VERISHA KHANAM JURGENA TUSHA DANYAL TAHERI ABKOUH LAITH AL-JANABI VESNA TEGELTIJA AND SARWAN KUMAR PURPOSE: Throughout the years, several scoring systems have been established to measure disease severity in efforts to predict patient mortality and help guide management. In patients with sepsis, organ failure has been proven to worsen outcome, therefore utility of scores such as Sequential Organ Failure Assessment (SOFA) has helped determine the severity of disease and predict mortality. Patients infected with SARS COV-2 were observed to have varying disease progression with multiorgan involvement. Through this study, we intend to investigate the use of the SOFA score in predicting mortality in critically ill patients who tested positive for SARS COV-2. The aim of this study is to determine if the SOFA score is a strong predictor of mortality in critical care patients admitted with SARS-COV2 infection.
An influx of SARS-COV2 infection has led to several unanswered questions, one such question raised was how to risk stratify these patients in order to better direct further management. The MuLBSTA score recently developed by Guo L. et al. in Shanghai, China is designed to predict 90-day mortality in patients with viral pneumonia. Since very little is known regarding patients with SARS COV-2 infection and COVID-19 disease, we aim to explore the applicability of MuLBSTA score in predicting disease severity and risk of mortality in these patients.
, a viral pneumonia associated with a new coronavirus SARS COV-2 emerged in Wuhan, China and quickly spread throughout the world causing high mortality rates. As of May 30th,2020, coronavirus disease 2019 (COVID-19) has been confirmed in 56,884 people in Michigan, with case fatality rate of 10%. Since very little is known regarding patients with COVID-19 disease, we aim to describe the clinical characteristics and outcomes of patients hospitalized in a Michigan community hospital. METHODS: A single centre, retrospective chart review of 163 hospitalized patients with confirmed cases of COVID-19 at a community hospital from March 15 to April 10, 2020. Cases were confirmed by real-time polymerase chain reaction testing of nasopharyngeal samples. Epidemiological, demographic, laboratory and overall outcomes were obtained from electronic medical record. Data collected was then analysed using SPSS software. RESULTS: A total of 163 patients were reviewed and included in the study. Median age of patient with confirmed SARS-COV2 infection was 70 years (mean 68, range, 30-101), of which 52.8% were female, 60.7% white and 33.7% African American. The most common comorbidities were hypertension (112, 68.7%), obesity (79, 48.6%), and hyperlipidemia (54, 33.1%). Patients presented with shortness of breath (109, 66.9%), cough (107, 65.6%) and fever (99, 60.7%). Gastrointestinal symptoms were found in 81 (49.6%) of patients with the most common symptom being diarrhea in 44 (27%) patients. There were 66 (40.5%) patients with fever >100.4F on admission. Multilobe infiltrates were found in chest x-ray of 115 (70.6%) patients. Within one-month, overall mortality was noted to be 29.5%. Mean length of stay of non-intensive care unit (ICU) patients was 6.46 days (range 1-19) when compared 15.5 days (range 3-46) for ICU patients. During hospitalization, 55 patients (33.7%) (median age 68 years, 54.5% female, 60.1% white) were treated in the ICU of which 43(78.2%) required mechanical ventilation and 28 (50.9%) died. For patients requiring mechanical ventilation, 27 (62.8%) died and 16 (37.2%) were discharged alive. CONCLUSIONS: This study provides insight into presenting characteristics, demographics and overall outcome of patients hospitalized with COVID-19 in a Michigan community hospital. CLINICAL IMPLICATIONS: In medical emergencies like the COVID pandemic, it is important to analyze patient demographics in order to help identify the population most at risk. Knowledge of the most vulnerable population not only allows us to come up with strategies to help control the spread of disease but also helps us risk stratify the patients for better resource allocation. It is crucial to learn from an outbreak like this so we can be better prepared for the future.
Acute hip fracture is deemed an emergent orthopedic intervention, such interventions can be complicated if the patient is on anticoagulation for chronic thromboembolic disease. We are presenting a case of an elderly patient who presented with an acute hip fracture with an elevated INR that required rapid reversal, which unfortunately led to a fatal thromboembolic event. CASE PRESENTATION:The patient 80 year-old female with PMH of DVT, PE, and Factor V Leiden on warfarin was admitted for management of an acute hip fracture. On presentation, her INR was 4, and was given vitamin K for INR reversal. Intraoperatively, there were no acute events. The following morning, the patient was found to be less responsive. The laboratory studies revealed high anion gap metabolic acidosis secondary to elevated lactate indicative of bowel ischemia. The patient was intubated due to worsening mentation. Her CTA of abdomen and chest was significant for moderate to severe stenosis of celiac axis, severe narrowing of splenic, common hepatic artery and gastric artery. Unfortunately, she eventually was placed in comfort care.DISCUSSION: Any acute stress including trauma can induce systemic inflammation leading to an increased risk of thromboembolism. Immunothrombosis describes an activation of neutrophils usually triggered by recognition of damaged cells, specifically neutrophils extracellular traps (NETs) and their interaction with various intracellular and extracellular proteins triggering coagulation cascade. Therefore, in a patient with underlying coagulopathy requiring lifelong anticoagulation an extreme caution must be taken while reversing anticoagulation. CONCLUSIONS:Our patient underwent an emergent hip replacement surgery after reversal of warfarin, however due to her underlying hypercoagulable state and recent surgery, she suffered from multiple thrombotic events that eventually led to her demise. There are no guidelines that provide the most appropriate way to reverse anticoagulation in patients with underlying hypercoagulable state. 1 out of 500 people suffer from an underlying disease that puts them at risk of thromboembolic events. It is imperative to develop guidelines for reversal of anticoagulation in patients with diseases that places them at risk of hypercoagulable state to ensure safety while undergoing surgical procedures.
INTRODUCTION: One of the major complications of diabetes mellitus includes hypercoagulability due to platelet hyperactivity, coagulation activation, and hypofibrinolysis. Acute hyperglycemia is hypothesized to exacerbate the coagulation pathway by enhancing the activities of factor VII, VIII and tissue factor pathway inhibitor. The prothrombic state observed in diabetic ketoacidosis (DKA) is due to endothelial activation, augmented activity of platelets, and increased concentration of von Willebrand factor. In the case of inflammatory bowel disease (IBD), however, thrombotic events occur due to an increase in coagulation factors including factor V, VII, VIII, prothrombin, and the thrombin-antithrombin complex. Other studies have noted that the decrease in factor XIII in active Crohn's disease is related to consumption of factor XIII in forming microthrombis. We are presenting a unique case of a STEMI that was provoked by the presence of two hypercoagulable disorders, IBD and DKA. CASE PRESENTATION:The patient is a 41-year-old male with significant PMH of type I diabetes mellitus complicated by gastroparesis and multiple admissions for diabetic ketoacidosis, as well as Crohn's disease not on immunosuppressive therapy. The patient presented with a chief complaint of intractable nausea, vomiting and diffuse, non-radiating abdominal pain. On admission, he was tachycardic, tachypneic, and normotensive. His laboratory studies were consistent with DKA. Abdominal X-ray showed fluid distension in the stomach, similar to previous CT abdomen findings, coinciding with his significant history of gastroparesis. EKG revealed ST elevations in leads II, III, aVF and V3-V6. He underwent a cardiac catheterization, which revealed thrombus in the proximal segment of the right coronary artery with no obvious underlying coronary artery disease. He underwent mechanical thrombectomy only, with no stent deployed. The patient was discharged with goal-directed medical therapy and to continue dual-antiplatelet therapy for one year.DISCUSSION: DKA can cause various complications including hypercoagulability. There are proposed hypotheses for risk of developing thromboembolic disease in both DKA and IBD. The patient had a significant history of recurrent admissions due to DKA with non-specific EKG changes. The patient in this case had a history of Crohn's disease, and was not on any immunosuppressive medications. If the patient's comorbidities had been better controlled, it is possible that the patient would not have suffered this STEMI. CONCLUSIONS:The patient had two hypercoagulable disorders that could have led to formation of the intracoronary thrombus. This case demonstrates the importance of management of chronic diseases and their effects on other organ systems.
INTRODUCTION: Diarrheal disease is one of the leading causes of death across the globe. Acute diarrhea in older adults is mostly due to underlying infectious etiology. Patients with underlying systemic lupus erythematosus (SLE) it is important to consider an acute exacerbation of the disease if presenting with diarrhea and abdominal pain. We are presenting a case of 60-yearold female with remote history of SLE, not on immunosuppressive therapy who presented with rash, dyspnea and acute onset of diarrhea.CASE PRESENTATION: A 60-year-old female with medical history of SLE diagnosed 20 years ago, not on immunosuppressive therapy, and other comorbidities who presented to the emergency department with chief complaint of worsening skin rash, dyspnea and diarrhea. She noted a lacy, macular erythematous rash in both the proximal and distal areas of the arms with a marginated appearance with a central clearing that has been ongoing for over one year; it was not alleviated with topicals. Also, she had multiple loose watery and dyspnea that has been ongoing for the past two weeks. She was treated for an asthma exacerbation seven months ago with oral steroids. Upon presentation, she was tachycardic with mild leukocytosis, lactic acidosis with concern of an underlying abdominal infection. She was empirically started on broad spectrum antibiotics and IV fluids. Significantly elevated CRP and presence of a reticular rash prompted starting IV steroids for concern of vasculitis. Skin biopsy showed leukocytoclastic vasculitis. Serological work-up was significant for positive rheumatoid factor, anti-SSA and ANA. After a few doses of IV steroids, her symptoms improved with dissipation of the rash. With clinical improvement with IV steroids and negative stool cultures, it was suspected that the patient suffered from lupus mesenteric vasculitis. DISCUSSION:The prevalence of vasculitis in a patient with SLE ranges between 11-36%, with cutaneous involvement accounting for 82% of vasculitis and visceral 12.3%. Mesenteric vasculitis is the rarest, and most dangerous complication of SLE that is reported in 0.2 -9.7% of all SLE patients. In this patient's case, she did not have significant knowledge regarding her initial diagnosis of SLE. However, she had been receiving oral steroids for management of asthma or skin rashes intermittently that could have helped control potential SLE flares. For the past seven months, she was not any immunosuppressants that could contribute to worsening rash and diarrhea. A typical presentation of acute diarrhea usually warrants an underlying infectious or inflammatory etiology. This patient's case characteristic rash and remote history of SLE prompt us to further evaluate for an underlying autoimmune culprit due to her symptoms. CONCLUSIONS:It is imperative that we evaluate such patients with an underlying autoimmune disease for any exacerbation as a potential cause of presenting symptoms.
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