Maximum White Blood Cell Count Research Articles

Correlation between postoperative systemic inflammatory response and prognosis in patients with advanced gastric cancer.

411 Background: Several studies have shown that postoperative infectious complications correlate with poor prognosis in various malignancies, but the prognostic significance of the postoperative inflammatory response in patients with gastric cancer remains unclear. The aim of study was to examine whether the systemic inflammatory response present in the early phase of the postoperative state correlates with long-term outcomes and to identify markers in patients with advanced gastric cancer. We evaluated C-reactive protein (CRP) and white blood cell (WBC) count as simple and versatile markers of postoperative systemic inflammation in clinical practice that may be suitable for detecting the magnitude of inflammatory reaction. Methods: This study retrospectively reviewed 444 patients who underwent radical gastrectomy for stage II/III gastric cancer. We evaluated maximum serum C-reactive protein (CRPmax) and white blood cell count (WBCmax), defined as the maximum serum CRP level and maximum WBC count during the interval from surgery until discharge, as systemic inflammation markers. Results: In univariate analyses, CRPmax, WBCmax and infectious complications were significantly associated with both overall survival (OS) (p<0.001, p<0.001 and p=0.011, respectively) and relapse-free survival (RFS) (p<0.001, p=0.001 and p<0.001, respectively). Multivariate analysis revealed that high CRPmax (>9.2 mg/dL) was an independent prognostic factor for OS (hazard ratio (HR) 1.69, 95% confidence interval (CI) 1.18–2.42, p=0.004) and RFS (HR 1.42, 95%CI 1.02–1.98, p=0.038), while WBCmax and infectious complications were not. Regarding the pattern of recurrence, hematogenous recurrence was significantly more frequent in the high-CRPmax group (16.7%) than in the low-CRPmax group (3.8%, p<0.001). Conclusions: CRPmax, which reflects the magnitude of systemic inflammation induced by surgical stress and postoperative complications in the early phase after surgery, may be a promising prognostic indicator in patients with stage II/III gastric cancer who undergo curative resection.

Distinguishing characteristics of xanthogranulomatous cholecystitis and gallbladder adenocarcinoma: a persistent diagnostic dilemma.

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis which can resemble gallbladder adenocarcinoma (GAC) on preoperative imaging and present technical challenges in the performance of cholecystectomy. We examined our experience with each pathology to identify distinguishing characteristics that may guide patient counseling and surgical management. A retrospective review of all pathologically confirmed cases of XGC and GAC following cholecystectomy between 2015 and 2021 at a single institution was performed. Clinical, biochemical, radiographic, and intraoperative features were compared. There were 37 cases of XGC and 20 cases of GAC. Patients with GAC were older (mean 70.3years vs 58.0, p = 0.01) and exclusively female (100% vs 45.9%, p < 0.0001). There were no significant differences in accompanying symptoms between groups (nausea/vomiting, fevers, or jaundice). The mean maximum white blood cell count was elevated for XGC compared to GAC (16.4 vs 8.6 respectively, p = 0.044); however, there were no differences in the remainder of the biochemical profile, including bilirubin, liver transaminases, CEA, and CA 19-9. The presence of an intraluminal mass (61.1% vs 9.1%, p = 0.0001) and lymphadenopathy (18.8%. vs 0.0%, p = 0.045) were associated with malignancy, whereas gallbladder wall thickening as reported on imaging (87.9% vs 38.9%, p = 0.0008) and gallstones (76.5% vs. 50.0%, p = 0.053) were more often present with XGC. Cases of XGC more often had significant adhesions/inflammation (83.8% vs 55.0%, p = 0.03). Clinical features that may favor benign chronic cholecystitis over gallbladder adenocarcinoma include younger age, male gender, current or prior leukocytosis, and the absence of an intraluminal mass or lymphadenopathy. Laparoscopic cholecystectomy is a safe surgical option for equivocal presentations. Intraoperative frozen section or intentional staging of more extensive procedures based upon final histopathology are valuable surgical strategies.

Time to Look for Another Infectious Source? White Blood Cell Trends during Ventilator-Associated Pneumonia

Background: Ventilator-associated pneumonia (VAP) continues to plague patients in intensive care units (ICUs) throughout the world. Persistent leukocytosis despite antibiotic treatment for VAP can have many etiologies including normal inflammatory response, inadequate VAP antimicrobial therapy, and the presence of additional infectious diagnoses. Hypothesis: Surgical patients with VAP and a second infectious source have a different white blood cell count (WBC) trend than patients with VAP alone. Patients and Methods: Retrospective, single-center study of surgical ICU patients diagnosed with VAP (>104 CFU/mL on semi-quantitative culture) between January 2019 and June 2020. Chart review identified additional infections diagnosed during VAP treatment. White blood cell count values were compared between patients treated for VAP alone (VAP-alone) and those with additional infections (VAP-plus) using a Wilcoxon test. Univariable analysis compared admission type, surgeries, and steroid use between cohorts. Results: Eighty-eight VAPs were included for analysis; 61 (69%) were VAP-alone and 27 (31%) VAP-plus. Average age was 47.1 ± 16.7 years, 78% were male, and 93% were trauma admissions. Median hospital day of VAP diagnosis was six (interquartile range [IQR], 4-10). Nearly all patients (99%) were started on initial antibiotic agents to which the VAP organism was sensitive. Daily WBC was higher for VAP-plus compared with VAP-alone on days five, six, and seven of treatment. The maximum WBC was higher for VAP-plus (21.6 k/mcL vs. 16.1 k/mcL; p = 0.02). There were no differences in admission types, number of surgeries, or steroid use between groups. Conclusions: Providers should have increased suspicion for additional sources of infection when ICU patients with a VAP continue to have elevated WBC despite appropriate antibiotic therapy.

Optimizing Treatment of Hand Infections: Is MRSA Coverage Always Necessary?

Background:Multiple publications have highlighted the prevalence of methicillin resistant Staphylococcus aureus (MRSA) as a cause of hand infections. We hypothesized that these publications have shifted the empiric treatment of hand infections. The aim of this study was to identify the current standard of care, the most common causative bacteria, and factors leading to extended length of stay for hand infection patients at a suburban hospital to improve treatment and establish an optimized care protocol.Methods:Retrospective cohort analysis was conducted to identify all patients admitted for hand infections over an 8-year period. A comprehensive chart review of each patient’s hospital course was completed.Results:A total of 70 patients were included. Maximum white blood cell count ≥ 12 was associated with a significantly longer hospital length of stay (9.1 days versus 5.4 days) compared to WBC values < 12 (P < 0.05). Also, 11 out of 23 (47.8%) underwent two or more incision and drainages (I&D’s), compared with patients with maximum WBC < 12. Vancomycin use as an empiric antibiotic was widespread (68 patients, 97.1%), despite only 14 (20%) having MRSA positive cultures. Univariate analysis identified a significant increased likelihood for increased length of stay (P < 0.05) and rise in creatinine (P < 0.05) in patients with an initial vancomycin trough level > 20.Conclusions:This analysis of hand infection treatment in a suburban hospital demonstrates the incidence of MRSA hand infections may not be universally high across institutions. Each hospital should review its own data to optimize hand infection treatment and its associated costs.

Incidence of healthcare-associated infections in patients with fever during the first 48 hours after decannulation from veno-venous extracorporeal membrane oxygenation.

Fevers following decannulation from veno-venous extracorporeal membrane oxygenation often trigger an infectious workup; however, the yield of this workup is unknown. We investigated the incidence of post-veno-venous extracorporeal membrane oxygenation decannulation fever as well as the incidence and nature of healthcare-associated infections in this population within 48 hours of decannulation. All patients treated with veno-venous extracorporeal membrane oxygenation for acute respiratory failure who survived to decannulation between August 2014 and November 2018 were retrospectively reviewed. Trauma patients and bridge to lung transplant patients were excluded. The highest temperature and maximum white blood cell count in the 24 hours preceding and the 48 hours following decannulation were obtained. All culture data obtained in the 48 hours following decannulation were reviewed. Healthcare-associated infections included blood stream infections, ventilator-associated pneumonia, and urinary tract infections. A total of 143 patients survived to decannulation from veno-venous extracorporeal membrane oxygenation and were included in the study. In total, 73 patients (51%) were febrile in the 48 hours following decannulation. Among this cohort, seven healthcare-associated infections were found, including five urinary tract infections, one blood stream infection, and one ventilator-associated pneumonia. In the afebrile cohort (70 patients), four healthcare-associated infections were found, including one catheter-associated urinary tract infection, two blood stream infections, and one ventilator-associated pneumonia. In all decannulated patients, the majority of healthcare-associated infections were urinary tract infections (55%). No central line-associated blood stream infections were identified in either cohort. When comparing febrile to non-febrile cohorts, there was a significant difference between pre- and post-decannulation highest temperature (p < 0.001) but not maximum white blood cell count (p = 0.66 and p = 0.714) between the two groups. Among all positive culture data, the most commonly isolated organism was Klebsiella pneumoniae (41.7%) followed by Escherichia coli (33%). Median hospital length of stay and time on extracorporeal membrane oxygenation were shorter in the afebrile group compared to the febrile group; however, this did not reach a statistical difference. Fever is common in the 48 hours following decannulation from veno-venous extracorporeal membrane oxygenation. Differentiating infection from non-infectious fever in the post-decannulation veno-venous extracorporeal membrane oxygenation population remains challenging. In our febrile post-decannulation cohort, the incidence of healthcare-associated infections was low. The majority were diagnosed with a urinary tract infection. We believe obtaining cultures in febrile patients in the immediate decannulation period from veno-venous extracorporeal membrane oxygenation has utility, and even in the absence of other clinical suspicion, should be considered. However, based on our data, a urinalysis and urine culture may be sufficient as an initial work up to identify the source of infection.

Fever and inflammatory markers do not predict infection in pediatric ventricular assist device recipient

ObjectiveWe sought to assess the relationship between serious infections and fever, white blood cell count (WBC), and C-reactive protein (CRP) levels in children on ventricular assist device (VAD). MethodsWe retrospectively reviewed all children who underwent VAD placement from 2006 to 2014 at Children's Hospital of Pittsburgh. Daily maximum temperature, maximum WBC, CRP levels, microbiologic data and antibiotic use were abstracted from the electronic health record. Serious infection was defined as bacteremia, mediastinitis and/or driveline infection. ResultsThirty-six consecutive patients underwent VAD placement with mean age of 7.1 years ±6.3 years (range 9 days −18.1 years). The median duration of VAD support was 24 days (1–102 days). Patients were on antibiotics for 58% of total VAD days. We found no drive line infections or mediastinitis and only 5 episodes of blood stream infections in 4 patients (11%) during 1167 total days. Fever was present on 23% of total VAD days and nearly all (35/36) patients had at least one day of fever. CRP was elevated in 298 of 318 (94%) of all samples tested. 53% (448/851) of the total WBC assessments were elevated. On detailed analysis of confirmed bloodstream infection, only 2 of the 5 episodes were associated with fever within 24 h of the positive culture. WBC and CRP levels (drawn within 24 h of positive culture) were normal in 2/5 (40%). ConclusionsDespite a low prevalence of serious infection in our pediatric VAD cohort, we found that fever, elevated WBC and CRP were common. This suggests that traditional markers of infection are unreliable. Fever, elevated WBC count and elevated CRP were poorly predictive of serious bacterial infection in our pediatric VAD cohort. Their presence alone should not be an indication for long-term antibiotics.

Clinical outcome of paraquat poisoning during pregnancy

Objectives: We aimed to describe clinical characteristics and outcomes of paraquat poisoning in pregnant patients, their fetuses, and newborns.Methods: We performed a retrospective study of pregnant patients who were exposed to paraquat, from the Ramathibodi Poison Center Toxic Exposure Surveillance System, during a 5-year period.Results: Thirty-six patients, representing every trimester, were included. All experienced oral exposure with a mean age of 22.7 years and mean gestational age (GA) of 23.1 weeks. Most had gastrointestinal symptoms and signs. Systemic effects, which mainly comprised of acute kidney injury (AKI), were found in 13 patients (36.1%); obstetric complications were noted in five patients (13.9%). Medical treatment included intravenous dexamethasone and cyclophosphamide. Some patients received hemodialysis and endotracheal intubation. Nine patients delivered during hospitalization; four newborns (maternal GAs of 30–36 weeks with systemic effects) died after delivery. One patient with GA 26 weeks delivered and died, but her newborn survived. Mortality rates of pregnant patients and their offspring delivered in-hospital were 25% and 44.4%, respectively; all deaths occurred in patients with systemic toxicity. The median length of hospital stay was 6 days. Notably, AKI, hepatotoxicity, and maximum white blood cell count significantly differed between dead and surviving patients. We followed-up 15 surviving patients who were discharged before delivery to assess delivery outcomes. All 15 patients and newborns survived without reports of congenital anomalies.Conclusions: Paraquat poisoning during pregnancy caused high fatalities in pregnant patients, fetuses, and newborns who were delivered during hospitalization, especially among patients with systemic effects. The GA of the pregnancy affected fetal outcomes, both in utero and at birth. Selective, appropriate management is warranted and might be guided by poisoning severity and the GA of the pregnancy.

Association of Severity of Posttraumatic Stress Disorder With Inflammation: Using Total White Blood Cell Count as a Marker

Background Inflammation is known to be associated with posttraumatic stress disorder. It is not known if total white blood cell count, a routinely checked inflammatory marker, is associated with posttraumatic stress disorder symptom trajectories using medical record data. Methods We used latent class growth analysis to identify three-year posttraumatic stress disorder symptom trajectories using posttraumatic stress disorder (PTSD) Checklist (PCL) scores. The outcome for each patient was maximum white blood cell count from index posttraumatic stress disorder diagnosis to last PCL. Using linear regression analysis, we then calculated and compared the average white blood cell count for each trajectory before and after controlling for age, gender, race, obesity, smoking, diabetes, hypertension, cardiovascular disease, depression, and other comorbid inflammatory conditions. Results Patients were 40.2 (SD ± 13.5) years of age, 83.7% males and 67.9% white. We identified three PCL trajectory groups based on symptom severity over time: “moderate-large decrease,” “moderate-severe-slight decrease,” and “severe-persistent.” In adjusted analyses, “severe-persistent” versus “moderate-large decrease” had significantly higher white blood cell count (B = 0.64; 95%CI = 0.18, 1.09; p = .006). Although non-significant, “moderate-severe-slight decrease” versus “moderate-large decrease” also had a higher white blood cell count (B = 0.42; 95% CI: −0.02, 0.86; p = .061). Conclusion Persistently severe posttraumatic stress disorder is associated with a higher white blood cell count than improving posttraumatic stress disorder. White blood cell appears to have utility for measuring the association between psychiatric disorders and inflammation in retrospective cohort studies involving large administrative medical record data bases.

Factors Influencing Cyst Infection in Autosomal Dominant Polycystic Kidney Disease

Background: Cyst infection is a frequent and serious complication of autosomal dominant polycystic kidney disease (ADPKD) that is often difficult to treat. However, the factors influencing cyst infection are still unknown. Therefore, we investigated clinical factors related to the duration of hospitalization and death due to cyst infection. Methods: All ADPKD patients undergoing cyst drainage or nephrectomy or partial hepatectomy at Toranomon Hospital from January 2004 to March 2016, in whom cyst fluid analysis showed bacteria or neutrophils indicating definite cyst infection, were reviewed retrospectively. Factors influencing the duration of hospitalization and death due to cyst infection were analyzed. Results: A total of 243 patients with cyst infection were enrolled, including 104 men and 139 women (mean age: 62.6 ± 10.0 years). Seventeen patients died of cyst infection. Multivariate logistic regression analysis revealed that hepatomegaly, positive cyst contents culture, and the maximum white blood cell (WBC) count were significantly associated with death from cyst infection. Death was significantly more likely if patients had massive hepatomegaly (≥5,113.2 mL) compared with mild hepatomegaly (< 1,898.7 mL; odds ratio 38.1; 95% CI 2.9–492.6, p = 0.0004). Multivariate Cox proportional hazards analysis revealed that older age, dialysis duration, hepatic transcatheter arterial embolization, maximum WBC count, and hepatomegaly were significantly associated with longer hospital stay for cyst infection, while female sex, nephrectomy, serum albumin, and serum cholinesterase were significantly associated with shorter hospital stay. Discharge alive from hospital was significantly associated with massive hepatomegaly versus mild hepatomegaly (hazard ratio 0.0072; 95% CI 0.0008–0.0659, p < 0.0001). Conclusions: Hepatomegaly was strongly associated with both death and longer hospital stay due to cyst infection.

Comparative Effectiveness of Rasburicase and Allopurinol in Children with Acute Lymphoblastic Leukemia: An Emulated Pragmatic Trial Using Observational Data

Introduction: Children with newly diagnosed acute lymphoblastic leukemia (ALL) are at risk for developing tumor lysis syndrome (TLS), an oncologic emergency with potentially severe consequences. Effective TLS management centers on prevention, achieved in large part through control of hyperuricemia with allopurinol or rasburicase. Though rasburicase is known to be very effective for children at high TLS risk, there are limited evidence-based data to guide its usage. Currently available guidelines rely on expert opinion and provide conflicting recommendations, especially for patients at intermediate TLS risk. To address this data gap, we emulated a randomized clinical trial (RCT) to test the efficacy of rasburicase in intermediate risk TLS. We hypothesized that rasburicase would not provide benefit for children with ALL who were classified as being at intermediate TLS risk based on white blood cell count (WBC), uric acid (UA), and creatinine (Cr).Study Design: We used observational data from the Pediatric Health Information Systems (PHIS) administrative database to emulate a RCT assessing the effectiveness of rasburicase initiation (Hernan & Robins Am J Epidemiol. 2016). The source population consisted of the subset of an established cohort of newly diagnosed ALL patients, who were treated at 6 centers that contributed laboratory values to PHIS from 2007-2012. We mimicked rasburicase initiation trials (“pseudo-trials”) over time, where each day of the initial diagnostic admission (up to day 4) represented the start of a new pseudo-trial. For each pseudo-trial, a child was considered eligible if he received at least one dose of allopurinol or rasburicase and had a maximum WBC <100/mL, UA <10mg/dL, and Cr <1.5 times the upper limit of normal (ULN) during the 2-day baseline evaluation window. Each child could thus contribute to a maximum of 4 pseudo-trials. For each trial, children were assigned to the non-initiator arm if they received allopurinol-only, or to the rasburicase-initiator arm if they started rasburicase. Rasburicase exposed patients were not eligible for subsequent trials.Study Outcome: The primary outcome was acute kidney injury (AKI), defined as a Cr >1.5 times the ULN. Secondary outcomes were receipt of dialysis, inpatient length of stay (LOS) and mortality. Follow-up for the outcomes started on day 3 of each pseudo-trial and ended 7 days later for AKI and dialysis or 35 days later for LOS and mortality. An intention-to-treat analysis was used. To adjust for potential confounding by baseline covariates, the propensity to receive rasburicase was estimated using a logistic regression model that informed calculation of inverse probability weights (IPW). IPW-adjusted frequency tables were constructed for AKI, dialysis, and mortality. For LOS, linear regression models with IPW and generalized estimating equations for repeated trials were used.Results: Of 945 eligible children, 44 initiated rasburicase (ever-initiators) and 901 never initiated rasburicase (never-initiators). Compared to the non-initiators, ever-initiators were more likely to be male (p=0.040), non-Hispanic white (p=0.018), have private insurance (p=0.028), and have higher WBC (p<.0001), UA (p<.0001) and creatinine (p=0.019) at baseline. The final analyses included 3,175 eligible trial patients. IPW-adjusted analyses suggested no differences in frequency of AKI (2.72% vs. 0.34%, p=0.545), receipt of dialysis (0.51% vs. 0%, p=1.000), mortality (0.06% vs. 0.04% p=1.000) or inpatient LOS (mean 14.7 days vs. 11.0 days, p=0.18) between the initiator and non-initiator arms.Conclusion: Our results suggest that administration of rasburicase may not decrease the frequency of AKI, receipt of dialysis, mortality or decrease LOS for children with newly diagnosed ALL at intermediate TLS risk. Though only 44 rasburicase initiators were identified, which limited the power, these results represent data from the largest pediatric ALL cohort with both laboratory values and resource utilization. If replicated in other cohorts, such findings have the potential to impact guidelines for rasburicase use and greater standardization of rasburicase utilization across centers. Similar to previous reports, we also found that males were more likely to initiate rasburicase, a finding that deserves further exploration, given that males are more likely to have G6PD deficiency, a contraindication to rasburicase use. DisclosuresFisher:Pfizer: Research Funding; Merck: Research Funding.

722. Normal Clinical Signs and Duration of Antibiotics in Hospitalized Patients with Pneumonia

BackgroundThe most common reason for antibiotic prescribing in hospitalized patients is suspected respiratory tract infection. In many cases, however, antibiotics may be started when the diagnosis is unclear and continued for a fixed course regardless of patients’ clinical trajectories. We sought to characterize the distribution of clinical signs in patients started on antibiotics for possible pneumonia, number of days to normalization of clinical signs, and duration of antibiotics beyond when signs normalized.MethodsWe performed a retrospective analysis on 43,820 consecutive adults admitted to Brigham and Women’s Hospital from May 2017 to January 2018. We identified all nonventilated patients started on antibiotics for pneumonia using clinicians’ stated indications in their medication orders. We analyzed the distribution of clinical signs indicative of pneumonia (maximum temperature, maximum white blood cell count, median respiratory rate, and supplemental oxygen need) on the first day of antibiotics. We then calculated median days to normalization for each sign, total days of antibiotics for pneumonia, and duration of antibiotics beyond when all signs normalized.ResultsWe identified 2,754 nonventilated patients started on antibiotics for pneumonia. On the first day of antibiotics, 38%had oxygen saturations ≥95% without supplemental oxygen, 78% had normal temperatures, 63% had normal white blood cell counts, and 79% had median respiratory rates <22 breaths/minute. All signs were normal in 25% of patients. Amongst those with at least one abnormal clinical sign on the first day of antibiotics, all signs returned to normal within a median of 3 days (IQR 2–7 days). Antibiotics were nonetheless continued for ≥3 more days in 33% of these patients.ConclusionPneumonia is a major driver of antibiotic utilization in hospitalized patients but we found 25% of cases lacked the cardinal clinical signs of pneumonia and antibiotics were continued for ≥3 days after all clinical signs normalized in a third of the 75% of patients who did have signs of pneumonia. These findings suggest substantial opportunities to improve antibiotic prescribing for suspected respiratory tract infections in hospitalized patients.Disclosures All authors: No reported disclosures.

The incidence and timing of leukocyte overshoot after pegfilgrastim administration.

Pegfilgrastim is a PEGylated formulation of filgrastim with a long half-life. It is highly convenient and less burdensome for patients. However, white blood cell count may temporarily increase after administration; in particular, a leukocyte overshoot may be observed. The present study retrospectively examined the incidence and timing of leukocyte overshoot after pegfilgrastim administration. Fifty-five patients (118 occasions of pegfilgrastim) were evaluated. Leukocyte overshoot was defined as white blood cell count ≥10,000/mm3 exceeding the reference value. Leukocyte overshoot was observed in 71.2% (84/118) occasions, in 76.4% (42/55) patients. The maximum white blood cell count ≥30,000/mm3 was observed in 30.5% (36/118) occasions in 45.5% (25/55) patients and was observed in 39.3% (33/84) occasions on day 1 after pegfilgrastim administration and 26.2% (22/84) on day 2. Leukocyte overshoot has been observed in only 23.1% (9/39) patients administered with normal granulocyte colony-stimulating factor. However, there were no patients with white blood cell counts ≥30,000/mm3. There was a higher frequency of occurrence of leukocyte overshoot in response to pegfilgrastim than in response to normal granulocyte colony-stimulating factor. High incidence of leukocyte overshoot was observed when blood was collected 1-2 days after administration of pegfilgrastim. It is important for patients to understand the characteristics of pegfilgrastim by conducting pharmaceutical guidance.

Relationship between white blood cell count elevation and clinical response after G-CSF priming chemotherapy for acute myeloid leukemia.

We retrospectively analyzed the relationship between white blood cell (WBC) count elevation after priming and clinical response in 115 patients with AML (61 untreated and 54 relapsed or refractory) treated with low-dose cytarabine, aclarubicin, and G-CSF priming. Receiver operating characteristic curve analysis showed that the ratio of maximum WBC count to pretreatment WBC count (WBCratio) was most strongly associated with complete remission (CR) in previously untreated patients among several parameters we analyzed in this study; however, the prediction accuracy was not clinically significant considering the area under the curve of 0.694. Based on the cutoff value of the WBCratio, CR rate and event-free survival in the high WBCratio group were significantly better than those in the low WBCratio group in untreated patients. Regarding the WBC differential counts, a high ratio of the maximum to pretreatment value of neutrophils rather than that of peripheral blasts was associated with a superior CR rate. In addition, an increase in blasts after G-CSF priming had a significant negative impact on CR rate in untreated patients. In conclusion, an increase in blast counts after G-CSF priming was not predictive of achieving CR.

Sex Differences in Inflammatory Response and Acid-Base Balance in Prepubertal Children with Severe Sepsis.

The severity and prognosis of various acute inflammatory conditions, such as sepsis, differ between males and females. The mechanisms underlying these sex differences probably involve both hormonal and genetic factors. In order to evaluate a possible genetic influence, we reviewed clinical signs and biological inflammatory markers of prepubertal children with severe sepsis admitted to the pediatric intensive care unit (PICU). A total of 142 prepubertal children, 66 girls and 76 boys, suffering from severe sepsis and admitted to the PICU were included. The survival rate demonstrated a tendency to be higher in females (P = 0.14). Maximum white blood cell count (23,800 cells/μL [15,110-34,600] in girls vs. 19,025 cells/μL [12,358-26,098] in boys, P = 0.02), neutrophil count (16,944 cells/μL [10,620-27,540] vs. 13,756 cells/μL [8410-20,110], P = 0.03), and C-reactive protein level (26.2 mg/dL [15.7-33.6] vs. 18.8 mg/dL [11.1-30.0], P = 0.04) were all significantly higher in girls. Girls also exhibited significantly longer fever duration (2 days [1-6] vs. 1 day [1-3] for the boys, P <0.01), lower pH on admission (7.32 [7.25-7.39] vs. 7.37 [7.31-7.43] P = 0.03), and lower base excess (-6 mEq/L [-10.7 to -0.8] vs. -2.3 mEq/L [-6.6 to -2.6], P <0.01), as well as lower bicarbonate levels (19.1 mEq/l [15.9-24.0] vs. 21.15 mEq/l [18.3-26.68], P = 0.04), when compared with the boys. Our study revealed higher neutrophilic inflammation, as well as lower pH on admission, in girls with severe sepsis; associated with longer fever duration, which could contribute to better pathogen clearance. However, further studies are needed to demonstrate the link between acidosis and modulation of the immune response.

Association of Plasma Pentraxin-3 Levels on Admission with In-hospital Mortality in Patients with Acute Type A Aortic Dissection

Background:Acute aortic dissection is a life-threatening cardiovascular emergency. Pentraxin-3 (PTX3) is proposed as a prognostic marker and found to be related to worse clinical outcomes in various cardiovascular diseases. This study sought to investigate the association of circulating PTX3 levels with in-hospital mortality in patients with acute Type A aortic dissection (TAAD).Methods:A total of 98 patients with TAAD between January 2012 and December 2015 were enrolled in this study. Plasma concentrations of PTX3 were measured upon admission using a high-sensitivity enzyme-linked immunosorbent assay system. Patients were divided into two groups as patients died during hospitalization (Group 1) and those who survived (Group 2). The clinical, laboratory variables, and imaging findings were analyzed between the two groups, and predictors for in-hospital mortality were evaluated using multivariate analysis.Results:During the hospital stay, 32 (33%) patients died and 66 (67%) survived. The patients who died during hospitalization had significantly higher PTX3 levels on admission compared to those who survived. Pearson's correlation analysis demonstrated that PTX3 correlated positively with high-sensitivity C-reactive protein (hsCRP), maximum white blood cell count, and aortic diameter. Multivariate logistic regression analysis demonstrated that PTX3 levels, coronary involvement, cardiac tamponade, and a conservative treatment strategy are significant independent predictors of in-hospital mortality in patients with TAAD. The receiver operating characteristic curve analysis further illustrated that PTX3 levels on admission were strong predictors of mortality with an area under the curve of 0.89. A PTX3 level ≥5.46 ng/ml showed a sensitivity of 88% and a specificity of 79%, and an hsCRP concentration ≥9.5 mg/L had a sensitivity of 80% and a specificity of 69% for predicting in-hospital mortality.Conclusion:High PTX3 levels on admission are independently associated with the in-hospital mortality in patients with TAAD.

Postpercutaneous Nephrolithotomy Systemic Inflammatory Response Syndrome Is Not Associated With Unplanned Readmission

To investigate the incidence of systemic inflammatory response syndrome (SIRS) following percutaneous nephrolithotomy (PCNL) and evaluate any association with unplanned 90-day readmission. We retrospectively reviewed consecutive patients undergoing PCNL in 2 dedicated endourologic practices between 2009 and 2013. We collected patient demographics, perioperative culture data, and operative characteristics. SIRS was defined as having 2 or more of the following: maximum white blood cell count >12,000 or <4000, temperature >38 or <34°C, heart rate >90, and respiratory rate >20 within the first 24 hours following PCNL. Proportions between groups were compared to identify significant associations. We identified 389 patients undergoing PCNL and 43% (167 of 389) met SIRS criteria, more commonly in patients with multiple PCNL accesses (OR 2.3; CI: 1.1-4.8, P = .025). Readmission was required in 8% (31 of 389), most commonly for infection (n = 21). Although possession of a struvite stone was associated with unplanned readmission (16% vs 4%, P < .01), SIRS in the absence of fever within 48 hours postoperative was not associated with readmission (29.4% vs 25.8%, P = .837). Nearly half of the patients undergoing PCNL met the criteria for SIRS within the first postoperative day. There was no association between SIRS and unplanned readmission in the postoperative PCNL patient. Despite discharge during the first postoperative day, patients with SIRS (without fever or struvite stones) had no increased risk for unplanned return. Our findings suggest that the development of SIRS immediately following PCNL does not preclude safe discharge on the first postoperative day.

MP82-13 POST PCNL SIRS IS NOT A PREDICTOR OF UNPLANNED READMISSION

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation I1 Apr 2016MP82-13 POST PCNL SIRS IS NOT A PREDICTOR OF UNPLANNED READMISSION Rachel Moses, Vidit Sharma, Eric Raffin, Boyd Viers, Deepak Agarwal, Amy Krambeck, and Vernon Pais Rachel MosesRachel Moses More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Eric RaffinEric Raffin More articles by this author , Boyd ViersBoyd Viers More articles by this author , Deepak AgarwalDeepak Agarwal More articles by this author , Amy KrambeckAmy Krambeck More articles by this author , and Vernon PaisVernon Pais More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2154AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Postoperative Systemic Inflammatory Response Syndrome (SIRS) may be considered an ominous predictor of unplanned infectious complications and readmissions. Anecdotally, otherwise well patients following percutaneous nephrolithotomy (PCNL) will meet criteria for SIRS. We sought to evaluate whether SIRS following PCNL is predictive of unplanned 90 day readmission. METHODS We retrospectively reviewed consecutive patients undergoing PCNL in two dedicated endourologic practices. Patient characteristics including demographics, perioperative urine cultures, stone composition, and operative characteristics were collected. SIRS was defined as having two or more of the following: maximum white blood cell count < 4,000 or >12,000, temperature< 34°C or >38°C, heart rate >90bmp, and respiratory rate >20bpm within 24hrs following PCNL. Univariate and multivariate analyses were used to identify significant associations. RESULTS We identified 389 patients undergoing PCNL, 43% (167/382) that met criteria for SIRS within 24hrs of PCNL. No patient with a temperature >38.4°C was discharged within 48 hours post operatively. On bivariate analysis, length of stay >48hrs (32% vs 13%, p=<0.01), preoperative oral antibiotics (71% vs. 61%, p=0.03), positive intraoperative stone culture (22% vs. 13%, p=0.01), multiple PCNL accesses (17% vs. 6%, p<0.01), and struvite stones (10% vs. 5%, p=0.03) were more likely to develop postoperative SIRS. When excluding febrile patients, LOS>48hrs was no longer associated. On multivariate analysis, multiple PCNL accesses (OR 2.3; 1.1-4.8, p=0.02) was the only significant factor associated with SIRS. Overall, readmission within 90 days was required in 8% (31/389). The most common reason for readmission was infection 68% (21/31). Possession of a struvite stone was the only characteristic associated with unplanned 90day readmission (16% vs. 4%, p<0.01). There were no differences in readmission rates between patients with perioperative SIRS (26% vs. 44% p=0.14) and patients with afebrile SIRS discharged within 48hours (26% vs. 29%, p=0.84). CONCLUSIONS More than 43% of patients met criteria for SIRS following PCNL. Although perhaps an ominous prognosticator in other settings, there was no significant correlation between SIRS and any cause or infection related 90 day readmission in this postoperative PCNL cohort. In the absence of fever, patients undergoing PCNL that meet SIRS criteria may in fact be safely discharged on postoperative day one without increased risk of unplanned readmission. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1077 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Rachel Moses More articles by this author Vidit Sharma More articles by this author Eric Raffin More articles by this author Boyd Viers More articles by this author Deepak Agarwal More articles by this author Amy Krambeck More articles by this author Vernon Pais More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Influence of in-line microfilters on systemic inflammation in adult critically ill patients: a prospective, randomized, controlled open-label trial

BackgroundIn critically ill children, in-line microfilters may reduce the incidence of the systemic inflammatory response syndrome (SIRS), the overall complication and organ dysfunction rate. No data on the use of in-line microfilters exist in critically ill adults.MethodsIn this prospective, randomized, controlled open-label study, we evaluated the influence of in-line microfilters on systemic immune activation in 504 critically ill adults with a central venous catheter in place and an expected length of stay in the intensive care unit >24 h. Patients were randomized to have in-line microfilters placed into all intravenous lines (intervention group) or usual care (control group). The primary endpoint was the number of intensive care unit days with SIRS. Secondary endpoints were the incidence of SIRS, SIRS criteria per day, duration of invasive mechanical ventilation, intensive care unit length of stay, the incidence of acute lung injury, maximum C-reactive protein, maximum white blood cell count, incidence of new candida and/or central-line-associated bloodstream infections, incidence of new thromboembolic complications, cumulative insulin requirements and presence of hyper- or hypoglycemia.ResultsThe study groups did not differ in any baseline variable. There was no difference in the number of days in the intensive care unit with SIRS between microfilter and control patients [2 (0.8–4.7) vs. 1.8 (0.7–4.4), p = 0.62]. Except for a higher incidence of SIRS in microfilter patients (99.6 vs. 96.8 %, p = 0.04), no difference between the groups was observed in any secondary outcome parameter. Results did not change when only patients with an intensive care unit length of stay of greater than 7 days were included in the analysis. The rate of adverse events was comparable between microfilter and control patients. In two patients allocated to the microfilter group, the study intervention was discontinued for technical reasons. Use of in-line microfilters was associated with additional costs.ConclusionsThe use of in-line microfilters failed to modulate systemic inflammation and clinical outcome parameters in critically ill adults.Trial registration: Clinical Trials NCT01534390

R PheWAS: data analysis and plotting tools for phenome-wide association studies in the R environment.

Phenome-wide association studies (PheWAS) have been used to replicate known genetic associations and discover new phenotype associations for genetic variants. This PheWAS implementation allows users to translate ICD-9 codes to PheWAS case and control groups, perform analyses using these and/or other phenotypes with covariate adjustments and plot the results. We demonstrate the methods by replicating a PheWAS on rs3135388 (near HLA-DRB, associated with multiple sclerosis) and performing a novel PheWAS using an individual's maximum white blood cell count (WBC) as a continuous measure. Our results for rs3135388 replicate known associations with more significant results than the original study on the same dataset. Our PheWAS of WBC found expected results, including associations with infections, myeloproliferative diseases and associated conditions, such as anemia. These results demonstrate the performance of the improved classification scheme and the flexibility of PheWAS encapsulated in this package. This R package is freely available under the Gnu Public License (GPL-3) from http://phewascatalog.org. It is implemented in native R and is platform independent.

Impact of Acute Kidney Injury on In-Hospital Outcomes in Patients With DeBakey Type III Acute Aortic Dissection

The relation between the incidence and severity of acute kidney injury (AKI) and clinical outcomes remains unclear in patients with DeBakey type III acute aortic dissection (AAD). We retrospectively assessed 56 patients admitted to our hospital for type III AAD within 48 hours of the onset of symptoms. The presence of AKI was identified, and its severity was staged on the basis of changes in serum creatinine (SCr) levels within 7 days after admission. We investigated the relations between AKI and clinical presentations, in-hospital complications, and predischarge renal function; AKI was observed in 20 patients (36%). After adjusting for age, gender, and body mass index, the incidence of AKI was associated with a history of hypertension, electrocardiographic ST-T changes, DeBakey type IIIb, and SCr level on admission. Maximum white blood cell count and serum C-reactive protein level were higher in patients with AKI than in those without AKI. AKI was associated with a greater incidence of in-hospital complications (70% vs 39%, p = 0.03) and higher SCr levels at discharge (1.1 [range 1.0 to 2.0] vs 0.9 [range 0.7 to 1.0] mg/dl, p = 0.0001). These associations were more pronounced in patients with relatively severe AKI. Multivariate analysis revealed that SCr level on admission and DeBakey type IIIb with renal artery involvement were major predictors of AKI. In conclusion, renal function on admission and renal artery involvement were significant risk factors for AKI, which was associated with poor outcomes and enhanced inflammatory response during hospitalization in patients with type III AAD.