Intensive Care Unit Admission Rate Research Articles

Intensive care following in-hospital cardiac arrest / periarrest calls—experience from one Scottish hospital

BackgroundIn-hospital cardiac arrest/periarrest is a recognised trigger for consideration of admission to the intensive care unit (ICU). We aimed to investigate the rates of ICU admission following in-hospital cardiac arrest/periarrest, evaluate the outcomes of such patients and assess whether anticipatory care planning had taken place prior to the adult resuscitation team being called.MethodsAnalysis of all referrals to the ICU page-holder within our district general hospital is between 1st November 2018 and 31st May 2019. From this, the frequency of adult resuscitation team calls was determined. Case notes were then reviewed to determine details of the events, patient outcomes and the use of anticipatory care planning tools on wards.ResultsOf the 506 referrals to the ICU page-holder, 141 (27.9%) were adult resuscitation team calls (114 periarrests and 27 cardiac arrests). Twelve patients were excluded due to health records being unavailable. Admission rates to ICU were low — 17.4% for cardiac arrests (4/23 patients), 5.7% (6/106) following periarrest. The primary reason for not admitting to ICU was patients being “too well” at the time of review (78/129 — 60.5%). Prior to adult resuscitation team call, treatment escalation plans had been completed in 27.9% (36/129) with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms present in 15.5% of cases (20/129). Four cardiac arrest calls were made in the presence of a valid DNACPR form, frequently due to a lack of awareness of the patient’s resuscitation status.ConclusionsThis study highlights the significant workload for the ICU page-holder brought about by adult resuscitation team calls. There is a low admission rate from these calls, and, at the time of resuscitation team call, anticipatory planning is frequently either incomplete or poorly communicated. Addressing these issues requires a collaborative approach between ICU and non-ICU physicians and highlights the need for larger studies to develop scoring systems to aid objective admission decision-making.

Comparison of pediatric pelvic fractures and associated injuries caused by different types of road traffic accidents

PurposeTo explore the clinical characteristics of pediatric pelvic fracturs caused by traffic accidents and to analyze the accompanying injuries and complications. MethodsA total of 222 cases involved traffic accidents was enrolled in this case-control study. The data of children with pelvic fractures caused by traffic accidents who were admitted to our hospital from January 2006 to December 2021 were analyzed retrospectively. Sex, age, Tile classification, abbreviated injury scale score, injury severity score, mortality, and accompanying injuries were studied. The ANOVA was used for measurement data, and the non-parametric rank sum test was used for non-normally distributed data. The Fisher's exact probability method was used for the count data. ResultsOf all enrolled cases, 140 are boys and 82 are girls, including 144 aged < 6 years, 65 aged between 6 and 12 years, and 13 aged > 12 years. Depending on the injury mechanism, there are 15 cases involving pedestrians vs. motorcycles (PVM), 91 cases involving pedestrians vs. passenger cars (PVC), 78 cases involving pedestrians vs. commercial vehicles (PVV), and 38 cases involving motor vehicles vs. motor vehicles (MVM). Associated injuries are reported in 198 cases (89.2%), primarily involving the abdomen injury in 144 cases (64.9%), and lower limb injury in 99 cases (44.6%). PVV injury involves longer hospital stay (p = 0.004). Intensive care unit admission rate is significantly higher in the MVM group than in other groups (p = 0.004). Head injury (p = 0.001) and face injury (p = 0.037) are more common in the MVM group, whereas abdominal injury (p = 0.048) and lower limb injury (p = 0.037) are more common in the PVV group. In the MVM group, the brain injury (p = 0.004) and femoral neck injury (p = 0.044) are more common. In the PVM group, the mediastinum (p = 0.004), ear (p = 0.009), lumbar vertebrae (p = 0.008), and spinal cord (p = 0.011) are the most vulnerable regions, while in the PVV group, the perineum (p < 0.001), urethra (p = 0.001), rectum (p = 0.006), anus (p = 0.004), and lower limb soft tissues (p = 0.024) are the most vulnerable regions. Children aged > 12 years have higher pelvic abbreviated injury scale scores (p = 0.019). There are significant differences in the classification of pelvic fractures among children < 6, 6 – 12, and > 12 years of age, with Tile C being more likely to occur in children > 12 years of age (p = 0.033). Children aged > 12 years are more likely to sustain injuries to the spleen (p = 0.022), kidneys (p = 0.019), pancreas (p < 0.001), lumbar vertebrae (p = 0.013), and sacrum (p = 0.024). The MVM group has the highest complication rate (p = 0.003). ConclusionPVC is the leading cause of the abdomen and lower extremities injury and has the most concomitant injuries. Different traffic injuries often lead to different associated injuries. Older children are more likely to sustain more severe pelvic fractures and peripelvic organs injuries. The MVM group has the highest extent of injury and complication rates.

Comparison of validity of Korean triage and acuity scale levels assessed by triage nurse in real-time and by retrospectively applying strict systemic inflammatory response syndrome criteria in patients with fever

The strict application of vital signs has substantial risk of over-triage. Therefore, this study assessed the predictive value of Korean Triage and Acuity Scale (KTAS) level calculated using strict Systemic Inflammatory Response Syndrome (SIRS) criteria versus that evaluated by a verified triage nurse (TN). The study is based on a retrospective observational cohort of a single-center emergency department (ED) from 01 May 2018 to 30 April 2019. Study subjects were patients aged ≥18 years with fever. Intensive care unit admission rate or death in ED (IADE) and general ward admission rate according to two differently defined KTAS levels were compared by receiver operating characteristic curve and logistic regression. A total of 2322 patients were included. In comparing the area under the curves (AUCs) of TN- and SIRS-KTAS, TN-KTAS’ predictive power for IADE (0.802) was higher than that of SIRS-KTAS (0.7440, p = 0.0489). The odds ratio of level 3 for IADE (1.35) was not significantly different from that of level 4 in SIRS-KTAS (p = 0.5429). In KTAS, the severity of illness in patients was more accurately predicted by the triage nurse’s decision based on clinical experience than the strict application of SIRS criteria with only vital signs.

Assessment of Delay in Door-to-antibiotic Administration Time after Arrival to the Hospital among Post-chemotherapy Febrile Neutropenia Patients: A Cohort Study

ntroduction: Febrile Neutropenia (FN), a common side effect of chemotherapy, is regarded as an oncologic emergency necessitating prompt treatment. A delay in door-to-antibiotic administration time is associated with poor patient outcomes. Aim: To assess the time lag in the administration of antibiotics after arrival at the hospital in patients with solid/haematological malignancy presenting with post-chemotherapy FN. Materials and Methods: This was a cohort study conducted in the Department of Medical Oncology at Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India, over a period of one year from December 2019 to November 2020 among 80 patients with solid or haematological malignancy who presented with fever and Absolute Neutrophil Count (ANC) &lt;1000/mm3 to the Outpatient Department (OPD) or the Emergency Department and were diagnosed with FN post-chemotherapy. Upon obtaining consent, these patients were enrolled, and the timing of antibiotic administration was noted for the study participants. The participants were further followed-up for the assessment of morbidity {in terms of Intensive Care Unit (ICU) admission)}, duration of hospital stay, delay in the further chemotherapy schedule, and survival status. Data was entered into MS Excel and analysed using Statistical Packages for Social Sciences (SPSS) version 16.0. Associations were established using Chi-square tests. Results: Out of a total of 80 study participants, the mean±SD age was 45.6±18.3 years, and the number of males was 43 (53.8%). Total 57 (71.25%) patients were on chemotherapy for solid organ malignancies. The median delay in door-to-antibiotic time was 120 minutes (ranging from 30 to 260 minutes). The median day of presentation with FN after chemotherapy was day 7. Delay in antibiotic administration was found to have a significant impact on the further chemotherapy schedule and doses (p=0.004). However, ICU admission rates (p=0.133), length of hospital stay (p=0.662), and mortality (p=0.201) were not significantly associated with the delay in antibiotic administration. Conclusion: The adoption of standardised algorithms and protocols for the management of FN and ensuring timely healthseeking by the patients shall help reduce the delay in Time-toantibiotic Administration (TTA).

Managed Care After Discharge of COVID-19 Patients in North Iran

Background and Purpose: After-discharge follow-up is one of the branches of managed care used for information exchange, health education, early diagnosis of symptoms, symptom management, and high-quality aftercare services. The present study aims to elucidate the managed care of COVID-19 patients after discharge from hospitals affiliated with Mazandaran University of Medical Sciences, Mazandaran Province, Iran. Materials and Methods: The present cross-sectional study was conducted in 2019. The study sample included all COVID-19 patients discharged from public, private, and social security hospitals affiliated with Mazandaran University of Medical Sciences. The census method was used to recruit 14625 discharged patients. The data collection tool was based on the information registration form “Follow-up of the treatment process of discharged COVID-19 patients,” which was prepared in three sections (demographic, clinical characteristics, and follow-up of the treatment process) based on the opinions of 15 experts. Data analysis was carried out via the chi-square test in SPSS software, version 21. Results: The findings of the demographic section showed that 35.8% of COVID-19-related admissions were over 65 years old. Intensive care unit (ICU) admissions were necessary for 13% of cases, with the highest ICU admission rates among those aged 65 and above. Based on the findings of the clinical characteristics section, the most common underlying disease (46.7%) was diabetes, and the most common symptom upon admission was fever (higher than 38°C) (44.8%). Also, according to the findings of the “treatment follow-up” section, 7.04% of the discharged patients were readmitted, and 14.5% of patients infected their family members with COVID-19. Also, 57.82% adhered to the health and safety protocols and self-quarantine at home, which varied in different months. Conclusion: Follow-up after the discharge of COVID-19 patients as one of the branches of managed care increased the compliance with health principles and decreased the rate of COVID-19 infection of the patient’s family members and the readmission of patients. Therefore, appropriate follow-up after discharge is suggested as a low-cost method to shorten the recovery period of patients, prevent other family members from contracting this disease, and detect the worsening of disease symptoms among discharged patients.

Locoregional Anesthesia's Association With Reduced Intensive Care Unit Stay After Elective Endovascular Aneurysm Repair: Impact of Temporal Changes in Practice Patterns

BackgroundElective endovascular aneurysm repair (EVAR) can be performed via local anesthetics and/or regional (epidural or spinal) anesthesia (locoregional [LR]), versus general anesthesia (GA), conferring reduced intensive care unit (ICU) and hospital stays. Current analyses fail to account for temporal changes in vascular practice. Therefore, this study aimed to confirm reductions in ICU and hospital stays among LR patients while accounting for changes in practice patterns. Materials and methodsUsing the Society for Vascular Surgery's Vascular Quality Initiative, elective EVARs from August 2003 to June 2021 were grouped into LR or GA. Outcomes included ICU admission and prolonged hospital stay (>2 d). Procedures were stratified into groups of 2 y periods, and outcomes were analyzed within each time period. Univariable and multivariate analyses were used to assess outcomes. ResultsLR was associated with reduced ICU admissions (22.3% versus 32.1%, P < 0.001) and prolonged hospital stays (14.3% versus 7.9%, P < 0.001) overall. When stratified by year, LR maintained its association with reduced ICU admissions in 2014-2015 (21.8% versus 34.0%, P < 0.001), 2016-2017 (23.6% versus 31.6%, P < 0.001), 2018-2019 (18.5% versus 30.2%, P < 0.001), and 2020-2021 (15.8% versus 28.8%, P < 0.001), although this was highly facility dependent. LR was associated with fewer prolonged hospital stays in 2014-2015 (15.6% versus 20.4%, P = 0.001) and 2016-2017 (13.3% versus 16.6%, P = 0.006) but not after 2017. ConclusionsGA and LR have similar rates of prolonged hospital stays after 2017, while LR anesthesia was associated with reduced rates of ICU admissions, although this is facility-dependent, providing a potential avenue for resource preservation in patients suitable for LR.

Safety and effectiveness of remdesivir for the treatment of COVID-19 patients with end-stage renal disease: A retrospective cohort study

BackgroundRemdesivir has been used to treat severe coronavirus 2019 (COVID-19); however, its safety and effectiveness in patients remain unclear. This study aimed to investigate the safety and effectiveness of remdesivir in patients with COVID-19 with end-stage renal disease (ESRD). MethodsThis retrospective study used the Chang Gung Research Database (CGRD) and extracted data from 21,621 adult patients with COVID-19 diagnosed between April 2021 and September 2022. The patients were divided into groups based on their remdesivir use and the presence of ESRD. The adverse effects of remdesivir and their outcomes were analyzed after propensity score matching. ResultsTo compare the adverse effects of remdesivir, propensity scores were used for one-to-one matching between patients with and without ESRD treated with remdesivir (N=110). There were no statistically significant differences in heart rates, blood glucose levels, variations in hemoglobin levels before and after remdesivir use, or liver function between the two groups after remdesivir use. A comparison was made between patients with ESRD using remdesivir and those not using remdesivir after propensity score matching (N=44). Although a shorter length of stay (LOS), lower intensive care unit (ICU) admission rate, and lower intubation rate were noted in the ESRD group treated with remdesivir, the difference was not statistically significant. ConclusionRemdesivir is safe for use in patients with COVID-19 and ESRD; no increased adverse effects were noted compared with patients without ESRD. However, the effectiveness of remdesivir use in patients with COVID-19 and ESRD remains uncertain.

Impact of extra-ampullary duodenal adenocarcinoma subtypes on surgical and oncological outcomes following pancreaticoduodenectomy.

There is little information about the relevance of extra-ampullary duodenal adenocarcinoma (EDA) subtypes. The aim of this study was to evaluate the impact of EDA subtypes on surgical and oncological outcomes following pancreatoduodenectomy (PD). Consecutive patients undergoing PD for EDA from 2000 to 2019 were analyzed. Results were stratified by pathologic subtype (intestinal versus non-intestinal). Uni-and multivariable analyses were performed using standard statistical methods. The study population consisted of 70 patients, of whom 49 (70%) had an intestinal phenotype. EDA with intestinal phenotype was more frequently proximal to the Ampulla of Vater, while non-intestinal EDA was more frequently found distally (76% vs. 33%, p = 0.002). Patients with intestinal EDA were less likely to experience severe morbidity, with decreased reoperation and unplanned Intensive Care Unit admission rates relative to non-intestinal subtypes (2% vs. 29% p = 0.002, and 2% vs. 19%, p = 0.007, respectively). The median follow-up post-pancreatectomy was 73months. Intestinal EDA was associated with improved overall and disease-free survival, with 3-year and 5-year survival rates of 71% vs. 29% and 53% vs. 24%, respectively. (p = 0.019 and p = 0.025). Intestinal-type EDA, which more often arises from supra-ampullary duodenum, was associated with better postoperative outcomes and improved survival.

COVID-19 in cancer patients: patient characteristics and outcomes in the post-COVID-19 vaccination period.

It wasaimed herein to investigate coronavirus disease (COVID-19) in cancer patients and compare hematological and solid organ cancer patients in terms of the course and outcome of this disease. Data from cancer patients with laboratory-confirmed COVID-19 infection were analyzed retrospectively. Risk factors for poor prognosis and the effect of vaccination on the clinical outcomes of the patients were evaluated. A total of 403 cancer patients who were diagnosed with COVID-19 between March 1st, 2021, and November 30th, 2022, were included, of whom 329 (81.6%) had solid and 74 (18.4%) had hematological cancers. Hospitalization and intensive care unit (ICU) admission rates were significantly higher in the hematological cancer patients compared to the solid organ cancer patients (73.0% vs. 35.9%, p< 0.001 and 25.7% vs. 14.0%, p= 0.013, respectively). The COVID-19-related case fatality rate (CFR) was defined as 15.4%, and it was higher in the hematologicalcancer patientsthan inthe solid organ cancer patients (23.0% vs. 13.7%, p= 0.045) and was higher in patients with metastatic/advanced disease compared to the other cancer stages (p< 0.001). In the solid organ cancergroup, hospitalization, ICU admission, and the COVID-19 CFR were higher in patients with respiratory and genitourinary cancers (p< 0.001). A total of 288 (71.8%) patients had receivedCOVID-19 vaccination; 164 (56.94%) had≤2 doses and 124 (43.06%) had≥3 doses. The hospitalization rate was higher in patients with ≤2 doses of vaccine compared to those with ≥3 doses (48.2% vs. 29.8%,p= 0.002). Patients with COVID-19-related death had higher levels of leucocyte, neutrophil, D-dimer, troponin, C-reactive protein (CRP), procalcitonin, and ferritin and lower levels of lymphocyte than the survivors. In the logistic regression analysis,the risk of COVID-19-related mortality was higher in the hematological cancer patients(OR:1.726), those who were male (OR:1.757), and with the Pre-Delta/Delta variants (OR:1.817). This study revealed that there is an increased risk of COVID-19-related serious events (hospitalization, ICU admission, or death) in patients with hematological cancerscompared with those who have solid organ cancers. It wasalso shown that receiving ≥3 doses of COVID-19 vaccine is more protective against severe illness and the need for hospitalization than ≤2 doses.

Obesity and Outcomes of Kawasaki Disease and COVID-19–Related Multisystem Inflammatory Syndrome in Children

ImportanceObesity may affect the clinical course of Kawasaki disease (KD) in children and multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.ObjectiveTo compare the prevalence of obesity and associations with clinical outcomes in patients with KD or MIS-C.Design, Setting, and ParticipantsIn this cohort study, analysis of International Kawasaki Disease Registry (IKDR) data on contemporaneous patients was conducted between January 1, 2020, and July 31, 2022 (42 sites, 8 countries). Patients with MIS-C (defined by Centers for Disease Control and Prevention criteria) and patients with KD (defined by American Heart Association criteria) were included. Patients with KD who had evidence of a recent COVID-19 infection or missing or unknown COVID-19 status were excluded.Main Outcomes and MeasuresPatient demographic characteristics, clinical features, disease course, and outcome variables were collected from the IKDR data set. Using body mass index (BMI)/weight z score percentile equivalents, patient weight was categorized as normal weight (BMI &amp;amp;lt;85th percentile), overweight (BMI ≥85th to &amp;amp;lt;95th percentile), and obese (BMI ≥95th percentile). The association between adiposity category and clinical features and outcomes was determined separately for KD and MIS-C patient groups.ResultsOf 1767 children, 338 with KD (median age, 2.5 [IQR, 1.2-5.0] years; 60.4% male) and 1429 with MIS-C (median age, 8.7 [IQR, 5.3-12.4] years; 61.4% male) were contemporaneously included in the study. For patients with MIS-C vs KD, the prevalence of overweight (17.1% vs 11.5%) and obesity (23.7% vs 11.5%) was significantly higher (P &amp;amp;lt; .001), with significantly higher adiposity z scores, even after adjustment for age, sex, and race and ethnicity. For patients with KD, apart from intensive care unit admission rate, adiposity category was not associated with laboratory test features or outcomes. For patients with MIS-C, higher adiposity category was associated with worse laboratory test values and outcomes, including a greater likelihood of shock, intensive care unit admission and inotrope requirement, and increased inflammatory markers, creatinine levels, and alanine aminotransferase levels. Adiposity category was not associated with coronary artery abnormalities for either MIS-C or KD.Conclusions and RelevanceIn this international cohort study, obesity was more prevalent for patients with MIS-C vs KD, and associated with more severe presentation, laboratory test features, and outcomes. These findings suggest that obesity as a comorbid factor should be considered at the clinical presentation in children with MIS-C.

Impact of scoliosis on gestational outcome.

To demonstrate the impact of scoliosis on pregnancy and gestational outcome. We retrospectively evaluated gestational outcomes of pregnant women with scoliosis at Hacettepe University Hospital between 2008 and 2018. Cases were grouped according to the presence of previous scoliosis surgery and compared in terms of gestational week at birth, birthweight, rate of neonatal intensive care unit admission, hospitalization during pregnancy, route of delivery, type of anesthesia at labor and postpartum intensive care unit admission rate. Ejection fraction (EF), functional vital capacity (FVC), forced expiratory volume (FEV1) and FEV1/FVC ratio values were also recorded. A total of 23 women were included, of whom 12 (52.2%) had a prior scoliosis surgery. One of the 23 (4.3%) cases was terminated due to respiratory problems, while the remaining 22 cases resulted in deliveries. The median gestational week at birth was 38.2 and the median birth weight was 3150 g. Median (range) maternal height was 143 (80-160) cm while median (range) maternal weight was 51 (35-86) kg. Three (13.6%) were diagnosed with restrictive lung disease. No significant difference was found between operated and non-operated groups in terms of respiratory function test results, cardiac EF and other related demographic and clinical features. Overall cesarean delivery rate was 63.6% (14/22) and cesarean section rate was significantly higher in the operated group (83.3% versus 40%) (p=0.04). Cesarean section rate was increased in this cohort of pregnancies in women with scoliosis and who had previous scoliosis surgery.

Characteristics and outcomes of patients hospitalized for infection with influenza, SARS-CoV-2 or respiratory syncytial virus in the season 2022/2023 in a large German primary care centre

BackgroundIn 2022/2023, Influenza A and Respiratory Syncytial Virus (RSV) reappeared in hospitalized patients, which was in parallel to ongoing SARS-CoV-2 infections. The aim of our study was to compare the characteristics and outcomes of these infections during the same time.MethodsWe included patients of all ages with a positive polymerase chain reaction (PCR) test for Influenza A/B, RSV, or SARS-CoV-2 virus hospitalized in the neurological, internal or paediatric units of the RoMed Hospital Rosenheim, Germany, between October 1st 2022 and February 28th 2023.ResultsA total of 906 patients were included (45.6% female; median age 68.0 years; 21.9% Influenza A, 48.2% SARS-CoV-2, 28.3% RSV). Influenza B (0.2%) and co-infections (1.5%) played a minor role. In patients aged ≥ 18 years (n = 637, 71%), Influenza A, SARS-CoV-2 and RSV groups differed in age (median 72, 79, 76 years, respectively; p < 0.001). Comorbidities, particularly asthma and COPD, were most prevalent for RSV. 103 patients were admitted to the intensive care unit (ICU) (16.3% Influenza A, 15.3% SARS-CoV-2, 19.2% RSV; p = 0.649), 56 died (6.8% Influenza A, 9% SARS-CoV-2, 11.1% RSV; p = 0.496). RSV showed the highest frequencies of low-flow oxygen supplementation for admission and stay. Differences in the length of stay were minor (median 7 days). Conversely, in patients aged < 18 years (n = 261, 28,8%), 19.5%, 17.6% and 60.2% were in the Influenza A, SARS-CoV-2 and RSV groups, respectively; 0.4% showed Influenza B and 2.3% co-infections. 17 patients were admitted to ICU (3.9% Influenza A, 9.6% RSV, 0% SARS-CoV-2); none died. RSV showed the highest frequencies of high- and low-flow oxygen supplementation, SARS-CoV-2 the lowest.ConclusionWhen comparing infections with Influenza, SARS-CoV-2 and RSV in the winter 2022/2023 in hospitalized adult patients, rates of ICU admission and mortality were similar. RSV showed the highest frequencies of obstructive airway diseases, and of oxygen supplementation. The latter was also true in children/adolescents, in whom RSV dominated. Thus, in the situation of declining importance of SARS-CoV-2, RSV showed a disease burden that was relatively higher than that from Influenza and SARS-CoV-2 across ages, and this might be relevant for the seasons coming.

Fetal and maternal outcomes of segmental uterine resection in emergency and planned placenta percreta deliveries.

This study evaluated maternal and fetal outcomes of emergency uterine resection versus planned segmental uterine resection in patients with placenta percreta (PPC) and placenta previa (PP). Patients with PP and PPC who underwent planned or emergency segmental uterine resection were included in this study. Demographic data, hemorrhagic morbidities, intra- and postoperative complications, length of hospital stay, surgical duration, and peri- and neonatal morbidities were compared. A total of 141 PPC and PP cases were included in this study. Twenty-five patients (17.73%) underwent emergency uterine resection, while 116 (82.27%) underwent planned segmental uterine resections. The postoperative hemoglobin changes, operation times, total blood transfusion, bladder injury, and length of hospital stay did not differ significantly between groups (P=0.7, P=0.6, P=0.9, P=0.9, and P=0.2, respectively). Fetal weights, 5-minute Apgar scores, and neonatal intensive care unit admission rates did not differ significantly between groups. The gestational age at delivery of patients presenting with bleeding was lower than that of patients who were admitted in active labor and underwent elective surgery (32 weeks [95% confidence interval [CI], 26-37] vs. 35 weeks [95% CI, 34-35]; P=0.037). Using a multidisciplinary approach, this study performed at a tertiary center showed that maternal and fetal morbidity and mortality did not differ significantly between emergency versus planned segmental uterine resection.

Racial difference in mortality among COVID-19 hospitalizations in California

In the US, racial disparities in hospital outcomes are well documented. We explored whether race was associated with all-cause in-hospital mortality and intensive care unit (ICU) admission among COVID-19 patients in California. This was a retrospective analysis of California State Inpatient Database during 2020. Hospitalizations ≥ 18 years of age for COVID-19 were included. Cox proportional hazards with mixed effects were used for associations between race and in-hospital mortality. Logistic regression was used for the association between race and ICU admission. Among 87,934 COVID-19 hospitalizations, majority were Hispanics (56.5%), followed by White (27.3%), Asian, Pacific Islander, Native American (9.9%), and Black (6.3%). Cox regression showed higher mortality risk among Hispanics, compared to Whites (hazard ratio, 0.91; 95% CI 0.87–0.96), Blacks (hazard ratio, 0.87; 95% CI 0.79–0.94), and Asian, Pacific Islander, Native American (hazard ratio, 0.89; 95% CI 0.83–0.95). Logistic regression showed that the odds of ICU admission were significantly higher among Hispanics, compared to Whites (OR, 1.70; 95% CI 1.67–1.74), Blacks (OR, 1.70; 95% CI 1.64–1.78), and Asian, Pacific Islander, Native American (OR, 1.82; 95% CI 1.76–1.89). We found significant disparities in mortality among COVID-19 hospitalizations in California. Hispanics were the worst affected with the highest mortality and ICU admission rates.

Ischaemic stroke in patients with diabetes requiring urgent procedures during the COVID-19 pandemic in South Korea: a retrospective, nationwide, population-based cohort study using data from the National Emergency Department Information System

ObjectivesThe COVID-19 pandemic resulted in suboptimal care for ischaemic stroke. Patients with diabetes mellitus (DM), a high-risk group for stroke, had compromised routine care during the pandemic, which increases the...

Patient Outcomes and Rate of Intensive Care Unit Admissions Following Bariatric Surgery: A Retrospective Cohort Study of 775 Patients.

Background The last two decades have seen a significant rise in obesity and its adverse consequences across the globe. Bariatric surgery has emerged as a widely employed therapeutic approach for weight reduction and alleviating the risk of obesity-related chronic diseases such as diabetes, cardiovascular diseases, and cancer. As bariatric procedures are gaining popularity, the complications associated with these procedures can not be ignored. This retrospective study aimed to investigate the incidence of intensive care unit (ICU) admissions following bariatric surgery and ICU-related mortality. Methodology This retrospective study conducted at King Hamad University Hospital, Bahrain evaluated the patient outcomes and the rate of ICU admissions following bariatric surgery between 2018 and 2022. Demographic data of the patients were extracted from electronic health records. The primary endpoint was ICU admission incidence and mortality, while secondary outcomes included risk factors, duration of ICU stay, and complications leading to ICU admission. Results Of the 775 patients included, 66.3% were female. The mean age of the patients was 35.92 ± 21.12 years. Over 91% of the patients had a body mass index above 30 kg/m2. The most common primary procedure was laparoscopic sleeve gastrectomy (75%), followed by gastric bypass (22.6%). In revision bariatric surgery, the majority (91.3%) had a conversion from sleeve gastrectomy to gastric bypass. Overall, 0.77% of patients were admitted to the ICU, with the majority being unplanned ICU admissions (0.52%). The average ICU stay was 21 days (1 to 54 days). The most common reason for ICU admission was sepsis, septic shock, and gastric leakage. Conclusions The results of this study show a relatively lower number of ICU admissions after bariatric surgery compared to previous studies.

Comparison of Fluid Resuscitation with Lactate Ringer's Versus Normal Saline in Acute Pancreatitis: An Updated Meta-Analysis.

Fluid resuscitation is one of the main therapies for acute pancreatitis (AP). There is still no consensus on the type of fluid resuscitation. This study investigated the differences between lactate Ringer's (LR) and normal saline (NS) in treating AP. Two authors systematically searched Web of Science, Embase (via OVID), Cochrane Library, and PubMed to find all published research before July, 2023. The odds of moderately severe/severe AP and intensive care unit (ICU) admission are set as primary endpoints. This meta-analysis included 5 RCTs and 4 observational studies with 1424 AP patients in LR (n = 651) and NS (n = 773) groups. The results suggested that the odds of moderately severe/severe AP (OR 0.48; 95%Cl 0.34 to 0.67; P < 0.001) and ICU admission (OR 0.37; 95%Cl 0.16 to 0.87; P = 0.02) were lower in the LR group compared to NS group. In addition, the LR group had lower rates of local complications (OR 0.54; 95%Cl 0.32 to 0.92; P = 0.02), lower level of CRP, as well as a shorter hospital stay (WMD, - 1.09days; 95%Cl - 1.72 to - 0.47days; P < 0.001) than the NS group. Other outcomes, such as mortality, the rate of organ failure, SIRS, acute fluid collection, pancreatic necrosis, pseudocysts, and volume overload, did not differ significantly between two groups (P > 0.05). LR is preferred over NS as it decreases the odds of moderately severe/severe AP, the rate of ICU admission, local complication, and length of hospital stay. However, large-scale RCT are lacking to support these evidence.

Impact of Outpatient Administration of Cytarabine Consolidation Chemotherapy on Hospital Length of Stay in Adults with Acute Myeloid Leukemia

Background: Administration of 3-4 cycles of high/intermediate dose cytarabine (H/IDAC) reduces relapse of acute myeloid leukemia (AML) and bridges patients (pts) to allograft. There is no accepted standard model of safely delivering H/IDAC in these pts. To reduce reliance on inpatient (inpt) chemotherapy administration and safely avoid or forestall hospitalization during cycles, we developed an outpatient (outpt) protocol to deliver H/IDAC. Pts were assigned outpt or inpt treatment at their hematologist's discretion. We aimed to evaluate the benefits and safety of our model in this retrospective observational study. Methods: Pts diagnosed with AML and treated with intensive induction chemotherapy between 2015 and 2020 were identified; included pts received ≥1 consolidation cycle of 1-3g/m² cytarabine over 3 hours BID, dose adjusted for age and renal function, on days 1, 3 &amp; 5 of a planned 28-day cycle. Outpts received H/IDAC via computerized ambulatory delivery device (CADD) pump and central venous access device (CVAD), attended days 1-6, then 3 times a week for blood product support until count recovery; elective readmission was not mandated. Pts were educated to present to hospital if unwell. Inpts were admitted for H/IDAC but could be discharged prior to count recovery. Antimicrobial prophylaxis consisted of antifungal agents and valaciclovir. The primary endpoint was mean duration of hospital admission (LOS) per consolidation cycle. As pts may have been treated on an inpt and/or outpt basis, generalized estimating equations were used to compare LOS clustered by pt. Secondary outcomes included death during H/IDAC; intensive care unit (ICU) admission; time to admission; blood product use; cycle length; bacteremia; time to count recovery; relapse free survival (RFS) and overall survival (OS). Results: Of 109 pts identified, 62 pts were included and 47 pts excluded (not AML=3; induction death=7; refractory leukemia=14; alternative=13; no consolidation=10). Median age was 55.2 years (range 18.2-70.3); 31 (50%) males; ELN 2010 fav=23 (37.1%), Int-2/3 = 30 (48.4%), Adv=8 (12.9%); denovo AML in 60 (96.7%); and therapy related in 2 (3.2%). FLT3-ITD, NPM1 and bi-allelic CEBPA mutations detected in 11 (17.7%), 27 (43.5%) and 2 (3.2%) pts, respectively. Fifty-nine pts (95.1%) received 7+3 idarubicin induction and 7 (11.3%) received midostaurin. A total of 131 cycles of H/IDAC were administered; 81 (61.8%) were commenced as outpt and 50 (38.2%) as inpt. Twenty-seven (43.6%) pts commenced all cycles as an outpt. Those commencing consolidation as an outpt spent, on average, 10.3 fewer days in hospital per cycle. The mean (SD) LOS for outpt and inpt was 11 (8.3) versus 21.3 (8) days (p&amp;lt;0.001), respectively. For each consolidation cycle, outpts spent less time in hospital (mean, [SD]): cycle 1, 12.6 (10.3) vs 20.7 (8.0) days (RR 1.6, p=0.007); cycle 2, 11.6 (7.2) vs 21.4 (8.3) days (RR 1.8, p=0.001); cycle 3, 8.4 (5.8) vs 24.6 (7.4) days (RR 2.9, p&amp;lt;0.001). There were no deaths among inpts and one death in outpts (septic shock). ICU admission occurred in 8/81 (9.9%) cycles in outpts vs 1/50 cycles (2%) in inpts (p=0.12). Mean ICU LOS for outpts vs inpts in cycle 1 was 17.6 days vs 1.6; cycle 2, 5.1 vs 0 days; and cycle 3, 4.2 vs 0 days. Bacteremia was detected in 41 cycles (31.3%), with 38 isolates (gram pos=17, gram neg=21) in 31 outpt cycles (38.2%) and 15 isolates (gram pos=6, gram neg=9) in 10 inpt cycles (20%). Median time to admission in outpts was 14 days (IQR, 3-21); 15 (18.5%) cycles did not result in pt admission. There were no differences in timing of admissions by cycle number nor time-point to prompt elective admission (Fig.1). There was no difference in packed cell or platelet transfusion requirement between inpts and outpts. Time to blood count recovery was similar. No improvement was seen in cycle length. The proportion undergoing allogeneic transplant in first remission was 37.1%, and at any time, 59.7%. Over a median follow up of 3.3 years, median RFS was 2 years and OS, not reached. Conclusion: In selected pts, outpt based AML H/IDAC consolidation therapy significantly reduced hospital length of stay compared with inpts. There was no impact on cycle length. Bacteremia and ICU admission rates were higher in outpts, and strategies such as remote monitoring or pre-emptive hospitalization could be considered. Our findings suggest outpt consolidation should be considered in a supported clinical setting.

Granulocyte Colony-Stimulating Factor Use in Patients with Hemophagocytic Lymphohistiocytosis: A Single Center Experience

Background: Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening syndrome caused by activation of T cells that results in extreme inflammation. HLH is commonly associated with underlying conditions such as infection, autoimmune disease, or malignancy. HLH management includes treatment directed at the specific trigger, suppression of maladaptive cytokines, and inhibition of T cell and macrophage proliferation. Granulocyte colony-stimulating factor (GCSF) is a myeloid growth factor that stimulates the production, maturation, and activation of neutrophils. GCSF may theoretically promote production of inflammatory cytokines and enhance hemophagocytosis, thereby intensifying HLH. By contrast, GCSF could play a vital role in the treatment of granulocytopenia caused by HLH and thus limit the development of infections. There is a paucity of data examining the role of GCSF in patients with HLH. Current literature is limited to case reports of HLH exacerbated by GCSF administration. Practice patterns of GCSF use in HLH are highly variable, both within and between institutions. Aim: To compare the clinical course and overall survival of patients with HLH who received GCSF treatment and those who did not. Methods: We performed a retrospective, single-center cohort study of patients admitted with a diagnosis code of HLH from July 1997 through February 2023. Patients at least 18 years old with active HLH were included. Each case was reviewed to confirm the diagnosis of HLH based on available diagnostic evaluation and the final discharge diagnoses as documented by the primary treating team. In cases indeterminate for HLH, a second independent reviewer performed additional evaluation to reach consensus. The primary outcome was overall survival as determined by the Kaplan Meier method with statistical comparison using the log-rank test. Other examined outcomes included: incidence of infection, length of hospital stay (LOS), incidence of intensive care unit (ICU) admissions, length of ICU stay, incidence of 30-day re-admissions due to HLH, and time to first change in HLH-directed therapy. Results: Database analysis revealed 130 patients with a diagnosis code of HLH, of which 68 patients met inclusion criteria. The study cohort comprised 26 patients that received GCSF treatment and 42 patients that did not. The median follow-up time was 3.1 months (interquartile range [IQR] 0.6-29.4). The most common HLH triggers were infection (30.8% GCSF group vs 45.2% control, p=0.31) and malignancy (65.5% GCSF group vs 19% control, p&amp;lt;0.001). A median of 10 doses (IQR 6-16) of GCSF were administered per patient in the GCSF group, and the median time between diagnosis and the first administered dose was 6.5 days (IQR 2.25-18.75). Median overall survival in the GCSF group was 122.6 months compared to 1.5 months in the control group (p=0.02, Figure 1). There was a higher but statistically insignificant difference in infection rate in the GCSF arm (92.3%) compared to the control arm (71.4%, p=0.06). The median LOS was higher in the GCSF group (38 days vs 15 days, p&amp;lt;0.001). Rates of ICU admission (53.4% vs 62%, p=0.69), intubation and mechanical ventilation (34.6% vs 33.3%, p=1.0), and initiation of renal replacement therapy (23.1% vs 16.7%, p=0.74) were similar across the GCSF and control groups, respectively. Two patients in each group were re-admitted for HLH within 30 days of initial discharge. The median time to change in HLH-directed therapy was not reached in either group, and there was no significant difference in incidence of therapy change between groups at 1, 3, or 6 months (Figure 2). Conclusions: In this single center, retrospective cohort study of patients with HLH, treatment with GCSF was not associated with inferior overall survival. While over-representation of a malignancy-associated trigger in the GCSF group may confound interpretation of this result, it nevertheless reflects an important clinical finding that contradicts previously published case report-level evidence. This study highlights the need for further prospective investigation of GCSF administration in HLH.

The Impact of Adding Rituximab to the Standard Chemotherapy + TKI Regimen in Adults with Philadelphia-Positive B Acute Lymphoblastic Leukemia: A Multicenter Retrospective Study

Introduction: The addition of rituximab to the treatment of CD20-positive (CD20+) Philadelphia chromosome (Ph)-negative acute lymphoblastic leukemia (ALL) patients has demonstrated considerable benefits in terms of event-free survival in a large randomized clinical trial, as well as overall survival (OS) in retrospective analyses. Consequently, it is now an integral part of the standard care chemotherapy regimen for these patients. Conversely, Ph-positive (Ph+) B-ALL patients have been excluded from these trials and are typically managed with tyrosine-kinase inhibitors (TKI) in combination with chemotherapy, steroids, or novel agents such as blinatumomab. However, the potential benefits and concerns of adding rituximab to CD20+ Ph+ B-ALL patients remain uncertain, as there are worries about prolonged immunosuppression and potential infectious complications. Methods: We conducted a multicenter retrospective study involving five tertiary care centers in Mexico. The study included patients older than 16 years with newly diagnosed Ph-positive B ALL between January 2009 and June 2022, according to the WHO criteria. CD20+ was defined as CD20 expression ≥20% by flow cytometry. The decision to administer rituximab was based on the physician's discretion. The primary objective was to compare the 3-year OS between CD20-negative patients and CD20-positive patients who received or did not receive rituximab, and as secondary objectives to evaluate infection rates and mortality during induction with the addition of rituximab. Results: The study comprised 119 patients who met the inclusion criteria. The median age at diagnosis was 38 years (16 - 73), with 52.1% being male. The median white blood cell count (WBC) count was 114 x 10 9/L (0.5 - 466). Of these, 45 patients (37.8%) had CD20+ B-ALL, and 24 of them (53.3%) received rituximab. A total of 111 patients (93.2%) received TKI treatment, with imatinib being the most common (79%), followed by dasatinib (13.4%) and ponatinib (0.8%). The majority of the patients received either Hyper-CVAD (41.2%) or a local adult regimen (31.9%). There were no significant differences in age, WBC count, or treatment/TKI between patients who received rituximab and those who did not. Table 1 presents the characteristics of the population based on CD20 expression and treatment. Early mortality was 5.8%, with no significant difference observed between patients who received rituximab and those who did not (0% vs. 7.4%; OR 0.78, 95% CI 0.71 - 0.86, p=0.342). The rate of neutropenic fever during induction was 72.3%, and it was lower in patients who received rituximab (50.0% vs. 77.9%; OR 0.28, 95% CI 0.11 - 0.72, p=0.010). The intensive care unit (ICU) admission rate during induction was 11.8%, with no significant difference observed between patients with or without rituximab (8.3% vs. 12.6%; OR 0.62, 95% CI 0.13 - 3.01, p=0.733). Molecular response at 3 months was measured in 72 patients and the use of rituximab was associated with a non-significant higher rate: 83.3% vs 57.4% with an OR of 3.71 (95% CI, 0.96-14.33, p=0.056).The median OS for the entire cohort was 20 months (95% CI, 13.34 - 26.65), with a 3-year OS of 35.7%. The leading cause of death was disease progression (77.3%), while 10.7% died in remission: 7.7% of CD20- patients, 21.4% of CD20+ patients without rituximab, and 11.1% of CD20+ patients receiving rituximab (p=0.436). There was a trend towards a better OS in CD20+ patients who received rituximab: median OS not reached vs. 21 months (95% CI 13.27 - 28.72) in CD20- patients, and 13 months (95% CI 9.7 - 16.29) in CD20+ patients without rituximab. The 3-year OS rates for these groups were 52.7%, 34%, and 24.6%, respectively (p=0.222; Figure 1). Conclusions: In real-world practice, rituximab is added to the chemotherapy regimen and TKI in 53.3% of CD20+ Ph+ B-ALL cases. Rituximab is not associated with a higher incidence of infections, ICU admission, early mortality, or deaths in remission. Although there is no significant benefit observed, there is a trend towards better OS with the addition of rituximab to the standard treatment of CD20+ Ph+ ALL. There is an unmet need to explore the concomitant use of rituximab and TKI in prospective studies.