Polyagglutination in Hospitalized Patients: A Prospective Study

A hospital population at high risk for red cell polyagglutination was studied prospectively in search for cryptantigen exposure. The patients included in this study suffered from: malignancies, sepsis, direct antiglobulin test (DAT) negative anemias and various combinations of these three. 238 patients were examined, and 18 of these (7.6%) were found to have exposed cryptantigens on their erythrocytes. This is an unexpectedly high percentage. Our findings suggest that cryptantigen exposure on the red cells is a more common phenomenon than previously described, especially when looked for in a carefully chosen population. The red cells of these patients are potentially polyagglutinable, and screening with lectins will ensure their pretransfusion identification and evaluation.     

Intensive-Dose Tinzaparin in Hospitalized COVID-19 Patients: The INTERACT Study

(1) Background: It is well-established that coronavirus disease-2019 (COVID-19) is highly pro-inflammatory, leading to activation of the coagulation cascade. COVID-19-induced hypercoagulability is associated with adverse outcomes and mortality. Current guidelines recommend that hospitalized COVID-19 patients should receive pharmacological prophylaxis against venous thromboembolism (VTE). (2) INTERACT is a retrospective, phase IV, observational cohort study aiming to evaluate the overall clinical effectiveness and safety of a higher than conventionally used prophylactic dose of anticoagulation with tinzaparin administered for VTE prevention in non-critically ill COVID-19 patients with moderate disease severity. (3) Results: A total of 705 patients from 13 hospitals in Greece participated in the study (55% men, median age 62 years). Anticoagulation with tinzaparin was initiated immediately after admission. A full therapeutic dose was received by 36.3% of the participants (mean ± SD 166 ± 33 IU/Kgr/day) and the remaining patients (63.9%) received an intermediate dose (mean ± SD 114 ± 22 IU/Kgr/day). The median treatment duration was 13 days (Q1–Q3: 8–20 days). During the study (April 2020 to November 2021), 14 thrombotic events (2.0%) were diagnosed (i.e., three cases of pulmonary embolism (PE) and 11 cases of deep venous thrombosis, DVT). Four bleeding events were recorded (0.6%). In-hospital death occurred in 12 patients (1.7%). Thrombosis was associated with increasing age (median: 74.5 years, Q1–Q3: 62–79, for patients with thrombosis vs. 61.9 years, Q1–Q3: 49–72, p = 0.0149), increased D-dimer levels for all three evaluation time points (at admission: 2490, Q1–Q3: 1580–6480 vs. 700, Q1–Q3: 400–1475, p < 0.0001), one week ± two days after admission (3510, Q1–Q3: 1458–9500 vs. 619, Q1–Q3: 352–1054.5, p < 0.0001), as well as upon discharge (1618.5, Q1–Q3: 1010–2255 vs. 500, Q1–Q3: 294–918, p < 0.0001). Clinical and laboratory improvement was affirmed by decreasing D-dimer and CRP levels, increasing platelet numbers and oxygen saturation measurements, and a drop in the World Health Organization (WHO) progression scale. (4) Conclusions: The findings of our study are in favor of prophylactic anticoagulation with an intermediate to full therapeutic dose of tinzaparin among non-critically ill patients hospitalized with COVID-19.     

Good's Syndrome Patients Hospitalized for Infections: A Single-Center Retrospective Study

Good''s syndrome (GS) is a rare combination of thymoma and hypogammaglobulinemia, resulting in immunodeficiency. Patients with GS are highly susceptible to bacterial infection, particularly encapsulated bacterial infection in upper and lower respiratory tracts. Good''s syndrome patients with moderate-to- severe infection are often hospitalized. Clinical features of GS patients remain to be characterized.Patients with the discharge diagnosis of GS and simultaneous infection from Peking Union Medical College Hospital between January 2001 and July 2015 were retrospectively analyzed.Among 14 hospitalized GS patients, 12 of them were admitted for severe infections. Mean patient age was 56.7 + 10.1 years. Average concentrations of serum IgG, IgA, and IgM were 2.3 + 1.9 g/L, 0.28 + 0.28 g/L, and 0.06 + 0.07 g/L, respectively. Respiratory and intestinal tracts were the most common sites for infection, which occurred in 7 and 4 patients, respectively. Pathogens identified in 10 patients included cytomegalovirus in 5 patients, Pneumocystis jirovecii, Clostridium difficile in 2 patients, Klebsiella pneumonia in 2 patients, and Streptococcus pneumonia and Hemophilus influenza in 1 patient. Ten patients were treated with antibiotics and immunoglobulin replacement. Only 1 patient who was on immunosuppressant therapy died from P. jirovecii pneumonia.Infection was the most frequent cause for hospitalization of GS patients. Both respiratory and intestinal tracts were the most common sites of infection. Cytomegalovirus and P. jirovecii represented 2 common opportunistic pathogens isolated from hospitalized GS patients with infections.     

Preparation for Colonoscopy in Hospitalized Patients

Successful colonoscopy depends on good preparation of the colon before the procedure. Inadequate preparation may lead to cancelled or repeat procedures and compromise patient safety, quality of care, and cost effectiveness. The primary aim of this study was to isolate factors that affect preparation success, especially in older, more severely ill, bedridden patients. The secondary aim was to examine the possible differences in preparation quality between ambulatory and hospitalized patients and the impact of a staff educational program on the preparation of hospitalized patients for colonoscopy. The study group included 303 consecutive ambulatory patients and 104 hospitalized patients referred for colonoscopy between January and March 2002, before the department introduced an educational program on colonoscopy preparation, and 310 ambulatory patients and 105 hospitalized patients referred for colonoscopy between January and March 2003. All patients completed an ad hoc questionnaire, and the findings were compared between ambulatory and hospitalized patients and between patients treated before and after the educational program. Polyethylene glycol was used significantly more often for colonoscopy preparation in hospitalized patients than in ambulatory patients (53.1% versus 8.8%; P=.0001). The hospitalized group was characterized by more incomplete or repeated colonoscopies and poorer preparation quality. On multivariate analysis, the variables found to be independent predictors of good preparation were successful patient completion of the preparatory procedure according to instructions, colonoscopy performed for follow-up after polypectomy, and preparation with sodium phosphate. The educational intervention had no impact on the quality of preparation. In conclusion, sodium phosphate preparation and complete adherence to preparation instructions are the most important factors for successful colonoscopy preparation. Current preparatory methods for hospitalized and severely ill patients need to be revised.     

The Clinical Course of Cirrhosis Patients Hospitalized for Acute Hepatic Deterioration: A Prospective Bicentric Study

Patients with cirrhosis are vulnerable to acute hepatic insults and are more likely to develop rapid hepatic deterioration. The aim of this study is to describe the clinical course of patients with cirrhosis and hospitalized for acute hepatic deterioration (AHD).This is a prospective study involving 163 patients with cirrhosis and AHD. The occurrence of organ failures, systemic inflammatory response syndrome (SIRS), and infections during hospital stay were recorded and the relationship between organ failure and death or SIRS/infection was subsequently analyzed.Of 163 patients, 35 did not develop any organ failure during in-hospital follow-ups (90-day mortality: 0%); 84 had intrahepatic organ failures (IH-OFs, defined by liver and/or coagulation failure) (90-day mortality: 22.0%); and 44 patients developed extra-hepatic organ failures (EH-OFs, defined by kidney, cerebral, circulation, and respiratory failure) on the basis of IH-OF with a 90-day mortality of 90.9%. On multivariable analysis by a Cox proportion hazard model, age, WBC, presence of IH-OF, and EH-OF all predicted 90-day death. A logistic regression analysis identified SIRS being associated with the development of EH-OF. Furthermore, IH-OF at admission and infections occurred during the hospital stay were shown to be another 2 potential risk factors.The clinical course of cirrhosis patients with acute hepatic injury was characterized by 3 consecutive stages (AHD, IH-OF, and EH-OF), which provided a clear risk stratification. The PIRO criteria provided an accurate frame for prognostication of those patients. The systemic inflammatory response syndrome may be a target for blocking the progression to the EH-OF stage.     

Exploring Sacred Moments in Hospitalized Patients: An Exploratory Qualitative Study

Background“Sacred moments” are brief periods of time in which people experience a deep interconnectedness that may possess spiritual qualities and emotions. This concept has been shown to have a positive impact on individuals’ overall well-being and stress in mental health settings. The concept of sacred moments has not been studied in acute care hospital settings.ObjectiveTo better understand the occurrence of sacred moments among hospitalized patients and their healthcare workers.DesignAn exploratory qualitative study that included in-depth interviews with patients and healthcare workers at two academic medical centers in the Midwestern United States.ParticipantsHospital healthcare workers (e.g., physicians, nurses, ancillary staff) and discharged patients with a recent hospital stay.ApproachSemi-structured telephone interviews were conducted with 30 participants between August 2020 and April 2021. Interviews were recorded and transcribed before conducting thematic analysis.Key ResultsBoth healthcare workers and patients reported having experienced at least one sacred moment. Interview findings were organized into three main domains including (1) several common elements described by participants as marking these moments; (2) benefits experienced by both patients and healthcare workers; and (3) suggestions for fostering sacred moments within the hospital setting.ConclusionsAmong our participants, sacred moments were extremely common with the vast majority reporting to have experienced at least one in their lifetime. These moments were described as profound and important and shared many common elements. Our findings can be used to help recognize, understand, and promote sacred moments between hospitalized patients and healthcare workers.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07999-z.KEY WORDS: sacred moment(s), whole health, spirituality, religiosity in medicine     

Prognostic Factors in Patients Hospitalized for Heart Failure

Each year, there are over one million hospitalizations for heart failure in the United States, with a similar number in Western Europe. Although these patients respond to initial therapies, they have very high short and intermediate term (2-6 months) mortality and readmission rates, while the healthcare system incurs substantial costs. Several risk prediction models that can accurately identify high-risk patients have been developed using data from clinical trials, large registries or administrative databases. Use of multi-variable risk models at the time of hospital admission or discharge offers better risk stratification and should be encouraged, as it allows for appropriate allocation of existing resources and development of clinical trials testing new treatment strategies for patients admitted with heart failure.     

住院患者静脉血栓栓塞危险因素的分析

目的 通过对住院期间发生静脉血栓栓塞症（Venous thromboembolism,VTE）患者危险因素的分析,探讨VTE发生的高危因素。探索应用Caprini风险评估模型评估住院患者VTE发生风险的有效性。方法 对2012年1月1日至2012年12月31日在煤炭总院及朝阳医院确诊为VTE的住院患者进行研究。287例符合入选条件的被纳入研究。收集患者的一般资料、VTE危险因素、相关实验室检查及影像学检查结果等。分析VTE与各危险因素之间的关系。应用Caprini风险评估模型患者进行VTE风险评估。随访患者出院后VTE复发情况及生存状态。结果 1.287例患者中,92例（32.1％）患者仅患有DVT,93例（32.4％）患者仅患有PTE,102例（35.5％）患者同时患有DVT及PTE。155例为内科患者,132例为外科患者。2.VTE患者危险因素排在前五位的依次是：BMI>25 kg/m2（63.2％）,蛋白C或蛋白S缺乏（52.4%）,血清同型半胱氨酸升高（50%）,长期卧床136例（47.4％）,严重肺部疾病132例（46.0％）。3.与内科患者相比,Caprini模型评估外科患者VTE发生风险更为有效,且差异有统计学意义（风险评估分值在内科患者6.68±3.27,外科患者7.84±3.45,P=0.004）。4. 随访中,48例患者复发性VTE,复发率为18.5%。其中极高危患者的复发率最高（29.0％）,其次为高危患者（6.5％）,低中危患者无VTE复发。生存曲线显示极高危患者VTE复发风险最高,且差异有统计学意义（P=0.021）。结论 1.住院患者VTE的高危因素包括：BMI>25kg/m2,蛋白C或蛋白S缺乏,血清同型半胱氨酸升高,长期卧床,严重肺部疾病。2. Caprini模型评估外科患者VTE发生风险较内科患者更为有效,并且为预测VTE复发风险提供参考。     

Management of Hyperkalemia in Hospitalized Patients

PurposeThe aim of this study was to determine the incidence of treatment of hyperkalemia in hospitalized patients.MethodsThis is a prospective chart review of adults in a tertiary care hospital with hyperkalemia (serum potassium [K⁺] ≥ 5.1 mEq/L) over a 6-month period. The treatments and their effectiveness, causative factors and associated electrocardiographic (ECG) changes were examined.ResultsThere were 154 hyperkalemic episodes, 32 with K⁺ ≥ 6.5 mEq/L and 122 with K⁺< 6.5 mEq/L. Overall, 97% received treatment for an average K⁺ of 5.9 mEq/L. Sodium polystyrene sulfonate (SPS) was included in 95% of the regimens. incremental doses of sPs monotherapy yielded potassium reductions between 0.7 and 1.1 mEq/L, and inadequate responses (K⁺ < 0.5 mEq/L) were less frequent with higher doses. There were no differences in the effectiveness of SPS among dialysis-dependent, chronic kidney disease, or nonchronic kidney disease patients. Greater reductions in potassium were observed using a combination of treatments. ECGs were performed in 44% of patients, and 50% showed no ECG changes despite K⁺ being ≥ 6.5 mEq/L. The most common abnormality, peaked T waves, was associated with a higher frequency of calcium administration but not with the number of K⁺-lowering therapies.ConclusionsAlmost all the patients were treated for hyperkalemia. Oral SPS monotherapy was the predominant treatment with the best response at the highest dose. Some combination therapies had greater K⁺ reductions but were used infrequently. An ECG was obtained in about 50% of the cases, but two thirds showed no K⁺-related changes. Reduced kidney function was associated with 70% of hyperkalemic episodes. Angiotensin-converting enzyme inhibitors and trimethoprim were the most commonly implicated medications.     

Impact of Hypoglycemia in Hospitalized Patients

Hypoglycemia is a common problem in hospitalized patients, particularly the elderly, frail, and severely ill. Hypoglycemia has been implicated in the development of adverse clinical outcomes, including increased mortality. Fear of iatrogenic hypoglycemia remains an obstacle to adequate inpatient glycemic control. However, evidence from large clinical trials is mixed: several intensive care unit studies have shown either reduced or no change in mortality with intensive glycemic control, despite high rates of iatrogenic hypoglycemia, and only 1 large study showed higher mortality. In the general ward setting, the association of hypoglycemia with worse outcomes and mortality has been frequently reported, but after multivariate adjustment for comorbidities this association disappears. Spontaneous hypoglycemia, rather than iatrogenic hypoglycemia, is strongly associated with mortality suggesting that hypoglycemia behaves as a biomarker rather than a causative factor of adverse outcomes. Inpatient glycemic management should be patient-centered, follow the current guidelines, and aimed at preventing hypoglycemia.     

Proteinuria and Clinical Outcomes in Hospitalized COVID-19 Patients: A Retrospective Single-Center Study

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