Severity Of Illness In Patients Research Articles

Expert provider survey of longitudinal assessment in patients with pulmonary arterial hypertension

BackgroundPatients suffering from pulmonary arterial hypertension (PAH) demand frequent assessment to keep pace with a dynamic and sometimes rapidly progressive disease course. To improve our understanding of patient monitoring, we conducted a survey of pulmonary hypertension (PH) providers to establish real-world practice patterns. ObjectiveTo evaluate the type and frequency of patient assessment methods employed by expert PH providers following PAH diagnosis MethodsA descriptive cross-sectional survey of PH providers across the United States was utilized to assess provider practices. Between September 14, 2017 to October 17, 2017, a survey was distributed electronically to PH experts assessing follow-up frequency and testing evaluation of patients with PAH. Results40 (11.4%) providers completed the survey, representing cardiologists, pulmonologists, and advanced practice providers at centers who cared for an average of 95 patients per year with PAH. Follow-up testing and clinic evaluation was influenced by severity of patient illness. Frequency of re-assessment of clinic follow-up, six-minute walk test, echocardiogram, brain natriuretic peptide, and right heart catheterization in various clinical scenarios all reflected disparate practice. ConclusionsCurrent clinical practice patterns in the monitoring of patients with PAH are variable and do not necessarily reflect guideline-based practices, suggesting the need for further research and improved guidelines on the frequency of follow up and repeat testing.

Effects of physical activity on the severity of illness and mortality in COVID-19 patients: A systematic review and meta-analysis.

Purpose: This systematic review and meta-analysis investigated the association between Physical activity (PA) before Coronavirus Disease 2019 (COVID-19) infection and the severity of illness and mortality in COVID-19 patients. Methods: A comprehensive search was undertaken to identify retrospective and nonrandomized controlled trial studies comparing the severity and mortality of COVID-19 infection among COVID-19 patients who had previously reported their participation in PA with those who had not. The databases searched were PubMed, Cochrane Library, Scopus, Science Direct, EMBASE, OPENGREY.EU, and ClinicalTrials.gov. The risk of bias was assessed using the Newcastle-Ottawa Scale. A random-effects model was used for determining pairwise meta-analyses. The protocol was registered with PROSPERO (CRD42021262548). Results: Eighteen studies met the inclusion criteria (5 cross-sectional, 12 cohort, and 1 case-control studies). All 1 618 680 subjects were adults. PA significantly decreased the risk of death in COVID-19 patients (odds ratio [OR] 0.34; 95% confidence interval [CI], 0.19-0.62; p < 0.001) and the risk of severe outcomes (OR 0.60; 95% CI, 0.48-0.76; p < 0.001). Subgroup analysis showed that PA for ≥150min/wk at a moderate intensity or ≥75min/wk at a vigorous intensity reduced the risks of severity and mortality. Vigorous PA reduced mortality risk, whereas moderate to vigorous PA reduced the risks of severity and mortality. Conclusion: PA before infection might reduce severity and mortality in COVID-19 patients, especially PA ≥ 150min/wk of moderate activity or ≥75min/wk of vigorous activity. However, careful interpretations should be considered due to the difference in PA patterns and severity definitions among included studies. This finding implies that engaging in regular PA, even in different patterns, has beneficial effects on the severity and mortality of COVID-19 patients.

Evaluation of the utility of NEWS2 during the COVID-19 pandemic

The emergence of the COVID-19 pandemic resulted in a dramatic increase in acutely ill patients presenting to hospitals with life-threatening acute respiratory disease. There was an immediate need for effective triage systems to facilitate clinical decision making. This review assesses the performance of the National Early Warning Score 2 (NEWS2) in two contexts. Firstly, the ability to detect acute illness severity and likely clinical deterioration in patients presenting to hospitals with COVID-19. Secondly, the use of NEWS2 in the longitudinal monitoring to detect acute clinical deterioration in hospitalised patients with COVID-19. NEWS2 appeared to be at least comparable and, often, superior to other scoring systems (such as qSOFA and CURB-65), and provided an earlier alert of deterioration. A NEWS2 of 5 had high short-term sensitivity within and was unlikely to miss patients with COVID-19 who go on to deteriorate, but this comes with moderate specificity. However, the specificity of these systems is likely underestimated because preventing deterioration is their purpose.NEWS2 is an adjunct to clinical decision making and has served that purpose during the COVID-19 pandemic, playing an important role in communicating illness severity, clinical deterioration, triaging patients to appropriate levels of care and prompting completion of treatment escalation plans for those with high scores and at imminent risk of deterioration.

Correlation of Quantitative CRP Values with Fibrinogen Levels in Covid-19 Patients at Dr. Hospital. Mohammad Hoesin Palembang

COVID-19 is a contagious acute respiratory disease caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). In COVID-19 infection, there may be a high inflammatory response, causing thromboinflammatory processes through cytokine storm mechanisms, complement activation, and endothelial damage. Thus, the sequence of events can be seen from increased levels of CRP, fibrinogen, and other acute-phase proteins synthesized by the liver. The CRP value is useful for assessing the degree of inflammation which is widely used in predicting disease severity, prognosis, and mortality in COVID-19 patients, while fibrinogen levels are useful for assessing the severity of disease and hypercoagulation in COVID-19 patients. This study aims to determine the correlation between quantitative CRP and fibrinogen levels, as well as the correlation of fibrinogen levels with the severity of COVID-19 disease. This study was an observational correlative analytic study with a retrospective approach. The research was conducted at the Department of Internal Medicine of RSMH Palembang in May 2022 by taking medical record data of COVID-19 patients from May 2021 to September 2021. The research subjects are adult COVID-19 confirmed case patients who have not received standard therapy and anticoagulant drugs. The data taken are general characteristics, routine blood tests, blood chemistry, blood gas analysis, and hemostasis function. Data processing and analysis were done using SPSS version 25.0 for windows. There were 263 subjects, consisting of 26 subjects (26.2%) with mild degrees, 95 subjects (36.1%) with moderate degrees, 49 subjects (18.6%) with severe degrees, and 50 subjects (19%) with critical degrees. The correlation between CRP values and fibrinogen levels was obtained with a correlation coefficient of r = 0.574, while the correlation between fibrinogen levels and the severity of disease was obtained at r = 0.490. In this study, there was a strong correlation between quantitative CRP value and fibrinogen levels and a moderate correlation between fibrinogen levels and the severity of illness in COVID-19 patients at RSMH Palembang. These two parameters can be used as predictors of the severity of COVID-19 disease.

Transient Leukopenia Induced by Combination Therapy for Severe SARS-CoV-2 Pneumonia.

Current National Institutes of Health treatment guidelines recommend remdesivir for patients with a high risk of progression. In patients requiring minimal supplemental oxygen, remdesivir or dexamethasone monotherapy is recommended, while in patients requiring high-flow oxygen or non-invasive ventilation, dexamethasone monotherapy or dexamethasone plus remdesivir is recommended. Baricitinib or tocilizumab can be added in patients requiring oxygen supplementation.Clinicians should be aware of transient leukocytopenia that can be induced with combination therapy of dexamethasone, remdesivir and baricitinib during the early phase of treatment of SARS-CoV-2 patients.The evaluation approach for leukopenia should consider autoimmune disorders, inflammatory diseases, infections, malignancy, and medication and toxin exposure.

Quantification of diaphragmatic dynamic dysfunction in septic patients by bedside ultrasound

Although diaphragmatic dysfunction is an important indicator of severity of illness and poor prognosis in ICU patients, there is no convenient and practical method to monitor diaphragmatic function. This study was designed to analyze diaphragmatic dynamic dysfunction by bedside ultrasound in septic patients and provide quantitative evidence to assess diaphragm function systematically. This prospective observational study was conducted from October 2019 to January 2021 in the Department of Respiratory and Critical Care Medicine. 74 patients suffered from sepsis were recruited and divided into two groups, sepsis group 1 (2 ≤ SOFA ≤ 5, n = 41) and sepsis group 2 (SOFA > 5, n = 33). 107 healthy volunteers were randomly recruited as the control group. In all participants, the diaphragmatic thickness and excursion were measured directly and the dynamic parameters including thickening fraction (TF), EQB/EDB, Contractile velocity, and area under diaphragmatic movement curve (AUDMC) were calculated by bedside ultrasound during quiet breathing (QB) and deep breathing (DB). Each parameter among three groups was analyzed separately by covariance analysis, which was adjusted by age, sex, body mass index, MAP, hypertension, and diabetes. First, contractile dysfunction occurred before diaphragmatic atrophy both in sepsis group 1 and sepsis group 2. Second, compared with the control group, the dynamic parameters showed significant decrease in sepsis group 1 and more obvious change in sepsis group 2, including TF, EQB/EDB. Third, the maximum contractile velocity decreased in sepsis group 1, reflecting the damage of intrinsic contraction efficiency accurately. Finally, per breathing AUDMC in two septic groups were lower than those in control group. However, per minute AUDMC was compensated by increasing respiratory rate in sepsis group 1, whereas it failed to be compensated which indicated gradual failure of diaphragm in sepsis group 2. Diaphragmatic ultrasound can be used to quantitatively evaluate the severity of sepsis patients whose contractile dysfunction occurred before diaphragmatic atrophy. As dynamic parameters, TF and EQB/EDB are early indicator associated with diaphragmatic injury. Furthermore, maximum contractile velocity can reflect intrinsic contraction efficiency accurately. AUDMC can evaluate diaphragmatic breathing effort and endurance to overcome resistance loads effectively.

Serum lactate is associated with increased illness severity in immunocompromised pediatric hematology oncology patients presenting to the emergency department with fever.

IntroductionDetermining which febrile pediatric hematology/oncology (PHO) patients will decompensate from severe infection is a significant challenge. Serum lactate is a well-established marker of illness severity in general adult and pediatric populations, however its utility in PHO patients is unclear given that chemotherapy, organ dysfunction, and cancer itself can alter lactate metabolism. In this retrospective analysis, we studied the association of initial serum lactate in febrile immunosuppressed PHO patients with illness severity, defined by the incidence of clinical deterioration events (CDE) and invasive bacterial infection (IBI) within 48 hours.MethodsReceiver operating characteristic (ROC) curves were reported using initial lactate within two hours of arrival as the sole predictor for CDE and IBI within 48 hours. Using a generalized estimating equations (GEE) approach, the association of lactate with CDE and IBI within 48 hours was tested in univariate and multivariable analyses including covariates based on Quasi-likelihood under Independence Model Criterion (QIC). Additionally, the association of lactate with secondary outcomes (i.e., hospital length of stay (LOS), intensive care unit (PICU) admission, PICU LOS, non-invasive infection) was assessed.ResultsAmong 897 encounters, 48 encounters had ≥1 CDE (5%), and 96 had ≥1 IBI (11%) within 48 hours. Elevated lactate was associated with increased CDE in univariate (OR 1.77, 95%CI: 1.48-2.12, p<0.001) and multivariable (OR 1.82, 95%CI: 1.43-2.32, p<0.001) analyses, longer hospitalization (OR 1.15, 95%CI: 1.07-1.24, p<0.001), increased PICU admission (OR 1.68, 95%CI: 1.41-2.0, p<0.001), and longer PICU LOS (OR 1.21, 95%CI: 1.04-1.4, p=0.01). Elevated lactate was associated with increased IBI in univariate (OR 1.40, 95%CI: 1.16-1.69, p<0.001) and multivariable (OR 1.49, 95%CI: 1.23-1.79, p<0.001) analyses. Lactate level was not significantly associated with increased odds of non-invasive infection (p=0.09). The QIC of the model was superior with lactate included for both CDE (305 vs. 325) and IBI (563 vs. 579).ConclusionsThese data demonstrated an independent association of elevated initial lactate level and increased illness severity in febrile PHO patients, suggesting that serum lactate could be incorporated into future risk stratification strategies for this population.

3.17 The Impact of Executive Functioning Deficit on Illness Severity in Patients With an ADHD Diagnosis: A Real-World Data Study

Executive functioning (EF) is a multifaceted neuropsychological construct that allows individuals to engage in goal-directed and novel problem-solving behaviors. EF deficits have been identified in a subgroup of patients with ADHD. Heterogeneity in peer, family, and academic functioning among individuals with ADHD has been related to EF performance. Electronic health record (EHR) data captures the presentation of patients with ADHD in a real-world clinical setting and is therefore well suited to study the impact of EF deficits on ADHD illness severity.

High Prevalence of Fungal and NDM-OXA Producing Gram-Negative Bacterial Superinfections in the Second Wave of Coronavirus Disease 2019 in India: Experience from a Dedicated Coronavirus Disease 2019 Hospital in North India.

During the second wave of coronavirus disease 2019 (COVID-19), superinfection caused by fungus and multidrug-resistant bacteria worsened the severity of illness in COVID-19 patients. Limited studies from India reported the antimicrobial resistance pattern of secondary infections. In this study, we aim to study the epidemiology of pathogens causing superinfections and genotyping of Gram-negative isolates in COVID-19 patients. This retrospective study was conducted at a dedicated COVID-19 center, India. The identification of bacteria/fungi was done by Vitek2® and matrix-assisted laser desorption/ionization-time of flight mass spectrometry system. Identification of beta-lactamase genes was done using thermal cycler. The diagnosis of mucormycosis was based on 10% potassium hydroxide direct microscopy. Statistical analyses were performed using STATA version 15.1 (StataCorp., College Station, TX, USA). For continuous variables, mean and standard deviation were computed. For comparing proportions of secondary infections across admission location and outcomes, the Chi-squared test of independence was used. To compare the mean and median between intensive care units and outcomes, an independent t-test and a Mann-Whitney test were used. Of all the clinical samples, 45.4% of samples were cultured positive for secondary infections. Acinetobacter baumannii (35%) was the most common Gram-negative pathogen, while among Gram positive, it was Enterococcus faecium (40%). Among fungus, Candida spp. (61%) predominates followed by molds. Colistin and tigecycline proved effective against these pathogens. blaNDM was the most prevalent gene followed by the blaOX among the carbapenemase genes. The mortality rate among COVID-19 patients with secondary infection was significantly higher compared to the overall mortality rate in COVID-19 patients.

194 Discordance of Pneumonia Diagnoses from Admission to Discharge: A Retrospective Cohort Analysis of 118 Veterans Affairs Emergency Departments

194 Discordance of Pneumonia Diagnoses from Admission to Discharge: A Retrospective Cohort Analysis of 118 Veterans Affairs Emergency Departments

Implementing and Evaluating a Pilot Therapeutic Music Program in the Intensive Care Unit

Background: Therapeutic music has been shown to provide significant physical and mental health benefits to patients, yet limited information is available on the impact of live classical music in the intensive care unit (ICU) setting.&#x0D; Objective: The purpose of this initiative was to implement and evaluate a therapeutic music program in the ICU.&#x0D; Methods: A descriptive survey methodology was used to obtain information from volunteer musicians and clinical nurses. Researchers used a 12-item anonymous web-based survey to collect information on the therapeutic music program's acceptability, appropriateness, and feasibility. The survey also included questions addressing potential barriers to and facilitators of implementing therapeutic music in the ICU.&#x0D; Results: A total of 15 nursing staff and 6 volunteer musicians completed the online survey. Of the 15 nurse respondents (9 clinical nursing staff, 3 advanced practice, 3 other), a majority (n=10, 66.7%) identified that therapeutic music was acceptable in the ICU. Similarly, a majority (n=11, 73.3%) indicated that therapeutic music was appropriate and feasible. Of the volunteer musicians, all (n=6, 100%) identified several factors that helped to facilitate the program including having an upright piano with large casters (wheels) for enhanced mobility to play music. Most (n=5, 83.3%) identified having a patient and family-centered care environment and supportive ICU staff, and four (66.7%) identified private ICU rooms and trained musicians as useful. Several barriers were also identified, including severity of patient illness and infection prevention concerns (n=5, 83.3%), space limitations in the ICU and patient privacy concerns (n=2, 33.35%), and patients being asleep (n=1, 16.75%).&#x0D; Conclusions: The results of this initiative indicated that therapeutic music in the ICU was rated as acceptable, appropriate, and feasible. Volunteer musicians reported the ability to provide live music in the ICU to be a beneficial and enjoyable experience. The program has been transitioned to a virtual format using a large iPad on wheels due to COVID-19-related visitation restrictions.

Development and validation of an early warning model for hospitalized COVID-19 patients: a multi-center retrospective cohort study

BackgroundTimely identification of deteriorating COVID-19 patients is needed to guide changes in clinical management and admission to intensive care units (ICUs). There is significant concern that widely used Early warning scores (EWSs) underestimate illness severity in COVID-19 patients and therefore, we developed an early warning model specifically for COVID-19 patients.MethodsWe retrospectively collected electronic medical record data to extract predictors and used these to fit a random forest model. To simulate the situation in which the model would have been developed after the first and implemented during the second COVID-19 ‘wave’ in the Netherlands, we performed a temporal validation by splitting all included patients into groups admitted before and after August 1, 2020. Furthermore, we propose a method for dynamic model updating to retain model performance over time. We evaluated model discrimination and calibration, performed a decision curve analysis, and quantified the importance of predictors using SHapley Additive exPlanations values.ResultsWe included 3514 COVID-19 patient admissions from six Dutch hospitals between February 2020 and May 2021, and included a total of 18 predictors for model fitting. The model showed a higher discriminative performance in terms of partial area under the receiver operating characteristic curve (0.82 [0.80–0.84]) compared to the National early warning score (0.72 [0.69–0.74]) and the Modified early warning score (0.67 [0.65–0.69]), a greater net benefit over a range of clinically relevant model thresholds, and relatively good calibration (intercept = 0.03 [− 0.09 to 0.14], slope = 0.79 [0.73–0.86]).ConclusionsThis study shows the potential benefit of moving from early warning models for the general inpatient population to models for specific patient groups. Further (independent) validation of the model is needed.

Use of Theory in Quality Innovations: Shift Change Protocol in the Emergency Department.

Inconsistent and nonstandardized patient handoffs can increase the risk of adverse events. Using change theory may promote adoption of effective handoff processes. A Midwest emergency department (ED) had no standardized practice for shift change handoffs. Previous handoff quality improvement efforts had been unsuccessful. A pre/postintervention pilot project design was used. Nurses' compliance with the new handoff protocol was evaluated. Using Diffusion of Innovation (DOI) theory, an evidence-based shift change protocol was designed and implemented, which included a comprehensive handoff tool specific to the ED. Four elements in the new shift change process saw statistically significant improvements after implementation, including discussion of the patient's illness severity ( P = .001), synthesis of the patient's care ( P < .001), completing a bedside safety checklist ( P < .001), and providing a formal transition-of-care process ( P < .001). Using DOI theory may improve the adoption of new shift change practices.

The Mediation Effect of Peripheral Biomarkers of Calcium Metabolism and Chronotypes in Bipolar Disorder Psychopathology.

Calcium (Ca++) metabolism may be impaired in several psychiatric diseases. We hypothesize that calcium imbalance might also correlate with a specific chronotype and could be recognized as a marker of illness severity in bipolar disorder (BD). We aimed to (1) identify the association between calcium imbalance and a specific chronotype in a cohort of BD patients, and (2) test the mediation role of high parathyroid hormone (PTH) levels towards a specific chronotype and illness severity in BD patients. Patients’ socio-demographic and clinical characteristics were collected with an ad-hoc schedule. We administered the Hamilton Depression Rating Scale (HAM-D), the Hamilton Rating Scale for Anxiety (HAM-A), the Young Mania Rating Scale (YMRS), and the Morningness Eveningness Questionnaire (MEQ). 100 patients affected by BD were recruited. The Kruskal-Wallis test showed a significant difference between the three MEQ groups in PTH levels (p < 0.001) and vitamin D levels (p = 0.048) but not in Ca++ levels (p = 0.426). Dwass-Steel-Critchlow-Fligner Pairwise analyses performed concerning three MEQ groups revealed significantly higher scores on PTH levels in MEQ-E subjects compared to MEQ-M and MEQ-I (in both cases, p < 0.001). No differences emerged between calcium levels among the three chronotypes. The mediation analysis has shown that elevated PTH levels are directly influenced by more severe HAM-A, HAM-D, and YMRS scores. MEQ-E could be a marker related to BD and predispose to various factors influencing mood symptoms. The combination of vitamin D therapy in MEQ-E may help to improve prognosis in this subtype of patients affected by BD.

Effect of COVID-19 on Serum Activity of Liver Enzymes: Is This Associated with Severity and Mortality Rate?

Abstract Introduction Coronavirus disease 2019 (COVID-19) is a viral infection caused by a novel coronavirus known as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease raises an enormous public health challenge for the international community. Liver enzymes have been reported to be frequently elevated in hospitalized patients with severe COVID-19 disease. Materials and Methods This article is a narrative review of abnormal liver tests and liver injury as a manifestation of progression to severe pneumonia. We collected data from the PubMed database (National Library of Medicine, Bethesda, Maryland, United States). We used the search term “abnormal liver test” and relevant records were measured. The review article was organized thematically. Results This narrative review aims to summarize the available clinical data on abnormal liver enzymes in coronavirus infection and its association with the risk of mortality, severer pneumonia, and systemic inflammation. Some clinical studies refer to abnormal liver tests and liver injury as a manifestation of progression to severe pneumonia. Recent research verified the relationship between hepatic liver enzyme activities and liver damage in patients with COVID-19, which suggested that it might reflect the infection severity and the mortality risk. Thus, this review investigated the correlation between liver serum enzymes level and the severity of COVID-19 patients, by reviewing investigating the relationship between the illness severity in COVID-19 patients with abnormal liver tests, liver pathology, and markers of inflammation. Conclusion In the current pandemic of SARS-CoV-2, abnormalities of liver enzyme tests were commonly observed in patients with COVID-19. However, because of multiorgan damages that observed in COVID-19 patients, various issues should be considered such as the pathology and pathophysiology of the liver tissue, especially on the activation process of the immune response and cytokine storm to prevent the severity of the disease.

MedML: Fusing medical knowledge and machine learning models for early pediatric COVID-19 hospitalization and severity prediction

SummaryThe COVID-19 pandemic has caused devastating economic and social disruption. This has led to a nationwide call for models to predict hospitalization and severe illness in patients with COVID-19 to inform the distribution of limited healthcare resources. To address this challenge, we propose a machine learning model, MedML, to conduct the hospitalization and severity prediction for the pediatric population using electronic health records. MedML extracts the most predictive features based on medical knowledge and propensity scores from over 6 million medical concepts and incorporates the inter-feature relationships in medical knowledge graphs via graph neural networks. We evaluate MedML on the National Cohort Collaborative (N3C) dataset. MedML achieves up to a 7% higher AUROC and 14% higher AUPRC compared to the best baseline machine learning models. MedML is a new machine learnig framework to incorporate clinical domain knowledge and is more predictive and explainable than current data-driven methods.

Factors Associated With Severe Illness in Patients Aged

To describe coronavirus disease 2019 (COVID-19)-related pediatric hospitalizations during a period of B.1.617.2 (Δ) variant predominance and to determine age-specific factors associated with severe illness. We abstracted data from medical charts to conduct a cross-sectional study of patients aged <21 years hospitalized at 6 United States children's hospitals from July to August 2021 for COVID-19 or with an incidental positive severe acute respiratory syndrome coronavirus 2 test. Among patients with COVID-19, we assessed factors associated with severe illness by calculating age-stratified prevalence ratios (PR). We defined severe illness as receiving high-flow nasal cannula, positive airway pressure, or invasive mechanical ventilation. Of 947 hospitalized patients, 759 (80.1%) had COVID-19, of whom 287 (37.8%) had severe illness. Factors associated with severe illness included coinfection with respiratory syncytial virus (RSV) (PR 3.64) and bacteria (PR 1.88) in infants; RSV coinfection in patients aged 1 to 4 years (PR 1.96); and obesity in patients aged 5 to 11 (PR 2.20) and 12 to 17 years (PR 2.48). Having ≥2 underlying medical conditions was associated with severe illness in patients aged <1 (PR 1.82), 5 to 11 (PR 3.72), and 12 to 17 years (PR 3.19). Among patients hospitalized for COVID-19, factors associated with severe illness included RSV coinfection in those aged <5 years, obesity in those aged 5 to 17 years, and other underlying conditions for all age groups <18 years. These findings can inform pediatric practice, risk communication, and prevention strategies, including vaccination against COVID-19.

Effect Of Exogenous Melatonin on the Incidence of Delirium and Its Association with Severity of Illness in Postoperative Surgical ICU Patients

Background: Delirium is common in critically ill intensive care unit (ICU) patients and has been documented in up to 87 percent of patients. Sleep deprivation and delirium have been associated. Alteration of melatonin production has been associated with delirium. Melatonin acts via melatonin receptors present in the suprachiasmatic nuclei (SCN) and promotes sleep by attenuating the wake-promoting signal from the SCN. Objective: To determine the relationship between exogenous melatonin and the incidence of delirium and its association of with severity of illness, measured in term of APACHE II, procalcitonin level at the time of admission and daily SOFA score. Patients and Methods: Design: Randomised placebo-control study. Setting: the study was conducted in critical care setting in a tertiary level ICU. Participants: Postoperative patients age between 20-60 years who are going to be ventilated more than 48 hours without any contraindication to enteral medications. Interventions: Study group received melatonin 5 mg through the enteral route. Main outcome measures: To determine the effect of exogenous melatonin on the incidence of delirium in postoperative patients who require mechanical ventilation for more than 24 hours. The secondary outcome measures are procalcitonin (PCT) value at admission and disease severity scores like APACHE II and SOFA. Results: No statistically significant difference was found in admission incidence of delirium or procalcitonin. Age was higher in those patients that developed delirium (p &lt; 0.05). Conclusions: Although the incidence of delirium is not affected by exogenous melatonin or higher APACHE scores, it had a significant correlation with higher procalcitonin, that in turn indicated an association with delirium and sepsis. It was found that there is increased risk of developing delirium with increasing age.

The Use of the SMART-COP Score in Predicting Severity Outcomes Among Patients With Community-Acquired Pneumonia: A Meta-Analysis.

Pneumonia is a pathological process of interstitial lung tissue and distal airway and alveolar infection and infiltration. SMART-COP (systolic blood pressure, multilobar infiltrates, albumin, respiratory rate, tachycardia, confusion, oxygen, and pH) is a severity score method designed to identify individuals who require intensive respiratory or vasopressor support (IRVS) support due to pneumonia. Therefore, it is important for management decisions in pneumonia. This meta-analysis was conducted to determine the performance of the SMART-COP score in predicting the prognosis and severity of patients presenting with community-acquired pneumonia (CAP). The current meta-analysis was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search was conducted using Medline, Embase, and CINAHL to identify relevant studies assessing the validity of the SMART-COP score in predicting the severity of patients with CAP. Overall, nine studies were included in the current meta-analysis. A pooled sensitivity of the SMART-COP score to predict the use of IRVS is 89% (95% CI: 84%-92%) while its specificity is 68% (95% CI: 65%-70%). The pooled sensitivity of the SMART-COP score to predict 30-day mortality is 92% (95% CI: 89%-94%) while its specificity is 39% (95% CI: 37%-42%). To summarize, SMART-COP is a new, eight-variable instrument that appears to accurately identify patients with CAP who will require IRVS and 30-day mortality. Our findings show that SMART-COP will be a valuable tool for clinicians in accurately predicting illness severity in CAP patients as compared to other scoring systems. SMART-COP can be useful to identify patients who need urgent management.

Hypoglycemia Is Associated With Worse Outcomes in Patients With Cholangitis Despite Undergoing Endoscopic Retrograde Cholangiopancreatography

BackgroundHypoglycemia has been associated with poorer outcomes in hospitalized patients undergoing surgical interventions. In cholangitis, endoscopic retrograde cholangiopancreatography (ERCP) is often a critical adjunct to surgery, capable of diagnosing and treating various biliary and pancreatic pathologies. While technically less invasive than surgery, the effect of hypoglycemia on clinical outcomes of patients with cholangitis undergoing ERCP has not been elucidated.MethodologyData were extracted from the National Inpatient Sample (NIS) database from 2016 to 2019. Using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, patients diagnosed with cholangitis and underwent ERCP were identified. Baseline demographic data, comorbidities, in-hospital mortality, hospital charges, and hospital length of stay (LOS) were extracted and compared based on the presence or absence of hypoglycemia. Statistical analysis was done using t-test and chi-square analyses. A multivariate analysis for the mortality odds ratio (OR) was calculated to adjust for possible confounders.ResultsA total of 256,540 patients with cholangitis who underwent ERCP were identified, and 2,810 of them had hypoglycemia during their hospitalization. The mean age of the hypoglycemia group was 64.41 years. Most patients were females (54%) and whites (57%). More patients in the hypoglycemia group had a history of alcoholism and congestive heart failure (CHF). Hypoglycemia was associated with higher odds of in-hospital mortality (OR = 6.71, confidence interval (CI) = 5.49-8.2; p < 0.0001). In addition to hypoglycemia, age >65 years, non-white race, and CHF were independently associated with higher mortality. Moreover, patients with hypoglycemia had higher total hospital charges ($87,147 vs. $133,400; p < 0.0001) and a significant increase in the LOS (9.7 vs. 6.7 days; p < 0.0001).ConclusionsPrevious studies in the surgical literature have linked hypoglycemia to increased incidence of atrial fibrillation, usage of mechanical ventilation, and application of circulatory support. Hypoglycemia may also affect the metabolism of the heart, leading to myocardial ischemia and malignant arrhythmias. However, it is unclear if hypoglycemia represents a proxy for the severity of patient illness as septic shock and renal insufficiency are common etiologies that may strongly impact mortality. Therefore, careful glycemic control during hospitalization should be practiced as hypoglycemia serves as a poor prognostic indicator that should not be overlooked.