Prolonged Hospital Research Articles

6431 Comparison of Diagnostic Scoring Systems for Myxedema Coma

Abstract Disclosure: K.S. Wei: None. A. Joyo: None. A.N. Lim: None. T.E. Angell: None. Introduction: Myxedema coma (MC) is a rare condition of severe hypothyroidism with high mortality. Diagnostic scoring systems exist, such as criteria by Popoveniuc et al. (2014) and Chiong et al. (2015), which both include categories of: “highly likely MC” (hlMC), “suggestive of MC” (sMC), and “unlikely MC” (uMC). Because few data support their clinical utility, we performed an analysis comparing these diagnostic criteria and associations with mortality and hospital measures. Methods: Patients with MC were included from a retrospective cohort of hospitalized adult patients with TSH greater than or equal to 10 mIU/L and free thyroxine (fT4) below the lower reference limit. Initial clinical diagnosis of MC was generally based on: hypothyroidism, precipitating illness, hypothermia, and altered mentation. Data collection included patient characteristics, mortality, ICU admission, and hospital length of stay (LOS). Patients were post-hoc categorized based on criteria of Popoveniuc and Chiong. Results: Of 386 initial patients, 25 patients had a clinical diagnosis of MC (median age = 60.1 years [IQR: 53.6-70.0]; 10/25 [40%] female). Median TSH was 58 mIU/L (IQR: 33.8-93.3) and median fT4 was 0.48 ng/dL (IQR: 0.16-0.68). All patients received IV levothyroxine and supportive care. Using Popoveniuc, 20/25 (80%) patients were hlMC and 5/25 (20%) were sMC. In contrast, using Chiong, 11/25 (44%) were hlMC, while 14/25 (56%) were sMC. No patient was considered uMC by either system. 10/25 (40%) patients were hlMC in both systems. 10/25 (40%) were hlMC in Popoveniuc but not Chiong, while only 1/25 (4%) was hlMC in Chiong but not Popoveniuc. Finally, 4/25 (16%) were not hlMC in either system. Mortality occurred in 3/25 (12%) patients, 2 of which were hlMC in Popoveniuc but not Chiong. There was a trend toward longer median hospital LOS in patients identified as hlMC vs not hlMC using Popoveniuc (11 days [IQR: 5.3-37.0] vs. 3.0 days [IQR: 2.0-17.5], p=0.07) but no statistically significant differences in hospital LOS were noted. There were no significant differences in ICU admission or LOS. Conclusion: Existing diagnostic scoring criteria of MC identified most patients but differed in their categorizations. Some cases of clinically diagnosed MC were not identified as hlMC by either scoring criteria. Criteria by Popoveniuc et al. appears to better capture patients most at risk for mortality and prolonged hospitalization. Presentation: 6/2/2024

12620 Developing Hospital Protocols For Managing Patients With Hypertriglyceridemia-induced Acute Pancreatitis In Diabetic Ketoacidosis Hospitalizations

Abstract Disclosure: U. Agbedia-ejughemre: None. Methods: We queried the combined 2017-2020 nationwide inpatient sample database for all adult hospitalizations for DKA with and without HTG-AP using the ICD-10 revision codes. Baseline characteristics were compared between DKA hospitalizations with and without HTG-AP using Pearson’s χ2 tests and Student’s t-test for categorical and continuous variables. Study endpoints were the incidence, predictors, and outcomes of HTG-AP, including mortality, hospitalization duration, mean hospital costs, and acute in-hospital complications (sepsis, ARDS, and acute renal failure). Predictors of HTG-AP were assessed using stepwise multivariable logistic regression analysis. Illness severity, baseline risk of mortality, and comorbidity burden were adjusted using APR-DRG metrics and CCI. Prolonged hospitalization was defined as the length of hospital stay in the top decile of hospital stay for all hospitalizations in the study. Results: We analyzed 630,435 hospitalizations for DKA. The study cohort was 51.4% male, 57.6% white Americans and 26.1% Blacks, with a mean age of 40 (SD, 16.2) years. Incidence of HTG-AP was 2.1% (13,445). Hospitalizations with HTG-AP were older (mean age: 44 vs. 40 years; P<0.001) and had greater comorbidity (CCI score of 2: 38.7 vs. 33.8; P<0.001) compared with DKA hospitalizations without HTG-AP. While DKA hospitalizations showed an uptrend, increasing from 105,769 to 199,429 hospitalizations (Average annual percent change [AAPC]: 27.04%; P=0.029), the incidence of HTG-AP showed a downtrend from 2650 (2.5%) to 4085 (2.0%) (P=0.006). Predictors of HTG-AP included Hispanic (aOR: 2.45; 95% CI: 1.95-3.07; P<0.001) or Asian race (aOR: 2.48; 95% CI: 1.37-4.48; P=0.003), private insurance (aOR: 1.57; 95% CI: 1.10-2.25; P=0.013), self-pay (aOR: 2.2; 95% CI: 1.49-3.27; P<0.001), APR-DRG moderate risk of mortality (aOR: 1.52; 1.21-1.92; P<0.001), APR-DRG major loss of function (aOR: 1.46; 95% CI: 1.31-1.69; P<0.001), dyslipidemia (aOR: 1.87; 95% CI: 1.47-2.38; P<0.001), hypertension (aOR: 1.39; 95% CI: 1.13-1.72; P=0.002), obesity (aOR: 3.09; 95% CI: 2.42-3.96; P<0.001), obstructive sleep apnea (aOR: 2.05; 95% CI: 1.35-3.10; P=0.001), chronic liver disease (aOR: 9.44; 95% CI: 6.61-13.48; P<0.001), old MI (aOR: 2.11; 95% CI: 1.02-4.38; P=0.045), and COPD (aOR: 2.31; 95% CI: 1.47-3.64; P<0.001). DKA hospitalizations with HTG-AP were correlated with higher risk of septicemia (aOR: 1.20; 95% CI: 1.05-1.69; P=0.029), ARDS (aOR: 1.24; 95% CI; 1.04-2.07; P=0.004), and resource use, including prolonged hospitalization (26.3% vs. 11.1%; P<0.001), and higher mean hospital costs ($57,773 vs. $32,692; P<0.001). Conclusion: HTG-AP was linked to worse outcomes, excluding mortality, in hospital admissions for DKA. There is a need for enhanced diagnostic guidelines and protocols targeting this subgroup of patients could improve outcomes. Presentation: 6/2/2024

8165 A Case Of Rhabdomyolysis-Induced Hypocalcemia And Hypercalcemia

Abstract Disclosure: A. Desai: None. A.L. Izzi: None. B. Flores Chang: None. A. Sajan: None. Introduction: Rhabdomyolysis is a syndrome characterized by muscle breakdown and the release of intracellular muscle contents into circulation. It is associated with electrolyte abnormalities and acute renal failure that can lead to prolonged hospitalization. We report a case of persistent hypercalcemia from recovery of acute renal failure and severe rhabdomyolysis. Case Description: A 47-year-old man with past medical history of polysubstance use initially presented with opiate-induced acute encephalopathy and respiratory failure. He developed severe rhabdomyolysis during the hospital course leading to acute renal failure requiring hemodialysis with hypocalcemia. The initial labs showed corrected calcium 6.2 mg/dL [9.2-11.0], ionized calcium 3.48 mg/dL [4.65-5.28], creatinine kinase level was >72,600 U/L [38-174], BUN 110 mg/dL [8-23], creatinine 7.8 mg/dL [0.6-1.2], and GFR 7 ml/min/BSA. His renal function improved over the next several days in the hospital. The serum creatinine improved to 4 mg/dL, BUN 49 mg/dL and GFR 20 ml/min/BSA respectively after couple of intermittent dialysis sessions. Six days after the last hemodialysis session, patient developed severe hypercalcemia with corrected calcium values ranging from 13.5 to 14.7 mg/dL and ionized calcium 7.41 mg/dL. Labs showed PTH 10 pg/mL [15-65], 1,25-dihydroxyvitamin D <10.0 pg/dL [21-65] and 25-OH Vitamin D levels 15.3 ng/ mL [30-96], which is consistent non-PTH medicated hypercalcemia. The 24-hour urine calcium was 696 mg [0-300 mg/24 hrs, 2900 cc]. PTH-related peptide was not collected. He was treated with intermittent doses of calcitonin and a single dose of pamidronate when the calcium levels were >13 mg/dL. Hypercalcemia resolved in eleven days after initially noted to have hypercalcemia. The corrected calcium improved to 10.1 mg/dL on the day of discharge. Discussion:Severe rhabdomyolysis is associated with acute kidney injury. The initial hypocalcemic phase during rhabdomyolysis is due to entry of calcium into damaged myocytes and deposition of calcium salts in damaged muscle. This is seen in the oliguric phase of acute kidney injury. After the recovery of rhabdomyolysis, the polyuric phase persists during renal recovery. During this time, up to one third of patients may have rebound hypercalcemia due to massive muscle calcium release. As per case reports the hypercalcemia phase lasts from 8 days to 3.5 months. In our case, the patient initially developed hypocalcemia in the oliguric phase of acute kidney injury from rhabdomyolysis. He developed hypercalcemia in the polyuric phase of renal recovery. The hypercalcemia resolved with intravenous hydration, calcitonin and pamidronate. Rhabdomyolysis is a rare cause for both hypocalcemia and hypercalcemia. Our case highlights the biphasic calcium response associated with rhabdomyolysis in the setting of renal impairment and recovery. Presentation: 6/1/2024

7315 Does Protein Energy Malnutrition Impact Outcomes in Hypothyroidism? A National Inpatient Sample Analysis

Abstract Disclosure: S. Karki: None. B. Neupane: None. S. Neupane: None. A. Bhandari: None. U. Farooq: None. K. Rajamani: None. Introduction: Hypothyroidism poses a significant public health burden in the United States, affecting approximately 4.6 % of the population. Various nutritional deficiencies can adversely affect thyroid function, potentially leading to thyroid disorders. Despite this, there is limited literature exploring the influence of Protein Energy Malnutrition (PEM) on outcomes in hypothyroidism. Objective of our study:This investigation aims to assess the impact of PEM on the healthcare burden and costs associated with hospitalizations in patients with and without hypothyroidism. Methods: A retrospective study was conducted using the National Inpatient Sample (NIS) data from 2017 to 2020. Among the 14,418,310 patients aged 18 and above with a primary diagnosis of hypothyroidism, two groups were formed based on the presence or absence of PEM, determined by International Classification of Diseases (ICD-10) codes. Statistical analysis was performed using STATA, employing the student’s t-test and Fischer’s exact test for continuous variables and proportions, respectively. Adjusted odds ratio was calculated through multivariate regression analysis. The primary outcome was mortality, with secondary outcomes encompassing mean length of stay (LOS), total cost, and various medical complications. Trends in mortality, LOS and total cost were compared for both groups. Results: Out of 14,418,310 hypothyroid patients, 7.06% (1,1018,310) were diagnosed with PEM. Patients with PEM exhibited higher mortality (6.80 % vs. 2.39 %, p<0.001), extended mean length of hospital stay (8.88 days vs. 4.85 days, p<0.001), and higher increased total hospitalization costs ($96,443 vs. $58,262, p<0.001). Furthermore, patients with PEM had elevated rates of various complications, including acute coronary syndrome, septic shock, pulmonary edema, mechanical ventilation, acute respiratory failure, acute respiratory distress syndrome, acute kidney injury, and cerebrovascular accident. Increasing trends in mortality, length of stay, and total cost of hospitalization were observed in hypothyroid patients with PEM. A similar upward trend was noted in hypothyroid patients without PEM. Conclusion: Our study underscores that the presence of PEM in hypothyroid patients substantially increases the healthcare burden, which is reflected in elevated mortality rates, prolonged hospital stays, higher total costs, and a range of adverse outcomes. Screening of PEM in hypothyroid patients is recommended, and early nutritional interventions, possibly involving dieticians, may mitigate these adverse effects. Further research is warranted to explore the association between PEM and hypothyroidism, as well as strategies for early identification and intervention. Presentation: 6/1/2024

12609 Navigating The Therapeutic Challenge Of Post-surgical Hypoparathyroidism And Refractory Hypocalcemia

Abstract Disclosure: D. Fawcett: None. A. Domingo: None. Introduction: Post-surgical hypoparathyroidism poses a challenge due to calcium metabolism disturbances, ranging from mild to life-threatening complications. Despite advancements, vigilant monitoring and tailored interventions are vital for optimizing outcomes. Refractory hypocalcemia, resistant to standard therapies, underscores the need for specialized care to prevent prolonged hospitalization and morbidity. Case description: A 68-year-old woman with a history of Graves' disease and parathyroid carcinoma underwent total thyroidectomy and parathyroidectomy in January 2024. She presented to the emergency department for the second time with a recurrence of bilateral hand and perioral paresthesias, along with numbness, tingling, and weakness throughout her body. Notably, she had a prior hospital admission with similar symptoms and was discharged on calcium carbonate, magnesium, calcitriol, and vitamin D3. Vital signs were not provided. Initial laboratory workup revealed a calcium level of 4.3, with corrected calcium at 5.8, and magnesium levels at 1.8, supplemented with magnesium oxide. A 24-hour urine calcium test, vitamin D, and malabsorptive workup for celiac disease were unremarkable. Immunoglobulin A was low; however, tissue transglutaminase IgA and anti-gliadin antibodies were negative. An electrocardiogram showed a normal sinus rhythm with QT prolongation to 570 ms. Despite resuming her home regimen, her calcium level remained low, prompting initiation of calcium infusion. Consultations with endocrinology and nephrology were made, necessitating close monitoring and uptitration of calcium and vitamin D supplements for achievement and maintenance of low normal calcium levels. High doses of 3g TID of calcium and calcitriol 2mcg PO TID allowed for symptom control and discharge with outpatient follow-up with endocrinology and nephrology. Conclusion: Supplemental therapy with calcium and vitamin D analogues is standard for managing post-surgical hypoparathyroidism. Early identification and adequate management prevent hypocalcemia-related complications, including tetany, seizures, and cardiovascular anomalies such as QTc prolongation, as seen in our patient, which can result in torsade de pointes. Multidisciplinary care alongside nephrology was paramount. Serum calcium should be maintained in the low normal range, and 24-hour urine calcium excretion should also be closely monitored. Daily hydrochlorothiazide can be used to prevent hypercalciuria. In recurrent cases, as in our patient, titration of calcium and vitamin D analogues is imperative. Long-term consequences, including renal dysfunction, osteoporosis, and increased cardiovascular risk, underscore the necessity for timely diagnosis and management. Presentation: 6/2/2024

Piloting a Collaborative Psychosocial Intervention for Hospitalized Infants and Their Caregivers

Abstract The diagnosis of cancer or cardiac abnormalities in infants is often associated with prolonged hospitalization, which can negatively impact caregiver-child bonding due to separation, medical stressors, and changes in the caregiving role. The purpose of this study was to pilot an interdisciplinary psychosocial intervention including songwriting, an expressive journal and activity book, and a bonding assessment. Interventions were facilitated by a board-certified music therapist and Certified Child Life Specialist. A total of 15 families completed the pretest, four intervention sessions, and post intervention test. Quantitative data suggest increased caregiver–child bonding and increased caregiver confidence. Caregivers reported high levels of satisfaction with the intervention in qualitative responses. In summary, results from this pilot study lay the groundwork for a future larger-scale evaluation.

Antibiotic tolerance among clinical isolates: mechanisms, detection, prevalence, and significance.

SUMMARYAntibiotic treatment failures in the absence of resistance are not uncommon. Recently, attention has grown around the phenomenon of antibiotic tolerance, an underappreciated contributor to recalcitrant infections first detected in the 1970s. Tolerance describes the ability of a bacterial population to survive transient exposure to an otherwise lethal concentration of antibiotic without exhibiting resistance. With advances in genomics, we are gaining a better understanding of the molecular mechanisms behind tolerance, and several studies have sought to examine the clinical prevalence of tolerance. Attempts have also been made to assess the clinical significance of tolerance through in vivo infection models and prospective/retrospective clinical studies. Here, we review the data available on the molecular mechanisms, detection, prevalence, and clinical significance of genotypic tolerance that span ~50 years. We discuss the need for standardized methodology and interpretation criteria for tolerance detection and the impact that methodological inconsistencies have on our ability to accurately assess the scale of the problem. In terms of the clinical significance of tolerance, studies suggest that tolerance contributes to worse outcomes for patients (e.g., higher mortality, prolonged hospitalization), but historical data from animal models are varied. Furthermore, we lack the necessary information to effectively treat tolerant infections. Overall, while the tolerance field is gaining much-needed traction, the underlying clinical significance of tolerance that underpins all tolerance research is still far from clear and requires attention.

Postoperative challenges addressed through nursing care of patients receiving lower extremity tumor prosthesis

BackgroundPatients with primary Bone Sarcoma and Giant Cell Tumors in the lower extremities often require major surgery involving tumor prostheses. The postoperative course for this patient group can be complex and influenced by various factors and challenges that demand careful nursing care. This study aims to identify challenges related to the nursing care of individuals with primary bone tumors following surgery for tumor prostheses in the lower extremities.MethodsA retrospective cohort study of 15 patients treated at Rigshospitalet, Copenhagen, Denmark, between November 5. 2016, and April 1. 2020 was conducted by medical record review, focusing on challenges related to postoperative nursing care. All patients with the surgery code “Bone Excision” were identified within the surgery booking system and screened for eligibility.ResultsPatients experienced postoperative challenges such as severe pain, prolonged time to mobilization (mean: 4 days), and defecation (mean: 5 days). The mean length of stay at the Rigshospitalet was 13 days. Furthermore, eleven patients (73%) reported disrupted sleep and nausea.ConclusionPatients undergoing tumor prosthesis surgery in the lower extremities face considerable postoperative challenges that contribute to a prolonged hospital stay. These challenges, including severe pain, delayed mobilization, and gastrointestinal issues, significantly impact recovery. The findings highlight the urgent need for targeted nursing interventions to address these issues effectively. Enhanced pain management protocols, early mobilization strategies, and comprehensive postoperative care plans are essential to improve patient outcomes and reduce the length of hospital stays. Addressing these challenges through dedicated nursing care is crucial for optimizing the recovery process for patients receiving lower extremity tumor prostheses.

Effect of Preoperative Geriatric Nutritional Risk Index on Prognosis in Patients after Surgery for Lower Gastrointestinal Perforation

Introduction: Geriatric Nutritional Risk Index (GNRI) is a reliable index derived from serum albumin levels, height, and weight. Although various prognostic factors have been studied, the effect of preoperative nutritional status on surgical outcomes remains unexplored. This study aimed to evaluate the efficacy of the GNRI in predicting postoperative outcomes of lower gastrointestinal perforation. Methods: Eighty patients treated at our institution between January 2016 and December 2022 were retrospectively analyzed. This study primarily focused on the correlation between preoperative GNRI and two key outcomes: postoperative hospital stay duration and 1-year mortality rate. Results: Our findings revealed a significant association between low GNRI scores and increased 1-year mortality (odd ratio 4.0, 95% confidence interval [CI] 1.1–16, p = 0.025). Kaplan-Meier analysis and log-rank test showed that patients in the low GNRI group had markedly poorer overall survival rates than those in the high GNRI group (12-month survival rate 0.88 [95% CI: 0.75–0.95] vs. 0.65 [95% CI: 0.47–0.78]; p = 0.018). Additionally, both univariate and multivariate analyses indicated that lower GNRI scores were associated with prolonged hospital stays. Conclusion: We showed that a low GNRI score was associated with high mortality and prolonged hospital stay after emergency surgery for lower gastrointestinal perforation.

Predictive Factors for Onset of Moderate-to-Severe Disability Following Hospital Discharge Due to Rib Fractures.

According to previous studies, a prolonged hospital stay, along with the patient's clinical features, can lead to the onset of disability. This study aimed to identify predictive factors of moderate-to-severe disability following hospital discharge in rib fracture patients. We conducted a retrospective study with hospitalized adult patients with rib fractures who received conservative treatment. Patients' clinical profiles and characteristics were collected from their clinical histories and healthcare professional records. Overall, patients exhibited a 44% rate of moderate-to-severe disability after a six-day hospital stay. The incidence of patients with a prolonged hospital stay who showed disabilities was associated with male sex (HR 0.73, p < 0.001), presence of first rib fracture (HR 1.78, p = 0.047), presence of flail chest (HR 1.29, p = 0.046), severity of lung injury (HR 1.65, p < 0.001), and functional status (HR 1.37, p < 0.001). Moderate-to-severe disability in patients with rib fractures may depend on factors such as sex, functionality, severity of lung injury, and presence of first rib fracture and flail chest during a prolonged hospital stay.

Unraveling Pneumomediastinum in COVID-19 Patients: Insights from a High-Volume-Center Case-Control Study.

Pneumomediastinum (PNM) is a severe complication in COVID-19 patients, potentially exacerbating morbidity and requiring heightened clinical attention. This study aims to identify risk factors, clinical characteristics, and outcomes associated with PNM in COVID-19 patients hospitalized for respiratory failure in our institution. Among 4513 patients admitted in our institution and testing positive for COVID-19 infection during the peak of the COVID-19 pandemic in Italy (1 March 2020 to 31 July 2020), we conducted a single-center, retrospective case-control study focusing our analysis on those with severe disease (respiratory failure). The cohort included a total of 65 patients (32 with PNM and 33 without PNM in the same period). Data were retrospectively collected from hospital records, including demographics, comorbidities, smoking history, clinical and laboratory findings, and imaging results. Statistical analyses were performed using Fisher's exact test and Student's t-test, with significance set at α = 0.05. Patients with PNM were significantly younger (54.9 ± 18.5 vs. 65.4 ± 14.3 years, p = 0.0214) and exhibited higher inflammatory markers, particularly white blood cells count (WBC) at admission (11.4 ± 5.4 vs. 6.5 ± 4.1, p < 0.0001). Although smoking status, body mass index (BMI), and major comorbidities did not differ significantly between groups, COPD was more prevalent in the PNM group (46.9% vs. 15.1%, p = 0.0148). Radiologically, ground-glass opacities (GGOs) and consolidations were more frequent in PNM patients (93.7% vs. 51.5%, p = 0.0002; 78.1% vs. 42.2%, p = 0.0051, respectively). PNM was associated with longer hospital stays (28.5 ± 14.9 vs. 12.0 ± 7.2 days, p < 0.0001) and a higher need for invasive mechanical ventilation (53.1% vs. 30.3%, p = 0.0619). However, mortality rates did not differ significantly between groups. PNM in patients with severe COVID-19 infection is associated with younger age, elevated inflammatory markers, and extensive lung involvement, contributing to increased morbidity and prolonged hospitalization. Early detection and tailored management strategies, including optimized respiratory support and aggressive anti-inflammatory therapies, are crucial in mitigating the adverse outcomes associated with PNM. Further research is needed to validate these findings and improve clinical protocols for managing this complication.

Discovery of novel protective agents for infection-related delirium through bispectral electroencephalography

Delirium is a multifactorial medical condition of waxing and waning impairment across various domains of mental functioning over time. Importantly, delirium is also one of the greatest risk factors for prolonged hospitalization, morbidity, and mortality. Studying this important condition is challenging due to the difficulty in both objective diagnosis in patients and validation of laboratory models. As a result, there is a lack of protective treatments for delirium. Our recent studies report the efficacy of bispectral electroencephalography (BSEEG) in diagnosing delirium in patients and predicting patient outcomes, advancing the concept that this simple measure could represent an additional vital sign for patients. Here, we applied BSEEG to characterize and validate a novel lipopolysaccharide (LPS) mouse model of infection-related delirium. We then applied this model to evaluate the protective efficacy of three putative therapeutic agents: the conventional antipsychotic medication haloperidol, the neuroprotective compound P7C3-A20, and the antibiotic minocycline. Aged mice were more susceptible than young mice to LPS-induced aberration in BSEEG, reminiscent of the greater vulnerability of older adults to delirium. In both young and old mice, P7C3-A20 and minocycline administration prevented LPS-induced BSEEG abnormality. By contrast, haloperidol did not. P7C3-A20 and minocycline have been shown to limit different aspects of LPS toxicity, and our data offers proof of principle that these agents might help protect patients from developing infection-related delirium. Thus, utilization of BSEEG in a mouse model for infection-related delirium can identify putative therapeutic agents for applications in patient clinical trials.

Association between length of hospital stay before and after surgery and nutritional risk according to NRE-2017 - A secondary analysis of a cohort study.

to evaluate the predictive ability of the Nutritional Risk Emergency - 2017 (NRE) to predict prolonged length of stay, ICU admission intra-mortality and readmission, severe postoperative complications. a prospective cohort was conducted with surgical patients admitted in a public tertiary hospital. The NRE-2017 tool was applied for detecting malnutrition risk in hospitalized patients. Surgical complications were assessed by Clavien-Dindo. Patients were followed during hospitalization to identify length of stay as well as stay after surgery in the Intensive Care Unit (ICU). Regression analysis was performed to assess the association between risk of malnutrition and clinical outcomes. we included 162 elective surgery patients; 79 patients were identified with nutritional risk using the NRE-2017 (≥ 1.5) tool and 83 without nutritional risk. Patients with nutritional risk were at higher risk of prolonged hospitalization [18 (10-36) days vs. 13 (7-23 days); p: 0.006] and ICU hospitalization [6 (2-14 days vs. 3.5 (1-7 days; p: 0.020]. There was an association between surgical complications and nutritional risk independently, but the significance was lost when adjusting the analysis. There was no association with mortality and readmission in this sample of patients. the NRE-2017 tool was associated with hospital stay in those patients at nutritional risk, however there was no association with mortality and readmission.

Establishment of a platform based on dual RPA combined with CRISPR/Cas12a for the detection of Klebsiella pneumoniae and its KPC resistance gene.

Carbapenem resistant Klebsiella pneumoniae (CRKP) can cause serious hospital- and community-acquired infections. Treatment for CRKP infection is limited, resulting in prolonged hospitalization and high consultation costs. The KPC genotype has the highest detection rate of CRKP, and its mortality rate is higher than the overall mortality rate of CRKP. However, traditional testing methods have disadvantages such as long time and reliance on complex and sophisticated instruments, which are not conducive to rapid screening for CRKP. Therefore, this study aimed to establish a detection platform for early screening of CRKP so that effective antimicrobial therapy could be administered promptly to prevent the widespread spread of CRKP. We integrated dual RPA with CRISPR/Cas12a to establish a dual platform for the detection of K. pneumoniae (Kp) rcsA-specific gene and KPC resistance gene. Four result reading methods were established, including fluorescence detection (FD), blue light irradiation detection (BLID), ultraviolet irradiation detection (UID), and lateral flow test strips (LFTS). For the rcsA gene, the LOD of FD was 1 × 10pg/μL, and the other three methods could detect 1 × 101pg/μL of bacterial DNA. As for the KPC gene, four resultant readout methods were able to detect 1 × 102pg/μL of bacterial DNA. In 59 clinical strains tested, the dual RPA-CRISPR/Cas12a detection of the rcsA had 100% sensitivity, specificity, and accuracy compared to the culture method. Compared with the drug sensitivity test, the sensitivity of dual RPA-CRISPR/Cas12a detection for the KPC was 85.71%, the specificity was 100%, and the accuracy was 94.92%. In summary, our dual RPA-CRISPR/Cas12a platform proved to be rapid, precise, and convenient for the efficient detection of Kp with KPC in the laboratory or at the point of care.

Implementation of a Multidisciplinary Enhanced Recovery After Surgery (ERAS) Program for Cytoreductive Surgery (CRS) With Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) can be associated with prolonged hospital stays. A novel Enhanced Recovery After Surgery (ERAS) based on ERAS Society guidelines was designed and implemented. The primary outcome was ERAS compliance. Secondary outcomes included length of stay (LOS) and postoperative complications. A retrospective study on patients who underwent CRS/HIPEC between 2018 and 2022, with ERAS implementation in 2022. Health records were reviewed. Statistical analysis included descriptive statistics, Wilcoxon tests, Student t-test, and χ2 and binomial negative regression. Health Ethics Research Board approval was obtained. Eighty patients underwent CRS/HIPEC: 59 in the pre-ERAS group and 21 in the post-ERAS group. Groups were similar in age, comorbidities, and Peritoneal Carcinomatosis Index. ERAS compliance increased from 32.8% to 70.8% (p < 0.001). Median LOS decreased from 14 to 9 days (p < 0.001). Comparing pre-ERAS to post-ERAS showed no significant difference in the major morbidity rate (13.6% vs. 9.5%) or 30-day readmission (9.4% vs. 4.8%) and no mortalities. Controlling for patient characteristics, the mean LOS decreased by 6.94 days (p < 0.001). Implementation of an ERAS CRS/HIPEC program is safe and allows for improved compliance to ERAS protocols and a significant reduction in LOS.

A-282 Purpura fulminans caused by Haemophilus influenzae: case report of unusual etiology

Abstract Background Fulminant purpura is a clinical syndrome characterized by a purplish, ischemic-looking skin rash, commonly accompanied by systemic symptoms ranging from acute febrile syndrome to septic shock. Due to high lethality of possible infectious etiologies, immediate recognition and early initiation of empirical antimicrobial therapy are crucial to ensure better outcomes. Interdisciplinary collaboration among healthcare teams, infectious disease specialists and microbiologists is essential to ensure accurate and early microbiological diagnosis. Methods This work aims to report a case of Haemophilus influenzae-induced purpura fulminans that occurred in Fortaleza-CE, a coastal city in northeastern Brazil, highlighting clinical recognition and microbiological identification, based on review of medical records. Results Case report A 59-year-old man, originally from Germany, was on vacation in Brazil. He presented to emergency medical service with an acute onset of fever, abdominal pain and diarrhea, progressing to decreased level of consciousness and purplish ischemic skin lesions with hemorrhagic bullae on trunk and extremities (Figure 1), with no history of trauma. Upon admission, the blood exams showed bicytopenia - 1900 leukocytes/µL (86% segmented) and 51,000 platelets/µL - and very high C-reactive protein (41.58 mg/dL). Although empirical antimicrobial therapy with vancomycin and piperacillin-tazobactam was initiated, patient progressed to septic shock, hepatic dysfunction, requiring mechanical ventilation, vasopressor support, and renal replacement therapy. Blood cultures from hospital admission were positive after about 14 hours and allowed isolation of small and translucent colonies in Chocolate PVX plate Agar (BioMerieux™). Maldi tof analysis by Vitek MS identified H. influenzae (99.9 % accuracy). Despite prolonged hospitalization due to multiple organ dysfunctions, patient had a positive outcome. Conclusions This case illustrates the importance of immediate recognition of the syndrome coupled with assertive empirical treatment and early microbiological diagnosis for a positive clinical outcome, even in a severe presentation. Multiprofessional approach is essential for accurate and early diagnosis.

Emergent Ablation for VentricularTachycardia: Predictors of Prolonged Hospitalization and Mortality.

Patients with ventricular tachycardia (VT) frequently present in unstable VT and are subject to urgent/high-risk ablation procedures. Clinical predictors of prolonged hospitalization and mortality are needed for optimal management of these patients. This study seeks to identify factors associated with prolonged hospitalization and mortality in emergent unplanned VT ablation procedures. Fifty consecutive patients hospitalized emergently for VT with structural heart disease who underwent catheter ablation were prospectively followed up for outcomes and complications. Of the 50 patients (mean ± SD age 67.6 ± 12.8 years), 86.0% were male, 62.0% had ischemic cardiomyopathy, and their median left ventricular ejection fraction was 28.5%. Hospital stay<7days (median 3days) occurred in 28 (56.0%) patients (Group 1) and >7days (median 10days) or death<7days occurred in 22 (44.0%) patients (Group 2). PAINESD score and left ventricular ejection fraction were similar between the groups. Compared with Group 1, Group 2 had significantly worse NYHA functional class III or higher (25.0% vs 63.6%; P=0.006), electrical storm (46.4% vs 77.3%; P=0.027), and prior failed VT ablation (35.7% vs 68.2%; P=0.023). Multivariable analysis showed that NYHA functional class III or higher and prior failed VT ablation were predictive of prolonged hospital stay. After ablation, compared with Group 1, Group 2 had worse heart failure (10.7% vs 54.5%; P=0.001), VT recurrences (3.6% vs 68.2%; P< 0.001), and 7 deaths within 30days. Patients undergoing emergent VT ablation are at high risk for prolonged hospital stay, which is predicted by NYHA functional class III or higher and a prior failed ablation. Early VT recurrences and worsening heart failure contribute to prolonged hospitalization and a high 30-day mortality.

Institutional insights into engraftment syndrome: A cohort study on allogeneic transplantation outcomes

BackgroundEngraftment syndrome (ES) is a clinical condition that may occur during neutrophil recovery after hematopoietic stem cell transplantation (HSCT). Diagnosis is challenging because of the varying diagnostic criteria and the controversial relationship between ES and graft-versus-host disease (GVHD). ObjectiveTo investigate the incidence of ES and its relationship with GVHD in patients undergoing allogeneic HSCT at our institution. Study designThis retrospective cohort study included patients who underwent allogeneic HSCT (alloHSCT) at a Brazilian tertiary hospital between January 2015 and December 2016. ES was diagnosed based on the Spitzer or Maiolino criteria. ResultsOf the 79 patients who underwent alloHSCT, three presented with graft failure and were excluded from the analysis. The incidence of ES, according to both Spitzer's and Maiolino's criteria, was 16.5 % and 9.8 % in patients older than 14 years and 28.6 % in children, respectively, with a significant correlation (P < 0.05, Pearson's chi-squared test). ES was associated with prolonged hospitalization (P = 0.01; Student's t-test). No correlation was observed between acute GVHD and ES. There was a positive correlation between the use of broad-spectrum antibiotics against multidrug-resistant bacteria and ES development (P < 0.05, Pearson's chi-squared test). ConclusionsThe general incidence of ES in this cohort was consistent with that reported in the literature. Remarkably, ES was associated with prolonged hospitalization (14 days longer than in patients without ES). Moreover, patients who used antibiotics against multidrug-resistant bacteria had a higher incidence of ES.

Clinical Characteristics of the Extensively Prolonged Hospitalization: A Retrospective Analysis at a Large Tertiary Medical Center

Background: Prolonged hospitalizations have contributed to the concentration of American healthcare spending in a small subset of patients. Research related to such events is scarce. Methods: The authors performed a retrospective analysis of hospitalizations at a tertiary care center between 2012 and 2022. Extensively prolonged hospitalization (EPH) was defined as an uninterrupted hospital stay of at least 183 days. Patient data, including past medical history, hospital complications, barriers to discharge, and long-term outcomes were collected. Results: Among 393,474 unique adult hospitalizations, mean length of stay was 5.49 days. There were 42 EPH, making up 0.01% of all admissions and 0.69% of hospital days. Patients with EPH were 62% male and had a median age of 58.5 years old. EPH featured a mean of 8.88 CTs and 2.12 MRIs. MRSA blood culture positivity was documented in 48% of cases. Mechanical ventilation and gastrostomy tube placement were performed in 88% and 71% of EPH, respectively. In 64% of cases, patients were medically stable for discharge and awaiting post-acute facility bed availability for at least three months. In-hospital death occurred in 31% of cases. Among patients who survived hospitalization, none were able to live independently, and median post-discharge survival was 94 days. At five-year follow-up, 1 patient (2%) was still alive. Conclusions: These findings emphasize the importance of non-medical barriers to discharge in EPH. While larger studies are needed, this study suggests that long-term outcomes in EPH are grim.

The impact of frailty on chemotherapy intolerance in patients with cervical cancer : A longitudinal study

ObjectivesTo explore the potential effects of frailty on chemotherapy intolerance in patients with cervical cancer. MethodsA longitudinal study of patients with cervical cancer undergoing postoperative Adjuvant Chemotherapy(ACT)was conducted at a hospital in Northwest China from July 2020 to December 2021. Baseline frailty was assessed using the Tilburg Frailty Indicator. Chemotherapy intolerance was obtained from electronic medical records during the intervals between each postoperative chemotherapy session. We used Generalized Estimating Equations (GEE) to determine the predictors and cox regression analysis to analyze the impact of frailty on chemotherapy intolerance. ResultsA total of 259 patients with postoperative cervical cancer with a mean age of 52.5 years (SD=10.3) participated in this study. The incidence of chemotherapy intolerance in the frail group at T1, T2, T3 and T4 was 51.6%, 38.9%, 55.6% and 73.7%, respectively. The patients with frailty were more likely to have chemotherapy intolerance (OR=1.495, 95% CI: 1.074-2.080, P<0.05), prolonged hospitalizations (OR=1.577, 95% CI: 1.086-2.291, P<0.05) and unplanned readmissions (OR=2.304, 95% CI: 1.387-3.829, P<0.05) compared to the patients without frailty. Cox regression analysis showed that frailty increased the risk of chemotherapy intolerance by 1.681-fold (HR = 1.681, 95%CI 1.041∼2.713; P<0.05) and unplanned readmissions by 2.812-fold (HR = 2.812, 95%CI 1.521∼5.200; P<0.05). ConclusionsFrailty can lead to an increased risk of chemotherapy intolerance in patients with cervical cancer undergoing postoperative ACT, and patients with frailty are more likely to experience prolonged hospitalizations and unplanned readmissions.