Higher Serum Urea Research Articles

Thirst distress in outpatients with heart failure in a Mediterranean zone of Spain.

AimsThis study aimed to evaluate psychometric properties of the Spanish version of the Thirst Distress Scale for patients with Heart Failure (TDS‐HF) and to describe thirst distress‐associated factors in outpatients at a heart failure (HF) clinic in Spain. Thirst is common in patients with HF, but thirst distress has rarely been addressed and may significantly decrease quality of life.Methods and resultsA cross‐sectional study was performed assessing perceived thirst distress by patients with HF during the preceding 3 days, with the TDS‐HF (scores 8 to 40). Univariable and multivariable linear regression analyses were performed to identify variables independently associated with thirst distress. Three‐hundred two HF outpatients were included (age 67 ± 12 years, 74% male, HF duration 82 ± 75 months, left ventricular ejection fraction 42 ± 14%). Most patients were on treatment with fluid restriction (99%), sodium restriction (99%), and diuretics (70%). The psychometric evaluation of the Spanish version of the TDS‐HF showed satisfactory item‐total and inter‐item correlations (range from 0.77 to 0.85 and 0.60 to 0.84, respectively), and internal consistency was 0.95 (Cronbach's alpha). The majority perceived mild to moderate thirst distress, and 18% perceived it as high or severe. The mean score obtained was 16.2 ± 9.3 (median 13, Q1–Q3 8–20). Higher serum urea {beta coefficient 1.6 [95% confidence interval (CI) 0.267 to 2.92], P = 0.019} and lower potassium [beta coefficient −3.63 (85% CI −6.32 to −0.93), P = 0.009] remained significantly associated with thirst distress in the multivariable analysis, together with the dose of diuretics [beta coefficient 2.98 (95% CI 1.37 to 4.59), P < 0.001]. Treatment with angiotensin receptor blocker showed an independent protective effect [beta coefficient −3.62 (95% CI −6.89 to −0.345), P = 0.03].ConclusionsThe psychometric evaluation of the Spanish version of the TDS‐HF showed good psychometric properties. One in five patients experienced severe distress by thirst, but the majority had mild to moderate thirst distress. The dose of diuretics and angiotensin receptor blocker treatment influence thirst distress and could be clinically important targets to relieve thirst distress in patients with HF.

Serum biochemical reference ranges for lambs from birth to 1 year of age in the tropics

The study aimed to determine the biochemical reference ranges for lambs from birth to 1 year of age in the tropics. Data were obtained from experiments performed in several institutions and commercial farms using Santa Inês, Dorper, Lacaune, Morada Nova, Bergamacia and Suffolk lambs reared under different conditions (grazing, feedlot, semi-feedlot) from 2006 to 2017. Serum energy-, protein-, mineral-, and enzyme-related metabolites were evaluated. The metabolic energy profile included data from glucose, cholesterol, triglycerides, fructosamine, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and very-low-density lipoprotein cholesterol; the metabolic protein profile included total protein, uric acid, urea, albumin, and creatinine; the metabolic mineral profile included data on calcium, phosphorus, and magnesium; and the metabolic enzymatic profile included the enzymes aspartate aminotransferase, gamma-glutamyl transferase, alkaline phosphatase, and creatine kinase. The reference ranges were estimated using confidence intervals with a 95% confidence level, and percentiles were estimated or bootstrapped nonparametrically when the data were not normally distributed. The serum biochemical reference ranges determined for lambs are strongly divergent from those established by one of the most cited books on the topic, especially considering the high serum urea and cholesterol concentrations and low levels of blood glucose observed. Therefore, the serum biochemical reference ranges for lambs from birth to 1 year of age in the tropics differ from international data, which consider adult sheep in temperate climate zones.

Neurovascular coupling dysfunction in end-stage renal disease patients related to cognitive impairment

We aimed to investigate the neurovascular coupling (NVC) dysfunction in end-stage renal disease (ESRD) patients related with cognitive impairment. Twenty-five ESRD patients and 22 healthy controls were enrolled. To assess the NVC dysfunctional pattern, resting-state functional MRI and arterial spin labeling were explored to estimate the coupling of spontaneous neuronal activity and cerebral blood perfusion based on amplitude of low-frequency fluctuation (ALFF)-cerebral blood flow (CBF), fractional ALFF (fALFF)-CBF, regional homogeneity (ReHo)-CBF, and degree centrality (DC)-CBF correlation coefficients. Multivariate partial least-squares correlation and mediation analyses were used to evaluate the relationship among NVC dysfunctional pattern, cognitive impairment and clinical characteristics. The NVC dysfunctional patterns in ESRD patients were significantly decreased in 34 brain regions compared with healthy controls. The decreased fALFF-CBF coefficients in the cingulate gyrus (CG) were associated positively with lower kinetic transfer/volume urea (Kt/V) and lower short-term memory scores, and were negatively associated with higher serum urea. The relationship between Kt/V and memory deficits of ESRD patients was partially mediated by the fALFF-CBF alteration of the CG. These findings reveal the NVC dysfunction may be a potential neural mechanism for cognitive impairment in ESRD. The regional NVC dysfunction may mediate the impact of dialysis adequacy on memory function.

English

BACKGROUND Chronic liver disease causes an imbalance in the coagulation system, but available data on liver disease and risk of venous thrombosis are conflicting. Clinical studies are therefore needed to understand the prevalence and risk factors associated with mortality to decide appropriate care of these patients. We studied the incidence of venous thrombosis in three CTP (Child-Turcotte-Pugh) class of cirrhotic patients and associated risk factors predicting 90-day mortality. METHODS A cross sectional observational study of one-year duration was conducted at a tertiary-care teaching hospital among patients admitted with chronic liver disease. 150 hospitalised patients with cirrhosis were enrolled and followed up for 3 months. Incidence of thrombosis was recorded in different CTP subclass. Threemonth mortality rates in different subgroups were compared by using normal test of proportions. The association between types of thrombosis and CTP class of liver cirrhosis was studied using Mann-Whitney U test, a non-parametric test. Mortality association with various parameters was evaluated using non-parametric test. Pvalue of ≤ 0.05 was considered significant. RESULTS Incidence of venous thrombosis in cirrhotic patients was 4 % in this study. Association of thrombosis with various clinical parameters and different CTP subclass was statistically non-significant. During the 3-months follow-up 24 patients died. Deceased had higher CTP score (mean CTP score - 9.58) as compared to survivors (mean CTP - 8.48) (P-value 0.049). Presence of ascites (Pvalue 0.037), higher serum urea (P-value 0.001), creatinine (P = 0.004), and total leucocyte count (P = 0.008) were significantly associated with mortality. CONCLUSIONS Thrombosis in chronic liver disease (CLD) especially portal vein is common and presents a therapeutic challenge as these patients are also at increased risk of bleeding. Higher CTP score, serum creatinine, leucocyte count and presence of ascites in CLD patients at admission are poor prognostic markers. KEYWORDS Deep Venous Thrombosis, Chronic Liver Disease, Cirrhosis, Thrombosis, Portal Vein Thrombosis

The Risk Factors and Clinical Outcomes Associated with Acute Kidney Injury in Patients with COVID-19: Data from a Large Cohort in Iran

Introduction: Kidney involvement, ranging from mild hematuria and proteinuria to acute kidney injury (AKI) in patients with coronavirus disease-2019 (COVID-19), is a recent finding with various incidence rates reported among hospitalized patients with COVID-19. Given the various AKI rates and their associated risk factors, lack of AKI recovery in the majority of patients hospitalized with COVID-19, and limited data regarding AKI in patients with COVID-19 in Iran, we aim to investigate the potential risk factors for AKI development and its incidence in patients hospitalized with COVID-19. Methods: In this retrospective cohort study, we enrolled adult patients referred to the Sina Hospital, Iran, from February 20 to May 14, 2020, with either a positive PCR test or a highly susceptible chest computed tomography features consistent with COVID-19 diagnosis. AKI was defined according to the kidney disease improving global outcomes criteria, and patients were stratified based on their AKI staging. We evaluated the risk indicators associated with AKI during hospitalization besides in-hospital outcomes and recovery rate at the time of discharge. Results: We evaluated 516 patients with a mean age of 57.6 ± 16.1 years and a male-to-female ratio of 1.69 who were admitted with the COVID-19 diagnosis. AKI development was observed among 194 (37.6%) patients, comprising 61.9% patients in stage 1, 18.0% in stage 2, and 20.1% in stage 3. Out of all patients, AKI occurred in 58 (11.2%) patients during the hospital course, and 136 (26.3%) patients arrived with AKI upon admission. AKI development was positively associated with all of the in-hospital outcomes, including intensive care unit admissions, need for invasive ventilation, acute respiratory distress syndrome (ARDS), acute cardiac injury, acute liver injury, multiorgan damage, and mortality. Patients with stage 3 AKI showed a significantly higher mortality rate, ARDS, and need for invasive ventilation than other stages. After multivariable analysis, male sex (odds ratio [OR]: 11.27), chronic kidney disease (CKD) (OR: 6.89), history of hypertension (OR: 1.69), disease severity (OR: 2.27), and high urea levels (OR: 1.04) on admission were independent risk indicators of AKI development. Among 117 (28.1%) patients who experienced AKI and survived, only 33 (28.2%) patients made a recovery from the AKI, and 84 (71.8%) patients did not exhibit full recovery at the time of discharge. Discussion/Conclusion: We found that male sex, history of CKD, hypertension, disease severity, and high serum urea were independent risk factors associated with AKI in patients with COVID-19. Also, higher stages of AKI were associated with increased risk of mortality and in-hospital complications. Our results indicate a necessity for more precise care and monitoring for AKI during hospitalization in patients with COVID-19, and lack of AKI recovery at the time of discharge is a common complication in such patients.

Acute kidney injury in hospitalized cirrhotic patients: Risk factors, type of kidney injury, and survival.

Background and AimAcute kidney injury (AKI) is a common complication of chronic liver disease (CLD). We performed a prospective study to evaluate the risk factors and spectrum of AKI among decompensated cirrhosis (DC) patients and the impact of AKI on survival.MethodsThis study was conducted in consecutive DC patients hospitalized in SCB Medical College between December 2016 and October 2018. AKI was defined as per ICA criteria. Demographic, clinical, and laboratory parameters and outcomes were compared between patients with and without AKI.ResultsA total of 576 DC subjects were enrolled, 315 (54.69%) of whom had AKI; 34% (n = 106) had stage 1A, 28% (n = 90) stage 1B, 21% (n = 65) stage 2, and 17% (n = 54) stage 3 AKI. Alcohol was the predominant cause of CLD (66.7%). In 207 (65.7%) patients, diuretic/lactulose/nonsteroidal anti‐inflammatory drugs use was noted, and infection was present in 190 (60.3%) patients. Compared to those without AKI, patients with AKI had higher leucocyte count, higher serum urea and creatinine, higher Child‐Turcotte‐Pugh, higher Model of End‐Stage Liver Disease (MELD) scores (P < 0.001), longer hospital stay, and lower survival at 28 days and 90 days (P < 0.001). Besides, in patients with stages 1A to 3 AKI, there were differences in overall survival at 28 days (P < 0.001) and 90 days (P < 0.001).ConclusionsOver half of DC patients had AKI, and alcohol was the most common cause of cirrhosis in them. Use of AKI‐precipitating medications was the most common cause of AKI, followed by bacterial infection. AKI patients had increased prevalence of acute‐on‐chronic liver failure and had prolonged hospitalization and lower survival both at 28 days and 90 days.

Mechanism of how carbamylation reduces albumin binding to FcRn contributing to increased vascular clearance.

Chronic kidney disease results in high serum urea concentrations leading to excessive protein carbamylation, primarily albumin. This is associated with increased cardiovascular disease and mortality. Multiple methods were used to address whether carbamylation alters albumin metabolism. Intravital two-photon imaging of the Munich Wistar Frömter (MWF) rat kidney and liver allowed us to characterize filtration and proximal tubule uptake and liver uptake. Microscale thermophoresis enabled quantification of cubilin (CUB7,8 domain) and FcRn binding. Finally, multiple biophysical methods including dynamic light scattering, small-angle X-ray scattering, LC-MS/MS and in silico analyses were used to identify the critical structural alterations and amino acid modifications of rat albumin. Carbamylation of albumin reduced binding to CUB7,8 and FcRn in a dose-dependent fashion. Carbamylation markedly increased vascular clearance of carbamylated rat serum albumin (cRSA) and altered distribution of cRSA in both the kidney and liver at 16 h post intravenous injection. By evaluating the time course of carbamylation and associated charge, size, shape, and binding parameters in combination with in silico analysis and mass spectrometry, the critical binding interaction impacting carbamylated albumin's reduced FcRn binding was identified as K524. Carbamylation of RSA had no effect on glomerular filtration or proximal tubule uptake. These data indicate urea-mediated time-dependent carbamylation of albumin lysine K524 resulted in reduced binding to CUB7,8 and FcRn that contribute to altered albumin transport, leading to increased vascular clearance and increased liver and endothelial tissue accumulation.

Prognostic Factors for 30-Day Mortality in Critically Ill Patients With Coronavirus Disease 2019: An Observational Cohort Study.

To identify characteristics that predict 30-day mortality among patients critically ill with coronavirus disease 2019 in England, Wales, and Northern Ireland. Observational cohort study. A total of 258 adult critical care units. A total of 10,362 patients with confirmed coronavirus disease 2019 with a start of critical care between March 1, 2020, and June 22, 2020, of whom 9,990 were eligible (excluding patients with a duration of critical care less than 24 hr or missing core variables). The main outcome measure was time to death within 30 days of the start of critical care. Of 9,990 eligible patients (median age 60 yr, 70% male), 3,933 died within 30 days of the start of critical care. As of July 22, 2020, 189 patients were still receiving critical care and a further 446 were still in acute hospital. Data were missing for between 0.1% and 7.2% of patients across prognostic factors. We imputed missing data ten-fold, using fully conditional specification and continuous variables were modeled using restricted cubic splines. Associations between the candidate prognostic factors and time to death within 30 days of the start of critical care were determined after adjustment for multiple variables with Cox proportional hazards modeling. Significant associations were identified for age, ethnicity, deprivation, body mass index, prior dependency, immunocompromise, lowest systolic blood pressure, highest heart rate, highest respiratory rate, Pao2/Fio2 ratio (and interaction with mechanical ventilation), highest blood lactate concentration, highest serum urea, and lowest platelet count over the first 24 hours of critical care. Nonsignificant associations were found for sex, sedation, highest temperature, and lowest hemoglobin concentration. We identified patient characteristics that predict an increased likelihood of death within 30 days of the start of critical care for patients with coronavirus disease 2019. These findings may support development of a prediction model for benchmarking critical care providers.

Prevalence of cerebral edema among diabetic ketoacidosis patients.

Cerebral edema (CE) is the most severe complication of diabetic ketoacidosis (DKA) in children. There is no accurate knowledge of CE pathogenesis and its onset has been related to intravenous rehydration therapy during the initial treatment. To estimate the prevalence of CE among DKA patients treated at Hospital General de Niños Pedro de Elizalde with intravenous rehydration and analyze potential risk factors for the development of CE. Cross-sectional prevalence study and exploratory analysis to compare clinical and laboratory characteristics between patients with and without CE. Patients aged 1-18 years hospitalized with the diagnosis of DKA between January 1st, 2005 and December 31st, 2014 were included. A total of 693 DKA events from 561 medical records were analyzed. Ten patients had evidence of CE (1.44 %; 95 % confidence interval: 0.8-2.6). Patients with CE had higher serum urea levels (p &#60; 0.001), lower carbon dioxide pressure (p &#60; 0.001), and lower serum sodium levels (p &#60; 0.001) than those without CE. The prevalence of CE among DKA patients was 1.44 %, smaller than that reported in our country (1.8 %). The risk factors at admission associated with CE development were high serum urea levels, hyponatremia, and hypocapnia.

Failure of target attainment of beta-lactam antibiotics in critically ill patients and associated risk factors: a two-center prospective study (EXPAT)

BackgroundEarly and appropriate antibiotic dosing is associated with improved clinical outcomes in critically ill patients, yet target attainment remains a challenge. Traditional antibiotic dosing is not suitable in critically ill patients, since these patients undergo physiological alterations that strongly affect antibiotic exposure. For beta-lactam antibiotics, the unbound plasma concentrations above at least one to four times the minimal inhibitory concentration (MIC) for 100% of the dosing interval (100%ƒT > 1–4×MIC) have been proposed as pharmacodynamic targets (PDTs) to maximize bacteriological and clinical responses. The objectives of this study are to describe the PDT attainment in critically ill patients and to identify risk factors for target non-attainment.MethodsThis prospective observational study was performed in two ICUs in the Netherlands. We enrolled adult patients treated with the following beta-lactam antibiotics: amoxicillin (with or without clavulanic acid), cefotaxime, ceftazidime, ceftriaxone, cefuroxime, and meropenem. Based on five samples within a dosing interval at day 2 of therapy, the time unbound concentrations above the epidemiological cut-off (ƒT > MICECOFF and ƒT > 4×MICECOFF) were determined. Secondary endpoints were estimated multivariate binomial and binary logistic regression models, for examining the association of PDT attainment with patient characteristics and clinical outcomes.ResultsA total of 147 patients were included, of whom 63.3% achieved PDT of 100%ƒT > MICECOFF and 36.7% achieved 100%ƒT > 4×MICECOFF. Regression analysis identified male gender, estimated glomerular filtration rate (eGFR) ≥ 90 mL/min/1.73 m2, and high body mass index (BMI) as risk factors for target non-attainment. Use of continuous renal replacement therapy (CRRT) and high serum urea significantly increased the probability of target attainment. In addition, we found a significant association between the 100%ƒT > MICECOFF target attainment and ICU length of stay (LOS), but no significant correlation was found for the 30-day survival.ConclusionsTraditional beta-lactam dosing results in low target attainment in the majority of critically ill patients. Male gender, high BMI, and high eGFR were significant risk factors for target non-attainment. These predictors, together with therapeutic drug monitoring, may help ICU clinicians in optimizing beta-lactam dosing in critically ill patients.Trial registrationNetherlands Trial Registry (EXPAT trial), NTR 5632. Registered on 7 December 2015.

Parameters Predicting Poor Prognosis in Patients with Malignant Ascites in Yangon General Hospital

Prognosis for patients with malignant ascites is poor and median survival is only a few months. Treatment of malignant ascites ranges from simple drainage procedures to chemotherapy and debulking surgery. Careful selection of treatment modality by using clinicpathological parameters could improve not only the survival but also the quality of life of the patients. So this hospital-based prospective study aimed to find out the parameters predicting poor prognosis among patients with confirmed malignant ascites admitted to Oncology Department, Yangon General Hospital. This study included 102 patients with malignant ascites. Among them, 19(18.6%) were male patients and 83(81.4%) were female with age ranging from 15 to 73 years (mean age 46.35±12.9 years). Common cancers associated with malignant ascites were ovarian cancer (32.35%), stomach cancer (19.61%) and breast cancer (9.80%). Sixty-four percent of patients presented with stage IV. Common metastatic sites were liver (37.27%), peritoneum (16.67%) and lungs (11.76%) and 28 patients (27.45%) had more than one site of metastasis. Eight patients (7.8%) were in Eastern Cooperative Oncology Group (ECOG) per-formance status score 1 and 23 patients (22.5%) were in ECOG score 4. The time interval between first diagnosis and development of malignant ascites ranged from 0 to 120 months. Only 33 patients (32.4%) were still alive after 6-month follow- up. High serum urea level was associated with better prognosis (OR =0.19, 95% CI 0.04-0.99), however, primary advanced stage (OR=3.30, 95% CI 1.26-258.62), and high serum creatinine level (OR=9.15, 95% CI 1.71-71.21) significantly worsened the prognosis in patients with malignant ascites.

A clinical and pathological description of 320 cases of naturally acquired Babesia rossi infection in dogs

Babesia rossi causes the most severe clinical disease in dogs of all the babesia parasites. We included 320 naturally-infected dogs that presented for care at the Onderstepoort Veterinary Academic Hospital between 2006 and 2016. All dogs had mono-infections confirmed by multiplex PCR. The data allowed more accurate clinical classification of the disease and identified parameters that were associated with disease severity and death. Odds ratios for dying were significant (P < 0.05) for increased band neutrophil count, collapse at presentation; presence of cerebral signs; hypoglycaemia; hyperlactatemia; high urea, high creatinine; hyperbilirubinaemia; hypercortisolaemia; and hypothyroxinaemia. Joint component analysis confirmed that the variables with significant odds ratios grouped together with death. Yet, multivariate logistic regression was unable to identify a group of significant independent predictors of death. Receiver Operator Characteristic curves indicated that low total thyroid hormone, high bilirubin, high serum urea and high cortisol concentrations were the variables with the highest sensitivity and specificity for death. These data provide both the clinician and researcher with a set of easily-measured laboratory and clinical assessments to classify cases into those that are uncomplicated and those that are complicated. The disease is complex and multisystemic and probably involves mechanisms more proximal in the pathogenesis than those that have been evaluated.

Evaluating Serum Urea, Creatinine and Hemoglobin Level in Chronic Renal Failure of Pre and Post Dialysis at St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia

Objective: The objective of this study was to evaluate serum urea, creatinine and hemoglobin level in chronic renal failure pre and post dialysis at St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia.&#x0D; Methodology: Cross sectional study design was conducted From February to May 2017 to all chronic kidney failure patients Ethio-Egyptian Nephrology unit in SPHMMC Addis Ababa Ethiopia. 5 ml of the blood will be obtained from each patient before and after dialysis. Each sample was divided in to two; half of the blood was placed in tubes containing anticoagulant (EDTA) and half in clot activator tubes. Clotted blood was centrifuge to separate serum and used for the estimation of creatinine and urea. Non-clotted blood samples were used for complete blood count and hemoglobin in blood Analyzer Sysmax KX-21. Percentages of reduction in urea and creatinine values were calculated using the values of blood samples withdrawn from each patient before and after each hemodialysis sessions.&#x0D; Results: A total of 33 chronic kidney patients participated in this study. Out of this only 26 patients (78.79%) attend the dialysis unit for four months the rest either passed away or kidney transplantation done. The study population comprised 80.8% male and 19.2% female. Before the dialysis, 12 (46.2%) patients serum urea level was 101-122 mg/dl, however after dialysis, 14 (53.8%) patients had serum urea level were between 20 – 50.99 mg/dl and 11 (42.3%) patients had serum urea level were between 51 – 100 mg/dl. Most of the patients, (53.8%) undergoing hemodialysis serum creatinine level before dialysis were between 7.6 – 10.5 mg/dl. The majority of patients’ (42.3%), serum creatinine level after dialysis was between 3.0 – 3.92 mg/dl. The majority (73.1%) of the patient hemoglobin level was between 7.0 – 11.0 mg/dl and 23.1% of the patients were between 11.1 – 14.0 mg/dl. Patients with chronic kidney disease have high serum urea and creatinine level before hemodialysis.&#x0D; Conclusion: Hemodialysis decreases the burden of kidney in chronic kidney disease patients.

Escherichia coli bloodstream infection outcomes and preventability: a six-month prospective observational study

BackgroundEscherichia coli bloodstream infection (BSI) is a common and serious problem, and incidence and antibiotic resistance are increasing. AimTo understand the drivers of outcomes and factors associated with preventable cases at the study institution. MethodsBetween 1st November 2017 and 30th April 2018, cases of E. coli BSI in adults treated as inpatients at the study institution were included in a prospective cohort. Clinical, demographic and laboratory features were recorded, with seven-, 30- and 90-day mortality and length of hospital stay post BSI. Qualitative data on preventability were reviewed independently by two infection specialists. FindingsIn total, 195 cases in 188 patients were included in the analysis. Empirical antibiotics showed in-vitro resistance in 30.9% of cases. Thirty-day mortality was 23.6%, with a median length of hospital stay of seven days. On multi-variable analysis, 30-day mortality was associated with higher Charlson score, residential home residency, higher respiratory rate and higher serum urea, whilst prolonged length of stay was associated with hospital-acquired E. coli BSI. Fifty patients were felt to have avoidable BSI, all of which were health care associated; urinary catheter use, antibiotic-related and procedural complications were the areas of preventability. ConclusionsE. coli BSI has an appreciable mortality, with little in the way of modifiable risk factors for mortality or prolonged hospital stay. Attention to urinary catheter use is likely to be the most useful way to reduce the incidence, but current UK reduction targets may be unachievable.

Does Etiology of Pancreatitis Matter? Differences in Outcomes Among Patients With Post-Endoscopic Retrograde Cholangiopancreatography, Acute Biliary, and Alcoholic Pancreatitis.

We compared outcomes of acute alcoholic pancreatitis (AAP), acute biliary pancreatitis (ABP), and post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). This was a retrospective cohort study conducted at a tertiary care center between June 2007 and June 2012. A total of 300 (68%) patients were diagnosed with AAP, 88 (20%) with ABP, and 55 (12%) with PEP. Longer length of hospital stay (LOHS) was more common in ABP (23%) as compared with AAP (10%) and PEP (7%, P = 0.025). Pseudocyst (P = 0.048), organ failure (OF) (P = 0.01), need for interventions (P ≤ 0.001), and mortality (P = 0.002) occurred more in ABP as compared with other groups. Systemic inflammatory response syndrome was associated with LOHS of more than 10 days (P = 0.01) and multi-OF (P = 0.05). Chronic pancreatitis was associated more with pseudocyst (P < 0.001) and mortality (P = 0.03). Serum urea nitrogen of greater than 25 g/dL predicted LOHS of more than 10 days (P = 0.02), OF (P < 0.001), multi-OF (P < 0.001), and persistent OF (P < 0.001). Acute biliary pancreatitis is a more severe disease compared with PEP and AAP. Chronic pancreatitis, systemic inflammatory response syndrome, and high serum urea nitrogen are important predictors of morbidity.

Electronic health records accurately predict renal replacement therapy in acute kidney injury

BackgroundElectronic health records (EHR) detect the onset of acute kidney injury (AKI) in hospitalized patients, and may identify those at highest risk of mortality and renal replacement therapy (RRT), for earlier targeted intervention.MethodsProspective observational study to derive prediction models for hospital mortality and RRT, in inpatients aged ≥18 years with AKI detected by EHR over 1 year in a tertiary institution, fulfilling modified KDIGO criterion based on serial serum creatinine (sCr) measures.ResultsWe studied 3333 patients with AKI, of 77,873 unique patient admissions, giving an AKI incidence of 4%. KDIGO AKI stages at detection were 1(74%), 2(15%), 3(10%); corresponding peak AKI staging in hospital were 61, 20, 19%. 392 patients (12%) died, and 174 (5%) received RRT. Multivariate logistic regression identified AKI onset in ICU, haematological malignancy, higher delta sCr (sCr rise from AKI detection till peak), higher serum potassium and baseline eGFR, as independent predictors of both mortality and RRT. Additionally, older age, higher serum urea, pneumonia and intraabdominal infections, acute cardiac diseases, solid organ malignancy, cerebrovascular disease, current need for RRT and admission under a medical specialty predicted mortality. The AUROC for RRT prediction was 0.94, averaging 0.93 after 10-fold cross-validation. Corresponding AUROC for mortality prediction was 0.9 and 0.9 after validation. Decision tree analysis for RRT prediction achieved a balanced accuracy of 70.4%, and identified delta-sCr ≥ 148 μmol/L as the key factor that predicted RRT.ConclusionCase fatality was high with significant renal deterioration following hospital-wide AKI. EHR clinical model was highly accurate for both RRT prediction and for mortality; allowing excellent risk-stratification with potential for real-time deployment.

Surgical Management of Malignant Intestinal Obstruction: Outcome and Prognostic Factors.

Background: Malignant intestinal obstruction is a frequent complication in advanced stages cancer patients. The prognosis is poor, with mean survival rate beneath 3 months. Clinical treatment, endoscopic or surgical procedures are options for malignant intestinal obstruction management. There is no generally accepted management strategy. Objectives: To evaluate prognostic factors of patients with malignant intestinal obstruction who underwent surgical treatment. Methods: A retrospective analysis was performed including patients of a single institution with diagnosis of malignant intestinal obstruction. Demographic data, in-hospital stay, postoperative complications, and overall survival were assessed. Logistic regression was used to evaluate associated prognostic factors. Results: Two hundred thirty-three surgeries were performed due to suspicion for malignant intestinal obstruction over a seven-year period. This diagnosis was confirmed in 210 operations (90.1%). The main causes of malignant obstruction were colorectal (49.5%) and gynecological cancer (21.9%). The rate of severe complications was 11.42%. In-hospital mortality rate was 40.95% (CI 95%: 34.16-47.74%). Functional status impairment,high serum urea, and low albumin levels were associated to higher mortality rate. Conclusion: Malignant intestinal obstruction implies poor prognosis, with high in-hospital mortality rate and severe postoperative complications. The decision regarding management of malignant intestinal obstruction must be multimodal and individualized, according to individual prognostic factors.

Serum glucose, urea nitrogen, cholesterol, and total proteins in crossbred repeat breeder and normally cyclic cows.

Objective:This study was designed to determine and compare the serum glucose, urea nitrogen, cholesterol, and total protein (TP) level in crossbred repeat breeder (RB) and normally cyclic cows to find out the relationship of these metabolic factors with repeat breeding syndrome (RBS).Materials and Methods:A total of 592 breedable cows from 34 farms were examined from Mymensingh and Chittagong districts. Seventy cows were identified as RB cows and another 10 cows were randomly selected as normally cyclic control cows for this study. Blood sample from each cow was collected and the serum was separated. The serum samples were analyzed by auto blood analyzer.Results:Cows affected with RBS had significant variation in their glucose, urea, and cholesterol levels. Serum glucose (43.00 gm/dl) level was significantly lower than in normally cyclic cows. On the other hand, serum urea and cholesterol levels were significantly higher than in normally cyclic cows. However, the TP concentrations did not differ between RB and cyclic cows. RB cows had a lower trend (6.815 mg/dl) of serum TP than in normally cyclic cows.Conclusion:This research might help scientists and veterinarians to understand that the high serum urea and cholesterol level along with low glucose and TP level could have some effect in the development of RBS in crossbred cows. It will potentially help veterinary practitioners and farmers to take preventive measures against RBS of crossbred cows.

Matrix metalloproteinase-9, 10, and stress hyperglycaemia in acute kidney injury.

This study investigated the effect of matrix metalloproteinase (MMP)-9 and 10, and stress hyperglycaemia on the necessity of emergency renal replacement therapy (RRT) and mortality in nondiabetic geriatric patients with acute kidney injury (AKI). The present observational and longitudinal study included 101 nondiabetic geriatric patients (age >65 years) with AKI. The serum levels of MMP-9 and MMP-10 were evaluated in these patients. Serum glucose level >140 mg/dL at the time of admission was accepted as stress hyperglycaemia. The average age of patients was 81 ± 7.1 years. Stress hyperglycaemia was diagnosed in 34.6% of the cases; the majority of these cases were patients with high-serum urea, CRP, and chronic kidney disease. The average levels of MMP-9 and MMP-10 were found to be 199 ± 38 and 16.5 ± 7.5 ng/mL, respectively. Thirty-one cases (30.6%) mortality during hospitalization and 20 cases (20%) underwent emergency RRT. Multiregression analysis showed the serum urea (P < .001) and stress hyperglycaemia (P = .03) to be independently associated with mortality. Also, serum urea (P = .01), potassium level (P = .03), and MMP-10 levels (P = .03) were independently associated with the necessity of the emergency RRT. The MMP-9 levels exhibited no relation with the necessity of emergency RRT and mortality. Stress hyperglycaemia is a common condition among nondiabetic geriatric patients with AKI and is related to mortality. Serum MMP-10 levels serve as an important predictor of the necessity of emergency RRT in these patients.

Thirst in heart failure: what do we know so far?

Thirst is a common and burdensome symptom of heart failure, which impacts adversely on quality of life. To date, there is limited research on the prevalence of thirst, the factors associated with thirst and interventions to help manage thirst in heart failure. This review summarizes key empirical research developments of thirst. Recent research shows that the heart failure syndrome, medications, self-care practice such as fluid restriction and anxiety contributes greatly to increased thirst in patients with heart failure. In addition, predictors such as being younger, male patient, with high symptom burden and serum urea is also associated with thirst. There are no intervention studies to manage thirst, only reports of various strategies recommended to heart failure patients in clinical practice. Despite the burden of thirst in heart failure patients, strategies to relieve thirst remains insufficiently addressed in literature. Further research to improve the understanding of the severity of thirst and its relationship to possible factors associated with thirst is required in order to develop future interventions to either prevent or alleviate troublesome thirst in patients with heart failure.