First Week Of Admission Research Articles

One‐year mortality in NSTEMI patients is unaffected by timing of PCI within the first week of admission: Results of a real‐world cohort analysis

We aimed to explore the impact of time to percutaneous coronary intervention (PCI) (T2P) on 1-year mortality in non-ST-elevation myocardial infarction (NSTEMI) patients. The current guidelines recommend an early invasive strategy for NSTEMI patients. However, impact of an early invasive strategy on mortality is a matter of debate. For that reason, real world data are of great value to determine the optimal treatment window. This retrospective single center cohort study was performed in a high-volume PCI center in Amsterdam, The Netherlands. Intermediate- and high-risk NSTEMI patients undergoing PCI were included. The main discriminant was timing of PCI after admission (T2P), stratified according to different time windows (<24 h, 24-72 h, 72 h-7 days or >7 days). We analyzed 1-year mortality and the time distribution of overall survival. In total, 848 patients treated between January 1, 2016 and January 1, 2018 were included in the analysis. T2P was <24 h in 145 patients, 24-72 h in 192 patients, 72 h-7 days in 275 patients, and >7 days in 236 patients. The mean GRACE-risk score was 127.1 (SD 28.7), 130.0 (33.1), 133.8 (32.1), and 148.7 (34.6) respectively, p=<0.001. After adjusting for confounders, 1-year mortality in patients with T2P <24 h did not significantly differ when compared with T2P 24-72 h (OR=1.08; 95% CI=0.33-3.51) and T2P 72 h-7 days (OR 1.72; 95% CI=0.57-5.21) but was significantly higher in T2P >7 days (OR=3.20; 95% CI=1.06-9.68). In an unselected cohort of patients with NSTEMI, treatment by PCI <24 h did not lead to improved survival as compared to aT2P <7 days strategy. Delay in PCI >7 days after admission resulted in worse outcome.

Effects of parenteral nutrition and hydration on survival in advanced cancer patients with malignant bowel obstruction: secondary analysis of a multicenter prospective cohort study.

The benefits of parenteral nutrition and hydration (PNH) in patients with advanced cancer remain unknown. Therefore, we conducted a prospective multicenter cohort study to assess the effects of PNH on survival in patients with malignant bowel obstruction (MBO). The present study was a secondary analysis. Data on primary nutritional administration routes during the first week of admission to palliative care units, i.e., parenteral nutrition and parenteral hydration, were obtained. Data on the averaged calorie sufficiency rate/total calorie intake (75% ≤ or 750kcal/day ≤ , 50-75% or 500-750kcal/day, 25-50% or 250-500kcal/day, and < 25% or < 250kcal/day) were also obtained. Participants with MBO were included and divided into two groups: PNH-high (25% ≤ or 250kcal/day ≤) and PNH-low (< 25% or < 250kcal/day). We performed time-to-event analyses using the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression analyses. Patients were divided into the PNH-high (n = 68) and PNH-low (n = 76) groups. A significant difference was observed in survival rates between the two groups (log-rank P < 0.001). Median survival times were 35.5 (95% CI 27-44) and 17.5 (95% CI 13-21) days, respectively. In the multivariate-adjusted model, a significantly lower risk of mortality was observed in Cox's proportional hazard model in the PNH-high group (HR 0.55 (95% CI 0.36-0.83), P = 0.005) than in the PNH-low group. The present results indicated the beneficial effects of PNH for prolonging survival in advanced cancer patients with MBO in palliative care units.

Computed tomography features predictive of intra-abdominal hypertension in acute necrotizing pancreatitis: A prospective study.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in acute pancreatitis (AP) are associated with development and worsening of organ failures and poor prognosis. Limited studies suggest that contrast-enhanced computed tomography(CECT) can predict the presence of IAH/ACS.We aimedto study clinical profile of patients with AP and IAH and identify predictive factors of IAH on CECT abdomen. Consecutive patients admitted with moderately severe and severe acute pancreatitis (SAP) were recruited. Clinical and radiological data were recorded prospectively. Intra-abdominal pressure was measured via a urinary catheter to document the presence of IAH/ACS. CECT abdomen was done within the first week of admission and various features that may predict the presence of IAH were studied. Thirty-seven patients (24 SAP) (mean age: 39.78 ± 13.43years and 67.6% males) with APwere studied. The most common etiology was alcohol (37.7%). IAH developed in 54.05% of patients; patients with IAH had significantly higher bedside index of severity in AP (BISAP), Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) score, persistent acute lung injury (ALI), persistent acute kidney injury (AKI), persistent cardiovascular failure (CVSF), intensive care unit (ICU) stay, and mortality. Among the CT predictors, patients with IAH more commonly had moderate-gross ascites (60% vs. 23.5%, p-value - 0.026), a pancreatic necrosis of > 50% (50% vs. 17.6%, p-value - 0.04), and a round belly sign (RBS) (50% vs. 5.9%, p-value 0.03). On multivariate analysis, only RBS was predictive of IAH (odds ratio 12.6, 95% confidence interval 1.3-124.2, p-value 0.03). The sensitivity, specificity, positive predictive value, and negative predictive value for RBS were 50%, 94.12%, 90.9%, and 61.54%, respectively. Presence of RBS, moderate-gross ascites, and pancreatic necrosis of > 50% on CECT can predict the presence of IAH in these groups of patients.

Multiple organ failure might be an indication for prophylactic antifungal therapy in acute pancreatitis.

Significant conflicts regarding prophylactic antifungal treatment in acute pancreatitis (AP) exist among current literatures and guidelines. The key to resolving this controversial issue is to identify risk factors for intra-abdominal fungal infection (AFI) among patients with AP. A single-center, retrospective cohort of 826 patients with AP between January 2014 to December 2019 was analysed to study the risk factors of AFI. Of the 826 patients with AP, 10 patients (1.2%) developed AFI, including 2 cases in moderately severe AP (MSAP) and 8 in severe AP (SAP). The incidence of AFI was significantly higher in patients with SAP compared with MSAP and mild AP (10.3 vs. 0.8% vs. 0, P < 0.001). SAP patients with AFI were more likely to have multiple organ failure (MOF) (OR = 13.4; 95% CI 1.6-115.5), organ failure lasting more than 1 week (OR = 5.1; 95% CI 1.0-27.0), and surgical intervention within first week of admission (OR = 7.4; 95% CI 1.0-53.6). Multivariable analysis identified MOF (OR = 14.3; 95% CI 1.2-173.8) as the only independent risk factor of AFI. MOF might be the indication of prophylactic antifungal therapy in patients with AP.

Reducing the dosing frequency of selective digestive tract decontamination to three times daily provides effective decontamination of Gram-negative bacteria

This study evaluated the effectiveness of selective digestive tract decontamination (SDD) application three times daily (t.i.d.) compared to the standard four times daily (q.i.d.). Retrospective equivalence (combined non-inferiority and non-superiority design) study with a before-and-after design on a tertiary ICU in which the SDD frequency was reduced from q.i.d. to t.i.d. All patients with ICU admissions ≥72h and with ≥2 surveillance cultures collected on different dates were included in this study. We compared successful decontamination of Gram-negative bacteria (GNB). Furthermore, time to decontamination, ICU-acquired GNB bacteraemia and 28-day mortality were compared between the two groups. In total 1958 ICU admissions (1236 q.i.d., 722 t.i.d). Decontamination was achieved during the first week of admission in 77% and 76% of patients receiving SDD q.i.d and t.i.d., respectively. Successful decontamination within 14 days (without consecutive acquisition of Gram-negative bacteria) was achieved in 69.3% of the admissions with q.i.d. versus 66.8% in t.i.d. SDD (p-value = 0.2519). The proportions of successful decontamination of GNB were equivalent in both groups (−0.025, 98% CI: −0.087; 0.037). There was no significant difference in time to decontamination between the two regimens (log-rank test p-value = 0.55). Incidence (episodes/1000 days) of ICU-acquired GNB bacteraemia was 0.9 in both groups, and OR for death at day 28 in the t.i.d. group compared to the q.i.d. group was 0.99 (95% confidence interval, 0.80–1.21). This study shows that a t.i.d. application regimen achieves similar outcomes to the standard q.i.d. regime, for both microbiological and clinical outcome measures.

Outcome of management of preterm babies born below 34 weeks of gestation in a level - 3 Neonatal ICU of a teaching institution in a backward district of Kerala- A retrospective analysis

Background: Preterm birth is considered as the main cause of neonatal morbidity and mortality. This also results in major sequelae in surviving children. It is essential to establish the factors leading to pretermdelivery and the clinical profile of preterm infants. This is particularly important in a backward district where 20% of populations are tribal with poor access to health care. This study retrospectively analyses the outcome of care of preterm infants in a level 3 NICU. Objectives: I) To study the outcome of management of preterm babies below 34 weeks of gestational age at birth in a backward district of Kerala. 2) To evaluate the risk factors for mortality and permanent sequelae in these babies. Materials and Methods: This is a retrospective analysis of hospital records of preterm infants admitted in a neonatal ICU of a tertiary teaching hospital for one year from 1st of January 2017 till 31st of December 2017. Both inborn and out born infants born below 34 weeks of gestational age are included. Maternal and baby related factors are taken into account. All the infants are provided level 3 care and the details of the treatment and outcome are studied. The data are entered in Microsoft excel and analyzed. Results: Out of the 1036 babies admitted in this NICU over the year (01/01/2017 to 31/12/2017) 141 preterm babies who were born below 34 weeks of gestational age are included in this study. Lowest gestational age was 24 weeks. Lowest birth weight recorded is 364 grams. 6 infants died in the hospital and birth weight and gestational age are directly related to mortality. Conclusion: Out of 141 preterm infants, with a gestational age below 34 weeks’ gestational age at birth, admitted in the NICU, 6 (4.25%) died. Majority died in the first week of admission. Most of the children had multiple congenital anomalies and comorbid illnesses which is managed successfully in the NICU. Shortest hospital stay was 1 day and longest stay was 79 days, with

EVALUATION OF CLINICAL PROFILE AND PATTERN OF CONJUCTIVAL CONGESTION IN MILD COVID -19 PATIENTS IN DESIGNATED COVID-19 HOSPITALS.

Background: SARS-COV-2 is thought to be transmitted from person to person mainly through respiratory droplets or close contact. The most common symptoms of COVID -19 are fever, cough, slight dyspnoea, sore throat, headache and fatigue. Complications in severe cases include pneumonia, renal failure, etc. Methods: A retrospective cross-sectional study was conducted in Department of Ophthalmology GMC Jammu in collaboration with the Department of Microbiology, GMC Jammu, upon 139 mild Covid-19 positive patients, kept under isolation during the period: March 2020 to August 2020. Patients with fever, upper respiratory symptoms, or asymptomatic individuals who were confirmed positive for COVID -19 by reverse transcription-polymerase chain reaction from nasophayngeal swabs were included in the study. Results: The mean age of patients was: 37-years. 37 patients diagnosed as Covid-19 positive showed no symptom of Covid-19. 72 (51.8%) patients were surely healthy individuals without any kind of illness or co-morbidities. While only 16 patients (11.5%) reported with conjunctivitis (congestion) or a recent history thereof. Three patients had developed conjunctival congestion without Covid-19 symptoms. 8 patients had recent history before the onset of Covid-19 symptoms. Most of the patients had manifestation within the first week of admission. Conclusions: Conjunctival congestion is significant ocular manifestation among Covid-19 patients. Covid-19 related history and symptoms should therefore include such ocular examinations as well and sufficient precaution is implemented while dealing with conjunctivitis patients showing mild symptoms of Covid-19. Key words: SARS-COV-2, COVID-19, Conjunctival Congestion, Nasophayngeal Swabs

Early administration of aripiprazole long-acting injectable in acute inpatients with schizophrenia: a clinical report.

Fifty-one patients suffering an acute episode of schizophrenia and treated with aripiprazole long-acting injectable (ALAI) were chosen to elaborate an observational study in two in-patient units in Spain, in order to examine the effects of early administration during a hospital admission. When treatment with ALAI is administered in the first week of admission (in 31 patients, 60.78%), hospitalization time is significantly reduced, 12.1 days on average. It can be concluded that ALAI is an effective treatment for these patients. Analysis in economic terms and comparison with other LAI antipsychotics are interesting lines for further research.

Trajectory of Serum Bilirubin Predicts Spontaneous Recovery in a Real-World Cohort of Patients With Alcoholic Hepatitis

Alcoholic hepatitis (AH) is a severe condition with poor short-term prognosis. Specific treatment with corticosteroids slightly improves short-term survival but is associated with infection and is not used in many centers. A reliable method to identify patients who will recover spontaneously will minimise the numbers of patients who experience side effects of available treatments. We analysed the trajectory of serum bilirubin concentration over the course of hospital admissions in patients with AH to predict spontaneous survival and the need for treatment. data from 426 patients were analysed. Based on bilirubin trajectory, patients were categorized into three groups: 'fast fallers' (bilirubin <0.8 x admission value at day 7), 'static' (bilirubin of >0.9 - <1.2 x admission value) and 'rapid risers' (bilirubin of ≥1.2 x admission bilirubin). Fast fallers had significantly better 90-day survival compared to other groups (log rank p < .001), and showed no benefit of corticosteroid therapy (OR for survival at 28 days of treatment, 0.94, 95% CI 0.06 - 8.41). These findings remained even amongst patients with severe disease based on initial DF, GAHS or MELD scores. We present an intuitive method of classifying patients with AH based on the trajectory of bilirubin over the first week of admission. It is complimentary to existing scores that identify candidates for corticosteroid treatment or assess response to treatment. This method identifies a group of patients with AH who recover spontaneously and can avoid corticosteroid therapy.

Echocardiographic and Electrocardiographic Findings in COVID-19 Patients: A Cross-Sectional Study

Background: There are still many gaps in our knowledge regarding the direct cardiovascular injuries due to COVID-19 infection. In this study, we tried to find out the effect of SARS-CoV-2 infection on cardiac function in patients without any history of structural heart disease by electrocardiographic and echocardiographic evaluations. Methods: This was a cross-sectional study on patients with COVID-19 infection admitted to Imam Reza hospital, Mashhad, Iran between 14 April and 21 September 2020. COVID-19 infection was verified by a positive reverse-transcriptase polymerase chain reaction (PCR) assay for SARS-CoV-2 using nasopharyngeal/oropharyngeal samples. We enrolled all patients over 18 years old with definite diagnosis of COVID-19 infection. At admission, demographic data, comorbid conditions, physical examination, Lung CT scan and laboratory findings were recorded. All patients underwent a comprehensive transthoracic echocardiography at the first week of admission. Clinical and imaging data were collected prospectively. Findings: In total, 142 patients were enrolled in this study. The mean age of participants was 60.69± 15.70 years (range: 30-90 years). Most patients were male (82, 57.7%). The most common findings were left axis deviation (15.5%) in ECG and Right ventricle (RV) dysfunction (34.5%) in echocardiography. Multivariate analysis showed that O2 saturation at admission was independently a predictor of re-hospitalization (P<0.001). Moreover, pulmonary artery systolic pressure (PASP) (P=0.026), RV enlargement (P=0.037) and also dyslipidemia (P=0.002) were significant predictors of in-hospital mortality after adjusting the analysis for potential cofounders. RV size (P<0.001), dyslipidemia (P<0.001), ejection fraction (EF) (P<0.001), age (P=0.020), systolic blood pressure (P=0.001), O2 saturation (P=0.018) and diabetes (P=0.025) independently predicted 30-days mortality. Interpretation: Echocardiography can be used for risk assessment in patients with COVID-19, especially in those with previous history of diabetes and dyslipidemia. The infection could result in Ventricular dysfunction, even in those without previous history of structural heart disease. Funding Statement: There is no funding. Declaration of Interests: Authors declared no conflict of interest. Ethics Approval Statement: Mashhad University of Medical Sciences was the approved the study design and its ethical committee approved the study.

Long-term prognosis of non-st-segment elevation acute myocardial infarction with ischemic mitral regurgitation: Algerian cohort

Ischemic mitral regurgitation (MR) is a common complication of acute myocardial infarction and has a negative impact on prognosis. However, few studies have been carried out on MR after non-ST-segment elevation acute myocardial infarction (NSTEMI). Our objective was to investigate the incidence, clinical predictors, and long-term prognostic implications of MR in patients with NSTEMI. The prospective study included 237 consecutive patients who were discharged in functional class I or II after a first NSTEMI. Each underwent echocardiography during the first week of admission, and patients were followed up clinically for a median of 1011 days. The incidence of readmission for heart failure, unstable angina, reinfarction, death, or all combined (ie, the combined event or major adverse cardiac event [MACE]) was recorded. The patients’ mean age was 66 (13) years and 74% were male. The incidence of MR was 40% (grade I in 71 patients, grade II in 15, grade III in 6, and grade IV in 3). Age, diabetes mellitus, multivessel disease and MR (HR = 2.17; 95% confidence interval, 1.30–3.64; P = 0.003) were all independently associated with a poor long-term prognosis, in terms of MACEs. Even the milder grades of MR were associated with more events. In our milieu, MR frequently occurs after NSTEMI. Its presence together with other unfavorable factors implies a poor long-term prognosis. This is also true for milder grades of MR. Consequently, MR should be fully assessed and followed-up after NSTEMI in all patients.

Relationship between changes in the course of COVID-19 and ratio of neutrophils-to-lymphocytes and related parameters in patients with severe vs. common disease.

To assess the relationship between the neutrophil-to-lymphocyte ratio (NLR) and related parameters to the severity of coronavirus disease 2019 (COVID-19) symptoms. Clinical data from 38 COVID-19 patients who were diagnosed, treated and discharged from the Qishan Hospital in Yantai over the period from January to February 2020 were analysed. NLR and procalcitonin (PCT) were determined in the first and fourth weeks after their admission, along with the clinical characteristics and laboratory test results of these patients. Based on results as obtained on the first and fourth weeks after admission, five indices consisting of NLR, white blood cells, neutrophils, lymphocytes (LY) and monocytes (MON) were selected to generate receiver operating characteristic curves, while optimal cutoff values, sensitivities and specificities were obtained according to the Yuden index. Statistically significant differences in neutrophils, LY and the NLR were present in the severe vs. moderate COVID-19 group from the first to the fourth week of their hospitalisation. The cut-off value of NLR for predicting the severity of COVID-19 was 4.425, with a sensitivity of 0.855 and a specificity of 0.979. A statistically significant positive correlation was present between PCT and NLR in the severe group as determined within the first week of admission. NLR can serve as a predictor of COVID-19 disease severity as patients' progress from the first to the fourth week of their hospitalisation. The statistically significant positive correlation between levels of NLR and PCT in severe patients indicated that increases in NLR were accompanied with gradual increases in PCT.

Diaphragmatic atrophy and dysfunction in critically ill mechanically ventilated children.

The extent of diaphragmatic atrophy and dysfunction in critically ill children from developing countries is not established. To estimate changes in ultrasound measurements of diaphragmatic thickness over the first week of mechanical ventilation. To assess magnitude and risk factors of diaphragmatic atrophy. In an observational cohort study, children aged 1-18 years, requiring mechanical ventilation were included. Ultrasound measurements of diaphragmatic thickness at end-expiration (DTe) and end-inspiration (DTi), and diaphragmatic thickening fraction (DTF) were performed daily during the first week of admission, and pre- and post-extubation. Diaphragmatic atrophy (%) and atrophy rate (rate of decline in DTe, % per day) were calculated. Of 55 children (74.6% boys) enrolled, 20 (36.4%) died. Of 35 children with planned extubation, 5 (14.3%) required reintubation. Baseline median (interquartile range [IQR]) DTe, DTi, and DTF were 1.27 mm (1, 1.6), 1.76 mm (1.35, 2.10),and 33.75% (26.90, 44.60), respectively. There was a significant reduction in DTe over the first week of mechanical ventilation (p < .001), median (IQR) diaphragmatic atrophy and atrophy rate of 9.91% (5.26, 17.35) and 2.01% (1.08, 3.04)per day, respectively. Diaphragmatic atrophy rate was lower in pressure targeted ventilation (n = 44; 1.79%[1.03, 2.87])than volume targeted ventilation (n = 11; 3.10% [1.31, 5.49]), p = .038. There was no difference in diaphragmatic parameters (atrophy rate, and peri-extubation DTe and DTF) in extubation success versus failure. The diaphragm undergoes progressive atrophy during the first week of mechanical ventilation in critically ill children. Future studies should evaluate ventilation strategies to reduce the diaphragmatic atrophy.

Diagnosis and treatment of an elderly patient with 2019-nCoV pneumonia and acute exacerbation of chronic obstructive pulmonary disease in Gansu Province: A case report

BACKGROUNDIn December 2019, the first patient with 2019-novel coronavirus (2019-nCoV) was reported in Wuhan, China, and the disease spread rapidly across the country and surrounding countries within 2 mo. As of February 29, 2020, a total of 91 confirmed cases had been reported in Gansu Province. This case report of the diagnosis and treatment of an elderly patient with 2019-nCoV pneumonia complicated by acute exacerbation of chronic obstructive pulmonary disease in Gansu Province aims to provide a better reference for the treatment of patients in the future.CASE SUMMARYThe patient, a 94-year-old female, lived in Maiji District of Tianshui, Gansu Province, China. On January 30, 2020, she was admitted to the Fourth People’s Hospital of Tianshui after 9 d of close contact with a patient with 2019-nCoV pneumonia. She was subsequently admitted to Gansu Provincial Hospital of Traditional Chinese Medicine for isolation and transferred to Tianshui Gansu Provincial Hospital of Infectious Diseases on February 3, 2020 for treatment. Upon initial examination, her body temperature was 36.7 °C , pulse was 80, breathing was 20, and blood pressure was 130/80 mmHg. She was conscious with normal development and normal nutrition. The pharynx was not red, and bilateral tonsils were not red and swollen. The lungs sounded slightly coarse with no dry or wet rales. The first symptoms were cough and fatigue on 2 February. The patient was hospitalized for 12 d. After active treatment, she was discharged on February 14 with a good prognosis.CONCLUSIONA history of exposure to the affected area or patient is a major cause of 2019-nCoV infection, and population clustering is a high risk factor for transmission. Patients may not necessarily have respiratory system symptoms as the only clinical manifestation but may also have concomitant or first onset digestive symptoms. Attention should be paid to the prevention and treatment of multiple organ dysfunction syndrome. Nucleic acid testing is extremely important and needs to be repeated several times. Laboratory and auxiliary examination indicators during the first week of admission are extremely important. It is feasible to carry out dynamic and continuous index monitoring, which can predict and guide the prevention and treatment of multiple organ dysfunction and the prognosis of the disease.

High suicide rates during psychiatric inpatient stay and shortly after discharge

Over recent decades, intense efforts to address suicides in psychiatric admitted people have been initiated. The aim was to calculate suicide rates, rate ratios, population attributable risks (PAR) and trends among people admitted to or recently discharged from psychiatric wards. Using a cohort design, we obtained nationwide register data on 6292932 individuals aged 15+ living in Denmark during 1995-2016. Of these, 178703 (5.73%) males and 201033 females (6.33%) had been admitted to psychiatric hospital. Incidence rate ratios (IRR) were obtained using Poisson regression analyses while adjusting for age and calendar period. Trends were assessed using joinpoint analyses. In total, 15075 persons died by suicide, of which 6174 had been psychiatrically admitted. Among males, the suicide rate during the first week of admission and after discharge was 3409 and 3148 per 100000 person-years, respectively. The corresponding values for females were 1267 and 1631. Generally, estimated suicide rates were highest in those with affective or anxiety stress disorders. During first week of hospitalization, the IRR was 237 for males and of 322 for females when compared with those never hospitalized. In first week after discharge, the IRR was 225 and 425 for males and females, respectively. PAR estimates indicated 6% of male suicides and 13% of female suicides attributes to first week of admission and discharge. The inpatient suicide rate decreased annually 2.5% until 2009 followed by a 7.5% annual percentage increase. The suicide rate after discharge decreased steadily annually over the study period. Despite finding declining post-discharge suicide rates, the period surrounding a psychiatric admission was still associated with extremely high suicide rates.

Oral health: something to worry about in individuals with acquired brain injury?

ABSTRACT Objectives To investigate the oral health status in patients with acquired brain injury (ABI) admitted at neurorehabilitation setting. Methods 132 individuals with ABI were examined within their first week of admission. Individuals’ socio-behavioral history, length of stay in acute care etc. were recorded. Comprehensive clinical oral examination consisting of acute conditions [dental plaque, bleeding on probing (BOP)] and chronic conditions [periodontal status, tooth loss] were recorded. Results The average length of stay in acute care was 41 days before admission at neurorehabilitation. It was observed that 42% and 50% of the patients with ABI had visible plaque and active BOP in >60% of all examined sites respectively. All patients suffered from periodontitis and 74% had severe periodontitis (Stage III), indicating a chronic inflammatory destruction of the supporting tissues. Each participant had at least two decayed teeth, five filled and five extracted teeth. Conclusions Presence of dental plaque and BOP, an acute condition, speculates that poor oral health worsened while patients were at acute care setting. Majority of individuals had severe periodontitis indicating chronic poor oral health. Thus, indicating the need of not only planning treatment strategies while hospitalization but also uplifting the prevention of oral diseases much earlier in life.

Implementing an intensive care unit (ICU) diary program at a large academic medical center: Results from a randomized control trial evaluating psychological morbidity associated with critical illness

BackgroundPsychological morbidity in both patients and family members related to the intensive care unit (ICU) experience is an often overlooked, and potentially persistent, healthcare problem recognized by the Society of Critical Care Medicine as Post-intensive Care Syndrome (PICS). ICU diaries are an intervention increasingly under study with potential to mitigate ICU-related psychological morbidity, including ICU-related post-traumatic stress disorder (PTSD), depression and anxiety. As we encounter a growing number of ICU survivors, in particular in the wake of the coronavirus pandemic, clinicians must be equipped to understand the severity and prevalence of significant psychiatric complications of critical illness. MethodsWe compared the efficacy of the ICU diary, written by family and healthcare workers during the patient's intensive care course, versus education alone in reducing acute PTSD symptoms after discharge. Patients with an ICU stay >72 h, who were intubated and mechanically ventilated over 24 h, were recruited and randomized to either receive a diary at bedside with psychoeducation or psychoeducation alone. Intervention patients received their ICU diary within the first week of admission into the intensive care unit. Psychological symptom screening with IES-R, PHQ-8, HADS and GAD-7 was conducted at baseline within 1 week of ICU discharge and at weeks 4, 12, and 24 after ICU discharge. Change from baseline in these scores was assessed using Wilcoxon rank sum tests. ResultsFrom September 26, 2017 to September 25, 2018, our team screened 265 patients from the surgical and medical ICUs at a single large academic urban hospital. 60 patients were enrolled and randomized, of which 35 patients completed post-discharge follow-up, (n = 18) in the diary intervention group and (n = 17) in the education-only control group. The control group had a significantly greater decrease in PTSD, hyperarousal, and depression symptoms at week 4 compared to the intervention group. There were no significant differences in other measures, or at other follow-up intervals. Both study groups exhibited clinically significant PTSD symptoms at all timepoints after ICU discharge. Follow-up phone interviews with patients revealed that while many were interested in getting follow-up for their symptoms, there were many barriers to accessing appropriate therapy and clinical attention. ConclusionsResults from psychological screening tools demonstrate no benefit of ICU diaries versus bedside education-alone in reducing PTSD symptoms related to the intensive care stay. However, our study finds an important gap in clinical practice – patients at high risk for PICS are infrequently connected to appropriate follow-up care. Perhaps ICU diaries would prove beneficial if utilized to support the work within a program providing wrap-around services and close psychiatric follow up for PICS patients. This study demonstrates the high prevalence of ICU-related PTSD in our cohort of survivors, the high barrier to accessing care for appropriate treatment of PICS, and the consequence of that barrier—prolonged psychological morbidity. Trial registrationNCT04305353. Grant identificationGH-17-022 (Arnold P. Gold Foundation).

COVID-19: clinical course and outcomes of 36 hemodialysis patients in Spain

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia emerged in Wuhan, China in December 2019. Unfortunately, there is a lack of evidence about the optimal management of novel coronavirus disease 2019 (COVID-19), and even less is available in patients on maintenance hemodialysis therapy than in the general population. In this retrospective, observational, single-center study, we analyzed the clinical course and outcomes of all maintenance hemodialysis patients hospitalized with COVID-19 from March 12th to April 10th, 2020 as confirmed by real-time polymerase chain reaction. Baseline features, clinical course, laboratory data, and different therapies were compared between survivors and nonsurvivors to identify risk factors associated with mortality. Among the 36 patients, 11 (30.5%) died, and 7 were able to be discharged within the observation period. Clinical and radiological evolution during the first week of admission were predictive of mortality. Among the 36 patients, 18 had worsening of their clinical status, as defined by severe hypoxia with oxygen therapy requirements greater than 4 L/min and radiological worsening. Significantly, 11 of those 18 patients (61.1%) died. None of the classical cardiovascular risk factors in the general population were associated with higher mortality. Compared to survivors, nonsurvivors had significantly longer dialysis vintage, increased lactate dehydrogenase (490 U/l ± 120 U/l vs. 281 U/l ± 151 U/l, P = 0.008) and C-reactive protein levels (18.3 mg/dl ± 13.7 mg/dl vs. 8.1 mg/dl ± 8.1 mg/dl, P = 0.021), and a lower lymphocyte count (0.38 ×103/µl ± 0.14 ×103/µl vs. 0.76 ×103/µl ± 0.48 ×103/µl, P = 0.04) 1 week after clinical onset. Thus, the mortality among hospitalized hemodialysis patients diagnosed with COVID-19 is high. Certain laboratory tests can be used to predict a worsening clinical course.

Effect of Early Tracheostomy on Mortality of Mechanically Ventilated Patients with Guillain-Barré Syndrome: A Nationwide Observational Study.

BackgroundPatients with Guillain–Barré syndrome (GBS) who require mechanical ventilation (MV) are regarded as candidates for early tracheostomy because of the high risk of prolonged MV; however, the association between early tracheostomy and favorable outcomes in patients with GBS remains unclear. In this study, we evaluated the association between early tracheostomy and outcomes in mechanically ventilated patients with GBS.MethodsThis retrospective observational study included adult patients with GBS identified in the Japanese Diagnosis Procedure Combination national inpatient database from July 1, 2010, to March 31, 2018, who initiated MV within the first week of admission and who received MV for more than 1 week. Early tracheostomy was defined as tracheostomy performed within 7 days of MV. The primary outcome was in-hospital mortality, and the secondary outcomes were 28-day mortality, nosocomial pneumonia, length of hospital stay, length of intensive care unit (ICU) stay, duration of MV, duration of sedation, duration of analgesia, duration of delirium, and total hospitalization costs. Propensity scores for early tracheostomy were calculated using a logistic regression model on the following variables: age; sex; body mass index; Japan Coma Scale status at admission; Charlson comorbidity index score; comorbidity of chronic pulmonary disease; complication of pneumonia at admission; complication of hyponatremia at admission; neurological presentation at admission; ambulance use; referral from other hospitals; treatment year; days from hospital admission to MV initiation; ICU admission until the day of MV initiation; and treatments until the day of MV initiation. Stabilized inverse probability of treatment weighting analyses was performed to compare the outcomes between patients with and without early tracheostomy.ResultsAmong 919 eligible patients, 654 patients (71%) underwent tracheostomy, with 136 patients (15%) receiving early tracheostomy. Overall, the median time from initiation of MV to tracheostomy was 12 days (interquartile range 8–15 days). After stabilized inverse probability of treatment weighting, early tracheostomy was not associated with lower in-hospital mortality (risk difference 0.4%; 95% confidence interval − 5.6 to 6.7%) compared with patients without early tracheostomy. There were no significant differences in 28-day mortality (risk difference − 1.3%; 95% confidence interval − 3.5 to 0.9%) and incidence of nosocomial pneumonia (risk difference − 2.6%; 95% confidence interval − 9.1 to 4.2%) between the two groups. None of the other secondary outcomes differed significantly between the groups.ConclusionsEarly tracheostomy was not significantly associated with decreased mortality or morbidity in patients with GBS requiring MV for more than 1 week.

502 Use of Hydrocortisone, Vitamin C, and Thiamine to Treat Burn Sepsis: A Case Series

Abstract Introduction Sepsis remains a leading cause of morbidity and mortality in burn patients. Therefore, novel treatment adjuncts are of constant interest. Early studies by Marik et al. have suggested that bundled use of intravenous hydrocortisone, vitamin C, and thiamine may improve outcomes in intensive care patients diagnosed with systemic sepsis. However, to our knowledge, evaluation of this treatment modality has not been applied to burn patients. Methods Chart review of seven patients with major cutaneous injuries admitted to our burn center and treated with the adjunct therapy as per Marik et al. occurred. Baseline characteristics, treatment, and outcome variables were identified. Variables abstracted include demographics, injury characteristics, comorbidities, discharge disposition, length of stay, mechanical ventilation, use of vasopressors, acute kidney injury, blood cultures, white blood cell count, lactate, creatinine, predicted mortality (modified BAUX, APACHE II, APACHE IV, and SOFA scores), procalcitonin, quantitative culture and histology results, time to first excision, and time to final surgery and/or healing. Results Five patients sustained flame burns ranging from 24% to 46% total body surface area. One patient was admitted for road rash causing full thickness injury and one with toxic epidermal necrolysis encompassing 90% total body surface area. Ages ranged from 19 to 74 years. Modified BAUX with APACHE II and IV scores were used to predict baseline mortality risk. Four of the seven patients succumbed to their injuries, two within the first week of admission. Of the remaining cases, all required fewer vasopressors after beginning adjunct therapy. Among survivors, SOFA scores suggested greater than 95.2% predicted mortality at start of adjunct therapy and within four days, predicted mortality ranged from less than 33.3% to 50%. Conclusions The aim of this case series is to review our early experience with this novel treatment in burn patients. No conclusions can be drawn at this time. It is understood that continued research must be conducted to support correlation between intervention and outcomes. Optimism is present based upon early non-burn studies and our regional burn center experience. A prospective study is currently being developed at our burn center. Applicability of Research to Practice This case series explores a potential treatment adjunct to decrease morbidity and mortality from burn sepsis.