Depressive Symptoms and Malnutrition are Associated with Other Geriatric Syndromes and Increase Risk for 30-Day Readmission in Hospitalized Older Adults: A Prospective Cohort Study

Background: Readmission in older adults is typically complex with multiple contributing factors. We aim to examine how two prevalent and potentially modifiable geriatric conditions – depressive symptoms and malnutrition – relate to other geriatric syndromes and 30-day readmission in hospitalized older adults. Methods: Consecutive admissions of patients >65 years to a general medical department were recruited over 15 months. Patients were screened for depression, malnutrition, delirium, cognitive impairment, and frailty at admission. Medical records were reviewed for intermediary events including poor oral intake and functional decline during hospitalization. Unplanned readmission within 30-days of discharge was tracked through the hospital’s electronic health records and follow-up telephone interviews. We use directed acyclic graphs (DAGs) to depict the relationship of depressive symptoms and malnutrition with geriatric syndromes that constitute covariates of interest and 30-day readmission outcome. Multiple logistic regression was performed for the independent associations of depressive symptoms and malnutrition with 30-day readmission, adjusting for variables based on DAG-identified minimal adjustment set. Results: We recruited 1619 consecutive admissions, with mean age 76.4 (7.9) years and 51.3% females. 30-day readmission occurred in 331 (22.0%) patients. Depressive symptoms (OR 1.55, 95% CI 1.15-2.07), malnutrition (OR 1.59, 95% CI 1.14-2.23), higher comorbidity burden, hospitalization in the one-year preceding index admission, frailty, delirium, as well as functional decline and poor oral intake during the index admission, were more commonly observed among patients who were readmitted within 30 days of discharge (P<0.05). Patients with active depressive symptoms were significantly more likely to be frail (OR=1.62, 95% CI 1.22-2.16), had poor oral intake (OR=1.35, 95% CI 1.02-1.79) and functional decline during admission (OR=1.58, 95% CI 1.11-2.23). Malnutrition at admission was significantly associated with frailty, delirium, cognitive impairment and poor oral intake during hospitalization (P<0.05). In minimal adjustment set identified by DAG, depressive symptoms (OR=1.38, 95% CI 1.02-1.86) remained significantly associated with 30-day readmission. The association of malnutrition with 30-day readmission was attenuated after adjusting for age, ethnicity and depressive symptoms in the minimal adjustment set (OR=1.40, 95% CI 0.99-1.98, P=0.06). Conclusion: The observed causal associations support screening and targeted interventions for depressive symptoms and malnutrition during admission and in the post-acute period.

COVID-19 pandemic exacerbates eating disorder by social and intrafamilial isolations: importance of familial relationships (Preprint)

UNSTRUCTURED Background: Coronavirus disease-2019 (COVID-19) pandemic makes children and their parents psychologically stressed. We present a patient with an eating disorder (ED) that rapidly worsened due to stresses and isolations and that was improved by family meeting to reconstitute their relationships, during the pandemic. Case presentation: A father found that his 9-year daughter rapidly lost her weight because of poor oral intake. Her weight had already stopped gaining before the pandemic and rapidly decreased to 22 kg during the pandemic. We diagnosed her as having an ED and administrated nasogastric tube feeding. We guessed that not only social isolations but a disruption of relationship between her and her parents, both of which occurred by the pandemic, also caused her ED. In a family meeting, she revealed that she felt anxious more during the pandemic. After the meeting, her parents rescheduled their works and have dinners together every night. She could eat sufficiently and weigh 31.8 kg. Conclusions: ED children, whose symptoms worsened during the pandemic, are increased during the pandemic since they feel loneliness by social and intrafamilial isolations. Furthermore, the parents are also stressed during the pandemic. Children including those with ED experienced stress directly from the advent of the COVID-19 pandemic and indirectly from their parents. Pediatricians should be concerned that children might experience great stress during and after the pandemic.

Constitutional Symptoms

Some of these are well known to produce distress but others are not as commonly thought of as symptoms which require palliation. Fatigue is nearly ubiquitous at the end of life and in all serious illness patients. While it may not be as obvious as pain or vomiting, it can be just as debilitating. Anorexia is not usually difficult for the patient but can be very hard for family/caregivers to understand. Hiccoughs are obvious but when intractable or chronic are also very uncomfortable and may predispose to poor oral intake. Ascites causes a host of other symptoms uncluding dyspnea and often requires surgical intervention. Fever and sweating cause discomfort but may also contribute to volume depletion and electrolyte disturbances.

What is your diagnosis? Labial adhesions – Classification and treatment

An 8-month-old Caucasian female infant with a history of two urinary tract infections presented with fever, poor oral intake, and increased irritability for 3 days prior to presentation. The mother reported a fever T max 103F and a strong odor of urine. Mother denied any cold, cough, diarrhea, vomiting, rash, and sick contacts at home. Her initial vitals were normal other than a temperature of 101F. The infant was alert, active and comfortable in her mother’s lap. On examination of her external genitalia, there was fused labia minora at the midline forming a midline raphe, and pinhole urethral opening was also noted (Figure 1). Due to close approximation of labia minora and tiny urethral opening, we were unbale to catheterize the bladder. According to the mother, previous attempts to catheterize the bladder for urinary samples were never successful as well. We confirmed the labial adhesions as shown in (Figure 1) based on our clinical examination and a presumptive diagnosis of UTI was made based on a positive bag urine sample and her symptoms.

Clinical Characteristics According to Age and Duration of Symptoms to Be Considered for Rapid Diagnosis of Pediatric Intussusception

Purpose: The purpose of this study was to evaluate whether clinical findings in children with ileocolic intussusception differ based on age and duration of symptoms and to assess the clinical characteristics of diagnosed and undiagnosed patients to determine which symptoms make diagnosis more difficult.Methods: We reviewed 536 medical records of &lt;15-year-old children diagnosed with ileocolic intussusception between 2008 and 2019. We divided the children into three categories according to age (&lt;1 year, 1–2 years, and ≥2 years). The children were also divided into two groups based on whether symptoms lasted for more or &lt;6 h. Diagnosed and undiagnosed children were assessed separately during for the initial evaluation.Results: Following analysis of the three age groups, bloody stool, post-enema bloody stool, diarrhea, vomiting, poor oral intake, and lethargy were more frequent in children aged &lt;1 year. In children aged ≥2 years, non-specific abdominal pain was more frequent and the undiagnosed rate was higher. Following analysis of the duration of symptoms, paroxysmal pain was significantly more frequent in the early group (&lt;6 h), and bloody stool and fever were significantly more frequent in the late group (≥6 h). Nonspecific abdominal pain was more frequent and the door-to-diagnosis time was significantly longer in the undiagnosed group than in the diagnosed group.Conclusions: Clinical findings of ileocolic intussusception vary depending on the age and duration of symptoms. Younger children with paroxysmal pain, vomiting, bloody stool, poor oral intake, or lethargy should be suspected of having intussusception. In older children, non-specific abdominal pain without bloody stool may be a symptom of intussusception. Glycerin enema is helpful in diagnosing intussusception in children with no typical symptoms.

Impact of coronavirus disease 2019 in a child who underwent ventricular septal defect device closure: a case report

Background Studies about the incidence and severity of coronavirus disease 2019 (COVID-19) in children are still significantly lower than those in adults. Moreover, data on the effect of COVID-19 in children with congenital heart disease (CHD) are limited. To the best of our knowledge, this study first reported mortality in a child with CHD who acquired COVID-19. Case summary A 16-month-old boy presented to the emergency department due to shortness of breath, fever, cough, and poor oral intake. He tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). He required mechanical ventilation for rapidly progressing respiratory failure. The patient had a large mid-muscular ventricular septal defect (VSD) that was closed percutaneously at the age of 13 months. Moreover, we followed his hospital sequelae from admission to death. Discussion This child had multiple risk factors, including malnutrition and persistent pulmonary hypertension (PH) after late closure of the VSD. The pre-existing PH could have been aggravated by the lung condition associated with COVID-19 and the respiratory failure triggered by SARS-CoV-2 infection. The patient presented with ventricular systolic dysfunction, elevated troponin serum levels and newly developed trifascicular block, which were indicative of myocardial injury. The elevated inflammatory markers and multi-organ dysfunction seem to corroborate multisystem inflammatory syndrome in children, which was described recently among paediatric patients with COVID-19.

Hepatobiliary Manifistations of COVID-19 in Sickle Cell Disease: A Case Report

Hepatobiliary manifestation of COVID-19 in Sickle Cell Disease: A Case report. Background and aim: SARS-CoV-2 belongs to the Coronaviridae family, and the virus began spreading worldwide in late December 2019. It mainly affects the respiratory system. However, some studies have shown an increasing number of patients reporting gastrointestinal manifestations associated with COVID-19. There is little clinical experience of COVID-19 patients with sickle cell disease (SCD) especially in our country, and most reported cases presented with acute chest syndrome (ACS). Sickle cell hepatopathy is common and ranges from benign hyperbilirubinemia and biliary sludge to overt liver failure, but it is unclear how this is affected by COVID-19. Case presentation: We report a case of a 5-year-old Saudi, non-obese female who was diagnosed as sickle B+ thalassemia (HbS: 71.9%, HbA 1.4%, HbA2: 6 & HbF: 20.7%) and was on hydroxyurea, folic acid, and vitamin D. The child came to our Emergency Department on 28/7/2020 with a one-week history of generalized abdominal pain related to the food ingestion and associated with vomiting and diarrhea. There is a history of jaundice, dark urine, and clay-like stool. There was no documented fever, history of cough, or respiratory distress. There was a history of contact with Covid-19 patient. On clinical examination, the child was vitally stable but jaundiced. She was in pain with tenderness over the right part of the abdomen but no organomegaly; other systematic examinations were normal. Her initial laboratory finding showed elevated liver enzyme (ALT: 148U/L, AST: 89U/L, GGT:150U/L, ALP:149U/L) with direct hyperbilirubinemia (total bilirubin 4.5mg/dl and direct bilirubin 2.6 mg/dl), high reticulocyte, and stable hemoglobin (10 mg/dl). She had a normal leukocyte count, platelet count, inflammatory markers, and pancreatic enzymes. Her abdominal U/S showed no hepatic focal lesions detected with normal size liver and no evidence of intrahepatic bile duct dilatation. In addition, the common bile duct and the portal vein were not dilated. The gallbladder showed normal wall thickening and was partially filled with sludge without stones (Figure 1). The child was kept on diet restriction and treated with maintenance intravenous fluid (IVF) and paracetamol. Hydroxyurea was stopped. Her gastrointestinal manifestations improved, and the liver enzymes subsided within days (Figure 2). After four days, the child was discharged home. Two days later, she was readmitted with poor oral intake and generalized upper limb pain (vaso-occlusive crisis). There was no clinical finding on examination. Her laboratory finding was acceptable, and she was started on IVF and analgesia. On 8/8/2020, she was discharged in very good clinical condition. Conclusions: It is clear that COVID-19 has significant impact on SCD. Poor oral intake that associated with viral infection can cause biliary sludge and Close follow-up is essential for those patients. Further studies are needed to support this finding. Disclosures No relevant conflicts of interest to declare.

SAT-670 The Perfect Storm for Diabetic Ketoacidosis

Background Diabetic Ketoacidosis (DKA) is a life-threatening endocrine emergency characterized by metabolic acidosis occurring in the setting of hyperglycemia due to relative insulin deficiency leading to lipolysis and production of serum ketones. Clinical circumstances can potentiate this process, such as acute infection or insulin discontinuation. Additionally, patients on SGLT2-inhibitors are at risk for euglycemic DKA. In people with type 2 diabetes, DKA is uncommon; however, a combination of precipitating factors in these patients can lead to a greater risk of DKA, particularly in the setting of SGLT2-inhibitor use. Clinical Case A 63 year old male with past medical history significant for uncontrolled type 2 diabetes (10 year duration, HgA1c=11.2%, on insulins detemir and aspart, metformin, and empagliflozin), coronary artery disease, and treatment refractory antibody-negative polymyositis (baseline CPK levels ~1000-2000, on a burst of prednisone for flare) presented with fever (101.2F), fatigue, myalgias, and nausea with poor oral intake and insulin cessation after recent IV zoledronic acid infusion for prevention of steroid-induced osteoporosis. He was found to be acidemic with bicarbonate=16, AG=18, Cr=1.6 (baseline 1.1), lactic acid=2.9, glucose=245, glucosuria/ketonuria, serum osmolality=295, and CPK=3613. No infectious etiology was found. Differential diagnosis of precipitating factors of DKA includes: steroid-induced hyperglycemia with lipolysis and insulin resistance; starvation ketosis from poor oral intake due to bisphosphonate-induced flu-like illness; metformin-associated lactic acidosis in setting of acute kidney injury; ketone production secondary to insulin cessation in setting of febrile illness; and SGLT2-inhibitor use with dehydration secondary to decompensated hyperglycemia. He was treated for DKA with insulin and volume resuscitation. He was discharged with discontinuation of empagliflozin. Conclusion In people with type 2 diabetes and multiple medical problems, a collusion of clinical factors leading to acidemia can occur simultaneously and lead to a drastically increased risk of DKA, especially in the setting of SGLT2-inhibitor use. Clinicians should have heightened awareness of minor predisposing factors that in combination can increase risk of DKA in a patient with type 2 diabetes.