Applicability of the GLIM criteria for the diagnosis of malnutrition in older adults in the emergency ward: A pilot validation study.

BACKGROUND & AIMS: Acutely ill older adults are at higher risk of malnutrition. This study aimed to explore the applicability and accuracy of the GLIM criteria to diagnose malnutrition in acutely ill older adults in the emergency ward (EW). METHODS: We performed a retrospective secondary analysis, of an ongoing cohort study, in 165 participants over 65 years of age admitted to the EW of a Brazilian university hospital. Nutrition assessment included anthropometry, the Simplified Nutritional Assessment Questionnaire (SNAQ), the Malnutrition Screening Tool (MST), and the Mini-Nutritional Assessment (MNA). We diagnosed malnutrition using GLIM criteria, defined by the parallel presence of at least one phenotypic [nonvolitional weight loss (WL), low BMI, low muscle mass (MM)] and one etiologic criterion [reduced food intake or assimilation (RFI), disease burden/inflammation]. We used the receiver operating characteristic (ROC) curves and Cox and logistic regression for data analyses. RESULTS: GLIM criteria, following the MNA-SF screening, classified 50.3% of participants as malnourished, 29.1% of them in a severe stage. Validation of the diagnosis using MNA-FF as a reference showed good accuracy (AUC = 0.84), and moderate sensitivity (76%) and specificity (75.1%). All phenotypic criteria combined with RFI showed the best metrics. Malnutrition showed a trend for an increased risk of transference to intensive care unit (OR = 2.08, 95% CI 0.99, 4.35), and severe malnutrition for in-hospital mortality (HR = 4.23, 95% CI 1.2, 14.9). CONCLUSION: GLIM criteria, following MNA-SF screening, appear to be a feasible approach to diagnose malnutrition in acutely ill older adults in the EW. Nonvolitional WL combined with RFI or acute inflammation were the best components identified and are easily accessible, allowing their potential use in clinical practice.

Mesenchymal Stem/Stromal Cells and Their Derivates in Acute Diseases: Emergency in the Post-COVID-19 Times.

The current coronavirus disease-19 (COVID-19) pandemic has strongly revived the pressing need to incorporate new therapeutic alternatives to deal with medical situations that result in a dramatic breakdown in the body's normal homeostasis [...].

Do surgical emergencies stay at home? Observations from the first United States Coronavirus epicenter.

BACKGROUND: During the coronavirus disease 2019 pandemic, New York instituted a statewide stay-at-home mandate to lower viral transmission. While public health guidelines advised continued provision of timely care for patients, disruption of safety-net health care and public fear have been proposed to be related to indirect deaths because of delays in presentation. We hypothesized that admissions for emergency general surgery (EGS) diagnoses would decrease during the pandemic and that mortality for these patients would increase. METHODS: A multicenter observational study comparing EGS admissions from January to May 2020 to 2018 and 2019 across 11 NYC hospitals in the largest public health care system in the United States was performed. Emergency general surgery diagnoses were defined using International Classification Diseases, Tenth Revision, codes and grouped into seven common diagnosis categories: appendicitis, cholecystitis, small/large bowel, peptic ulcer disease, groin hernia, ventral hernia, and necrotizing soft tissue infection. Baseline demographics were compared including age, race/ethnicity, and payor status. Outcomes included coronavirus disease (COVID) status and mortality. RESULTS: A total of 1,376 patients were admitted for EGS diagnoses from January to May 2020, a decrease compared with both 2018 (1,789) and 2019 (1,668) (p < 0.0001). This drop was most notable after the stay-at-home mandate (March 22, 2020; week 12). From March to May 2020, 3.3%, 19.2%, and 6.0% of EGS admissions were incidentally COVID positive, respectively. Mortality increased in March to May 2020 compared with 2019 (2.2% vs. 0.7%); this difference was statistically significant between April 2020 and April 2019 (4.1% vs. 0.9%, p = 0.045). CONCLUSION: Supporting our hypothesis, the coronavirus disease 2019 pandemic and subsequent stay-at-home mandate resulted in decreased EGS admissions between March and May 2020 compared with prior years. During this time, there was also a statistically significant increase in mortality, which peaked at the height of COVID infection rates in our population. LEVEL OF EVIDENCE: Epidemiological, level IV.

Retrograde Open Mesenteric Stenting for Acute and Chronic Mesenteric Ischaemia: Results from an Intestinal Stroke Centre.

OBJECTIVE: To report the intra-operative adverse events (IOAEs) and the initial and one year outcomes of retrograde open mesenteric stenting (ROMS) using balloon expandable covered stents for acute and chronic mesenteric ischaemia. METHODS: Clinical data and outcomes of all consecutive patients treated with ROMS for acute and chronic mesenteric ischaemia at an intestinal stroke centre between November 2012 and September 2019 were reviewed. ROMS was performed using balloon expandable covered stents. Endpoints included IOAEs, in hospital mortality, post-operative complications, and re-interventions. One year overall survival, freedom from re-intervention, primary patency and assisted primary patency rates were analysed using the Kaplan-Meier time to event method. RESULTS: During the study period, 379 patients were referred to the centre for acute or chronic mesenteric ischaemia. Thirty-seven patients who underwent the ROMS procedure were included. All the patients had severe atherosclerotic mesenteric lesions. The ROMS technical success rate was 89% in this cohort. The rate of IOAEs was 19% and included four cases of retrograde recanalisation failure. All ROMS failures occurred in patients presenting with flush superior mesenteric artery occlusion and they were treated by mesenteric bypass. Ten patients (27%) underwent bowel resection, four of which resulted in a short bowel syndrome (11%). The in hospital mortality rate was 27%. Post-operative complications and re-intervention rates were 67% (n = 25) and 32% (n = 12), respectively. The median follow up was 20.2 months (interquartile range 29). The estimated one year overall survival for the cohort was 70.1% (95% confidence interval [CI] 52.5% - 82.2%). The estimated freedom from re-intervention at one year was 61.1% (95% CI 42.3 - 75.4). The one year primary patency and assisted primary patency rates were 84.54% (95% CI 63.34 - 94) and 92.4% (95% CI 72.8 - 98), respectively. CONCLUSION: ROMS procedures offer acceptable one year outcomes for mesenteric ischaemia but are associated with frequent stent related complications. Precise pre-operative planning, high quality imaging, and meticulous stent placement techniques may limit the occurrence of such events.

Score performance of SAPS 2 and SAPS 3 in combination with biomarkers IL-6, PCT or CRP.

OBJECTIVE: We aimed to evaluate the effects of combining the Simplified-Acute-Physiology-Score (SAPS) 2 or the SAPS 3 with Interleukin-6 (IL-6) or Procalcitonin (PCT) or C-Reactive Protein (CRP) concentrations for predicting in-hospital mortality. MATERIAL AND METHODS: This retrospective study was conducted in an interdisciplinary 22-bed intensive care unit (ICU) at a German university hospital. Within an 18-month period, SAPS 2 and SAPS 3 were calculated for 514 critically ill patients that were admitted to the internal medicine department. To evaluate discrimination performance, the area under the receiver operating characteristic curves (AUROCs) and the 95% confidence intervals (95% CIs) were calculated for each score, exclusively or in combination with IL-6 or PCT or CRP. DeLong test was used to compare different AUROCs. RESULTS: The SAPS 2 exhibited a better discrimination performance than SAPS 3 with AUROCs of 0.81 (95% CI, 0.76-0.86) and 0.72 (95% CI, 0.66-0.78), respectively. Overall, combination of the SAPS 2 with IL-6 showed the best discrimination performance (AUROC 0.82; 95% CI, 0.77-0.87), albeit not significantly different from SAPS2. IL-6 performed better than PCT and CRP with AUROCs of 0.75 (95% CI, 0.69-0.81), 0.72 (95% CI, 0.66-0.77) and 0.65 (95% CI, 0.59-0.72), respectively. Performance of the SAPS 3 improved significantly when combined with IL-6 (AUROC 0.76; 95% CI, 0.69-0.81) or PCT (AUROC 0.73; 95% CI, 0.67-0.78). CONCLUSIONS: Our analysis provided evidence that the risk stratification performance of the SAPS 3 and, to a lesser degree, also of the SAPS 2 can increase when combined with IL-6. A more accurate detection of aberrant or dysregulated systemic immunological responses (by IL-6) may explain the higher performance achieved by SAPS 3 + IL-6 vs. SAPS 3. Thus, implementation of IL-6 in critical care scores can improve prediction outcomes, especially in patients experiencing acute inflammatory conditions; however, statistical results may vary across hospital types and/or patient populations with different case mix.

[Current trends in emergency abdominal surgery in the Russian Federation]. / Sovremennye tendentsii v neotlozhnoi abdominal'noi khirurgii v Rossiiskoi Federatsii.

OBJECTIVE: To analyze morbidity and factors affecting mortality in emergency abdominal surgery in the Russian Federation. MATERIAL AND METHODS: The study included patients with acute abdominal diseases aged 18 years and older. All patients were hospitalized in emergency surgical care departments of 3.194 state healthcare institutions in 84 regions of the Russian Federation in 2018. Morbidity, surgical activity and mortality were analyzed. RESULTS: There were 680.337 cases of hospitalization in emergency surgical department, morbidity rate was 582 cases per 100 000. The most common emergency surgical diseases were acute appendicitis (142.3 cases per 100 000), acute cholecystitis (139.0 cases per 100 000) and acute pancreatitis (131.2 cases per 100 000). Surgery was performed in 399.051 (58.7%) patients. In-hospital mortality rate was 2.4% (16 051 cases). CONCLUSION: There are certain factors affecting mortality rate in acute abdominal diseases. The leading problems in organizing emergency surgical care in Russia are insufficient equipment of rural and small municipal surgical hospitals, different staffing with surgeons in rural areas and large cities and late hospitalization of patients.

National trends and outcomes in timing of ERCP in patients with cholangitis.

INTRODUCTION: Guidelines recommend early endoscopic retrograde cholangiopancreatography for the management of acute cholangitis, but the definition of the term "early" remains debatable. This study analyzed national trends in the timing of endoscopic retrograde cholangiopancreatography and identified the ideal time to perform preoperative endoscopic retrograde cholangiopancreatography in patients with acute cholangitis. METHODS: The 2005 to 2016 National Inpatient Sample was used to identify patients undergoing cholecystectomy for acute cholangitis. Severity of cholangitis was defined using the 2013 Tokyo Grading Criteria, where Tokyo grade III patients were defined as having organ dysfunction and non-Tokyo grade III patients were defined as grades I and II. Multivariable regressions (accounting for patient and hospital characteristics) were used to identify the timing of preoperative endoscopic retrograde cholangiopancreatography associated with the least mortality risk. RESULTS: Of 91,051 patients undergoing cholecystectomy for cholangitis, 55% underwent preoperative endoscopic retrograde cholangiopancreatography: 24% of patients received endoscopic retrograde cholangiopancreatography on the day of admission, 41% on hospital day 2, and the use of endoscopic retrograde cholangiopancreatography decreased gradually thereafter. Mortality rates remained under 1% if endoscopic retrograde cholangiopancreatography was performed during the first 3 days and increased as endoscopic retrograde cholangiopancreatography was performed during days 4 to 7 (P < .001). On multivariable regression, endoscopic retrograde cholangiopancreatography performed >72 hours after admission was associated with increased mortality (adjusted odds ratio 1.80, P = .01). Receiving endoscopic retrograde cholangiopancreatography P > 72 hours increased risk of death among Tokyo grade III patients (adjusted odds ratio 1.88, P = .01). Overall, during the study period, the utilization of preoperative endoscopic retrograde cholangiopancreatography for all grades of acute cholangitis increased from 39% of patients in 2005 to 51% in 2016 (P < .001). CONCLUSION: There has been an increase in the use of endoscopic retrograde cholangiopancreatography for acute cholangitis. Although endoscopic retrograde cholangiopancreatography on the day of admission was not associated with a decrease in mortality in patients with Tokyo grade III disease, endoscopic retrograde cholangiopancreatography within 72 hours of hospitalization was associated with decreased in-hospital mortality.

Retrograde open mesenteric stenting should be considered as the initial approach to acute mesenteric ischemia.

OBJECTIVE: Retrograde open mesenteric stenting (ROMS) is an alternative to traditional bypass in patients who present with acute mesenteric ischemia (AMI). However, there is a paucity of data comparing outcomes of ROMS with other open surgical approaches. This study represents the largest single-institution experience with ROMS and aims to compare outcomes of ROMS with those of conventional mesenteric bypass. METHODS: All patients who presented with AMI from 2008 to 2019 and who were treated with either ROMS or mesenteric bypass were included in the study. Patient, procedure, and outcome variables were compared. Bypass and ROMS patients were compared using univariate statistics. RESULTS: A total of 34 patients who presented with AMI needing bypass were included in the study; 16 underwent mesenteric bypass, and 18 underwent ROMS. ROMS patients tended to be older than bypass patients and had higher rates of comorbidities. Bypass patients were more likely to have a history of chronic mesenteric symptoms (68.8% vs 27.8%; P = .019). Bypass procedures also took longer than ROMS procedures (302 vs 189 minutes; P < .01). The majority of ROMS procedures were not performed in a hybrid room (77.8%). Within 1 year, one stent thrombosed in a ROMS patient, requiring later mesenteric bypass. In the bypass group, one conduit thrombosed, ultimately resulting in perioperative death, and one bypass anastomosis stenosed, requiring angioplasty. Complication, unanticipated reintervention, and mortality rates were otherwise similar between groups. CONCLUSIONS: Complication, reintervention, and mortality rates after ROMS are similar to those of mesenteric bypass in the setting of AMI. Given similar postoperative outcomes and ability to perform these procedures in a conventional operating room but with significantly shorter operative times, ROMS should be considered a first-line option in acute situations when the operator is comfortable performing the procedure.

Comparison of American Association for the Surgery of Trauma grading scale with modified Hinchey classification in acute colonic diverticulitis: A pilot study.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) developed a severity scale for surgical conditions, including diverticulitis. The Hinchey classification requires operative intervention yet remains the established scoring system for acute diverticulitis. This is a pilot study to compare the AAST grading scale for acute colonic diverticulitis with the traditional Hinchey classification. We hypothesize that the AAST classification scale is equivalent to the Hinchey in predicting outcomes. METHODS: This is a retrospective cohort study at an academic medical center. A consecutive sample of patients with acute diverticulitis and computed tomography imaging was reviewed. Chart review identified demographic and physiologic data with interventional and clinical outcomes. Each computed tomography scan was assigned AAST and modified Hinchey classification scores by a radiologist. Multivariate regression and receiver operating characteristic curve analysis compared six outcomes: need for procedure, complication, intensive care unit (ICU) admission, length of stay, 30-day readmission, and mortality. RESULTS: One hundred twenty-nine patients were included. Of the total patients, 42.6% required procedural intervention, 21.7% required ICU admission, 18.6% were readmitted, and 6.2% died. Both AAST and Hinchey predicted the need for operation (AAST odds ratios, 1.55, 12.7, 18.09, and 77.24 for stages 2-5; Hinchey odds ratios, 8.85, 11.49, and 22.9 for stages 1b-3, stage 4 predicted perfectly). The need for operation c-statistics (area under the curve) for AAST and Hinchey was 0.80 and 0.83 for Hinchey and AAST, respectively (p = 0.35). The complication c-statistics curve for AAST and Hinchey was 0.83 and 0.80, respectively (p = 0.33). The AAST and Hinchey scores were less predictive for ICU admission, readmission, and mortality with c-statistics of less than 0.80. CONCLUSION: The AAST grading of acute diverticulitis is equivalent to the modified Hinchey classification in predicting procedural intervention and complications. The AAST system may be preferable to Hinchey because it can be applied preoperatively. Although this pilot study demonstrated that the AAST score predicts surgical need, a larger study is required to evaluate the AAST score for other outcomes. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Pre-emptive thoracic endovascular aortic repair is unnecessary in extended type A (DeBakey type I) aortic dissections.

OBJECTIVE: Pre-emptive thoracic endovascular aortic repair (TEVAR) improves late survival and limits progression of disease after type B aortic dissection, but the potential value of pre-emptive TEVAR has not been evaluated after type A dissection extending beyond the aortic arch (DeBakey type I). The purpose of this study was to compare disease progression and need for aortic intervention in survivors of acute, extended type A (ExTA) dissections after initial repair of the ascending aorta versus acute type B aortic dissections. METHODS: Consecutive patients presenting with ExTA or type B dissections between 2011 and 2018 were studied. Forty-three patients with ExTA and 44 with type B dissections who survived to discharge and had follow-up imaging studies were included in the analysis. Study end points included progression of aortic disease (>5 mm growth or extension), need for intervention, and death. RESULTS: The groups were not different for age, sex, atherosclerotic risk factors, or extent of dissection distal to the left subclavian artery. Following emergent ascending aortic repair, five ExTA patients (12%) underwent TEVAR within 4 months after discharge. Despite optimal medical treatment, 29 type B patients (66%) underwent early or late TEVAR (P < .001). During a mean follow-up of 38 ± 30 months, 38 ExTA patients (88%) did not require intervention-23 (53%) of whom showed no disease progression. In comparison, during a mean follow-up of 18 ± 6 months, 14 type B patients (32%) did not require intervention-nine (20%) of whom showed no disease progression (P = .003). There was one aortic-related late death in the ExTA group and two in the type B group. Compared with ExTA patients, type B patients had significantly worse intervention-free survival and intervention/growth-free survival (log rank, P < .001). CONCLUSIONS: In contrast with type B dissections, these midterm results demonstrate that one-half of ExTA aortic dissections show no disease progression in the thoracic or abdominal aorta, and few require additional interventions. After initial repair of the ascending aorta, pre-emptive TEVAR does not seem to be justified in patients with acute, ExTA dissections.

Efficacy and Safety of Early vs Elective Colonoscopy for Acute Lower Gastrointestinal Bleeding.

BACKGROUND & AIMS: We performed a large, multicenter, randomized controlled trial to determine the efficacy and safety of early colonoscopy on outcomes of patients with acute lower gastrointestinal bleeding (ALGIB). METHODS: We performed an open-label study at 15 hospitals in Japan of 170 patients with ALGIB randomly assigned (1:1) to groups that underwent early colonoscopy (within 24 hours of initial visit to the hospital) or elective colonoscopy (24-96 hours after hospital admission). The primary outcome was identification of stigmata of recent hemorrhage (SRH). Secondary outcomes were rebleeding within 30 days, endoscopic treatment success, need for transfusion, length of stay, thrombotic events within 30 days, death within 30 days, and adverse events. RESULTS: SRH were identified in 17 of 79 patients (21.5%) in the early colonoscopy group vs 17 of 80 patients (21.3%) in the elective colonoscopy group (difference, 0.3; 95% confidence interval, -12.5 to 13.0; P = .967). Rebleeding within 30 days of hospital admission occurred in 15.3% of patients in the early colonoscopy group and 6.7% of patients in the elective colonoscopy group (difference, 8.6; 95% confidence interval, -1.4 to 18.7); there were no significant differences between groups in successful endoscopic treatment rate, transfusion rate, length of stay, thrombotic events, or death within 30 days. The adverse event of hemorrhagic shock occurred during bowel preparation in no patient in the early group vs 2 patients (2.5%) in the elective colonoscopy group. CONCLUSIONS: In a randomized controlled study, we found that colonoscopy within 24 hours after hospital admission did not increase SRH or reduce rebleeding compared with colonoscopy at 24-96 hours in patients with ALGIB. ClinicalTrials.gov, Numbers: UMIN000021129 and NCT03098173.

Combination of red blood cell distribution width and body mass index (COR-BMI) predicts in-hospital mortality in patients with different diagnoses?

BACKGROUND: The combination of red blood cell distribution width and body mass index (COR-BMI) is indicated as a new prognostic index of survival in patients with laryngeal cancer. However, the ability of this prediction in other types of cancer or whether its use can be expanded to non-oncological patients is unknown. The aim of this study was to investigate the prediction of prognosis of in-hospital mortality of the COR-BMI in oncological and non-oncological patients. METHODS: A retrospective study was performed with all hospitalized patients between 2014 and 2016, totaling 2930 patients, 262 oncological and 2668 non-oncological. The COR-BMI was divided into three classes: 0, RDW ≤ 13.1% and BMI ≥ 25 kg/m2; 1, RDW ≤ 13.1% and BMI < 18.5 or ≥ 18.5 but < 25 kg/m2 and RDW > 13.1% and BMI ≥ 18.5 but < 25 or BMI ≥ 25 kg/m2; and 2, RDW > 13.1% and BMI < 18.5 kg/m2. In order to analyze the relationship between COR-BMI and in-hospital mortality in the studied population, the Cox Proportional Hazards Model was used in a multivariate analysis based on a conceptual model. RESULTS: The COR-BMI was an independent predictor of in-hospital mortality in non-oncological patients (1 versus 0: HR = 3.34; CI = 1.60-6.96, p = 0.001; 2 versus 0: HR = 3.38; CI = 1.22-9.39, p = 0.019). The survival rate of these patients was lower among those with the highest scores on the COR-BMI. This prediction was not found in oncological patients. CONCLUSION: The present study suggests that the COR-BMI may have its practical use expanded to non-oncological patients as an independent predictor of in-hospital mortality.

Prognostic factors of mortality after surgery in infective endocarditis: systematic review and meta-analysis.

PURPOSE: There is a lack of consensus about which endocarditis-specific preoperative characteristics have an actual impact over postoperative mortality. Our objective was the identification and quantification of these factors. METHODS: We performed a systematic review of all the studies which reported factors related to in-hospital mortality after surgery for acute infective endocarditis, conducted according to PRISMA recommendations. A search string was constructed and applied on three different databases. Two investigators independently reviewed the retrieved references. Quality assessment was performed for identification of potential biases. All the variables that were included in at least two validated risk scores were meta-analyzed independently, and the pooled estimates were expressed as odds ratios (OR) with their confidence intervals (CI). RESULTS: The final sample consisted on 16 studies, comprising a total of 7484 patients. The overall pooled OR were statistically significant (p < 0.05) for: age (OR 1.03, 95% CI 1.00-1.05), female sex (OR 1.56, 95% CI 1.35-1.81), urgent or emergency surgery (OR 2.39 95% CI 1.91-3.00), previous cardiac surgery (OR 2.19, 95% CI 1.84-2.61), NYHA ≥ III (OR 1.84, 95% CI 1.33-2.55), cardiogenic shock (OR 4.15, 95% CI 3.06-5.64), prosthetic valve (OR 1.98, 95% CI 1.68-2.33), multivalvular affection (OR 1.35, 95% CI 1.01-1.82), renal failure (OR 2.57, 95% CI 2.15-3.06), paravalvular abscess (OR 2.39, 95% CI 1.77-3.22) and S. aureus infection (OR 2.27, 95% CI 1.89-2.73). CONCLUSIONS: After a systematic review, we identified 11 preoperative factors related to an increased postoperative mortality. The meta-analysis of each of these factors showed a significant association with an increased in-hospital mortality after surgery for active infective endocarditis. Graph summary of the Pooled Odds Ratios of the 11 preoperative factors analyzed after the systematic review and meta-analysis.

[Emergency surgery in Russian Federation (in Russian only)]. / Sostoianie ékstrennoi khirurgicheskoi pomoshchi v Rossiiskoi Federatsii.

In the following article, we present the key trends in emergency surgical care in the Russian Federation between 2000 and 2017. The study used data from federal statistical observations and a survey of state medical institutions in 80 regions encompassing 99.3% of the country's population. We discovered a change in the correlation between acute abdominal diseases, particularly a significant reduction in the occurrence of acute appendicitis and perforated peptic ulcer. Reduction in the number of emergency surgeries by 27.8% annually was also observed. Mortality rate decreased in cases of strangulated hernia, acute cholecystitis and acute pancreatitis, while it is stable for bowel obstruction and acute appendicitis and increasing in perforated peptic ulcer cases. The total annual number of lethal outcomes due to acute abdominal diseases was decreased by 1900 cases. Significant changes were observed in mortality rate and minimally invasive surgeries proportions between federal districts and individual regions of the country. The range of administrative measures was proposed.

Tocilizumab as first-line therapy for steroid-refractory acute graft-versus-host-disease: analysis of a single-center experience.

Acute graft-versus-host-disease (aGVHD) is a complication after allogeneic stem cell transplant. After the failure of treatment with high dose corticosteroids, steroid-refractory aGVHD (SR aGVHD) is associated with high rates of mortality. Tocilizumab has evidence of activity in SR aGVHD. For patients ineligible for trials, the OSU James Comprehensive Cancer Center has been utilizing tocilizumab as first-line therapy for SR aGVHD. We retrospectively report on 15 patients who received tocilizumab. aGVHD grading and responses were based on consensus criteria. Median age at transplant was 49 years. Median time to tocilizumab administration was 9 days (range, 3-16). Six patients had complete responses (40%) with a resolution of aGVHD. From the last contact, median overall survival for responders was not yet reached vs. 31 days for non-responders (p = .0002). Patients with skin and/or GI aGVHD demonstrated the greatest benefit. Patients with liver aGVHD did not respond. Future studies are needed to evaluate tocilizumab prior to steroid failure.

Nutrition Care of Critically Ill Patients with Leukemia: A Retrospective Study.

Adults with acute leukemia (AL) are at high risk of malnutrition due to their disease and treatment side effects and may be admitted to the intensive care unit (ICU), further increasing the risk of malnutrition. Although ICU care includes some form of nutrition, patients typically receive less than prescribed energy and protein. Our objective was to characterize the nutrition care for critically ill patients with AL. We completed a retrospective review of adults with AL admitted to the Medical/Surgical ICU >24 hours. Descriptive statistics were performed on collected data including: demographics, APACHE II and Nutric scores, nutrition therapy, reasons for withholding nutrition, and mortality status at discharge. Data were collected on 154 AL patients with an average APACHE II score of 27 and Nutric score of 5.96. ICU mortality was 36%. Enteral nutrition (EN) was most commonly prescribed. Patients on EN received 55% of energy and 51% of protein prescribed. EN was commonly withheld for airway management and gastrointestinal impairment. Patients with AL received low amounts of energy and protein in the ICU and had a high Nutric score. Strategies and barriers to improve protein intake in this population are identified.

The Impact of Pediatric Palliative Care Involvement in the Care of Critically Ill Patients without Complex Chronic Conditions.

Background: The impact of pediatric palliative care (PPC) is well established for children with chronic complex diseases. However, PPC likely also benefits previously healthy children with acute life-threatening conditions. Objective: To determine the incidence and impact of PPC for previously healthy patients who died in a pediatric hospital. Design: Retrospective chart review of all pediatric deaths over four years. Setting/Subjects: Patients were 0 to 25 years old, died during an inpatient stay at an academic pediatric hospital ≥48 hours after admission, and had no complex chronic conditions (CCCs) before admission. Measurements: One hundred sixty-seven patients met the eligibility criteria. Most died in intensive care settings (n = 149, 89%), and few (n = 34, 20%) received PPC consultations or services. Results: Patients who received PPC services were more likely to receive a multidisciplinary care conference than did patients without PPC support (70.5% vs. 39.9%; p = 0.001), which also occurred earlier for patients who received PPC services (seven days vs. two days before death; p = 0.04). Most patients had documented end-of-life planning in their medical records; however, this occurred earlier for patients who received PPC consultation (9.5 days before death) than for those who did not (two days before death; p < 0.0001). Patients receiving PPC support (67.7%) were also more likely to have a do-not-resuscitate/intubate order before death than those who did not (39.9%; p = 0.004). Conclusions: Pediatric patients without known CCCs who subsequently die as inpatients benefit from PPC in terms of goals of care discussions and documentation of end-of-life care preferences.

Timing of upper gastrointestinal endoscopy does not influence short-term outcomes in patients with acute variceal bleeding.

AIM: To examine the association between the timing of endoscopy and the short-term outcomes of acute variceal bleeding in cirrhotic patients. METHODS: This retrospective study included 274 consecutive patients admitted with acute esophageal variceal bleeding of two tertiary hospitals in Korea. We adjusted confounding factors using the Cox proportional hazards model and the inverse probability weighting (IPW) method. The primary outcome was the mortality of patients within 6 wk. RESULTS: A total of 173 patients received urgent endoscopy (i.e., ≤ 12 h after admission), and 101 patients received non-urgent endoscopy (> 12 h after admission). The 6-wk mortality rate was 22.5% in the urgent endoscopy group and 29.7% in the non-urgent endoscopy group, and there was no significant difference between the two groups before (P = 0.266) and after IPW (P = 0.639). The length of hospital stay was statistically different between the urgent group and non-urgent group (P = 0.033); however, there was no significant difference in the in-hospital mortality rate between the two groups (8.1% vs 7.9%, P = 0.960). In multivariate analyses, timing of endoscopy was not associated with 6-wk mortality (hazard ratio, 1.297; 95% confidence interval, 0.806-2.089; P = 0.284). CONCLUSION: In cirrhotic patients with acute variceal bleeding, the timing of endoscopy may be independent of short-term mortality.

Evolution of incidence, mortality and cost of nontraumatic abdominal emergencies treated in Brasil in a period of nine years

SUMMARY OBJECTIVE: To evaluate the incidence, mortality and cost of non-traumatic abdominal emergencies treated in Brazilian emergency departments. METHODS: This paper used DataSus information from 2008 to 2016 (http://www.tabnet.datasus.gov.br). The number of hospitalizations, costs - AIH length of stay and mortality rates were described in acute appendicitis, acute cholecystitis, acute pancreatitis, acute diverticulitis, gastric and duodenal ulcer, and inflammatory intestinal disease. RESULTS: The disease that had the highest growth in hospitalization was diverticular bowel disease with an increase of 68.2%. For the period of nine years, there were no significant changes in the average length of hospital stay, with the highest increase in gastric and duodenal ulcer with a growth of 15.9%. The mortality rate of gastric and duodenal ulcer disease increased by 95.63%, which is significantly high when compared to the other diseases. All had their costs increased but the one that proportionally had the highest increase in the last nine years was the duodenal and gastric ulcer, with an increase of 85.4%. CONCLUSION: Non-traumatic abdominal emergencies are extremely prevalent. Hence, the importance of having updated and comparative data on the mortality rate, number of hospitalization and cost generated by these diseases to provide better healthcare services in public hospitals.

RESUMO OBJETIVO: Avaliar a evolução da Incidência, mortalidade e custo das urgências abdominais não traumáticas atendidas nos serviços de emergência do Brasil durante o período de nove anos. MÉTODOS: Este trabalho utilizou informações do DataSus de 2008 a 2016, (http://www.tabnet.datasus.gov.br). Foram analisados número de internações, valor médio das internações (AIH), valor total das internações, dias de permanência hospitalar e taxa de mortalidade das seguintes doenças: apendicite aguda, colecistite aguda, pancreatite aguda, diverticulite aguda, úlcera gástrica e duodenal, e doença inflamatória intestinal. RESULTADOS: A doença que teve o maior crescimento do número de internações foi a doença diverticular do intestino, com o valor de 68,2%. Ao longo dos nove anos não houve grandes variações da média de permanência hospitalar, sendo que o maior aumento foi o da úlcera gástrica e duodenal, com crescimento de 15,9%. A taxa de mortalidade da doença por úlcera gástrica e duodenal teve um aumento de 95,63%, consideravelmente significante quando comparada com as outras doenças. Todas tiveram seus valores de AIH aumentados, porém, a que proporcionalmente teve o maior aumento nos últimos nove anos foi a úlcera gástrica e duodenal, com um acréscimo de 85,4%. CONCLUSÃO: As urgências abdominais de origem não traumática são de extrema prevalência, por isso a importância em ter dados atualizados e comparativos sobre a taxa de mortalidade, o número de internações e os custos gerados por essas doenças, para melhor planejamento dos serviços públicos de saúde.