Ward Admission Research Articles

Case Report Chest Non-contrast ct-scan findings and follow up a patient suspected covid-19 infection

Background Covid-19 is an infection caused by SARS-CoV-2. Chest X-Ray (CXR) examination doesn’t show the radiographiccharacteristic of Covid-19 infection. Thorax CT-Scan is the gold standard imaging for pneumonia Covid-19 infection.Aim The purpose of this report is to describe a case of bronchopneumonia in a male patient aged 48 years old at Bethesda Hospital Yogyakarta during the Covid-19 pandemic.Case Description A 48 years old male patient came to the Bethesda Hospital in Yogyakarta with a complaint of fever 1 week before being hospitalized. The patient also complained of cough, sore throat, rhinorrhea, shortness of breath, malaise, and decreased appetite. The rapid test result shows SARS-CoV2 IgM and IgG (+), PCR swab Covid-19 results (+). Bronchopneumonia was concluded by CXR examination and chest non-contrast CT-Scan showed Covid-19 infection imaging characteristics. Later on, the patient showed clinical and radiological improvement.Conclusion Covid-19 is an infection caused by the SARS-CoV-2. Common symptoms are fever, cough, sore throat, shortness of breath, and malaise. CXR examinations on patients with Covid-19 infection show images of pneumonia, in this case, bronchopneumonia was concluded. CT-scan shows characteristic imaging of Covid-19 infection can support the decision on regular ward admission versus ICU and for follow-up in regular ward admission.

Restrictive interventions on a psychiatric admission ward before and after COVID-19.

Restrictive interventions (seclusion, restraint and special observations) are used on psychiatric wards when there are no other means available to keep a patient or others safe. These measures can be traumatic, and the Mental Health Commission and the Health Service Executive are focused on minimising their use. We set out to determine whether, following a COVID related reduction in bed numbers on a high dependency psychiatric ward in St John of God Hospital in Dublin, there was a change in their incidence. Data on restrictive interventions and challenging behaviours were gathered for 9-month periods before and after March 2020 when COVID related ward changes took place. Figures were also collected on seclusion and restraint for the previous 18 months for a longer-term view. Ward and hospital occupancy levels were also recorded. Between the two time periods, episodes of seclusion fell by 53% and episodes of restraint by 56%. The hours devoted to special observation declined by 30% and incidents of challenging behaviours fell by 26%. Ward occupancy levels fell by only 5%. The longer-term comparison of figures for seclusion and restraint point towards a downward trend from mid-2019 that was accentuated in the post-COVID period. The changes found may relate to reduced crowding on the ward or other COVID related factors such as the emphasis on social distancing and a shared sense of purpose on the ward. The longer-term trend points towards an emerging cultural shift. The challenge now is to sustain and build upon these changes.

Association between Stress Hyperglycemia and Adverse Outcomes in Children Visiting the Pediatric Emergency Department.

Stress hyperglycemia (SH) is often identified in patients visiting the pediatric emergency department (PED), and SH in adults has been associated with adverse outcomes, including mortality. In this retrospective study, we determined the adverse outcomes according to blood glucose (BG) levels of children visiting the PED of tertiary hospitals. Data were collected from the electronic medical records of children aged <18 years between 1 January 2011 and 31 December 2020. A total of 44,905 visits were included in the analysis. SH was identified in 1506 patients, with an incidence rate of 3.4%. Compared to those without SH, patients with SH had significantly higher ward admission rates (52.6% vs. 35.9%, p < 0.001), intensive care unit admission rates (2.6% vs. 0.7%, p < 0.001), and mortality rates (2.7% vs. 0.3%, p < 0.001). Compared to the normoglycemic group of 45 ≤ BG < 150 mg/dL, the odds ratios (95% CI) for mortality were 5.61 (3.35–9.37), 27.96 (14.95–52.26), 44.22 (17.03–114.82), and 39.94 (16.31–97.81) for levels 150 ≤ BG < 200, 200 ≤ BG < 250, 250 ≤ BG < 300 and ≥300 mg/dL, respectively. This suggests that SH is common in children visiting the PED and is associated with higher adverse outcomes. Thus, there is a need to quickly identify its cause and take prompt intervention to resolve it.

CLINICAL PROFILE OF PATIENTS WITH ACUTE EPICHLOROHYDRIN POISONING - AN OBSERVATIONAL STUDY

Epichlorohydrin is an organochlorine compound and a epoxide. It is a colourless liquid with a pungent, garlic like odour, moderately soluble in water, but miscible with most polar organic solvents. It is used in the production of glycerol, plastics, epoxy glues and resins, epoxy diluents and elastomers. Epichlorohydrin is a common chemical used in industry and Accidental exposure to Epichlorohydrin can occur in workers working in glycerol, plastics, epoxy glues and resins, epoxy diluents and elastomer factories.To study the clinical profile of patients with Acute Epichlorohydrin Poisoning And identify the frequency and nature of lung involvement.30 patients of age 18 and above with Acute Epichlorohydrin poisoning were included in the study. Symptomatology and History, ABG, chest Xray and Hrct chest findings were included in the clinical profile. Distribution of responses were examined using frequencies and percentages and cross tabulation were done between various subgroups.All the patients had accidental direct exposure to Epichlorohydrin. All the patients presented with acute onset respiratory distress and dry cough. Burning sensation and redness and watering from eyes with watering from nose were present in all the patients. Burning sensation in the throat was present in two third of the patient. Two third of the patients developed ARDS and of them 60 % developed moderate to severe ARDS. Two thirds of the patient required ICU admission and out of them 60 % required NIV support and rest 40% were managed by Oxygen via Facemask. Rest one third patient required admission in general ward. All the patients show heterogenous opacities in chest Xray. All the patients show patchy areas of consolidation with Ground Glass changes in HRCT Chest. Two third of the patients show pleural effusion in both Chest Xray and HRCT Chest and out of them 80 % patients show bilateral pleural effusion.ARDS of varying degree with mucosal irritation is the most common presenting feature of patients with ACUTE EPICHLOROHYDRIN POISONING. Pneumonia with HRCT chest showing Ground Glass Opacities are common.

Utility of lung ultrasound in following up COVID-19 patients over a 3-month period

Lung ultrasound (LUS) examination has been shown to have a potential diagnostic and prognostic role in SARS-CoV-2 pneumonia disease. We evaluated the role of a new LUS score protocol (14 windows evaluation, graded score 0–3) in patients with SARS-CoV-2 pneumonia and the association of LUS patterns with clinical findings in acute stage and after three month from disease recovery. First, a cohort of 52 consecutive laboratory-confirmed SARS-CoV-2 patients underwent LUS examination upon the admission in an Internal Medicine ward. A total LUS score as the sum of the scores at each explored area was computed,and we investigated the association between LUS score and the clinical worsening. Then 47 patients who survived the first COVID-19 wave and who underwent a 3-stage LUS examination (T0 “access to ER”; T1 “ward hospitalization”; T2 “post-COVID outpatient”) were enrolled for the longitudinal study. In the acute stage, we observed that a median LUS score above 24 was associated with an almost 6-fold increase in the odds of worsening. In the longitudinal observation, we seen that LUS score's variation between T0 and T2 resulted to be statistically significant, as well a difference of LUS score between patients with or without pleural effusion, maintained over time.

Change in Disease Dynamics and Health Care Utilisation in Children during COVID 19 in a Tertiary Care Hospital of Eastern India

This retrospective, observational study was conducted by collecting data from medical records during COVID 19 pandemic from March 2020 till August 2020. This was compared with the data of 2019 during similar months. The impact of COVID 19 on use of preventive and curative paediatric health care service units like outpatient department, casualty, intensive care and immunization clinic were assessed. Data from 2019 to 2020 were compared using standard parametric and nonparametric tests. There was a significant decline in routine OPD (68%) attendance during the COVID 19 period as compared to pre-COVID period. Paediatric ward admissions and PICU admissions were decreased by 55% and 42% respectively. We also observed a significant 43% decline in the number of children attending immunization clinic in the year 2020. The fear of COVID 19 pandemic and the measures taken to control the pandemic has affected the health seeking behaviour of patients. This evaluation of trends in healthcare use may help in planning the delivery of healthcare service delivery in future.

Pattern of orthopaedic case presentations at the rivers state university teaching hospital: a ten-year review

Background: Pattern of diseases help institutions and governments to know the dominant disease conditions and how to allocate scarce resources. Knowledge of the pattern of orthopedic disease conditions seen and treated in the Rivers State university teaching hospital will help in guiding the repositioning effort of the department/discipline, especially in the light of the new status of the institution as a teaching hospital for teaching, service delivery and research. The aim of this study therefore was to determine the pattern of orthopedic cases seen in the surgery department of the Rivers State university teaching hospital from January 2010 to January 2019.Methods: A descriptive retrospective cross-sectional study was carried out at the emergency room, clinic, operating theatre, and wards of the surgery department of the Rivers State university teaching hospital, using hospital registers. The study was analyzed using the Microsoft excel spreadsheet.Results: There were 2854 orthopedic emergency room cases seen, comprising 621 fractures, 463 lumbar spondylosis/ spondylolisthesis, 392-foot ulcer/sepsis, 375 dislocations, 310 acute osteomyelitis, and 864 osteoarthritis with other conditions. The common orthopedic cases seen in the out-patient clinics in descending order of occurrence were lumbar spondylitis / spondylolisthesis (881), osteoarthritis (655), fractures (560), dislocations (227), etc.Conclusions: Trauma-related disease care constituted the bulk of work of the orthopedic surgeon in our environment in the emergency room, operating theatre and ward admissions, and younger males were more affected.

Assessment of Patients’ Satisfaction with Nursing Care in Babcock University Teaching Hospital, Ilishan-Remo, Ogun State, Nigeria

Patient satisfaction has become an established outcome indicator of the quality and the efficiency of the health care systems. Patient satisfaction with nursing services is considered the most important factor in the moulding of the overall patient satisfaction with hospital services, and reflects the ability of the provider to meet the patients’ needs. This study therefore sought to investigate patients’ satisfaction with rendered nursing care and services in Babcock University Teaching Hospital, Ilishan-Remo, Ogun State, Nigeria. This study adopted descriptive survey research design. The study population were in-patients who have spent at least one night on admission in Medical, Surgical, Obstetrics and Gynaecology wards. Convenient non-probability sampling technique was used in recruiting the 151 respondents of this study. The instrument for data collection was a pretested semi-structured self-administered questionnaire consisting of 4 Sections (A-D). The instrument was validated through face and content validity by experts in Nursing Science and Tests and Measurement. Test re-test method was used to establish the reliability of the instrument while the reliability coefficient value of 0.827 was derived after subjecting the data collected to Pearson’s Moment Correlation Statistics. The questionnaires were distributed by the researcher conveniently to inpatients of the selected wards. Descriptive and inferential statistics were used to analyse the data collected. The findings revealed that Majority (93%) of the patients showed excellent satisfaction with the quality of nursing care received, and have positive perception (83.9%) and suitable experiences with nursing care (62.4%) during their stay on the wards. It was recommended among others that patients’ opinion for improving quality of nursing care should be taken into considerations to improve the quality of nursing care.

Disease burden of cardiovascular conditions complicating pregnancy in Sri Lanka: a protocol

Background Cardiovascular diseases (CVD) are the commonest indirect medical cause of maternal deaths worldwide, both in high-income and low and middle-income countries. To minimize the effects of CVD in pregnancy, proper risk assessment and appropriate referral is required. In Sri Lanka, cardiovascular disease complicating pregnancy is a significant cause of maternal mortality, second only to postpartum hemorrhage. Screening for CVD in pregnancy in Sri Lanka is limited to a routine clinical assessment. Evidence-based guidelines are yet to be developed, and this deficit may have resulted in a substantial underestimation of the CVD burden. This study aims to determine the burden of CVD in early pregnancy and develop a risk prediction model to be used in field pregnancy clinics in Sri Lanka to reduce CVD effects in pregnancy. Methods A prospective cohort study was carried out in the Anuradhapura district, Sri Lanka. Following registration to the antenatal care, pregnant women fulfilling the eligibility criteria were invited to attend a special clinic at their relevant Medical Officer of Health (MOH) area. Risk assessment was done through history and a clinical examination, and suspected/probable cases were referred for an echocardiogram by a consultant cardiologist. All the recruited participants in the first trimester were prospectively followed up and screened again between 24–28 weeks of the period of amenorrhoea (POA). Antenatal ward admissions with CVD complicating pregnancy will be extracted, and a telephone interview will be carried out between 6–12 weeks after the expected delivery date to cover postpartum morbidities. Discussion This proposed study will be the largest of its kind carried out in the local setting. The study's findings will be beneficial for policymakers to develop guidelines to reduce maternal cardiovascular disease morbidities and mortalities in Sri Lanka.

Urinary free cortisol and childhood maltreatments ineating disorder patients: New evidence foranecophenotype subgroup.

IntroductionIncreasing neurobiological evidence has suggested the presence of a specific ecophenotype in people with eating disorders (EDs) linked to early maltreatment. Urinary‐free cortisol could strengthen the data and show specific relationships between maltreated subtypes and the hormonal profiles of patients with EDs. This study aims to evaluate the presence of different urinary cortisol in drug‐free patients in the acute phase of the disorder and its relationship with childhood maltreatment.MethodsA sample of 78 female patients with ED is included in the study. Childhood maltreatment history and 24‐h urinary free cortisol (24‐h UFC) are evaluated at a specialised ED ward admission.ResultsPatients with a maltreatment history show more blunted 24‐h UFC levels than peers without childhood maltreatment (p = 0.001). Regression analysis showed that child abuse is a predictor of the reduction of 24‐h UFC (p < 0.001), with physical abuse (p = 0.011) and sexual abuse (p = 0.050) that could have a more specific impact than other maltreatment subtypes.DiscussionChildhood maltreatment should be evaluated in ED patients due to its biological impact on the hormonal stress axis, which could impair the ability of patients to respond to standardized ED treatment.

702 COMMUNICATION CHALLENGES BETWEEN DOCTORS &amp; RELATIVES DURING THE COVID-19 PANDEMIC: SIMPLE INTERVENTIONS WITH MEANINGFUL IMPACT

Background& Aims Visiting restrictions during the COVID-19 pandemic resulted in reduced and inconsistent communication with the next-of-kin of elderly inpatients. This project aimed to improve communication between doctors and patients’ relatives in accordance with the GMC Good Medical Practice guidelines which outline that doctors ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.MethodsWe created a virtual whiteboard on an elderly care ward in an inner London hospital documenting patient demographics, details of named next-of-kin and when they had been contacted. We aimed to update next-of-kin within 48-hours of ward admission and subsequently twice weekly. The outcome was measured via identical ‘pre- and post-intervention’ questionnaires recording the next-of-kin’s satisfaction with communication from the doctors. Questionnaires included 11 questions utilising a 5-point Likert scale for satisfaction. Results were anonymised and analysed using Microsoft Excel.ResultsSatisfaction with communication improved in 10 of the 11 domains of the questionnaire following intervention. Cumulative satisfaction scores post-intervention (N = 13) in comparison to pre-intervention (N = 25) were closer to the total possible satisfaction score per question for these 10 domains. The mean cumulative satisfaction score across all domains was 60% post-intervention compared with 44% pre-intervention. Satisfaction following intervention was particularly improved in the domains of frequency of communication (60% post-intervention.32.8% pre-intervention) and how adequately questions and concerns were addressed (69.2% post-intervention; 45.6% pre-intervention).ConclusionDuring the COVID-19 pandemic healthcare professionals have had to adapt in communicating with patients’ next-of-kin. Our Introduction of robust standards and a virtual whiteboard to track communication resulted in improved satisfaction and proved useful in adapting to remote communication. We propose that similar practice and standards are extended across additional wards to encourage widespread optimal and consistent communication between doctors and patients’ relatives, an integral part of patient care.

Changing epidemiology of traumatic brain injury among the working-aged in Finland: Admissions and neurosurgical operations.

Recent studies from Finland have highlighted an increase in the incidence of traumatic brain injuries (TBI) in older age groups and high overall mortality. We performed a comprehensive study on the changing epidemiology of TBI focusing on the acute events in the Finnish working-age population. Nationwide databases were searched for all emergency ward admissions with a TBI diagnosis for persons of 16-69years of age during 2004-2018. In the Finnish working-age population, there were 52,487,099 person-years, 38,810TBI-related hospital admissions, 4664 acute neurosurgical operations (ANO), and 2247 cases of in-hospital mortality (IHM). The TBI-related hospital admission incidence was 94/100,000 person-years in men, 44/100,000 in women, and 69/100,000 overall. The incidence rate of admissions increased in women, while in men and overall, the rate decreased. The incidence rate increased in the group of 60-69years in both genders. Lowest incidence rates were observed in the age group of 30-39years. Occurrence risk for TBI admission was higher in men in all age groups. Trends of ANOs decreased overall, while decompressive craniectomy was the only operation type in which a rise in incidence was found. Evacuation of acute subdural hematoma was the most common ANO. Mean length of stay and IHM rate halved during the study years. In Finland, the epidemiology of acute working-aged TBI has significantly changed. The rates of admission incidences, ANOs, and IHM nowadays represent the lower end of the range of these acute events reported in the western world.

Initial computed tomography features of known inpatient ward versus intensive care admission COVID-19 cases: is there any difference?

Objectives: The aim of this study was to evaluate initial computed tomography (CT), basic clinical and demographic features of cases with COVID-19 pneumonia with known inpatient ward and intensive care unit hospitalization. Methods: A total of 200 cases (103 males, 97 females; age range: 18-92 years) were retrospectively and randomly collected whom were hospitalized and followed up at infectious disease inpatient ward and intensive care unit (ICU). The initial CT findings were interpreted by two radiologists at the same session by consensus. Results: Cough (61%) and fever (54%) were the main symptoms at the onset presentation. Initial chest CT imaging revealed that 79.5% ground-glass opacities. Bilateral distribution (62.5%), peripheral and central distribution (45.5%), dorsal and ventral involvement (52.5%) were identified in all cases. CT features predominantly were at right and left lower lobes (69.5%, 62.5%; respectively). Cases with known ICU admission had statistically significant differences with inpatient ward admission cases in regards to CT features included mixed GGO and consolidation, bronchial wall thickening, pleural effusion, subpleural band, emphysema, coronary calcification, cardiothoracic ratio, aorta diameter. Conclusions: Initial CT features may be helpful for foreseeing admission to ICU as in clinical features.

Intensive care unit capacity and mortality in older adults: a three nations retrospective observational cohort study

BackgroundIntensive care unit (ICU) admissions among older adults are expected to increase, while the benefit remains uncertain. The availability of ICU beds varies between hospitals and between countries and is an important factor in the decision to admit older adults in the ICU. We aimed to assess if a non-restrictive approach to ICU older adults admission is associated with a corresponding change in survival.MethodsRetrospective cohort study that included patients ≥ 80 years who were admitted to each of the three participating hospitals in Australia, Israel, and the United States (USA), between the years 2006–2015, each with distinct ICU capacities and admission criteria. The primary outcomes were in-hospital mortality and all-cause mortality at 6, 12, 18, and 24 months following index hospitalization.ResultsThe cohort included 62,866 patients with a mean age of 85.9 ± 4.6 years and 58.8% were women. The ICU admission rates were 22.5%, 2.6% and 2.3% in USA, Australia, and Israel, respectively. We constructed a model for ICU admissions based on the USA cohort (highest availability of ICU beds) and then calculated the expected probabilities for the Israeli and Australian cohorts. For the patients in the highest quintile of the admission model, actual ICU admission rates were 67.6% in USA, 22.1% in Australia and 6.0% in Israel. Of these, in-hospital death rates were 52.3% in Israel, 29.8% in Australia, and 22.1% in USA. Two years after hospital discharge, the survival rates in the USA and Australia were 53%, while in Israel 48%.ConclusionICU admission of adults ≥ 80 years is associated with increased in-hospital survival compared to ward admission, but survival rates 2 years later are similar.

Role of admission cardiotocography in predicting the obstetric outcome in term antenatal women: A prospective observational study.

Admission cardiotocography (CTG) used for fetal heart rate monitoring is an easy, cost-effective, non-invasive screening method for fetal well-being. To evaluate the role of admission CTG in predicting fetal hypoxia in term antenatal women during labour ward admission and to correlate the results with perinatal and maternal outcomes. The present prospective observational study was conducted in the Obstetrics and Gynecology Department of the rural tertiary centre in Northern India over one year on 100 term antenatal women admitted to the labour ward in the first stage of labour. Participants were subjected to admission CTG for 20 minutes, and the pattern of fetal heart rate (reactive, suspicious, ominous) was recorded. Perinatal and maternal outcomes were assessed based on the fetal heart rate pattern on the admission CTG. Of 100 term antenatal women, 51 were low-risk and 49 were high-risk cases. In the low-risk group, 92.16% had reactive traces, 3.92% suspicious and 3.92% ominous traces on admission CTG, whereas, in the high-risk group, 40.81% had reactive, 32.65% suspicious and 26.54% ominous tracing (p < 0.0001). The most common mode of delivery in both groups with ominous tracing was cesarean section (p = 0.0001). Abnormal CTG was significantly associated with adverse perinatal outcomes including poor one-minute Apgar scores (p < 0.05), need for resuscitation and NICU admission (p < 0.05). The specificity and negative predictive value of admission CTG in low- and high-risk groups were 97.9% and 93.6%, and 85.0% and 85.0%, respectively. Admission CTG is an effective, inexpensive, non-invasive technique to detect fetal hypoxia in low-and high-risk pregnancies in developing countries with an increased workload.

Incidence of candidemia and prevalence of azole-resistant candidemia at a tertiary South African hospital - A retrospective laboratory analysis 2016-2020.

BackgroundCandidemia is associated with high morbidity and mortality. The epidemiology of candidemia has changed globally over the past 20 years. South African surveillance demonstrated a shift in epidemiology from Candida albicans to non-albicans species including Candida parapsilosis and Candida auris. Hospital-level candidemia incidence from South Africa has not been reported previously.MethodsWe performed a retrospective laboratory-based analysis of blood cultures with confirmed causative agents of candidemia. Ward type, department, gender and admission to critical care units were captured. Data were analysed in Microsoft Excel, Statistical Package for the Social Sciences (SPSS) and Epitools.ResultsThe incidence of candidemia during the study period was 2.87 per 1000 admissions. The total proportion of non-albicans species causing candidemia was 425/618 (69.7%). Overall, 65.4% of candidemia cases occurred in non-critical care units. There was a significant increase in the proportion of C. auris isolates between 2016 and 2020 (p < 0.001). Isolation of C. auris was associated with admission to critical care units (p < 0.001, odds ration [OR] 3.856, 95% confidence interval [CI]: 2.360–6.300). The proportion of azole-resistant candidemia cases increased from 21/53 (39.6%) in 2016 to 41/59 (69.5%) in 2020 (p = 0.002).ConclusionThe incidence of candidemia remained stable over the five-year study period. However, the proportion of C. auris isolates increased significantly during the study period as did the overall proportion of azole-resistant candidemia. Antifungal stewardship and continued hospital-level surveillance are imperative.

Impaired long-term outcomes of patients with schizophrenia spectrum disorder after coronary artery bypass surgery: nationwide case-control study.

Patients with schizophrenia spectrum disorder have increased risk of coronary artery disease. To investigate long-term outcomes of patients with schizophrenia spectrum disorder and coronary artery disease after coronary artery bypass grafting surgery (CABG). Data from patients with schizophrenia spectrum disorder (n = 126) were retrospectively compared with propensity-matched (1:20) control patients without schizophrenia spectrum disorder (n = 2520) in a multicentre study in Finland. All patients were treated with CABG. The median follow-up was 7.1 years. The primary outcome was all-cause mortality. Patients with diagnosed schizophrenia spectrum disorder had an elevated risk of 10-year mortality after CABG, compared with control patients (42.7 v. 30.3%; hazard ratio 1.56; 95% CI 1.13-2.17; P = 0.008). Schizophrenia spectrum diagnosis was associated with a higher risk of major adverse cardiovascular events during follow-up (49.9 v. 32.6%, subdistribution hazard ratio 1.59; 95% CI 1.18-2.15; P = 0.003). Myocardial infarction (subdistribution hazard ratio 1.86; P = 0.003) and cardiovascular mortality (subdistribution hazard ratio 1.65; P = 0.017) were more frequent in patients with versus those without schizophrenia spectrum disorder, but there was no difference for stroke. Psychiatric ward admission, antipsychotic medication, antidepressant use and benzodiazepine use before CABG were not associated with outcome differences. After CABG, patients with schizophrenia spectrum disorder received statin therapy less often and had lower doses; the use of other cardiovascular medications was similar between schizophrenia spectrum and control groups. Patients with schizophrenia spectrum disorder have higher long-term risks of death and major adverse cardiovascular events after CABG. The results underline the vulnerability of these patients and highlight the importance of intensive secondary prevention and risk factor optimisation.

Dosage and clinical outcomes of medical emergency team and conventional referral mediated unplanned intensive care admissions.

Background: Unplanned intensive care unit (ICU) admission occurs via activation of medical emergency team (MET) and conventional ICU referral (CIR), i.e., ICU consultation. We aimed to compare the dosage, association with unplanned ICU admissions and hospital mortality between MET and CIR systems. Methods: We performed a retrospective, single centre observational study on unplanned ICU admissions from hospital wards between July 2017 and June 2018. We evaluated the dosage (expressed per 1000 admissions) and association of CIR and MET system with unplanned ICU admission using Chi-square test. The relationship (unadjusted and adjusted to Australia and New Zealand risk of death (ANZROD) and lead time) between unplanned ICU admission pathway (MET vs CIR) and hospital mortality was tested by binary logistic regression analysis [Odds ratio (OR) with 95% confidence interval (CI)]. Results: Out of 38,628 patients hospitalised, 679 had unplanned ICU admission (2%) with an ICU admission rate of 18 per 1000 ward admissions. There were 2153 MET and 453 CIR activations, producing a dosage of 56 and 12 per 1000 admissions, respectively. Higher unplanned ICU admission was significantly associated with CIR compared to MET activation (324/453 (71.5%) vs 355/2153 (16.5%) p < 0.001). On binary logistic regression, MET system was significantly associated with higher hospital mortality on unadjusted analysis (OR 1.65 (95% CI: 1.09-2.48) p = 0.02) but not after adjustment with ANZROD and lead time (OR 1.15 (95% CI: 0.71-1.86), p = 0.58). Conclusions: Compared to CIR, MET system had higher dosage but lower frequency of unplanned ICU admissions and lacked independent association with hospital mortality.

Impact of cytokine storm on severity of COVID-19 disease in a private hospital in West Jakarta prior to vaccination.

Coronavirus Disease 2019 (COVID-19) has become a worldwide pandemic and is a threat to global health. Patients who experienced cytokine storms tend to have a high mortality rate. However, to date, no study has investigated the impact of cytokine storms. This retrospective cohort study included only COVID-19 positive patients hospitalized in a Private Hospital in West Jakarta between March and September 2020. All patients were not vaccinated during this period and treatment was based on the guidelines by the Ministry of Health Indonesia. A convenience sampling method was used and all patients who met the inclusion criteria were enrolled. The clinical outcome of COVID-19 patients following medical therapy was either cured (85.7%) or died (14.3%), with 14.3% patients reported to have cytokine storm, from which 23.1% led to fatalities. A plasma immunoglobulin (Gammaraas®) and/or tocilizumab (interleukin-6 receptor antagonist; Actemra®) injection was utilised to treat the cytokine storm while remdesivir and oseltamivir were administered to ameliorate COVID-19. Most (61.5%) patients who experienced the cytokine storm were male; mean age 60 years. Interestingly, all patients who experienced the cytokine storm had hypertension or/ and diabetes complication (100%). Fever, cough and shortness of breath were also the common symptoms (100.0%). Almost all (92.3%) patients with cytokine storm had to be treated in the intensive care unit (ICU). Most (76.9%) patients who had cytokine storm received hydroxychloroquine and all had antibiotics [1) azithromycin + levofloxacin or 2) meropenam for critically ill patients] and vitamins such as vitamins C and B-complex as well as mineral. Unfortunately, from this group, 23.1% patients died while the remaining 70% of patients recovered. A significant (p<0.05) correlation was established between cytokine storms and age, the presence of comorbidity, diabetes, hypertension, fever, shortness of breath, having oxygen saturation (SPO2) less than 93%, cold, fatigue, ward of admission, the severity of COVID-19 disease, duration of treatment as well as the use of remdesivir, Actemra® and Gammaraas®. Most patients recovered after receiving a combination treatment (oseltamivir + remdesivir + Antibiotics + Vitamin/Mineral) for approximately 11 days with a 90% survival rate. On the contrary, patients who received oseltamivir + hydroxychloroquine + Gammaraas® + antibiotics +Vitamin/Mineral, had a 83% survival rate after being admitted to the hospital for about ten days. Factors influencing the development of a cytokine storm include age, duration of treatment, comorbidity, symptoms, type of admission ward and severity of infection. Most patients (76.92%) with cytokine storm who received Gammaraas®/Actemra®, survived although they were in the severe and critical levels (87.17%). Overall, based on the treatment duration and survival rate, the most effective therapy was a combination of oseltamivir + favipiravir + hydroxychloroquine + antibiotics + vitamins/minerals.

Intensive care unit observation after pancreatectomy: Treating the patient or the surgeon?

Routine intensive care unit admission (ICUA) is commonplace following pancreatectomy, particularly pancreaticoduodenectomy. The value of this practice in avoiding failure-to-rescue is poorly studied. We queried our institutional National Surgical Quality Improvement Project database for patients undergoing pancreatectomy from 2013 to 2020. Postoperative dispositions, ICU courses, and hospital cost data in United States Dollars (USD) were captured. Data were analyzed with multivariable logistic regression. Six-hundred-thirty-seven patients were identified; 404 (63%) underwent pancreaticoduodenectomy. Postoperatively, 398 (99%) pancreaticoduodenectomies and 110 (47%) distal pancreatectomies had ICUA; two-thirds (n = 318, 63%) did not require immediate postoperative ICU-level interventions at ICUA. Of these, 17 (5.3%) subsequently required ICU-level interventions during initial ICUA, most commonly antiarrhythmic infusion (n = 12). Thirty-day and 90-day mortality in patients requiring immediate ICU-level interventions was 5% (n = 10) and 8% (n = 16) versus 0.3% (n = 1) and 1.2% (n = 4) in those without, respectively. Hospital length of stay was significantly longer with initial ICU-level interventions (median 11 vs. 9 days, p < 0.001), as were total ICU costs (mean 8683 vs. 14611 USD, p < 0.001). At high-volume pancreas centers, patients without immediate postoperative ICU-level interventions are very low risk for failure-to-rescue. Ward admission with a low threshold for care escalation presents a significant opportunity for cost-savings and un-burdening ICUs.