Major Bleeding in Adults Undergoing Peripheral Extracorporeal Membrane Oxygenation (ECMO): Prognosis and Predictors

Background. Major bleeding has been a common and serious complication with poor outcomes in ECMO patients. With a novel, less-invasive cannulation approach and closer coagulation monitoring regime, the incidence of major bleeding is currently not determined yet. Our study aims to examine the incidence of major bleeding, its determinants, and association with mortality in peripheral-ECMO patients. Method. We conducted a single-center retrospective study on adult patients undergoing peripheral-ECMO between January 2019 and January 2020 at a tertiary referral hospital. Determinants of major bleeding were defined by logistic regression analysis. Risk factors of in-hospital mortality were determined by Cox proportional hazard regression analysis. Results. Major bleeding was reported in 33/105 patients (31.4%) and was associated with higher in-hospital mortality [adjusted hazard ratio (aHR) 3.56, 95% confidence interval (CI) 1.63–7.80, p < 0.001 ). There were no significant difference in age, sex, ECMO indications, ECMO modality, pre-ECMO APACHE-II and SOFA scores between two groups with and without major bleeding. Only APTT >72 seconds [adjusted odds ratio (aOR) 7.10, 95% CI 2.60–19.50, p < 0.001 ], fibrinogen <2 g/L [aOR = 7.10, 95% CI 2.60–19.50, p < 0.001 ], and ACT >220 seconds [aOR = 3.9, 95% CI 1.20–11.80, p = 0.017 ] on days with major bleeding were independent predictors. Conclusions. In summary, major bleeding still had a fairly high incidence and poor outcome in peripheral-ECMO patients. APTT > 72 seconds, fibrinogen < 2 g/L were the strongest predicting factors for major bleeding events.

Local Recurrence After Endoscopic Submucosal Dissection of Early Gastric Cancer

Background: Endoscopic submucosal dissection (ESD) is considered the treatment of choice for early gastric cancer (EGC) with a negligible risk of lymph node metastasis. However, locally recurrent lesions on artificial ulcer scars are difficult to manage. Therefore, predicting the risk of local recurrence after ESD is important to manage and prevent the event. This study aimed to elucidate risk factors associated with local recurrence after ESD of EGC.Methods: Between November 2008 and February 2016, consecutive patients (n=641; mean age, 69.3±9.5 years; men, 77.2%) with EGC who underwent ESD at a single tertiary referral hospital were retrospectively analyzed to evaluate the incidence and factors associated with local recurrence. Local recurrence was defined as the development of neoplastic lesions at or adjacent to the site of the post-ESD scar.Results: En bloc and complete resection rates were 97.8% and 93.6%, respectively. The local recurrence rate after ESD was 3.1%. The mean follow-up period after ESD was 50.7±32.5 months. One case of gastric cancer-related death (0.15%) was noted, wherein the patient had refused additive surgical resection after ESD for EGC with lymphatic and deep submucosal invasion. Lesion size ≥15 mm, incomplete histologic resection, undifferentiated adenocarcinoma, scar, and absence of erythema of the surface were associated with a higher risk of local recurrence. Conclusions: Predicting local recurrence during regular endoscopic surveillance after ESD is important, especially in patients with a larger lesion size (≥15 mm), incomplete histologic resection, surface changes of scars, and no erythema of the surface.

Estrogen receptor beta (ERβ) expression in different subtypes of malignant pleural mesothelioma

Background: Estrogen receptor beta (ERβ) is a potential target for cancer therapy as a tumor suppressor. Malignant pleural mesothelioma (MPM) is a rare but fatal cancer. This study tries to estimate the incidence of ERβ expression in the various subtypes of MPM tumors. Methods and Materials: In a retrospective study performed at a pulmonary tertiary referral hospital, formalin-fixed paraffin-embedded human tissues of 46 definitive MPM were evaluated for expression of ERβ by immunohistochemistry. Results: ERβ was detected in 14 cases (30.4%) out of the total 46 patients with a mean age of 58.08±11.59 SD, including 33 (71.7%) males. There was no statistically significant difference in patients with positive ERβ staining versus negative cases in age and sex (P >0.05). MPM subtypes included 36 (78.2%) cases of epithelioid mesothelioma, 3 (6.5%) cases of sarcomatoid, 5 (10.8%) cases of biphasic, and 2 (4.3%) cases of desmoplastic subtype. ERβ expression was observed only in epithelioid (11 of total 36 cases) and biphasic (3 of total 5 cases) tumors. There was no significant difference in the incidence of ERβ expression in different subtypes of malignant pleural mesothelioma. Statistical analysis shows a significant difference in the expression of ERβ in the epithelioid subtype (with a more favorable prognosis) versus non-epithelioid subtypes (with poor prognosis, including sarcomatoid, desmoplastic, and biphasic) (P = 0.024). Discussion and Conclusion: Considering the higher proportion of the epithelioid type of MPM with ERβ expression, this highlights the role of ERβ in target therapy of MPM tumor, especially in the epithelioid subtype with a more favorable prognosis. A better understanding of the pathology of mesothelioma will eventually contribute to the development of therapies beyond the existing therapeutic platform.

Evaluation of Multiplex Real-time PCR and WHO Criteria for Diagnosing Childhood Bacterial Meningitis in a Tertiary Referral Hospital in Iran

Background: Childhood bacterial meningitis (BM) requires prompt and precise diagnosis to provide proper treatment and decline mortality and morbidity. Objectives: We aimed to evaluate the World Health Organization (WHO) criteria and polymerase chain reaction (PCR) for diagnosing BM in children admitted to a tertiary referral hospital in Shiraz, southern Iran. Materials: We included all 492 children aged one month to 17 years suspected of meningitis who had cerebrospinal fluid (CSF) leukocytosis admitted to Nemazi Hospital from August 2016 to September 2017. The CSF specimens were examined for routine analysis, Gram staining, and culture. A multiplex real-time PCR was used to identify Streptococcus pneumoniae, Haemophilus influenzae type b (Hib), and Neisseria meningitidis in the CSF samples. Seven viruses were also investigated using real-time PCR. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using the WHO criteria and the multiplex real-time PCR results. Results: Seventy-four CSF samples had leukocytosis. Nineteen (22.9%) patients had BM caused by S. pneumoniae (n = 14), Hib (n = 2), Salmonella enterica (n = 2), and N. meningitidis (n = 1). The PCR test detected all cases, except for two with Salmonella meningitis (sensitivity 89.4%, specificity 100%, PPV 100%, and NPV 96%). The WHO criteria detected all cases, except three who received antibiotics at least four days before performing lumbar puncture (sensitivity 84.2%, specificity 98.2%, PPV 94.1%, and NPV 94.7%). Enterovirus was the most common viral etiology (6.75%). Conclusions: The WHO criteria and the multiplex real-time PCR had high accuracy in our setting, and their use could decrease the antibiotic over-prescription in febrile children suspected of meningitis.

Clinical presentations, diagnostics, treatments and treatment costs of children and adults with febrile illness in a tertiary referral hospital in south-eastern Guinea: A retrospective longitudinal cohort study

Background Febrile illness is frequent among patients in the tropics. It is caused by a wide variety of common diseases such as malaria or gastrointestinal infections but also by less common but highly contagious pathogens with epidemic potential. This study describes the clinical features of adult and paediatric patients with febrile illness in in the largest tertiary referral hospital in south-eastern Guinea, a region at high risk for viral haemorrhagic fever outbreaks. The study further compares their diagnostic characteristics, treatments and outcomes with non-febrile patients in order to contribute to the local epidemiology of febrile illness. Methods We used retrospective data collection to record demographic and clinical data of all incoming patients during a study period of three months. For the follow-up study of inpatients, we retrospectively reviewed patient charts for diagnostic characteristics, diagnoses and outcomes. Results Of the 4317 incoming patients during the study period, 9.5% had a febrile illness. The most used diagnostic measures to identify causative agents in febrile patients were point-of-care tests and most treatments relied on antibiotics. Most common discharge diagnoses for febrile inpatients were malaria (9.6% adults, 56.7% children), salmonella gastroenteritis/typhoid (10.6% adults, 7.8% children) and respiratory infection/pneumonia (5.3% adults, 18.7% children). Inpatient mortality for children was significantly higher in febrile than non-febrile children (18.5% vs. 5.1%, p<0.001) and considerably higher in febrile than non-febrile adults (29.8% vs. 25.0%, p = 0.404). Conclusions Malaria, respiratory infection and gastroenteritis are considered the main causes for febrile illness. The wide reliance on rapid diagnostic tests to diagnose febrile patients not only risks to over- or under-diagnose certain diseases but also leaves the possibility of highly infectious diseases in febrile patients unexplored. Furthermore, the heavy reliance on antibiotics risks to cause antimicrobial resistance. High mortality rates in febrile patients, especially children, should be of concern to public health authorities.

Comparison of the Clinical Outcomes of Patients With Positive Xpert Carba-R Tests for Carbapenemase-Producing Enterobacterales According to Culture Positivity

Background We aimed to compare the clinical outcomes of patients with positive Xpert Carba-R assay results for carbapenemase-producing Enterobacterales (CPE) according to CPE culture positivity. Methods We retrospectively collected data for patients with positive CPE (positive Xpert Carba-R or culture) who underwent both tests from August 2018 to March 2021 in a 2700-bed tertiary referral hospital in Seoul, South Korea. We compared the clinical outcomes of patients positive for Xpert Carba-R according to whether they were positive (XPCP) or negative (XPCN) for CPE culture. Results Of 322 patients with CPE who underwent both Xpert Carba-R and culture, 313 (97%) were positive for Xpert Carba-R for CPE. Of these, 87 (28%) were XPCN, and 226 (72%) were XPCP. XPCN patients were less likely to have a history of previous antibiotic use (75.9% vs 90.3%; P = .001) and to have Klebsiella pneumoniae carbapenemase (21.8% vs 48.9%; P &lt; .001). None of the XPCN patients developed infection from colonization within 6 months, whereas 13.4% (29/216) of the XPCP patients did (P &lt; .001). XPCN patients had lower transmission rates than XPCP patients (3.0% [9/305] vs 6.3% [37/592]; P = .03). There was no significant difference in CPE clearance from positive culture results between XPCN and XPCP patients (40.0% [8/20] vs 26.7% [55/206]; P = .21). Conclusions Our study suggests that XPCN patients had lower rates of both infection and transmission than XPCP patients. The Xpert Carba-R assay is clinically useful not only for rapid identification of CPE but also for predicting risks of infection and transmission when performed along with culture.

Lower GCS is Related to Poor Outcome among Acute Stroke Patients with COVID-19 in A Tertiary Referral Hospital in Indonesia

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic has forced the health workforce to take mitigative measures such as physical distancing, screening, personal protective equipment donning, and confinement on patient care. We aimed to study the outcome of acute stroke patients with suspected, probable, or confirmed COVID-19 in a tertiary referral hospital in Indonesia during the first year of COVID-19 pandemic.METHODS: This was a retrospective study examining all medical records of adult patients suffering from acute stroke with suspected or confirmed COVID-19 who were admitted to R.D. Kandou Hospital, Manado, Indonesia, between March 2020 to March 2021. Clinical and laboratory parameters were compared between subjects with poor and good outcomes based on Glasgow Outcome Scale (GOS), divided into poor outcome (GOS 1-3) and good outcome (GOS 4-5).RESULTS: Fourty-six eligible subjects were enrolled in the study. Based on the GOS, 36 subjects (78.3%) were admitted to the hospital with poor prognosis. On admission, the median Glasgow Coma Scale (GCS) was 11, breathlessness was found in 54.3% of subjects, fever was found in only 15 subjects (32.6%), and the lowest oxygen saturation on admission 95%. We found that GCS significantly related to outcome after controlled for other factors using the logistic regression method (p=0.03; 95% CI=1.08-4.78).CONCLUSION: Lower GCS can be used to predict poor outcome in acute stroke patients with COVID-19.KEYWORDS: COVID-19, acute stroke, Glasgow Coma Scale, outcome, Indonesia

Study of maternal deaths with COVID-19 infection in a tertiary care centre

Background: COVID-19 has been a major speed braker not only for world economy and development but also for health sector. The susceptible population including elderly, co-morbid adults and pregnant females were likewise affected in both major COVID-19 waves in India. Association between COVID-19 cases and pregnancy has been studied throughout the world.COVID-19 is associated with substantial risk of morbidity and mortality in postpartum patients and their infants world-wide, compared with their not-infected pregnant counter-parts, especially if these individuals were symptomatic or have comorbidities.Methods: This single-centre prospective observational study, included all consecutive maternal mortalities with COVID-19 infection admitted to Lokmanya Tilak municipal medical college and general hospital (Mumbai, India), a tertiary referral hospital, from 1 April 2020, to June 2021.In this study, a total of 390 patients were included who were found COVID-19 positive during the study period and 17 patients who died during their admission in hospital. The relation of risk factors and demographics were studied for all the patients.Results: The COVID-19 related maternal mortality was more in women of age group 20-30 years (89%). Most women presented to our centre with complaints of fever, cough, cold or breathlessness (55.5%). Patients who succumbed to COVID-19 were mostly primiparous patients (52.9%) and died within 5 days of delivery (46%). 64% of patients died following 5 days of diagnosis of COVID-19.The co-morbidity present in most patients with COVID-19 associated maternal mortality was pre-eclampsia (31.5%). Most patients were referred with only 17% patients registered at our centre and the type of delay involved in management was mostly Type 1 and 2 (82.2%)Conclusions: Multi-centre retrospective analysis with larger population size is required in order for this to be statistically significant.