Hours Of Hospital Admission Research Articles

A Knowledge Distillation Ensemble Framework for Predicting Short- and Long-Term Hospitalization Outcomes From Electronic Health Records Data.

The ability to perform accurate prognosis is crucial for proactive clinical decision making, informed resource management and personalised care. Existing outcome prediction models suffer from a low recall of infrequent positive outcomes. We present a highly-scalable and robust machine learning framework to automatically predict adversity represented by mortality and ICU admission and readmission from time-series of vital signs and laboratory results obtained within the first 24 hours of hospital admission. The stacked ensemble platform comprises two components: a) an unsupervised LSTM Autoencoder that learns an optimal representation of the time-series, using it to differentiate the less frequent patterns which conclude with an adverse event from the majority patterns that do not, and b) a gradient boosting model, which relies on the constructed representation to refine prediction by incorporating static features. The model is used to assess a patient's risk of adversity and provides visual justifications of its prediction. Results of three case studies show that the model outperforms existing platforms in ICU and general ward settings, achieving average Precision-Recall Areas Under the Curve (PR-AUCs) of 0.891 (95% CI: 0.878-0.939) for mortality and 0.908 (95% CI: 0.870-0.935) in predicting ICU admission and readmission.

Can B-Type Natriuretic Peptide (BNP) Levels Serve as an Early Predictor of Clinical Severity in Patients with COVID-19 Pneumonia?

COVID-19 has continued to aggressively spread and kill. The incidence of complications and associated mortality rates are high. Cardiac damage, which is related to survival, is one of these. The purpose of this study is to assess the role of BNP, a cardiac biomarker, in predicting mortality in COVID-19. This single-center, prospective observational study was performed from July to September 2020 in a tertiary university hospital designated for the treatment of COVID-19 patients. Patients whose diagnoses were confirmed with real-time polymerase chain reaction (RT-PCR) tested nasopharyngeal swabs and with thoracic computed tomography (CT) findings compatible with COVID-19 pneumonia were included in the study. All clinical and laboratory data were obtained within the first 24 hours of hospital admission. To determine the risk of in-hospital death, patients were followed from admission until their discharge (1 to 15 days). The primary outcome was in-hospital death, defined as the case-fatality ratio. Among all biomarkers that were included in the multivariate analysis only high BNP levels was independently associated with mortality [Mean 1.012, 95% CI (1.005 - 1.02 pg/mL) (p = 0.002)]. Mortality was found to be significantly associated with older age and higher BNP, LDH, AST, HGB, PLT, ferritin, D-dimer, and CRP levels. In addition, mortality was found to be higher with longer duration of hospitalization (p = 0.041). Our fundamental goal for COVID-19 is to determine whether the hospitalized patients are in the mortality risk group at an early stage of disease. Adding measurement of BNP levels to routine laboratory tests for COVID-19 may be a practical approach to determine the patients with a high risk of mortality.

Profile of poisoning cases treated in a teaching hospital of Northeast India with special reference to Poison severity score: A cross-sectional study.

Poisoning has been one of the greatest medical emergencies from the dawn of human civilization, posing threat to mankind. Tripura being a seven sister state of Northeast India have a unique topography, diverse ethnic groups, cross-cultural food habits, agriculture, and a horticulture-based economy that draws some distinctive type of poisoning threats compared to the rest of the Indian subcontinent. The present study was carried out to find out the epidemiological factors, toxicological profiles, and clinical outcomes of patients after consumption of poison. A cross-sectional study on 212 patients with a complaint of poisoning was conducted in a teaching hospital in Tripura, India, for 2 years, and the data were analyzed by using SPSS-15 (Statistical Package for the Social Sciences) software. Out of 212 participants, males from lower socioeconomic status, farmers by occupation, and belonging to the age group of 21-30 years predominated other categories. Organophosphorus compounds were majorly ingested (38.7%). Suicide was the most common manner of poisoning (62.73%). The majority of the patients (75%) died during treatment, 39.15% of patients died in the initial 24 hours and 43.87% of the patients had severe life-threatening symptoms [grade 3 of poison severity score (PSS)] during the first 72 hours of hospital admission. A Spearman rho value of -0.740 and a P value <0.001 were found while establishing a relationship between survival time and PSS. Poisoning by any agents and means produces adverse effects on the human body which further influences the clinical outcome. Therefore, proper knowledge and attention regarding its clinico-toxico-epidemiological profile, accurate and timely diagnosis, and satisfactory management and prevention strategies are necessary.

Emergency brain imaging findings in children with first afebril convulsion

Convulsion is the most common neurological disease seen in childhood and constitutes 4-10% of all neurological diseases and 2% of the admissions to child emergency rooms. While the primary purpose of performing emergency neuroimaging in a child presenting with the first afebrile convulsion is to investigate intracranial pathologies that may require urgent intervention. The cranial imaging to be performed for this purpose are transfontanellar ultrasonography, computed tomography, and magnetic resonance imaging. We aimed to evaluate the necessity, the contribution to diagnosis, and the effect of treatment of magnetic resonance imaging that was performed in the emergency rooms. Patients who were admitted to the pediatric emergency room for a one-year complaint of their first afebrile convulsion and performed brain magnetic resonance imaging in the pediatric emergency room within the first 24 hours of hospital admission were evaluated retrospectively. A statistically significant correlation was found between the abnormal magnetic resonance imaging and abnormal physical examination of the patients (p&lt;0.001). By the brain magnetic resonance imaging findings acute changes were made in the treatment of 7 cases (1.3%) There was no statistically significant relationship between the magnetic resonance imaging abnormality and emergency seizures. We determined that it would be more appropriate to perform magnetic resonance imaging in outpatient clinics in cases where transportation can be provided early, in cases above 6 years of age without risk factors, and have a normal examination. Nonetheless, higher magnetic resonance imaging rates lead to lower computed tomography rates and ıts beneficial for pediatric patients in limiting radiation and providing definitive structural imaging for seizures.

Uticaj tajminga operacije preloma kuka na krajnji ishod lečenja

Introduction: Globally, the incidence of hip fractures has had an increasing trend, due to longer life expectancy. It is estimated that, by 2050, it will have reached 6.26 million cases a year. The aim of our review is the analysis of available literature on the relationship between the timing of hip fracture surgery and its impact on morbidity and mortality. Results: Over 85% of patients who suffer hip fracture are individuals older than 65 years with existing comorbidities. Even with adequate and optimal treatment, age and comorbidities predispose these patients to a worse prognosis and higher morbidity and mortality, as compared to the general population. The official position of AAOS is that patients who are operated on within 48 hours of hospital admission have a better treatment outcome. The reasons for delaying surgical treatment can be divided into medical and nonmedical. A large number of published studies support the claim that patients who are operated on 24 hours within hospital admission have a better outcome in terms of complications and mortality (after 30 days and after one year) than patients who are operated on later. On the other hand, several retrospective studies and meta-analyzes have shown that there is no significant difference in mortality between patients operated on 24 h, 36 h, and 48 h after admission. However, in these studies, surgical treatment within 4 days of admission has been identified as the most significant factor correlating with reduced mortality. Conclusion: Patients with hip fractures should be operated on within 24 hours of admission unless they have an acute medical condition that prevents surgery. If there is a medical condition that can be corrected, this window is prolonged to 48 hours, but the waiting time for surgical treatment should not be longer than 4 days.

Bloodstream infections in hospitalized patients before and during the COVID-19 surge in a community hospital in the South Bronx

Bloodstream infections in hospitalized patients before and during the COVID-19 surge in a community hospital in the South Bronx

Clinical application of AIMS65 score to predict outcome in patients with acute upper gastrointestinal bleeding

BACKGROUND: Acute upper gastrointestinal bleeding (AUGIB) is a potentially life-threatening condition that requires rapid assessment in the emergency department. The current available scores are complex and have not been widely used in clinical practice. AIMS65 score is a simple score that can be used to risk stratify patients with AUGIB.&#x0D; METHODS: This was a descriptive cross-sectional study done at a single tertiary centre, NAMS, Bir Hospital among the patients presenting with AUGIB from August 2018 to January 2019. AIMS65 scores were calculated in patients presenting with acute UGIB by allotting 1 point each for albumin level &lt; 3g/dl, INR &gt; 1.5, alteration in mental status, systolic blood pressure ≤90 mm Hg, and age ≥65 years. Risk stratification was done during the initial 12 hours of hospital admission.&#x0D; RESULTS: A total of 84 patients consisting of 68 males and 16 females were enrolled in our study, with age ranging from 27 to 80 years. ICU admission, endoscopic therapy and blood transfusion were required in 22,44 and 49 patients respectively. In-patient mortality, the need for blood transfusion, endoscopic therapy or ICU admission were higher in those with AIMS65 score ≥ 2 showing statistically significant positive association (p=0.000).&#x0D; CONCLUSION: AIMS65 score is a simple non-endoscopic risk score that can be applied in patients of acute upper gastrointestinal bleeding to risk stratify and to predict in-patient mortality, the need for blood transfusion, endoscopic therapy or ICU admission.

299. D-dimer as an ICU Admission Risk Predictor in COVID-19 Patients, A Prospective Study

BackgroundSince the onset of the 2019 coronavirus disease 2019 (COVID-19) pandemic, the rapid increase in community-acquired pneumonia (CAP) cases has led to an excessive rate of intensive care units (ICU) admissions, a rate varying between 5-18%, depending on the country. Consequently, the study of serum biomarkers, such as D-dimer, have been utilized to identify patient with severe disease. However, further data is needed to confirm the association between this serum concentration of D-dimer and the risk of ICU admission. Thus, the aim of this study was to determine if serum concentration of D-dimer predict the risk of ICU admission in patients with COVID-19 and CAP. MethodsA prospective observational study was carried out at the Clinica Universidad de La Sabana, Colombia. Patients older than 18 years old, hospitalized for COVID-19 or CAP were included. Then, patients were stratified into ICU and non-ICU patients. Plasma samples were collected within the first 24 hours of hospital admission to quantify D-dimer using the PATHFAST system. Concentrations were compared among groups and to assess the biomarker capacity to predict ICU admission risk, ROC curves were used. Finally, a DeLong test was applied to compare their differences. ResultsA total of 240 patients diagnosed with lower respiratory tract infection were included in the study. 88 patients were COVID-19 negative (CAP) and 152 were positive. Plasma concentrations of D-dimer (µg/ml) were significantly higher in COVID-19 patients admitted to the ICU when compared with non-ICU COVID-19 admitted patients (Median [IQR]; 1.54 [0.9-3.25] Vs. 1.13 [0.69-1.69], p=0.005). The area under curve (AUC) ROC to predict ICU admission was 0.62 among COVID-19 patients. DeLong’s test p value was 0.24. Serum D-dimer an ICU admission ConclusionD-dimer seems to be a promising tool to identify COVID-19 patients with disease. However, this predicting capacity was not observed in CAP patients. Further studies are needed to identify the mechanisms underling the elevation of D-dimer in COVID-19 patients. Disclosures All Authors: No reported disclosures

457. High Levels of Serum Troponin I Indicate Higher Mortality Risk in Patients with COVID-19

BackgroundUp until this day, over 3.5 million fatalities related to coronavirus disease 2019 (COVID-19) have been registered worldwide by the World Health Organization. Healthcare professionals require prognostic tools for COVID-19 patients in order to guide treatment strategies. Elevated troponin levels, a biomarker of cardiac injury, have been detected among patients with COVID-19, hence associating it with cardiac injury. Although several studies have mentioned it, the role of troponin as a prognosis biomarker is unclear. Elevation in troponin levels has been observed in patients with community-acquired pneumonia (CAP). However, its association with mortality is scarcely mentioned in literature. Thus, we sought to determine the utility of serum troponin I levels as a mortality predictor for patients with COVID-19 and CAP. MethodsA prospective observational study was carried out at Clinica Universidad de La Sabana, Colombia, with patients hospitalized due to CAP and COVID-19. Troponin biomarker was quantified in serum samples using the PATHFAST system within the first 24 hours of hospital admission. Serum concentrations of troponin were compared among study groups. To assess the biomarker′s capacity to predict mortality, ROC curves were used, quantifying their differences through the DeLong′s test. ResultsA total of 88 patients with CAP and 152 with COVID-19 were included in the study. In all cohort the median [IQR] serum concentration of troponin (ng/ml) was higher in those who died (34.2, [9.74-384] vs 5.89, [2.44-27.9] p< 0.001). Furthermore, troponin was higher in deceased patients with COVID-19 vs those who survived (77.35 [11.9-346.5] vs. 4.88 [2.10-13.02], p< 0.001). However, there was no significant difference between CAP deceased and not deceased patients (18.1 [8.52-398] vs 15.7 [3.75-62.8], p=0.16). Although sample size might be a limitation when analyzing these results, the AUC ROC of troponin I to predict mortality was 0.799 for COVID-19 and 0.615 for CAP, the DeLongs test for compared ROC curves was a p= 0.0351. A. Serum troponin I and mortality due to lower respiratory tract infections B. Serum troponin I to predict mortality in patients with lower tract infections C. ROC curve for serum troponin I to predict risk of mortalityConclusionOverall, troponin levels were higher among deceased patients. Our findings suggest that high troponin levels are a mortality predictor for patients with COVID-19.Disclosures All Authors: No reported disclosures

350. Joint Modeling of EHR and CXR Data to Predict COVID-19 Deterioration

BackgroundInfectious respiratory-track pathogens are a common trigger of healthcare capacity strain, e.g. the COVID19 pandemic. Patient risk stratification models to identify low-risk patients can help improve patient care processes and allocate limited resources. Many existing deterioration indices are based entirely on structured data from the Electronic Health Record (EHR) and ignore important information from other data sources. However, chest radiographs have been demonstrated to be helpful in predicting the progress of respiratory diseases. We developed a joint EHR and chest x-ray (CXR) model method and applied it to identify low-risk COVID19+ patients within the first 48 hours of hospital admission. MethodsAll COVID19+ patients admitted to a large urban hospital between March 2020 and February 2021 were included. We trained an image model using large public chest radiograph datasets and fine-tuned this model to predict acute dyspnea using a cohort from the same hospital. We then combined this image model with two existing EHR deterioration indices to predict the risk of a COVID19+ patient being intubated, receiving a nasal cannula, or being treated with a vasopressor. We evaluated models’ ability to identify low-risk patients by using the positive predictive value (PPV). ResultsThe image-augmented deterioration index was able to identify 12% of 716 COVID-19+ patients as low risk with 0.95 positive predictive value in the first 48 hours of admission. In contrast, when used individually, the EHR and CXR models each identified roughly 3% of the patients with a PPV of 0.95.Predicting Low Risk Patients Aggregated predictions for COVID19 positive patients within the first 48 hours of admission, shown with exponential weight moving average and 95% CIs. Each plot shows the number of patients flagged as low-risk by lowest aggregated prediction and the resulting accuracy for that fraction of patients. The bottom plot compares the MCURES fused model to the MCURES model. The top plot compares the EDI fused model to the EDI model.ConclusionOur multi-modal models were able to identify far more patients at low-risk of COVID19 deterioration than models trained on either modality alone. This indicates the importance of combining structured data with chest X-rays when creating a deterioration index performance for infectious respiratory-track diseases.Disclosures All Authors: No reported disclosures

1335. High Serum Levels of Interleukin-10 as a Predictor Factor of In-Hospital Mortality in COVID-19 Patients

BackgroundSince the spread of SARS-CoV-2 worldwide, there has been the need for scores and biomarkers to identify patients at risk of died or requiring admission to the intensive care units (ICU) admission. Interleukin-10 (IL-10) is released as a response to the infection, stimulating inflammatory pathways in the acute phase response. Thus, previous studies have shown that high serum concentrations IL-10 can be identify patients with severe community acquired pneumonia (CAP). Nevertheless, there is a lack of information regarding the capacity of IL-10 to identify severe COVID-19. Thus, the aim of this study was to determine the capacity of IL-10 as a prediction factor for mortality in hospital admitted patients with COVID-19 compared with CAP patients.MethodsA prospective observational study was carried out at the Clinica Universidad de La Sabana, Colombia. Patients older than 18 years and old, hospitalized due to COVID 19 or CAP, were included. Patients were stratified into COVID-19 and non-COVID-19 patients. IL-10 levels were quantified in serum samples using the LUMINEX technology. Serum samples were collected within the first 24 hours of hospital admission. Afterward, concentrations of interleukinwere statistically compared among groups. ROC curves were calculated. ResultsA total of 88 patients with CAP and 152 patients with COVID-19 were enrolled in the study. The median [with IQR] serum concentration of IL-10 were higher in those patients who died (81.1 [30.7-148.9] vs 18.8 [8.3-48.4] p-value < 0.0001). Then, comparing the study group, the median concentration of IL-10 levels among patients deceased by COVID-19 were higher than patients those who survived (85.1 [40-149.8] vs 32.4 [13.9-56.7] p-value < 0.001). In addition, IL-10 levels were higher in patients who survived COVID-19 compared with those who survived CAP (32.4 [13.9-56.7] vs 10.6 [4.9-18] p-value < 0.0001). The area under curve (AUC) ROC of IL-10 to predict mortality risk was 0.754 for all cohort. DeLong′s test comparing ROC curves in COVID-19 and CAP patients had a p= 0.744. ConclusionHigh serum levels of IL-10 are a good predictor of in-hospital mortality among COVID-19 patients. However, this risk association was not observed in CAP patients. Further studies are needed. Disclosures All Authors: No reported disclosures

531. Risk Factors and Therapeutic Interventions Associated with Mortality in Veterans Diagnosed With SARS-CoV-2 Infection (or COVID-19) Admitted to a Large Academic Medical Center

BackgroundPatient and treatment-related factors have been used to stratify COVID-19 outcomes; however, studies in the general population and specifically veterans have yielded variable results. This study was designed to assess how baseline characteristics and interventions correlate with clinical outcomes in patients admitted with COVID-19 at a large academic Veterans Affairs hospital.MethodsRetrospective chart review was conducted on veterans admitted to the hospital with COVID-19 between March 1 to December 31, 2020. Veterans without respiratory symptoms attributed to COVID-19 or enrolled in a COVID-19 clinical trial were excluded. Primary outcome was in-hospital mortality up to 28 days. Secondary outcomes were 90-day mortality, discharge to higher level of care or remained in the hospital within 28 days, and discharge with new oxygen requirement within 28 days. Patient characteristics and therapeutic interventions were assessed for correlation with primary and secondary outcomes. ResultsOf 497 hospitalized patients reviewed, 293 were included for analysis; 94% were male; average age was 68 years with 64.9% of veterans greater than 65 years of age; 43.7% were Black; 17.4% were Hispanic. In-hospital mortality at 28-days and 90-day mortality were 18.1% and 21.5%, respectively. At discharge, 34.1% had a new oxygen requirement and 17.5% went to a higher level of care. Patients that died in-hospital were more likely to be greater than 65 years of age (p< 0.001), Hispanic (p=0.007), have chronic kidney disease (CKD) (p=0.005), be admitted to ICU (p< 0.001); receive dexamethasone (p< 0.001), convalescent plasma (p< 0.001), or antibiotics (p< 0.001); require mechanical ventilation (p< 0.001); or have new onset atrial fibrillation (p< 0.001). Veterans also had higher levels of inflammatory markers within 48 hours of hospital admission (see Table 2) and longer length of hospital stay (< 0.001). There was a trend for patients that died in the hospital within 28-days to be less likely to be Black (p=0.06).Table 1. Primary and Secondary Outcomes of Study Population (n=293) Table 2. Patient Characteristics Stratified by Primary Outcome Table 3. Characteristics of the Patients that Survived to Discharge Stratified by Secondary Outcome Measures ConclusionPatients were more likely to die in-hospital within 28-days if they were greater than 65 years of age, Hispanic and had CKD. Veterans that died in-hospital within 28-days had higher inflammatory marker levels and were more likely to receive COVID-19 treatments. Disclosures All Authors: No reported disclosures

696. Optimal Duration of Prophylactic Antibiotics in Patients with Cirrhosis and Upper Gastrointestinal Bleeding

Abstract Background Spontaneous bacterial peritonitis (SBP) is a serious complication of variceal hemorrhage. Guidelines recommend a maximum of seven days of antibiotics after variceal hemorrhage to prevent SBP and reduce rates of rebleeding and mortality. However, studies supporting these guidelines used varied durations of therapy including those with less than seven days. The objective of this study was to determine if less than seven days of antibiotic prophylaxis was noninferior to seven or more days in patients with cirrhosis and variceal hemorrhage. Methods This was a single-center, retrospective cohort conducted from August 2019 to August 2020 including adult patients who received treatment for variceal hemorrhage and antibiotics for prevention of SBP during hospitalization. Patients were excluded if they were diagnosed with non-variceal hemorrhage, received treatment with antibiotics within 72 hours prior to the variceal hemorrhage, or expired or transitioned to end of life care within 48 hours of hospital admission. The primary outcome was in-hospital mortality. Secondary outcomes included SBP within the first 30 days after variceal hemorrhage, 30-day mortality, 30-day readmission rate, incidence of rebleeding at seven and 30 days, incidence of Clostridioides difficile infection, and intensive care unit and hospital length of stay. Results 64 patients were included with 45 patients in the less than seven days group and 19 patients in the seven or more days of antibiotic prophylaxis group. In each group, patients were primarily male with a median age of approximately 60 years. There was no difference in the primary outcome of in-hospital mortality between the less than seven days group as compared to the seven or more days group (22.2% vs 0%, p=1). No difference was identified between the less than seven days group as compared to the seven or more days group for any of the secondary outcomes. Conclusion This study identified no difference in patient-centered outcomes when comparing less than seven days of prophylactic antibiotics to seven or more days in patients with variceal hemorrhage. Less than seven days of prophylactic antibiotics may be a reasonable duration for prevention of SBP. Disclosures All Authors: No reported disclosures

A mixed-methods feasibility study of a sit-to-stand based exercise programme to maintain knee-extension muscle strength for older patients during hospitalisation.

Objectives:To determine the acceptability of an exercise programme and to identify barriers and facilitators to compliance with the programme from the participants’ perspective.Methods:Patients aged 75 years or older were recruited within the first 36 hours of hospital admission. Participants were randomised to complete two strengthening-based (intervention arm) or stretching-based (control arm) exercise sessions per-day. At hospital discharge, participants were asked to take part in interviews with a member of the research team exploring the barriers and facilitators to adherence to the intervention.Results:15 participants (7 intervention arm, 8 control arm) were recruited before the trial was stopped due to COVID-19. Both groups showed reductions in knee-extension strength, and improvements in functional mobility at discharge from hospital. A total of 23/60 intervention sessions were classed as ‘complete’, 12/60 as partially complete, and 25/60 were missed entirely. Eight participants took part in interviews. Intrinsic factors that impacted participation in the research, related to current health, health beliefs, and experience of multi-morbidity or functional decline. Staff had both a positive and negative effect on participant adherence to the intervention.Conclusions:The exercise intervention was well received, with most participants describing health benefits, though intervention fidelity was lower than expected.

Abstract 12228: Metformin Use in Patients Hospitalized With COVID-19: Lower Inflammation, Oxidative Stress, and Thrombotic Risk Markers and Better Clinical Outcomes

Introduction: Diabetes mellitus (DM) is associated with a greater risk of COVID-19 and an increased mortality when the disease is contracted. Metformin use in patients with DM is associated with less COVID-19-related mortality, but the underlying mechanism behind this association remains unclear. Hypothesis: We hypothesize that inhibitory effect of metformin on markers of inflammation, oxidative stress, and hypercoagulability is associate with better clinical outcomes. Methods: Patients with DM on metformin (n=34) and metformin naïve (n=41), and patients without DM (n=73) were enrolled within 48 hours of hospital admission and were diagnosed with COVID-19 by reverse transcription-polymerase chain reaction assay. Laboratory assessments were conducted within 48 hours of hospital admission. The chi-squared test was used to determine whether there was a significant difference in frequencies between disease groups; p&lt; 0.05 was considered a significant difference between groups. Results: DM patients on metformin compared to naïve patients had a lower white blood cell count (p=0.02), d-dimer (p=0.04), urinary 11-dehydro thromboxane B 2 (p=0.01) and urinary liver-type fatty acid binding protein (p=0.03) levels and had lower sequential organ failure assessment score (p=0.0002), intubation rate (p=0.03), and a trend for fewer hospitalized days (p=0.13), lower in-hospital mortality (p= 0.12) and lower mortality plus nonfatal thrombotic event occurrences (p=0.10). Patients on metformin had similar clinical outcomes compared to patients without DM. Conclusion: In conclusion, metformin treatment in COVID-19 patients with DM was associated with lower markers of inflammation, renal ischemia, and thrombosis; and fewer hospitalized days and intubation requirement. Further focused studies are required to support these findings.

Abstract 12563: The Trajectory of Platelet Factor 4 in Acute Myocardial Infarction and the Impact of PCSK9-Inhibition

Introduction: Increased platelet activity during the peri- and early post-infarction period may contribute to adverse outcomes during that time. Platelet factor 4 (PF4) promotes coagulation and inflammation. The trajectory of PF4 and the impact of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition on that trajectory are unknown. Hypothesis: Early administration of the PCSK9 inhibitor evulocumab, added to dual anti-platelet therapy, inhibits a rise in PF4 during the early post-infarction period. Methods: Participants from the Evolocumab in Acute Coronary Syndrome trials (EVACS; NCT03515304, NCT04082442), with a NSTEMI and a troponin-I of &gt; 5 ng/ml or a STEMI were randomized to placebo or to 420 mg SQ of evolocumab within 24 hours of hospitalization. We performed serial ex vivo serum PF4 levels obtained at baseline (prior to study drug administration), and at days 1 and 30 and PF4 values were normalized to total platelet count. Normally distributed data were summarized using means and standard deviations and non-normally distributed data using medians and interquartile ranges. Results: Twenty-three participants were randomized to placebo and 23 to evolocumab. Mean age was 60±13 years, 48% were women, 22% were African American and 96% were on dual anti platelet therapy. Baseline PF4 concentrations (expressed as ng/1k platelets) did not differ between the two groups (placebo: 9.3 [4-12] vs evolocumab 8.0 [4-12], p=0.8). There was no significant change in PF4 in the placebo group from baseline to day 1 but a significant increase to 13.0 [11-14], p&lt;0.01 (baseline vs 30 days) at 30 days (+32%). In contrast, there were no significant changes from baseline in the evolocumab group at either of the timepoints. At 30 days PF4 was higher in the placebo group 13.06 [11-14] than the evolocumab group 10.7 [6-13], p=0.04. Further analysis of results in the evolocumab group did not show any significant changes in PF4 based on the type of P2Y12 inhibitor used and no association with the change in LDL-cholesterol. Conclusion: A rise in PF4 levels was observed during the early post-infarction period in acute myocardial infarction patients. This rise was reversed by a single 420 mg SQ dose of evolocumab administered within 24 hours of hospital admission.

Bioelectric impedance body composition and phase angle in relation to 90-day adverse outcome in hospitalized COVID-19 ward and ICU patients: The prospective BIAC-19 study.

Background & aimsGaining insight into readily obtainable baseline characteristics that allow prediction of adverse outcome in COVID-19 aids both treatment and healthcare planning. Bioelectric impedance (BIA) Phase Angle (PhA) is correlated with outcome in a multitude of diseases and may be of added value in predicting adverse outcome of COVID-19. We aimed to associate baseline body composition parameters with 90-day adverse outcome of COVID-19 including ICU-admission and to explore the added predictive value of baseline PhA.MethodsWe performed a prospective observational study, conducting BIA amongst COVID-19 patients within 24 hours of hospital admission, with a follow-up of 90 days. Data were compared between ward-only and ICU-patients. Regression models were used to assess the associations between baseline characteristics, body composition and 90-day adverse outcome, including a composite outcome score of morbidity, ICU-admission, and mortality. An ROC-curve was used to explore the added predictive value of PhA to other clinical parameters at baseline for the prediction of adverse outcome.ResultsOne-hundred-and-fifty patients were included. Mean age was 68 (66–70) years, 67% were male. Forty-one (27%) patients were admitted to ICU and 77 (51%) met the criteria of the composite outcome score. In multiple regression, PhA was independently, inversely correlated with risk of ICU-admission (OR .531, p = .021), complications (OR .579, p = .031), hospital length of stay (OR .875, p = .037) and the composite outcome score (OR .502, p = .012). An ROC-curve showed that the incorporation of PhA in a composite risk-score improved the discriminative power for the composite outcome from poor to fair, compared to individual predictors (AUC 0.79 (95% CI 0.71–0.87)).ConclusionBIA measurements including Phase Angle are independently correlated with an adverse outcome of COVID-19. Interpretation of Phase Angle can be a valuable addition to risk assessment of adverse outcome of COVID-19 at hospital admission.Clinical Trial RegistrationNetherlands Trial Register number NL8562, registered 2020-04-21.

Clinical and epidemiological characteristics of COVID-19 mortality in Saudi Arabia.

Objectives:To analyze the clinical and epidemiological characteristics for 224 of in-hospital coronavirus disease 2019 (COVID-19) mortality cases. This study’s clinical implications provide insight into the significant death indicators among COVID-19 patients and the outbreak burden on the healthcare system in the Kingdom of Saudi Arabia (KSA).Methods:A multi-center retrospective cross-sectional study conducted among all COVID-19 mortality cases admitted to 15 Armed Forces hospitals across KSA, from March to July 2020. Demographic data, clinical presentations, laboratory investigations, and complications of COVID-19 mortality cases were collected and analyzed.Results:The mean age was 69.66±14.68 years, and 142 (63.4%) of the cases were male. Overall, 30% of the COVID-19 mortalities occurred in the first 24 hours of hospital admission, while 50% occurred on day 10. The most prevalent comorbidities were diabetes mellitus (DM, 73.7%), followed by hypertension (HTN, 69.6%). Logistic regression for risk factors in all mortality cases revealed that direct mortality cases from COVID-19 were more likely to develop acute respiratory distress syndrome (odds ratio [OR]: 1.75, confidence intervel [CI: 0.89-3.43]; p=0.102) and acute kidney injury (OR: 1.01, CI: [0.54-1.90]; p=0.960).Conclusion:Aging, male gender and the high prevalence of the underlying diseases such as, DM and HTN were a significant death indicators among COVID-19 mortality cases in KSA. Increases in serum ferritin, procalcitonin, C-reactive protein (CRP), and D-dimer levels can be used as indicators of disease progression.

Antimicrobial Stewardship in Bronchiolitis: A Retrospective Cohort Study of Three PICUs in Canada.

To determine the association between the implementation of an antimicrobial stewardship program at a local PICU and to determine the association between the presence of an antimicrobial stewardship programs and antimicrobial use across three Canadian PICUs, among critically ill children with bronchiolitis. A multicenter retrospective cohort study. Three Canadian PICUs over two winter seasons. An antimicrobial stewardship program was implemented at PICU 1 at the end of season 1. Patients less than or equal to 2 years old admitted with bronchiolitis. We used regression models with an interaction term between site (PICU 1 and PICU 2) and season (1 and 2) as the primary analysis to determine the association between implementation of an antimicrobial stewardship program at PICU 1 and 1) the proportion of antimicrobials discontinued 72 hours after hospital admission (logistic regression), 2) antimicrobial treatment duration (negative binomial regression), and 3) antimicrobial prescriptions within 48 hours of hospital admission (logistic regression). As a secondary analysis, we determined the association between having an antimicrobial stewardship program present and the aforementioned outcomes across the three PICUs. A total of 372 patients were included. During seasons 1 and 2, median age was 2.2 months (interquartile range, 1.2-6.2 mo) and 2.1 months (interquartile range, 1.3-6.8 mo), respectively. Among patients with viral bronchiolitis, implementation of an antimicrobial stewardship program at PICU 1 was associated with increased odds of discontinuing antimicrobials (odds ratio, 25.63; 95% CI, 2.86-326.29), but not with antimicrobial duration (odds ratio, 0.56; 95% CI, 0.31-1.02) or antimicrobial prescriptions (odds ratio, 0.33; 95% CI, 0.10-1.04). The presence of an antimicrobial stewardship program was similarly associated with antimicrobial discontinuation among patients with viral bronchiolitis (odds ratio, 20.79; 95% CI, 2.46-244.92), but not with antimicrobial duration (odds ratio, 0.57; 95% CI, 0.32-1.03) or antimicrobial prescriptions (odds ratio, 0.37; 95% CI, 0.12-1.11). Antimicrobial stewardship programs were associated with increased likelihood of discontinuing antimicrobial treatments in the PICU patients with viral bronchiolitis. However, larger studies are needed to further determine the role of an antimicrobial stewardship programs in reducing unnecessary antimicrobial use in this patient population.

Prehospital Lactate is Associated with the Need for Blood in Trauma

Background: Traumatic hemorrhage is the leading cause of preventable death, and its effects are often evident within the first 24 hours of hospital admission. We investigated the relationship between prehospital lactate measurement and administration of hospital blood products and life-saving interventions (LSIs) within 24 hours of hospital admission. Methods: We included trauma patients with recorded prehospital venous lactate transported by a single critical care transport service to a Level I trauma center between 2012 and 2019. We abstracted vital signs, mission type, anatomic location of injury, prehospital administration of crystalloid and blood products, and hospital LSIs started within 24 hours of admission. We used logistic regression to determine the association of prehospital lactate and in-hospital administration of blood products in groups with or without hypotensive patients. We investigated the effect of prehospital lactate concentration on secondary outcomes such as LSIs and mortality. Results: We included 2,170 patients transported from the scene or emergency department (ED), of whom 1,821 (84%) were normotensive. The median concentration of prehospital lactate was 2.10 mmol/L for the main population (IQR = 1.40–3.30) and 2.00 mmol/L for the normotensive subgroup (IQR = 1.30–2.90). A higher prehospital lactate concentration was associated with higher odds of needing early hospital blood products in the whole study population (OR = 1.12, (95% CI 1.06–1.20), p < 0.01) and in the normotensive subgroup (OR = 1.13, (95% CI 1.03–1.22), p = 0.01). These positive associations were also observed with the secondary outcome of hospital LSIs, and higher prehospital lactate was also associated with higher odds of mortality (OR = 1.32, (95% CI 1.20–1.45), p < 0.01). Conclusions: Higher concentrations of prehospital lactate were associated with the need for in-hospital blood transfusion within 24 hours of admission. The relationship between lactate and blood transfusion persisted among normotensive patients. Further work is needed to incorporate prehospital lactate into decision support tools for prehospital blood administration.