Unit Admission Research Articles

1058-P: Diabetic Ketoacidosis during Pregnancy: Maternal Characteristics and Pregnancy Outcomes

Diabetic ketoacidosis (DKA) during pregnancy is an obstetric emergency associated with morbidity and mortality. As this condition is rare (affecting 1-3% pregnant women with preexisting diabetes) , available data are limited. The aim of this retrospective cohort study is to present comprehensive data on maternal characteristics and pregnancy outcomes for women with DKA who attended our center for prenatal care from 2001-21. In total 71 DKA episodes were identified in 58 women, of whom 86% (n=50) had type 1 diabetes mellitus and 83% (n=48) were White. The mean (±SD) maternal age was 28 (±7) years and diabetes duration was (±7) years. Pregnancy loss during or within 1 week of the DKA episode occurred in 17% (6 miscarriages and 4 stillbirths) . There were no maternal deaths. Women were poorly prepared for pregnancy [mean 1st trimester HbA1c 9.3 (±2.5) %]. Social stressors were present in 52% (n=30) and 24% (n=14) reported smoking. The mean gestational age at DKA was 25.4 weeks (16.3 weeks for pregnancies with fetal demise vs. 27.5 weeks for livebirths, p<0.001) . Insulin non-adherence was the most common precipitating factor (40%) , followed by infection (23%) , and a new diagnosis of type 1 diabetes (10%) . Pre-existing hyperemesis was associated with fetal demise (31%, n=4 vs. 3%, n=2 among livebirths; p=0.004) . The mean plasma glucose at presentation was 362 mg/dL and the β-hydroxybutyrate was 4.2 mmol/L, with 28 (39%) women requiring intensive care unit (ICU) admission. Among livebirths, the mean gestational age at delivery was 32.7 weeks with 41% (n=21) requiring emergency cesarean. Large for gestational age occurred in 29% (n=17) and 8% (n=4) had shoulder dystocia. Congenital anomaly was present in 10% (n=5) . Neonatal hypoglycemia occurred in 60% (n=29) and neonatal ICU admission was required in 52% (n=25) . In summary, pregnancies affected by DKA continue to be associated with numerous adverse pregnancy outcomes. Future work should focus on optimizing prevention strategies in high-risk women. Disclosure M.Dhanasekaran: None. S.Mohan: None. D.Erickson: None. P.Shah: None. L.M.Szymanski: None. A.Vella: Advisory Panel; Crinetics Pharmaceuticals, Inc., Rezolute, Inc., vTv Therapeutics, Zealand Pharma A/S, Other Relationship; Novo Nordisk. A.M.Egan: None. Funding National Institutes of Health (K12 HD065987/HD/NICHD)

1210-P: Associations between HbA1c, Area Level Social Vulnerability, and Poor COVID-Outcomes

Background: HbA1c has been associated with COVID-poor outcomes in diabetic and non-diabetic populations, while patients living in census tracts with high levels of social vulnerability [measured using the CDC’s Social Vulnerability Index (SVI) ] have experienced poorer outcomes. Objective: To examine associations between HbA1c, area level social vulnerability and poor COVID outcomes in patients who tested positive for COVID and were captured in the electronic medical record (EMR) at a large academic institution in the Southeastern United States. Methods: HbA1c and SVI, collected up to 3 years prior to a positive COVID test, were extracted from the EMR. HbA1c and SVI were compared by poor outcome status [hospitalization, intensive care unit (ICU) admission, and mortality]. Bayesian logistic regression was used to examine associations between HbA1c [≤5.7%; 5.7%-<6.5%; and ≥6.5%], SVI [living in high SVI census tract vs low SVI tract] and each COVID outcome separately. Multivariable models were adjusted for sex, age, race, body mass index and diabetes status. Results presented as odds ratios (OR) and 95% confidence intervals (95% CI) . Results: N=3,7patients were identified [mean age: 54 years (SD 16.3) , 60% female, 47% Black]. Patients with HbA1c ≥ 6.5% and those living in a high SVI census tract were more likely to experience a poor COVID outcome (p’s<0.0001) . In multivariable models, patients with HbA1c ≥ 6.5% had higher odds of hospitalization (OR 1.79, 95% CI 1.44-2.22) ; ICU admission (OR 2.13, 95% CI 1.78-2.55) ; and mortality (OR 1.60, 95% CI 1.12-2.28) . Patients living in a high SVI census tract had higher odds of hospitalization (OR 2.47, 95% CI 1.94-3.15) ; ICU admission (OR 2.58, 95% CI 2.12-3.14) ; and mortality (OR 2.07, 95% CI 1.39-3.09) . Conclusion: HbA1c ≥6.5% and living in a census tract with high social vulnerability were independently associated with poor COVID-outcomes. Findings highlight the need to assess HbA1c and area level social determinants in the context of COVID. Disclosure C.R.Howell: None. L.Zhang: None. S.Williams: None. N.Yi: None. W.Garvey: Other Relationship; Boehringer Ingelheim International GmbH, Eli Lilly and Company, Epitomee, JAZZ Pharmaceuticals, Novo Nordisk, Novo Nordisk, Pfizer Inc., Pfizer Inc. A.Cherrington: Consultant; Bayer AG, Other Relationship; Novo Nordisk. Funding This work was supported by funding from the National Institute on Minority Health and Health Disparities (U54MD008176) .

1239-P: Predictors for COVID-Severity among Hospitalized Patients with Diabetes in Japan

Background: COVID-is a pandemic disease caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) . Diabetes is a major risk factor for the severe progression and outcome of COVID-infection. Although some risk factors have been revealed, determining undetected risk factors for severe infection would enable identifying patients who may benefit from aggressive supportive care and early intervention. Methods: A retrospective observational study of 100 diabetes patients who were admitted with confirmed COVID-infection was conducted. The patients were divided into two groups - severe and moderate - based on intensive care unit (ICU) admission. The differences between the groups were analyzed with multivariable logistic regression to reveal the risk factors. Results: Of 100 patients, the mean (SD) age was 62.1 (13.0) years, 70 (70.0%) were male, and 48 (48.0%) were ≥ 65 years. Among patients with severe COVID-infection, 25 (25%) were admitted to ICU, and one patient died. Patients with severe infection had a significantly lower albumin level (severe 2.81 ± 0.37 g/dL vs. moderate 3.39 ± 0.50, p<0.01) , and a higher blood glucose (221.5 ± 91.3 mg/dL vs. 178.9 ± 73.4, p=0.02) , white blood cell count (8969 ± 5002 /μL vs. 6227 ± 2644, p=0.01) , C-reactive protein (CRP) (12.5 ± 9.2 mg/dL vs. 6.4 ± 5.5, p<0.01) , and lactate dehydrogenase (572.5 ± 165.9 U/L vs. 353.5 ± 150.9, p<0.01) level than did patients without severe infection. There was no significant difference with hypertension, dyslipidemia, smoking, obesity, and HbA1c. Patients with severe infection had significantly lower total protein and albumin levels. On multivariable logistic regression analysis, risk factors for severe infection included CRP on admission (odds ratio [OR], 1.090; 95% CI, 1.005-1.183) , age (OR, 0.944; 95% CI, 0.899-0.991) , and albumin (OR, 0.036; 95% CI, 0.007-0.191) . Conclusions: In patients with diabetes, albumin was an independent predictor for the development of severe COVID-19. Disclosure M.Shoji: None. N.Teramoto: None. A.Hayashi: None. Y.Maeda: None. H.Ochiai: None. A.Tsukagoshi: None. Y.Maezawa: None. M.Koshizaka: None. K.Yokote: None.

Intelligence outcome of pediatric intensive care unit survivors: a systematic meta-analysis and meta-regression

BackgroundLong-term morbidity after pediatric intensive care unit (PICU) admission is a growing concern. Both critical illness and accompanying PICU treatments may impact neurocognitive development as assessed by its gold standard measure; intelligence. This meta-analysis and meta-regression quantifies intelligence outcome after PICU admission and explores risk factors for poor intelligence outcome.MethodsPubMed, Embase, CINAHL and PsycINFO were searched for relevant studies, published from database inception until September 7, 2021. Using random-effects meta-analysis, we calculated the standardized mean difference in full-scale intelligence quotient (FSIQ) between PICU survivors and controls across all included studies and additionally distinguishing between PICU subgroups based on indications for admission. Relation between demographic and clinical risk factors and study’s FSIQ effect sizes was investigated using random-effects meta-regression analysis.ResultsA total of 123 articles was included, published between 1973 and 2021, including 8,119 PICU survivors and 1,757 controls. We found 0.47 SD (7.1 IQ-points) lower FSIQ scores in PICU survivors compared to controls (95%CI -0.55 to -0.40, p < .001). All studied PICU subgroups had lower FSIQ compared to controls (range 0.38–0.88 SD). Later year of PICU admission (range 1972–2016) and longer PICU stay were related to greater FSIQ impairment (R2 = 21%, 95%CI -0.021 to -0.007, p < .001 and R2 = 2%, 95%CI -0.027 to -0.002, p = .03, respectively), whereas male sex and higher rate of survivors were related to smaller FSIQ impairment (R2 = 5%, 95%CI 0.001 to 0.014, p = .03 and R2 = 11%, 95%CI 0.006 to 0.022, p < .001, respectively). Meta-regression in PICU subgroups showed that later year of PICU admission was related to greater FSIQ impairment in children admitted after cardiac surgery and heart- or heart–lung transplantation. Male sex was related to smaller FSIQ impairment in children admitted after cardiac surgery. Older age at PICU admission and older age at follow-up were related to smaller FSIQ impairment in children admitted after heart- or heart–lung transplantation.ConclusionsPICU survivors, distinguished in a wide range of subgroups, are at risk of intelligence impairment. Length of PICU stay, female sex and lower rate of survivors were related to greater intelligence impairment. Intelligence outcome has worsened over the years, potentially reflecting the increasing percentage of children surviving PICU admission.

COVID-19 in patients with gynecologic cancer: A preliminary report from the COVID-19 and Cancer Consortium (CCC19).

5508 Background: Limited information exists regarding the severity of short-term outcomes among patients with gynecologic cancer who are infected with SARS-CoV-2. Methods: Patients with gynecologic cancer and laboratory confirmed SARS-CoV-2 infection were identified from the international CCC19 registry. We estimated odds ratios (OR) from ordinal logistic regression for associations with severity of COVID-19 outcomes, defined from least to most severe as hospitalization, intensive care unit (ICU) admittance, mechanical ventilation, and 30-day mortality. Results: Of 842 patients identified, 48% had endometrial cancer, 24% had ovarian cancer, 22% had cervical cancer, and 6% had dual primary/other gynecologic cancers. The majority were from the United States (86%), most were non-Hispanic White (46%), and the median age was 62 years (IQR 52-72). The majority were diagnosed with localized disease (68%); only 18 (2%) and 15 (2%) were fully or partially vaccinated, respectively. In the 3 months prior to COVID-19, 36% had any cancer treatment, with chemotherapy the most common (23%). When diagnosed with COVID-19, most patients were in remission (50%), while 37% had active disease, including 22% with metastatic disease. Most patients presented with typical COVID-19 symptoms (76%); few had a poor ECOG performance status (PS ≥2, 14%). Outcomes included hospitalization (50%), ICU admittance (12%), mechanical ventilation (8%), and death within 30 days of testing positive for SARS-CoV-2 (10%). In unadjusted models, increasing age (OR: 1.03 1.02-1.04) and Black race (OR 1.91, 1.31-2.77) were associated with increased severity of COVID-19 outcomes. Compared to patients in remission for ≥5 years, those with progressive disease had increased severity (OR 1.88, 1.25-2.82), while those in remission for &lt; 5 years or with stable disease had decreased severity of COVID-19 outcomes (OR 0.55, 0.39-0.76). In multivariable models that included adjustment for age, race, and cancer status, additional factors associated with increased COVID-19 outcome severity included cardiac (OR 1.57, 1.13-2.19) and renal (OR 2.00, 1.33-3.00) comorbidities, an ECOG PS ≥2 (OR 5.15, 3.21-8.27), having pneumonia or pneumonitis (OR 4.08, 2.94-5.66), venous thromboembolism (OR 4.67, 2.49-8.75), sepsis (OR 14.2, 9.05-22.1), or a co-infection within ±2 weeks of SARS-CoV-2 (OR: 4.40, 2.91-6.65); asymptomatic SARS-CoV-2 infection was associated with decreased severity of outcomes (OR: 0.25, 0.16-0.38). The overall case fatality rate was 15.7%. Conclusions: Patients with gynecologic cancer experience significant morbidity and mortality related to infection with SARS-CoV-2. Age, race, cancer status, co-morbidities, and COVID-19 complications were associated with more severe COVID-19 outcomes, along the continuum from least to most, of hospitalization, ICU admittance, mechanical ventilation, and 30-day mortality.

Postpartum psychosis treatment: review of mother-baby units

IntroductionPostpartum Psychosis is an underdiagnosticated psychiatric condition that may be suffered by mothers within a year since delivery. It is a severe syndrome in which symptoms such as delusions, hallucinations and disorganized thinking may appear. The traditional approach of admitting the mothers separated from their children has shown harmful consequences. This has led to the creation of Mother-Baby Units (MBU), psychiatric admission units dedicated to full-time housing mothers and their babies.Objectives To evaluate the evidence available regarding the potential benefits of MBU not only for the mothers, the babies, but for the mother-baby bond. To analyse postpartum psychosis risk factors and prognosis.MethodsA thorough review of scientific literature and databases regarding postpartum psychosis and MBU has been carried out. Additionally, international mental health care guidelines for perinatal mental disorders were analysed.ResultsA wide range of related aspects were studied for the present work, including characteristics of the patients, differences in the self- assessment scales of depression, anxiety, postpartum attachment of the mother to the baby at admission and at discharge and the work and social adaptation. Other studies analysed the percentage of mother-baby separation at discharge, as well as the most frequent delusions, and the potential effect of childhood trauma on these patients.ConclusionsThe available evidence suggest that MBU may be helpful for the improvement of the mental health in women suffering perinatal mental disorders and for the building of a secure attachment style in the baby. The results of the interventions included in MBU programs also show promotion of a positive mother-baby relationship.DisclosureNo significant relationships.

Diabetes Mellitus and Related Admission Factors Among Hospitalized Patients in King Abdul-Aziz University Hospital in Jeddah, Saudi Arabia.

BackgroundDiabetes mellitus (DM) is a rapidly increasing serious health problem that affects the population all over the world. The increasing prevalence of DM in Saudi Arabia is reflected in our hospital admissions as well. This study aimed to assess the proportion of DM (including type 1 and type 2 diabetes) among hospitalized patients and the reasons for admissions to the medical unit at King Abdul-Aziz University Hospital (KAUH) in Jeddah, Saudi Arabia.MethodsWe conducted a hospital record-based cross-sectional study at KAUH from January to April 2021. The study included all adult patients admitted to the internal medicine wards and isolation unit but excluded patients in the coronary care unit and those with gestational diabetes. We reviewed the medical records to collect demographic data, causes of admission, laboratory results, and outcomes.ResultsAmong the hospitalized patients, 49.9% had DM. The most common associated risk factors and causes of admission among patients with DM were hypertension (HTN; 73.2%) and dyslipidemia (43.1%). Other less common reasons for admission were heart failure (20.6%), coronavirus disease-2019 (COVID-19; 17.8%), chronic kidney disease (CKD; 14.5%), pneumonia (12.3%), and stroke (10%). Dyslipidemia, HTN, CKD, diabetic ketoacidosis, heart failure, and need for intensive care unit (ICU) admission were significantly higher in diabetic patients as compared to patients without diabetes. HTN, dyslipidemia, CKD, heart failure, stroke, acute abdomen, and malignancy were significantly higher in patients with type 2 diabetes. Among diabetic patients, those with non-Saudi nationality, low hemoglobin level, dyslipidemia, pneumonia, sepsis, and requiring ICU admission had a greater risk of death.ConclusionsThe high burden of DM on the secondary healthcare level in Saudi Arabia highlights the need for effective diabetes prevention and treatment strategies in primary care and hospital outpatient settings. Such measures would help reduce the hospitalization rate and ease the healthcare system’s burden.

Lessons learned: Characteristics of first-year COVID-19 hospital outbreaks

Background: At the start of the COVID-19 pandemic, the DC Department of Health (DC Health) mandated new case reporting for early outbreak detection: (1) weekly healthcare personnel (HCP) absenteeism line lists indicating staff absent for confirmed or suspected SARS-CoV-2, (2) daily line lists of all SARS-CoV-2–positive inpatients, and (3) hospital contact tracing. Between March 27, 2020, and December 31, 2020, DC Health detected 36 confirmed and 14 suspected hospital outbreaks, of which only 18% (8 confirmed and 1 suspect) were known to the affected hospital. DC Health learned which outbreaks warranted early or aggressive intervention by tracking outbreak characteristics across its jurisdiction. This allowed prioritization of during surges when it was difficult for DC Health and hospital staff to investigate every outbreak. Methods: Potential outbreaks in short-stay and inpatient rehabilitation hospitals were flagged after identifying SARS-CoV-2 hospital-onset (HO) inpatients or staff clusters on line lists. Variables of interest in line lists included specimen collection and hospital admission dates, units or departments, and patient contact. Facility contact tracing by infection preventionists further verified epidemiological links among cases. Outbreak details were systematically tracked in a locally developed REDCap database and were analyzed if they had an initial case, outbreak start date, or an investigation start date in 2020. Frequency procedures, SQL statements, and date calculations were computed using SAS Enterprise Guide version 8.3 software. Results: Confirmed outbreaks had an average of 6.92 (range, 0–32) HCP and 2.58 (range, 0–22) patient cases, with 69% being confirmed-HO cases and 31% probable HO. Moreover, 53% of confirmed outbreaks occurred in the following departments: cardiac, behavioral health, intensive care, and environmental services (EVS)/facilities. All of these departments had recurrent outbreaks. Behavioral health, medical and cardiac units had the highest number of patient cases. On average, confirmed outbreak investigations lasted 24.6 days, with outbreaks prolonged in the ICU (40.25 days) and the medical unit (37.67 days). Top triggers for investigations ultimately classified as confirmed outbreaks were (1) positive symptomatic HCP, (2) confirmed-HO cases, and (3) exposures from positive HCP. Conclusions: The dynamic nature of COVID-19 created challenges in detecting and responding to hospital outbreaks. Developing a low-resource outbreak tracking system helped identify outbreak types and triggers that warranted early or aggressive interventions. Understanding the characteristics of hospital outbreaks was critical for maximizing infection control resources during surges of infectious disease outbreaks, such as COVID-19. Hospitals or local health departments could adapt this system to meet their needs.Funding: NoneDisclosures: None

Association between delta anion gap and hospital mortality for patients in cardiothoracic surgery recovery unit: a retrospective cohort study

BackgroundsHigh level of anion gap (AG) was associated with organic acidosis. This study aimed to explore the relationship between delta AG (ΔAG = AGmax − AGmin) during first 3 days after intensive care unit (ICU) admission and hospital mortality for patients admitted in the cardiothoracic surgery recovery unit (CSRU).MethodsIn this retrospective cohort study, we identified patients from the open access database called Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC III). A logistic regression model was established to predict hospital mortality by adjusting confounding factors using a stepwise backward elimination method. We conducted receiver operating characteristic (ROC) curves to compare the diagnostic performance of acid–base variables. Cox regression model and Kaplan Meier curve were applied to predict patients’ 90-day overall survival (OS).ResultsA total of 2,860 patients were identified. ΔAG was an independent predictive factor of hospital mortality (OR = 1.24 per 1 mEq/L increase, 95% CI: 1.11–1.39, p < 0.001). The area under curve (AUC) values of ΔAG suggested a good diagnostic accuracy (AUC = 0.769). We established the following formula to estimate patients’ hospital mortality: Logit(P) = − 15.69 + 0.21ΔAG + 0.13age-0.21BE + 2.69AKF. After calculating Youden index, patients with ΔAG ≥ 7 was considered at high risk (OR = 4.23, 95% CI: 1.22–14.63, p = 0.023). Kaplan Meier curve demonstrated that patients with ΔAG ≥ 7 had a poorer 90-day OS (Adjusted HR = 3.20, 95% CI: 1.81–5.65, p < 0.001).ConclusionΔAG is a prognostic factor of hospital mortality and 90-day OS. More prospective studies are needed to verify and update our findings.

The Ramathibodi early warning score as a sepsis screening tool does not reduce the timing of antibiotic administration

BackgroundAdministration of antibiotics to septic patients within 1 h was recommended in 2018 by the Surviving Sepsis Campaign (SSC) as a strategy to improve survival outcomes. The use of sepsis screening tools in emergency departments (EDs) is important for early diagnosis and initiation of sepsis care. This study aimed to assess the impact of the Ramathibodi early warning score (REWs) on the administration of antibiotics within 1 h of presentation.MethodsThis was an observational retrospective cohort study with propensity score matching between the sepsis-3 criteria (pre-period) and the REWs (post-period) as screening tools in adult patients with sepsis in EDs. The primary outcome was the proportion of receiving antibiotics within 1 h of presentation in the pre- and post-periods.ResultsA total of 476 patients were analyzed without propensity matching. The proportion of antibiotic administration within 1 h was higher in patients screened using the REWs compared with standard of care in the total study population (79.5% vs. 61.4%, p < 0.001). After propensity score matching, 153 patients were included in both groups. The proportion of antibiotic administration within 1 h was similar in patients screened using the REWs and those receiving standard of care (79.7% vs. 80.4%, p = 0.886). However, time to intensive care unit (ICU) admission was faster in patients screened using the REWs. Delays in receiving antibiotics of longer than 3 h were associated with increased mortality (adjusted hazard ratio 7.04, 95% confidence interval 1.45 to 34.11, p = 0.015).ConclusionsImplementing the REWs as a tool in sepsis screening protocols in EDs did not improve rates of antibiotic administration within 1 h as recommended by the SSC. However, time to ICU admission was improved after implementation of the REWs.

Clinical characteristics and cardiovascular risk factors associated with clinical outcome in hospitalized patients with COVID-19

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a new coronavirus, was originally recognized as a pandemic by the WHO on early, a new coronavirus, was originally recognized as a pandemic by the WHO on early 2020, and has infected over 243 million people worldwide, killing about five million people between then and October 2021. Objectives: We investigated the relationship between clinical characteristics, cardiovascular risk factors and echocardiographic findings and in-hospital outcomes of patients who were admitted for COVID-19. Patients and Methods: A retrospective review of 216 hospitalized patients with COVID-19 who were admitted to Chamran hospital from March 2019 to April 2021 was conducted. Patients’ characteristics cardiovascular risk factors, echocardiographic findings, clinical outcomes (discharge (complete recovery/ partial recovery) and in-hospital mortality) were recorded. To analyze risk factors associated with outcomes in patients with COVID-19, univariate and multivariate ordinal logistic regression models were conducted. Results: The most common underlying diseases in patients were hypertension (HTN) (57.9%) and diabetes mellitus (DM) (37.9%), respectively. Cognitive disorders (20.8%) and mitral regurgitation (MR) were the most complication and echocardiographic finding of the patients. In our study, six variables were found to be associated with patient’s outcomes, including age, body mass index (BMI), DM, chronic pulmonary diseases, number of hospitalization days and number of an intensive care unit (ICU) admission days. Conclusion: Our analysis suggests that age, male gender, BMI, number of hospitalization days and ICU admission, chronic pulmonary disease and diabetes are associated with a higher risk of in-hospital mortality and worst prognosis in patients infected by SARS-CoV-2.

Is prior use of renin-angiotensin system (RAS) inhibitors associated with more favourable outcome in COVID-19 hospitalized patients?

Objective: We aimed to investigate the extent of pulmonary involvement and adverse outcomes in patients receiving angiotensin-converting enzyme inhibitor (ACEI)/ angiotensin II receptor blocker (ARB) versus who did not, in hospitalized coronavirus infectious disease 2019 (COVID-19) patients.&#x0D; Methods: All COVID-19 patients with a positive polymerase chain reaction (PCR) test, who were admitted to our tertiary referral hospitals in Tehran, Iran between January 2021 and May 2021, and had an on-admission chest computed tomography (CT) scan, were included. The patients were divided into two groups (receiving ACEI/ARB and who did not) for further analysis. The outcomes of interest in our study were the extent of pulmonary involvement, intensive care unit (ICU) admission, and death.&#x0D; Results: A total of 893 participants (mean age of 58.6±15.4 years; female, 522 (58.4%)) were enrolled. Among them, 368 (41.2%) participants had hypertension, and use of ACEI/ARB was reported in 183 (20.5%) participants. Of all, 409 (45.8%) participants required ICU admission, and 259 (29%) participants succumbed to death. We found that participants who received ACEI/ARB were less likely to progress critical disease and experienced significantly lower ICU admission (P=0.022) and death (P&lt;0.001). On multivariable analysis adjusting for age, sex, and comorbidities, this relationship remained statistically significant for death (odds ratio (OR): 0.23 [0.14-0.38], P&lt;0.001) and ICU admission (OR: 0.49 [0.32-0.73], P=0.001).&#x0D; Conclusion: Our findings showed that COVID-19 patients who receiving ACEI/ARB prior to hospitalization vs. those who did not, had more favorable outcomes.

MO318: Utility of D-Dimer Levels in Predicting the Renal Outcome of Acute Kidney Injury in Moderate and Severe COVID-19: A Retrospective Study

BACKGROUND AND AIMSAcute kidney injury (AKI) is a potential complication of COVID-19 and the hypercoagulation tendency of SARS-CoV-2 infection is considered one of the underlying mechanisms. Fibrinolysis markers have been described as severity parameters, independent of clinically manifested thromboembolic events. The aim of this study is to evaluate the contribution of D-dimer testing in appreciating the extent of AKI and renal function recovery in COVID-19.METHODWe have conducted a retrospective study on 253 AKI adult patients confirmed with SARS-CoV-2 infection by molecular testing and hospitalized in two emergency university hospitals over the course of 6 months. Diagnosis and staging of AKI were performed with KDIGO 2012 criteria. We analysed the impact of peak D-dimers on the severity of AKI, recovery of renal function and need for renal replacement therapy (RRT). Additionally, we searched the relationship between D-dimers and survival and COVID-19 severity parameters. Severity of respiratory failure was classified as mild-moderate (no support or low-flow oxygen) and severe (mechanical ventilation: continuous positive airway pressure and endotracheal intubation). All data was analysed using IBM SPSS Statistics v.25 (IBM, Corp.).RESULTSThe average age was 72.4 ± 13.33 years, 159 patients were male (62.84%). According to KDIGO staging, 79 patients were in stage 1, 74 in stage 2 and 100 patients in stage 3. Overall mortality was 50.59% (N = 128). The mean peak of D-dimers was 6.08 ± 6.53 µg/mL. We found a significant direct relationship between D-dimers and AKI stage (3.72 ± 5.84 µg/mL—stage 1; 6.67 ± 6.60 µg/mL—stage 2; 7.50 ± 6.46 µg/mL—stage 3; P < .0001). There was a significant inverse relationship between D-dimers and odds of renal recovery, lower values being noted in the complete renal recovery group (3.79 ± 5.10 µg/mL, N = 77) compared with partial recovery (5.22 ± 6.89 µg/mL, N = 57; P < .02), while D-dimers were strikingly high in patients needing RRT (8.11 ± 5.92 µg/mL, N = 29). Regarding the severity of respiratory failure, we found that mild-moderate cases had lower D-dimers (4.23 ± 5.46 µg/mL, N = 146) compared with severe failure (8.60 ± 7.00 µg/mL, N = 107; P < .003). Intensive care unit (ICU) admission was also correlated with levels of D-dimers (8.55 ± 6.76 µg/mL, N = 107 versus non-ICU 4.27 ± 5.70 µg/mL, N = 146; P < .01). D-dimers were higher in deceased patients (7.91 ± 6.60 µg/mL) compared with survivors (4.20 ± 5.88 µg/mL; P < 0.001) (Table 1).Table 1.CountN (%)Peak D-dimer levels (average ± SD; µg/mL)Statistical significance (P-value)Entire cohort2536.08 ± 6.53AKI severityKDIGO stage 1KDIGO stage 2KDIGO stage 3 79 (31.22)74 (29.24)100 (39.52) 3.72 ± 5.846.67 ± 6.607.50 ± 6.46 P < .0001*Kruskal–Wallis H TestRecovery of renal functionTotalPartialNeed for HDNone (excl. death) 77 (30.43)57 (22.52)29 (11.46)8 (3.16) 3.79 ± 5.105.22 ± 6.898.11 ± 5.926.25 ± 5.75 P < .02*Kruskal–Wallis H TestAKI timingAt admissionDuring hospitalization 172 (67.98)81 (32.01) 5.75 ± 6.336.77 ± 6.86 P = .307, ns**Mann–Whitney U TestRespiratory supportNone/low-flow oxygenCPAP/ETI 146 (57.7)107 (42.29) 4.23 ± 5.468.60 ± 7.00 P < .003**Mann–Whitney U TestICUNon-ICU107 (42.29)146 (57.70)8.55 ± 6.764.27 ± 5.70 P < .001**Mann–Whitney U TestMortalitySurvivedDeceased 125 (49.40)128 (50.59) 4.20 ± 5.887.91 ± 6.60 P < .001**Mann–Whitney U TestSD, standard deviation; HD, haemodialysis; CPAP, continous positive airway pressure; ETI, endotracheal intubation; ICU, intensive care unit; and ns, not significant.CONCLUSIONIncreased D-dimer levels in COVID-19-associated AKI have a negative impact on the severity of AKI, need for RRT and recovery of renal function. AKI patients with high levels of D-dimers are more often admitted to the ICU, have an increased need for mechanical ventilation and have poor survival. Due to the additional negative impact of AKI in COVID-19 and possible preventability of severe disease, D-dimers may be a useful tool to assess the need and duration of adequate prophylactic anticoagulation.

The appropriateness of abdominal X-ray requests in the acute medical initial admissions unit.

Abdominal X-rays are frequently requested by clinicians in the Aberdeen Royal Infirmary acute medical initial assessment unit. The proportion of indicated abdominal X-rays requested within 24 hours of admission was retrospectively examined. This process was repeated after displaying an educational poster with the Royal College of Radiologists guidelines (cycle 2) and a graded assertive communication poster (cycles 3 and 4); a tool to enable junior doctors to challenge inappropriate requests for abdominal X-rays from seniors. Only 47.2% of abdominal X-ray requests were deemed appropriate in cycle 1. A 1.54% reduction in abdominal X-ray requests and an 11.5% increase in indicated abdominal X-rays were noted after cycle 2. Cycle 3 led to a statistically significant improvement with 2.6% fewer patients undergoing an abdominal X-ray and a 24.6% increase in indicated abdominal X-rays. This improvement was sustained in cycle 4. Promoting graded assertive communication is an effective means of helping junior doctors to challenge seniors requesting non-indicated abdominal X-rays.

Lung function six months after severe COVID-19: Does time, in fact, heal all wounds?

BackgroundCOVID-19 has been associated with persistent symptoms and functional changes, especially in those surviving severe disease. MethodsWe conducted a prospective multicenter study in patients with severe COVID-19 to determine respiratory sequelae. Patients were stratified into two groups: ward admission (WA) and intensive care unit (ICU) admission. In each follow-up visit, the patients where inquired about cough and dyspnea, and performed spirometry, lung volumes, carbon monoxide diffusion capacity (DLCO), 6-minute walk test (6MWT), and respiratory muscle strength (MIP and MEP). Results of pulmonary function tests at 45 days and 6 months after hospital admission were compared using paired analysis. Results211 patients were included, 112 in WA and 99 in ICU. Dyspnea persisted in 64.7% in the WA and 66.7% in the ICU group after 6 months. Lung function measures showed significant improvement between 45 days and 6 months, both in WA and ICU groups in VC, FVC, FEV1, total lung capacity, and 6MW distance measures. The improvement in the proportions of the altered functional parameters was significant in the ICU group for VC (44.2% 45 d; 20.8% 6 m; p = 0,014), FVC (47.6% 45 d; 28% 6 m; p = 0,003), FEV1 (45.1% 45 d; 28% 6 m; p = 0,044), DLCO (33.8% 45 d; 7.7% 6 m; p < 0,0001). ConclusionSix months follow-up of patients with the severe forms of COVID-19 showed significant improvement in the lung function measures compared to 45 days post hospital discharge. The difference was more evident in those requiring ICU admission.

Impact of Meconium-Stained Amniotic Fluid on Neonatal Outcome in a Tertiary Hospital.

ObjectiveThe aim of this study was to determine the perinatal outcome of pregnant patients complicated with meconium-stained amniotic fluid (MSAF) compared with clear amniotic fluid.MethodologyThis prospective cross-sectional study was conducted in the Department of Obstetrics and Gynecology in collaboration with the Department of Pediatrics at Indira Gandhi Institute of Medical Sciences, Patna, India, from September 2016 to January 2018. A total of 200 patients were included in the study after taking their written consent. Out of these 200 patients, 100 patients had MSAF, and the other 100 patients with clear liquor were taken as controls after fulfilling the inclusion and exclusion criteria. These two groups of patients were compared regarding various maternal and neonatal parameters. These parameters were compared and tested statistically for significance.ResultsAmong the 100 patients with MSAF, 20 patients had grade 1 meconium (X), 22 patients had grade 2 meconium (Y), and 58 patients had grade 3 meconium (Z). The majority of patients in the MSAF group were primigravida and more than 25 years of age. In addition, 47% of patients in the MSAF group had some associated high-risk factors and 50% of patients had non-reassuring fetal heart rate patterns, and among these, 39 patients had grade 3 MSAF (X). In the MSAF group, 49% of patients had undergone lower segment cesarean section (LSCS), whereas in the non-MSAF group, it was 37%. Also, 30% of babies in the MSAF group and 13% in the non-MSAF group had neonatal intensive care unit (NICU) admission; 22% of babies in the MSAF group and 12% of babies in the non-MSAF group had an adverse neonatal outcome. Meconium aspiration syndrome was present in 14% of the patients in the MSAF group, and among these, two babies had neonatal death and both had severe birth asphyxia. In the non-MSAF group, there was one neonatal death due to neonatal sepsis. However, after statistically analyzing the neonatal outcome in both the groups, there was no statistical difference between the two groups (p<0.001).ConclusionMSAF is associated with increased frequency of operative delivery, poor neonatal outcomes, and increased NICU admission. Management of labor with MSAF requires appropriate intrapartum care with continuous fetal heart rate monitoring, and this can reduce unnecessary cesarean sections in patients with MSAF.

Implementation of a machine learning application in preoperative risk assessment for hip repair surgery

BackgroundThis study aims to develop a machine learning-based application in a real-world medical domain to assist anesthesiologists in assessing the risk of complications in patients after a hip surgery.MethodsData from adult patients who underwent hip repair surgery at Chi-Mei Medical Center and its 2 branch hospitals from January 1, 2013, to March 31, 2020, were analyzed. Patients with incomplete data were excluded. A total of 22 features were included in the algorithms, including demographics, comorbidities, and major preoperative laboratory data from the database. The primary outcome was a composite of adverse events (in-hospital mortality, acute myocardial infarction, stroke, respiratory, hepatic and renal failure, and sepsis). Secondary outcomes were intensive care unit (ICU) admission and prolonged length of stay (PLOS). The data obtained were imported into 7 machine learning algorithms to predict the risk of adverse outcomes. Seventy percent of the data were randomly selected for training, leaving 30% for testing. The performances of the models were evaluated by the area under the receiver operating characteristic curve (AUROC). The optimal algorithm with the highest AUROC was used to build a web-based application, then integrated into the hospital information system (HIS) for clinical use.ResultsData from 4,448 patients were analyzed; 102 (2.3%), 160 (3.6%), and 401 (9.0%) patients had primary composite adverse outcomes, ICU admission, and PLOS, respectively. Our optimal model had a superior performance (AUROC by DeLong test) than that of ASA-PS in predicting the primary composite outcomes (0.810 vs. 0.629, p < 0.01), ICU admission (0.835 vs. 0.692, p < 0.01), and PLOS (0.832 vs. 0.618, p < 0.01).ConclusionsThe hospital-specific machine learning model outperformed the ASA-PS in risk assessment. This web-based application gained high satisfaction from anesthesiologists after online use.

A Comparative Study of Maternal-Fetal Outcomes in Pregnant Women With Induction of Labor and Spontaneous Onset of Labor in a Rural Tertiary Care Center

OBJECTIVEThe present prospective observational study was conducted to study the incidence, indications, and outcomes of induction of labor in a tertiary care center.MATERIAL AND METHODThe study group of this prospective cross-sectional study was constituted by all term pregnant women underwent trial of labor. The whole study group was further subdivided in two groups, group 1: Was having all pregnant women with spontaneous onset of labor pains and group 2 was containing all pregnant women underwent induction of labor. For induction only prostaglandins (PGE1 25 microgram tablet and PGE2 gel) were used. The measure of outcome included assessment of the incidence of induction in term pregnant women, major indications of induction of labor, duration of labor, mode of delivery, intrapartum and postpartum maternal-fetal complications and duration of hospital stay. The study group included 3264 pregnant women and was differentiated into group 1 with 2,588 pregnant women and group 2 with 676 pregnant women.RESULTSThe incidence of induction was 20.71%. Major indications of induction were a fetus who was postdates, premature rupture of membranes, and preeclampsia. The average duration of the induction to delivery interval was 19.13 ± 15.14 hours (hrs.) and admission to delivery interval in the spontaneous labor group was 8.79 ± 07.18 hrs. The incidence of cesarean delivery was 19.52% in the induction group (gp2). Failed induction was the most common indication of lower segment cesarean section (CS). The incidence of CS was 15.99% in spontaneous group (gp1) and fetal distress was most common indication in this group. With this study, we found the importance of rest after the induction process was completed. During this watchful rest period, 51 pregnant women delivered vaginally. The neonatal intensive care unit (NICU) admission and neonatal death rate was more in group 1.CONCLUSIONThis study revealed that the incidence and indications of induction of labor among term pregnant women were similar to developed countries in spite of active physical life. The complication rate, operative intervention and hospital stay was more with induction group.

The effect of treatment and clinical course during Emergency Department stay on severity scoring and predicted mortality risk in Intensive Care patients

BackgroundTreatment and the clinical course during Emergency Department (ED) stay before Intensive Care Unit (ICU) admission may affect predicted mortality risk calculated by the Acute Physiology and Chronic Health Evaluation (APACHE)-IV, causing lead-time bias. As a result, comparing standardized mortality ratios (SMRs) among hospitals may be difficult if they differ in the location where initial stabilization takes place. The aim of this study was to assess to what extent predicted mortality risk would be affected if the APACHE-IV score was recalculated with the initial physiological variables from the ED. Secondly, to evaluate whether ED Length of Stay (LOS) was associated with a change (delta) in these APACHE-IV scores.MethodsAn observational multicenter cohort study including ICU patients admitted from the ED. Data from two Dutch quality registries were linked: the Netherlands Emergency department Evaluation Database (NEED) and the National Intensive Care Evaluation (NICE) registry. The ICU APACHE-IV, predicted mortality, and SMR based on data of the first 24 h of ICU admission were compared with an ED APACHE-IV model, using the most deviating physiological variables from the ED or ICU.ResultsA total of 1398 patients were included. The predicted mortality from the ICU APACHE-IV (median 0.10; IQR 0.03–0.30) was significantly lower compared to the ED APACHE-IV model (median 0.13; 0.04–0.36; p < 0.01). The SMR changed from 0.63 (95%CI 0.54–0.72) to 0.55 (95%CI 0.47–0.63) based on ED APACHE-IV. Predicted mortality risk changed more than 5% in 321 (23.2%) patients by using the ED APACHE-IV. ED LOS > 3.9 h was associated with a slight increase in delta APACHE-IV of 1.6 (95% CI 0.4–2.8) compared to ED LOS < 1.7 h.ConclusionPredicted mortality risks and SMRs calculated by the APACHE IV scores are not directly comparable in patients admitted from the ED if hospitals differ in their policy to stabilize patients in the ED before ICU admission. Future research should focus on developing models to adjust for these differences.

Comparisons of six endoscopy independent scoring systems for the prediction of clinical outcomes for elderly and younger patients with upper gastrointestinal bleeding

ObjectivesTo compare the predictive ability of six pre-endoscopic scoring systems (ABC, AIMS65, GBS, MAP(ASH), pRS, and T-score) for outcomes of upper gastrointestinal bleeding (UGIB) in elderly and younger patients.MethodsA retrospective study of 1260 patients, including 530 elderly patients (age ge 65) and 730 younger patients (age < 65) presenting with UGIB, was performed at Zhongda Hospital Southeast University, from January 2015 to December 2020. Six scoring systems were used.ResultsABC had the largest areas under the curve (AUCs) of 0.827 (0.792–0.858), and 0.958 (0.929–0.987) for elderly and younger groups for predicting mortality respectively. The differences of the AUCs for predicting the outcome of mortality and rebleeding between the two groups were significant for ABC and pRS (p < 0.01). For intervention prediction, significant differences were observed only for pRS [AUC 0.623 (0.578–0.669) vs. 0.699 (0.646–0.752)] (p < 0.05) between the two groups. For intensive care unit (ICU) admission, the AUC for MAP (ASH) [0.791 (0.718–0.865) vs. 0.891 (0.831–0.950)] and pRS [0.610 (0.514–0.706) vs. 0.891 (0.699–0.865)] were more effective for the younger group (p < 0.05 and p < 0.01, respectively). For comparison of scoring systems in the same cohort, ABC was significantly higher than pRS: AUC 0.710 (0.699–0.853, p < 0.05) and T-score 0.670 (0.628–0.710, p < 0.01) for predicting mortality in the elderly group. In the younger group, ABC was significantly higher than GBS and T-score (p < 0.01). MAP(ASH) performs the best in predicting intervention in both groups.ConclusionsABC and pRS are more accurate for predicting mortality and rebleeding in the younger cohort, and pRS may not be suitable for elderly patients. There was no difference between the two study populations for GBS, AIMS65, and T-score. Except for ICU admission, MAP(ASH) showed fair accuracy for both cohorts.