Tertiary Care Public Teaching Hospital Research Articles

Prognostic importance of neutrophil-lymphocyte ratio in non-dialysis chronic kidney disease patients—a hospital-based prospective cohort

Aim: In patients with cancer, ischemic heart disease, and peripheral vascular disease, the neutrophil-lymphocyte ratio (NLR), a measure of systemic inflammation, has been demonstrated to predict mortality. This study aimed to evaluate the inflammatory status, and also examine the impact of NLR on renal outcomes (mortality and composite endpoints) in non-dialysis chronic kidney disease (CKD) patients. Methods: This prospective cohort was conducted at a tertiary care public teaching hospital. The NLR greater than 3.53 was taken as an indication of systemic inflammation. The outcome measures include composite endpoints (end-stage renal disease, dialysis commencement, doubling serum creatinine from the baseline), and mortality. Kaplan-Meier plots and a multivariate Cox proportional hazard model were employed to analyze the outcomes. Results: A cohort of 360 patients aged 53.7 years ± 13.9 years had a median follow-up of 14 months ± 4.24 months and was evaluated for inflammatory status and renal outcomes. The proportion of inflammation was found to be 101 (28.7%). Higher NLR levels had shown an increased incidence of mortality (5.3%) and composite endpoints (12.3%). In reference to the NLR quartile (Q1), the highest quartile (Q4) had shown 3 times increased hazards for mortality and 95.0% increased risk of hazards for composite endpoints Q4 hazard ratio (HR) 3.09; 95% confidence interval (CI) 1.38–6.91 (P = 0.006), and Q4 HR 1.93; 95% CI 1.22–3.08 (P = 0.005), respectively. Higher NLR was positively associated with urea, creatinine, alkaline phosphatase, Pt-Global web tool©/Patient-Generated Subjective Global Assessment score and negatively correlated with estimated glomerular filtration rate, albumin, hemoglobin. Conclusions: NLR is a potential predictor of mortality and composite endpoints in CKD patients even before they undergo dialysis. Additionally, inflammation should be regarded as a common comorbid condition in CKD patients due to its high prevalence.

Nutritional status, symptom burden, and predictive validity of the Pt-Global web tool/PG-SGA in CKD patients: A hospital based cross sectional study.

Despite not being frequently recognized, malnutrition, a consequence of chronic kidney disease, negatively affects morbidity, mortality, functional activity, and patient's quality of life. Management of this condition is made more difficult by the dearth of knowledge regarding the symptom burden brought on by inadequate nutritional status. Additionally, there are multiple tools to evaluate nutritional status in CKD; but, Pt-Global web tool/PG-SGA used in oncology, has not been investigated in chronic kidney disease patients. This study aimed to explore the nutritional status, symptom burden and also investigate the predictive validity of Pt-Global web tool/PG-SGA among pre-dialysis diabetic and non-diabetic chronic kidney disease patients. This cross-sectional study was carried out at a renal clinic of a tertiary care public teaching hospital. Nutritional status and symptom burden was evaluated by employing a 'Pt-Global web tool/PG-SGA' which is considered as a preeminent interdisciplinary tool in oncology and other chronic catabolic conditions. The predictive validity of the Pt-Global web tool/PG-SGA, referred as overall score for malnutrition was ascertained using Receiver Operating Curves (ROC). The conclusions were drawn using descriptive statistics, correlation, and regression analysis. In a sample of 450 pre-dialysis CKD patients, the malnutrition was present in 292(64.9%) patients. Diabetic CKD patients exhibit higher proportion of malnutrition 159(35.3%). The prevalence of malnutrition was exacerbated by eGFR reduction. The overall Pt-Global web tool/PGA-SGA score was significantly influenced by the symptoms of fatigue (81.5%), appetite loss (54.8%), physical pain (45.3%), constipation (31.78%), dry mouth (26.2%), and feeling full quickly (25.8%). The ROC analysis showed that the AUC for the total PG-SGA score was 0.988 (95% CI: 0.976-1.000), indicating that it is a reliable indicator of malnutrition. The sensitivity (84.2%) for identifying malnutrition was low when using the conventional tool cut off score of ≥9. Instead, it was discovered that a score of ≥3 had a greater sensitivity (99.3%) and specificity (44.3%) and was therefore recommended. This study not only presents empirical evidence of poor nutritional status in CKD patients but also reveals that it is worse in patients with diabetes, hypoalbuminemia, and poorer kidney function (well recognized risk factors for cardiovascular disease). Early diagnosis and management of symptoms contributing malnutrition will reduce mortality and CKD progression. The Pt-Global web tool/PG-SGA total score of 3 or more appears to be the ideal cut off score for identifying malnutrition, which can be utilized by dietician for improving malnutrition.

Clinical and radiographic assessment of periodontal status among patients with post-COVID mucormycosis: A cross-sectional study.

An escalation in cases of rhinomaxillary mucormycosis among post-COVID patients is being reported. However, there is limited information about periodontal features in mucormycosis cases. This study explored the periodontal signs and symptoms among post-COVID mucormycosis individuals. This cross-sectional study was carried out with a total of 25 post-COVID mucormycosis patients attending tertiary care public teaching hospital. Clinical and radiographic assessments were done. An elevation in mean probing pocket depth (PPD) up to 6.21 ± 2.7 mm was noted. Nearly 16%-40% of patients had Miller's Grade III mobility in the affected site. Forty-four per cent had localized single or multiple abscess, 40% had palatal swelling, 32% had necrosis of soft tissue and bone exposure, and 52% had maxillary dentoalveolar segmental mobility in the affected site. Radiographic examination revealed varying stages of interdental bone loss. The present study observed an increase in mobility and mean PPD which did not commiserate with interdental bone loss in the affected maxillary region.

MO569: Assessment of Inflammation Using Neutrophil-Lymphocyte Ratio Among Non-Dialyzed Chronic Kidney Disease Patients—A Prospective Observational Study

Abstract BACKGROUND AND AIMS Persistent low-grade inflammation is intimately linked to the pathophysiology of chronic kidney disease and contributes grossly to poor nutritional status and mortality. There is insufficient evidence on inflammation in relation to diabetic status, stages of CKD among chronic kidney disease patients before the commencement of dialysis. This study has characterized the prevalence and factors of inflammation among pre-dialysis chronic kidney disease patients at a tertiary care public teaching hospital. METHOD This longitudinal observational study adopted neutrophil–lymphocyte ratio (>3.53) to evaluate the inflammatory status among pre-dialysis chronic kidney disease patients. Glomerular filtration rate (eGFR) calculated by CKD-EPI equation from National Kidney Foundation was used as a measure of renal function. Multiple/multinomial regression analysis was also performed to determine the predictors of inflammatory status. RESULTS A total of 450 non-dialysis chronic kidney disease patients with or with diabetes were recruited during the period of study, consisting of 265 males and 185 females. Patients were aged 53.9 ± 14.2 years. According to neutrophil–lymphocyte ratio, the prevalence of inflammation among chronic kidney disease patients was found to be 91 (20.2%). The chronic kidney disease patients with diabetes 51(11.3%) were found to have higher rates of inflammation than non-diabetic chronic kidney disease patients 40 (8.9%). The adult age group 57 (12.7%) suffered more with inflammation than the elderly 34 (7.6%). Patients with severe malnutrition 42 (9.3%) were noted to have higher prevalence of inflammation followed by well-nourished 27 (6.0%) and mild/moderately malnourished population 22 (4.9%). The extent of inflammation was found to increase {CKD stage 1–2 (0.6%), CKD stage 3a-3b 34 (7.6%), CKD stage 4–5 54 (12.0%)} with decrease in renal residual function. Serum albumin, nutritional status and serum phosphorous have shown a significant association with the inflammatory status among chronic kidney disease patients. CONCLUSION The current findings demonstrate that the inflammation should be regarded as a familiar comorbid condition in chronic kidney disease. The intensity of inflammation is greater in patients with poorer renal function, comorbid diabetes and higher age. Future work needs to be aligned with respect to comprehensive understanding of inflammation mechanisms among patients with chronic kidney disease.

Accuracy of the Simplified HOSPITAL Score to Predict Nonelective Readmission in a Brazilian Tertiary Care Public Teaching Hospital.

Predictive models to identify patients at high risk of readmission have gained the attention of health care teams, which have focused the strategies to reduce unnecessary readmissions on the "at-risk" patients. The HOSPITAL score includes 7 predictor variables with a C-statistic of 0.70 or more when applied to international datasets. Its simplified version retains a C-statistic at around the same level, but only incipient external validation has been attempted to date. The primary objective of this study was to evaluate the prognostic accuracy of the simplified HOSPITAL score to predict nonelective hospital readmissions in a tertiary care public teaching hospital in Brazil. We used a retrospective cohort that included all patients discharged from the internal medicine service of a Brazilian tertiary care public teaching hospital in 2018. We excluded patients who died before index discharge, were transferred to another institution, left against medical advice, or were readmitted electively. We calculated the simplified HOSPITAL score for each admission, and admissions were divided into low (0-4 points) or high risk (≥ 5 points) of nonelective 30-day readmission. We estimated accuracy, area under the receiver operating characteristic curve (AUC), and observed/expected (O/E) readmission ratio; the latter using the mid-P exact test with Miettinen's modification at a 95% confidence interval (CI). A P value < .05 was considered significant. A total of 4472 hospital discharges were analyzed during the study period after application of the exclusion criteria. The nonelective 30-day readmission rate was 14.0% (n = 625). Of all patients discharged, 3173 (71.0%) were considered to be at low risk and 1299 (29.0%) at high risk of readmission according to the simplified HOSPITAL score. The AUC was 0.68 (95% CI: 0.66-0.71; P < .001). The nonelective 30-day readmission rate was 9.2% in the low-risk group (expected: 9.2%; O/E: 1.0 [95% CI: 0.89-1.12]) and 25.7% in the high-risk group (expected: 27.2%; O/E: 0.95 [95% CI: 0.85-1.05]) ( P < .001). At a cut-off of 5 points, the score had a sensitivity of 53.4%, specificity of 74.9%, positive predictive value of 25.7%, and negative predictive value (NPV) of 90.8%. The parameters of the score were almost identical to the original study, with better applicability to exclude low-risk patients given its high NPV. Additional adjustments are still needed for better applicability in daily clinical practice.

Burden and correlates of cognitive impairment among hypertensive patients in Tanzania: a cross-sectional study

BackgroundThe evolution of cognitive impairment of vascular origin is increasingly becoming a prominent health threat particularly in this era where hypertension is the leading contributor of global disease burden and overall health loss. Hypertension is associated with the alteration of the cerebral microcirculation coupled by unfavorable vascular remodeling with consequential slowing of mental processing speed, reduced abstract reasoning, loss of linguistic abilities, and attention and memory deficits. Owing to the rapidly rising burden of hypertension in Tanzania, we sought to assess the prevalence and correlates of cognitive impairment among hypertensive patients attending a tertiary cardiovascular hospital in Tanzania.MethodologyA hospital-based cross-sectional study was conducted at Jakaya Kikwete Cardiac Institute, a tertiary care public teaching hospital in Dar es Salaam, Tanzania between March 2020 and February 2021. A consecutive sampling method was utilized to recruit consented hypertensive outpatients during their scheduled clinic visit. General Practitioner Assessment of Cognition (GPCOG) Score was utilized in the assessment of cognitive functions. All statistical analyses utilized STATA v11.0 software. Pearson Chi square and Student’s T-test were used to compare categorical and continuous variables respectively. Logistic regression analyses were used to assess for factors associated with cognitive impairment. Odd ratios with 95% confidence intervals and p-values are reported. All tests were 2-sided and p < 0.05 was used to denote a statistical significance.ResultsA total of 1201 hypertensive patients were enrolled in this study. The mean age was 58.1 years and females constituted nearly two-thirds of the study population. About three quarters had excess body weight, 16.6% had diabetes, 7.7% had history of stroke, 5.7% had heart failure, 16.7% had renal dysfunction, 53.7% had anemia, 27.7% had hypertriglyceridemia, 38.5% had elevated LDL, and 2.4% were HIV-infected. Nearly two-thirds of participants had uncontrolled blood pressure and 8.7% had orthostatic hypotension. Overall, 524 (43.6%) of participants had cognitive impairment. During bivariate analysis in a logistic regression model of 16 characteristics, 14 parameters showed association with cognitive functions. However, after controlling for confounders, multivariate analysis revealed ≤primary education (OR 3.5, 95%CI 2.4–5.2, p < 0.001), unemployed state (OR 1.7, 95%CI 1.2–2.6, p < 0.01), rural habitation (OR 1.8, 95%CI 1.1–2.9, p = 0.01) and renal dysfunction (OR 1.7, 95%CI 1.0–2.7, p = 0.04) to have independent association with cognitive impairment.ConclusionThis present study underscore that cognitive decline is considerably prevalent among individuals with systemic hypertension. In view of this, it is pivotal to incorporate cognitive assessment in routine evaluation of hypertensive patients.

Malnutrition among elderly a multifactorial condition to flourish: Evidence from a cross-sectional study

AimThe negative outcomes like an increased risk of falling, anemia, immune dysregulation, impaired cognitive status, reduced muscle function, increased morbidity and mortality associated with malnutrition are believed to affect the economy of the country in the future years. In this backdrop, this study aims to evaluate the nutritional status and different risk factors associated with malnutrition among elderly patients at a tertiary care public teaching hospital. MethodsThis questionnaire-based study utilized the “Mini Nutritional Assessment-Short Form” tool to evaluate the nutritional status of elderly inpatients (aged 60 years or more). The data obtained from 235 participants reporting in the medicine department is presented. Based upon MNA-SF tool parameters, a well-determined score was obtained and on the basis of scores, the patients were categorized into “normal” (12–14), “at risk of malnutrition” (8–11 points) and “malnourished” (0–7 points). Multinomial logistic regression was performed to study the influence of different determinants on the nutritional status among elderly inpatients. ResultsThe studied sample had a high frequency of 50.2% for the patients who are “at risk of malnutrition” and 46.4% of patients were “malnourished”. Based on the evaluated scores of MNA-SF tool, this study also confirms that the mobility functions, the decline in food intake and weight loss are major risk factors for malnutrition. ConclusionsA very high prevalence of malnutrition was observed, in consonance with the previous reports. The findings also indicate that malnutrition is a multifactorial condition mostly associated with mobility dysfunction followed by somatic factors and socio-demographic factors. Further studies are required to map the risk factors in order to avoid the associated negative outcomes.

A Study on Evaluation of Fall Risk Among Geriatric Patients At A Tertiary Care Public Teaching Hospital

A Study on Evaluation of Fall Risk Among Geriatric Patients At A Tertiary Care Public Teaching Hospital

Emerging trends of nosocomial pneumonia in intensive care unit of a tertiary care public teaching hospital in Western India.

Background:Nosocomial pneumonia poses great challenge to an intensivist. Detailed information about hospital-acquired pneumonia (HAP) and ventilator-acquired pneumonia (VAP) is crucial for prevention and optimal management, thus improving quality Intensive Care Unit (ICU) care. Hence, we aimed to study the current trend of nosocomial pneumonia in ICU.Materials and Methods:It was a prospective observational cohort study, conducted in the ICU of a tertiary care teaching public hospital over a period of 18 months. We studied clinical profile and outcome of 120 adult patients who developed VAP/HAP during the study period. We also analyzed the causative organisms, antibiotic sensitivity, and resistance pattern in these patients.Results:Out of 120 patients, 29 patients were HAP and 91 patients were VAP. Mortality was 60% (72), and development of VAP and requirement of mechanical ventilation showed significant association with mortality (P < 0.00001). Most common organism causing HAP was Staphylococcus aureus (43.4%) and VAP was Klebsiella pneumoniae (49%). Maximum antibiotic sensitivity was found to piperacillin + tazobactam (58.8%), followed by imipenem (49.5%) and meropenem (41.8%), whereas maximum antibiotic resistance was found to cefepime (95.1%), followed by ceftazidime and amoxicillin (91.2%).Conclusion:Nosocomial pneumonia showed high incidence (17.44%) and mortality (60%). Common organisms identified were S. aureus and K. pneumoniae. Resistance was high for commonly used antibiotics and high antibiotic sensitivity for piperacillin + tazobactam and carbapenem.

PSY6 - Prevalence and Management of Anemia in Patients of Chronic Kidney Disease at a Tertiary Care Public Teaching Hospital: Evidence from a Cross Sectional Study

PSY6 - Prevalence and Management of Anemia in Patients of Chronic Kidney Disease at a Tertiary Care Public Teaching Hospital: Evidence from a Cross Sectional Study

PIH17 - Assessment of Prescribing Pattern in Elderly Inpatients at Tertiary Care Public Teaching Hospital

PIH17 - Assessment of Prescribing Pattern in Elderly Inpatients at Tertiary Care Public Teaching Hospital

Drug Utilization Pattern in Chronic Kidney Disease Patients at a Tertiary Care Public Teaching Hospital: Evidence from a Cross- Sectional Study

Introduction: Patients with chronic kidney disease usually have multiple co-morbidities and, therefore, require multiple pills. Objective: To evaluate the prescribing pattern in patients of chronic kidney disease. Method: This study  was carried out at a renal clinic of medicine OPD of a tertiary care public teaching hospital for a period of one year. Patients diagnosed with CKD according to KDIGO guideline were included in the study. Medications were classified into different groups on the basis of Anatomic Therapeutic Chemical (ATC) classification Results: A total of 408 patients diagnosed with CKD were included in study. The average age of the patients was 53.8 (6.4). Of all, 18% of the patients were on dialysis. It was found that 42% of the patients belonged to end stage of renal disease. The mean (SD) of drugs was found to be 6.57 (2.3). Only 19% of the drugs prescribed out of Indian National List of Essential Medicine (NLEM). No drug was found to be prescribed by generic name. Out of total 2,681 drugs prescribed, most commonly prescribed were cardiovascular drugs (33.9%). Further, it was also found that 14.7% of the patients were prescribed with antimicrobials. Among all, 22.3% of the patients were vaccinated with hepatitis B vaccine. Five most commonly prescribed drugs were calcium carbonate, vitamin D, iron, torsemide and amlodipine (13.9%, 12.2%, 11.5%, 8.1% and 6.1%, respectively). Ninety-five percent of the patients were prescribed phosphate binder (PB). Calcium carbonate was the most commonly used PB prescribed to 91.1% of the patients. Sevelamer was prescribed to only 18 patients. Conclusion: The calcium based phosphate binders were found to be the most commonly prescribed drug. Maximum number of drugs was prescribed from cardiovascular drugs. Prescribing was found consistent with NLEM.

Intento de Suicidio Vía Ingesta de Fármacos en Niños

Suicide attempts in children are an important worldwide cause of morbidity and mortality and an emerging reason for admission in Pediatric Critical Care.  Objective:  Identify the epidemiologic and clinical characteristics of patients with drug poisoning with a suicide purpose as an admission cause in a Chilean Pediatric Intensive Care Unit (PICU).  Design:  Retrospective observational study.  Setting:  14 beds PICU of a tertiary care public teaching hospital in Santiago de Chile.  Material and Method:  All patients admitted to the PICU between January 2005 and December 2008 for self-inflicted drug poisoning with an expressed intention of suicide were included. Analysis of the PICU clinical chart was performed with sampling on an excel data base. For seasonal distribution we used statistical analysis  Xil.  Results:  178 of 3045 PICU admissions were diagnosed as drug poisoning (5,8%), 108 of them for suicide attempts (60,6 %).The number of annual patients increased, with highest incidence in spring and autumn and lowest in winter. Mean and median age was 13 years, 8,4% less than 12 years. 88,9% were females. They used polipharmacy in 57%. Drugs were taken from home. Antidepressants and sedatives were the most often used. An underlying psychiatric condition was present in 100 cases (92,6%). Associated factors were family disfunction, school problems, abuse and violation and bullying. Mean PICU stay was 1,46 days with 16,7 % requiring transient mechanical ventilation No death was reported in this serie.  Conclusions:  The number of cases of suicide attempt via drug ingestion as a motive for admission in PICU is increasing, causing a raising number of short and transient admissions, more in spring less in winter. Risk factors were mostly an underlying psychiatric disorder and family disfunction.

Directions for clinical practice improvement in HFE gene mutation testing

To audit the clinical indications for HFE gene mutation testing in a consecutive series of requests. Retrospective audit of reasons prompting 187 HFE test requests received between June 2003 and June 2005, by examination of the request form, hospital notes (when available) and, when required, information from the referring doctor. A tertiary care public teaching hospital laboratory, Perth, Western Australia. Reasons prompting requests for HFE genotype testing and compliance with accepted clinical indications (biochemical evidence of iron overload on repeated samples, or a first-degree relative with either haemochromatosis or a C282Y mutation). Insufficient clinical details in requests prevented the inclusion of interpretive comments in HFE genotype reports in 70 of 187 cases (37%). Re-evaluation after collation of the missing details for all but seven requests revealed that 103 of the 180 auditable requests (57%) had been prompted for reasons other than biochemical evidence of iron accumulation or family history. A substantial proportion of HFE genotype test requests are made for inappropriate reasons. Clinical practice could be improved by educating doctors on the practical utility of this genetic test and by laboratories taking steps to secure the clinical information needed to include appropriate interpretive comments in their reports.

Queuing for coronary angiography during severe supply-demand mismatch in a US public hospital: analysis of a waiting list registry.

Adverse cardiac events have been reported in patients waiting for either coronary surgery or angioplasty. However, data on the risk of adverse events while awaiting coronary angiography are limited, and none are available from a US population. To quantify cardiac outcomes in patients waiting for elective coronary angiography. Observational cohort study of 381 adult outpatients (mean [SD] age, 55 [12] years; 64% male; 61% white) on a waiting list for coronary angiography at a US tertiary care public teaching hospital during 1993-1994. Rates of cardiac death, nonfatal myocardial infarction, and hospitalizations for unstable angina or heart failure as a function of amount of time spent on a waiting list. Sixty-six patients were dropped from the waiting list but were included in the study analysis. During a mean (SD) follow-up of 8.4 (6.5) months, cardiac death, myocardial infarction, and hospitalization occurred in 6 (1.6%), 4 (1.0%), and 26 (6.8%) patients, respectively. The probability of events was minimal in the first 2 weeks and increased steadily between 3 and 13 weeks. By Cox multivariate analysis, 2 variables independently identified an increased risk of adverse events: a strongly positive treadmill exercise electrocardiogram or positive stress imaging result at referral (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.22-4.16; P=.01) and the use of 2 to 3 anti-ischemic medications (OR, 1.98; 95% CI, 1.19-3.96; P=.04). Among 311 patients who ultimately underwent angiography, those with adverse events had a higher prevalence of coronary disease (96% vs 60%; P<.001), more frequently required revascularization (93% vs 53%; P<.001), and had longer hospital stays (mean [SD], 6.2 [4.3] vs 1.3 [0.7] days; P=.001). Our data suggest that in a cohort referred for coronary angiography, delaying the procedure places some patients at risk for death, myocardial infarction, unplanned hospitalization, a longer hospital stay, and, potentially, a poorer prognosis. Waits longer than 2 weeks should be avoided, and patients with strongly positive stress test results and those who require 2 to 3 anti-ischemic medications should be prioritized for early intervention.