Correlation of Platelet-Lymphocyte Ratio (PLR) as 28-Days Sepsis Mortality Predictor in Intensive Care Unit of RSMH Palembang

Introduction. Inflammatory and anti-inflammatory response are important in pathophysiology and mortality of sepsis. Platelet as first line inflammatory marker was found increasing during early phase of infection. Decrease in lymphocyte was caused by disrupted balance between inflammatory and anti-inflammatory response. Platelet-to- lymphocyte ratio (PLR) is a cheap and accessible biomarker of sepsis mortality. This study aims to find the sensitivity and specificity of PLR as mortality predictor of sepsis in 28 days. Methods. This observational analytic study with retrospective cohort design was conducted to 91 sepsis patients in intensive care unit of Dr. Mohammad Hoesin Palembang Central Hospital between January and December 2019. Samples were secondarily collected from medical record during June-July 2020. Data was analyzed using chi-square test, cog regression test, and ROC curve analysis. Results. The result found 50 patients (54,9%) died in 28 days. Morbidity score (Charlson) was the only statistically significant mortality parameter (p=0,009). The study reported PLR cut-off point of >272,22. The sensitivity and specificity of PLR as 28-days sepsis mortality predictor are 84% and 80,49% respectively. Conclusion. PLR is alternatively reliable mortality predictor in sepsis patient, accounted to its relatively high sensitivity and specificity.

Consensus Defined Diastolic Dysfunction and Cardiac Postoperative Morbidity Score: A Prospective Observational Study

Diastolic dysfunction is associated with major adverse outcomes following cardiac surgery. We hypothesized that multisystem endpoints of morbidity would be higher in patients with diastolic dysfunction. A total of 142 patients undergoing cardiac surgical procedures with cardiopulmonary bypass were included in the study. Intraoperative assessments of diastolic function according to the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines using transesophageal echocardiography were performed. Cardiac Postoperative Morbidity Score (CPOMS) on days 3, 5, 8, and 15; length of stay in ICU and hospital; duration of intubation; incidence of new atrial fibrillation; 30-day major adverse cardiac and cerebrovascular events were recorded. Diastolic function was determinable in 96.7% of the dataset pre and poststernotomy assessment (n = 240). Diastolic dysfunction was present in 70.9% (n = 88) of measurements before sternotomy and 75% (n = 93) after sternal closure. Diastolic dysfunction at either stage was associated with greater CPOMS on D5 (p = 0.009) and D8 (p = 0.009), with CPOMS scores 1.24 (p = 0.01) higher than in patients with normal function. Diastolic dysfunction was also associated with longer durations of intubation (p = 0.001), ICU length of stay (p = 0.019), and new postoperative atrial fibrillation (p = 0.016, OR (95% CI) = 4.50 (1.22–25.17)). We were able to apply the updated ASE/EACVI guidelines and grade diastolic dysfunction in the majority of patients. Any grade of diastolic dysfunction was associated with greater all-cause morbidity, compared with patients with normal diastolic function.

Blood Type Does Not Affect Morbidity or Mortality in COVID-19 Infections, As Assessed By a Clinical Severity Scoring System

Introduction: Coronavirus disease (COVID-19), caused by the novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), continues to lead to worldwide morbidity and mortality. This study aimed to determine if there was an association between blood type and clinical outcomes measured by a calculated morbidity score and mortality rates in patients infected with SARS-CoV-2 at our institution. The secondary aim was to investigate the association between patient characteristics (specifically age, gender, comorbid conditions, and race) and clinical outcomes and mortality in patients with confirmed SARS-COV-2 infection. Methods: Logistic regression was used to determine what factors were associated with death. A total morbidity score was constructed based on overall patient's COVID-19 clinical course. This score was modeled using Quasi-Poisson regression. Bayesian variable selection was used for the logistic regression to obtain a posterior probability that blood type is important in predicting worsened clinical outcomes and death. Results: Patients with blood type B were more likely to be African American, and patients with blood type AB were less likely to be male. Neither Blood type nor Rh+ status was a significant moderator of death or total morbidity score in regression analyses. Deviance based tests showed that blood type and Rh+ status could be omitted from each regression without a significant decrease in prediction accuracy. Bayesian variable selection showed that the posterior probability that any blood type related covariates were important in predicting death was .10. Increased age (aOR = 3.37, 95% CI = 2.44 - 4.67), male gender (aOR = 1.35, 95% CI = 1.08-1.69), and number of comorbid conditions (aOR = 1.28, 95% CI = 1.01-1.63) were the only covariates that were significantly associated with death. The only significant factors in predicting total morbidity score were age (aOR = 1.45; 95% CI = 1.349-1.555) and gender (aOR = 1.17; 95% CI = 1.109-1.243). Conclusion: In a large cohort of COVID-19 positive patients treated at a tertiary care hospital serving a low income population in New Orleans, there is strong evidence that blood type was not a significant predictor of clinical course or death in patients hospitalized with COVID 19. Older age and male gender led to worse clinical outcomes and higher rates of death; whereas older age, male gender, and comorbidities predicted a worse clinical course and higher morbidity score. Race was not a predictor of clinical course or death. Disclosures No relevant conflicts of interest to declare.

One year outcomes of heart failure multispecialty multidisciplinary team virtual meetings

Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model. This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings. A total of 189 patients were discussed from January-December 2020. This was uninterrupted during the COVID-19 pandemic. The mean age was 70.3±18.1 years and median follow-up 6 months (range 1–13 months). The mean Charlson Co-morbidity score was 5.3±1.2 and Rockwood Frailty Score was 4.9±1. The mean number of outpatient clinic attendances avoided was 1.7±0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p<0.01) with a saving of around 730 bed days (estimated cost-saving £260,000). The HF multispecialty virtual MDT approach provides seamless integration of primary care community services with secondary and tertiary care. Consensus decision from MDT meetings provides holistic approach for HF patients with comorbidities and frailty, and reduces inconvenience to patients by preventing the need to attend multiple specialty clinics. This approach can also lead to significant cost-savings to the healthcare system. FUNDunding Acknowledgement Type of funding sources: None.

Emergency department visits and inpatient hospitalizations among older patients with brain metastases: A dual population- and institution-level analysis

Background Older patients with brain metastases (BrM) commonly experience symptoms that prompt acute medical evaluation. We characterized emergency department (ED) visits and inpatient hospitalizations in this population. Methods We identified 17,789 and 361 Medicare enrollees diagnosed with BrM using the Surveillance, Epidemiology, and End Results-Medicare database (2010-2016) and an institutional database (2007-2016), respectively. Predictors of ED visits and hospitalizations were assessed using Poisson regression. Results The institutional cohort averaged 3.3 ED visits/1.9 hospitalizations per person-year, with intracranial disease being the most common reason for presentation/admission. SEER-Medicare patients averaged 2.8 ED visits/2.0 hospitalizations per person-year. For patients with synchronous BrM (N=7,834), adjusted risk factors for ED utilization and hospitalization, respectively, included: male sex (rate ratio [RR]=1.15 [95% CI=1.09-1.22], p<0.001; RR=1.21 [95% CI=1.13-1.29], p<0.001); African American vs. white race (RR=1.30 [95% CI=1.18-1.42], p<0.001; RR=1.25 [95% CI=1.13-1.39], p<0.001); unmarried status (RR=1.07 [95% CI=1.01-1.14], p=0.02; RR=1.09 [95% CI=1.02-1.17], p=0.01); Charlson co-morbidity score >2 (RR=1.27 [95% CI=1.17-1.37], p<0.001; RR=1.36 [95% CI=1.24-1.49], p<0.001); and receipt of non-stereotactic vs. stereotactic radiation (RR=1.44 [95% CI=1.34-1.55, p<0.001; RR=1.49 [95% CI=1.37-1.62, p<0.001). For patients with metachronous BrM (N=9,955), ED visits and hospitalizations were more common after vs. before BrM diagnosis (2.6 vs. 1.2 ED visits per person-year; 1.8 vs. 0.9 hospitalizations per person-year, respectively; RR=2.24 [95% CI=2.15-2.33], p<0.001; RR=2.06 [95% CI=1.98-2.15], p<0.001, respectively). Conclusions Older patients with BrM commonly receive hospital-level care secondary to intracranial disease, especially in select subpopulations. Enhanced care coordination, closer outpatient follow-up, and patient navigator programs seem warranted for this population.

Real-world practice patterns in treatment of metastatic breast cancer in Washington State.

e13038 Background: Evidence-based, national guidelines for the management of metastatic breast cancer (MBC) recommend numerous treatment options that do not capture the nuances of real-world practice. Disparities may exist across Washington State with financial implications for patients and health systems. The objective of this study was to assess practice patterns around treatment of ER+/HER2- MBC in actual clinical practice. Methods: We collaborated with Hutchinson Institute for Cancer Outcomes Research (HICOR) to link enrollment and insurance claims records with Washington State cancer registries from 2008-2017. Our cohort comprised of women >18 years old with de novo ER+/HER2- MBC who met enrollment criteria in one of four payors (Premera, Regence, Medicare, or Medicaid). We identified receipt of first line treatment, categorized as CDK4/6 inhibitors plus endocrine therapy (CDKi+ET), chemotherapy (CT), or endocrine therapy alone (ET). We examined factors influencing treatment selection using Fisher's and Kruskal-Wallis tests. Total costs (defined as costs from inpatient and outpatient claims one year after diagnosis) was estimated for patients and payors. Results: We identified 140 patients with de novo ER+/HER2- MBC with median age of 64 (range 28-95). The majority of the cohort were Caucasian (90%) with the rest comprising of Asian, Black, American Indian, and Hispanic patients. Based on the Rural Urban Commuting Area (RUCA) classification, patients predominantly lived in metropolitan neighborhoods (96%). Over 20% of patients lived in areas of high deprivation (area of deprivation index, ADI, 8-10). Patients had either Commercial (40.7%), Medicaid/Medicare (43.6%) or multiple (15.7%) insurance. Our data show that 17 patients (12%) received first line therapy with CDKi + ET, 64 patients (46%) with CT, and 59 patients (42%) with ET alone. Factors influencing treatment selection include age, co-morbidity score, and payor type. Older patients (>65 years old) were more likely to receive ET alone compared to younger patients (56% vs 44%, p value <0.001). Patients with high co-morbidity score were more likely to receive ET (30%) compared to CT (5%) or CDKi + ET (23%), p value <0.001. Patients with commercial insurance made up over 50% of patients in our cohort who received CDKi +ET, while Medicare-insured patients were most likely to receive ET alone (p value <0.001). We estimated the mean cost of receiving first line therapy with CDKi +ET ($20,368 and $175,932), CT ($10,624 and $117,847) and ET alone ($13,292 and $60,338) for patients and payors, respectively (costs inflated to December 2019). Conclusions: Our study shows substantial variation across Washington state in treatment selection and costs for patients with metastatic breast cancer in the first-line setting. Our findings demonstrate the need for initiatives to standardize quality of care relative to clinical guidelines in metastatic breast cancer care.

Surface and air contamination with SARS-CoV-2 from hospitalized COVID-19 patients in Toronto, Canada

Background The aim of this prospective cohort study was to determine the burden of SARS-CoV-2 in air and on surfaces in rooms of patients hospitalized with COVID-19, and to identify patient characteristics associated with SARS-CoV-2 environmental contamination. Methods Nasopharyngeal swabs, surface, and air samples were collected from the rooms of 78 inpatients with COVID-19 at six acute care hospitals in Toronto from March to May 2020. Samples were tested for SARS-CoV-2 viral RNA and cultured to determine potential infectivity. Whole viral genomes were sequenced from nasopharyngeal and surface samples. Association between patient factors and detection of SARS-CoV-2 RNA in surface samples were investigated using a mixed-effects logistic regression model. Findings SARS-CoV-2 RNA was detected from surfaces (125/474 samples; 42/78 patients) and air (3/146 samples; 3/45 patients) in COVID-19 patient rooms; 14% (6/42) of surface samples from three patients yielded viable virus. Viral sequences from nasopharyngeal and surface samples clustered by patient. Multivariable analysis indicated hypoxia at admission, a PCR-positive nasopharyngeal swab with a cycle threshold of ≤30 on or after surface sampling date, higher Charlson co-morbidity score, and shorter time from onset of illness to sample date were significantly associated with detection of SARS-CoV-2 RNA in surface samples. Interpretation The infrequent recovery of infectious SARS-CoV-2 virus from the environment suggests that the risk to healthcare workers from air and near-patient surfaces in acute care hospital wards is likely limited. Surface contamination was greater when patients were earlier in their course of illness and in those with hypoxia, multiple co-morbidities, and higher SARS-CoV-2 RNA concentration in NP swabs. Our results suggest that, while early detection and isolation of COVID-19 patients is important, air and surfaces may pose limited risk a few days after admission to acute care hospitals.

Illness perceptions predict distress in patients with chronic kidney disease

Background Patients diagnosed with chronic kidney disease (CKD) report increased distress associated with their clinical diagnosis. Distress in patients with predialysis CKD, has been linked to several adverse events; including increased risk of hospitalisation, early dialysis initiation and even death, suggesting that distress is a matter of great concern during routine care in predialysis CKD. Aims The present study aimed to assess the nature of illness perceptions and the level of distress in a CKD cohort diagnosed with different stages of kidney disease. It also aimed to explore the correlates of distress and to create a model for distress and its associated predictors making use of hierarchical regression analysis. Methods A sample of 200 patients diagnosed with Chronic Kidney Disease were recruited for this study from the nephrology outpatient clinics of Mater Dei Hospital, Malta. The participants were assessed for their; illness perceptions, treatment beliefs, level of depression and anxiety, coping style, as well as treatment adherence. Routine clinical information was also collected for participants, including a co-morbidity score. Results A percentage of 33.5% of the participants reported moderate distress, whilst 9.5% reported severe distress. Stronger illness identity, a perception of timeline as being increasingly chronic or cyclical in nature, greater consequences and higher emotional representations were associated with more advanced stages of CKD. In contrast, lower personal and treatment control and poorer illness coherence were associated with more advanced stages of CKD. Results from the hierarchical regression analysis showed that illness perceptions contributed significantly to distress over and above the clinical kidney factors. Being female, having low haemoglobin and specific illness perceptions including; perceptions of greater symptomatology, longer timeline, low personal control and strong emotional representations, as well as resorting to maladaptive coping, were all significantly associated with distress symptoms. Nevertheless, illness perceptions accounted for the greatest variance in distress thus indicating that the contribution of illness perceptions is greater than that made by the other known covariates. Conclusion Illness perceptions hold a principal role in explaining distress in CKD, relative to other traditional covariates. For this reason, illness perceptions should be addressed as a primary modifiable component in the development of distress in CKD.

Systematic review of grading systems for adverse surgical outcomes

Background: Grading scales for adverse surgical outcomes have been poorly characterized to date. The primary aim of this study was to conduct a systematic review to enumerate the various frameworks for grading adverse postoperative outcomes; our secondary objective was to outline the properties of each grading system, identifying its strengths and weaknesses. Methods: We searched 9 databases (Africa Wide Information, Biosis, Cochrane, Embase, Global Health, LILACs, Medline, PubMed and Web of Science) from 1992 (the year the Clavien–Dindo classification system was developed) until Mar. 2, 2017, for studies that aimed to develop or improve on an already existing generalizable system for grading adverse postoperative outcomes. Study selection was duplicated as per PRISMA recommendations. Procedure-specific grading systems were excluded. We assessed the framework, strengths and weaknesses of the systems qualitatively. Results: We identified 9 studies on 8 adverse outcome grading systems with frameworks generalizable to any surgical procedure. Most systems have not been widely incorporated in the literature. Seven of the 8 systems were produced without including patients’ perspectives. Four allowed the derivation of a composite morbidity score, which had limited tangible significance for patients. Conclusion: Although each instrument identified offered its own advantages, none satisfied the need for a patient-centred tool capable of generating a composite score of all possible postoperative adverse outcomes (complications, sequelae and failure) that enables comparison of noninterventional and surgical management of disease. There is a need for development of a more comprehensive, patient-centred grading system for adverse postoperative outcomes.

Clinico-Radiological Correlation in 26 Egyptian Children with Glutaric Acidemia Type 1

Background Glutaric acidemia type 1 (GA1) is an inherited neurometabolic disease with significant morbidity. However, neuro-radiological correlation is not completely understood. Objective The study aimed to characterize the neuroimaging findings and their association with neurological phenotype in GA1 children. Methods Twenty-six Egyptian children (median age = 12 months) diagnosed with GA1 underwent clinical evaluation and brain magnetic resonance imaging (MRI). We objectively assessed the severity of neurological phenotype at the time of MRI using movement disorder (MD) and morbidity scores. Evaluation of brain MRI abnormalities followed a systematic and region-specific scoring approach. Brain MRI findings and scores were correlated with MD and morbidity scores, disease onset, and presence of seizures. Results Fifteen (57.7%) cases had insidious onset, eight (30.8%) manifested acute onset, whereas three (11.5%) were asymptomatic. Ten (38.5%) cases had seizures, five of which had no acute encephalopathic crisis. Putamen and caudate abnormalities (found in all acute onset, 93.3 and 73.3% of insidious onset, and one of three asymptomatic cases) were significantly related to MD (p = 0.007 and 0.013) and morbidity (p = 0.005 and 0.003) scores. Globus pallidus abnormalities (50% of acute onset, 46.7% of insidious onset, and one of three of asymptomatic cases) were significantly associated with morbidity score (p = 0.023). Other MRI brain abnormalities as well as gray and white matter score showed no significant association with neurological phenotype. Younger age at onset, acute onset, and seizures were significantly associated with worse neurological manifestations. Conclusion Patients with GA1 manifest characteristic and region-specific brain MRI abnormalities, but only striatal affection appears to correlate with neurological phenotype.