Hours Of Hospital Admission Research Articles

The role of C-reactive protein testing in predicting the severity of acute pancreatitis

Background: Acute pancreatitis is a common gastrointestinal disease and timely severity stratification is crucial in reducing the mortality and morbidity of the patients. Many markers have been studied for their role as a single predictor of the severity of the disease. Our study is aimed to evaluate the performance of C-reactive protein (CRP) testing as a single biomarker in predicting the severity of acute pancreatitis. Methods: Retrospective observational study with data collection and content analysis design. Patients were divided according to the acute physiology and chronic health evaluation (APACHE II) score into two categories, mild and severe. CRP testing was obtained within 48 h of hospital admission. Results: Our results showed that out of 99 patients, 82 patients had a mild attack of acute pancreatitis, while 17 patients had a severe form of the disease. The mean CRP level of patients with severe acute pancreatitis was significantly higher than the mean CRP level of patients with the mild form of the disease. There was a fair agreement between CRP level and the APACHE II score. Conclusion: C-reactive protein (CRP) test obtained within 48 hours of hospital admission is a helpful tool in predicting the severity of acute pancreatitis.

Role of Sepsis-3 Criteria and C-Reactive Protein in the Diagnosis of Sepsis in Critically ill Patients

Introduction: In the recent days, large proportion of the Intensive Care Unit (ICU) admissions ending in poor outcomes is impacted by pathological conditions like sepsis and septic shock. Hence, early diagnosis and appropriate therapy within the first hours of hospital admission plays a major role. Simple markers like C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), blood counts are still relied upon for suspected sepsis cases. Aim: To study the prevalence of sepsis and to evaluate the utility of the simple ideal markers like CRP, ESR, and blood counts for early diagnosis of sepsis in critically ill patients. Materials and Methods: This was a prospective observational study performed in the ICU of KMCH Institute of Allied Health Sciences, Coimbatore, Tamil Nadu, India, using 112 blood samples collected from patients admitted with clinical suspicion of sepsis. The samples were subjected to CRP estimation using turbidimetric immunoassay and blood culture. The data obtained were analysed using Statistical Package for the Social Sciences (SPSS) software version 21.0. The sensitivity, specificity, negative and positive predictive values were calculated. Results: Among a total of 112, the number of patients who abided the sepsis-3 definitions with positive qSOFA (quick Sepsis related Organ Failure Assessment) score was 50%. The most common co- morbid condition among the sepsis patients were diabetes mellitus (39.2%). The most frequent site of infection was respiratory tract (37.5%). Majority of infections were by gram-negative organisms (82%), the commonly isolated gram negative organisms were Klebsiella pneumoniae (25.9%) and Escherichia coli (25.9%). The sensitivity of CRP was 81% and specificity was 49% while the Positive Predictive Value (PPV) and Negative Predictive Value (NPV) was 60% and 56%, respectively. The prevalence of sepsis in present study was 50%. Conclusion: The study highlights the usefulness of CRP in identifying patients with sepsis in those who present with positive qSOFA score. Also, CRP could be very useful in resource-limited places, where newer biomarkers and guidance of an intensivist or sepsis expert are not available.

Use of Remdesivir in Patients With COVID-19 on Hemodialysis: A Study of Safety and Tolerance

BackgroundThere are scarce data regarding the use of remdesivir in patients with severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) and end-stage renal disease as US Food and Drug Administration cautions against its use in patients with an estimated glomerular filtration rate <30 ml/min/1.73m2 unless the potential benefits outweigh the potential risks. We studied the compassionate use and safety profile of remdesivir in patients with end-stage renal disease and moderate to severe SARS-CoV-2 infection.MethodsWe conducted an observational prospective study in 48 dialysis-dependent patients with SARS-CoV-2 infection who received remdesivir as part of institutional treatment protocol. During the treatment period, 100 mg of remdesivir was given 4 hours before hemodialysis sessions. Liver function tests, inflammatory markers such as serum C-reactive protein, serum ferritin and lactate dehydrogenase levels, and oxygen requirement before and after remdesivir treatment were compared.ResultsThere were no events of significant liver function test alterations with the administration of 2 to 6 doses of remdesivir. A significant decline in serum C-reactive protein level (P < 0.001) was noted. More than two thirds (68.57%) of patients showed an improvement in oxygen requirement. Early administration of remdesivir within 48 hours of hospital admission shortened the duration of hospitalization by a mean of 5.5 days (P = 0.001).ConclusionRemdesivir was well tolerated and found safe in our study. If initiated within 48 hours of hospitalization, it reduces recovery time. Assessing the mortality benefits of remdesivir in these patients requires a randomized controlled trial with a larger population.

A Retrospective Observational Study of Hypoxic COVID-19 Patients Treated with Immunomodulatory Drugs in a Tertiary Care Hospital.

ObjectivesTo describe the demographics and evaluate the clinical outcomes of hypoxic coronavirus disease-2019 (COVID-19) patients treated with different immunomodulatory (IM) drugs in a resource-limited setting.Materials and methodsWe conducted a retrospective cohort study of these patients admitted to our hospital between March 22 and May 31, 2020. Data were abstracted from multiple electronic data sources or patient charts to provide information on patient characteristics, clinical, laboratory variables, and outcomes.ResultsA total of 134 patients met the inclusion criteria and were followed up till June 7, 2020. The median age of the patients was 55.6 years (range 20–89 years) and 68% were men. At least one comorbidity was seen in 72% of the patients with diabetes (44%) and hypertension (46%) being the most common. At triage, fever (82%), shortness of breath (77%), and cough (61%) were the most common presenting symptoms. A PaO2/FiO2 ratio less than 300 was seen in 60%, and 4.5% required invasive mechanical ventilation within 72 hours of hospital admission. Five immunomodulatory agents (hydroxychloroquine, methylprednisolone, colchicine, etoricoxib, and tocilizumab) were administered in different combinations. Overall, in-hospital mortality was 26.9%, and 32% required mechanical ventilation. Around 69% of patients were discharged home. Five variables (SpO2, PaO2/FiO2 ratio, leucocytosis, lymphopenia, and creatinine) on admission were found to be significant in the patients who died.ConclusionOur study provides the characteristics and outcomes of hypoxic COVID-19 patients treated with IM drugs in varied combination. Five independent variables were strong predictors of mortality.How to cite this articleMahale N, Rajhans P, Godavarthy P, Narasimhan VL, Oak G, Marreddy S, et al. A Retrospective Observational Study of Hypoxic COVID-19 Patients Treated with Immunomodulatory Drugs in a Tertiary Care Hospital. Indian J Crit Care Med 2020;24(11):1020–1027.

Malnutrition and nutrition impact symptoms (NIS) in surgical patients with cancer.

Background and aimNutrition impact symptoms (NIS) are common in cancer patients and the negative impacts on nutritional status indicate the need for research, diagnosis and nutritional intervention in order to reduce the risk of malnutrition. We aimed to verify the presence of malnutrition, the need for nutritional intervention, NIS and their influence on the nutritional status of surgical patients with cancer.MethodsThis cross-sectional study was carried out in a public tertiary hospital, from March 2017 to October 2019. Nutritional status, the need for nutritional intervention and NIS were assessed through the Patient-Generated Subjective Global Assessment (PG-SGA) in the first 48 hours of hospital admission.ResultsAmong the 135 patients evaluated, 55.6% were elderly and 51.1% were male; patients had a median age of 62 years and a predominance of cancer located in the lower gastrointestinal tract (35.6%). Malnutrition and the need for nutritional intervention were identified in 60.0% and 90.4% of cases, respectively. The presence of three or more NIS was reported by 51.9% of patients. Significant differences in NIS were observed according to sex, PG-SGA classification and PG-SGA score. After logistic regression analysis, it was determined that the symptoms that increased the chances of malnutrition were anorexia, constipation, strange taste, mouth sores and others (depression, dental or financial problems).ConclusionMalnutrition, the need for nutritional intervention and the presence of three or more NIS were elevated in the patients evaluated. Malnutrition was associated with the presence of NIS, indicating the need for attention and care in antineoplastic treatment.

Validation of Inflammopathic, Adaptive, and Coagulopathic Sepsis Endotypes in Coronavirus Disease 2019.

Complex critical syndromes like sepsis and coronavirus disease 2019 may be composed of underling "endotypes," which may respond differently to treatment. The aim of this study was to test whether a previously defined bacterial sepsis endotypes classifier recapitulates the same clinical and immunological endotypes in coronavirus disease 2019. Prospective single-center observational cohort study. Patients were enrolled in Athens, Greece, and blood was shipped to Inflammatix (Burlingame, CA) for analysis. Adult patients within 24 hours of hospital admission with coronavirus disease 2019 confirmed by polymerase chain reaction and chest radiography. None. We studied 97 patients with coronavirus disease 2019, of which 50 went on to severe respiratory failure (SRF) and 16 died. We applied a previously defined 33-messenger RNA classifier to assign endotype (Inflammopathic, Adaptive, or Coagulopathic) to each patient. We tested endotype status against other clinical parameters including laboratory values, severity scores, and outcomes. Patients were assigned as Inflammopathic (29%), Adaptive (44%), or Coagulopathic (27%), similar to our prior study in bacterial sepsis. Adaptive patients had lower rates of SRF and no deaths. Coagulopathic and Inflammopathic endotypes had 42% and 18% mortality rates, respectively. The Coagulopathic group showed highest d-dimers, and the Inflammopathic group showed highest C-reactive protein and interleukin-6 levels. Our predefined 33-messenger RNA endotypes classifier recapitulated immune phenotypes in viral sepsis (coronavirus disease 2019) despite its prior training and validation only in bacterial sepsis. Further work should focus on continued validation of the endotypes and their interaction with immunomodulatory therapy.

An observational cohort study of bacterial co-infection and implications for empirical antibiotic therapy in patients presenting with COVID-19 to hospitals in North West London.

ObjectivesTo describe the prevalence and nature of bacterial co-infections in COVID-19 patients within 48 hours of hospital admission and assess the appropriateness of empirical antibiotic treatment they received.MethodsIn this retrospective observational cohort study, we included all adult non-pregnant patients who were admitted to two acute hospitals in North West London in March and April 2020 and confirmed to have COVID-19 infection within 2 days of admission. Results of microbiological specimens taken within 48 hours of admission were reviewed and their clinical significance was assessed. Empirical antibiotic treatment of representative patients was reviewed. Patient age, gender, co-morbidities, inflammatory markers at admission, admission to ICU and 30 day all-cause in-hospital mortality were collected and compared between patients with and without bacterial co-infections.ResultsOf the 1396 COVID-19 patients included, 37 patients (2.7%) had clinically important bacterial co-infection within 48 hours of admission. The majority of patients (36/37 in those with co-infection and 98/100 in selected patients without co-infection) received empirical antibiotic treatment. There was no significant difference in age, gender, pre-existing illnesses, ICU admission or 30 day all-cause mortality in those with and without bacterial co-infection. However, white cell count, neutrophil count and CRP on admission were significantly higher in patients with bacterial co-infections.ConclusionsWe found that bacterial co-infection was infrequent in hospitalized COVID-19 patients within 48 hours of admission. These results suggest that empirical antimicrobial treatment may not be necessary in all patients presenting with COVID-19 infection, although the decision could be guided by high inflammatory markers.

Disseminated Intravascular Coagulation Score Evolution in 48 Hours Predicts Early Death in Newly-Diagnosed Chemotherapy-Treated Acute Promyelocytic Leukemia Patients

Introduction Acute Promyelocytic Leukemia (APL) prognosis has largely improved over the past decades and is now the acute leukemia with the highest cure rates. However, its early death rate, which reaches 30% in several real-world studies, is the main obstacle to achieving lifelong remission in most patients. Several reports have suggested a potential role of the Disseminated Intravascular Coagulation (DIC) Score of the International Society of Thrombosis and Hemostasis as a marker of bleeding and death in APL. Since the APL-induced coagulopathy and hyperfibrinolysis are responsible for most early deaths, a method to assess the severity of the coagulopathy could guide the daily patient management and the intensity of the blood products used. We aimed to test the hypothesis of whether the improvement of the DIC Score through coagulopathy support can improve the rate of early death in APL. Methods This retrospective, single-center study, included consecutively admitted patients with newly diagnosed genetically confirmed Acute Promyelocytic Leukemia between 2000 and 2020, who were treated with ATRA + anthracycline protocols and prednisolone 0.5 mg/kg differentiation syndrome prophylaxis. All patients received platelets, fibrinogen, and/or fresh frozen plasma according to published clinical indications. Baseline demographics and clinical data were collected, and the DIC Score was calculated at diagnosis and after 48 hours for each patient, using fibrinogen, platelets, prothrombin time and d-dimers. "DIC Score improvement" was defined as an increase of ≥1 point in the calculated score at 48 hours; a stable or decreasing score were considered "no-improvement". A 30-day follow-up for each patient was conducted, and any death during this period was considered in the early-death group. Statistical analysis was performed using Stata, with chi-square test and Mann-Whitney test for differences between groups, and logistic regression for the analysis of predictors of early death. Results A total of 67 patients were included, after excluding 9 patients for missing coagulation values, 8 for first-line arsenic trioxide treatment, and 7 patients for death within 48 hours of hospital admission. The median age was 53 years (25-82), and 29.9% of patients were aged &amp;gt;60 years old. The 30-day mortality rate for this cohort was 31.3%. Comparing the baseline differences between the two groups, the only statistically significant difference detected was a less frequent improvement of the DIC Score over 48 hours in the early-death group (42.86% versus 76.09% in the remaining patients, p=0.008). There was no difference in the Sanz Risk distribution nor age between the two groups. The univariate analysis of predictors of death in 30 days (logistic regression) yielded age &amp;gt;60 years and 48h-improvement of the DIC Score as potential predictors of death. A multivariate analysis model was built incorporating these 2 variables with the Sanz Risk (the number of events in this study permitted only a 3-variable prognostic model), and it identified age&amp;gt;60 years (OR 4.84 [1.37-17.10]; p=0.014) and the lack of a 48-hour improvement in the DIC Score (OR 5.46 [1.61-18.47]; p=0.006) as independent predictors of early death. In patients under 60 years old, having no improvement in the DIC Score over 48 hours is still associated with almost five times superior odds of 30-day mortality (OR 4.55; p=0.038). Conclusion In this cohort, we identified a lack of DIC Score improvement and age&amp;gt;60 years as independent predictive factors of early death in APL. These findings identified a new independent predictor of early death using a dynamic DIC Score assessment, which is easily accessible and calculated, and illustrate how this score can be applied daily in the clinical care of APL patients. Together with the current APL treatment strategies, the intensification of measures to control the leukemia-associated coagulopathy in patients who do not show a DIC Score improvement in the first 48 hours after diagnosis could decrease the early death rate in this otherwise highly-curable leukemia. Disclosures Brioso Infante: Astellas: Speakers Bureau; Novartis: Speakers Bureau.

A Longer Route to the PICU Can Lead to a Longer Stay in the PICU: A Single-Center Retrospective Cohort Study.

Admission to the pediatric ICU versus general pediatric floor for patients is a significant triage decision for emergency department physicians. Escalation of care within 24 hours of hospital admission is considered as a quality metric for pediatric E.R. There exists, however, a lack of data to show that such escalation leads to a poor outcome. A retrospective cohort study was conducted to compare outcomes of patients who required escalation of care within 24 hours of hospital admission to the pediatric ICU (cases) from 01/01 2015 to 02/28 2019 with those who were directly admitted from emergency department to the PICU (controls). A total of 327 cases were compared to 931 controls. Univariate and multivariable regression analysis was done to compare the length of stay and mortality data. Patients who required escalation of care were significantly younger (median age 1.9 years compared to 4.6 years for controls) and had lower severity of illness score (PIM 3). Cases had a much higher proportion of respiratory diagnosis. ICU length of stay, hospital length of stay and the direct cost was significantly higher for cases compared to controls. This difference persisted for all age groups and respiratory diagnosis. The cost of care, however, was only different for 1-5 years and >5 years age groups. The difference in ICU length of stay (Δ11.1%) and hospital length of stay (Δ7.8%) persisted on multivariate regression analysis after controlling for age, sex, PIM3 score, and diagnostic variables. There was no difference in mortality on the univariate or multivariate analysis between the 2 groups. Patients who required escalation of care within 24 hours of hospital admissions have more prolonged ICU and hospital stay and potentially increased cost of care. This measure should be considered while making patient disposition decisions in the emergency department.

Effectiveness of Multilayered Polyurethane Foam Dressings to Prevent Hospital-Acquired Sacral Pressure Injuries in Patients With Hip Fracture: A Randomized Controlled Trial.

The purpose of this study was to determine the effectiveness of a multilayered polyurethane foam dressing applied within 24 hours of hospital admission compared with standard preventive pressure injury (PI) care in reducing sacral PI occurrence in older patients with hip fractures. Open-label, parallel-group, 2-arm, superiority trial. The sample comprised older patients aged 69 to 97 years admitted to a 1500-bed university hospital in Bologna, Italy, for hip fracture surgery. Patients were randomly allocated to an intervention or control group. Both groups received standard evidence-based PI preventive care in accordance with National Pressure Ulcer Advisory Panel guidelines. In addition, patients in the intervention group received a single 12.9 × 12.9-cm multilayered polyurethane foam dressing shaped for the sacrum area applied within 24 hours of hospital admission. Bivariate analysis on primary and secondary outcomes and baseline characteristics was performed to compare group differences, and a survival analysis was used to determine the difference in PI incidence rates per group. Sixty-eight patients completed the trial; 34 patients were allocated to the intervention group and 34 patients to the control group. A trend toward significance was observed for sacral PI occurrence in the intervention group (intervention: 20.6%; control: 2.9%; P = .054). The foam dressing allowed significantly longer time (days) to PI occurrence (intervention: 5.9 ± 1.60; control: 2.7 ± 0.96; P = .003). These findings suggest that multilayered polyurethane foam dressings are not superior to the standard preventive PI care alone and should be used with caution, especially when multiple dressing changes may occur. Further exploration of the role of multilayered polyurethane foam dressings in preventing PI development is warranted.

Hydroxychloroquine in Hospitalized Patients with COVID-19: Real-World Experience Assessing Mortality.

introduction Hydroxychloroquine (HCQ) for coronavirus disease 2019 (COVID‐19) is presently being used off‐label or within a clinical trial. objectives We investigated a multinational database of patients with COVID‐19 with real‐world data containing outcomes and their relationship to HCQ use. The primary outcome was all‐cause mortality within 30 days of follow‐up. methods This was a retrospective cohort study of patients receiving HCQ within 48 hours of hospital admission. Medications, preexisting conditions, clinical measures on admission, and outcomes were recorded. results Among patients with a diagnosis of COVID‐19 in our propensity‐matched cohort, the mean ages ± SD were 62.3 ± 15.9 years (53.7% male) and 61.9 ± 16.0 years (53.0% male) in the HCQ and no‐HCQ groups, respectively. There was no difference in overall 30‐day mortality between the HCQ and no‐HCQ groups (HCQ 13.1%, n=367; no HCQ 13.6%, n=367; odds ratio 0.95, 95% confidence interval 0.62–1.46) after propensity matching. Although statistically insignificant, the HCQ‐azithromycin (AZ) group had an overall mortality rate of 14.6% (n=199) compared with propensity‐matched no‐HCQ–AZ cohort’s rate of 12.1% (n=199, OR 1.24, 95% CI 0.70–2.22). Importantly, however, there was no trend in this cohort’s overall mortality/arrhythmogenesis outcome (HCQ‐AZ 17.1%, no HCQ–no AZ 17.1%; OR 1.0, 95% CI 0.6–1.7). conclusions We report from a large retrospective multinational database analysis of COVID‐19 outcomes with HCQ and overall mortality in hospitalized patients. There was no statistically significant increase in mortality and mortality‐arrhythmia with HCQ or HCQ‐AZ.

A second C-reactive protein (CRP) test to detect inflammatory burst in patients with acute bacterial infections presenting with a first relatively low CRP.

A first C-reactive protein (CRP) test, as often performed by clinicians during the presentation of patients with an acute bacterial infection, might be misleading. The aim of our study was to explore the dynamic between a second CRP test taken within 12 hours from admission CRP test in a cohort of patients diagnosed with acute bacterial infection in comparison to CRP in a control group of apparently healthy individuals.This was a historical cohort study comprised of all patients admitted to the Sourasky Tel-Aviv Medical Center, Israel, between July 2007 and March 2016. The study cohort included adult patients who were diagnosed as having an infection, assumed to be of bacterial etiology (cellulitis and erysipelas, pneumonia, cholecystitis, pyelonephritis, or septicemia), who had a CRP test during the first 6 hours of hospital admission (baseline CRP), and a successive CRP test up to 12 hours from the first one (recurrent CRP). The control group was of healthy subjects who attended our medical center for a routine annual check-up.The study included 950 patients. Baseline CRP ranged from 0.04 to 454 mg/L. The median CRP velocity was 0.53 mg/L/h. Patients were grouped by baseline CRP into 4 groups (CRP < 10, 10–74.9, 75–199.9, ≥200). There was an increase in median CRP velocity between the first (0.48 mg/L/h) and the second (0.93 mg/L/h) groups, which then was decreased in the next 2 groups (0.46 and −2.58 mg/L/h, respectively). In 45 of 103 (44%) patients of the group of baseline CRP concentration less than 10 mg/dL with bacterial diagnosis, there was a complete overlap with CRP values of apparently healthy individuals during their routine annual checkup.A first single low CRP result cannot exclude the presence of a significant bacterial infection. Patients with acute bacterial infection might present with a relatively low CRP value that at times correspond to normal limit CRP concentrations. A second test, obtained within 12 hours of admission, might serve as an important tool to identify patient with an evolving inflammatory burst commonly seen during acute bacterial infection.

Phase Angle Is an Independent Predictor of 6-Month Mortality in Patients With Decompensated Cirrhosis: A Prospective Cohort Study.

This study aimed to evaluate the nutrition status through phase angle (PA) and its association with mortality in patients with decompensated cirrhosis. A prospective cohort study was performed with hospitalized decompensated cirrhotic patients. Nutrition status was assessed by PA, bioelectrical impedance vector analysis (BIVA), and Subjective Global Assessment (SGA) within 72 hours of hospital admission. The best PA cutoff point for malnutrition diagnosis was determined by ROC curve analysis, considering the SGA as the reference standard. Predictors of 6-month mortality were identified using Cox proportional hazards models, adjusted for Child-Pugh and MELD scores, and hepatocellular carcinoma. This study included 97 patients, 63% male (n = 61), with a mean age of 60.1 ± 10.3 years. The median follow-up time of patients was 11.2 months (IQR, 2.4-21). Overall mortality was 58.8% (n = 57) and 6-month mortality was 35.1% (n = 34). Nutrition assessment according to BIVA indicated a risk for cachexia and normal hydration. Patients with values of PA ≤5.52° were considered malnourished. Malnourished patients according to PA (58.8%, n = 57) had a higher risk of 6-month mortality (HR = 3.44; 95% CI, 1.51-7.84; P = .003), and each increase of 1° in PA values was associated with a reduction of 53% in 6-month mortality risk. The PA is an independent predictor of 6-month mortality in patients with decompensated cirrhosis. Therefore, PA may be useful to assess the nutrition status and identify patients at the highest risk of mortality in clinical practice.

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

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

Predictors of Mortality in Newborn Admitted in Special Care Baby Unit (SCABU) of Dhaka Shishu Hospital

Background: The current neonatal mortality rate of Bangladesh is very high compared to developed countries.&#x0D; Objective: The objective of the study was to find out the predictors that are associated with mortality in newborn admitted in Special Care Baby Unit (SCABU) of Dhaka Shishu (Children) Hospital.&#x0D; Methods: This prospective study was conducted in the SCABU of Dhaka Shishu (Children) Hospital from 1st June 2016 to 30 November 2016. A semi-structured questionnaire was prepared before the study. Data were collected from the attendents of each neonate by asking questions who died at the neonatal period after hospital admission. Detail history regarding gestational age, birth weight, place of birth, person conducting delivery, mood of delivery, problem at birth, residence, reasons of referral, vehicle during transport, condition of baby at arrival, time taken during transport and need for any resuscitation was recorded. Data were analyzed by using SPSS version 16.&#x0D; Result: Total 970 neonates were admitted during data collection period out of them 98(10.10%) died. Majority (58.16%) of the death occurred in neonate who was admitted before 72 hours of age having gestational age &lt;37 weeks (65.31%). Majority of the neonates were from urban area (56.12%) but from poor socioeconomic status (54.08%) and only 32.65% were on regular antenatal care. Majority were delivered by normal delivery at home and attended by TBA. Among the neonates 30.61% reached hospital only by ambulance and 64.29% were found hypothermic during admission. Majority 70(71.43%) were died within 24 hours of hospital admission. Neonatal sepsis, perinatal asphyxia and prematurity contributed majority of neonatal death.&#x0D; Conclusion: Early (age &lt;72 hours) and premature neonates, neonates from poor socioeconomic background, lack of antenatal care, home delivery, lack of facility in local areas, inadequate transport and unstable initial condition contributed majority of neonatal death. Neonatal sepsis, perinatal asphyxia and prematurity contributed most of neonatal death.&#x0D; DS (Child) H J 2019; 35(2) : 123-129

A Retrospective Study Comparing Radiological to Histopathological Diagnosis After Laparoscopic Cholecystectomy for Suspected Cholecystitis.

IntroductionAcute calculus cholecystitis is one of the most common causes of acute abdominal pain in patients presenting to the emergency department, representing a third of all surgical emergency hospital admissions. Laparoscopic surgery is typically performed within 24 to 48 hours of hospital admission. Due to similarities in presentation, it is often difficult to differentiate between biliary colic and acute cholecystitis. Currently, it is not clear how the clinical and radiological diagnosis of acute calculus cholecystitis correlates with the histopathological diagnosis. MethodsWe performed a retrospective analysis of 350 patients who underwent laparoscopic cholecystectomy in our community hospital for acute calculus cholecystitis. The aim was to compare pre-operative radiological diagnoses of acute calculous cholecystitis to post-operative histopathological diagnosis. Four radiographic modalities were used for diagnosis of acute calculous cholecystitis: ultrasound, computerized tomography, MRI, and hepatobiliary scintigraphy (HIDA scan). A correlation was found between both the clinical pain of biliary origin and radiological diagnosis with subsequent histopathological diagnosis after laparoscopic surgery.ResultsWhen the four commonly used imaging modalities were compared, HIDA scan had the highest sensitivity and ultrasound had the highest specificity in successfully diagnosing acute calculus cholecystitis that had been confirmed with histopathological analysis.ConclusionNo absolute correlation was found between any of the imaging modalities when compared to the pathological diagnosis. The ultrasound had maximum specificity, while the HIDA scan had maximum sensitivity when radiological imaging was compared to histopathology.

S0594 The Effect of Early Endoscopy on Geriatric Patients Admitted With Non-Variceal Upper Gastrointestinal Bleeding

INTRODUCTION: The annual incidence of hospital admission for nonvariceal upper gastrointestinal bleeding (NVGIB) in the United States is estimated to be 48 to 160 per 100,000 population, with an associated mortality rate of 2.5 to 5%. Age greater than 65 years is a well-defined risk factor for increased mortality in patients with NVGIB. In this study, we utilized a nationwide database from 2016-2017 to study if early esophagogastroduodenoscopy (EGD), within 24 hours of hospital admission, improves outcomes among elderly patients with all causes of NVGIB. METHODS: We utilized the Nationwide Inpatient Sample database between January 2016 and December 2017 and included all the patients who were admitted with a primary diagnosis of NVGIB and underwent at least one EGD. Propensity scores were calculated using patient demographic factors, Elixhauser comorbidity index, bleeding severity indicators, and hospital characteristics. Inverse probability of Treatment Weighting (IPTW) was calculated based on the propensity scores and used to adjust for confounders. RESULTS: 625,530 patients were admitted to hospitals in the United States with a primary diagnosis of NVGIB between 2016 and 2017. Of those patients, 120,835 met our eligibility criteria; 24,830 underwent early EGD, and 96,005 patients underwent late EGD, Figure 1. Baseline characteristics of both groups are illustrated in Table 1. Our analysis showed that the adjusted mean difference of length of stay and total charges decreased by 1.17 days (95% CI 1.04–1.30, P < 0.001), and $5,717.24 (95% CI 4,034.57 – 7,399.91, P < 0.001), respectively, in the early EGD group. Early EGD increased the odds ratio of death 1.32 (95% CI 1.06–1.64, P 0.01) and hospital transfer 1.48 (95% CI 1.22–1.81, P < 0.001). There was no significant difference between the two groups regarding discharge to nursing facility, home health aide utilization after discharge, and the need for surgery or interventional radiology procedures, Table 2. CONCLUSION: In a nationwide study of geriatric patients with NVGIB, we found that early upper EGD is associated with decreased hospital stay and hospital charges, but also with increased mortality and hospital transfer. Further research is indicated to determine the optimal management of this vulnerable patient population.Table 1.: Baseline characteristicTable 2.: Secondary outcomesFigure 1.: Flow chart of the study population. *Total excluded discharges surpass the actual number of excluded patients due to overlap.

Clinical and Genetic Characteristics of Extended-Spectrum Beta-Lactamase–Producing Enterobacteriaceae Among Canadian Children

Background: Infections with extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-E) in nonoutbreak settings have not demonstrated the presence of dominant strains. Our objective was to determine the incidence, clinical characteristics, and genetic characteristics of ESBL-E infections among a group of Canadian children. Methods: From 2012 through 2017, patients aged ≤18 years with first-episode ESBL-E infections who presented at a pediatric center were reviewed. All clinical isolates were phenotypically identified in the laboratory as ESBL-producers. Demographic and clinical data were collected, including comorbid conditions, presence of devices, and previous antibacterial exposure. Community-associated infection was defined as a positive culture from a sterile site within the first 48 hours of hospital admission and no healthcare exposure during the preceding year. Isolates were sent to the Public Health Ontario Laboratory for whole-genome sequencing. Multilocus sequence typing was used to determine clonal relationship. Results: During the study period, 102 patients were identified with first-episode ESBL-E infection, and the proportion of ESBL-E isolates among all clinical isolates of E. coli and Klebsiella spp increased from 0.6% to 2.6% between 2012 and 2017, respectively (P = .001). The median age was 1 year (interquartile range, 0.8–5 years). Women comprised 66% of cases. No comorbid conditions were noted among 58 patients (57%), and 24% had previous antibiotic exposure, most frequently a cephalosporin (16%). ESBL-E was most frequently isolated in the urine (91%) and least frequently in the blood (2.2%) and was predominantly Escherichia coli (90%). Infection was most frequently diagnosed in the outpatient setting (61%); there were 11 healthcare-associated infections. Whole-genome sequencing of ESBL-E isolates revealed predominance of blaCTX-M-15 (63 isolates, 62%) and blaCTX-M-27 (16%) genes, and sequence type (ST) 131 (41%). Mutations conferring fluoroquinolone nonsusceptibility were noted among 62 isolates (61%), most frequently associated with ST131 (38 of 62 isolates, 61%) and among all 5 isolates with ST1193, an emerging multidrug-resistant E. coli clone. In addition, 15 patients had recurrence of ESBL-E infection at median of 113 days (IQR, 26–208); blaCTX-M-27 was found in 33% of recurrent infections compared to 12% of primary infections (P = 0.045). Conclusions: This study is the first in Canada to provide whole-genome sequencing data regarding ESBL-E in a pediatric population. The gene blaCTX-M-15 and ST131 clone were predominant. More than 60% of infections were community associated and demonstrated cross resistance to fluoroquinolones. With 76% of infections in antibiotic-naïve children, ESBL-E is a public health concern, and a One Health approach is critical to understanding the epidemiology and curbing the spread of multidrug-resistant Enterobacteriaceae.Funding: NoneDisclosures: None

197 The Use of High-Risk Medications in the Emergency Department and the Prevalent Delirium within the First 24 Hours of Hospitalization

Delirium is a global brain dysfunction that is serious and common. We conducted an observational study using a hospital-wide database to examine whether opioid, benzodiazepines, and anticholinergics in the emergency department (ED) are associated with positive delirium screening. This was a retrospective cohort study, including patients aged 65 years and older who were hospitalized from ED at a tertiary care academic medical center from 2014 to 2017. We extracted demographic and clinical variables to examine the association with a positive delirium screen. Medication administration record was extracted for opioids, benzodiazepines, and anticholinergics given during the ED stay. Nurses used the Delirium Observation Screening Scale (DOSS) twice daily to assess delirium during hospitalization as part of a standard institutional protocol. The outcome was a positive DOSS within 24 hours of hospital admission. We identified 2010 visits (25.34%) with a positive delirium screen and 877 (11.06%) visits with a diagnosis of delirium from ICD9/10 codes among 7932 encounters. A total of 4331 (54.60%) received opioids, 3562 (44.91%) received benzodiazepines, and 2341 (29.51%) received anticholinergics. A total of 877 (11.06%) received a combination of opioids, benzodiazepines, and anticholinergics. In this cohort, the odds ratios for positive delirium were 1.12 (95% CI 0.98, 1.28) for opioids, 1.33 (95% CI 1.17, 1.51) for benzodiazepines, and 1.24 (CI 1.08, 1.41) for anticholinergics administered in the ED after adjusting for age, sex, known history of risk factors for delirium, and pain scale. The odds ratio for positive delirium for patients who received drugs from all three categories vs. those who received none was 2.04 (95% CI 1.63, 2.55). (Figure. This Forest plot shows the list of variables from ED and the odds of having positive delirium screening within the first 24 hours of hospitalization. The age reference group 65-74). In this study, the use of benzodiazepines, anticholinergics, and the combination of opioids, benzodiazepines, and anticholinergics in the ED were associated with a positive DOSS within 24 hours of hospitalization.

Desarrollo y validación interna de un modelo de predicción clínica del riesgo de infección bacteriana nosocomial en pacientes con lupus eritematoso sistémico

IntroductionPatients with systemic lupus erythematosus (SLE) have an increased risk of developing community-acquired infections, as well as those associated with health care. Bacterial infections are the most common and serious while these patients are in hospital. ObjectiveTo develop, and internally validate, a clinical prediction model for the prognosis of the risk of hospital-acquired bacterial infection in SLE patients using clinical and laboratory data obtained during the first hours of hospital admission. MethodsAn analysis was performed on retrospective cohort of patients with SLE older than 16 years and admitted for reasons other than bacterial infection in 2 highly complex hospitals in Medellín between 2011 and 2016. The characteristics of the patients who developed a bacterial infection were compared between day 3 and day 15 of hospital admission with those who did not develop one. The significant variables in the bivariate analysis were used for the construction of the model using multivariate logistic regression. ResultsA total of 765 episodes were included, of which 98 (12.8%) presented the outcome of interest. Thirty-five candidate predictors were considered. The variables incorporated in the final model were: age, neutrophil count, SLEDAI lupus activity score, use of a bladder catheter, use of a central venous catheter in the first 72h, glucocorticoid doses in the previous month, and use of an antimalarial drug in the 3 previous months. The discrimination capacity of the model was acceptable to good (AUC-ROC 0.74; 95% CI 0.69-0.80). The Hosmer-Lemeshow goodness of fit test (P=.637) suggested adequate calibration. ConclusionA clinical prediction model of prognostic risk of nosocomial bacterial infection in patients with SLE has been developed. This model is made up of simple clinical and laboratory variables available at the time of hospital admission. External validation and clinical impact studies are required before routine implementation.