Clinical role of intrarenal venous flow patterns in decompensated heart failure with worsening renal function.

Introduction: The clinical implication of intrarenal venous flow patterns in decompensated heart failure with worsening renal function is unknown. We aimed to study the relationship between intrarenal venous flow patterns, inferior vena cava volume status, caval index, clinical degree of congestion and the renal outcome in patients with decompensated heart failure and worsening renal function. Secondary objectives were to study the combined endpoint of readmission and mortality rate within 30 days (after the last scan) among intrarenal venous flow patterns and the effect of congestion status on the renal outcome. Methods: Twenty-three patients admitted for decompensated heart failure (ejection fraction ⩽40%) with worsening renal function (absolute increase in serum creatinine of 26.5 µmol/L or ⩾1.5-fold increment from baseline) were enrolled in this study. A total of 64 scans were performed. Patients were visited on day 0, 2, 4 and 7 (or earlier if discharged). Patients were called 30 days after discharge to evaluate readmission or mortality. Intrarenal venous flow patterns were ranked from continuous, interrupted, biphasic, to monophasic. Clinical congestion was scored from 0 to 7. Results: Intrarenal venous flow patterns had statistically significant positive correlations with inferior vena cava volume status (Spearman's ρ, 0.51; p < 0.01) and congestion score (ρ, 0.65; p < 0.01) and a significant negative correlation with caval index (ρ, -0.53; p < 0.01). Intrarenal venous flow patterns were not significant in predicting estimated glomerular filtration rate improvement or the combined endpoint. Reduced congestion significantly predicted an estimated glomerular filtration rate improvement on the following scan day (p = 0.04, odds ratio = 4.3, 95% confidence interval = 1.1-17.2). Conclusion: Although intrarenal venous flow patterns correlate with other congestive parameters, clinical congestion status rather than intrarenal venous flow patterns predicted the renal outcome.

Reduction of central-line-associated bloodstream infection (CLABSI) in resource limited, nonintensive care unit (ICU) settings.

PURPOSE: There was limited study available on successful intervention for central-line-associated bloodstream infection (CLABSI) done at nonintensive care unit (ICU) and resources-limited setting. The objective of this study was to design, implement and evaluate a strategy to reduce CLABSI rate in non-ICU settings at general medical wards of Hospital Tuanku Ja'afar Seremban. DESIGN/METHODOLOGY/APPROACH: Preinterventional study was conducted in one-month period of January 2019, followed by intervention period from February to March 2019. Postintervention study was conducted from April to July 2019. The CLABSI rates were compared between pre and postintervention periods. A multifaceted intervention bundle was implemented, which comprised (1) educational program for healthcare workers, (2) weekly audit and feedback and (3) implementation of central line bundle of care. FINDINGS: There was a significant overall reduction of CLABSI rate between preintervention and postintervention period [incidence rate ratio (IRR) of 0.06 (95 percent CI, 0.01-0.33; P = 0.001)]. PRACTICAL IMPLICATIONS: CLABSI rates were reduced by a multifaceted intervention bundle, even in non-ICU and resource-limited setting. This includes a preinterventional study to identify the risk factors followed by a local adaption of the recommended care bundles. This study recommends resources-limited hospitals to design a strategy that is suitable for their own local setting to reduce CLABSI. ORIGINALITY/VALUE: This study demonstrated the feasibility of a multifaceted intervention bundle that was locally adapted with an evidence-based approach to reduce CLABSI rate in non-ICU and resource-limited setting.

Neurological deterioration and its risk score in total anterior circulation infarct.

OBJECTIVES: Specific factors and its predictive parameters for neurological deterioration in total anterior circulation infarct (TACI) were not known. Our objective was to determine the risk factors and risk scores for neurological deterioration in TACI. The secondary objective was to determine the effect of antiplatelet therapy in TACI. PATIENTS AND METHODS: This was a single-center cohort study. 46 patients with TACI were enrolled and followed up for 30 days, discharged, or death; whichever earlier. The National Institutes of Health Stroke Scale (NIHSS) was performed daily by investigators who are NIHSS certified and radiological findings were confirmed by a certified radiologist. Neurological deterioration was defined by a drop in NIHSS by 2 points or Glasgow Coma Scale (GCS) by 1 point. Clinical, laboratory and radiological variables were evaluated. Significant predictive variables were given a score based on its co-efficient values in multivariate analysis. RESULTS: Lower Alberta stroke program early CT score (ASPECTS) and higher numbers of early computed tomography (CT) sign of middle cerebral artery (MCA) infarct were significant risk factor for neurological deterioration with p < 0.001 (OR: 3.41, 95% CI 1.78-6.51) and p < 0.001 (OR 18.19, 95% CI 3.82-86.55) respectively. A score of 1 assigned for 3 early CT signs of MCA infarct, 2 for 4 early CT signs of MCA infarct, and 1 for ASPECTS < 6. Receiver operating characteristic (ROC) showed a total score of 2 predicted neurological deterioration in TACI (Area under the curve 0.953, with sensitivity and specificity of 78.9% and 93% respectively). CONCLUSION: A simple 2 variables risk score formula was significant in predicting neurological deterioration. Antiplatelet may be recommended for TACI, further study is required.

Diagnostic accuracy of pneumonia in Hospital Tuanku Ja’afar Seremban, a tertiary hospital

@#Objectives: The primary objective of this study was to describe the accuracy of pneumonia diagnosis, both community-acquired pneumonia (CAP) and hospitalacquired pneumonia (HAP). Secondary objectives were describing the choice of antibiotics used, pathogens isolated, and predictive parameters in diagnosing pneumonia. Methods: This was a prospective cross-sectional study to determine the accuracy of the diagnosis of CAP and HAP admitted to Hospital Tuanku Ja’afar. All patients aged ≥12 years admitted to the general medical ward with the diagnosis of CAP or HAP were included in the study. Chest radiograph interpretation was done by certified radiologists. An accurate diagnosis of pneumonia was defined by clinical signs and symptoms of pneumonia supported by radiographical evidence. Results: A total of 159 patients were enrolled into the study from January 2018 to February 2018. Of these only 59(37.1%) cases were accurately diagnosed as pneumonia. Amongst those with pneumonia diagnosis made by the emergency department, medical officers and specialists of medical department; 65.4%, 60% and 47.3% respectively were not pneumonia. Amoxicillin with clavulanate and azithromycin were amongst the most common first choice of antibiotic used (46.5%). In this study, pathogens were isolated either by blood culture or sputum culture in only 20 (12.6%) patients. There was no significant predictive parameter identified in this study, which included white cell counts, Creactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), and Pao2/FiO2 ratio. Conclusion: About two-thirds of patients diagnosed with pneumonia did not have a compatible radiological finding. Better tools and systems are needed to aid in the diagnosis of pneumonia