Presence Of Tachycardia Research Articles

Prevalence and factors associated with radiological alterations in patients with mild SARS-COV-2 infection: Cross-sectional study at a private clinic in Buenos Aires, Argentina

Introduction: The SARS-COV-2 infection has been characterized by the heterogeneity in the clinical presentation. The knowledge development, as well as the availability of resources have modified the way to evaluate patients. During 2020 in argentina, the realization of chest images was a routine practice regardless of the clinical condition. Objectives: To explore the associated factors that determine the radiological alteration in patients with the diagnostic suspicion of a mild SARS- COV-2 infection and to estimate their prevalence. Methods: Cross-sectional study between March and October 2020 in patients with mild infection suspicion and later confirmation through the PCR study. Results: 687 patients were recruited. The prevalence in the whole population was 16% for chest radiography and 14% for Scans. The presence of tachycardia (p:0,016), oxygen saturation lower than 94% breathing environmental air (p:0,03) and more than 5 days from the beginning of symptoms (0,03) result into factors associated with the findings of imaging alterations. Conclusions: In patients with a mild condition who consult within 5 days from the beginning of the symptoms, without tachycardia and without oxygen requirement, the realization of lung imaging would not be recommended due to the scarce possibility of pathological findings.

Determinants of the onset and prognosis of the post-COVID-19 condition: a 2-year prospective observational cohort study

At least 5-10% of subjects surviving COVID-19 develop the post-COVID-19 condition (PCC) or "Long COVID". The clinical presentation of PCC is heterogeneous, its pathogenesis is being deciphered, and objective, validated biomarkers are lacking. It is unknown if PCC is a single entity or a heterogeneous syndrome with overlapping pathophysiological basis. The large US RECOVER study identified four clusters of subjects with PCC according to their presenting symptoms. However, the long-term clinical implications of PCC remain unknown. We conducted a 2-year prospective cohort study of subjects surviving COVID-19, including individuals fulfilling the WHO PCC definition and subjects with full clinical recovery. We systematically collected post-COVID-19 symptoms using prespecified questionnaires and performed additional diagnostic imaging tests when needed. Factors associated with PCC were identified and modelled using logistic regression. Unsupervised clustering analysis was used to group subjects with PCC according to their presenting symptoms. Factors associated with PCC recovery were modelled using a direct acyclic graph approach. The study included 548 individuals, 341 with PCC, followed for a median of 23 months (IQR 16.5-23.5), and 207 subjects fully recovered. In the model with the best fit, subjects who were male and had tertiary studies were less likely to develop PCC, whereas a history of headache, or presence of tachycardia, fatigue, neurocognitive and neurosensitive complaints and dyspnea at COVID-19 diagnosis predicted the development of PCC. The cluster analysis revealed the presence of three symptom clusters with an additive number of symptoms. Only 26 subjects (7.6%) recovered from PCC during follow-up; almost all of them (n=24) belonged to the less symptomatic cluster A, dominated mainly by fatigue. Recovery from PCC was more likely in subjects who were male, required ICU admission, or had cardiovascular comorbidities, hyporexia and/or smell/taste alterations during acute COVID-19. Subjects presenting with muscle pain, impaired attention, dyspnea, or tachycardia, conversely, were less likely to recover from PCC. Preexisting medical and socioeconomic factors, as well as acute COVID-19 symptoms, are associated with the development of and recovery from the PCC. Recovery is extremely rare during the first 2 years, posing a major challenge to healthcare systems. Fundació Lluita contra les Infeccions.

The Use of Albumin-to-bilirubin Score in Predicting Variceal Bleed: A Pilot Study from Pakistan.

Majid Z, Khan SA, Akbar N, et al. The Use of Albumin-to-bilirubin Score in Predicting Variceal Bleed: A Pilot Study from Pakistan. Euroasian J Hepato-Gastroenterol 2022;12(2):77-80.

Clinical Features and Outcomes of Acute Chlorine Gas Inhalation; a Brief Report.

Introduction:On March 6th,2020, chlorine gas leak was reported at Engro Polymer & Chemicals Plant in Karachi City, Pakistan. This study aimed to evaluate the clinical features and outcomes of patients who presented to emergency department (ED) following this event.Methods:This retrospective cross-sectional study, evaluated the clinical features and outcomes (length of hospital stay, complications, and mechanical ventilation requirement) of patients presenting to ED of Aga Khan University Hospital, Karachi, Pakistan, with history of chlorine gas exposure at the Engro Plant from 6th March to 14th March 2020. Results:38 patients with mean age of 33.1 ± 8.1 years presented to ED with history of chlorine gas exposure (100% male). 4 (10.5%) cases had comorbid diseases. Most common presenting symptom was dyspnea, observed in 33 (86.8%) cases, followed by cough, seen in 27 (71.1%) subjects. 13.2% (5/38) patients had infiltration on chest x-ray and 33 (86.8 %) required hospitalization. 6 (15.8%) patients had repeat presentation requiring hospitalization or ED visit. 18 (47.4%) were managed with high flow oxygen therapy, 9 (23.7%) required non-invasive ventilation and one patient was intubated due to development of pneumo-mediastinum. Mean length of stay was 1.55 ± 1.58 days and no patients died. Presence of tachycardia was the only finding significantly associated with need for oxygen (p = 0.033) and non-invasive ventilation (p = 0.012).Conclusion:The majority of patients presenting with acute chlorine gas exposure showed good clinical outcomes and rapid recovery, however, a high index of suspicion and vigilance should be maintained for complications such as pneumomediastinum and acute respiratory distress syndrome in these patients.

Прогнозування та діагностика правошлуночкової серцевої недостатності та дисфункції шлуночків серця в період загострення бронхіальної астми у дітей

Актуальність. Бронхіальна астма (БА) вже в дитячому віці може супроводжуватись серцево-судинними ускладненнями у вигляді синдрому гострого легеневого серця, дисфункції шлуночків серця, метаболічної кардіоміопатії, порушень ритму і провідності, що не тільки обтяжує перебіг захворювання, але й додатково знижує якість життя пацієнтів. Ремоделювання серця при БА передує клінічним проявам серцевої недостатності та може самостійно поглиблювати систолічну і діастолічну дисфункцію шлуночків. Мета. Удосконалення прогнозування розвитку серцево-судинних ускладнень у період загострення БА в дітей шляхом визначення факторів ризику розвитку дисфункції шлуночків і розробки додаткових інформативних клініко-ехокардіографічних діагностичних критеріїв правошлуночкової серцевої недостатності. Матеріали та методи. Під нашим спостереженням перебували 85 дітей, хворих на БА, віком від 5 до 17 років, у яких застосовано методи пульсоксиметрії, спірографії, електрокардіографії, допплер-ехокардіографії. Обстеження проводилось у періоді загострення БА при госпіталізації хворого і в періоді поліпшення стану, на 5–6-ту добу перебування у відділенні пульмоалергології комунального закладу «Обласна дитяча клінічна лікарня» Дніпропетровської обласної ради. Критеріями включення в дослідження були алергічна та змішана персистуюча средньотяжка і тяжка астма в період загострення. В дослідження не ввійшли хворі на БА діти в період ремісії, діти з інтермітуючим перебігом астми та легкою персистуючою БА. Для визначення типу й ступеня вентиляційної недостатності використовували метод спірографії з оцінкою показників життєвої ємності легень (ЖЄЛ), об’єму форсованого видиху за 1 секунду (ОФВ1), ОФВ1/ЖЄЛ. Математичне і статистичне опрацювання матеріалів дослідження проводили з використанням методів біостатистики, реалізованих у пакетах програм Microsoft Excel (Office Home Business 2KB4Y-6H9DB-BM47K-749PV-PG3KT), Statistica 6.1 (StatSoft Inc., серійний № AGAR909E415822FA). Результати. Визначено прогностичні клінічні фактори ризику розвитку систоло-діастолічної дисфункції шлуночків серця у випадку можливого нападу БА, до яких було віднесено: наявність у хворої дитини БА тяжкого перебігу; наявність тахікардії у спокої; порушення реполяризації в міокарді шлуночків на електрокардіограмі; наявність у хворого на астму супутнього хронічного тонзиліту; бактеріоносійство у носоглотці; жіночу стать. Розроблено додаткові інформативні діагностичні критерії розвитку правошлуночкової серцевої недостатності в період загострення БА у дітей. Установлено, що застосування еуфіліну поряд із ­b2-агоністами для бронхолітичної терапії дітей у період загострення БА негативно впливає на діастолічну функцію шлуночків серця і сприяє збереженню підвищеного тиску в легеневій артерії. Висновки. Питання покращення можливостей прогнозування розвитку дисфункції шлуночків серця та своєчасної діагностики серцево-судинних ускладнень у період загострення БА у дітей вирішується шляхом визначення клінічних факторів ризику розвитку дисфункції шлуночків і розробки додаткових інформативних клініко-ехокардіографічних діагностичних критеріїв правошлуночкової серцевої недостатності.

Category II non-reassuring fetal heart rate pattern and risk of admission to Neonatal Intensive Care Unit

Background: The relationship between non-reassuring fetal heart rate (FHR) pattern, acidemia at birth and neonatal morbidity remains unclear. Our aim was to compare low versus high pH cord blood infants of women detected with a Category II FHR pattern for which the impact is unclear. Methods: A prospective study of 185 low-risk pregnant women in labor at > 370/7 weeks of gestation with a singleton fetus was conducted at a single center. Category II trace was defined by the presence of tachycardia or bradycardia, variable and late decelerations, marked variability at least 30 minutes in the 120 minutes prior to delivery. The primary outcome included the need for resuscitation and Neonatal Intensive Care Unit (NICU) admission. The cohort was also stratified into three categories according to admission to NICU and pH threshold ([i] umbilical artery blood pH 7.15 and admitted; [iii] not admitted). Results: 23% (43/185) of infants of women detected with Category II FHR pattern needed NICU admission. Category II FHR pattern was associated with low pH at birth, and the need for resuscitation was more frequent among infants in the lower pH group (73% vs. 10%, p < 0.05). Indices of right (tricuspid annular plane systolic excursion [TAPSE]: 7.3 ± 0.9 mm) and left ventricular performance (fractional shortening: 31% ± 8.9%, transmitral E’/A’ 0.9 ± 0.3) were low compared to normative data for healthy infants. CK, CK-MB, and left-to-right/bidirectional shunts at PFO and PDA were higher overall at 72 hours of age. Conclusions: Category II FHR is associated with resuscitation at birth, NICU admission, and length of hospitalization.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Affirming Arrhythmia Diagnosis Using All Available Electrocardiography Leads.

Scenario: The rhythm strip below (leads II and V1) was an alarm for ventricular tachycardia (VT) in a 72-year-old man being treated in the cardiac intensive care unit for an acute exacerbation of heart failure. The patient was intubated and thus unable to report symptoms. His blood pressure was unchanged during the alarm (90/50 mm Hg). The patient has a history of coronary artery disease, heart failure due to ischemic heart disease, and paroxysmal atrial fibrillation. The nurse noted the wide QRS complex in lead II but not V1 and wondered if this was true VT given the wide QRS complex; thus, he printed a rhythm strip with additional electrocardiography (ECG) leads (see next page).The baseline rhythm is sinus tachycardia with left bundle branch block pattern (ie, P waves present, QRS > 120 milliseconds, deep S wave in V1, and discordant T waves). There is a single episode of nonsustained VT (NSVT, ie, >6 consecutive premature beats at rate >120/min and lasting <30 seconds). Throughout, there are low-amplitude QRS segments during baseline rhythm (most likely due to heart failure).Although VT is not entirely distinguishable in leads II and V1, which are typically displayed on the bedside monitor, evaluation of leads I and III confirms that this arrhythmia is NSVT, emphasizing the importance of examining multiple leads during arrhythmia interpretation. Lead V1 is typically very useful for diagnosing wide complex tachycardias versus supraventricular tachycardia with aberrancy; however, lead V1 is not helpful in this example, most likely because the abnormal depolarization of the myocardium is perpendicular to where this lead is on the body surface; thus, visible and distinct QRS waveforms are not seen. Although lead II is somewhat better for assessing the origin of this arrhythmia, leads I and III are very helpful and confirm the presence of NSVT. One strong ECG criterion for VT is a QRS width greater than 0.16 seconds (4 small boxes), which is met in lead I.In patients with underlying structural heart disease, myocardial infarction, and/or heart failure, the chance of a wide complex tachycardia being VT is 90%. Patients with heart failure (this patient’s primary problem) often have VT, and it is a significant cause of mortality in such patients. This patient was taking amiodarone to prevent VT before admission and continued receiving this medication during hospitalization; hence, he was on guideline-based therapy. Given this, his QT interval measured at the upper limit of normal is expected. Although antiarrhythmic drugs are commonly used to prevent and treat VT, this strategy is not always effective for preventing VT in patients with heart failure. Cardiology should be notified. Determine why and for how long this patient has been in sinus tachycardia and treat as indicated. One source of VT is myocardial ischemia, which could be exacerbated in the presence of tachycardia via demand-related ischemia. Given the underlying left bundle branch block, ST-segment interpretation for ischemia is con-founded. Treat this problem if indicated. Measure potassium and magnesium levels to ensure they are not the problem. Vigilant ECG monitoring should be continued because this rhythm could recur and deteriorate into ventricular fibrillation. Consider applying multifunction pads to the patient’s torso if ischemia is suspected and/or electrolyte levels are abnormal. Anticipate an evaluation for an implantable cardioverter defibrillator.

The Relationship Between Heart Rate and Body Temperature in Critically Ill Patients.

The presence of tachycardia in critically ill patients is frequently used as an indication of severity of illness and to guide treatment decisions but can be influenced by body temperature, thus confounding its interpretation. There are few data available on the relationship between body temperature and heart rate in critically ill patients. Retrospective analysis of prospectively collected data. Mixed medical-surgical university hospital ICU. All patients admitted to the ICU between November 2006 and August 2019. Body temperature was recorded in the electronic medical records at least hourly, from invasive measurements (esophageal probe, indwelling urinary catheter, pulse contour cardiac output monitoring system, or pulmonary artery catheter) or manual tympanic recordings. Heart rate was monitored continuously and hourly values were recorded in the electronic medical record. Change in heart rate with change in body temperature was assessed by extracting pairs of simultaneous body temperature and corresponding heart rate measurements from the electronic medical record: 472,941 simultaneous pairs were obtained from the 9,046 patients admitted during the study period. Each 1°C increase in body temperature between 32.0°C and 42.0°C was associated with an 8.35 beats/min increase in heart rate. Crude linear regression showed an r2 of 0.855 between body temperature and heart rate. Heart rate increased more in females than in males (9.46 vs 7.24 beats/min for each 1°C, p < 0.0001); this relationship was not affected by age or adrenergic drugs. The increase in heart rate was related to the severity of organ dysfunction. Increase in body temperature is associated with a linear increase in heart rate of 9.46 beats/min/°C in female and 7.24 beats/min/°C in male patients. These observations will help to correctly interpret heart rate values at different body temperatures and enable more accurate evaluation of other factors associated with tachycardia.

Development and Validation of a Risk Scoring Model for Early Prediction of Severe Colon Ischemia.

Colon ischemia (CI) is injury to the intestines secondary to insufficient blood flow. Its clinical severity can range from mild to life-threatening. To investigate predictive risk factors for CI and propose a scoring model for severe outcomes. We retrospectively analyzed the medical records of patients admitted to Chungnam National University Hospital from January 2010 to December 2018. CI was defined as severe when patients required surgery immediately or after initial conservative management, death occurred after hospitalization, or symptoms persisted after 2weeks. By controlling for possible confounders from the logistic regression analysis, we obtained a new risk scoring model for the early prediction of severe CI. Furthermore, using the area under the receiver operating characteristics curve (AUROC), we assessed the accuracy of the model. A total of 274 patients endoscopically diagnosed with CI were included, of whom 181 had severe CI. In the multivariate analysis, tachycardia, elevated C-reactive protein, Favier endoscopic classification stage ≥ 2, and history of hypertension were independently and significantly associated with severe CI. The AUROC of the model was 0.749. This risk scoring model based on the presence of tachycardia, elevated C-reactive protein level, unfavorable endoscopic findings by Favier's classification, and the history of hypertension could be used to predict severe CI outcomes at an early stage.

Confounders and Pharmacological Characterization When Using the QT, JTp, and Tpe Intervals in Beagle Dogs.

Corrected QT (QTc) interval is an essential proarrhythmic risk biomarker, but recent data have identified limitations to its use. The J to T-peak (JTp) interval is an alternative biomarker for evaluating drug-induced proarrhythmic risk. The aim of this study was to evaluate pharmacological effects using spatial magnitude leads and DII electrocardiogram (ECG) leads and common ECG confounders (ie, stress and body temperature changes) on covariate adjusted QT (QTca), covariate adjusted JTp (JTpca), and covariate adjusted T-peak to T-end (Tpeca) intervals. Beagle dogs were exposed to body hyper- (42 °C) or hypothermic (33 °C) conditions or were administered epinephrine to assess confounding effects on heart rate corrected QTca, JTpca, and Tpeca intervals. Dofetilide (0.1, 0.3, 1.0 mg/kg), ranolazine (100, 140, 200 mg/kg), and verapamil (7, 15, 30, 43, 62.5 mg/kg) were administered to evaluate pharmacological effects. Covariate adjusted QT (slope -12.57 ms/°C) and JTpca (-14.79 ms/°C) were negatively correlated with body temperature but Tpeca was minimally affected. Epinephrine was associated with QTca and JTpca shortening, which could be related to undercorrection in the presence of tachycardia, while minimal effects were observed for Tpeca. There were no significant ECG change following ranolazine administration. Verapamil decreased QTca and JTpca intervals and increased Tpeca, whereas dofetilide increased QTca and JTpca intervals but had inconsistent effects on Tpeca. Results highlight potential confounders on QTc interval, but also on JTpca and Tpeca intervals in nonclinical studies. These potential confounding effects may be relevant to the interpretation of ECG data obtained from nonclinical drug safety studies with Beagle dogs.

Trauma Coagulopathy and Its Outcomes.

Background and Objectives: Trauma coagulopathy begins at the moment of trauma. This study investigated whether coagulopathy upon arrival in the emergency room (ER) is correlated with increased hemotransfusion requirement, more hemodynamic instability, more severe anatomical damage, a greater need for hospitalization, and hospitalization in the intensive care unit (ICU). We also analyzed whether trauma coagulopathy is correlated with unfavorable indices, such as acidemia, lactate increase, and base excess (BE) increase. Material and Methods: We conducted a prospective, monocentric, observational study of all patients (n = 503) referred to the Department of Emergency and Acceptance, IRCCS Fondazione Policlinico San Matteo, Pavia, for major trauma from 1 January 2018 to 30 January 2019. Results: Of the 503 patients, 204 had trauma coagulopathy (group 1), whereas 299 patients (group 2) did not. Group 1 had a higher hemotransfusion rate than group 2. In group 1, 15% of patients showed hemodynamic instability compared with only 8% of group 2. The shock index (SI) distribution was worse in group 1 than in group 2. Group 1 was more often hypotensive, tachycardic, and with low oxygen saturation, and had a more severe injury severity score than group 2. In addition, 47% of group 1 had three or more body districts involved compared with 23% of group 2. The hospitalization rate was higher in group 1 than in group 2 (76% vs. 58%). The length of hospitalization was >10 days for 45% of group 1 compared with 28% of group 2. The hospitalization rate in the ICU was higher in group 1 than in group 2 (22% vs. 14.8%). The average duration of ICU hospitalization was longer in group 1 than in group 2 (12.5 vs. 9.78 days). Mortality was higher in group 1 than in group 2 (3.92% vs. 0.98%). Group 1 more often had acidemia and high lactates than group 2. Group 1 also more often had BE <−6. Conclusions: Trauma coagulopathy patients, upon arrival in the ER, have greater hemotransfusion (p = 0.016) requirements and need hospitalization (p = 0.032) more frequently than patients without trauma coagulopathy. Trauma coagulopathy seems to be more present in patients with a higher injury severity score (ISS) (p = 0.000) and a greater number of anatomical districts involved (p = 0.000). Head trauma (p = 0.000) and abdominal trauma (p = 0.057) seem related to the development of trauma coagulopathy. Males seem more exposed than females in developing trauma coagulopathy (p = 0.018). Upon arrival in the ER, the presence of tachycardia or alteration of SI and its derivatives can allow early detection of patients with trauma coagulopathy.

Pediatric Sepsis in Our Community: A Point Prevalence Study

Abstract Objective Hospital-based studies are the main sources of epidemiologic data on pediatric sepsis, underrepresenting those managed as outpatients. This may disadvantage community providers, especially when determining triage, referral, and follow-up. Our objective was to characterize sepsis in nonhospitalized children and describe resources allocated to their care. Methods This was a point prevalence study conducted in 11 primary care (PC) offices, 2 urgent care (UC) centers, and 1 pediatric emergency department (ED) serving Western New York. Patients aged 18 years and younger evaluated at a participating site on one of four study dates over a 12-month period were eligible to participate. Patients were included if temperature and heart rate and/or respiratory rate were documented during their visit. The primary outcome was the prevalence of sepsis in participating sites. Results Of 3,269 eligible children, 52.6% (n = 1,719) met inclusion criteria, 91% of whom (n = 1,576) were evaluated for acute infection. Sepsis criteria were met by 8.8% of these patients (22.4% in ED, 13.0% in UC centers, and 1.6% in PC offices). Most (74%) patients with sepsis were managed solely by initial site and sent home. However, meeting sepsis criteria was associated with higher odds of escalation of care beyond initial site (adjusted odds ratio [aOR]: 2.59, 95% confidence interval [CI]: 1.62–4.17). The presence of tachycardia (aOR: 2.88, 95% CI: 1.70–4.90) or a lower respiratory tract infection (aOR: 3.69, 95% CI: 2.28–5.99) was also independently associated with higher odds of care escalation. Conclusion Nearly 1 in 10 children seeking outpatient evaluation for infection met sepsis criteria. While most were managed without transfer or hospital admission, the diagnosis did carry higher odds of care escalation. Tachycardia and lower respiratory tract infections also conveyed an increased likelihood, suggesting additional screening possibilities for outpatient clinicians.

MON-LB009 Renin Angiotensin Aldosterone System Inactivation in Postural Orthostatic Tachycardia Syndrome

Postural Orthostatic Tachycardia Syndrome (POTS) is a clinical syndrome characterized by the presence of tachycardia in the absence of orthostatic hypotension; symptoms of orthostatic intolerance (presyncope and syncope) are present secondary to autonomic dysfunction (1). It is thought that one of the implications for POTS involves plasma volume disturbances leading to blood pooling. The Renin Angiotensin Aldosterone System (RAAS) is one system that assists in plasma volume regulation (2). In this study we hypothesized that these disturbances are brought about by an inactivation of RAAS. This was done by retrospectively reviewing the medical records of POTS patients. In these patients, diagnosis of POTS was established by an increase in Heart Rate of over 30 bpm within 10 minutes of tilt. Stroke Volume was used as a measure of volume disturbances; those POTS patients whose stroke volumes had not increased by the End of the Tilt as compared to their 6 minute supine baseline were considered to have an inactivation of RAAS. Our total sample of POTS patients numbered at 447, out of which 417 patients had lower stroke volumes at the end of their tilt table tests when compared to their baseline; this makes for 92.87% of our POTS Patient Sample. The average Stroke Volume at the 6 minute mark was calculated to be 74.67; the average stroke volume at the end of the tilt table test (30 minutes) was calculated to be 46.33 mL; . The results seen in this study show that more than 90% of our POTS Patient Sample there is no recovery of the stroke volume by the end of the tilt table test, this volume disturbance can be the result of decreased RAAS activation. This observation is supported by the difference found between average stroke volumes seen at 6 minute baseline and at 30 minutes of tilt. In normal individuals, we should see an increase in stroke volume at the end of the tilt as RAAS is activated. However, as patients with POTS are known to have lower plasma volumes (2), compounded with the inactivation of RAAS; the resulting hypovolemia will amplify the symptoms of POTS, increasing their severity. These patients should respond well to fludrocortisone, as there will be a correction of hemodynamic impairments (RAAS inactivation) leading to symptomatic relief (3). Further studies and analyses are needed to look into the levels of Renin and Aldosterone at Baseline & at Tilt, as well as the effects of fludrocortisone on such patients with RAAS inactivation.

Clinical and Laboratory Features Associated with Acute Kidney Injury in Severe Malaria.

Introduction:Critically ill severe malaria constitutes one of the major hospital admissions in Indian setting. Clinical studies identifying the factors associated with acute kidney injury (AKI) in malaria are lacking. This study aimed to identify these factors.Methods:This prospective observational study was conducted in a tertiary care center of North India. All adult patients with severe malaria were studied during 2012–2014.Results:The study included 79 patients and AKI was observed in 36 patients. Of these 79 patients, 52.7% were Plasmodium falciparum positive and 47.2% were Plasmodium vivax positive. In AKI patients, thrombocytopenia and jaundice were the most common other complications seen. Among P. vivax malarial patients, 17 (36%) patients had AKI. Features associated with AKI among patients admitted with P. vivax malaria were as follows: tachycardia (adjusted relative risk [RR]: 3.9; 95% confidence interval [CI]: 1.1–13.7), direct hyperbilirubinemia (adjusted RR: 4.7; 95% CI: 1.4–15.2), anemia (adjusted RR: 6; 95% CI: 1.7–22.4), and sepsis (adjusted RR: 3.3; 95% CI: 1.1–13.7). The presence of tachycardia, acidosis, cerebral malaria, acute respiratory distress syndrome/acute lung injury, hypotensive shock, and poor Glasgow Coma Scale were associated with higher mortality in patients with AKI. Patients who required mechanical ventilation and/or vasopressor support had higher mortality.Conclusion:P. vivax is an important cause of severe malaria with AKI in our setting. Various other clinical features are associated with AKI and related mortality.

Clinical and Laboratory Predictors of Positive CT Angiography in Patients With Lower Gastrointestinal Bleed

Introduction: Acute gastrointestinal (GI) hemorrhages are responsible for 1-2% of all hospitalizations nationwide, amounting to over 30,000 admissions annually. CT Angiography (CTA) is being increasingly utilized as a first-line study for the diagnosis of acute lower GI bleed, with reported high sensitivity and specificity rates. However, CTA is also a relatively expensive resource and carries the potential for contrast and radiation related complications. We aim to identify clinical and laboratory parameters, which may help improve the diagnostic yield of CTA. Methods: From January 2012 to 2017, a total of 202 patients underwent CTA for work-up of suspected acute GI bleed at Einstein Medical Center. The primary outcome (CTA scan positive for active bleed) was determined upon review by a board-certified interventional radiologist. Clinical parameters (blood transfusion requirement, tachycardia (>100bpm), hypotension (systolic blood pressure<90, diastolic blood pressure<60), medications (antiplatelet or anticoagulant) and coagulopathy (INR>1.5, thrombocytopenia<150,000) were evaluated for potential associations with positive CTA scan. Chi-squuare test was used to determine the statistical significance (P value<0.05). Results: Among the 202 patients who underwent CTangiography, a total of 49 (24.3%) had a CTA scan positive for active bleed. On analysis of clinical variables, no significant associations were found between positive CTA scan and hypotension (p=0.38), need for blood transfusion (p=0.97), use of antiplatelet agents (p=0.93), thrombocytopenia (p=0.78), or elevated INR >1.5 (p=0.39). However, an association was observed with the use of anti-coagulant medications, in as much as 27% of patients with positive CTA scan were therapeutically anticoagulated, versus only 14% of patients with negative CTA (p=0.05). A weaker trend was also witnessed between the presence of tachycardia and CTA findings (p=.087). Conclusion: Patients on therapeutic anticoagulation have a higher likelihood of positive diagnosis of active GI bleed on CT Angiography. Based on the modest sample size, no other significant clinical or laboratory parameters proved to be effective predictor for positive CTA. Thus the importance of clinical judgement in deciding the need of CTA in the work up of patients with lower GI bleed remains of utmost importance.

Multifactorial Prognostication of Remote Outcomes in Patients With Non-ST Elevation Acute Coronary Syndrome

Creation of a mathematical nonlinear regression model for prognostication of 1 year outcomes after non-ST elevation acute coronary syndrome (NSTE ACS) for optimization of rehabilitation, secondary prevention, and personalized approach to treatment. We included in this study 135 patients with confirmed NSTE ACS (mean age 59.1±6.1 years, 94 men and 41 women) admitted to hospital No 1 in Novosibirsk during 2010. During hospitalization and 1 year after discharge these patients received standard medical therapy. All patients underwent clinical and instrumental examination which included electrocardiography, echocardiography, Holter ECG monitoring. Program of clinical investigation also included determination of levels of inflammatory cytokines and molecular genetic studies. Effect of each of studied parameters on the probability of unfavorable one year prognosis was assessed by methods of correlation and factor analysis. The constructed mathematical model of multifactor prognostication of 1 year unfavorable or favorable outcomes after NSTE ACS included patient's age in years, presence of tachycardia at admission, Killip class >II, life-threatening paroxysmal tachyarrhythmias, as well as serum concentration of high-sensitivity C-reactive protein and CT genotype of a polymorphic variant rs1376251 of TAS2R50 gene. The use of the proposed model of multivariate prognostication of 1 year outcomes of NSTE ACS allows to improve the accuracy of events prediction, as it is based on data from Russian patients and takes into account the activity of subclinical inflammation and genotype of the patient. The model is simple to use and allows to personalize secondary prevention, which will facilitate lowering of total cardiovascular risk in these patients.

Association of Heart Rate with N-Terminal Pro-B-Type Natriuretic Peptide in Septic Patients: A Prospective Observational Cohort Study.

Excessive sympathetic stress has multiple adverse effects during critical illness including sepsis. Recent studies showed that heart rate control had a significant effect on reducing mortality in septic shock patients. Furthermore, elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in septic patients were reportedly associated with adverse outcome. However, no study has evaluated the relationship between hemodynamic profiles of septic patients and the circulating cardiac biomarker. Our objective was to determine whether hemodynamic profiles, specifically tachycardia and new-onset atrial fibrillation (AF), were associated with NT-proBNP elevation in septic patients. We consecutively enrolled patients admitted to our intensive care unit (ICU). NT-proBNP levels, heart rate, and rhythm at ICU admission were measured, and all clinical and laboratory data were prospectively collected. Tachycardia was defined as a heart rate of above 100 bpm. Ninety-five patients out of 267 patients (35.6%) were diagnosed as sepsis. Of these septic patients, 47 presented with tachycardia and 6 developed new-onset AF. Multivariate Cox regression analysis revealed that tachycardia was an independent predictor of 28-day overall survival in septic patients (hazard ratio, 4.22; 95% confidence interval, 1.10-27.72; P < 0.05), but not in nonseptic patients. Multivariate linear regression analysis demonstrated that the presence of tachycardia was an independent determinant of NT-proBNP elevation (P < 0.05) in septic patients, but not in nonseptic patients. Tachycardia was significantly and independently associated with NT-proBNP elevation and lower survival rate in septic patients, although no association was observed in nonseptic patients. Increased NT-proBNP in sepsis with tachycardia might predict poor outcomes in ICU.

Promising results from cyclophosphamide based immunosuppression therapy of thrombotic thrombocytopenic purpura.

Thrombotic thrombocytopenic purpura is a rare disease. Therefore, the small numbers of patients in trials results in statistically weak evidence supporting treatment guidelines. The aetiology of this disease is based on a deficiency of metalloproteinase 13 (ADAMTS-13), which leads to the creation of von Willebrand factor polymers and platelet microthrombosis in small vessels. Treatment relies on plasma exchange. Immunosuppression based on cyclophosphamide is not recommended in current guidelines. The aim of this study was to assess the early and long-term effects of treatment, and to evaluate therapy prognostic factors. This was a retrospective study of 10 patients hospitalized 14 times due to new or recurrent onset of TTP. Currently recommended treatment was used in all cases, including total plasma exchange (range 0.5-2 plasma volume). The volume of exchange plasma was 24.6 L (mean) over 20 days (median). All patients received glucocorticosteroids. Immuno-uppression (based on cyclophosphamide in 7 cases) was utilized in 70% of patients (9 patients). Of all 11 patients 9 (70%) survived and achieved remission. Fifty percent of patients stayed in long-lasting remission. Average follow-up time was 36 months (median 14.5 months, range 10 days to 108 months). Factors improving the chance of remission were: age below 55 years (p < 0.05), no tachycardia on admission to hospital (p < 0.001), and immunosuppression based on cyclophosphamide (p = 0.032). Presence of tachycardia on TTP onset and age above 55 years reduce the survival and remission rate. Remission from TTP is suggested to be caused by immunosuppression based on cyclophosphamide.

Gender and tachycardia: independent modulation of platelet reactivity in patients with atrial fibrillation.

BackgroundFemale patients with atrial fibrillation (AF) experience increased risk of thromboembolism compared to males, an observation that is reflected by its inclusion in the CHA2DS2VASc score. New onset AF (often associated with tachycardia) also confers upon patients increased thromboembolic risk. The mechanisms underlying this risk are uncertain, but new onset AF is associated with profound impairment of platelet nitric oxide (NO) signalling. Given that cardiovascular responses to catecholamines are gender-dependent, and that the presence of tachycardia in new onset AF may represent a response to catecholaminergic stimulation, we explored the potential impact of gender and tachycardia on platelet aggregation and NO signalling.MethodsInteractions were sought in 87 AF patients between the extent of adenosine diphosphate (ADP)-induced platelet aggregation, the anti-aggregatory effects of the NO donor, sodium nitroprusside, gender, and admission heart rate. The potential impact of platelet expression of thioredoxin-interacting protein (Txnip) was also evaluated.ResultsAnalysis of covariance confirmed the presence of physiological antagonism between platelet ADP and NO responses [F (1, 74) = 12.212, P < 0.01], while female sex correlated with impaired NO responses independent of platelet aggregability [F (2, 74) = 8.313, P < 0.01]. Admission heart rate correlated directly with platelet aggregation (r = 0.235, P < 0.05), and inversely with NO response (r = −0.331, P < 0.01). Txnip expression varied neither with gender nor with heart rate.ConclusionsThese results indicate that gender and heart rate are independent determinants of platelet function. Prospective studies of the putative benefit of reversal of tachycardia on restoration of normal platelet function are therefore a priority.