidities and presented with higher rates of AKI at admission and within 7 days (11.7% vs. 13.3% vs. 18% for COVID-19, influenza and RSV, respectively p = 0.001). Nevertheless, patients hospitalized withCOVID-19 had higher mortality (18% with COVID-19vs. 8.6% and 13.5% forinfluenza and RSV, respectively P < 0.001) and higher need ofmechanical ventilation (12.4% vs. 6.5% vs.8.2% for COVID-19, influenza and RSV, respectively, P = 0.002). High ferritin levels and low oxygen saturation were independent risk factors for severe AKI only in the COVID-19 group. AKI in the first 48h of admission and in the first 7 days of hospitalization were strong independent risk factors for adverse outcome in all groups. Despite many reports of direct kidney injury by SARS-COV-2, AKI was less in patients with COVID-19 compared to influenza and RSV patients. AKI was a prognostic marker for adverse outcome across all viruses.

Impact of hospital characteristics on best-practice adherence for gallstone pancreatitis: a nationwide analysis.

Current guidelines recommend cholecystectomy during the index admission for gallstone pancreatitis, and a growing body of evidence indicates that patients benefit from cholecystectomy within the first 48h of admission. We examined the impact of hospital characteristics on adherence to these data-driven practices. We queried the National Inpatient Sample for patients admitted for gallstone pancreatitis between October 2015 and December 2018. Patients who underwent same-admission cholecystectomy were identified by procedure codes. Cholecystectomies within the first two days were classified as early cholecystectomies. Multivariable logistic regression was used to determine the association between hospital characteristics and adherence to these practices. Of 163,390 admissions for gallstone pancreatitis, only 90,790 (55.6%) underwent cholecystectomy before discharge. Mean time from admission to cholecystectomy was 2.9days; 27.0% of patients (44,005) underwent early cholecystectomy. Odds of same-admission cholecystectomy were highest in large hospitals (OR 1.21, 95% CI 1.13-1.28), urban teaching centers (OR 1.33, 95% CI 1.21-1.46), and the South (OR 1.70, 95% CI 1.57-1.83). Odds of early cholecystectomy did not vary with hospital size, urban-rural status, or teaching status but were highest in the West (OR 1.98, 95% CI 1.80-2.18). Best-practice adherence for cholecystectomy in gallstone pancreatitis remains low despite an abundance of evidence and clinical practice guidelines. Active interventions are needed to improve delivery of surgical care for this patient population. Implementation efforts should focus on small hospitals, rural areas, and health systems in the Northeast region.

Impact of Aspergillus spp. isolation in the first 24 hours of admission in critically ill patients with severe influenza virus pneumonia

ObjectiveTo determine the incidence and impact of Aspergillus spp. isolation (AI) on ICU mortality in critically ill patients with severe influenza pneumonia during the first 24h of admission. DesignSecondary analysis of an observational and prospective cohort study. SettingICUs voluntary participating in the Spanish severe Influenza pneumonia registry, between June 2009 and June 2019. PatientsConsecutive patients admitted to the ICU with diagnosis of severe influenza pneumonia, confirmed by real-time polymerase chain reaction. InterventionsNone. Main variables of interestIncidence of AI in respiratory samples. Demographic variables, comorbidities, need for mechanical ventilation and the presence of shock according at admission. Acute Physiology and Chronic Health Evaluation II (APACHE II) scale calculated on ICU admission. Results3702 patients were analyzed in this study. AI incidence was 1.13% (n=42). Hematological malignancies (OR 4.39, 95% CI 1.92–10.04); HIV (OR 3.83, 95% CI 1.08–13.63), and other immunosuppression situations (OR 4.87, 95% CI 1.99–11.87) were factors independently associated with the presence of Aspergillus spp. The automatic CHAID decision tree showed that hematologic disease with an incidence of 3.3% was the most closely AI related variable. Hematological disease (OR 2.62 95% CI 1.95–3.51), immunosuppression (OR 2.05 95% CI 1.46–2.88) and AI (OR 3.24, 95% CI 1.60–6.53) were variables independently associated with ICU mortality. ConclusionsEmpirical antifungal treatment in our population may only be justified in immunocompromised patients. In moderate-high risk cases, active search for Aspergillus spp. should be implemented.

Effect of Race-Ethnicity and CT Angiography on Renal Injury During Blood Pressure Treatment for Intracerebral Hemorrhage.

Lowering blood pressure intensively in acute intracerebral hemorrhage (ICH) is associated with adverse renal events; Blacks and Hispanics have a higher incidence of ICH and kidney disease than Whites. In addition, CT angiography (CTA), which may also be associated with acute kidney injury (AKI), is often done in acute ICH. Our objective was to investigate the relationship between aggressive BP management, CTA, race-ethnicity and the risk of developing AKI in patients presenting with ICH. We retrospectively calculated the difference between the highest and lowest systolic blood pressure during the first 24h of admission in patients with spontaneous ICH over 30months. Creatinine (Cr) levels at admission were compared to the highest Cr level during the first 7days after admission. AKI was defined as any > 50% increase of baseline Cr during the first 7days. Logistic regression models were used to assess the association between race-ethnicity and CTA and AKI. We also analyzed the incidence of AKI stratified by race-ethnicity. A total of 394 patients were included (mean age ± SD 63 ± 14years), 160 patients (41%) were women, 162 (41%) Hispanic, 39 (10%) White and 189 (48%) Black. Most of the patients underwent CTA (73%). The prevalence of AKI was (18%), but no difference was found in AKI incidence (19% in Blacks vs. 17% in Whites vs. 18% in Hispanics (p = 0.940). In fully adjusted models, AKI was not associated with race-ethnicity (p = 0.665) or CTA (p = 0.187). The stratified analysis by race-ethnicity did not change our findings. We found no association between race-ethnicity or CTA and AKI during the acute management of ICH in a real-life stroke population. Our findings suggest that CTA can be safely obtained in acute ICH, even in populations of diverse race-ethnicity who may be more prone to adverse kidney events. CTA did not contribute to developing AKI.

Liver injury in Northern American patients with COVID-19

Presenter: Aleksandr Kalabin MD ;Columbia University at Harlem Hospital Background: Direct viral damage of organs/systems with subsequent inflammatory cascade is considered to be a major contributor to the pathogenesis of SARS-CoV-2 infection. Although lung is contemplated to be the primary organ targeted by the virus, recent reports predominantly from China and Europe provided evidence of affinity of COVID-19 to Angiotensin-converting enzyme 2(ACE 2) receptors expressed on gastrointestinal tract and liver parenchymal cells. The goal of our study was to investigate if SARS-CoV-2 virus affects liver function of Northern American population and if liver injury correlates with the disease severity in COVID-19 patients. Methods: Retrospective analysis of patients admitted with SARS-CoV-2 infection between March – April 2020 and liver function tests done within first 24h of admission. The primary outcome of interest was to determine if liver function is affected by COVOD-19 and assess the correlation with the disease severity. Patients were grouped into Non-intubated(NI-T) vs Intubated(I-T) patients and Survived(S) vs Deceased(D). Patients defined as survived were alive at the time of data accrual. Unpaired Student’s t-test was used for continues variables, Pearson Chi-square(χ2) test for categorical. P value < 0.05 was considered to represent statistically significant difference. Results: 183 patients were included, 73 Females(39.89%) and 110 males(60.11%). 114(62.30%) patients were African-Americans, 58(31.69%) Hispanics and 11 Asians(6.01%). Mean age was 64.77(SD 14.09), mean BMI 29.03(SD 7.36), mean body temperature 100.89(SD 1.68). 93 patients(50.82%) had GI complaints on presentation: most common symptoms were anorexia(54 patients, 29.51%), diarrhea(more than 3 loose stools per day, 41 patients, 22.40%), nausea/vomiting(33 patients, 18.03%) and abdominal pain(18 patients, 9.84%). Evaluation of LFTs on admission revealed mean aspartate aminotransferase(AST) of 63.83(SD 115.87), mean alanine transaminase(ALT) – 47.08(SD 85.64). Total bilirubin for the cohort was 0.64(SD 0.51), mean albumin 3.60(SD 0.52), mean Prothrombin time(PT) 14.38(SD 3.46), mean platelet count 220.94(83.59). Intubated patients tended to have significantly higher levels of AST(109.17 vs 53.97, P = 0.018), ALT(79.53 vs 40.03, P = 0.02) and total bilirubin(0.82 vs 0.60, P = 0.03) compared to non-intubated patents. This correlated with body temperature that was higher(101.38) for Intubated vs Non-intubated patients(100.70) (p = 0.0006), and acute phase reactants CRP(24.06 v 15.96, P = 0.019) and lactate(3.28 vs 2.13, P = 0.009). No difference between groups was observed for PT, platelets and albumin. Mean AST for Survived patients was 66.40 vs 50.41 for Deceased group(P = 0.51), mean ALT 48.89 vs 37.63(P = 0.53) and mean bilirubin 0.65 vs 0.60(P = 0.65) respectively. No difference between groups was observed for PT, platelets and albumin. CRP and lactate were higher in Deceased group compared to the Survived group:(27.09 vs 16.39, P = 0.008) and (3.33 vs 2.10 P = 0.005) respectively. Conclusion: Our study suggests direct viral injury to the liver parenchymal and biliary cells in Northern American patients with COVID-19 infection. Moreover, patients with elevated liver enzymes tended to have severe disease course, but no correlation with mortality was observed. Interestingly enough liver synthetic function of patients with SARS-CoV-2 infection was not significantly affected. While exact mechanisms of direct damage to the liver currently remain unclear and other explanations of elevated liver enzymes have been offered, more studies are needed to prove unambiguous interrelation between liver dysfunction and SARS-CoV-2 virus. [Formula presented]

Prognostic Value of Troponin-T and B-Type Natriuretic Peptide in Patients Hospitalized for COVID-19.

ResumoFundamento:A COVID-19 causa grave acometimento pulmonar, porém o sistema cardiovascular também pode ser afetado por miocardite, insuficiência cardíaca e choque. A elevação de biomarcadores cardíacos tem sido associada a um pior prognóstico.Objetivos:Avaliar o valor prognóstico da Troponina T (TnT) e do peptídeo natriurético tipo B (BNP) em pacientes internados por Covid-19.Métodos:Amostra de conveniência de pacientes hospitalizados por COVID-19. Foram coletados dados dos prontuários com o objetivo de avaliar a relação da TnT e o BNP medidos nas primeiras 24h de admissão com o desfecho combinado (DC) óbito ou necessidade de ventilação mecânica. Análise univariada comparou os grupos com e sem DC. Modelo multivariado de Cox foi utilizada para determinar preditores independentes do DC.Resultados:Avaliamos 183 pacientes (idade=66,8±17 anos, sendo 65,6% do sexo masculino). Tempo de acompanhamento foi de 7 dias (1 a 39 dias). O DC ocorreu em 24% dos pacientes. As medianas de TnT e BNP foram 0,011 e 0,041 ng/dl (p<0,001); 64 e 198 pg/dl (p<0,001) respectivamente para os grupos sem e com DC. Na análise univariada, além de TnT e BNP, idade, presença de doença coronariana, saturação de oxigênio, linfócitos, dímero-D, proteína C reativa titulada (PCR-t) e creatinina, foram diferentes entre os grupos com e sem desfechos. Na análise multivariada boostraped apenas TnT (1,12[IC95%1,03-1,47]) e PCR-t (1,04[IC95%1,00-1,10]) foram preditores independentes do DC.Conclusão:Nas primeiras 24h de admissão, TnT, mas não o BNP, foi marcador independente de mortalidade ou necessidade de ventilação mecânica invasiva. Este dado reforça ainda mais a importância clínica do acometimento cardíaco da COVID-19. (AArq Bras Cardiol. 2020; 115(4):660-666)

Effect of early hyperoxemia on the outcome in servere blunt chest trauma: A propensity score-based analysis of a single-center retrospective cohort.

Our study aimed to explore the association between early hyperoxemia of the first 24h on outcomes in patients with severe blunt chest trauma. In a level I trauma center, we conducted a retrospective study of 426 consecutive patients. Hyperoxemic groups were classified in severe (average PaO2≥200mmHg), moderate (≥150 and<200mmHg) or mild (≥ 100 and<200mmHg) and compared to control group (≥60 and<100mmHg) using a propensity score based analysis. The first endpoint was the incidence of a composite outcome including death and hospital-acquired pneumonia occurring from admission to day 28. The secondary endpoints were the incidence of death, the number of hospital-acquired pneumonia, mechanical ventilation-free days and intensive care unit-free day at day 28. The incidence of the composite endpoint was lower in the severe hyperoxemia group(OR, 0.25; 95%CI, 0.09-0.73; P<0.001) compared with control. The 28-day mortality incidence was lower in severe (OR, 0.23; 95%CI, 0.08-0.68; P<0.001) hyperoxemia group (OR, 0.41; 95%CI, 0.17-0.97; P=0.04). Significant association was found between hyperoxemia and secondary outcomes. In our cohort early hyperoxemia during the first 24h of admission after severe blunt chest trauma was not associated with worse outcome.

Comparison of scoring systems used in acute pancreatitis for predicting major adverse events

ObjectivesTimely identification of patients with acute pancreatitis who are likely to have a severe disease course is critical. Based on that, many scoring systems have been developed throughout the years. Although many of them are currently in use, none of them has been proven to be ideal. In this study, we aimed to compare the discriminatory power of relatively newer risk scores with the historical ones for predicting in-hospital major adverse events, 30-day mortality and 30-day readmission rate. Patients and methodsPatients who had been admitted due to acute pancreatitis were retrospectively investigated. Five risk scoring systems including HAPS, Ranson, BISAP, Glasgow, and JSS were calculated using the data of the first 24h of admission. Predictive accuracy of each scoring system was calculated using the area under the receiver-operating curve method. ResultsOverall 690 patients were included in the study. In-hospital major adverse events were observed in 139 (20.1%) patients of whom, 19 (2.5%) died during hospitalization. 30-day all-cause mortality and 30-day readmission were observed in 22 (3.2%) and 27 (3.9%) patients respectively. Negative predictive value of each score was markedly higher compared to positive predictive values. Among all, JSS scoring system showed the highest AUC values across all end-points (0.80 for in-hospital major adverse events; 0.94 for in-hospital mortality; 0.91 for 30-day mortality). However, all five scoring systems failed to predict 30-day readmission. DiscussionJSS was the best classifier among all five risk scoring systems particularly owing to its high sensitivity and negative predictive value.

Ventajas de la guardia de cardiología en un hospital secundario en el tratamiento de los pacientes con síndrome coronario agudo

Introduction and objectivesHospital care by a cardiologist has been shown to improve the prognosis of patients admitted with acute coronary syndrome (ACS), although on-call cardiologists are not common in second-level hospitals. MethodsRetrospective analysis of a cohort of patients admitted due to ACS using propensity-score matching to assess differences between both periods. ResultsThe study included 2257 patients, of which 33.2% were admitted during the cardiologist on-call period, with 734 pairs of patients being obtained using propensity score-matching. A shorter hospital stay was observed in patients admitted during the cardiologist on-call period (5.2 vs 6.3 days; P<.01) and this was one of the variables independently associated with the shorter hospital stay variable. Within the cardiologist on-call period there was a shorter stay in the intensive care unit (47.7% vs 54.5%; P=.03), mainly by the non-ST-elevation ACS patients (33.2% vs 19.1%; P<.01), and in weekdays. There were also higher rates of angiography and revascularisation within the first 24h of admission (76.2% vs 66.0%; P<.01). There were no differences in-hospital mortality or within the first 12 months after discharge between both periods. ConclusionsImplementation of on-call cardiology shortened the time to revascularization and hospital stay, as well as reducing the length of intensive care unit stay. These results support the usefulness of an on-call cardiologist in non-tertiary hospitals, at least for the benefit of ACS patients.

Inflammatory biomarkers as pronostic factors of mortality in critical ILL oncology patients at ICU.

e14535 Background: Inflammatory markers have been used as prognostic factors in multiple malignancies.In cancer patients, critically ill, the utility of these have limited data.The aim of our study is to determine whether neutrophil lymphocyte ratio (NLR) or lymphocyte platelet ratio(PLR) are prognostic factors for mortality in critically ill patients. Methods: We retrospectively analyzed data of 79 patients with solid tumors admitted to ICU at Sanna-Aliada Clinic between January 2018 to December 2018. Inflammatory markers results were obtained from laboratory tests performed during the first 24h of admission to ICU. Receiving operating characteristic (ROC) curves were constructed and the sensitivity, specificity, predictive values and probability indicators for the NLR and PLR. Results: A total of 79 patients were assessed, 39 women and 40 men. The average age was 60.28 years, median of 61 ( 18 to 91). 51.9% had metastatic disease. The most frequent places were lung 12 (15.2 %) and brain 9 (11,4%) . The main cause for admission to ICU was infectious disease (40.5%). The analysis of normality (Kolmogorov-Smirnov test) indicates that the variables age, hemoglobin, leukocytes, platelets, neutrophils, lymphocytes, have a normal deviation while the other variables: lactate, PCR, neutrophil to lymphocyte ratio (NLR) , Platelet to lymphocyte ratio (PLR) are not distributed normally. Regarding mortality, 44 patients were alive at 30 days (66.7%), and 30 (45.5%) were alive at 90 days. The average stay in the ICU was 8.43 days, with a median of 6, (SD 7.17, 1 to 40 days), 22.8% died in the ICU. The evaluation of PLR and NLR as a mortality marker is significant for the group of patients admitted to the ICU due to a noninfectious pathology, generating an area under the curve (AUC) of 0.706 for NLR (95% CI, 0.535 - 0.876, p-value = 0.035) and 0.767 for PLR (95% CI, 0.615-0.918; p-value = 0.006); the optimal cut point by Youden’s index for NLR was 8.29 and 267.94 for PLR (Sensitivity: 76%, Specificity: 67%). In contrast, the group with infectious pathology, the AUC was 0.47 for NLR (p = 0.78) and 0.42 for PLR (p = 0.44). The relationship of the biomarkers with stay in ICU was also evaluated, finding a statistically significant association with the lactate value (p = 0.024, Kruskal-Wallis) Conclusions: Inflammatory markers are useful as predictive markers of mortality in critically ill patients due to non-infectious causes. The lactate value serves as a predictive factor of stay in the ICU for all the patients. We suggest carrying out prospective studies to confirm the validity of our findings.

Procalcitonin as an excellent differential marker between uncomplicated and complicated acute appendicitis in adult patients.

The aim of this study was to assay the variation of procalcitonin (PCT) in adult patients with uncomplicated and complicated acute appendicitis. In total, 336 patients who underwent appendectomy from January 2016 to December 2017 were enrolled. Levels of inflammatory markers, the highest body temperature within the first 24h of admission (BTm) and the duration of operation were recorded. All appendectomy specimens were sent for histopathological examination. According to the histopathological results, 336 patients who underwent appendectomy were divided into uncomplicated acute appendicitis (UAA) group (246 cases) and complicated acute appendicitis (CAA) group (90 cases) for further analysis. The relationships of procalcitonin (PCT) and related indicators with UAA and CAA were evaluated by receiver operating characteristic (ROC) and binary logistic regression analysis. Age, the levels of PCT, and CRP were significantly higher in CAA group (P < 0.05). Spearman correlation analysis showed that PCT was positively correlated with age (r = 0.452, P < 0.01) and CRP (r = 0.715, P < 0.01). The area under the curve (AUC) of PCT, CRP and age were 0.987, 0.902, and 0.748, respectively. ROC analysis showed when PCT > 0.42ng/ml, it maximized the sensitivity and specificity. Logistic regression analysis indicated that PCT remained an independent risk factor for diagnosing CAA after adjusting with age and CRP (P < 0.05). Serum PCT levels increased significantly in patients with CAA. PCT could provide convenient evaluation method for the optimal treatment of acute appendicitis.

Long-term prognostic value of functional status and delirium in emergency patients with decompensated heart failure.

Heart failure (HF) is prevalent in older adults and is associated with impaired physical and cognitive function. However, these factors are rarely included in studies about long-term prognosis of HF. The aim of the study was to determine whether functional status and delirium at admission (prevalent delirium) would predict 1-year mortality in patients with decompensated HF (DHF). We performed a prospective observational study in adult patients with DHF attended at two Spanish Emergency Departments (ED) in the context of the Epidemiology Acute HF Emergency project. Functional status was assessed by Barthel Index (BI) and prevalent delirium by the Brief Confusion Assessment Method within the first 24h of admission. We used Kaplan-Meier survival curves for delirium and multivariable Cox regression models to estimated hazard ratio (HR) and survival probability for death while adjusting for six potential confounders. We enrolled 239 patients (age 81.7 ± 9.4years, women 61.1%). BI < 60 was 23.4 and 14.6% of patients had delirium. Age (HR 1.046 CI 95% 1.014-1.080, p < 0.004) and BI (HR 0.979 CI 95% 0.972-0.979, p < 0.001) were independently associated with 1-year mortality. In patients without severe functional dependence at admission, delirium (HR 3.579 CI 95% 1.730-7.403, p < 0.001) and age (HR 1.051 CI 95% 1.014-1.090, p = 0.007) independently predicted long-term mortality. Age and functional dependence are strong predictors of long-term mortality in patients with DHF. In patients without severe functional dependence, delirium-a potentially modifiable risk factor-identified a subgroup of patients with higher mortality. Evaluating functional status and delirium in ED could improve decision-making and future care of patients with DHF.

Incidence and evolution of sepsis-induced cardiomyopathy in a cohort of patients with sepsis and septic shock

ObjectiveThe aim of this study was to establish the incidence of septic cardiomyopathy (SM) in patients with sepsis and septic shock, to describe its characteristics and testing its evolution. DesignProspective cohort study. ParticipantsWe included 57 consecutive patients admitted to Intensive Care Unit, who met criteria of sepsis and septic shock. Principal variables of interestClinical and biochemical variables were analyzed. An echocardiogram was performed in the first 24h of admission, determining myocardial function parameters, and if the patients had left ventricular ejection fraction (LVEF) <50%) a second echocardiogram was performed. AmbitIntensive medical and surgical Care Service for Adults in University Hospital. ResultsThe mean age of the patients was 62.1±16.3 years. 58% were males. 22.8% had left ventricular dysfunction. The mean LVEF in patients with MS was lower than those without SM (34.1±10.6 vs 60.7±6.94%, P<.001), with complete recovery, in survivors, after the acute event (LVEF at discharge 56.1±6.3%, P=.04). Patients with SM had higher levels of procalcitonin (47.1±35.4 vs 18.9±24.5; P=.02) and higher score on the Sequential Organ Failure Assessment (SOFA score) (9.91±3.82 vs 7.47±3.41; P=.037). Mortality was not significantly different between both groups [4 (30.8%) vs 4 (9.1%); P=.07]. ConclusionsSM is not uncommon and is related to a higher scores on the severity scales. In the survivors, LVEF normalized after the recovery of the acute event.