Hours Of Hospital Admission Research Articles

Pediatric ICU Transfers Within 24 Hours of Admission From the Emergency Department: Rate of Transfer, Outcomes, and Clinical Characteristics

There is a paucity of data describing pediatric patients transferred to an ICU within 24 hours of hospital admission from the emergency department (ED). We conducted a retrospective cohort study of patients ≤21 years old transferred from an inpatient floor to an ICU within 24 hours of ED disposition from 2007 to 2016 in a tertiary children's hospital. Patients transferred to an ICU after planned operative procedures were excluded. Rate of transfer, clinical course, and baseline demographic and/or clinical characteristics of these patients are described. The study cohort consisted of 841 children, representing 1% of 82 397 non-ICU ED admissions over the 10-year period. Median age was 5.1 years, 43% had ≥1 complex chronic condition, and 47% were hospitalized within the previous year (27% in the ICU). The majority of transfers were for respiratory conditions (65%) and cardiovascular compromise (18%). Median time from hospitalization to ICU transfer was 9.1 hours (interquartile range 5.1-14.9 hours). Thirty-eight percent of transfers received 1 or more critical interventions within 72 hours of hospitalization, most commonly positive pressure ventilation (29%) and vasoactive infusion (9%). Median time to intervention from hospitalization was 13.6 hours (interquartile range 7.5-21.6 hours), 0.8% of children died within 72 hours of hospitalization, and 2.4% died overall. In this single pediatric academic center, 1% of hospitalized children were transferred to an ICU within 24 hours of ED disposition. One-third of patients received a critical intervention, and 2.4% died. Although most ED dispositions are appropriate, future efforts to identify patients at the highest risk of deterioration are warranted.

Accuracy and prevalence of defining characteristics of the diagnosis Impaired gas exchange in children

Objective: to evaluate the accuracy and to determine the prevalence of the defining characteristics of the nursing diagnosis Impaired gas exchange in children with respiratory diseases. Methods: cross-sectional study carried out with 236 children who were in the initial 48 hours of hospital admission. A questionnaire was used with sociodemographic data and physical examination of the respiratory system to identify the defining characteristics of the studied diagnosis. For the analysis of the accuracy,the sensitivity and specificity measures were calculated. Results: the diagnosis Impaired gas exchange was present in 21.6% of the sample and the most prevalent defining characteristics were dyspnea and tachycardia. Regarding the accuracy measures, the characteristics that presented high sensitivity values were dyspnea and abnormal respiratory pattern, while cyanosis, hypoxemia, and restlessness obtained high values of specificity. Conclusion: the characteristics that stood out both for the accuracy measures and for the prevalence were dyspnea and abnormal respiratory pattern.

Variation in Laboratory Test Naming Conventions in EHRs Within and Between Hospitals: A Nationwide Longitudinal Study.

Electronic health records provide clinically rich data for research and quality improvement work. However, the data are often unstructured text, may be inconsistently recorded and extracted into centralized databases, making them difficult to use for research. We sought to quantify the variation in how key laboratory measures are recorded in the Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW) across hospitals and over time. We included 6 laboratory tests commonly drawn within the first 24 hours of hospital admission (albumin, bilirubin, creatinine, hemoglobin, sodium, white blood cell count) from fiscal years 2005-2015. We assessed laboratory test capture for 5,454,411 acute hospital admissions at 121 sites across the VA. The mapping of standardized laboratory nomenclature (Logical Observation Identifiers Names and Codes, LOINCs) to test results in CDW varied within hospital by laboratory test. The relationship between LOINCs and laboratory test names improved over time; by FY2015, 109 (95.6%) hospitals had >90% of the 6 laboratory tests mapped to an appropriate LOINC. All fields used to classify test results are provided in an Appendix (Supplemental Digital Content 1, http://links.lww.com/MLR/B635). The use of electronic health record data for research requires assessing data consistency and quality. Using laboratory test results requires the use of both unstructured text fields and the identification of appropriate LOINCs. When using data from multiple facilities, the results should be carefully examined by facility and over time to maximize the capture of data fields.

Early Prediction of Prognosis in Elderly Acute Stroke Patients.

Retrospective observational cohort study. Academic comprehensive stroke center. Elderly acute stroke patients-2005-2009 (n = 462), 2010-2012 (n = 122), and 2016-2017 (n = 123). None. After institutional review board approval, we retrospectively queried elderly stroke patients' data from 2005 to 2009 (training dataset) to build a model to predict mortality. We designed a multivariable logistic regression model as a function of baseline severity of illness and laboratory tests, developed a nomogram, and applied it to patients from 2010 to 2012. Due to updated guidelines in 2013, we revalidated our model (2016-2017). The final model included stroke type (intracerebral hemorrhage vs ischemic stroke: odds ratio [95% CI] of 0.92 [0.50-1.68] and subarachnoid hemorrhage vs ischemic stroke: 1.0 [0.40-2.49]), year (1.01 [0.66-1.53]), age (1.78 [1.20-2.65] per 10 yr), smoking (8.0 [2.4-26.7]), mean arterial pressure less than 60 mm Hg (3.08 [1.67-5.67]), Glasgow Coma Scale (0.73 [0.66-0.80] per 1 point increment), WBC less than 11 K (0.31 [0.16-0.60]), creatinine (1.76 [1.17-2.64] for 2 vs 1), congestive heart failure (2.49 [1.06-5.82]), and warfarin (2.29 [1.17-4.47]). In summary, age, smoking, congestive heart failure, warfarin use, Glasgow Coma Scale, mean arterial pressure less than 60 mm Hg, admission WBC, and creatinine levels were independently associated with mortality in our training cohort. The model had internal area under the curve of 0.83 (0.79-0.89) after adjustment for over-fitting, indicating excellent discrimination. When applied to the test data from 2010 to 2012, the nomogram accurately predicted mortality with area under the curve of 0.79 (0.71-0.87) and scaled Brier's score of 0.17. Revalidation of the same model in the recent dataset from 2016 to 2017 confirmed accurate prediction with area under the curve of 0.83 (0.75-0.91) and scaled Brier's score of 0.27. Baseline medical problems, clinical severity, and basic laboratory tests available within the first 12 hours of admission provided strong independent predictors of in-hospital mortality in elderly acute stroke patients. Our nomogram may guide interventions to improve acute care of stroke.

Antipseudomonal monotherapy or combination therapy for older adults with community-onset pneumonia and multidrug-resistant risk factors: a retrospective cohort study

Infectious Diseases Society of America guidelines recommend empiric antipseudomonal combination therapy when Pseudomonas is suspected. However, combination antipseudomonal therapy is controversial. This study compares all-cause 30-day mortality in older patients who received antipseudomonal monotherapy (PMT) or antipseudomonal combination therapy (PCT) for the treatment of community-onset pneumonia. This population-based, retrospective cohort study used data from over 150 Veterans Health Administration hospitals. Patients were classified as being at low, medium, or high risk of drug-resistant pathogens. In total, 31,027 patients were assigned to PCT or PMT treatment arms based on antibiotics received in the first 48 hours of hospital admission. The unadjusted 30-day mortality difference between PCT and PMT was most pronounced in the low-risk group (18% vs 8%), followed by the medium-risk group (24% vs 18%) and then the high-risk group (39% vs 33%). PCT was associated with higher 30-day mortality than PMT overall (adjusted odds ratio [aOR], 1.54; 95% confidence interval [CI], 1.43-1.66) in all 3 risk groups: low (aOR, 1.69; 95% CI, 1.50-1.89), medium (aOR, 1.30; 95% CI, 1.14-1.48), and high (aOR, 1.21; 95% CI, 1.04-1.40). Older adults who received combination antipseudomonal therapy for community-onset pneumonia fared worse than those who received monotherapy. Empiric combination antipseudomonal therapy should not be routinely offered to all patients suspected of having pseudomonal pneumonia.

Factors related to delayed intensive care unit admission from emergency department—A retrospective cohort study

The delays in transferring patients from emergency department (ED) to intensive care unit (ICU) are known to be linked with several adverse events, including prolonged ICU stay and increased hospital mortality. The factors associated with delayed ICU admission include shortage of ICU beds, organizational factors, ED overcrowding, and patient-related factors, including sepsis as admission diagnosis. The aim of this study was to examine ED-related factors associated with prolonged ED stay. The study population consisted of adult patients admitted (n=479) from ED to ICU between 31 May 2016 and 19 March 2017 in Oulu University Hospital. A patient's ED length of stay (LOS) exceeding 180minutes was considered delayed. Most of the patients (380, 79.3%) were admitted to the ICU within 3hours of hospital admission. In a logistic regression analysis, odds ratios (ORs) for ED LOS>180minutes were as follows: for Glasgow Coma Scale score>9, 2.73 (1.39-5.32); for thrombocytes<100×109 /mmol, 6.69 (2.32-19.26); for absence of pre-arrival notification, 5.27 (3.04-9.14); and for radiological examination, 3.95 (1.72-9.10). Trauma and intoxicated patients had shorter ED LOS while patients with medical conditions had more often prolonged admissions. The delays in ICU admissions were linked to therapeutic and diagnostic procedures and absence of pre-arrival notification. Patients were admitted to the ICU on the basis of diagnosis instead of clinical risk. However, the delays were not associated with worsening outcome, which indicates that sufficient care can be provided at the ED while the ICU admission is pending.

Relationship between external ventricular drain clamp trials and ventriculoperitoneal shunt insertion following nontraumatic subarachnoid hemorrhage: a single-center study.

Currently, there is no established standard regarding the ideal number of external ventricular drain (EVD) clamp trials performed before ventriculoperitoneal (VP) shunt insertion following nontraumatic subarachnoid hemorrhage (SAH). In this study, the authors aimed to evaluate this relationship. A retrospective review of all patients presenting with SAH between July 2007 and December 2016 was performed. Patients with SAH who had received an EVD within the first 24 hours of hospital admission and had undergone at least 1 clamp trial prior to EVD removal were eligible for inclusion in the study. Patient demographics, clinical presentations, SAH etiologies and grades, clamp trial data, hospital lengths of stay, and functional outcomes were recorded. One hundred fourteen patients with nontraumatic SAH complicated by posthemorrhagic hydrocephalus were included in the study. The median patient age was 57 years (range 28-90 years), with a male/female ratio of 1:1.7. A ruptured aneurysm was the underlying etiology of SAH in 79.8% of patients. A majority of patients (69.4%) had a Hunt and Hess grade III-V on admission. The median number of clamp trials performed was 2 (range 1-6). A VP shunt was required in 40.4% of patients. In those who underwent 2 and 3 clamp trials, 60% and 38.9%, respectively, did not require subsequent VP shunt placement. Surgical placement of a VP shunt is associated with complications. Clamp trials are routinely performed before making the decision to insert a shunt. In the present study, the authors found that a significant percentage of patients passed their second and third clamp trials without requiring subsequent shunt insertion. These data support performing multiple clamp trials prior to shunt placement.

Nutritional status and evaluation of the perioperative fasting time among patients submitted to elective and emergency surgeries at a reference hospital.

to evaluate the clinical, surgical, and nutritional profile of surgical patients admitted to a reference hospital in Recife city, Pernambuco state, Brazil. a cross-sectional study carried out in the wards of the General Surgery Service of Hospital da Restauração Governador Paulo Guerra, from June to September 2018. We included adult and elderly patients (both genders) who were submitted to thoracoabdominal procedures and elective or emergency abdominal surgeries, and in which the assessment of nutritional status could be performed within 72 hours of hospital admission. Data on nutritional status and surgical procedures, as well as clinical and biochemical information, were collected. we studied 140 patients with median age of 45 years. Among all, 59.3% were female and 23% malnourished, according to Subjective Global Assessment. The median preoperative fasting time was 15 hours for size I surgeries and 13.5 hours for size II ones. Longer postoperative hospital stay showed a strong correlation with the total length of hospital stay in both surgical sizes. Malnourished patients had a longer period of perioperative fasting and hospital stay when compared to well-nourished patients (p<0.001). the perioperative fasting time for elective surgeries was longer than recommended by literature. Patients with longer fasting spent more time in hospital.

1881. Empiric Pseudomonal Monotherapy vs. Combination Therapy for Community-Onset Pneumonia in Older Adults

BackgroundPatients with pseudomonal pneumonia have a poor prognosis; therefore, IDSA guidelines recommend empiric antipseudomonal combination therapy when Pseudomonas is suspected, at least until treatment can be adjusted based on susceptibilities. However, combination antipseudomonal therapy is controversial. This study compared all-cause 30-day mortality in older patients who received antipseudomonal monotherapy (PMT) or antipseudomonal combination therapy (PCT) for the treatment of community-onset pneumonia.MethodsThis population-based cohort study used data from over 150 Veteran Health Administration hospitals. Patients were classified as low, medium, or high risk of drug-resistant pathogens according to a published rule. Patients were assigned to PCT or PMT groups based on antibiotics received in the first 48 hours of hospital admission. Separate multivariable logistic regression models were constructed to determine whether the choice of PCT or PMT was associated with 30-day mortality, after accounting for divergent baseline characteristics. Adjusted odds ratios (aORs) and 95% confidence intervals (95% CI) were calculated for the overall, low, medium, and high-risk groups.ResultsOf the 31,027 patients who met study criteria, 23% received PCT and 77% received PMT. Patients belonged to low (59%), medium (24%), and high (18%) risk groups. 30-day mortality was 18% overall, and increased among the groups: low (13%), medium (21%), and high (36%). Patient age (median of 78 years), race (>80% white), and sex (>98% male) were similar for patients receiving PCT and PMT. The unadjusted mortality difference between PCT and PMT was most pronounced in the low-risk group (18% vs. 8%, 10% absolute risk difference), followed by the medium (24% vs. 18%, 6% difference) and high (39% vs. 33%, 6% difference) risk groups. PCT was associated with higher 30-day mortality than PMT overall (aOR, 1.54; 95% CI, 1.43–1.66), and in all three groups: low (aOR, 1.69; 95% CI, 1.50–1.89), medium (aOR, 1.30; 95% CI, 1.14–1.48), and high (aOR, 1.21; 95% CI, 1.04–1.40).ConclusionOlder adults who received empiric combination antipseudomonal therapy for community-onset pneumonia fared worse than those who received monotherapy. Empiric combination antipseudomonal therapy should not be routinely offered to all patients suspected of having pseudomonal pneumonia.Disclosures All authors: No reported disclosures.

2266. Persistent Inflammation in HIV Patients With Community-Acquired Pneumonia and Its Correlation With Lung Injury

BackgroundHIV patients face higher rates of morbidity compared with the general population, largely due to the earlier development of age related diseases (cardiovascular, kidney, and liver disease). While it is likely that chronic immune activation and inflammation are the main contributors to this process, it’s relation to lung injury in HIV remains unknown. Despite restoration of systemic immune function following Antiretroviral Therapy, the risk for lower respiratory tract infection remain elevated in the HIV population. The objective of the study was to assess the relationship between pulmonary inflammation and lung injury.MethodsA prospective cohort study was performed, participants include patients hospitalized in Hospital Universitario San Vicente Fundación and Clínica SOMA, in Colombia. Patients were eligible if they were over the age of 18 and had a documented HIV infection or if they have HIV with newly diagnosed community acquired pneumonia (CAP). The main exclusion criteria were chronic lung disease and immunosuppression that is not due to HIV. Patients belonged to two groups: HIV and HIV + CAP. Plasma, sputum samples and pulmonary function test measurements (PFT) were retrieved within 48 hours of hospital admission and at one month follow-up. The concentrations of 13 biomarkers were measured and correlated with PFT values, followed by a comparison between the two groups.ResultsPrinciple Component Analysis revealed that CCL3, CCL4, BAFF, APRIL, and TIMP-1 accounts for the majority of the variation between the two groups. Furthermore, Kruskal–Wallis testing demonstrates that BAFF and CCL3 are elevated in the HIV + CAP group, compared with the HIV group (P < 0.005). Other markers of bacterial translocation and monocyte activation did not differ between these groups. FVC and FEV1 measurements are lower in the HIV + CAP group compared with the HIV group, while FEV1/FVC remain constant.ConclusionThe results of this study identify a unique constellation of biomarkers in HIV patients with CAP, this constellation of biomarkers consists of pro-inflammatory cytokines and regulators of extracellular matrix remodeling, hinting at the occurrence of an inflammatory and tissue injuring process in the lungs. This is supported by the restrictive ventilation pattern seen in this group of patients.Disclosures All authors: No reported disclosures.

Abstract 279: Cardiac Arrest is Associated With a Global Level Alteration in Oxygen Metabolism: A Clinical Pilot Study

Objective: We recently reported that a global-level metabolic alteration occurs after cardiac arrest (CA) in our high fidelity rodent model. The finding was that dissociation of O 2 consumption (VO 2 ) and carbon dioxide generation (VCO 2 ) resulted in a respiratory quotient (RQ: calculated by dividing VCO 2 by VO 2 ) that fell well outside the normally cited range of 0.7-1.0. We hypothesized that a lowered RQ is similarly found in human CA patients. Methods: The study consisted of three subject groups: 1) healthy volunteer, 2) post-surgical patient (control) and 3) post-CA patient. We measured the VO 2 and VCO 2 of mechanically ventilated subjects using the Douglas bag method. Inspiration and expiration gas samples were collected in two separate bags . and RQ was calculated from CO 2 and O 2 gas concentrations in the samples. The patients and healthy volunteers were ventilated using the same model mechanical ventilator. Alert healthy volunteers bit onto a mouthpiece and the samples were collected, while post-surgical and post-CA patients were unconscious during the measurements. We measured the RQ of healthy volunteers at normal and high fractions of inspired oxygen (FIO 2 ) in order to test the validity of our methods at various inspired O 2 levels. Results: The RQs of the three healthy volunteers were 0.83, 0.92 and 0.85 at an FIO 2 of 0.21 and 0.86, 0.88, and 0.83 at an FIO 2 of 0.90 respectively. The RQs of the two post-surgical patients were 0.92 and 0.88 at an FIO 2 of 0.5. None of the post-surgical patients had any complications following the surgery and all were discharged. The RQ of a post-CA patient measured 2.5 hours after the CA was found to be 0.72 at an FIO 2 of 0.9. The CA patient expired within 24 hours of hospital admission. Conclusions: The same trend between the findings of both our rodent study and the CA patient suggest that resuscitation from CA alters cellular metabolism on a global level. This metabolic alteration in turn causes the dissociation of O 2 consumption and CO 2 generation resulting in a lowered RQ. Our findings warrant a larger clinical study to confirm a lowered RQ in post-CA patients and bench work to elucidate the causative mechanism of this relationship.

Effect of Thiamine Administration on Lactate Clearance and Mortality in Patients With Septic Shock.

Mounting evidence has shown that critically ill patients are commonly thiamine deficient. We sought to test the hypothesis that critically ill patients with septic shock exposed to thiamine would demonstrate improved lactate clearance and more favorable clinical outcomes compared with those not receiving thiamine. Retrospective, single-center, matched cohort study. Tertiary care academic medical center. Adult patients admitted with an International Classification of Diseases, 9th Edition, or International Classification of Diseases, 10th Edition, diagnosis code of septic shock to either the medicine or surgery ICU. None. Patients who received IV thiamine supplementation within 24 hours of hospital admission were identified and compared with a matched cohort of patients not receiving thiamine. The primary objective was to determine if thiamine administration was associated with a reduced time to lactate clearance in septic shock. Secondary outcomes included 28-day mortality, acute kidney injury, and need for renal replacement therapy, and vasopressor and mechanical ventilation-free days. Two-thousand two-hundred seventy-two patients were screened, of whom 1,049 were eligible. The study consisted of 123 thiamine-treated patients matched with 246 patients who did not receive thiamine. Based on the Fine-Gray survival model, treatment with thiamine was associated with an improved likelihood of lactate clearance (subdistribution hazard ratio, 1.307; 95% CI, 1.002-1.704). Thiamine administration was also associated with a reduction in 28-day mortality (hazard ratio, 0.666; 95% CI, 0.490-0.905). There were no differences in any secondary outcomes. Thiamine administration within 24 hours of admission in patients presenting with septic shock was associated with improved lactate clearance and a reduction in 28-day mortality compared with matched controls.

Total serum calcium and corrected calcium as a predictor of severity in acute pancreatitis

Background: Acute pancreatitis is an acute inflammatory process of the pancreas. The Ranson and the modified Glasgow scores require 48 hours of data collection to asses’ severity. Hypocalcaemia is one of the components of Ranson's scoring system done to assess the severity of pancreatitis. Albumin-corrected calcium (ACC) has also been associated with severity, but no study has evaluated it as a prognostic severity factor within the first 24 h of the patient’s hospital admission. This study tries to evaluate total calcium and albumin corrected calcium as prognostic severity markers in acute pancreatitis within first 24 hour of admission.Methods: This prospective study was conducted in Bowring and Lady Curzon hospital, a tertiary care centre from June 2016 to May 2018. Inclusion criteria included all patients above 18 years of age, who presented within 72 hours of onset of epigastric pain. The clinical and demographic data with respect to gender, age, previous history of pancreatitis, total calcium taken 24 h after admission. In order to evaluate total calcium and albumin corrected calcium as prognostic factors of severity, the lowest total calcium values were collected within the first 24 h of hospital admission. These values were then corrected according to the serum albumin level.Results: A total of ninety-four patients were included in the study. There was no significant difference in the age of patients in each severity grade (p value: 0.242). No difference was observed in gender distribution of three groups. (P &gt;0.05). As compared to total calcium, mean values of albumin corrected calcium were 8.03, 7.18 and 6.28 for mild, moderate and severe acute pancreatitis respectively, which were also significant at 0.05.Conclusions: Total calcium and albumin-corrected calcium obtained within the first 24 hours of hospital admission are useful predictors of severity in acute pancreatitis.

Prehospital shock index, modified shock index, and pulse pressure heart rate ratio as predictors of massive blood transfusions in modern warfare injuries: A retrospective analysis

BackgroundMassive hemorrhage is the leading preventable cause of death in modern warfare injuries. Early and accurate detection of source of hemorrhage and massive blood transfusions remain the mainstay of management in such cases. Hemodynamic indices like shock index (SI), modified shock index (MSI), and pulse pressure heart rate (PP/HR) ratio have shown promising results in predicting massive transfusion in trauma patients. The present study aimed at assessing the accuracy of SI, MSI, and PP/HR ratio to predict the requirement of massive blood transfusions. MethodsA retrospective analysis was done from 1st January 2016 to 31st December 2016 of the data taken from the trauma register of our hospital. Data were analyzed, and scores of SI, MSI, and PP/HR ratio were evaluated using area under receiver operating curves (AUROCs). Massive transfusion was defined as requirement of ≥10 packed red blood cells (PRBCs) in the first 24 hours or ≥4 PRBCs in first hour of hospital admission. ResultsOf the 326 warfare casualties received, a total of 254 patients were enrolled, and 51(23%) patients required massive transfusion on arrival. SI had an AUROC value of 0.798 (95% confidence interval [CI] = 0.739–0.848) which is comparable to MSI at 0.787 (95% CI = 0.728–0.839) and PP/HR ratio with a value of 0.744 (95% CI = 0.681–0.800), (p<0.001). ConclusionSI, MSI, and PP/HR ratio are equally efficient in predicting massive transfusion in warfare injuries and can be used as rapidly available marker for prediction of massive transfusion in warfare injuries which can be lifesaving and time-saving.

Supermassive Transfusion: A 15-Year Single Center Experience and Outcomes

The objective of this study was to determine the survival outcome associated with large-volume blood transfusion after trauma. This was a retrospective study at a Level I trauma center from January 2000 to December 2014 that included trauma patients who received ≥25 units packed red blood cell (pRBC) within the first 24 hours of hospital admission. Univariate and multivariable logistic regressions identified risk factors for mortality. Receiver operating characteristic curve analysis evaluated the ability of pRBC volume to predict mortality. Among 74,065 adults (≥18 years old), 178 patients (0.24%) received ≥25 units of pRBC in the first 24 hours, of which 142 (79.8%) received 25 to 49 units, 28 (15.7%) received 50 to 74 units, and 8 (4.5%) received ≥75 units. Overall, 92.2 per cent were male, mean age 33.9 (±14.0), mean Injury Severity Score 28.9 (±14.3), and median Glasgow Coma Scale score 12 (3-15). The overall mortality was 65.2 per cent and 64.1 per cent for those receiving 25 to 49 units, 64.3 per cent for 50 to 74 units, and 87.5 per cent for ≥75 units. In univariate analysis, female gender was associated with lower mortality [odds ratio (OR) 0.24, P = 0.025]. Decreasing Glasgow Coma Scale (OR 0.82, P < 0.001), increasing Injury Severity Score (OR 1.07, P < 0.001), and thoracotomy (OR 3.91, P < 0.001) were associated with higher mortality. There was no transfusion cutoff that was significantly associated with higher mortality.

Acute cholecystitis - a cohort study in a real-world clinical setting (REWO study, NCT02796443).

BackgroundFor decades, the optimal timing of surgery for acute cholecystitis has been controversial. Recent meta-analyses and population-based studies favor early surgery. One recent large randomized trial has demonstrated that a delayed approach increases morbidity and cost compared to early surgery within 24 hours of hospital admission. Since cases of severe cholecystitis were excluded from this trial, we argue that these results do not reflect real-world clinical situations. From our point of view, these results were in contrast to the clinical experience with our patients; so, we decided to analyze critically all our patients with the null hypothesis that the patients treated with a delayed cholecystectomy after an acute cholecystitis have a similar or even better outcome than those treated with an early operative approach.Patients and methodsWe retrospectively analyzed clinical data from all patients with cholecystectomies in the period between January 2006 and September 2015. A total of 1,723 patients were categorized into four groups: early (n=138): urgent surgery of patients with acute cholecystitis within the first 72 hours of the onset of symptoms; intermediate (n=297): surgery of patients with acute cholecystitis within an average of 10 days after the onset of symptoms; delayed (n=427): initial non-surgical treatment of acute cholecystitis with surgery performed within 6–12 weeks of the onset of symptoms; and elective (n=868): cholecystectomy within a symptom-free interval of choice in patients with symptomatic cholecystolithiasis without signs of acute cholecystitis.ResultsIn a real-world scenario, early/intermediate cholecystectomy in acute cholecystitis was associated with a significant increase in morbidity and mortality (Clavien–Dindo score) compared to a delayed approach with surgery performed 6–12 weeks after the onset of symptoms. The adjusted linear rank statistics showed a decrease in the complication score with values of 2.29 in the early group, 0.48 in the intermediate group, –0.26 in the delayed group and –2.12 in the elective group. The results translate into a continuous decrease of the complication score from early over intermediate and delayed to the elective group.ConclusionThese results demonstrate that delayed cholecystectomy can be performed safely. In cases with severe cholecystitis, early and/or intermediate approaches still have a relatively high risk of morbidity and mortality.

Development and Validation of an Electronic Health Record–Based Machine Learning Model to Estimate Delirium Risk in Newly Hospitalized Patients Without Known Cognitive Impairment

Current methods for identifying hospitalized patients at increased risk of delirium require nurse-administered questionnaires with moderate accuracy. To develop and validate a machine learning model that predicts incident delirium risk based on electronic health data available on admission. Retrospective cohort study evaluating 5 machine learning algorithms to predict delirium using 796 clinical variables identified by an expert panel as relevant to delirium prediction and consistently available in electronic health records within 24 hours of admission. The training set comprised 14 227 adult patients with non-intensive care unit hospital stays and no delirium on admission who were discharged between January 1, 2016, and August 31, 2017, from UCSF Health, a large academic health institution. The test set comprised 3996 patients with hospital stays who were discharged between August 1, 2017, and November 30, 2017. Patient demographic characteristics, diagnoses, nursing records, laboratory results, and medications available in electronic health records during hospitalization. Delirium was defined as a positive Nursing Delirium Screening Scale or Confusion Assessment Method for the Intensive Care Unit score. Models were assessed using the area under the receiver operating characteristic curve (AUC) and compared against the 4-point scoring system AWOL (age >79 years, failure to spell world backward, disorientation to place, and higher nurse-rated illness severity), a validated delirium risk-assessment tool routinely administered in this cohort. The training set included 14 227 patients (5113 [35.9%] aged >64 years; 7335 [51.6%] female; 687 [4.8%] with delirium), and the test set included 3996 patients (1491 [37.3%] aged >64 years; 1966 [49.2%] female; 191 [4.8%] with delirium). In total, the analysis included 18 223 hospital admissions (6604 [36.2%] aged >64 years; 9301 [51.0%] female; 878 [4.8%] with delirium). The AWOL system achieved a baseline AUC of 0.678. The gradient boosting machine model performed best, with an AUC of 0.855. Setting specificity at 90%, the model had a 59.7% (95% CI, 52.4%-66.7%) sensitivity, 23.1% (95% CI, 20.5%-25.9%) positive predictive value, 97.8% (95% CI, 97.4%-98.1%) negative predictive value, and a number needed to screen of 4.8. Penalized logistic regression and random forest models also performed well, with AUCs of 0.854 and 0.848, respectively. Machine learning can be used to estimate hospital-acquired delirium risk using electronic health record data available within 24 hours of hospital admission. Such a model may allow more precise targeting of delirium prevention resources without increasing the burden on health care professionals.

Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia.

Children with acute pneumonia may be vitamin D deficient. Clinical trials have found that prophylactic vitamin D supplementation decreases the risk of developing pneumonia in children. Data on the therapeutic effects of vitamin D in acute childhood pneumonia are limited. To evaluate the efficacy and safety of vitamin D supplementation as an adjunct to antibiotics for the treatment of acute childhood pneumonia. We searched CENTRAL (2017, Issue 7), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register; Ovid MEDLINE Epub Ahead of Print; In-Process & Other Non-Indexed Citations; Ovid MEDLINE Daily and Ovid MEDLINE (1946 to July Week 4, 2017); and Embase (2010 to 28 July 2017). We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 28 July 2017. There were no language restrictions. Randomised controlled trials (RCTs) including children (aged over one month and up to five years) hospitalised with acute community-acquired pneumonia, as defined by the WHO acute respiratory infection guidelines, that compared vitamin D supplementation with control. Two review authors independently assessed studies for inclusion and extracted data. For dichotomous data, we extracted the number of participants experiencing the outcome and the total number of participants in each treatment group. For continuous data, we used the arithmetic mean and standard deviation (SD) for each treatment group together with numbers of participants in each group. We used standard methodological procedures expected by Cochrane. We included seven RCTs conducted in low-income countries that involved 1529 children (780 with pneumonia and 749 with severe or very severe pneumonia). Four studies used a single 100,000 IU dose of vitamin D₃ at the onset of illness or within 24 hours of hospital admission; two used a daily dose of oral vitamin D₃ (1000 IU for children aged up to one year and 2000 IU for children aged over one year) for five days; and one used a daily dose of oral vitamin D₃ (50,000 IU) for two days. One study reported microbiological and radiological diagnosis of pneumonia.The effects of vitamin D on outcomes were inconclusive when compared with control: time to resolution of acute illness (hours) (mean difference (MD) -0.95, 95% confidence interval (CI) -6.14 to 4.24; 3 studies; 935 children; low-quality evidence) mortality rate (risk ratio (RR) 0.97, 95% CI 0.06 to 15.28; 1 study; 193 children; very low-quality evidence); duration of hospitalisation (MD 0.49, 95% CI -8.41 to 9.4; 4 studies; 835 children; very low-quality evidence) and time to resolution of fever (MD 1.66, 95% CI -2.44 to 5.76; 4 studies; 584 children; very low-quality evidence).No major adverse events were reported.The GRADE assessment found very low-quality evidence (due to serious study limitations, inconsistencies, indirectness, and imprecision) for all outcomes except time to resolution of acute illness.One study was funded by the New Zealand Aid Corporation; one study was funded by an institutional grant; and five studies were unfunded. We are uncertain as to whether vitamin D has an important effect on outcomes because the results were imprecise. No major adverse events were reported. We assessed the quality of the evidence as very low to low. Several trials are ongoing and may provide additional information.

Inclusion of Unstructured Clinical Text Improves Early Prediction of Death or Prolonged ICU Stay.

Early prediction of undesired outcomes among newly hospitalized patients could improve patient triage and prompt conversations about patients' goals of care. We evaluated the performance of logistic regression, gradient boosting machine, random forest, and elastic net regression models, with and without unstructured clinical text data, to predict a binary composite outcome of in-hospital death or ICU length of stay greater than or equal to 7 days using data from the first 48 hours of hospitalization. Retrospective cohort study with split sampling for model training and testing. A single urban academic hospital. All hospitalized patients who required ICU care at the Beth Israel Deaconess Medical Center in Boston, MA, from 2001 to 2012. None. Among eligible 25,947 hospital admissions, we observed 5,504 (21.2%) in which patients died or had ICU length of stay greater than or equal to 7 days. The gradient boosting machine model had the highest discrimination without (area under the receiver operating characteristic curve, 0.83; 95% CI, 0.81-0.84) and with (area under the receiver operating characteristic curve, 0.89; 95% CI, 0.88-0.90) text-derived variables. Both gradient boosting machines and random forests outperformed logistic regression without text data (p < 0.001), whereas all models outperformed logistic regression with text data (p < 0.02). The inclusion of text data increased the discrimination of all four model types (p < 0.001). Among those models using text data, the increasing presence of terms "intubated" and "poor prognosis" were positively associated with mortality and ICU length of stay, whereas the term "extubated" was inversely associated with them. Variables extracted from unstructured clinical text from the first 48 hours of hospital admission using natural language processing techniques significantly improved the abilities of logistic regression and other machine learning models to predict which patients died or had long ICU stays. Learning health systems may adapt such models using open-source approaches to capture local variation in care patterns.

Renal Allografts from Brain Dead Donors Following Cerebral Gunshot Wounds

Renal allografts from brain dead donors following cerebral gunshot wounds. Introduction Severe brain injury following cerebral gunshot wounds may expose large amounts of tissue factor to the circulation and develop disseminated intravascular coagulation (DIC). DIC can lead to renal dysfunction. Objectives Analyse the validity for transplantation of kidneys harvested from brain dead donors (BDD) following cerebral gunshot wounds and the outcome of the transplanted renal grafts. Methods Retrospective descriptive study of renal allografts harvested from BDD following cerebral gunshot wounds, at a single center, between June 1, 2007 and May 31, 2017. Data on donors (patients´ characteristics, blood tests, associated injuries) and recipients (graft survival, rejection) were collected. Results We analysed data from six BDD following cerebral gunshot wounds (age 40.3 ± 9.6 years) without any cardiovascular risk factors, except one patient who had hypertension. All patients presented brain death in the first 24 hours of hospital admission. None of them had any associated injuries. One patient suffered a cardiopulmonary arrest (during 20 minutes) prior to ICU admission. One of the patients had elevated creatinine levels in the blood tests when he was admitted to the hospital. But, during the ICU length of stay, up to 50% of the patients presented acute renal failure. Fifty percent of the patients presented compatible or suggestive criteria for DIC. Four kidney grafts were not valid for transplantation because: acute renal failure (two kidney grafts), poor graft perfusion (one case) and complex vascular anomalies (one case). Eight kidney grafts (66.67%) were transplanted. Seven kidney grafts were transplanted in our center. One of them was explanted, in the first 24 hours after transplantation, due to cortical necrosis (pathology report: glomerular and vascular thrombotic microangiopathy lesions). Figure 1. The donor's contralateral kidney was not implanted due to poor perfusion. The pathology report of this kidney was: multiple fibrin trombi in glomerular capillaries and small-vessels (Figure 2). The remaining 6 grafts presented adequate function one year after the transplantation, except in one case which suffered underlying disease recurrence.Conclusion An accurate evaluation of kidney grafts from BDD following cerebral gunshot wounds is required, because those patients are at risk for DIC and acute renal failure. Almost all transplanted renal allografts from BDD, following cerebral gunshot wounds, had good results in our study. Pre-transplant biopsy and, perhaps, the reduction of ischemia time may be indicated. Further studies with larger simple sizes are needed.