Impact of Adherence to a Standardized Oxytocin Induction Protocol on Obstetric and Neonatal Outcomes.

BACKGROUND: Oxytocin protocols are employed to induce uterine contractions and progressive cervical changes, but they are associated with adverse maternal and neonatal outcomes. The aim of this study was to determine whether compliance with a checklist-based protocol for oxytocin administration was associated with changes in neonatal and maternal outcomes. METHODS: A retrospective cohort study of 86,786 pregnant women undergoing term (> 37 weeks) induction of labor between January 2015 and December 2017 was performed. Systemwide training in the use of an oxytocin administration protocol was provided to obstetricians and nurses. Pre-use and in-use oxytocin checklists were incorporated into each unit's policies and procedures. Subsequently, charts were reviewed and individually audited by an obstetric nurse who scored each record based on the documentation of variables in an oxytocin administration protocol and ranked adherence as complete or absent. Primary outcomes were postpartum hemorrhage, neonatal ICU (NICU) admission, and delivery by cesarean section. Bivariate analyses (t-tests) were performed on adherent and nonadherent groups for comparison of selected demographic variables and the primary outcome variables. Logistic regression was completed on the primary outcome variable with eight covariates. RESULTS: Among patients with complete adherence to the oxytocin administration protocol, the rate of cesarean section in the unadjusted analysis was 16.20%, compared to 18.54% for those with incomplete adherence; the rates of postpartum hemorrhage were 2.64% vs. 3.14%, respectively, and the rates of NICU admission were 3.03% vs. 3.86%, respectively. In the multivariable logistic regression, complete protocol adherence was associated with significantly lower odds of postpartum hemorrhage (adjusted odds ratio [OR] 0.85, 95% confidence interval [CI] 0.76-0.94) but higher odds of Cesarean section (adjusted OR 1.07, 95% CI 1.01-1.13); the adjusted OR for NICU admission was 0.90, which did not reach statistical significance (95% CI 0.81-1.00). Among the covariates, nulliparity and elective induction were the strongest predictors of the primary outcomes of cesarean section, postpartum hemorrhage, and NICU admission. CONCLUSION: Adherence to the oxytocin administration protocol was associated with a decrease in postpartum hemorrhage but an increased risk of delivery by cesarean section.

Significance of Chronic Kidney Disease on Morbidity and Mortality in Hospitalized Patients With COVID-19.

Background: Patients with comorbid illnesses are at risk for worse outcomes with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; COVID-19). Our research examined patients with chronic kidney disease (CKD) to establish whether it remains an independent risk factor for mortality and morbidity in patients with COVID-19. Methods: We conducted a retrospective cohort study using an electronic patient database in 2020. An observational dataset from 149 hospitals comprising a United States-based health system (HCA Healthcare) was analyzed. Hospitalized patients (N=11 086), aged 18 and above, with a COVID-19 polymerase chain reaction positive result between January 1, 2020, and September 1, 2020, were included in the initial data set.Primary outcomes were in-hospital death or discharge to hospice in patients with COVID-19. Secondary outcomes were individual components of the primary outcome including intensive care unit (ICU) admission, ventilator dependency, development of acute kidney injury (AKI), and in-hospital death. Baseline patient characteristics were recorded, including demographic variables and comorbidities. Results: A total of 11 086 patients were included in the analysis. The study group included patients with CKD (5543 patients). Patients in the control group (5543 patients) were propensity matched for age, race, sex, and ethnicity. The primary outcome of in-hospital death or discharge to hospice was observed in 20.96% of patients with CKD compared to 11.91% of the control group with an odds ratio of 1.58 (confidence interval 1.37-1.80). ICU admission was required for 37.20% of patients in the CKD group and 21.63% of patients in the control group (P < .001). Ventilator dependency was found in 14.41% of patients in the CKD group and 8.59% of patients in the control group (P < .01). Development of AKI was seen in 5.65% of patients in the CKD group and 2.90% of patients in the control group (P < .01). A logistic regression model confirmed an independent association between underlying CKD and in-hospital death or discharge to hospice in patients with COVID-19. Conclusion: Our study confirms an independent association between underlying CKD and poor outcomes among hospitalized patients with COVID-19, including in-hospital death or discharge to hospice.

Utility of the HScore for Predicting COVID-19 Severity.

BACKGROUND: Cytokine release syndrome is a life-threatening condition known to cause fever and multiple organ dysfunction and is suspected to be related to the severity of coronavirus disease 2019 (COVID-19). We sought to examine the utility of the HScore and non-cytokine markers of inflammation for predicting COVID-19 outcomes. We hypothesized that cytokine storm, assessed by a modified HScore, would be linked to more severe COVID-19 symptoms and higher mortality. METHODS:  A retrospective review of records from a large, private hospital system was conducted on patients with hemophagocytic lymphohistiocytosis (HLH) (2014-2019) and compared to a large cohort of COVID-19-positive patients (2020). Patients with a sufficient number of elements in their record for a modified HScore calculation (n=4663), were further subdivided into population 1 (POP1, n=67; HLH, n=493 COVID-19), which had eight HScore elements, and population 2 (POP2) with six available HScore elements (POP2, n=102; HLH, n=4561 COVID-19). RESULTS: Modified HScore predicted COVID-19 severity in POP1 and POP2 as measured by higher odds of being on a ventilator (POP2 OR: 1.46, CI: 1.42-1.5), ICU admission (POP2 OR: 1.38, CI: 1.34-1.42), a longer length of stay (p<0.0001), and higher mortality (POP2 OR: 1.34, CI: 1.31-1.39). C-reactive protein (CRP) and white blood cell (WBC) count were the most consistent non-cytokine predictors of COVID-19 severity. CONCLUSION:  Cytokine storm, evaluated using a modified HScore, appeared to play a role in the severity of COVID-19 infection, and selected non-cytokine markers of inflammation were predictive of disease severity.

Incidence of Acute Ischemic Stroke in Hospitalized Patients With Atrial Fibrillation Who Had Anticoagulation Interruption: A Retrospective Study.

BACKGROUND: Atrial fibrillation (AF) is one of the leading causes of acute ischemic stroke requiring anticoagulation. Many patients experience treatment interruption in the hospital setting. The aim of this study was to evaluate the effect of anticoagulation interruption on short-term risk of ischemic stroke in hospitalized patients with AF. METHODS: We performed a retrospective medical record review using the Hospital Corporation of America (HCA) database. We included patients admitted to our institution between December 2015 and December 2018 who had a prior history of AF. Patients were excluded if they had ischemic stroke, hemorrhagic stroke, history venous thromboembolism or mechanical valve on admission. We compared the incidence of ischemic stroke in patients in whom anticoagulation was interrupted for more than 48 h to those who continued anticoagulation. RESULTS: A total of 2,277 patients with history of AF were included in the study. In this cohort, 79 patients (3.47%) had anticoagulation interruption of more than 48 h during their hospital stay. There was no difference in incidence of stroke between the interruption and no interruption groups (1.27% (n = 1) vs. 0.23% (n = 5), P = 0.19). Interruption of anticoagulation did not associate with a significant increase in the risk of in-hospital ischemic stroke. CHA2DS2VASc score was a strong predictor of in-hospital stroke risk regardless of anticoagulation interruption (odds ratio: 7.199, 95% confidence interval: 2.920 - 17.751). CONCLUSION: In this study, the in-hospital incidence of ischemic stroke in patients with AF did not significantly increase by short-term anticoagulation interruption.

Emergency Department Utilization and Patient Outcomes During the COVID-19 Pandemic in America.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic precipitated fear of contagion and influenced many people to avoid the emergency department (ED). It is unknown if this avoidance effected overall health or disease mortality. OBJECTIVE: We aimed to quantify the decreased ED volume in the United States, determine whether it occurred simultaneously across the country, find which types of patients decreased, and measure resultant changes in patient outcomes. METHODS: We retrospectively accessed a multihospital, multistate electronic health records database managed by HCA Healthcare to obtain a case series of all patients presenting to an ED during the early COVID-19 pandemic (March 1-May 31, 2020) and the same dates in 2019 for comparison. We determined ED volume using weekly totals and grouped them by state. We also recorded final diagnoses codes and mortality data to describe patient types and outcomes. RESULTS: The weekly ED volume from 160 facilities dropped 44% from 141,408 patients (week 1, March 1-7, 2020) to a nadir of 79,618 patients (week 7, April 12-18, 2020), before rising back to 105,667 (week 13, May 24-30, 2020). Compared with 2019, this overall decline was statistically significant (p < 0.001). The decline was universal across disease categories except for infectious disease and respiratory illnesses, which increased. All-cause mortality increased during the pandemic, especially for those with infectious disease, circulatory, and respiratory illnesses. CONCLUSIONS: The COVID-19 pandemic and an apparent fear of contagion caused a decrease in ED presentations across our hospital system. The decline in ED volume was associated with increased ED mortality, perhaps from delayed ED presentations.

Correction: Recessive coding and regulatory mutations in FBLIM1 underlie the pathogenesis of chronic recurrent multifocal osteomyelitis (CRMO).

[This corrects the article DOI: 10.1371/journal.pone.0169687.].

Recessive coding and regulatory mutations in FBLIM1 underlie the pathogenesis of chronic recurrent multifocal osteomyelitis (CRMO).

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare, pediatric, autoinflammatory disease characterized by bone pain due to sterile osteomyelitis, and is often accompanied by psoriasis or inflammatory bowel disease. There are two syndromic forms of CRMO, Majeed syndrome and DIRA, for which the genetic cause is known. However, for the majority of cases of CRMO, the genetic basis is unknown. Via whole-exome sequencing, we detected a homozygous mutation in the filamin-binding domain of FBLIM1 in an affected child with consanguineous parents. Microarray analysis of bone marrow macrophages from the CRMO murine model (cmo) determined that the Fblim1 ortholog is the most differentially expressed gene, downregulated over 20-fold in the cmo mouse. We sequenced FBLIM1 in 96 CRMO subjects and found a second proband with a novel frameshift mutation in exon 6 and a rare regulatory variant. In SaOS2 cells, overexpressing the regulatory mutation showed the flanking region acts as an enhancer, and the mutation ablates enhancer activity. Our data implicate FBLIM1 in the pathogenesis of sterile bone inflammation and our findings suggest CRMO is a disorder of chronic inflammation and imbalanced bone remodeling.