Network Criteria Research Articles

Kinetic estimated glomerular filtration rate and drug dosing in critically ill patients with acute kidney injury-A prospective observational study.

To study the impact of kinetic glomerular filtration rate (kGFR) on clinical decision making and its implications on drug dosing compared to that of estimated GFR (eGFR) using chronic kidney disease epidemiology collaboration (CKD-EPI) equation in critically ill patients with acute kidney injury (AKI) admitted in a tertiary level intensive care unit (ICU). Cross-sectional, prospective, observational study design. All patients admitted to Medical ICU, Fortis Hospital, Bangalore with AKI defined as per AKI network (AKIN) criteria. Patients were recruited after approval from the scientific and institutional ethics committee, with written informed consent. Serum creatinine values at admission and further values were noted. GFR was calculated using both formulas (CKD-EPI and kGFR) and documented at all intervals of creatinine sampling. Drugs requiring renal dose modification along with the dosing were documented. Sample size was calculated after a pilot study and a total of 107 patients were analyzed. Incidence of AKI was 12.84%. The mean (±SD) eGFR was 37.25 (±29.4) and kGFR was 42.5 (±33.2), (p-value .003). 70 (65.42%) patients required drug dose change when kGFR was used. Dosing changes from Day 1 to Day 5 are 53/104 (50.9%), 39/81 (48.1%), 12/26 (46.1%), 2/9 (28.5%), 1/2 (50%). Predominant dose changes were for antimicrobials: vancomycin (35.7%), acyclovir (23.1%), and meropenem (23%). Drug dosing using different methods of GFR calculation showed a difference in the dosing in 65.42% of patients with AKI. Accounting for change in creatinine over time using kinetic GFR may lead to better drug dosing in critically ill patients with AKI. Our study shows that calculating GFR using kGFR formula instead of CKD-EPI may change drug dosages among patients with AKI admitted in ICU. By replacing conventional GFR estimation formulas with kGFR we may reduce the drug dosing inaccuracies that are currently prevalent in this cohort of patients.

P-396. Can ‘Handshake Stewardship’ Decrease Multi-Drug Resistant Healthcare-Associated Infections and All-Cause Mortality? - Insights from A South Indian Tertiary Hospital

Abstract Background Multi drug resistant Healthcare Associated Infections (MDR HAI) pose significant challenges for both patients and healthcare facilities, often stemming from inappropriate antibiotic usage. 'Handshake Stewardship' involves a proactive approach of auditing and providing feedback on antibiotic prescriptions to ensure their rationality, with discussions held confidentially with treating physicians. Endorsed by the Centers for Disease Control and Prevention and The Joint Commission, this method aims to engage clinicians in addressing clinical barriers to antimicrobial stewardship. Methods This study compares MDR HAI in the inpatients of two timelines, pre period May 2021 to April 2022 and post period May 2022 to April 2023. In the post period, the rationality of the antibiotic therapy is discussed with the clinician (in-person approach) by the Antimicrobial stewardship pharmacists within 24 hours of starting the monitored antibiotic. The clinician may or may not accept the interventions and the outcome was documented electronically. The primary outcome was the MDR HAI. Antimicrobial susceptibility testing was performed by the Clinical and Laboratory Standards Institute and ‘MDR’ was assigned as per the joint initiative document by the European Centre for Disease Prevention and Control (ECDC) and the Centers for Disease Control and Prevention (CDC). HAI referred from the CDC’s National Healthcare Safety Network (NHSN) criteria. The secondary outcome was all-cause mortality. Descriptive cross-tabulations and chi-square tests (for all Categorical variables) were performed. Results 83 HAIs in the pre phase period has 46 cases with MDR status in the culture report, whereas the post era reported 55 MDR status among 108 HAI cases. The post era has less percentage compared to the pre era with no statistical significance (p=0.319) (table -1). The MDR types depicted in table-2. It was found that all-cause mortality in MDR HAI showed no statistically significant difference (Pearson Chi-Square = 0.246) between pre and post phase. Conclusion 'Handshake Stewardship' did not lead to a significant reduction in MDR HAIs or all-cause mortality during the study period, further long-term evaluations are warranted to assess its effectiveness comprehensively. Disclosures All Authors: No reported disclosures

P-389. Review of Post Cesarian Section Surgical Site Infections in a Tertiary Care Hospital

Abstract Background Surgical site infection (SSI) is one of the most common complications following cesarean section (CSEC), variably ranging from 3% to 18%, and adds a significant burden to the healthcare system. Given its substantial implications, developing strategies to prevent SSIs are essential. We aimed to explore factors associated with an increased risk of these infections. Methods Retrospective observational study of post-CSEC SSIs from Jan 2021-Dec 2023 at Henry Ford Hospital in Detroit. SSIs were defined according to the National Healthcare Safety Network (NHSN) criteria. Cases were categorized as superficial incisional (SI), deep incisional (DI) and organ space (OS). Demographics, risk factors, clinical features, treatment, and outcomes were evaluated. Results 70 (3%) of 2,230 CSECs performed during the study period met criteria for post-CSEC SSI, of which 42 (60%) were SI, 4 (6%) DI, and 24 (34%) OS; 42 (60%) were emergency cases. The majority of patients were Black with mean age of 30.3 years (Table 1). Obesity (BMI >30), anemia (hemoglobin < 11), hypertension, prior abdominal surgery, Group B Strep colonization, and ruptured membranes at presentation were common. Most (86%) received perioperative antibiotics, and 69% were administered within 1 hour of incision; cefazolin was frequently used. Infection was diagnosed after a median of 11.5 days. Wound pain and drainage were the most prevalent symptoms. Manual chart review revealed 21% of cases did not have clinical symptoms or signs of infection. Cultures were obtained in 33% of patients, of which 91% were positive; common skin commensals were frequently isolated (Figure 1). Readmission was common, a quarter of patients required surgical intervention, and most cases were treated with antibiotics (Table 2). Complications included uterine dehiscence (9%) and half of these required hysterectomy. Organisms Identified on cultures in patients with post-CSEC SSI Conclusion In our cohort of patients with post-CSEC SSI, obesity and ruptured membranes were common, and more than half of the cases were performed emergently. Implementing evidence-based practices and recommendations are critical to reduce the burden of SSIs. Additionally, proper documentation and diagnostic stewardship are critical to accurately capture SSI cases and avoid unnecessary antibiotics. Disclosures All Authors: No reported disclosures

P-244. Antibiotic Prescribing Patterns in Ventilator Associated Pneumonia and their Effect on Carbapenem Resistant Organism Colonisation in Asian Hospitals

Abstract Background Ventilator-associated pneumonia (VAP) is associated with prolonged hospitalisation, excessive antibiotic use and high mortality. Antibiotic regimens used for VAP and their effect on development of carbapenem resistant (CR) organisms (CRO) have not been well characterised, especially in Asia.Table 1.Antibiotics used for index episode of VAP caused by carbapenem resistant organisms, and overall carbapenem use Methods The REGARD-VAP study was a randomised trial conducted in 39 intensive care units in Nepal, Singapore and Thailand. Adults aged ≥18 years with VAP (defined by the US CDC and Prevention National Healthcare Safety Network criteria), who had been mechanically ventilated for ≥48 hours, and received culture-directed antibiotics were enrolled. In culture-negative cases, antibiotics were prescribed as per local hospital antibiograms. We analysed the antibiotics prescribed in VAP and their association with CRO acquisition. We also assessed the effect of CRO colonisation on 60-day mortality and VAP recurrence.Table 2.Factors associated with new carbapenem-resistant organism (CRO) isolation in microbiological samples in a multivariable logistic regression model Carbapenem use for index episode of VAP was independently associated with higher odds ratio of new CRO colonization when adjusted for duration of antibiotics, and length of hospital stay. Duration of ICU stay was not included in this model due to high collinearity with length of hospital stay. Results The study enrolled 460 participants and the majority (47.4%) of VAP was caused by Gram-negative non-fermenters (VAPnf). Amongst participants with CR VAPnf, 56 (45.5%) received colistin-based regimens and 48 (39.0%) received beta-lactams. Amongst those with CR Enterobacterales, 11 (44.0%) received either a colistin-based regimen or beta-lactams. 52 different antibiotic regimens were used to treat CR VAP, and only one participant received a novel beta-lactam/beta-lactamase inhibitor (Ceftazidime-avibactam). 45.9% of all antibiotic regimens included carbapenems which was independently associated with new acquisition of CRO during the study period (OR 1.80, 95% CI 1.10 – 2.93, p=0.019). In a Cox regression model, CRO colonization (n=176, 38.3%) was associated with higher 60-day mortality (HR 1.66 (95%CI 1.21 – 2.28), p=0.002) and VAP recurrence (HR 8.37 (95% CI 4.28 – 16.38), p< 0.001) when adjusted for demographic factors, disease severity, comorbidities, antibiotic duration, and VAPnf.Figure 1.Cox-Regression Survival analysis showing 60-day mortality (left) and 60-day VAP recurrence (right) in participants with or without Carbapenem Resistant Organism (CRO) colonization. 60-day mortality and VAP recurrence was adjusted for demographic factors (patient age and gender), disease severity (qSOFA score and inotropic requirement at VAP diagnosis), comorbidities (Charlson comorbidity index and presence of congestive cardiac failure, acute coronary syndrome, chronic obstructive pulmonary disease, chronic kidney disease, cirrhosis, cancer, diabetes), duration of antibiotics prescribed for index episode of VAP, use of appropriate empiric antibiotics to which the organism was susceptible prior to switching to culture-directed antibiotics and cause of VAP (presence/ absence of Gram-negative non-fermenter). Participants with CRO colonization had increased hazards ratio of mortality and VAP recurrence. Conclusion In lower, middle- and high-income countries in Asia, variable antibiotic regimens were used for the treatment of VAP, majority consisting of colistin and carbapenem based regimens, with the latter being associated with higher rates of new CRO isolation. There is a need for better treatment options for these difficult to treat pathogens across the income spectrum in Asia. Disclosures Paul Tambyah, MBBS (S'pore), Diplomate, American Board of Internal Medicine and Infectious Diseases, Moderna: Grant/Research Support|Sanofi-Pasteur: Grant/Research Support

P-747. Surgical Site Infections Following Cesarean Sections Across a Large Safety Net Public Hospital System

Abstract Background Surgical site infections (SSIs) following Cesarean section (CSEC) can be associated with serious adverse outcomes. Pre-operative and intra-operative protocols have been established to minimize the risk of developing SSIs. Methods Patients undergoing CSEC in an 11-hospital public health system in New York City in 2023 were reviewed. SSIs were defined according to National Healthcare Safety Network criteria. Propensity score matching, using six variables (age, body mass index, diabetes mellitus, surgery duration, American Society of Anesthesiology score, and wound class), was used to create a control group for the patients with SSIs. Results Among the 4643 CSEC surgeries, 73 SSIs were recorded, including 49 superficial incisional, 6 deep incisional, and 18 deep/organ space SSIs. SSIs were detected during the initial admission in 7 cases, repeat hospitalizations in 33 cases, and in outpatient settings in 33 cases. A higher rate of SSIs was observed from four hospitals; zip codes for these patients had higher poverty levels than for those patients from the four hospitals with the lowest infection rates (23.4±8.6 vs. 17.7±9.7 per cent, P=.08). Comparing the SSI and control groups, no differences were found in race, ethnicity, blood loss, or surgical team composition. Although both groups had a similar proportion of patients residing in shelters, the SSI group had more recent immigrants than the control group (15 vs. 3, P=.004). Notably, recent immigrants with SSIs had fewer prenatal visits compared to the rest of the SSI group (5.53±3.44 vs. 7.72±3.98, P=.04), and 14 of the 15 SSIs in the recent immigrants were detected post-discharge from CSEC. Conclusion In a large public healthcare system, overall rates of SSIs following CSEC were low. Most infections were detected following discharge; living in neighborhoods of high poverty and being a recent immigrant appear to be risk factors for SSIs. While pre- and intra- operative protocols have been established to prevent SSIs, it appears postoperative factors (including wound care following discharge) warrant emphasis as well. Disclosures All Authors: No reported disclosures

Screening for Subclinical Atherosclerosis in Patients with Familial Hypercholesterolemia: Insights and Implications.

Background/Objectives: Familial hypercholesterolemia (FH) is a monogenic dyslipidemia that leads to early cardiovascular events. Subclinical atherosclerosis refers to the formation of atheromatous plaques in arterial beds before any clinical events. In our study, we investigated the presence, extent, and independent predictors of subclinical atherosclerosis among patients diagnosed with FH. Methods: This was a single-center, prospective, and cross-sectional study. This original study included 215 patients diagnosed with FH from a cohort of 1145 individuals assessed according to the Dutch Lipid Clinical Network (DLCN) criteria. Carotid and femoral ultrasonography were performed, and the coronary artery calcium score was measured to screen for subclinical atherosclerosis. Apolipoprotein A-I, apolipoprotein B, and lipoprotein (a) were analyzed using the nephelometric method. Results: The study cohort comprised 136 females (63%) with a mean age of 54 (43-62) years. The stigmata rate was 18%. The rate of statin use during subclinical atherosclerosis screening was 32% and only eight patients (4%) attained LDL-C values < 70 mg/dL. Subclinical atherosclerosis was observed in 148 patients (69%), with rates of 48%, 47.5%, and 40.5% in the coronary arteries, carotid bifurcation, and femoral bifurcation, respectively. Advanced age, male sex, high pretreatment low-density lipoprotein-cholesterol (LDL-C) level, diabetes, and a low Apo A-I/Apo B ratio were identified as independent predictors of subclinical atherosclerosis. Lp(a) levels ≥ 30 mg/dL predicted coronary atherosclerosis, while diabetes and low Apo A-I/Apo B ratios predicted carotid atherosclerosis, and smoking predicted femoral atherosclerosis. Conclusions: Subclinical atherosclerosis is prevalent, and medication adherence remains suboptimal among FH patients. Screening for subclinical atherosclerosis may impact the treatment strategies, via an increase in physician commitment to treatment protocols and improving patient compliance.

Assessing the Impact of the Prone Position on Acute Kidney Injury.

Background: Prone positioning is a standard intervention in managing patients with severe acute respiratory distress syndrome (ARDS) and is known to improve oxygenation. However, its effects on other organs, particularly the kidneys, are less well understood. This study aimed to assess the association between prone positioning and the development of acute kidney injury (AKI), specifically in overweight and obese patients. Methods: A retrospective pre-post study was conducted on a cohort of 60 critically ill ARDS patients who were placed in the prone position during hospitalization. The development of AKI was assessed using the Acute Kidney Injury Network (AKIN) criteria, with AKI measured by both creatinine levels (AKINCr) and urine output (AKINUO). Patients were divided into two groups based on body mass index (BMI): overweight/obese (BMI ≥ 25) and non-obese (BMI < 25). Data were collected before and after prone positioning. Results: In overweight/obese patients (n = 39, 57 cases), both the median AKINCr and AKINUO scores increased significantly following prone positioning (from 0 to 1, median p < 0.01, and from 0 to 2, median p < 0.01, respectively). No statistically significant changes in AKIN scores were observed in non-obese patients nor were significant differences found in either group after repositioning to supine. Conclusions: Prone positioning is associated with an increased risk of acute kidney injury in overweight and obese ARDS patients. This may be due to the kidneys' susceptibility to intra-abdominal hypertension in these patients. Further research is needed to explore optimal proning strategies for overweight and obese populations.

Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule.

The Pediatric Emergency Care Applied Research Network (PECARN) derived and externally validated a clinical prediction rule to identify children with blunt torso trauma at low risk for intraabdominal injuries undergoing acute intervention (IAIAI). Little is known about the risk for IAIAI when only one or two prediction rule variables are positive. We sought to determine the risk for IAIAI when either one or two PECARN intraabdominal injury rule variables are positive. We performed a planned secondary analysis of a prospective, multicenter study that included 7542 children (<18 years old) with blunt torso trauma evaluated in six emergency departments from December 2016 to August 2021. Patients with only one or two PECARN rule variables positive were included. The outcome was IAIAI (IAI undergoing therapeutic laparotomy, angiographic embolization, blood transfusion, or two or more nights of intravenous fluids). Among the 7542 children enrolled, 2986 (39.6%, 95% confidence interval [CI] 38.5%-40.7%) had one or two PECARN variables positive and were included. Of this subpopulation, 227 (7.6%, 95% CI 6.7%-8.6%) had intraabdominal injuries. In the 1639 patients with only one rule variable positive, 21 (1.3%, 95% CI 0.8%-2.0%) had IAIAI. In the 1347 patients with two rule variables positive, 27 (2.0%, 95% CI 1.3%-2.9%) had IAIAI. Risk for IAIAI for each variable was highest for Glasgow Coma Scale (GCS) score <14 (16/291, 5.5%, 95% CI 3.2%-8.8%) and abdominal wall trauma (three of 321, 0.9%, 95% CI 0.2%-2.7%). Risk for IAIAI when two variables were present was highest when decreased breath sounds (three of 44, 6.8%, 95% CI 1.4%-18.7%) and GCS <14 (10/207, 4.8%, 95% CI 2.3%-8.7%) were present with one other variable. Few children with blunt torso trauma and one or two PECARN predictor variables present have IAIAI. Those with GCS score <14, however, are at highest risk for IAIAI.

Spesolimab (Spevigo)

Canada’s Drug Agency (CDA-AMC) recommends that Spevigo should be reimbursed by public drug plans for the treatment of generalized pustular psoriasis (GPP) in adults and pediatric patients 12 years of age and older and weighing at least 40 kg if certain conditions are met. Spevigo should only be covered to treat adults and pediatric patients aged 12 years and older, weighing at least 40 kg, and living with GPP. Spevigo should be reimbursed for both the acute treatment of GPP flares and for the prevention of GPP flares for patients with a history of flares according to the European Rare and Severe Psoriasis Expert Network (ERASPEN) criteria. Spevigo should only be reimbursed if prescribed by clinicians (dermatologists or rheumatologists) with expertise in managing GPP and other types of psoriasis. For the prevention of flares, the initial authorization should be for 6 months of treatment. For continued renewal of Spevigo for the prevention of flares, the severity of GPP as measured by the generalized pustular psoriasis physician global assessment (GPPGA) total score at initiation should be maintained (not worsen), patient should experience fewer flares compared to baseline, and the reduction in the number of flares should be sustained. Spevigo should only be reimbursed if there is a reduction in drug price.

Network Management and Criteria for Consultants on Digital Transformation in Enterprises in Vietnam

The Ministry of Information and Communications has issued criteria and regulations for the recognition of individuals and organizations as consultants within the network supporting enterprises in their digital transformation, as outlined in Decision No. 376/QĐ-BTTTT dated March 13, 2023. This set of criteria includes specific evaluation standards for individuals and organizations participating in the Ministry's consultant network for digital transformation support. Consultants have utilized these evaluation criteria to enhance and supplement their capabilities, thereby improving the quality of their organizational activities in order to qualify for participation in the Ministry's assessment network for the level of digital transformation among enterprises. This study aims to analyze the content of the evaluation criteria and the outcomes related to the quality assessment of individuals and organizations within the consultant network for digital transformation support in Vietnam, as established by the Ministry of Information and Communications. The research findings highlight the current state of quality among consultants in the digital transformation sector, particularly concerning enterprise digital transformation. Additionally, the study proposes solutions to enhance the overall quality of consulting services, specifically in the area of digital transformation, to meet the growing demand for consultancy in the context of the Fourth Industrial Revolution.

Risk of acute kidney injury after contrast-enhanced MRI examinations in a pediatric population.

To investigate the associations between gadolinium-based contrast agent (GBCA) administration and the occurrence of acute kidney injury (AKI) in pediatric patients, and to determine the risks associated with AKI. This retrospective study was conducted on pediatric patients who underwent contrast-enhanced or unenhanced MRI between January 1st, 2015, and June 30th, 2021. Examinations were included if they had data on height and serum creatinine levels within 3 months before and 2 days after the examinations. AKI was defined according to the AKI Network criteria. Multivariable generalized estimating equations, propensity score analyses, and inverse probability of treatment weighting analysis were used to evaluate associations between GBCA and AKI. Subgroup analyses were conducted to evaluate the interaction effects of GBCA and each subgroup variable (age, sex, examination type, admission type, chronic kidney disease stage, diabetes mellitus, cardiovascular disease, or surgery or contrast-enhanced CT performed 7 days before and 2 days after MRI). A total of 2508 examinations were included (1996 with contrast-enhanced, 512 with unenhanced MRI). AKI occurred in 1.5% of the contrast group and 1.2% of the noncontrast group. Multivariable analysis showed no significant difference in AKI incidence between the groups (adjusted OR, 1.29 [95% CI: 0.53, 3.11]; p = 0.58). Propensity score matching and inverse probability of treatment weighting analysis also showed no significant association (p = 0.22 and p = 0.21, respectively). Subgroup analysis showed no significant interaction between GBCA and any of the subgroup variables. The study found no significant association between gadolinium-based contrast agent administration and the occurrence of acute kidney injury in pediatric patients. Question There is limited data on the development of acute kidney injury following exposure to gadolinium-based contrast agent in pediatric patients. Findings There was no significant association between the administration of gadolinium-based contrast agent and occurrence of acute kidney injury in pediatric patients. Clinical relevance The administration of gadolinium-based contrast agents does not increase the risk of acute kidney injury in pediatric patients following MRI.

Surgical Site Infections in Simultaneous Colorectal and Liver Resections for Metastatic Colorectal Adenocarcinoma.

Surgical site infections (SSIs) are a major driver of morbidity after combined liver and colorectal surgery for metastatic colorectal cancer. Available literature is inadequate to characterize risk factors and benchmarks for quality improvement. Consecutive cases of simultaneous liver and colorectal surgery for colorectal adenocarcinoma from November 2013 through September 2022 were reviewed for SSIs per National Surgical Quality Improvement Program (NSQIP) and National Healthcare Safety Network (NHSN) criteria. Univariable and multivariable logistic regression evaluated associations with NSQIP 30-day organ-space SSIs. In 580 procedures, the rate of 30-day organ-space SSIs was 16% (n=94) using NSQIP criteria and 11% (n=64) using NHSN criteria; 4% (n=24) had incisional SSIs by both criteria. Most organ-space SSIs were perihepatic, and a minority were associated with bile (26%) or anastomotic (15%) leak. Independent risk factors for organ-space SSIs included major liver resection, upper abdominal (compared with lower abdominal/pelvic) colorectal procedure, and ostomy reversal. Organ-space SSI rates increased over time by approximately 16% per calendar year (p=0.02) despite a declining rate of major liver resection; incisional SSI rates remained low. Overall, major morbidity was 22%, with 7-day median length of stay (interquartile range 6-9) and 0.3% 90-day mortality. Organ-space SSIs are a significant driver of postoperative morbidity in simultaneous liver and colorectal resections for metastatic colorectal adenocarcinoma. Our findings confirm simultaneous resection remains safe and interventions to mitigate the risk of perihepatic organ-space SSIs in high-risk patients are warranted.

Predictive Factors in Asymptomatic Bacteriuria Treatment

Background Asymptomatic bacteriuria (ASB) can often be inappropriately treated with antibiotics. The primary objective was to identify factors associated with antibiotic treatment of ASB. The secondary objective was to identify the prevalence of ASB treatment at our institution before and after Infectious Diseases Society of America (IDSA) updated Clinical Practice Guidelines for the Management of Asymptomatic Bacteriuria in 2019. 1 Methods This is a retrospective chart review of adults admitted to a rural Veterans Affairs Hospital in White River Junction, Vermont, with culture confirmed bacteriuria. Those who did not meet National Healthcare Safety Network criteria for diagnosis of urinary tract infection were classified as having ASB. Results The prevalence of ASB treatment was 58% (n = 61/106). Patients older than 80 years had 3.73 increased odds of receiving antibiotics for ASB (adjusted odds ratio 3.73, 95% confidence interval 1.43–9.71 P &lt; 0.01). Leukocytes &gt;5/hpf on urinalysis (adjusted odds ratio 4.45, confidence interval 1.19–16.57, P = 0.03) was significantly associated with antibiotic treatment in ASB. There was no significant difference between ASB treatment before 2019 versus after 2019. Conclusions Predictors of clinicians treating ASB with antibiotics were most significant in patients older than 80 years and those with leukocytes &gt;5/hpf on urinalysis. The 2019 IDSA guidance on avoiding antibiotic treatment for ASB was not well adopted to clinical practice for hospitalized patients at our institution.

Clinical and angiographic characteristics of patients with familial hypercholesterolemia presenting with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Familial hypercholesterolemia (FH) is a world public health problem that enhances the risk of premature coronary artery disease (CAD) with a high incidence of acute coronary syndrome. This study aimed to evaluate the clinical and angiographic characteristics of the patients with and without FH who had ST-elevation myocardial infarction (STEMI). It included 690 patients who presented with the first attack of STEMI and underwent primary percutaneous coronary interventions (PPCI). The patients were analyzed to diagnose FH according to the Dutch Lipid Clinic Network (DLCN) criteria. All angiograms were analyzed for the number of diseased vessels, Syntax score, thrombus burden grade, and final Thrombolysis in Myocardial Infarction (TIMI) flow grade. The majority of patients were male (72.6%) with a mean age of 54 ± 12 years. Based on DLCN criteria, they were classified into unlikely/possible FH (86.1%) and probable/definite FH (13.9%) groups. Probable/definite FH patients were significantly younger, and higher incidence of males < 55 years compared with unlikely/possible FH patients (p < 0.001 for each). Moreover, probable/definite FH patients had a higher frequency of three-vessel disease (p = 0.007) and Syntax score (p < 0.001) with a moderate positive correlation with the DLCN score (r = 0.592, p < 0.001). Furthermore, probable/definite FH patients showed a higher thrombus burden and final TIMI slow/no-reflow when compared to the unlikely/possible FH patients (p = 0.006 and p = 0.027, respectively). Patients with probable/definite FH and LDL-C level were independent predictors of high thrombus burden besides males < 55 years, and the number of diseased vessels. In conclusion, STEMI patients with FH were younger males and associated with severe CAD with frequent multivessel CAD, high anatomical complexity of CAD, and frequent high thrombus burden. Furthermore, FH was one of the predictors of high thrombus burden.

Minimizing Acute Kidney Injury in Pediatric Cardiac Surgery: Incidence, Early Detection, and Preemptive Measures.

Background Acute kidney injury (AKI) poses a significant challenge in pediatric cardiac surgery, having a profound impact on patient morbidity and mortality. This study aims to determine the incidence of AKI, explore novel biomarkers for early detection,assess potential risk factors along with preemptive strategies to minimize its incidence and compare the results with similar studies that did not use these interventions. Methods This prospective observational cohort study, conducted from October 2022 to June 2024 at a tertiary care center, involved 44 pediatric patients, aged three months to 15 years, undergoing cardiac surgery. Kidney function was assessed through preoperative and postoperative measurements of serum creatinine, urine output, blood urea, and newer biomarkers such as cystatin C and urine neutrophil gelatinase-associated lipocalin (NGAL). AKI was defined and classified using the Acute Kidney Injury Network (AKIN) criteria, based on increases in serum creatinine or reductions in urine output within the first three days post surgery. To reduce the risk of AKI, a low-dose vasopressin infusion and blood transfusion were administered to maintain renal perfusion and optimal hematocrit levels. The incidence of AKI was calculated and compared with other studies that did not utilize these strategies Results AKI occurred in 31.8% (n=14) of the pediatric patients undergoing cardiac surgery. To reduce the risk of AKI, preemptive low-dose vasopressin was used as a preventive strategy. Patients who developed AKI exhibited significant elevations in serum creatinine, blood urea, and cystatin C, with postoperative NGAL levels exceeding 50 ng/ml. The study found a strong correlation between lower intraoperative hematocrit levels (<30%) and a higher incidence of AKI (100% vs. 6.2%, p<0.001). Conclusions Effective management of intraoperative hematocrit levels and the preemptive use of vasopressin are promising strategies for reducing AKI risk by optimizing renal perfusion and function during cardiac surgery.Early detection through biomarkers like cystatin C and NGAL offers the potential for timely intervention and better patient outcomes. These findings contribute to improving risk assessment and perioperative management in pediatric patients vulnerable to AKI.

Alterations in serum levels of calcium, vitamin D, phosphorus, and parathyroid hormone in patients with clinically confirmed familial hypercholesterolemia: a cross-sectional study.

Familial hypercholesterolemia (FH), an autosomal dominant disease, is associated with an increased risk of premature cardiovascular disease (CVD). This study aimed to examine the variations in serum levels of calcium, vitamin D, phosphorus, and parathyroid hormone (PTH) among FH patients, as these factors have been associated with an increased susceptibility to CVD. In this cross-sectional study, the authors used data from Isfahan FH registry. The Dutch Lipid Clinic Network (DLCN) criteria was used for diagnoses of FH patients. Control group included participants with hyperlipidemia and were unlikely FH according to DLCN criteria. All biochemical parameters were measured using standard methods. A total of 131 patients (mean age, 53.1 ± 12.2; male, 51.4%) were included in the analysis. Patients with FH had lower serum vitamin D levels compared with control groups in the unadjusted model (P= 0.028). The relationship between serum vitamin D and FH was not significant after adjustment for traditional risk factor (P= 0.184). No significant association was observed between FH and serum calcium (P= 0.886), phosphorus (P= 0.463), and PTH (P= 0.849). Besides, there was no significant association between LDL-C or total cholesterol and serum minerals in FH patients. This study found no significant changes in serum calcium, vitamin D, phosphorus, and PTH in patients with FH.

Survival Outcomes According to NCCN Criteria for Resection Following Neoadjuvant Therapy for Patients with Localized Pancreatic Cancer.

This study aimed to assess the prognostic value of the National Comprehensive Cancer Network (NCCN) criteria for resection following neoadjuvant therapy for patients with localized pancreatic ductal adenocarcinoma (PDAC). This retrospective single-center study assessed 193 consecutive patients with localized PDAC (104 males and 89 females; mean age, 61.1 ± 9.4 years) who underwent neoadjuvant therapy followed by surgery between January 2010 and March 2021. Combined resectability and carbohydrate antigen (CA) 19-9 evaluation before and after neoadjuvant therapy was used to determine whether patients were eligible for resection according to the NCCN criteria. Post-surgical overall survival (OS), recurrence free survival (RFS), and pathologic results were evaluated and compared between patients considered eligible according to the NCCN criteria and those considered ineligible. Preoperative factors associated with better OS and RFS also were investigated. Of the 193 patients, 168 (87.0 %) were eligible for resection according to the NCCN criteria. The patients eligible according to the NCCN criteria showed marginally longer OS than those considered ineligible (p = 0.056). After adjustment of variables, meeting the NCCN criteria for resection was an independent predictor of better OS (hazard ratio, 0.57; 95 % confidence interval, 0.34-0.96; p = 0.034). The two groups had similar RFS. Lower T-staging (T2 or less) and less lympho-vascular invasion and peri-neural invasion were noted in the patients who met the NCCN criteria (p ≤ 0.045). The patients eligible for resection according to the NCCN criteria showed a trend toward longer OS and better pathologic results than the patients considered ineligible.

Clinical Assessment and Genetic Testing for Hereditary Polyposis Syndromes in an Italian Cohort of Patients with Colorectal Polyps.

Background: Hereditary polyposis syndromes are clinically and genetically heterogeneous conditions associated with increased colorectal cancer risk. They are classified based on polyp histology, inheritance mode, causal gene, and colonic and extracolonic manifestations. Their diagnosis is challenging due to overlapping and heterogeneous clinical presentations. Methods: A multigene next-generation sequencing panel was used to screen 75 index cases with colorectal polyps and a personal/family history of cancer for key hereditary polyposis-associated genes (APC, BMPR1A, MUTYH, PTEN, SMAD4, and STK11) in order to identify germline genetic variants. Results: In the screened index cases, we found 14 pathogenic variants involving APC, MUTYH, SMAD4, and STK11 and 6 variants of uncertain significance involving APC, BMPR1A, and SMAD4. In this cohort, four patients not fulfilling the recommended eligibility criteria of current National Comprehensive Cancer Network (NCCN) guidelines for genetic testing were molecularly diagnosed with a hereditary polyposis syndrome. Conclusions: Our findings indicate that stringent NCCN eligibility criteria for molecular screening may lead to missing some of the patients affected by hereditary polyposis syndromes. This highlights the need for a careful evaluation of patients' clinical manifestations, polyp number, age of polyp onset, and family history to select appropriate candidates for molecular diagnosis of these conditions.

Evaluation of the Frequency of Kidney Injury in the Postoperative Critical Care Unit (PACU): A Prospective Observational Study

Background: In the study, the frequency of postoperative acute kidney injury (AKI), factors associated with AKI, and the effect of AKI on outcomes in surgical cases treated in the Postoperative intensive care unit (PACU) in the postoperative period were investigated. Materials and Method: The study is a prospective and observational study. Surgical cases treated in the PACU in the postoperative period were included in our study. Demographic characteristics of the patients, characteristics of the operation and anesthesia, Charlson Comorbidity Index (CCI) values, American Society of Anesthesiologist (ASA) risk classes, preoperative biochemistry results and preoperative hemogram results were recorded. Patients' AKI was assessed using the Risk, Injury, Failure, Loss of Function, and End-Stage Renal Disease (RIFLE) and Acute Kidney Injury Network criteria(AKIN). Results: 583 postoperative cases were examined. The frequency of AKI in PACU was 17,7%. Age, preoperative CCI, BUN, GFR values, preoperative peptic ulcer history, preoperative calcium, total bilirubin levels and the urgency of operation were the preoperative reasons for AKI. Intraoperative use of blood and colloid also affected postoperative AKI. There was a relationship between AKI and the amount of crystalloid and FFP used in PACU. In patients with AKI, the frequency of inotropic use in PACU, the frequency of the use of IMV and the duration, cardiac complication, arrhythmia, respiratory system complications, sepsis and mortality rate were higher compared to patients without AKI (p

Bloodstream infections in a Brazilian Pediatric Tertiary Oncology Hospital: 30-month analysis regarding the classification of the infection, distribution of microorganisms and their resistance profile

Abstract Background Infections are a major cause of morbidity and mortality in pediatric oncology patients during their treatment. Bloodstream infections are the main site of infection in these patients. Bacteremia in these patients can be secondary to a primary infectious focus, result from central line associated bloodstream infections (CLABSIs) or mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI). Methods Descriptive study of bloodstream infections in pediatric patients undergoing oncological treatment and hematopoietic stem cell transplantation in a tertiary pediatric oncology hospital in Brazil from January 1st, 2021 to June 30th, 2023. Infections were classified according to the Centers for Disease Control and Prevention/ National Healthcare Safety Network (CDC/NHSN) criteria into CLABSIs, MBI-LCBIs and secondary bloodstream infections. Among the bloodstream infections that met CDC/NHSN criteria for CLABSI, were analyzed separately those who also met the criteria of catheter-related bloodstream infection (CRBSI) according to Infectious Diseases Society of America (IDSA). Results During this period were diagnosed 335 episodes of bloodstream infection (123 episodes in 2021, 150 in 2022 and 62 episodes in the first 6 months of 2023). There were 378 microorganisms isolated. These infections were classified into: 35% CLABSIs, 27% MBI-LCBIs, 23% CRBSIs, and 15% secondary bloodstream infections. Among the CLABSIs, the most common microorganisms were non-fermenting gram negative bacilli (NFGNB) 38%, enterobacteriaceae 35% and coagulase-negative staphylococcus (CoNS) 11%. Between CRBSIs, there were 31% enterobacteriaceae, 22% CoNS and 19% NFGNB. Among the MBI-LCBIs there were 66% enterobacteriaceae and 23% group viridans streptococci (VGS). Streptococcus pneumoniae (33%) was the most common microorganism in secondary infections followed by Staphylococcus aureus (17%). Assessing all infections together, the main enterobacteriaceae were Klebsiella spp. (40%) and only 50% of them were sensitive to cefepime while 10% were carbapenems resistant. Among NFGNB, 13% of Pseudomonas spp. and 5% of Acinetobacter spp. were carbapenems resistant. Between the gram-positive bacteria, 77% of the S. aureus were methicillin sensitive, the same percentage of the VGS were sensitive to cefepime. Conclusion Among bloodstream infections, there were a predominance of CLABSI followed by MBI-LCBIs. Antimicrobial resistance between gram-positive bacteria, is of little concern in our institution. In the case of gram-negative bacteria, resistance to cefepime is becoming worrying among enterobacteriaceae.