Evaluation the efficacy and safety of N-acetylcysteine inhalation spray in controlling the symptoms of patients with COVID-19: An open-label randomized controlled clinical trial

The aim of this study was to evaluate the effect and safety of N-acetylcysteine (NAC) inhalation spray in the treatment of patients with coronavirus disease 2019 (COVID-19). This randomized controlled clinical trial study was conducted on patients with COVID-19. Eligible patients (n = 250) were randomly allocated into the intervention group (routine treatment + NAC inhaler spray one puff per 12 h, for 7 days) or the control group who received routine treatment alone. Clinical features, hemodynamic, hematological, biochemical parameters and patient outcomes were assessed and compared before and after treatment. The mortality rate was significantly higher in the control group than in the intervention group (39.2% vs. 3.2%, p < 0.001). Significant differences were found between the two groups (intervention and control, respectively) for white blood cell count (6.2 vs. 7.8, p < 0.001), hemoglobin (12.3 vs. 13.3, p = 0.002), C-reactive protein (CRP: 6 vs. 11.5, p < 0.0001) and aspartate aminotransferase (AST: 32 vs. 25.5, p < 0.0001). No differences were seen for hospital length of stay (11.98 ± 3.61 vs. 11.81 ± 3.52, p = 0.814) or the requirement for intensive care unit (ICU) admission (7.2% vs. 11.2%, p = 0.274). NAC was beneficial in reducing the mortality rate in patients with COVID-19 and inflammatory parameters, and a reduction in the development of severe respiratory failure; however, it did not affect the length of hospital stay or the need for ICU admission. Data on the effectiveness of NAC for Severe Acute Respiratory Syndrome Coronavirus-2 is limited and further research is required.     

Clinical predictive values of extended-spectrum beta-lactamase carriage in patients admitted to medical wards

We aimed to reassess, through clinical items, populations at risk for extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) carriage at admission to hospital and to assess the risk of further positive clinical culture of ESBL-E among carriers. We performed a 5-month cohort study in a medicine ward of a 500-bed university teaching hospital in the Parisian area of France. All admitted patients were prospectively enrolled for rectal swabbing and clinical data collection, including bacterial infection at admission and during stay. Variables associated with ESBL-E carriage were identified by univariate and multivariate analysis. Five hundred patients were included. The prevalence of ESBL-E was 6.6% (33/500) upon admission. Only previous carriage of multidrug-resistant bacteria (MDRB) was associated with carriage (odds ratio [OR]: 17.7, 95% confidence interval (CI) 5.8–54.2, p < 0.001), yet, the positive predictive value (PPV) was not higher than 50%. When prior MDRB carriage was not considered in the multivariate analysis, only prior antibiotic consumption was found to be associated with carriage at admission (OR: 2.2 [1.1–4.5], p = 0.02). Two patients had ESBL-E infection at admission, yet, no patient became infected with ESBL-E during their stay. The clinical prediction of ESBL carriage at admission in our wards was found to be poorly efficient for assessing the at-risk population.     

Effect of prior pneumococcal vaccination on clinical outcome of hospitalized adults with community-acquired pneumococcal pneumonia

The aim of this study was to evaluate the effect of prior pneumococcal vaccination on the clinical outcome of 554 consecutive hospitalized adults with community-acquired pneumococcal pneumonia from 1995 to 2004, 61 of whom had been vaccinated in the 5 years before admission. Outcome variables that were compared in vaccinated and unvaccinated adults included the occurrence of bacteremia, the time to resolution of pneumonia symptoms, the length of hospital stay, and mortality. Prior pneumococcal vaccination was associated with a lower risk of bacteremia (odds ratio 0.46, 95% CI 0.22–0.98). Compared with unvaccinated patients, vaccine recipients had better clinical outcomes, which included a faster resolution of pneumonia symptoms. The median length of hospital stay was shorter in vaccinated patients (8.0 vs. 9.0 days; p=0.032). Overall case-fatality rates did not differ significantly between groups (1.6% vs. 6.2%; p=0.233). In conclusion, prior pneumococcal vaccination appears to be associated with a lower risk of bacteremia, a faster time to resolution of symptoms, and a shorter hospital stay in adults with pneumococcal pneumonia. The findings presented here provide additional support to the current vaccine recommendations and should encourage healthcare providers to increase pneumococcal vaccine coverage among targeted adult populations.     

Medical comorbidity in psychiatric inpatients: relation to clinical outcomes and hospital length of stay

Medical comorbidity is common in psychiatric inpatients and may be associated with substantial impairment and mortality. Few studies have examined the relation between this comorbidity and psychiatric outcomes. A series of 950 admissions to the Johns Hopkins Hospital Phipps Psychiatric Service were rated by attending psychiatrists at admission and discharge on symptom and functional measures. A subset was also evaluated on the General Medical Health Rating, a valid and reliable measure of seriousness of medical comorbidity. Attending psychiatrists were also asked at discharge whether medical comorbidity had been a focus of care during the hospitalization; medical comorbidity had been a focus of care in about 20% of the patients. Serious active medical comorbidity was present in 15% of patients on admission and 12% at discharge. Medical comorbidity was associated with a 10%-15% increase in psychiatric symptoms and functional impairment at discharge, even after adjustment for admission clinical status. In addition, when comorbidity had been a focus of care during the hospitalization, length of stay was prolonged by 3.25 days on average. Medical comorbidity has measurable effects on the psychiatric outcomes of psychiatric inpatients and in some cases prolongs hospital stay. Psychiatrists should redouble their efforts to detect and treat this comorbidity and should consider whether special inpatient units might be needed to care for psychiatric patients with complex medical comorbidity.     

Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes

BACKGROUND: A discharge against medical advice (AMA) after an asthma hospitalization is a frustrating problem for health care providers, yet little is known about this occurrence. OBJECTIVE: To determine the baseline characteristics, reasons for leaving, and clinical outcomes of patients with asthma who leave AMA. METHODS: A retrospective study from 1999 to 2004 of all asthma discharges from 3 large hospitals in Detroit compared those who left AMA with those who left with medical approval. RESULTS: There were 180 patients who left AMA and 3457 patients who had a standard discharge. Patients with asthma who left AMA were more likely to be younger, male, have Medicaid or lack insurance, require intensive care unit admission, and have a lower socioeconomic status than patients with asthma discharged with approval (P < .05 for all comparisons). There was no difference in race, day of the week admitted, or month admitted. Among records that documented a reason for leaving AMA, the most common was dissatisfaction with care, although a variety of motives were found. Finally, patients who left AMA were more likely to have an asthma relapse within 30 days. This included both emergency department revisits (21.7% vs 5.4%; P < .001) and readmission to the hospital (8.5% vs 3.2%; P < .001). CONCLUSION: Patients with asthma who leave AMA have demographic and hospital admission characteristics that differ from those who leave with approval. The reasons why patients with asthma leave AMA are varied. Within 30 days, patients with asthma who leave AMA have much higher readmission and emergency department return rates. CLINICAL IMPLICATIONS: Patients with asthma who leave AMA are at increased risk of relapse.     

Role of hospital stay and antibiotic use on Pseudomonas aeruginosa gastrointestinal colonization in hospitalized patients

The prospective cohort study presented here assessed the risk factors associated with Pseudomonas aeruginosa gastrointestinal colonization (PAGIC) in 933 patients hospitalized in five different wards in a French university hospital. A total of 195 patients were colonized. By logistic regression, hospitalization in an intensive care unit and length of hospital stay were independent risk factors. A significant association was observed between fluoroquinolone use and PAGIC caused by an ofloxacin-resistant strain (p<0.0001), imipenem use and PAGIC caused by an imipenem-resistant strain (p<0.0002) and ceftazidime use and PAGIC caused by a ceftazidime-resistant strain (p<0.02). The ecological impact of antibiotic use is of great clinical relevance and clinicians should consider antimicrobial resistance in order to limit the development and dissemination of resistant microorganisms.     

Economic Impact of<Emphasis Type="Italic"> Candida</Emphasis> Colonization and<Emphasis Type="Italic"> Candida</Emphasis> Infection in the Critically Ill Patient

The objective of the study presented here was to assess the economic impact of Candida colonization and Candida infection in critically ill patients admitted to intensive care units (ICUs). For this purpose, a prospective, cohort, observational, and multicenter study was designed. A total of 1,765 patients over the age of 18 years who were admitted for at least 7 days to 73 medical-surgical ICUs in 70 Spanish hospitals between May 1998 and January 1999 were studied. From day 7 of ICU admission to ICU discharge, samples of tracheal aspirates, pharyngeal exudates, gastric aspirates and urine were collected every week for culture. Prolonged length of stay was associated with severity of illness, Candida colonization or infection, infection by other fungi, antifungal therapy, treatment with more than one antifungal agent, and toxicity associated with this therapy. Compared to non-colonized, non-infected patients (n=720), patients with Candida colonization (n=880) had an extended ICU stay of 6.2 days (OR, 1.69; 95%CI, 1.53–1.87; P<0.001) and an extended hospital stay of 8.6 days (OR, 1.27; 95%CI, 1.16–1.40; P<0.001). The corresponding figures for patients with Candida infection (n=105) were 12.7 days for ICU stay (OR, 2.13; 95%CI, 1.72–2.64; P<0.001) and 15.5 days for hospital stay (OR, 1.23; 95%CI, 0.99–1.52; P=0.060). Candida colonization resulted in an additional 8,000 EUR in direct costs and Candida infection almost 16,000 EUR. Both Candida colonization and Candida infection had an important economic impact in terms of cost increases due to longer stays in both the ICU and in the hospital.     

Patients who leave the hospital against medical advice: the role of the psychiatric consultant

Previous studies have identified characteristics of patients who threaten to leave non-psychiatric units against medical advice, but few have described the role of the psychiatric consultant in the patient's decision. This study compared the medical records of 31 patients who threatened to leave the hospital against medical advice (AMA) and who were seen in consultation with the records of AMA-discharged patients who were not seen by a psychiatric consultant. Most patients who received consultations remained hospitalized or were discharged in regular fashion. Those seen soon after admission were most likely to stay. Patients were more likely to remain hospitalized if the consultant's recommendations had a practical, rather than a psychological, orientation.     

Inpatient epidemiology,healthcare utilization,and association with comorbidities of Turner syndrome: A National Inpatient Sample study

We aimed to investigate the prevalence, resource utilization, and comorbidities of patients with Turner syndrome (TS) hospitalized in the United States. We identified patients within the Nationwide Inpatient Sample database from the year 2017 to 2019. A propensity-matched cohort of non-TS patients from the same database was constructed to serve as comparators. There were 9845 TS patients, corresponding to inpatient prevalence of 10.4 per 100,000 admissions. The most common admission diagnosis was sepsis (27.9%). TS patients had higher inpatient mortality (adjusted odds ratio 2.16, 95% confidence interval 1.57–2.96) and morbidity, including shock, ICU admission, acute kidney injury, systemic inflammatory response syndrome, acute respiratory distress syndrome, and multi-organ failure. Increased risk of comorbidities, such as stroke, myocardial infarction, autoimmune diseases, and non-variceal gastrointestinal bleeding, was observed. TS patients had longer length of stay (LOS; 5.1 days vs. 4.5 days, p < 0.01) and displayed a mean additional $5382 (p < 0.01) in total hospital costs and a mean additional $20,083 (p < 0.01) in total hospitalization charges. In conclusion, hospitalization of patients with TS was associated with a significantly higher inpatient morbidity, mortality, expenditures, and longer LOS compared to non-TS patients. Patients with TS had a higher risk of cardiovascular complications, autoimmune diseases, and gastrointestinal bleeding.     

Factors associated with thrombocytopenia in severe leptospirosis (Weil's disease)

OBJECTIVE:

This study was conducted to investigate factors associated with thrombocytopenia in a large cohort of patients with leptospirosis in an endemic area.

METHODS:

This retrospective study included 374 consecutive patients with leptospirosis who were admitted to tertiary hospitals in Fortaleza, Brazil. All patients had a diagnosis of severe leptospirosis (Weil''s disease). Acute kidney injury was defined according to the RIFLE criteria. Thrombocytopenia was defined as a platelet count <100,000/mm³.

RESULTS:

A total of 374 patients were included, with a mean age of 36.1±15.5 years, and 83.4% were male. Thrombocytopenia was present at the time of hospital admission in 200 cases (53.5%), and it developed during the hospital stay in 150 cases (40.3%). The patients with thrombocytopenia had higher frequencies of dehydration (53% vs. 35.3%, p = 0.001), epistaxis (5.7% vs. 0.8%, p = 0.033), hematemesis (13% vs. 4.6%, p = 0.006), myalgia (91.5% vs. 84.5%, p = 0.038), hematuria (54.8% vs. 37.6%, p = 0.011), metabolic acidosis (18% vs. 9.2%, p = 0.016) and hypoalbuminemia (17.8% vs. 7.5%, p = 0.005). The independent risk factors associated with thrombocytopenia during the hospital stay were lengthy disease (OR: 1.2, p = 0.001) and acute kidney injury (OR: 6.6, p = 0.004). Mortality was not associated with thrombocytopenia at admission (12.5% vs. 12.6%, p = 1.000) or during the hospital stay (12.6% vs. 11.3%, p = 0.748).

CONCLUSIONS:

Thrombocytopenia is a frequent complication in leptospirosis, and this condition was present in more than half of patients at the time of hospital admission. Lengthy disease and acute kidney injury are risk factors for thrombocytopenia. There was no significant association between thrombocytopenia and mortality.     

Same-Day Bilateral Total Knee Arthroplasty: Incidence and Perioperative Outcome Trends from 2009 to 2016

BackgroundSame-day bilateral total knee arthroplasty (BiTKA) is a controversial topic in orthopedics, prompting a consensus statement to be released by national experts. To date, no studies have evaluated the trends of this method since these recommendations. This study utilized a national database to evaluate: 1) incidence; 2) patient characteristics; 3) hospital characteristics; and 4) inpatient course for same-day BiTKAs in the United States from 2009 to 2016.MethodThe National Inpatient Sample database was queried for individuals undergoing same-day BiTKAs, yielding 245,138 patients. Patient demographics included age, sex, race, obesity status and Charlson Comorbidity Index (CCI) score. Hospital characteristics consisted of location/teaching status, geographic region, charges, and costs. Inpatient course included length of stay, discharge disposition, and complications.ResultsSame-day BiTKA incidence decreased from 5.6% to 4.0% over the study (p < 0.001). Decreases in patient age and female proportion (p < 0.001 for both) were seen, while African American and Hispanic patients increased (p < 0.001), as did obese patient proportions (p < 0.001). Patients with CCI scores of 2 increased, while those with ≥3 decreased (p < 0.001). Hospital charges increased, while costs decreased (p < 0.001 for both). Length of stay following same-day BiTKA decreased (p < 0.001) and routine home discharges increased (p < 0.001). Most inpatient complications decreased, although the percentage of mechanical complications and respiratory failures increased (p < 0.01 for all).ConclusionsDuring the study period, younger patients with fewer comorbidities underwent BiTKAs, which likely resulted from improved patient assessment and management. Future investigations should include an evaluation of long-term complications and outcomes in certain patient populations for this procedure.     

Impact of multi-drug-resistant <Emphasis Type="Italic">Acinetobacter baumannii</Emphasis> on clinical outcomes

We conducted a retrospective matched cohort study to examine the impact of isolation of multi-drug-resistant (MDR) Acinetobacter baumannii on patient outcomes. Cases from whom MDR A. baumannii was isolated in a clinical culture (n = 118) were compared with controls from whom MDR A. baumannii was not isolated (n = 118). Cases and controls were matched according to ward, calendar month of hospitalization, and duration of hospitalization before culture. The following outcomes were compared in multivariable analysis: in-hospital mortality, length of stay, need for mechanical ventilation, and functional status at discharge. MDR A. baumannii was determined to be a pathogen in 72% of cases. In 36% of cases, the patient died, versus 21% of controls (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.17–4.16, P = 0.014). Median length of stay for surviving cases was 17 days, versus 11 for surviving controls (multiplicative effect 1.55, 95% CI 0.99–2.44, P = 0.057). Fifty-two percent of cases required mechanical ventilation, versus 25% of controls (OR 3.72, 95% CI 1.91–7.25, P<0.001); 60% of surviving cases were discharged with reduced functional status, versus 38% of controls (OR 4.4, 95% CI 1.66–11.61, P = 0.003). In multivariable analysis, clinical isolation of MDR A. baumannii remained a significant predictor of mortality (OR 6.23, 95% CI 1.31–29.5, P = 0.021), need for mechanical ventilation (OR 7.34, 95% CI 2.24–24.0, P<0.001), and reduced functional status on discharge (OR 7.93, 95% CI 1.1–56.85, P = 0.039). Thus, MDR A. baumannii acquisition is associated with severe adverse outcomes, including increased mortality, need for mechanical ventilation, and reduced functional status.     

Screening for enteroviral meningitis in infants and children—Is it useful in clinical practice?

Enteroviral meningitis in infants and children commonly leads to hospital admission. Diagnosing viral meningitis can be difficult clinically. We examined the usefulness of enteroviral polymerase chain reaction (PCR) testing using cerebrospinal fluid (CSF) samples on clinical practice by comparing positive enteroviral CSF PCR cases (n = 39/136) to negative controls using both clinical outcomes and laboratory parameters. A positive result correlated with a reduced admission to high dependency unit, reduced the duration of antibiotics and a shorter length of stay (P < .05). Adjusted CSF white cell count > 5/μL correlated with positive PCR (P < .05) but would have missed 32% of cases of enteroviral meningitis. Following these findings, an algorithm for the management of suspected viral meningitis has been introduced.     

Evaluation of antiviral therapies for coronavirus disease 2019 pneumonia in Shanghai,China

The aim of our study was to evaluate the therapeutic effect of antiviral drugs on coronavirus disease 2019 (COVID-19) pneumonia. Patients confirmed with COVID-19 pneumonia were enrolled and divided into seven groups according to the treatment option. Information including age, sex, and duration from illness onset to admission, clinical manifestations, and laboratory data at admission, and length of hospital stay were evaluated. The chest computed tomography (CT) imaging obtained at admission and after a 5-day treatment cycle were assessed. The clinical symptoms and laboratory tests at discharge were also assessed. At admission, no significant differences were found among the groups, including the duration from illness onset to admission, clinical symptoms, and main laboratory results. No significant differences were found among the groups in terms of the proportion of patients with pneumonia resolution (P = .151) after treatment or the length of hospital stay (P = .116). At discharge, 7 of 184 (4%) patients had a mild cough while their other symptoms had disappeared, and the proportion of patients with abnormal liver function and with increased leukocytes, neutrophils or erythrocyte sedimentation rate among the 184 patients were close to those at admission. According to the results, the inclusion of antiviral drugs in therapeutic regimens based on symptomatic treatment had no significant additional impact on the improvement in COVID-19 patients. In addition, the results of chest CT imaging, clinical manifestations, and laboratory tests at discharge were not completely consistent.     

Clinical and microbiological implications of time-to-positivity of blood cultures in patients with Gram-negative bacilli bacteremia

Time-to-positivity (TTP) is defined as the length of time from the beginning of culture incubation to the detection of bacterial growth by an automated system. The objective of this study was to assess the clinical and microbiological implications of TTP among patients with Gram-negative bacilli (GNB) bacteremia. This was a prospective, single-center, observational study. Patients aged 18 years or older with one or more blood cultures growing GNB were included and followed until hospital discharge or death. Patients were excluded if they were without symptoms of infection, if they had polymicrobial culture, or if the culture was positive with an obligate anaerobe. A multivariate logistic regression analysis was performed to determine the predictors of in-hospital mortality, including TTP (primary endpoint), demographics, disease severity, comorbidities, pathogen type, source of infection, time to symptom resolution, hospital/intensive care unit (ICU) length of stay, adequacy of empiric antibiotics, and presence of an extended-spectrum beta-lactamase (ESBL)-producing bacteria. One hundred consecutive patients with GNB bacteremia were enrolled. TTP was an independent predictor of mortality; for every hour that TTP was shorter, the risk of mortality increased by 10 % [odds ratio (OR) 1.10, 95 % confidence interval (CI) 1.00–1.21, p?=?0.049]. Other predictors of mortality included severity of illness, ESBL-producing GNB, and ICU admission within 24 h before culture. Mortality was highest among patients with inadequate empiric therapy (56 % vs. 14 %, p?<?0.001) and TTP <11 h (23.1 % vs. 8.3 %, p?=?0.18). Lactose-fermenting GNB had a shorter mean TTP than non-lactose fermenters (11.4 vs. 17.9 h, p?=?0.001). Among patients with bacteremia due to GNB, TTP values are inversely associated with mortality risk.     

Influence of Socioeconomic Status on Features and Outcome of Community-Acquired Pneumonia

 The influence of socioeconomic status on the features and evolution of community-acquired pneumonia in 107 consecutive hospitalized patients was investigated. Thirty-four (31.8%) patients were considered to have a low socioeconomic status. These patients were more likely immigrants, middle-aged, with fewer comorbid illnesses, and were more often tobacco, alcohol, or drug consumers (P<0.01). The distribution of etiologies was significantly different according to socioeconomic status, with tuberculosis occurring more frequently in the low socioeconomic group (P<0.05). Low socioeconomic status was not associated with a more severe presentation or outcome of pneumonia but was an independent factor that predicted a significantly longer length of hospitalization (5.9 days longer; 95% confidence interval, 2.2–9.5 days;P<0.003), entailing a substantial excess cost per hospital stay.     

Analysis of Risk Factors for Ventilator-Associated Pneumonia in a Multidisciplinary Intensive Care Unit

 A prospective study was conducted to determine the incidence, risk factors and pathogens of ventilator-associated pneumonia (VAP) in 198 patients requiring mechanical ventilation for more than 48 hours. VAP occurred in 67 (33.8%) patients. Risk factors associated with VAP were admission APACHE II score >20 (odds ratio [OR] 4.77, 95% confidence interval [CI] 2.04–11.27, P<0.001), mechanical ventilation >10 days (OR 44.4, 95% CI 2.16–26.7, P<0.0001), ICU length of stay >10 days (OR 9.4, 95% CI 3.55–25.65, P<0.0001), and admission PaO₂/FiO₂ ratio <200 mmHg (OR 3.4, 95% CI 1.00–11.41, P<0.05). Logistic regression analysis showed a relationship between VAP and length of stay in ICU, duration of fever and presence of catheter-related infection. The pathogens isolated were predominantly gram-negative bacteria (83.2%), with a high proportion of Acinetobacter spp. (35%) resistant to commonly used antimicrobial agents. The mortality rate was not influenced by VAP.     

Patient perceptions of quality in discharge instruction

The present study investigates patient perceptions of the quality of discharge instruction by assessing inpatients' ratings of care and service in the United States over the past 5 years (1997-2001) (n = 4,901,178). As expected, patients' ratings of "instructions given about how to care for yourself at home" showed a strong, consistent positive relationship with overall patient satisfaction from 1997 through 2001. Nevertheless, patient satisfaction with discharge instructions decreased significantly each year (p < 0.001). Patients gave lower ratings to the quality of discharge instruction than to the overall quality of their hospital stay which indicates a failure to match the quality delivered among other services within the hospital. Patient assessments of discharge instruction quality varied systematically among conditions. Patients with musculoskeletal diseases and disorders (MDC-8) rated discharge instruction considerably lower than all other patient groups. Patients' age, sex, self-described health status and length of stay did not predict patients' evaluations of discharge instructions. U.S. hospitals may not be meeting existing AMA and JCAHO standards for patient education and discharge.     

Psychological adjustemnt and attitudes toward success and failure

Investigated the relationship of performance on the Success-Failure Inventory (SFI) and severity of psychological maladjustment (as measured by the MMPI). Ss (N = 120) were male veterans admitted to a VA Medical Center's psychiatric Day Hospital program. Ss were divided at median of SFI scores to form two groups: (a) Success-attainment (N = 60); and (b) failure-avoidance (N = 60). Multivariate analysis of the MMPI validity and clinical scales indicated that the two groups differed significantly, F(13,104) = 4.46, p <0.0000), Success-attainment group, in contrast to failure-avoidance group, scored significantly higher on K (p <.01), and significantly lower on PT (p <0.000), SC (p <.002), and SI (p <.0000). Discriminant analysis revealed that 76.67% of Ss were classified correctly into a success-attainment vs. failure-avoidance group by using the MMPI scales (p <.001).