ICU Care Research Articles

Candidemia before and after the COVID-19 pandemic: An analysis of risk factors and outcomes in patients with candidemia

Background: An increase in candidemia has been observed throughout the world since the start of the COVID-19 pandemic. Patients with COVID-19 may have different risk factors, clinical presentations, and outcomes compared to patients without COVID-19. Methods: We conducted a retrospective chart review of all inpatients with candidemia at a large, academic medical center from April 30, 2019, to February 19, 2021. The first case of COVID-19 was detected at our institution March 2020 and patients were sorted into pre– versus post–COVID-19 pandemic groups. Data regarding clinical characteristics, risk factors, and outcomes were collected. The rate of candidemia per 10,000 patient days was calculated from January 2013 through February 2021. Results: In total, 202 patients were identified with candidemia: 92 cases were identified before the pandemic and 110 cases were identified after the pandemic began. Moreover, 33 (16.3%) patients were diagnosed with COVID-19 during the admission and 169 (83.7%) did not have COVID-19. Patients with COVID-19 were significantly more likely to be older (median, 64.5 vs 54.8 years; P = .0006) and to have a higher body mass index (32.8 vs 29.1; P = .03) than patients without COVID-19. Patients with COVID-19 were less likely have some of the traditional risk factors (eg, abdominal surgery, total parenteral nutrition, history of injecting drugs) for candidemia compared to patients without COVID-19. Patients with COVID-19 were significantly more likely to require ICU care (97.0% vs 67.5%; P < .001) and to require mechanical ventilation (90.9% vs 53.9%; P < .001), and they had higher mortality at 30 days (66.7% vs 31.4%; P < .001). A multivariate logistic regression model showed that COVID-19 (OR, 2.53; 95% CI, 1.09–5.90) and higher age (OR 1.45, 95% CI, 1.11–1.91) were significant predictors of 30 day mortality. Using a Poisson regression model, the incidence rate ratio for candidemia per month after the start of the COVID-19 pandemic was 2.09 (95% CI, 1.85–2.36; P < .0001) compared to the years prior. Conclusions: Rates of candidemia significantly increased after the start of the COVID-19 pandemic. Patients with candidemia in the post–COVID-19 era tend to have nontraditional risk factors, to be more critically ill, and to have increased mortality compared to patients in the pre–COVID-19 era. COVID-19 and higher age were independent predictors of mortality. More studies are needed to further define risk factors for candidemia in patients with COVID-19.Funding: NoneDisclosures: None

Exploring And Developing Instrument Measuring FSICU On Satisfaction Care Malay Version Among Relatives In Intensive Care Unit In Public Hospital: Preliminary Study

This study aims to measure the reliability and validity of FSICU Malay version of family member’s satisfaction with care (19 items) during the intensive care units stay. A cross-sectional study was conducted among 196 responds. The self-administered FS-ICU comprises of three domain and a total of 19 items. Descriptive analysis, Chronbach’s alpha and exploratory factor analysis were performed on the Malay version of FS-ICU. The final model exploratory factor analysis on the Malay version of FS-ICU indicated Bartlett’s Test of Sphericity was significant (Chi Square= 2321.013, p-value <0.000) and the Kaiser-Meyer-Olkin (KMO) were 0.878. In other words, the EFA procedure has grouped 19 items into three domains, one item from domain 3 were deleted since it failed to achieved the minimum requirement for factor loading of 0.6 and retained 18 items. The Chronbach’s alpha analysis of each domain in FSICU exceeded the threshold value of 0.6, therefore, the study concluded that instruments measuring the construct in this study namely ICU care services have achieved the internal validity.

Acute Kidney Injury in Elderly Patients With Coronavirus Infectious Disease: A Study of Incidence, Risk Factors, and Prognosis in Brazil.

Elderly patients with COVID-19 are at a higher risk of severity and death as not only several comorbidities but also aging itself has been considered a relevant risk factor. Acute kidney injury (AKI), one of the worst complications of SARS-CoV-2 infection, is associated with worse outcomes. Studies on AKI with COVID-19 in Latin-American patients of older age remain scarce. To determine AKI incidence and the risk factors associated with its development, as well as to compare outcome of elderly patients with or without AKI associated with SARS-CoV-2 infection. This retrospective cohort study evaluated patients with SARS-CoV2 infection admitted to a Public Tertiary Referral Hospital from 03/01/2020 to 12/31/2020, from admission to resolution (hospital discharge or death). Demographic, clinical, and laboratory data were collected from patients during hospitalization. Daily kidney function assessment was performed by measuring serum creatinine and urine output. AKI was diagnosed according to KDIGO 2012 criteria. Of the 347 patients with COVID-19 admitted to our hospital during the study period, 52.16% were elderly, with a median age of 72 years (65- 80 years). In this age group, most patients were males (56.91%), hypertensive (73.48%), and required ICU care (55.25%). AKI overall incidence in the elderly was 56.9%, with higher frequency in ICU patients (p < 0.001). There was a predominance of KDIGO 3 (50.48%), and acute kidney replacement therapy (AKRT) was required by 47.57% of the patients. The risk factors associated with AKI development were higher baseline creatinine level (OR 10.54, CI 1.22 -90.61, p = 0.032) and need for mechanical ventilation (OR 9.26, CI 1.08-79.26, p = 0.042). Mortality was also more frequent among patients with AKI (46.41%vs24.7%, p < 0.0001), with death being associated with CPK level (OR 1.009, CI 1.001-1.017, p = 0.042), need for mechanical ventilation (OR 17.71, CI 1.13-277.62, p = 0.002) and KDIGO 3 (OR 2.017 CI 1.039 -3.917, p = 0.038). AKI was frequent among the elderly hospitalized with COVID-19 and its risk factors were higher baseline creatinine and need for mechanical ventilation. AKI was independently associated with a higher risk of death.

Continue with ICU care - she is a spiritual being.

This case study discusses a dispute between the healthcare team and the patient's surrogate decision maker at a cancer centre. While the healthcare team deemed further care to be futile, the patient's husband argued that they should continue to try to reverse his wife's acute decline. This case study illustrates the inertia and moral distress that can result when there are differences between patients/surrogates and the healthcare team in their goals for intensive care. The issues of moral distress and an inability to make decisions were addressed by involving an ethics consultant, and by creating institutional mechanisms to address end-of-life issues at an earlier stage.

Improving Post-Injury Care: Key Family Caregiver Perspectives of Critical Illness After Injury.

BACKGROUND:There is little research about how caregiver experiences evolve from ICU admission to patient recovery, especially among caregivers for patients who have traumatic injuries. In this study, we characterize diverse caregiver experiences during and after ICU admission for injury.METHODS:This prospective observational study is based in a level 1 trauma center in Philadelphia, Pennsylvania. Longitudinal interviews among caregivers of patients who required ICU admission for traumatic injury were conducted from the time of ICU admission to 12 months after hospital discharge. Transcripts were analyzed using a qualitative descriptive approach.RESULTS:Sixty-five interviews were conducted with 19 caregivers. The interview results converged on four areas: experiences in the ICU, the aftermath of violent traumatic injury, caregiver responsibilities, and care in the context of the wider family. In the ICU, caregivers contended with worry and uncertainty, and they often hid these feelings. Many felt that they always needed to be at the bedside, leading to stress and exhaustion. Caregivers had difficulty communicating with their loved ones, and communication itself sometimes became a source of conflict. Over time, caregivers were burdened by many managerial responsibilities. In addition, violent traumatic injury caused an overlay of concern for patients’ safety. The need to plan for recovery caused caregivers to make substantial sacrifices. As a result of these difficult experiences, some caregivers and patients drew closer together, while others were divided by conflict.CONCLUSIONS:Illness after traumatic injury may be devastating for caregivers, disrupting emotional wellbeing and other aspects of life. Caregivers are variably prepared for the challenges of ICU care and caregiving through convalescence and require robust support during and after ICU admission to enable effective communication, resource access, and an ongoing relationship with the healthcare team.

Comparison of Apache IV Vs Apache II Scoring System in Predicting the Clinical Outcomes of patients in Intensive Care Unit

Background: Prognostication of critically ill patients is an integral part of the quality of care in ICU. The use of scoring system such as Acute Physiology and Chronic Health Evaluation (APACHE) to predict risk of mortality and evaluating outcome in critically ill patients is important in modern evidence-based medicine. the aim of the study was to compare the APACHE II and APACHE IV in predicting the mortality of patients intensive care unit. Methods: A prospective descriptive was among 100 adult patients admitted irrespective of diagnosis and managed for &gt;24hours in the 25 bedded multidisciplinary ICU of a tertiary care hospital. The APACHE II and APACHE IV scores were calculated using the online calculators, based on the worst values in the first 24hours of admission. All the study participants were followed up, to determine the observed mortality rates and length of stay of ICU which were compared with predicted mortality rates obtained from both the APACHE II and APACHE IV scoring systems. The receiver operator characteristic curves (ROC) were used to compare accuracy of the two scores using SPSS 20version. Results: There was no statistically significant difference in the estimated mortality rate of patients in ICU based on APACHE II and APACHE IV scoring system (t= 1.674) at p&lt;0.05 level. There was a significant weak correlation between actual length of stay and estimated length of stay based on APACHE IV score (r = 0.469) at p &lt; 0.01level. Discrimination for APACHE II and APACHE IV models were good with area under the curve of o.965 and 0.760 respectively. APACHE II was more accurate than APACEIV in this regard. Conclusion: Discrimination was more-better for APACHE II than APACHE IV model. there was a moderate correlation observed between the two models in this study.

Clinical Profile and Outcome of Hospitalized Confirmed Cases of Omicron Variant of SARS-CoV-2 Among Children in Pune, India.

BackgroundThe Omicron variant of SARS-CoV-2 infection was seen to be more infectious but less severe in children than adults with reduced hospitalization rates. There is a paucity of data on hospitalized children with confirmed Omicron variant.ObjectiveWe describe demographic, epidemiologic, clinical, radiological, laboratory features and outcomes of children with confirmed Omicron variant of SARS-CoV-2 infection admitted to a tertiary care teaching hospital in Pune, India.MethodologyChildren who tested positive for SARS-CoV-2 - Omicron variant and were admitted between 1st December 2021 and 28th February 2022 were included in the study.ResultsOut of a total of 37 Covid-positive children admitted during the study period, 16 underwent genome sequencing of which 14 were confirmed to be Omicron variant and two were Delta variant. The age range was one month to 12 years and seven (50%) were male. Common presenting features were fever (n=13, 93%), cough (n=7, 50%), seizures (n=7, 50%) and coryza (n=5, 36%). Comorbidities noted were epilepsy (n=3, 21%) and one each with Thalassemia Major, suspected inborn error of metabolism (IEM), operated anorectal malformation with hypospadias, chronic suppurative otitis media with complications (mastoiditis and facial nerve palsy), neonatal cholestasis and intracranial bleed with dural venous sinus thrombosis. Malnutrition was noted in 42%, pallor in 10 cases (71%). Severe anaemia (n=10, 71%), elevated ferritin (n=6, 43%), positive C-Reactive Protein (n=4, 28%) and deranged D-dimer (n=11, 78%) were noted. The Neutrophil to Lymphocyte ratio (NLR) was >3.3 in five (36%) children. Four (28%) had evidence of pneumonia on the chest radiograph. Oxygen therapy was needed in nine (64%) while two children (14%) required mechanical ventilation. There were two deaths (14%) in children with multiorgan dysfunction and refractory shock. Intravenous immunoglobulin and methylprednisolone were administered to one patient respectively (14%). The median hospital stay was 10 days (Interquartile range = 8).ConclusionHospitalized children with Omicron variant of SARS-CoV-2 who have underlying comorbidities may have severe presentations needing ICU care. Mortality rates are low with appropriate ICU care.

A Case Report on Fournier’s Gangrene and its Management

Fournier’s gangrene is an eruptive form of necrotizing fasciitis of the perineal &amp; genital regions. General burden in population is 1.6 cases per 1,00,000 men per year. It is a flesh-eating infection where the bacteria kill the soft tissues, often quickly including muscles, nerves and blood vessels. It presents with scrotum pain &amp; redness, tenderness or swollen perineal region along with rapid progression to gangrene and sloughing of tissues. Along with high fever spikes and leukocytosis which deteriorates to sepsis. The Route of infection is identifiable in 95% of cases which arises from anorectal, genito-urinary and cutaneous sources. The other risk factors include diabetes mellitus, morbid obesity, immune compromised, alcohol abuse, unprotected sex, masturbation, genital piercing, abscess and malignant neoplasms. However, in Healthy adults, the exact cause is unknown. Fournier’s Gangrene Severity Index (FGSI) is used to predict mortality risk. The basic treatment for Fournier’s gangrene includes an emergency surgical debridement with higher antibiotics therapy and ICU care. In this case report, we discussed a case of a young male of 24 years with necrotizing fasciitis of the perineal and genital regions, who was reconstructed and surgically managed in a two staged procedure with good outcome.

Outcome and Prognostic Factors of COVID-19 Infection in Swiss Cancer Patients: Final Results of SAKK 80/20 (CaSA).

Simple SummaryThe characterization of clinical outcomes and prognostic factors in COVID-19-infected cancer patients is important for health care authorities, policy makers and oncologists. We collected extensive data on COVID-19-infected cancer patients from 1 March 2020 over a one-year period. Among 455 patients included, death from COVID-19 infection occurred in 98 patients, resulting in a mortality rate of 21.5%. Age ≥ 65 years, non-curative disease, intensive care unit admission and oxygen requirement were particular and independent negative prognostic factors for death from COVID-19. COVID-19 severity and mortality in cancer patients remained high in a country (Switzerland) with a decentralized, high-quality, universal-acess health care system.Purpose: These are the final results of a national registry on cancer patients with COVID-19 in Switzerland. Methods: We collected data on symptomatic COVID-19-infected cancer patients from 23 Swiss sites over a one-year period starting on 1 March 2020. The main objective was to assess the outcome (i.e., mortality, rate of hospitalization, ICU admission) of COVID-19 infection in cancer patients; the main secondary objective was to define prognostic factors. Results: From 455 patients included, 205 patients (45%) had non-curative disease, 241 patients (53%) were hospitalized for COVID-19, 213 (47%) required oxygen, 43 (9%) invasive ventilation and 62 (14%) were admitted to the ICU. Death from COVID-19 infection occurred in 98 patients, resulting in a mortality rate of 21.5%. Age ≥65 years versus <65 years (OR 3.14, p = 0.003), non-curative versus curative disease (OR 2.42, p = 0.012), ICU admission (OR 4.45, p < 0.001) and oxygen requirement (OR 20.28, p < 0.001) were independently associated with increased mortality. Conclusions: We confirmed high COVID-19 severity and mortality in real-world cancer patients during the first and second wave of the pandemic in a country with a decentralized, high-quality, universal-access health care system. COVID-19-associated mortality was particularly high for those of older age in a non-curative disease setting, requiring oxygen or ICU care.

Maternal and perinatal outcomes of pre-referral magnesium sulfate treatment in severe preeclampsia patients

HIGHLIGHTS 1. Consumption of magnesium sulfate is recommended for prevention against eclampsia. 2. Magnesium sulfate administration to preeclamptic mothers is effective in reducing the risk of eclampsia.3. Pre-referral magnesium sulfate administration and maternal and perinatal outcomes in severe preeclampsia patients was analyzed.4. Magnesium sulfate did reduce eclampsia risk, but not ICU and NICU care rates, maternal mortality, perinatal asphyxia, and perinatal mortality. ABSTRACT Objectives: This study analyzed the association between pre- referral magnesium sulfate administration and maternal and perinatal outcomes in severe preeclampsia patients. Materials and Methods: This was a retrospective observational analytic study using cross-sectional design. Samples were 132 pregnant women with preeclampsia referred to dr. Saiful Anwar, Hospital Malang, Indonesia in 2019. Data were taken from the patients’ medical records. Maternal outcomes measured in this study were the incidence of eclampsia, ICU care, and maternal mortality, while the perinatal outcomes included the incidence of asphyxia, NICU care, and perinatal mortality. Results: Patients’ history of magnesium sulphate administration significantly associated with the incidence of eclampsia with p-value 0.035 and odds ratio (OR) 2.413, thus consumption of magnesium sulphate could reduce the risk of seizures. However, it did not associate with either maternal ICU care outcomes (p-value 0.087, OR 2.028), or maternal mortality (p-value 0.573). No relationship was found neither between history of magnesium sulphate administration in pregnant women with severe preeclampsia and perinatal outcomes nor with the incidence of asphyxia (p-value 0. 577, OR 0.795), with NICU treatment (p-value 0.205, OR 0.579), and with perinatal mortality (p-value 0.153, OR 3.259). Conclusion: Magnesium sulfate reduced the risk of eclampsia, yet it did not affect either the rate of ICU care, maternal mortality, incidence rate of perinatal asphyxia, the rate of NICU care, or perinatal mortality.

The Impact of COVID-19 Pandemic on Neuromyelitis Optica Disorder Patients, After one Year

Background: Coronavirus Disease 2019 (COVID-19) recently created a pandemic with high mortality. People with underlying diseases are prone to severe infection. The nature of NMOSD disease and its treatment by immunosuppressants predisposes patients to infection. Objectives: This study aimed to evaluate the effect of the COVID-19 pandemic on the clinical course of NMOSD and the characteristics of COVID-19 infection in NMOSD patients. Materials &amp; Methods: This descriptive study was performed in Isfahan City, Iran, Iran, from March 2020 to March 2021. We considered relapses during the epidemic and the year before and the presentation of COVID-19 infection in the patients of NMOSD Clinic of Isfahan Kashani hospital. Results: The study included 120 patients. Their Mean±SD age was 36.37±9.69 years, and the mean duration of disease was 8.49±5.35 years. Overall, they experienced 36 relapses during the year before the epidemic (ARR:0.3) and 29 during the COVID-19 epidemic (ARR:0.24). The maintenance therapy of NMOSD was rituximab in 96 cases, azathioprine in 22, and methotrexate in 2 ones. 35 patients infected by COVID-19 (based on RT-PCR test). 6 were admitted to the hospital, and two patients received ICU care. There was one death due to respiratory failure. Conclusion: Despite the suppression of the immune system, neither incidence nor the number of severe complications of COVID-19 infection was high. Therefore, regarding the disabling nature of NMOSD and the prolonged epidemic period, it may be reasonable to continue the routine treatment of these patients and train them to stick to health protection instructions.

Comparison of isolated respiratory and extrarespiratory mucormycosis: a 21-year observational study of 44 cases.

This study aimed to compare the clinical characteristics and outcomes of patients with isolated respiratory and extrarespiratory mucormycosis. Adult patients diagnosed with proven or probable invasive mucormycosis in a tertiary hospital in South Korea, between 1999 and 2020 were retrospectively reviewed. We compared the clinical, mycological characteristics, and outcomes of patients with isolated respiratory mucormycosis (IRM) and those with extrarespiratory mucormycosis (ERM). A total of 44 patients including 32 (72%) with IRM, and 12 (27%) with ERM were enrolled. Of these, 38 (86%) were classified as proven and 6 (14%) as probable invasive mucormycosis according to the EORTC/MSG criteria. Univariate analysis exhibited that old age, surgery, and intensive care unit were associated with ERM, and multivariable analysis revealed that variable associated with ERM was intensive care unit (aOR 9.80; 95% CI 2.07-46.35; P = 0.004). There were no significant differences in 90-day mortality between patients with IRM and ERM (38% vs 50%, P = 0.45). In multivariable analysis, neutropenia (aOR 6.88; 95% CI 1.67-28.27; P = 0.01) was an independent risk factor for 90-day mortality. More than a quarter of patients with mucormycosis had extrarespiratory manifestations, especially in patients who were admitted to intensive care unit. The mortality of the patients with ERM was comparable to that of the patients with IRM, although the patients with ERM received ICU care more frequently.

Delirium diagnosis without a gold standard: Evaluating diagnostic accuracy of combined delirium assessment tools

BackgroundFluctuating course of delirium and complexities of ICU care mean delirium symptoms are hard to identify or commonly confused with other disorders. Delirium is difficult to diagnose, and clinicians and researchers may combine assessments from multiple tools. We evaluated diagnostic accuracy of different combinations of delirium assessments performed in each enrolled patient.MethodsData were obtained from a previously conducted cross-sectional study. Eligible adult patients who remained admitted to ICU for >24 hours with at least one family member present were consecutively enrolled as patient-family dyads. Clinical delirium assessments (Intensive Care Delirium Screening Checklist [ICSDC] and Confusion Assessment Method-ICU [CAM-ICU]) were completed twice daily by bedside nurse or trained research assistant, respectively. Family delirium assessments (Family Confusion Assessment Method and Sour Seven) were completed once daily by family members. We pooled all delirium assessment tools in a single two-class latent model and pairwise (i.e., combined, clinical or family assessments) Bayesian analyses.ResultsSeventy-three patient-family dyads were included. Among clinical delirium assessments, the ICDSC had lower sensitivity (0.72; 95% Bayesian Credible [BC] interval 0.54–0.92) and higher specificity (0.90; 95%BC, 0.82–0.97) using Bayesian analyses compared to pooled latent class analysis and CAM-ICU had higher sensitivity (0.90; 95%BC, 0.70–1.00) and higher specificity (0.94; 95%BC, 0.80–1.00). Among family delirium assessments, the Family Confusion Assessment Method had higher sensitivity (0.83; 95%BC, 0.71–0.92) and higher specificity (0.93; 95%BC, 0.84–0.98) using Bayesian analyses compared to pooled latent class analysis and the Sour Seven had higher specificity (0.85; 95%BC, 0.67–0.99) but lower sensitivity (0.64; 95%BC 0.47–0.82).ConclusionsResults from delirium assessment tools are often combined owing to imperfect reference standards for delirium measurement. Pairwise Bayesian analyses that explicitly accounted for each tool’s (performed within same patient) prior sensitivity and specificity indicate that two combined clinical or two combined family delirium assessment tools have fair diagnostic accuracy.

Hubungan Gambaran X-RAY Thorax Bronkopneumonia dengan Leukositosis Pada Pasien Intensive care unit di RSUD dr. Chasbullah Abdul Madjid Kota Bekasi

Bronchopneumonia is the most common picture of pneumonia found, especially in the ICU. Bronchopneumonia occurs due to the interaction between infection and cellular immunity which causes peribronchial consolidation. This process can result in leukocytosis in the patient. This research is an observational analytic study with a cross sectional method which was carried out in RSUD dr. Chasbullah Abdulmajid Bekasi City, West Java with secondary data from patient medical records in the period 1 November 2021 – 19 December 2021. Samples were taken using the total sampling method from population being treated at the ICU Cattleya. The variables taken were age, gender, the diagnosis to be taken, the results of a chest X-ray, and the value of the patient. The sample used was 101 patients. The most demographic characteristics were men at 49.5%, the 18-64 year group at 68.3%, and the basic diagnosis of ICU care for cerebrovascular disease was 24.8%. Statistical test using Chi-square test found that there was no relationship between bronchopneumonia and leukocytosis (p=0.172; p&gt;0.05). This study showed that there was no association between chest x-ray bronchopneumonia and leukocytosis in ICU patients

RETROSPECTIVE ANALYSIS OF COVID-19 POSITIVE PARTURIENTS POSTED FOR CAESAREAN SECTION IN TERTIARY CARE CENTRE

Background And Aims: Parturients posted for LSCS present with physiological changes due to pregnancy and gravid uterus, may have associated co-morbidities, superadded by COVID 19 infection poses a real challenge for an anesthesiologist. Urgency in obstetric anesthesia and extreme precautions needed to avoid this contagious disease further increase the burden on the anesthesiologist. This study focuses on perioperative presentation, management, and outcome of patients in a tertiary level hospital. Method: 329 pregnant females with RAT or RTPCR positive for COVID 19 and undergoing cesarean section from 1st May 2020 to 31st July 2021 were included in this retrospective observational study. Data was collected and analyzed from OT, ICU, WARD records, patient medical and electronic records, and maternal mortality data. Results: Amongst 329 parturients, 98.48%(324/329) received spinal anesthesia, one received epidural anesthesia (0.30%) and 1.21%(4/329) required general anesthesia. The incidence of hypotension was 5.77% (19/329), managed with inj. Mephentermine without inotropes. The intraoperative course was uneventful except for one case of CRA, revived successfully. Nine patients (2.73%) required ICU care. Oxygen support by either nasal prongs or face masks was given to 3.95% (13/329) patients. Three patients (0.91%) required NIV support and three patients (0.91%) required invasive ventilation postoperatively. The overall mortality was 0.61% (2/329). The mean duration of hospital stay was found to be 8.2 ± 5.03 days Conclusion: Neuraxial anesthesia remains a technique of choice for LSCS and can be safely employed in the parturients even with moderate pneumonia. General anesthesia can be reserved for patients of severe covid pneumonia.

Predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia

BackgroundFactors associated with stroke mortality are understudied in sub-Saharan Africa but have implications for designing interventions that improve stroke outcomes. We investigated predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia. MethodsData from consecutive adults admitted with stroke at University Teaching Hospital in Lusaka, Zambia between October 2018 and March 2019 were retrospectively reviewed for clinical in-hospital outcomes. Vital status at 90-days post-discharge was determined through phone calls. Factors associated with stroke mortality were included in multivariable logistic regression models utilizing multiple imputation analysis to determine independent predictors of in-hospital and 90-days post-discharge mortality. ResultsIn-hospital mortality was 24%, and 90-day post-discharge mortality was 22% among those who survived hospitalization. Hemorrhagic and unknown strokes, ICU care, seizures, and aspiration pneumonia were significantly associated with in-hospital mortality. Among these, hemorrhagic stroke (OR 2.88, 95% CI 1.27–6.53, p = 0.01) and seizures (OR 29.5, 95% CI 2.14–406, p = 0.01) remained independent predictors of in-hospital mortality in multivariable analyses. Ninety-day post-discharge mortality was significantly associated with older age, previous stroke, atrial fibrillation, and aspiration pneumonia, but only older age (OR 1.04, 95% CI 1.01–1.06, p = 0.007) and aspiration pneumonia (OR 3.93, 95% CI 1.30–11.88, p = 0.02) remained independently associated with 90-day mortality in multivariable analyses. ConclusionThis Zambian stroke cohort had high in-hospital and 90-day post-discharge mortality that were associated with several in-hospital complications. Our data indicate the need for improvement in both acute stroke care and post-stroke systems of care to improve stroke outcomes in Zambia.

Incidence and influence of hyperCKemia in Legionella infection

IntroductionA number of case and case series descriptions established an association between Legionella infection and hyperCKemia, but the frequency and severity of hyperCKemia in Legionella infection remain unknown. This study aims to investigate the incidence, extent, and consequences of hyperCKemia in a large group of patients with Legionella infection. MethodsThis retrospective study included patients with confirmed Legionella infection during a ten-year period who received creatine kinase (CK) testing. Comparisons were performed between groups of Legionella patients with and without hyperCKemia. ResultsA total of 267 patients were included. HyperCKemia was present in 144 (53.9%) patients. The mean peak CK value was 9598 IU/L (range: 226 to 462,000 IU/L) while peak CK exceeded 1000 IU/L in 82 (56.9%) patients and 5000 IU/L in 33 (22.9%). When compared to patients without hyperCKemia, patients with hyperCKemia had higher incidences of neurologic symptoms (p = 0.036), acute renal failure (p = 0.028), dialysis requirement (p = 0.009), and need for ICU care (p = 0.016). HyperCKemia resolved in most Legionella patients by 7 days from CK peaking. DiscussionLegionella infection requiring hospitalization appears to be associated with increased incidence of hyperCKemia and rhabdomyolysis. Greater awareness of the high incidence and the possible severity of hyperCKemia is needed when treating patients with Legionella infection.

Characteristics and outcomes of prisoners hospitalized due to COVID-19 disease.

Correctional facilities have faced unique challenges during the COVID-19 pandemic. A COVID-19 outbreak was reported in the Federal Medical Center (FMC) in Lexington, Kentucky, a prison for inmates requiring medical and mental care. The main objective of this study was to examine clinical characteristics and outcomes of prisoners vs. non-prisoners admitted to the hospital due to COVID-19 disease. We did a retrospective, comparative cohort study of 86 consecutive COVID-19 patients admitted to the University of Kentucky hospital between March 1 and June 1, 2020. Among these, 37 patients were inmates from a single local FMC and 49 were non-inmates. Mean (SD) age of the cohort was 59.1 (14.5) years, 68.6% were male and 61.6% white. All inmates were men. No significant differences in age or race were observed between inmates and non-inmates. Hypertension (81%), obesity (62%), COPD/asthma (43%), diabetes (41%), coronary artery diseases (38%), and chronic kidney disease (22%) were among the most common comorbidities prevalent in inmates. Inmates had overall higher serum creatinine and C-reactive protein, more proteinuria, and lower platelet counts at the time of hospital admission when compared to non-inmates. Incidence of acute kidney injury (AKI) was more frequent in inmates (68 vs. 38% in non-inmates, p = 0.008). Overall, patients who developed AKI had higher acuity of illness with more requirement of ICU care and mechanical ventilation. Kidney replacement therapy (KRT) was provided to 12.8% of patients. Inpatient mortality occurred in 15.1% of patients and was not different in inmates vs. non-inmates (13.5 vs. 16.3%, p = 0.862). All survivors became independent of KRT, and ~ 1 of 10 survivors had a reduction of eGFR ≥ 25% from baseline by the time of discharge, which was more frequent in inmates vs. non-inmates, 15.6 vs. 2.4%, p = 0.042, respectively. Inmates represent a vulnerable population with prevalent comorbidity and susceptibility to COVID-19. When compared to non-inmates with COVID-19, inmates exhibited higher incidence of AKI and, for survivors, less kidney recovery by the time of hospital discharge. Surveillance of long-term sequela of COVID-19 is warranted in this susceptible inmate population.

Blood Type O Heart Transplant Candidates Have Longer Waitlist Times But Comparable Post-transplant Outcomes Under The Revised UNOS Organ Allocation Criteria

In October 2018 the United Network for Organ Sharing (UNOS) updated the heart allocation criteria aiming to improve mortality and reduce waitlist time. Although blood type (BT) O candidates had longer waitlist times and lower heart transplant (HT) rates under the prior guidelines, BT remains absent from the revised criteria. Accordingly, we evaluated the impact of the revised UNOS criteria on bridging strategies and waitlist and transplant outcomes based on candidate BT. Using UNOS registry data, we retrospectively evaluated 4,132 HT candidates and 2,727 recipients between Nov. 18, 2018 and Mar. 20, 2020. Statistical significance was defined as p<0.001. BT O was the most common blood type at time of HT listing: A 1,550 (38%), AB 182 (4%), B 593 (14%) and O 1,807 (44%). At listing there was no difference in the use of temporary mechanical support (TMCS) including intra-aortic balloon pump (IABP) (p=0.11) and extracorporeal mechanical oxygenation (ECMO) (p=0.16), nor listing status, though BT O were more frequently listed as status 4 (p=0.006). There was a trend towards less frequent LVAD use in BT O at listing: A 1,078 (70%), AB 132 (73%), B 418 (71%) and O 1,213 (67%) (p=0.19). Fewer BT O candidates underwent HT (A 1,020 (93%), AB 147 (94%), B 411 (92%) and O 889 (86%); p<0.001) and were more frequently listed as status 1 or 2: A 626 (56%), AB 70 (41%), B 262 (58%) and O 717 (73%) (p<0.001). At transplant, BT O were more likely to be in the ICU (A 52%, AB 44%, B 53% and O 61%; p<0.001) and require IABP support (A 30%, AB 18.3%, B 31% and O 36%; p<0.001). BT O also trended towards increased use of inotropes (A 37%, AB 36%, B 41% and O 42%; p <0.05) and ECMO (A 5.3%, AB 4.7%, B 4.8% and O 6.6%; p=0.41). There was no significant difference in LVAD use at the time of HT (p=0.63). BT O had significantly longer median time to transplantation (A 17 [IQR 6-61], AB 14 [IQR 6-47], B 20 [IQR 7-63] and O 23 [IQR 8-77] days; p<0.001) and a trend towards increased risk for waitlist mortality (p=0.2). Kaplan-Meier analysis showed no significant difference in post-transplant survival at one year (p=0.3) or outcomes including renal failure, stroke, pacemaker use, hospital length of stay and acute rejection at one year (p=0.2). Under the new UNOS allocation criteria BTO candidates continue to be transplanted at significantly lower rates. With longer waitlist times, there was a trend to list BT O at lower status and with less frequent LVAD use. At the time of transplantation significantly more BTO candidates were transplanted at higher status and with increased use of ICU care, inotropes and TMCS. This shift in bridging strategies may suggest BT O clinical deterioration, also reflected by the increased risk in waitlist mortality. However, post-transplant mortality and outcomes were not adversely affected, possibly mitigated by advancements in post-HT care. Long-term outcomes remain to be seen.

Outcomes of COVID-19 in an Advanced Heart Failure Practice: A Single Center Study

PurposePatients with heart failure (HF) carry an increased risk of mortality and morbidity with COVID-19. The objective of this study is to compare the outcomes of HF (stage C or D), Left Ventricular Assist Device (LVAD) or Heart Transplant (HTx) patients who were diagnosed with COVID-19.MethodsOut of 2635 patients followed in our program (HF=2234, LVAD=167, HTx=234), 96 patients diagnosed with COVID-19 infection between March 2020 to January 2021 were included in this study. Hospital length of stay (LOS), requirement for mechanical ventilation, and mortality rate were compared. Kaplan-Meier analysis was used to compare survival.ResultsThe distribution of COVID among the 96 patients was: HTx = 15.8%, LVAD = 9.6% and HF = 1.9%. Table 1 outlines the clinical characteristics and outcomes of the 3 cohorts. A total of 49 patients were hospitalized: 18 (41.9%) HF, 8 (50%) LVAD, and 23 (62.2%) HTx. Of the hospitalized patients, 5 (27.8%) required ICU care in the HF, 2 (25%) LVAD, and 6 (26.1%) HTx groups. The median ICU LOS was significantly higher in HTx (24 days, p=0.04) when compared to HF (10 days) group. HTx patients had the highest 180-day mortality, followed by LVAD, and then HF patients (18.9%, 12.5% and 11.6%, respectively). All deaths occurred within 50 days from diagnosis. Among LVAD patients, COPD was the highest predictor of mortality (69% prevalence).ConclusionThis report is among the first to describe the impact of COVID-19 on a comprehensive advanced heart failure (HF) practice. Our data highlights the risks of morbidity and mortality faced by HF and immunocompromised patients with COVID-19 infection. A mortality rate of 19% with HTx patients acquiring COVID is ominous (even if better than reported rates of 25%). Likewise, though not as high, mortality rates for COVID infected advanced HF and LVAD patients of 12% each represent substantial risk. Protecting these patients with all possible preventative and therapeutic options is an essential imperative.