Comparison of Outcomes among Chronic Kidney Disease V Patients with COVID-19 at the National Kidney and Transplant Institute: A Retrospective Cohort Study

Background. There is very little published data on outcomes of COVID-19 among chronic kidney disease (CKD) patients. We compared the outcomes of COVID-19 in a tertiary care renal hospital among CKD V patients on hemodialysis (HD), peritoneal dialysis (PD), and dialysis initiation, in terms of duration of hospitalization, in-patient mortality, and 30-day mortality. Methods. A total of 436 CKD V patients, on either HD, PD, or dialysis initiation, with COVID-19 who were admitted at the National Kidney and Transplant Institute (NKTI) from March 13, 2020, to August 31, 2020, were included. Kaplan–Meier survival analysis was performed. Comparison of probability of mortality by group was performed using Log-Rank test. p values ≤0.05 were considered statistically significant. Results. Among 436 CKD V patients, 298 (68%) were on HD, 103 (24%) were on PD, and 35 (8%) required dialysis initiation. Overall in-hospital mortality was 34%; 38% were on HD, 20% on PD, and 37% on dialysis initiation. Total 30-day mortality was 27%; 32% were on HD, 26% on PD, and 16% on dialysis initiation. Median follow-up was 24 days. Among the 137 deaths recorded, total median time to death was 10 days; 8.5 days, 15.5 days, and 9 days for HD, PD, and dialysis initiation groups, respectively. Probability of mortality was significantly higher in HD patients versus PD patients ( p < 0.00001 ) and in the dialysis initiation group compared to PD patients ( p = 0.0234 ). Mortality probability, however, was not significantly different in HD patients versus the dialysis initiation group ( p = 0.63 ). Conclusion. Among CKD V patients diagnosed with COVID-19 at the NKTI, those on HD and on dialysis initiation had significantly higher in-hospital and 30-day mortality, compared to patients on PD.

Time to death among HIV-infected under-five children after initiation of anti-retroviral therapy and its predictors in Oromiya liyu zone, Amhara region, Ethiopia: a retrospective cohort study

Background Human Immunodeficiency Virus (HIV) is infection which mainly attacks immune system of an individual. Its disease progress is rapid in children and if treatment is not initiated nearly half of infected children will die by the second year of infection. In Ethiopia, nearly twenty four percent of HIV related death is happen to under-five children; however studies done in this specific age group are limited are with poor evidence of predictors. Objectives To determine time to death and identify predictors of death in HIV infected under- five children on antiretroviral therapy in Amhara regional state, Oromia ‘liyu’ zone, Northeast Ethiopia, from 2014 to 2019. Methods Institution based retrospective follow up study was conducted in 376 under-five HIV- infected children on antiretroviral therapy from January 2014 to December 2019 in health institutions in Oromia Liyu Zone, Amhara region, Ethiopia. Multivariable Cox-proportional hazard regression model was used to identify independent predictors of mortality in HIV- infected under-five children on antiretroviral therapy. Result At the end of follow up, 304 (80.85%) of HIV-infected children were alive, 39 (10.95%) were lost to follow up, 12 (3.19%) were transferred out and 21 (5.59%) were reported dead due to HIV/AIDS. The cumulative survival probabilities of children after 3, 6, 12, 24 and 36 months were 0.99, 0.98, 0.97, 0.89 and 0.87 respectively. The overall mean time to death was 19.7 months (95%CI = 18.74–20.67) with incidence of 5.9 deaths per 100 child-months (95%CI: 3.89–9.09). Children with severe malnutrition at baseline (AHR = 4.9; 95 CI: 1.04, 23.50), advanced WHO clinical stage at enrolment (AHR = 3.9; CI: 1.37, 10.88), poor adherence to ART (AHR = 6.56; CI: 3.33, 10.14) and with no history of Isoniazide prophylaxis were significantly associated to higher mortality events (AHR = 3.6; CI: 1.24, 10.18). Conclusion Death of HIV-infected under-five children on ART is high within the first one year after enrolment. The risk of death increased if the child was malnourished at beginning of treatment, had poor ART adherence, with advanced WHO clinical stages and lack of Isoniazide prophylaxis during their age of infancy.

Natural history of nonhuman primates after conjunctival exposure to Ebola virus

Transmission of Ebola virus (EBOV) primarily occurs via contact exposure of mucosal surfaces with infected body fluids. Historically, nonhuman primate (NHP) challenge studies have employed intramuscular or small particle aerosol exposure, which are uniformly lethal routes of infection, but mimic worst-case scenarios such as a needlestick. When exposed by more likely routes of natural infection, limited NHP studies have shown delayed onset of disease and reduced mortality. Here we performed a series of systematic natural history studies in cynomolgus macaques with a range of conjunctival exposure doses. Challenge with 10,000 plaque forming units (PFU) of EBOV was uniformly lethal, whereas 5/6 subjects survived low and moderate dose challenges (100 or 500 PFU). Conjunctival challenge resulted in a protracted time-to death. Asymptomatic disease was observed in survivors with limited detection of EBOV replication. Inconsistent seropositivity in survivors may suggest physical or natural immunological barriers are sufficient to prevent widespread viral dissemination.

Chasing a rarity: a retrospective single-center evaluation of prognostic factors in primary gliosarcoma

Background and purpose Primary gliosarcoma (GS) is a rare variant of IDH-wildtype glioblastoma multiforme. We performed a single-center analysis to identify prognostic factors. Patients and methods We analyzed the records of 26 patients newly diagnosed with primary WHO grade IV GS. Factors of interest were clinical and treatment data, as well as molecular markers, time to recurrence, and time to death. Results Median follow-up was 9 months (range 5–21 months). Gross total resection did not lead to improved survival, most likely due to the relatively small sample size. Low symptom burden at the time of diagnosis was associated with longer PFS (P = 0.023) and OS (P = 0.018). Median OS in the entire cohort was 12 months. Neither MGMT promoter hypermethylation nor adjuvant temozolomide therapy influenced survival, consistent with some previous reports. Conclusion In this retrospective study, patients exhibiting low symptom burden at diagnosis showed improved survival. None of the other factors analyzed were associated with an altered outcome.

Attributable Mortality for Pediatric and Neonatal Central Line-Associated Bloodstream Infections in Greece

Central line-associated bloodstream infections (CLABSIs) are the most frequent pediatric hospital-acquired infections and significantly impact outcomes. The aim of this study was to estimate the attributable mortality for CLABSIs in pediatric and neonatal patients in Greece. A retrospective matched-cohort study was performed, in two tertiary pediatric hospitals. Inpatients with a central line in neonatal and pediatric intensive care units (NICUs and PICUs), hematology/oncology units, and a bone marrow transplantation unit between June 2012 and June 2015 were eligible. Patients with confirmed CLABSI were enrolled on the day of the event and were matched (1:1) to non-CLABSI patients by hospital, hospitalization unit, and length of stay prior to study enrollment (188 children enrolled, 94 CLABSIs). Attributable mortality was estimated. During the study period, 22 CLABSIs and nine non-CLABSIs died (23.4 vs. 9.6%, respectively, p = 0.011), leading to an attributable mortality of 13.8% (95% confidence interval [CI] = 3.4–24.3%). Children in PICUs were more likely to die, presenting an attributable mortality of 20.2% (95% CI = − 1.4–41.8%), without reaching, however, statistical significance. After multiple logistic regression, CLABSIs were four times more likely to die (odds ratio [OR] = 4.29, 95% CI = 1.28–14.36, p = 0.018). Survival analysis showed no difference in time to death after study enrollment between CLABSIs and non-CLABSIs (log-rank p = 0.137, overall median survival time = 7.8 months). Greek pediatric mortality rates are increased by the CLABSI occurrence, highlighting the importance of infection prevention strategies.

Day-To-Day Home Blood Pressure Variability and All-Cause Mortality in a Memory Clinic Population

Background: High day-to-day blood pressure variability (BPV) has been associated with an increased risk for cognitive decline and mortality in the general population. Whether BPV is associated with increased all-cause mortality in older people with cognitive impairment is unknown. Objective: To investigate the association between day-to-day home BPV and all-cause mortality in older patients attending a memory clinic. Methods: We included 279 patients attending a memory clinic, who measured home blood pressure (BP) for 7 consecutive days in the morning and evening. Within-subject BPV was defined as the variation independent of the mean (VIM). Time-to-death was verified through the Dutch population registry. Cox proportional hazard regression was used. Separate analyses were performed for morning-to-morning and evening-to-evening BPV. Results: Mean age was 73±9 years, dementia and mild cognitive impairment were diagnosed in 35% and 34% respectively, and mean home BP was 139/79 mmHg. After a mean follow-up of 3.2 years, 52 patients had died. Neither day-to-day systolic nor diastolic VIM were associated with mortality (adjusted hazard ratio [HR] systolic VIM: 0.99, 95% -CI 0.92–1.06, p = 0.770, HR diastolic VIM: 1.04, 95% -CI 0.93–1.17, p = 0.517). When morning and evening measurements were analyzed separately, systolic morning-to-morning VIM was associated with mortality (adjusted HR: 1.09, 95% -CI 1.01–1.18, p = 0.033). Conclusion: In this study, day-to-day BPV was not associated with all-cause mortality in patients attending a memory clinic. However, morning-to-morning BPV was. Due to the short assessment window, there is still a lack of clarity; hence future research is warranted to clarify the role of all BPV components in aging.

Clinical and Physiologic Factors Associated With Mode of Death in Pediatric Severe TBI

Aims and Objectives: Severe traumatic brain injury (sTBI) is the leading cause of death in children. Our aim was to determine the mode of death for children who died with sTBI in a Pediatric Critical Care Unit (PCCU) and evaluate factors associated with mortality.Methods: We performed a retrospective cohort study of all severely injured trauma patients (Injury Severity Score ≥ 12) with sTBI (Glasgow Coma Scale [GCS] ≤ 8 and Maximum Abbreviated Injury Scale ≥ 4) admitted to a Canadian PCCU (2000–2016). We analyzed mode of death, clinical factors, interventions, lab values within 24 h of admission (early) and pre-death (48 h prior to death), and reviewed meeting notes in patients who died in the PCCU.Results: Of 195 included patients with sTBI, 55 (28%) died in the PCCU. Of these, 31 (56%) had a physiologic death (neurologic determination of death or cardiac arrest), while 24 (44%) had withdrawal of life-sustaining therapies (WLST). Median (IQR) times to death were 35.2 (11.8, 86.4) hours in the physiologic group and 79.5 (17.6, 231.3) hours in the WLST group (p = 0.08). The physiologic group had higher partial thromboplastin time (PTT) within 24 h of admission (p = 0.04) and lower albumin prior to death (p = 0.04).Conclusions: Almost half of sTBI deaths in the PCCU were by WLST. There was a trend toward a longer time to death in these patients. We found few early and late (pre-death) factors associated with mode of death, namely higher PTT and lower albumin.

Acute oral toxicity of zinc phosphide: an assessment for wild house mice in Australia

BACKGROUND: The efficacy of zinc phosphide (ZnP) for broadacre control of wild house mice in Australia is being reported by growers as increasingly variable. Have mice become less sensitive over time or are they taking a sub-lethal dose and developing aversion? In this laboratory study the sensitivity of groups of wild caught and an outbred laboratory strain of mice was assessed using oral gavage of a range of ZnP concentrations. The willingness of mice to consume ZnP-coated grains was then determined. RESULTS: Each mouse group had very similar LD50 values (72 to 79 mg ZnP per kg body weight) which are significantly higher than previously reported. Time to death post-gavage ranged between 2.5 to 48 h. ZnP coated grains (50 mg ZnP per kg grain) presented in the absence of alternative food were consumed and 94 percent of wild mice died. Mice provided with alternative food and ZnP coated wheat grains (either 25 or 50 mg ZnP per kg grain) consumed toxic and non-toxic grains, and mortality was lower (33 to 55 percent). If a sublethal amount of ZnP coated grain was consumed, aversion occurred mostly in the presence of alternative food. CONCLUSIONS: The sensitivity of wild house mice to ZnP in Australia is significantly lower than previously assumed. Under laboratory conditions ZnP coated grains coated with a new higher dose (50 mg ZnP per kg grain) were readily consumed. Consumption of toxic grain occurred when alternative food was available but was decreased. It is important to assess the efficacy of the higher ZnP dose per grain under natural field conditions, especially when background food is low.

Factors Influencing Potentially Futile Treatments at the End of Life in a Multiethnic Asian Cardiology Setting: A Qualitative Study

Background. Modern medicine enables clinicians to save lives and prolong time to death, yet some treatments have little chance of conferring meaningful benefits for patients nearing the end-of-life. What clinicians perceive as driving futile treatment in the non-Western healthcare context is poorly understood. Aim. This study aimed to explore clinicians’ perceptions of the factors that influence futile treatment at the end of life within a tertiary hospital cardiac care setting. Design. We conducted semi-structured interviews with cardiologists, cardiac surgeons, and palliative care doctors from a large national cardiology center in Singapore. Interviews were transcribed verbatim and thematically analyzed. Results. A total of 32 clinicians were interviewed. We identified factors that contributed to the provision of potentially futile treatment in these theme areas: patient- and family-related, clinician-related, and institutional and societal factors. Family roles and cultural influences were most commonly cited by participants as affecting end-of-life decisions and altering the likelihood of futile treatment. Specialty-specific alignments within cardiology and availability of healthcare resources were also important factors underpinning futile treatment. Conclusion. Family-related factors were a primary driver for futile treatment in a non-Western, multicultural setting. Future interventions should consider a targeted approach accounting for cultural and contextual factors to prevent and reduce futile treatment.

Trends in length of stay for Neonatal Intensive Care Unit patients who die before hospital discharge

Objectives: To establish days between birth and death for neonates over a 14-year period, to determine if days between birth and death has changed over time across gestational age (GA) cohorts, and identify diagnoses which may put infants at high risk of prolonged hospitalization leading to death. Study Design: This was a single-site, retrospective chart review of inborn infants who died prior to hospital discharge. Results: 239 patients born between 1/1/2006 and 12/31/2020 met inclusion criteria. Days until death ranged from 0-300 with a median of 6 days (IQR= 23). Median days until death increased over time, with a statistically significant increase between epoch 1 and epoch 2 (p = 0.016) but not between epoch 2 and epoch 3 (p = 0.618). Extremely premature infants died earlier than more mature infants (p < 0.001). In addition, infants who died as a result of complex congenital heart disease or a gastrointestinal (GI) catastrophe died later (p < 0.001 and p < 0.001, respectively) than newborns without cardiac or GI issues. Conclusions: Our findings demonstrate an increase in time to death for newborns who did not survive to hospital discharge over a 14-year period. This trend suggests that the dynamics informing Meadows’ assertion that ‘doomed infants die early’ may be shifting, with some seriously ill infants who die before hospital discharge surviving longer than previously described. More research is needed to understand how best to care for babies who will not survive to discharge and to explore when supports such as palliative care consultation may be beneficial.