Liver biomarkers for prognosis in COVID-19

The novel coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).Mortality attributable to COVID-19 remains considerably high, with case fatality rates as high as 8-11%. Early medical intervention in patients who are seriously and critically ill with COVID-19 reduces fatal outcomes. Thus, there is an urgent need to identify biomarkers that could help clinicians determine which patients with SARS-CoV-2 infection are at a higher risk of developing the most adverse outcomes, which include intensive care unit (ICU) admission, invasive ventilation, and death. In COVID-19 patients experiencing the most severe form of the disease, tests of liver function are frequently abnormal and liver enzymes are found to be elevated. For this reason, we examine the most promising liver biomarkers for COVID-19 prognosis in an effort to help clinicians predict the risk of ARDS, ICU admission, and death at hospital admission. In patients meeting hospitalization criteria for COVID-19, serum albumin < 36 g/L is an independent risk factor for ICU admission, with an AUC of 0.989, whereas lactate dehydrogenase (LDH) values > 365 U/L accurately predict death with an AUC of 0.943.The clinical scores COVID-GRAM and SOFA that include measures of liver function such as albumin, LDH, and total bilirubin are also good predictors of pneumonia development, ICU admission, and death, with AUC values ranging from 0.88 to 0.978.Thus, serum albumin and LDH, together with clinical risk scores such as COVID-GRAM and SOFA, are the most accurate biomarkers in the prognosis of COVID-19.Copyright © 2021 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.

NR3C1 rs41423247: genetic predictor of complications in pneumonia caused by SARS-CoV-2

Background/Objectives: Runaway inflammation is a key feature of COVID-19. NR3C1 gene encodes for glucocorticoid receptor which plays an important role in inflammation reaction. The variant rs41423247 cause increased glucocorticoid receptors sensitivity. This study aimed to investigate the impact of variants of NR3C1 gene on the course of COVID-19 pneumonia in patients with necessarily artificial lung ventilation. Method(s): The study group included 20 patients (9 women and 11 men) with diagnosis viral COVID-19 pneumonia on artificial lung ventilation at the intensive care unit. All patients underwent daily standard examinations according clinical protocols. Determination of NR3C1 gene variants was carried out by using PCRRFLP. Result(s): There were found the significant negative correlations between NR3C1 gene variants and level of SpO2 (rS = -0.601, p = 0.008), Glasgow Coma Scale score (rS = -0.523, p = 0.026). Also, it was defined a protective effect of genotype CC at risk of development acute respiratory distress syndrome in this patients (chi2 = 4.38, p = 0.037, OR = 0.05 (CI:0.01-0.66)). Conclusion(s): The investigated variant rs41423247 of the NR3C1 gene may be the genetic predictor of complicated course of COVID-19 pneumonia. .

Isolated Hyoid Fracture Associated with Blunt Trauma

Trauma-related hyoid fractures are rare entities. These fractures represent only 0.002% of head and neck region fractures. Victims of hanging and strangling constitute the great majority of cases. Fractures associated with trauma are extremely rare. These fractures are difficult to diagnose and can easily be overlooked during physical examination. However, they are also important traumas since airway safety is endangered in these rare cases. We describe a case of a young male presenting with isolated neck injury associated with hitting an electric cable while riding a motorbike. Tenderness was present in the anterior neck region at physical examination, but movement was not restricted and no respiratory difficulty was determined. Isolated hyoid fracture was detected at tomography of the neck performed in the emergency department. Hyoid bone fractures should not be forgotten in patients with pain and tenderness in the anterior neck region following blunt trauma to the neck.©Copyright 2020 by Emergency Physicians Association of Turkey - Available online at www.jemcr.com.

L-Ornithine-L-Aspartate and Intermittent Renal Replacement Therapy in Fulminant Hepatitis A: A Case Report

Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. Since the introduction of an efficient vaccine, the incidence of infection has decreased but the number of cases has risen due to widespread community outbreaks among unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice, and are more common in older children and adults. People are often most infectious 14 days prior to and 7 days following the onset of jaundice. We will discuss the case of a young male patient, diagnosed with acute hepatitis A, leading to fulminant hepatitis refractory to conventional therapy and the development of subsequent kidney injury. The medical treatment through the course of hospitalization was challenging and included the use of L-ornithine-L-aspartate and prolonged intermittent hemodialysis, leading to a remarkable outcome. Hepatitis A is usually self-limited and vaccine-preventable;supportive care is often sufficient for treatment, and chronic infection or chronic liver disease rarely develops. However, fulminant hepatitis, although rare, can be very challenging to manage as in the case of our patient.Copyright © 2023 The Author(s).

Asymmetric Cerebral Perfusion in Comatose Extracorporeal Membrane Oxygenation Patients

Asymmetric cerebral perfusion can occur when extracorporeal membrane oxygenation (ECMO) flow competes with native cardiac circulation. It is unclear whether this phenomenon associates with brain injury. Diffuse correlation spectroscopy (DCS) provides continuous, laser-based, non-invasive, bedside monitoring of relative cerebral blood flow (rCBF). This study measured rCBF in ECMO patients via DCS to determine whether comatose patients experience asymmetric cerebral perfusion. Adults receiving ECMO for any indication were prospectively recruited from 12/2019-3/2021. Patients with prior neurologic injury, scalp/facial lacerations, and SARS-CoV-2 infection were excluded. DCS monitoring was performed daily during ECMO support with sensors placed on bilateral foreheads. Mean arterial pressure (MAP) was continuously recorded from the bedside monitor. The Glasgow Coma Scale (GCS) was assessed by clinical staff multiple times daily with sedation pauses, if possible, per standard of care. rCBF was calculated by comparing continuous cerebral blood flow (CBF) measurements to the daily median CBF, then averaged at each MAP value. Daily rCBF asymmetry was calculated by summing the absolute difference of rCBF between the two hemispheres at each MAP value, normalized for the total MAP range experienced by the patient that day. Twelve subjects were enrolled in this study (ages 21-78, 6 with cardiac arrest, 4 with acute heart failure, 2 with ARDS) and grouped by maximum GCS motor (GCS-M) score during ECMO, with 3 "comatose" subjects (GCS-M <= 4), and 9 "awake" subjects (GCS-M > 4). DCS was performed over 66 sessions with a mean duration of 131.83 +/- 1.13 minutes. Comatose subjects exhibited more rCBF asymmetry than awake subjects (0.28 +/- 0.06 mmHg-1 vs. 0.10 +/- 0.001 mmHg-1, p=0.045). No difference in asymmetry was noted between patients with or without cardiac arrest. We found that comatose ECMO subjects exhibited higher inter-hemispheric rCBF asymmetry over a range of blood pressures than awake subjects. Though our comatose sample is small, further validation of this finding and its causes, such as cerebrovascular dysregulation, is warranted.

Evaluation of patients with negative PCR tests after COVID-19 pneumonia in intermediate-level intensive care unit

Objectives: The need for an intensive care unit has increased during the pandemic of coronavirus disease (COVID-19). For this reason, intermediate-level intensive care units (IICUs) were established in hospitals worldwide. This study aims to evaluate the data of patients that hospitalized in IICU. Method(s): Patients under treatment for COVID-19 were followed up in IICU after the negative polymerized chain reaction test. A total of 52 patients were evaluated retrospectively between August 24, 2020 and March 1, 2021. The patients were divided into two groups according to discharge status from IICU (Group 1: exitus, Group 2: transferred to clinic, or discharged home). Demographic data, comorbidities, Acute Physiology and Chronic Health Evaluation II (APACHE II), Glasgow Coma Scale (GCS), treatments and procedures, and complications were recorded. Result(s): Seventeen (32.7%) of 52 patients who were followed up in IICU died. Thirty-five patients (67.3%) were transferred to the clinic or discharged home. The APACHE II scores at admission to IICU were higher in Group 1 (26.11 +/- 5.86) than in Group 2 (23.43 +/- 6.32) but not statistically significant. GCS was statistically significantly lower in Group 1 than in Group 2 (7.82 +/- 2.42 and 10.25 +/- 2.58, respectively, p = 0.002). Mechanical ventilation rate (82.3%) and the need for inotropic agents (76.5%) were higher in Group 1 (p = 0,034 and p < 0.001, respectively). Tracheostomy was applied to 5 of all patients, and percutaneous endoscopic gastrostomy was performed 4 of them. Conclusion(s): We think that IICU created during the pandemic provides effective treatment for patients needing intensive care. We think IICU is beneficial in providing quick patient discharge in tertiary intensive care units.Copyright © 2023 by Prusa Medical Publishing.

A local outbreak as mirror-like scenario for COVID-19 worldwide progression. Clinical presentation to the Emergency Department during one of the first sub-regional outbreak in Italy A lesson to learn

BACKGROUND: One of the most precocious Italian COVID-19 outbreaks began in February 2020 in Medicina, a small town in the province of Bologna. We compared the characteristics of different cohorts, to identify potential predictive factors for outcome: patients of Medicina outbreak versus those of the surrounding district (Imola), and before or after the local medical intervention. METHOD(S): Between March the 3rd and April the 9th, 2020 167 adults with COVID-19 were admitted to the Emergency Department (ED) (78 from Medicina cluster, 89 from Imola district). Data at ED presentation were collected;hospitalized patients were followed until death or discharge. RESULT(S): Medicina and Imola cohorts were similar in age, main comorbidities, clinical presentation, laboratory tests, arterial blood gas analysis (ABG), death and acute respiratory distress syndrome (ARDS) rates. Age, hypertension, diabetes, chronic obstructive pulmonary disease, dyspnea, body temperature, quickSOFA Score, elevated C-reactive protein (CRP), creatinine, urea, DELTA A-a O2, respiratory rate and FiO2 were associated with death and ARDS. Elevated Glasgow Coma Scale, diastolic blood pressure, oxygen peripheral saturation, P/F and pH were associated with patient survival and protective from ARDS. After the intervention in Medicina district, patients presenting at ED were younger and with long-lasting symptoms;CRP values were significantly lower, ABG and respiratory clinical parameters were less severely impaired. These differences did not affect the outcome. CONCLUSION(S): Since the results of our study are consistent with worldwide evidences, we suggest that the early insight of a small local SARS-CoV-2 outbreak can be representative and predictive of the subsequent course of the virus in wider areas. This must be kept in mind to manage next epidemic waves.Copyright © 2022 EDIZIONI MINERVA MEDICA.

Glial fibrillary acidic protein astrocytopathy in a patient with recent mRNA SARS-CoV-2 vaccination: COVERSHEET

Background: Literature describing triggers of GFAP astrocytopathy (GFAP-A) is limited. We report a case of GFAP-A in a patient with recent messenger ribonucleic acid (mRNA) severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) vaccination and discuss the possible pathogenesis. Case description: A 45-year-old gentleman presented with features of meningoencephalitis 31 days after the first dose and 4 days after the second dose of mRNA SARS-CoV-2 vaccination. He sequentially developed brainstem/cerebellar, autonomic and cord dysfunction. Cerebrospinal fluid was positive for GFAP autoantibody. Clinical improvement occurred after intravenous methylprednisolone and immunoglobulins. Conclusion(s): Although we are uncertain of a causal link of GFAP-A to mRNA vaccine, indirect activation of an underlying dysregulated immune milieu is plausible.Copyright © 2021 The Author(s)

4C Mortality Score and high-flow nasal oxygen therapy outcome in COVID-19

Background: High-flow nasal oxygen therapy (HFNO) is an established treatment for acute hypoxemic respiratory failure due to COVID-19. However, sometimes this treatment fails to prevent the need for invasive ventilation or evade death. A proposed tool to predict in-hospital mortality in patients with COVID-19 is the 4C Mortality score. Aim(s): To assess the factors related to HFNO failure in patients admitted to ICU for COVID-19. Method(s): In a retrospective analysis of 118 patients treated with HFNO after the failure of conventional oxygen therapy, HFNO failure was defined as either death or the need for invasive or non-invasive ventilation. In all patients, routine blood gases and biochemical blood analyses were performed. The 4C Mortality Score was recorded at admission, taking into account age, sex, number of comorbidities, initial respiratory rate and oxygen saturation, Glasgow coma scale, and levels of urea and C-reactive protein. Result(s): The mean age of the cohort was 59.5+/-1.2 years and mean BMI 32.5+/-6.1 kg/m2;73 (62%) patients were men. In 43 patients (36%), HFNO treatment failed. Patients in whom HFNO failed were older (62.7+/-12.6 vs 57.7+/-13.1 years, P=0.043), had lower PaO2/FiO2 index before HFNO initiation 83.1+/-29.9 vs 114.2+/-62.3, P=0.003), lower ROX index after 48 hours of HFNO treatment (5.7+/-2.4 vs 8.6+/-3.3, P<0.001), and higher 4C Mortality Score (11.1+/-3.2 vs 9.5+/-3.6, P=0.017). One point increase of the 4C score increased 1.15-times the risk of HFNO failure (95%CI: 1.02-1.28, P=0.02). Conclusion(s): A complex mortality predictor used in hospitalised COVID-19 patients was associated with HFNO failure besides the baseline severity of the respiratory failure.

Long-term outcome of patients with vaccine-induced immune thrombotic thrombocytopenia and cerebral venous sinus thrombosis

Introduction In early 2021, unanticipated thromboses, including cerebral venous sinus thrombosis (CVST) with thrombocytopenia, emerged as an adverse reaction (ADR) in patients who had been vaccinated with the AstraZeneca ChAdOx1 nCoV-19 vaccine. This ADR was termed vaccine-induced immune thrombotic thrombocytopenia (VITT) or thrombosis with thrombocytopenia syndrome (TTS). Although sporadic in nature, VITT can result in severe disease in the individual vaccinee. We followed up on the outcomes and status of neurological recovery of 49 cases of VITT with CVST that were reported to PEI. Method Assessment of the Extended Glasgow Outcome Scale (GOS-E) was performed within 3-6 months after the initial hospital admissions. Individual Glasgow Coma Scale (GCS) scores were reported by phone or electronically via a questionnaire or medical report by the treating physician of the hospital to which the patient was initially admitted. If a GCS score was not reported, an expert determined a score based on the patient's medical report. For most patients, follow-up was pursued about 3-6 months after hospital admission. The reported outcomes describe the patients' neurological status at 5-38 weeks (mean 20 weeks) after hospital admission. Outcomes were identified in 44 of the original 49 cases. Results Patient outcomes ranged from good recovery (13 patients, 29.6 %) to moderate disability (11 patients, 25.0 %) and severe disability or vegetative state (6 patients, 13.6 %). Fatal outcomes were reported in 14 patients (31.8 %). As anticipated, initial low GCS scores were associated with poor outcomes. By contrast, GCS scores > 10 were typically associated with improved neurological outcomes. Moreover, platelet count nadirs were correlated with patient outcomes. Low platelet counts were observed in fatal cases (GOS-E 1) with a mean count of 17,000 platelets/muL). Likewise, patients with better neurological outcomes (GOS-E scores of 5-6 and 7-8) presented with mean counts of 61,000 thrombocytes/muL. However, the course of the disease was not always predictable and showed significant individual variability. Conclusion We provide data on the outcome of VITT cases with CVST upon vaccination with the AstraZeneca adenoviral vector ChAdOx1 nCoV-19 COVID- 19 vaccine and found that the recovery of patients from CVST was very heterogeneous. While some patients exhibited good recoveries, others developed severe disabilities and major long-term complications. Collectively, our findings highlight the importance of paying attention to early signs of increased intracranial pressure and the onset of thrombocytopenia in patients with a recent history of vaccination with the AstraZeneca adenoviral vector ChAdOx1 nCoV-19 COVID-19 vaccine.

Applicability of the ROX index in decision-making for hospitalization in COVID-19 patients: ROX index in the outpatient COVID-19 cases

Aim: Data on the outpatient follow-up of COVID-19 cases is still scarce. Also, the significance of the ROX index in decision-making for hospitalization in the ambulatory COVID-19 cases remains unknown. The aim of this study is to determine the general characteristics of COVID-19 patients treated as outpatients and to investigate whether the ROX index is applicable in hospitalization decisions. Material(s) and Method(s): This retrospective cohort study was conducted in confirmed adult COVID-19 cases between 15 October 2020 and 01 March 2021. A total of 5240 confirmed COVID-19 patients were included in the present study. Factors affecting hospitalization were investigated. Result(s): The study population was divided into two groups as those who require hospitalization (n=672) and those who did not (n=4568). The number of male patients and the mean age of the patients were significantly higher in hospitalized patients group (p=0.046, p<0.001). ROX index that was calculated at the home visit on the third day of disease was found significantly lower in the group of hospitalized patients (p<0.001). There was a significant correlation between ROX index and inflammatory biomarkers in the present study (p<0.001). The ROX index was found the most accurate parameter for decision-making for hospitalization in ambulatory COVID-19 patients (AUC=0.794 CI=0.773-0.814, p<0.001). Discussion(s): The ROX index can be a useful and objective clinical tool for decision making for hospitalization in the ambulatory COVID-19 cases.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Neuroanesthesia practice during COVID-19: A single-center experience

The coronavirus disease 2019 (COVID-19) pandemic is a challenge for all health care providers (HCPs). Anesthesiologists are vulnerable to acquiring the disease during aerosol-generating procedures in operating theater and intensive care units. High index of suspicion, detailed history including travel history, strict hand hygiene, use of face masks, and appropriate personal protective equipment are some ways to minimize the risk of exposure to disease. Neurologic manifestations of COVID-19, modification of anesthesia regimen based on the procedure performed, and HCP safety are some implications relevant to a neuroanesthesiologist. National and international guidelines, recommendations, and position statements help in risk stratification, prioritization, and scheduling of neurosurgery and neurointervention procedures. Institutional protocols can be formulated based on the guidelines wherein each HCP has a definite role in this ever-changing scenario. Mental and physical well-being of HCPs is an integral part of successful management of patients. We present our experience in managing 143 patients during the lockdown period in India.Copyright © 2020 Wolters Kluwer Medknow Publications. All rights reserved.

The predictive role of Troponin I levels for mortality in geriatric patients transferred to the intensive care unit for COVID-19 pneumonia

Aim: Troponin I is an important prognostic marker in critically ill patients with COVID-19, similar to cytokines and other inflammatory mediators. The aim of this study was to evaluate the predictive value of troponin I levels for mortality in geriatric patients transferred to the intensive care unit for COVID-19 pneumonia according to age group. Material(s) and Method(s): Seventy-four patients with COVID-19 pneumonia were grouped according to age (Group 1:65-74 years, Group 2: 75-84 years, and Group 3: >= 85 years) and retrospectively analyzed. Demographics, clinical findings, laboratory results upon admission to the intensive care unit, and outcomes were compared among the groups. Predictive value of troponin I levels upon admission to intensive care unit (Troponin Iicu), difference in troponin levels between general wards and intensive care unit (Troponin Idiff), C-reactive protein, ferritin, lactate dehydrogenase, neutrophil-to-lymphocyte ratio, procalcitonin, and D-dimer levels for mortality were also investigated. Result(s): The mortality rate was 74.3% for the patients overall, and increased, albeit insignificantly, with increasing age. Neither Troponin Iicu nor Troponin Idiff was predictive for mortality for any of the age groups or for the patients overall. Ferritin, lactate dehydrogenase, neutrophil-to-lymphocyte ratio, and C-reactive protein levels were predictive for mortality for patients overall (p= 0.016, p= 0.001, p= 0.013, and p < 0.001, respectively). Discussion(s): For geriatric patients, troponin I levels at the time of the first admission to the ICU are not sufficient to predict mortality alone and should be evaluated together with other parameters.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Nasopharyngeal Myiasis in Intensive Care Unit (ICU) Patients: Report of Two Cases

Nosocomial myiasis is a rare event that has a higher incidence in the hospitals of poor and developing countries. The presence of nosocomial myiasis reflects the need for improved medical facilities and increased awareness among healthcare personnel. Severely ill patients are more susceptible, such as those with impaired consciousness, paralysis, and underlying diseases. The two cases here in described represent the first report of nosocomial myiasis in the Kurdistan Province, in Western Iran and one of them is the first report of myiasis involving a COVID-19-infected patient. The causal agent was Lucilia sericata. The taxonomical identification of the larvae of the second and third instar was based on the morphology of the cephaloskeleton, anterior spiracles, and peri-treme plaques.Copyright © 2023 Zobairy et al.

Comparison of scoring systems' mortality prediction ability in COVID-19 intensive care patients over 80 years of age

Aim: In this study, we aimed tto compare the 30-day mortality prediction abilities of the acute physiology and chronic health evaluation II (APACHE II), CURB-65, pneumonia severity index (PSI), A-DROP, Infectious Diseases Society of America/American Thoracic Society severity criteria, and I-ROAD scores in patients aged over 80 years admitted to the intensive care unit with COVID-19 pneumonia. Material(s) and Method(s): The study was conducted with a single-center retrospective observational design and included patients aged 80 years and older who were admitted to the intensive care unit due to COVID-19 pneumonia between March 2020 and August 2021. Patient demographic data, imaging findings, blood test results, discharge status, length of stay in the intensive care unit, duration of mechanical ventilation, inotropic drug administration status, presence/ absence of mortality and vital signs at the time of admission were obtained from the hospital automation system. Then, the above-mentioned scores were calculated and compared statistically. Result(s): The study was completed with 119 patients, 60 (50.4%) women and 59 (49.6%) men. The mean age of all patients was 84 (80-98) years, and the mortality rate was 84.03% (n=100). Among the scoring systems, I-ROAD had the highest area under the curve (AUC) value (0.703), APACHE II had the highest specificity (94%), and A-DROP had the highest sensitivity (64%). Discussion(s): According to our results, the I-ROAD scoring system is an effective tool that can be used in the prediction of mortality related to COVID-19 pneumonia among intensive care patients aged >=80.Copyright © 2023, Derman Medical Publishing. All rights reserved.

Acute Disseminated Encephalomyelitis Post COVID-19 Pneumonia.

Acute disseminated encephalomyelitis (ADEM) is a monophasic condition characterized by inflammation of the central nervous system. Besides multiple sclerosis, optic neuropathy, acute transverse myelitis, and neuromyelitis optica spectrum disorder, ADEM is a primary inflammatory demyelinating disorder of the central nervous system. It is estimated that approximately three-quarters of cases of encephalomyelitis occur after an infection or immunization, where the onset of neurological disease is coincident with a febrile event. Here, we report an 80-year-old woman with coronavirus disease pneumonia who developed sudden onset of decreased level of consciousness, focal seizure, and right-side weakness. Magnetic resonance imaging (MRI) of the brain showed a multifocal hemorrhagic lesion with surrounding edema, suggesting ADEM. An electroencephalogram (EEG) revealed moderate generalized encephalopathy. The patient received alternating pulse steroids with plasma exchange for five days. Subsequently, her Glasgow coma scale score continued to decrease, and thus, she required inotropic support until she expired.

Free floating aorto-iliac thrombosis: A rare complication of COVID-19 pneumonia

Arterial thrombosis encountered during sars-cov2 infections is a rare complication with a poor prognosis compared to venous ones. They generally occur in severe and critical clinical forms of covid19 [1,2]. The physiopathology of arterial thrombosis, even if not completely understood highlights hypercoagulability and excessive inflammation as risk factors with a major role of the endothelial lesions in their occurrence. The presence of cardiovascular risk factors in patients infected with covid19 is also discussed as a predisposing factor for arterial thrombosis [2,3]. We report the case of a North African male patient hospitalized for acute respiratory distress syndrome (ARDS) secondary to covid19 pneumonia, complicated by the occurrence of multiple arterial thrombosis of the aorto-iliac axis with the rare finding of two free floating thrombus in the aorta and the right common iliac artery. Clinically, the patient had developed acute bilateral lower limb ischemia and multi-organ failure and the evolution was dramatic with rapid worsening of the patient…s health and eventually his death. Thromboembolic complications are frequent during covid19 infection but the aortic localization is very rare. Its diagnosis is difficult and it has a poor prognosis. Our objective through this case report is to increase knowledge about arterial thromboembolic events while discussing their link to the sars-cov2 viral infection. © 2022

Massive empyema due to Lactococcus garvieae

Introduction Lactococcus garvieae, a zoonotic pathogen, may rarely infect humans through the consumption of fish. Documented manifestations of L. garvieae infection in humans include infective endocarditis, prosthetic joint infections, liver abscesses, peritoneal dialysis-associated peritonitis, osteomyelitis, meningitis, infective spondylodiscitis, acalculous cholecystitis, and urinary tract infection. Case report An 87-year-old female was hospitalized for coffee-ground emesis secondary to acute gastritis after eating cooked fish. One week after her discharge, she developed new-onset confusion and was returned to the hospital. Chest computed tomography revealed total consolidation of the left lung and a multiloculated left pleural effusion. The patient required intubation and direct admission to the intensive care unit. Pleural fluid and blood cultures grew L. garvieae, which was susceptible to ceftriaxone, penicillin, and vancomycin. Despite intensive antibiotic therapy and supportive care for thirteen days, the patient remained in irreversibl e shock, and the family opted for comfort care. Conclusions Heretofore unreported, this case demonstrates that L. garvieae can cause bronchopneumonia and empyema. Copyright © GERMS 2022.

Incorporating age improves the Glasgow Coma Scale score for predicting mortality from traumatic brain injury.

BACKGROUND: The Glasgow Coma Scale (GCS) score has been adapted into categories of severity (mild, moderate, and severe) and are ubiquitous in the trauma setting. This study sought to revise the GCS categories to account for an interaction by age and to determine the discrimination of the revised categories compared with the standard GCS categories. METHODS: The American College of Surgeons National Trauma Data Bank registry was used to identify patients with traumatic brain injury (TBI; ICD-9 codes 850-854.19) who were admitted to participating trauma centers from 2010 to 2015. The primary exposure variables were GCS score and age, categorized by decade (teens, 20s, 30s…, 80s). In-hospital mortality was the primary outcome for examining TBI severity/prognostication. Logistic regression was used to calculate the conditional probability of death by age decade and GCS in a development dataset (75% of patients). These probabilities were used to create a points-based revision of the GCS, categorized as low (mild), moderate, and high (severe). Performance of the revised versus standard GCS categories was compared in the validation dataset using area under the receiver operating characteristic (AUC) curves. RESULTS: The final population included 539,032 patients with TBI. Age modified the performance of the GCS, resulting in a novel categorization schema for each age decile. For patients in their 50s, performance of the revised GCS categories mirrored the standard GCS categorization (3-8, 9-12, 13-15); all other revised GCS categories were heavily modified by age. Model validation demonstrated the revised GCS categories statistically significantly outperformed the standard GCS categories at predicting mortality (AUC: 0.800 vs 0.755, p<0.001). The revised GCS categorization also outperformed the standard GCS categories for mortality within pre-specified subpopulations: blunt mechanism, isolated TBI, falls, non-transferred patients. DISCUSSION: We propose the revised age-adjusted GCS categories will improve severity assessment and provide a more uniform early prognostic indicator of mortality following traumatic brain injury. LEVEL OF EVIDENCE: III epidemiologic/prognostic.