Requiring ICU Admission Research Articles

Immune Dysfunction is Associated with Readmission in Survivors of Sepsis Following Infected Pancreatic Necrosis.

ObjectiveImmunosuppression is common in patients with infected pancreatic necrosis (IPN) and associated with morbidity and mortality. This study aimed to investigate the impact of immune status on mortality and readmission after hospital discharge in patients with IPN-related sepsis.MethodsIn this prospective observational study, eligible adult patients with IPN-related sepsis requiring ICU admission were included. Monocytic human leukocyte antigen DR (mHLA-DR), expression of regulatory T cells (Treg), and neutrophil CD88 (nCD88) were measured on the diagnosis of sepsis, ICU discharge, hospital discharge, and 15, 30, 60 days after hospital discharge. Logistic regression model was used to assess potential risk factors for readmission 60-days within the index discharge.ResultsA total of 53 patients were included, 13 died during hospitalization and one withdrew the consent soon after discharge. Among the survivors, a tendency of immune recovery was observed during the consecutive follow-ups, evidenced by the increased expression of mHLA-DR. Sixteen patients (41.03%) were readmitted within 60 days after the index discharge. In the multivariable regression model, APACHE II score when sepsis was diagnosed >9 and mHLA-DR at discharged <14,591 AB/C were found to be independent risk factors affecting readmission.ConclusionImmunosuppression is common in patients with IPN-related sepsis and can persist until two months after discharge. The compromised mHLA-DR level at discharge was associated with readmission within two months after discharge.

S679 Outcomes of Acute Gastrointestinal Bleeding in Patients With COVID-19: A Case Control Study

Introduction: COVID-19 patients are at high risk of acute gastrointestinal (AGIB) bleeding due to higher use of steroids, mechanical ventilation and use of anti-coagulation. Limited studies are available that evaluated the differences in outcomes of AGIB in COVID-19 patients with non-COVID-19 patients. The purpose of the study was to describe the characteristics and outcomes of COVID-19 positive patients with AGIB compared to matched controls with AGIB without COVID-19. Methods: This was a case control study including patients admitted from March 2020 to February 2021 with the diagnosis of AGIB. Patients were divided into two groups, COVID-19 positive and non-COVID patients. Our primary outcomes were in-hospital or 30 days mortality and length of stay. Secondary outcomes were rate of rebleeding, need for ICU level of care and need for blood transfusion. We performed matching without replacement by age (± 10 years) and sex. Patient’s characteristics are summarized using means and standard deviations or medians and interquartile ranges for continuous variables and frequency counts and percentages for categorical variables. The association between outcomes and AGIB in COVID-19 positive patients was estimated using conditional logistic regression models and odds ratios (OR) and 95% confidence intervals (CI) are reported. SAS. 9.4 was used for analysis. Results: Eighteen COVID-19 positive patients and 54 matched non-COVID-19 patients were included. Mean age was 69.7 years and 66.7% were male. Melena was the most common presentation and there was no significant difference in the hemoglobin on presentation between the two groups. The COVID-19 positive patients less frequently had endoscopies performed (33.3% vs 74.1%, p = 0.0059) and had greater steroid use (83.3% vs 14.8%, p < 0.0001) compared to non-COVID-19 patients. COVID-19 patients were more likely to have had an ICU stay (OR 20.41; 95% CI 2.59, 160.69; p=0.004) and had longer hospital length of stays (OR 1.08; 95% CI 1.03, 1.13; p=0.002). Mortality, readmission within 30 days, need for blood transfusion, and having rebleeding during the admission did not differ for COVID-19 and non-COVID-19 patients. Conclusion: COVID-19 patients with AGIB are more likely to require ICU admission and had longer length of stay. Despite significantly lower rate of endoscopic procedures performed in COVID-19 patients need for blood transfusion, mortality and rebleeding were not significantly different.

SWEET SYNDROME WITH PULMONARY INVOLVEMENT

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sweet syndrome (acute neutrophilic dermatosis) typically presents with cutaneous lesions, fever, and arthralgia. Sweet syndrome with pulmonary involvement is rare and to our knowledge, only 40 cases have been reported in the literature. In this case, we will highlight the clinical and radiographic findings seen in Sweet syndrome with pulmonary involvement. CASE PRESENTATION: A 58-year-old male with past medical history of GERD presented to the ED with worsening SOB and a nonproductive cough. He endorsed recent completion of Levofloxacin therapy for presumed pneumonia. Vital signs were notable for fever of 39º C. Patient was tachypneic and required 3L NC for O2 saturations > 92%. PE revealed decreased LLL sounds as well as erythematous nodules noted on bilateral lower extremities. CBC showed elevated WBC of 18.2. CMP and urinalysis were within normal limits. CT Chest showed bilateral ground glass opacities and minimal pleural effusions. IV Vancomycin and Zosyn were initiated for community acquired pneumonia coverage, however patient continued to spike fevers. Blood and urine cultures remained negative. On day eight of admission, bronchoscopy was performed. BAL and transbronchial biopsy showed extensive neutrophilic infiltrate. Skin biopsy also showed a dense dermal infiltrate composed of neutrophils. Four days after the biopsy, patient developed acute hypoxic respiratory failure requiring ICU admission for intubation. CT Chest showed worsening bilateral pleural effusions and ground glass opacities. Intravenous methylprednisolone was started with rapid improvement in patient's respiratory and cutaneous symptoms. Patient was eventually transitioned to oral prednisone. DISCUSSION: In this case, we present a patient with histopathological and radiographic findings of Sweet syndrome with pulmonary involvement. Our patient fulfills two major and at least two minor criteria of Sweet syndrome including abrupt onset of tender erythematous nodules and a dense dermal neutrophilic infiltrate without leukocytoclastic vasculitis on histology. Minor criteria included fever > 38º C, elevated ESR, neutrophilia, and a dramatic response to treatment with steroids. Prompt transbronchial and skin biopsies in combination with an excellent response to corticosteroid therapy confirmed the diagnosis of Sweet syndrome with pulmonary involvement. Our patient continues to require daily steroid therapy to prevent recurrence of symptoms. CONCLUSIONS: Overall, the aim of this case is to recognize the clinical and radiographic findings of pulmonary Sweet syndrome and to confirm the diagnosis based on the clinical criteria presented. Early initiation of corticosteroid therapy can result in favorable patient outcomes as discussed in this case. REFERENCE #1: Robbins CM, Mason SE, Hughey LC. Sweet Syndrome With Pulmonary Involvement in a Healthy Young Woman. Arch Dermatol. 2009;145(3):344–346. doi:10.1001/archdermatol.2008.610 REFERENCE #2: Fernandez-Bussy S, Labarca G, Cabello F, Cabello H, Folch E, Majid A. Sweet's syndrome with pulmonary involvement: Case report and literature review. Respir Med Case Rep. 2012;6:16-19. Published 2012 Oct 17. doi:10.1016/j.rmcr.2012.08.004 REFERENCE #3: Nofal A, Abdelmaksoud A, Amer H, Nofal E, Yosef A, Gharib K, Albalat W, Eldesouky F, Ebrahim HM, Abdelshafy AS, Fayed H. Sweet's syndrome: diagnostic criteria revisited. J Dtsch Dermatol Ges. 2017 Nov;15(11):1081-1088. doi: 10.1111/ddg.13350. Epub 2017 Oct 5. PMID: 28981179. DISCLOSURES: No relevant relationships by Huma Khan, source=Web Response

Clinical outcomes in patients co-infected with COVID-19 and Staphylococcus aureus: a scoping review

BackgroundEndemic to the hospital environment, Staphylococcus aureus (S. aureus) is a leading bacterial pathogen that causes deadly infections such as bacteremia and endocarditis. In past viral pandemics, it has been the principal cause of secondary bacterial infections, significantly increasing patient mortality rates. Our world now combats the rapid spread of COVID-19, leading to a pandemic with a death toll greatly surpassing those of many past pandemics. However, the impact of co-infection with S. aureus remains unclear. Therefore, we aimed to perform a high-quality scoping review of the literature to synthesize the existing evidence on the clinical outcomes of COVID-19 and S. aureus co-infection.MethodsA scoping review of the literature was conducted in PubMed, Scopus, Ovid MEDLINE, CINAHL, ScienceDirect, medRxiv, and the WHO COVID-19 database using a combination of terms. Articles that were in English, included patients infected with both COVID-19 and S. aureus, and provided a description of clinical outcomes for patients were eligible. From these articles, the following data were extracted: type of staphylococcal species, onset of co-infection, patient sex, age, symptoms, hospital interventions, and clinical outcomes. Quality assessments of final studies were also conducted using the Joanna Briggs Institute’s critical appraisal tools.ResultsSearches generated a total of 1922 publications, and 28 articles were eligible for the final analysis. Of the 115 co-infected patients, there were a total of 71 deaths (61.7%) and 41 discharges (35.7%), with 62 patients (53.9%) requiring ICU admission. Patients were infected with methicillin-sensitive and methicillin-resistant strains of S. aureus, with the majority (76.5%) acquiring co-infection with S. aureus following hospital admission for COVID-19. Aside from antibiotics, the most commonly reported hospital interventions were intubation with mechanical ventilation (74.8 %), central venous catheter (19.1 %), and corticosteroids (13.0 %).ConclusionsGiven the mortality rates reported thus far for patients co-infected with S. aureus and COVID-19, COVID-19 vaccination and outpatient treatment may be key initiatives for reducing hospital admission and S. aureus co-infection risk. Physician vigilance is recommended during COVID-19 interventions that may increase the risk of bacterial co-infection with pathogens, such as S. aureus, as the medical community’s understanding of these infection processes continues to evolve.

The first 1000 symptomatic pediatric SARS-CoV-2 infections in an integrated health care system: a prospective cohort study

BackgroundThe spectrum of illness and predictors of severity among children with SARS-CoV-2 infection are incompletely understood.MethodsActive surveillance was performed for SARS-CoV-2 by polymerase chain reaction among symptomatic pediatric patients in a quaternary care academic hospital laboratory beginning March 12, 2020. We obtained sociodemographic and clinical data 5 (+/-3) and 30 days after diagnosis via phone follow-up and medical record review. Logistic regression was used to assess predictors of hospitalization.ResultsThe first 1000 symptomatic pediatric patients were diagnosed in our institution between March 13, 2020 and September 28, 2020. Cough (52 %), headache (43 %), and sore throat (36 %) were the most common symptoms. Forty-one (4 %) were hospitalized; 8 required ICU admission, and 2 required mechanical ventilation (< 1 %). One patient developed multisystem inflammatory syndrome in children; one death was possibly associated with SARS-CoV-2 infection. Symptom resolution occurred by follow-up day 5 in 398/892 (45 %) patients and by day 30 in 443/471 (94 %) patients. Pre-existing medical condition (OR 7.7; 95 % CI 3.9–16.0), dyspnea (OR 6.8; 95 % CI 3.2–14.1), Black race or Hispanic ethnicity (OR 2.7; 95 % CI 1.3–5.5), and vomiting (OR 5.4; 95 % CI 1.2–20.6) were the strongest predictors of hospitalization. The model displayed excellent discriminative ability (AUC = 0.82, 95 % CI 0.76–0.88, Brier score = 0.03).ConclusionsIn 1000 pediatric patients with systematic follow-up, most SARS-CoV-2 infections were mild, brief, and rarely required hospitalization. Pediatric predictors of hospitalization included comorbid conditions, Black race, Hispanic ethnicity, dyspnea and vomiting and were distinct from those reported among adults.

Children and adolescents with disabilities in Brazil: effects of the COVID-19 pandemic

The present research aimed to perform data survey and analysis of children and teenagers among 0- to 19-year-olds related to SARS (severe acute respiratory syndrome) and COVID-19 in populations with or without disabilities during the year of 2020. The database used for the evaluations was Sivep-Gripe, made available by the Ministry of Health. The database did not present variables regarding the type of disability and a proxy was created by the binary variable of Down syndrome and by qualitative analysis of clinical data of descriptive morbidity. This limitation hindered the consideration of the experience of disability as an interaction between bodily impairments and the environment, as well as the generalization regarding cases in this population. The analysis variables included individual, regional and progression characteristics of the cases, such as the need for hospitalization, admission to the ICU, use of ventilatory supports and evolution of the cases for the recovery or death. 83,491 cases of children up to 19 years old were considered. Of this total, 2,370 (3.27%) were categorized with the disability proxy. The analyzes showed the differences between cases and progressions between children and young people without disabilities and by type of disability, with the highest proportions of COVID-19 cases found in those with physical, intellectual or psychosocial disabilities. Considering the age groups, we found higher frequencies of these cases among children up to 4 years old in general; with intellectual or psychosocial disabilities between 5 and 9 years; and those with physical disabilities between 14 and 19 years. The progression of the children's cases demonstrates the relevance of considering their vulnerability and its effects on hospital establishments, since they are more susceptible to being hospitalized, requiring ICU admissions and respiratory support. Even with the use of these resources for the maintenance of life, the proportion of children with disabilities who evolve to death is equivalent to more than double (in the cases of COVID-19) and triple (SARS) of those without disabilities. Based on these verifications, we emphasize the need to further investigate, plan and execute public policies that target this population, especially in relation to health services in the current context of increasing cases of COVID-19 and its variants across the country. In addition, we seek to contribute to academic discussions that address disability as a relevant social marker that permeates the different layers of inequality and social exclusion, exposed and deepened in the pandemic context.

Syndromic surveillance of the frequency and severity of respiratory compromise of brachycephalic dogs in ICUs.

Brachycephalic dogs (BCD) are increasingly popular companion animals and widely recognized to suffer from respiratory compromise based upon their conformation; however, the actual percentages of BCD in veterinary ICUs are unknown. This study aimed to evaluate a canine ICU census, as well as the presence, development, and severity of respiratory compromise in BCD using syndromic surveillance. Ten institutions provided surveillance data twice weekly over an 11-week study period. The total canine ICU census was 1254 dogs hospitalized during the days and times of the study period; of this population, 125 (10%) were BCD. Fifty-six (45%) BCD were hospitalized in ICUs because they were perceived to be at risk of respiratory complications while recovering from general anesthesia or had a nonrespiratory condition requiring ICU admission, with the remaining 69 dogs (55%) being treated for respiratory disease. Twenty dogs (16%) developed respiratory complications requiring ICU admission after initially being hospitalized for another condition. Four percent of dogs were supported with mechanical ventilation. Syndromic surveillance was a useful method for evaluating the number of BCD in a veterinary ICU. Almost 1 in 5 BCD developed respiratory compromise after initial evaluation for an unrelated problem. Ongoing evaluation of the medical issues associated with brachycephaly is warranted.

Convalescent Plasma for COVID-19- is it Time to Say Goodbye? A Single-Center, Retrospective, Observational Study from Northern India

Background: COVID-19 pandemic continues threatening the world with no effective treatment to tackle the menace. Till date, there is conflicting evidence on efficacy of CP in reducing COVID-19 related mortality. The objective of this study was to see disease progression and 7, 14 and 28-day mortality after CP therapy and analyze CP efficacy with/without Remdesivir.&#x0D; Materials and Methods: A retrospective single-centre observational study done from August 20, 2020, to 20 November 2020. Records of 294 COVID-19 patients with moderate to severe disease given CP therapy were analysed based on disease progression and length of hospital stay, further subcategorized on age, clinical profile, risk factors, ward/ICU, ventilatory support and co-administration of Remdesivir.&#x0D; Results: Lowest 7-day mortality rate was seen within age group 20-40 years (0%) and was highest in ≥61 years (24.3%). 87 patients on ventilatory support showed higher 28day mortality (48.28%) compared to non-ventilated (10.14%), (P&lt;0.00001). Lesser 7-day mortality was seen in early CP therapy ≤3 days of admission (P=0.01). Patients requiring ICU admission showed higher 14 and 28-day mortality compared to ward P=0.001%). Median (IQR) length of hospital stay from CP transfusion was shorter, 4 (3 to 9) days in group 2 (CP only) compared to 7 (4 to 12) days in group1 (CP+Remdesivir ).&#x0D; Conclusion: CP therapy in ≤3 days of hospital admission in COVID-19 patients with moderate to severe infection not on ventilatory support showed reduction in mortality and length of hospital stay. Length of hospital stay was shorter in the CP-only group as compared to the CP+ Remdesivir group.

PROGNOSTIC ROLE OF NLR AND RBS LEVELS IN DIABETIC PATIENTS WITH SEVERE COVID-19 DISEASE

Objective-This retrospective study was done to assess the role of NLR (Neutrophil to lymphocyte ratio) and RBS (RANDOM BLOOD SUGAR) levels at the time of admission as prognostic markers and correlate them with clinical outcome. Materials and methods:Atotal of 100 diabetic patients with severe COVID-19 Disease, requiring ICU admission were studied at SRN Hospital, Prayagraj. Blood samples were sent for various inammatory markers along with random blood glucose levels. Patients were divided as survivors and non- survivors. Results: The mean NLR was higher in the group of patients who did not survive (11.35±8.09) than in the patients who survived (7.79±5.27). Mean RBS (in mg/dL) in the survivor group and the non-survivor group at the time of admission was 232.19±133.75 and 333.41±130.81 respectively. The NLR, RBS, CRP cutoff were identied as &gt;7.247, &gt;254.6 mg/dL,&gt;12.86 mg/Lrespectively to predict mortality using the ROC curve (p value &lt;0.05). Conclusion:NLR and RBS at the time of admission can be easily used as surrogate markers for predictors of mortality. Screening and intensive glucose control is strictly recommended for all diabetic patients.

Trends and Variation in Length of Stay Among Hospitalized Febrile Infants ≤60 Days Old.

Researchers in recent studies suggest that hospitalized febrile infants aged ≤60 days may be safely discharged if bacterial cultures are negative after 24-36 hours of incubation. We aimed to describe trends and variation in length of stay (LOS) for hospitalized febrile infants across children's hospitals. We conducted a multicenter retrospective cohort study of febrile infants aged ≤60 days hospitalized from 2016 to 2019 at 39 hospitals in the Pediatric Health Information System database. We excluded infants with complex chronic conditions, bacterial infections, lower respiratory tract viral infections, and those who required ICU admission. The primary outcomes were trends in LOS overall and for individual hospitals, adjusted for patient demographics and clinical characteristics. We also evaluated the hospital-level association between LOS and 30-day readmissions. We identified 11 868 eligible febrile infant encounters. The adjusted mean LOS for the study cohort decreased from 44.0 hours in 2016 to 41.9 hours in 2019 (P < .001). There was substantial variation in adjusted mean LOS across children's hospitals, range 33.5-77.9 hours in 2016 and 30.4-100.0 hours in 2019. The change from 2016 to 2019 in adjusted mean LOS across individual hospitals also varied widely (-23.9 to +26.7 hours; median change -1.8 hours, interquartile range: -5.4 to 0.3). There was no association between hospital-level LOS and readmission rates (P = .70). The LOS for hospitalized febrile infants decreased marginally between 2016 and 2019, although overall LOS and change in LOS varied substantially across children's hospitals. Continued quality improvement efforts are needed to reduce LOS for hospitalized febrile infants.

The use of methylprednisolone in patients with Coronavirus disease 2019 (COVID-19) requiring intensive care hospitalization: a longitudinal observational study

The use of methylprednisolone in patients with Coronavirus disease 2019 (COVID-19) requiring intensive care hospitalization: a longitudinal observational study. Background : For a long time, the use of corticosteroids in critically ill patients with coronavirus disease 2019 (COVID-19) has been a controversial treatment. How- ever, given the conflicting evidence on this topic, we studied the effects of methylprednisolone on critically ill patients and - share here our experience on laboratory findings and the Pa02/FiO2 ratio (ratio of partial oxygen concentration on arterial blood gas sample to fraction of inspired oxygen). Methods : In a population of 68 patients hospitalized in the intensive care unit due because of COVID-19 infection, 28 patients with severe respiratory failure received methylprednisolone on a fixed 12-day regimen (125 mg IV for 2 days, followed by 2x0.5 mg/kg IV twice daily for 5 days, and then a decreasing regimen for 4 days until discontinuation). After day 5 and day 10, we analyzed the levels of CRP (C-reactive protein), lymphocytosis, D-dimer, LDH (lactate dehydrogenase) and PaO 2 /FiO 2 ratio of our patients. Results : We observed a significant decrease in median CRP levels between day 0 (start of methylprednisolone treatment) and day 5 (p=0.001), and between day 0 and day 10 (p=0.005). No decrease was seen between day 5 and 10 (p=0.352). The same increase in PaO 2 /FiO 2 was recorded between day 0 and day 5 (p=0.009), and between 0 and day 10 (p=0.019). For D-dimer, only a significant difference was found between day 0 and day 10 (p=0.018). No significant difference could be observed for lymphocytosis and LDH levels between the beginning of the treatment and day 5 or day 10. Conclusion : There is a strong and sustained significant decrease in CRP levels and a tilt in the PaO2/FiO2 ratio after starting methylprednisolone. A slower, but also significant decrease was found for D-dimer. Further research and control group analyses are needed to confirm that this effect is due to corticostreoid treatment. However, this indicates that methylprednisolone may play a very important role in the treatment of the severely ill COVID-19 patients requiring ICU admission.

Emergency medical admissions and COVID-19: impact on 30-day mortality and hospital length of stay

BackgroundThe COVID-19 pandemic has put considerable strain on healthcare systems.AimTo investigate the effect of the COVID-19 pandemic on 30-day in-hospital mortality, length of stay (LOS) and resource utilization in acute medical care.MethodsWe compared emergency medical admissions to a single secondary care centre during 2020 to the preceding 18 years (2002–2019). We investigated 30-day in-hospital mortality with a multiple variable logistic regression model. Utilization of procedures/services was related to LOS with zero truncated Poisson regression.ResultsThere were 132,715 admissions in 67,185 patients over the 19-year study. There was a linear reduction in 30-day in-hospital mortality over time; over the most recent 5 years (2016–2020), there was a relative risk reduction of 36%, from 7.9 to 4.3% with a number needed to treat of 27.7. Emergency medical admissions increased 18.8% to 10,452 in 2020 with COVID-19 admissions representing 3.5%. 18.6% of COVID-19 cases required ICU admission with a median stay of 10.1 days (IQR 3.8, 16.0). COVID-19 was a significant univariate predictor of 30-day in-hospital mortality, 18.5% (95%CI: 13.9, 23.1) vs. 3.0% (95%CI: 2.7, 3.4)—OR 7.3 (95%CI: 5.3, 10.1). ICU admission was the dominant outcome predictor—OR 12.4 (95%CI: 7.7, 20.1). COVID-19 mortality in the last third of 2020 improved—OR 0.64 (95%CI: 0.47, 0.86). Hospital LOS and resource utilization were increased.ConclusionA diagnosis of COVID-19 was associated with significantly increased mortality and LOS but represented only 3.5% of admissions and did not attenuate the established temporal decline in overall in-hospital mortality.

Risk Factors for SARS-CoV-2 Infection Severity in Abu Dhabi

BackgroundPrediction models are essential for informing screening, assessing prognosis, and examining options for treatment. This study aimed to assess the risk of SARS-CoV-2 infection severity in the Abu Dhabi population.MethodsThis is a mixed retrospective cohort study and case–control study to explore the associated factors of receiving treatment in the community, being hospitalized, or requiring complex hospital care among patients with a diagnosis of SARS-CoV-2. Of 641 patients included, 266 were hospitalized; 135 were hospitalized and either died or required complex care, i.e., required ICU admission, intubation, or oxygen and 131 did not develop severe disease requiring complex care. The third group (“controls”) were 375 patients who were not hospitalized. Logistic regression analyses were used to study predictors of disease severity.ResultsAmong hospitalized patients older age and low oxygen saturation at admission were the consistent and strongest predictors of an adverse outcome. Risk factors for the death in addition to age and low oxygen saturation were elevated white blood count and low reported physical activity. Chronic kidney disease and diabetes were also associated with more severe disease in logistic regression. The mortality rate among those with less than 30 min per week of physical activity was 4.9%, while the mortality rate was 0.35% for those with physical activity > 30 min at least once a week. The interval from the onset of symptoms to admission and mortality was found to have a significant inverse relationship, with worse survival for shorter intervals.ConclusionOxygen saturation is an important measure that should be introduced at screening sites and used in the risk assessment of patients with SARS-CoV-2. In addition, an older age was a consistent factor in all adverse outcomes, and other factors, such as low physical activity, elevated WBC, CKD, and DM, were also identified as risk factors.

Improving Surgical Quality for Patients With Mental Illnesses: A Narrative Review.

The aim of this study was to identify disparities in care for surgical patients with preexisting mental health diagnoses. Mental illness affects approximately 6.7 million Canadians. For them, stigma, comorbid disorders, and sequelae of psychiatric diagnoses can be barriers to equitable health care. The goal of this review is to define inequities in surgical care for patients with preexisting mental illness. We searched OVID Medline, Pubmed, EMBASE, and the Cochrane review files using a combination of search terms using a PICO (population, intervention, comparison, outcome) model focusing on surgical care for patients with mental illness. The literature on mental illness in surgical patients focused primarily on preoperative and postoperative disparities in surgical care between patients with and without a diagnosis of mental illness. Preoperatively, patients were 7.5% to 40% less likely to be deemed surgical candidates, were less likely to receive testing, and were more likely to present at later stages of their disease or have delayed surgical care. Similar themes arose in the postoperative period: patients with mental illness were more likely to require ICU admission, were up to 3 times more likely to have a prolonged length of hospital stay, had a 14% to 270% increased likelihood of having postoperative complications, and had significantly higher health care costs. Surgical patients with preexisting psychiatric diagnoses have a propensity for worse perioperative outcomes compared to patients without reported mental illness. Taking a thorough psychiatric history can potentially help surgical teams address disparities in access to care as well as anticipate and prevent adverse outcomes.

Legionella Pneumonia in the ICU: A Tertiary Care Center Experience Over 10 Years

OBJECTIVES:Few studies have reported the complications and outcomes of patients with Legionella pneumonia requiring ICU admission. The objective of our study is to report the clinical course, complications, and 30-day mortality of patients with Legionella pneumonia admitted to the critical care units at our medical center over a 10-year period.DESIGN:Retrospective observational study.SETTING:Tertiary care teaching hospital.PATIENTS:All adult (≥ 18 yr old) patients with Legionella pneumonia admitted to the ICUs from January 1, 2010, to December 31, 2019.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:A total of 88 patients with Legionella pneumonia were admitted to ICUs over the 10-year period. The majority of infections (n = 80; 90.9%) were community acquired. The median (interquartile range) age of patients was 60 years (51.5–71.0 yr); 58 (66%) were male, and 41 (46.6%) identified their race as Black. The median (interquartile range) Sequential Organ Failure Assessment score at ICU admission was 6 (3–9). The distribution of infections showed seasonal dominance with most cases (86%) occurring in the summer to early fall (May to October). Invasive mechanical ventilation was required in 62 patients (70.5%), septic shock developed in 57 patients (64.8%), and acute respiratory distress syndrome developed in 42 patients (47.7%). A majority of patients developed acute kidney injury (n = 69; 78.4%), with 15 (21.7%) receiving only intermittent hemodialysis and 15 (21.7%) requiring continuous renal replacement therapy. Ten patients required venovenous extracorporeal membrane oxygenation support; eight (80%) survived and were successfully decannulated. Overall 30-day mortality was 26.1% (n = 23). Advanced age, higher Sequential Organ Failure Assessment score at admission, and not receiving Legionella-specific antimicrobial therapy within 24 hours of hospital admission were predictors of 30-day mortality.CONCLUSIONS:Patients with Legionella pneumonia may require ICU admission and major organ support. Legionella-targeted antibiotics should be included in the empiric regimen for any patient with severe pneumonia. Outcomes of extracorporeal membrane oxygenation therapy in this population are encouraging.

Acute Kidney Injury in Pediatric Acute SARS-CoV-2 Infection and Multisystem Inflammatory Syndrome in Children (MIS-C): Is There a Difference?

Objective: To evaluate the prevalence and factors associated with the risk of acute kidney injury (AKI) in pediatric patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and multisystem inflammatory syndrome in children (MIS-C).Study Design: We performed a retrospective chart review of 113 patients with SARS-CoV-2 infection with or without MIS-C admitted at Children's Hospital of Michigan (CHM) from March to August 2020. Patient demographic details, laboratory data, imaging studies, echocardiography reports, and treatment data were collected.Results: Of the 92 patients included in the final analysis, 22 (24%) developed AKI with 8/22 (36%) developing stage 3 AKI. The prevalence of AKI was much higher in patients with MIS-C 15/28 (54%) vs. those with acute SARS-CoV-2 infection 7/64 (11%), (p < 0.001). Overall, when compared to patients without AKI, patients with AKI were older in age (11 vs. 6.5 years, p = 0.007), African American (86 vs. 58%, p = 0.028), had MIS-C diagnosis (68 vs. 19%, p < 0.001), required ICU admission (91 vs. 20%, p < 0.001), had cardiac dysfunction (63 vs. 16%, p < 0.001), required inotropic support (59 vs. 6%, p < 0.001) and had a greater elevation in inflammatory markers. In a multivariate analysis, requirement of inotropes [Odds Ratio (OR)−22.8, p < 0.001], African American race (OR-8.8, p = 0.023) and MIS-C diagnosis (OR-5.3, p = 0.013) were the most significant predictors for AKI. All patients had recovery of kidney function, and none required kidney replacement therapy.Conclusion: Children with acute SARS-CoV-2 infection and MIS-C are at risk for AKI, with the risk being significantly greater with MIS-C. The pathogenesis of AKI in acute SARS-CoV-2 infection appears to be a combination of both renal hypo-perfusion and direct renal parenchymal damage whereas in MIS-C, the renal injury appears to be predominantly pre-renal from cardiac dysfunction and capillary leak from a hyperinflammatory state. These factors should be considered by clinicians caring for these children with a special focus on renal protective strategies to aid in recovery and prevent additional injury to this high-risk subgroup.

COVID-Associated Pulmonary Aspergillosis and Its Related Outcomes: A Single-Center Prospective Observational Study

Background and objectiveInvasive pulmonary aspergillosis (IPA) is a frequent complication among neutropenic patients. It is increasingly being reported in critical coronavirus disease 2019 (COVID-19) patients requiring ICU admission and invasive mechanical ventilation (IMV) and is known as COVID-associated pulmonary aspergillosis (CAPA). We conducted this large prospective observational study to determine the frequency of CAPA and its outcomes in the ICU population.MethodologyThis was a prospective observational study. We recruited 307 reverse transcription-polymerase chain reaction (RT-PCR)-confirmed cases of severe COVID-19 pneumonia requiring IMV. We excluded those who did not require IMV or had been transferred out to other hospitals. The Chi-square test was applied to find the association between categorical variables. A p-value of <0.05 was considered statistically significant.ResultsOut of the 307 cases of mechanically ventilated COVID-19 pneumonia, 61 had probable CAPA. The median age was 60 years. Malignancy and cirrhosis were significant risk factors associated with CAPA (p=<0.001, 0.001, respectively). Aspergillus fumigatus was detected in 78.7% of the cases. The median length of ICU stay was 11 days [interquartile range (IQR): 4-14]. Among CAPA cases, 70.5% developed septic shock and required ionotropic support. Among 61 probable cases of CAPA, 91.8% did not survive and there was a strong correlation between CAPA and ICU mortality (p=0.001).ConclusionWe concluded that CAPA is a fatal complication of severe COVID-19 pneumonia and is associated with increased mortality.

CLINICAL PROFILE OF PLASMODIUM VIVAX MALARIA IN CHILDREN

Background: To study clinical presentations and complications of P. vivax malaria&#x0D; Methods: A prospective hospital-based clinical observational study was conducted on 100 patients under age of 14 years were enrolled in the study.&#x0D; Result: The most common presentation was fever followed by pallor. Among the total of 100 cases studied 2 cases died with a case fatality rate of 2%. Among the total of 100 cases studied 5 cases (10%) required ICU admission.&#x0D; Conclusion: P. vivax monoinfection tends to have severe complications in children. There is a need to review severity criteria for P. vivax malaria.&#x0D; Keywords: Vivax, Fever, ICU

The organisational response of a hospital critical care service to the COVID-19 pandemic: The Groote Schuur Hospital experience.

Background There are limited data about the coronavirus disease-19 (COVID-19)-related organisational responses and the challenges of expanding a critical care service in a resource-limited setting. Objectives To describe the ICU organisational response to the pandemic and the main outcomes of the intensive care service of a large state teaching hospital in South Africa. Methods Data were extracted from administrative records and a prospective patient database with ethical approval. An ICU expansion plan was developed, and resource constraints identified. A triage tool was distributed to referring wards and hospitals. Intensive care was reserved for patients who required invasive mechanical ventilation (IMV). The total number of ICU beds was increased from 25 to 54 at peak periods, with additional non-COVID ICU capacity required during the second wave. The availability of nursing staff was the main factor limiting expansion. A ward-based high flow nasal oxygen (HFNO) service reduced the need for ICU admission of patients who failed conventional oxygen therapy. A team was established to intubate and transfer patients requiring ICU admission but was only available for the first wave. Results We admitted 461 COVID-19 patients to the ICU over a 13-month period from 5 April 2020 to 5 May 2021 spanning two waves of admissions. The median age was 50 years and duration of ICU stay was 9 days. More than a third of the patients (35%; n=161) survived to hospital discharge. Conclusion Pre-planning, leadership, teamwork, flexibility and good communication were essential elements for an effective response. A shortage of nurses was the main constraint on ICU expansion. HFNO may have reduced the requirement for ICU admission, but patients intubated after failing HFNO had a poor prognosis. Contributions of the study We describe the organisational requirements to successfully expand critical care facilities and strategies to reduce the need for invasive mechanical ventilation in COVID-19 pneumonia. We also present the intensive care outcomes of these patients in a resource-constrained environment.

ICU Survivors at Increased Suicide Risk.

According to this study: Survivors of critical illness, particularly those who require ICU admission, are at increased risk for subsequent suicide and self-harm.