OBJECTIVES

Clinical pathways (CPs) ensure adherence to heart failure (HF) management guidelines. To optimize quality care in a low resource setting, an evidence-based care pathway for the management of acute HF was implemented at the emergency department (ED) of the Philippine General Hospital (PGH), the designated national tertiary hospital and referral center. This study aimed to describe the characteristics of adults with acute HF admitted at the ED and evaluate the quality of care they received, measured using physician adherence to the hospital’s acute heart failure CP.

METHODS

This was a retrospective, descriptive cohort study. We reviewed the inpatient charts of all adult patients with acute HF admitted to the ED of the PGH and referred to the Division of Cardiovascular Medicine between December 1, 2022 and May 31, 2023. Quality of care was assessed based on adherence to quality indicators adapted from routine and conditional order sets detailed in the pathway. Descriptive statistics was utilized to describe patient characteristics, quality of care, and outcomes.

RESULTS

Two hundred thirty-six (236) patients were included, with a mean age of 51.8 years. Majority were male (53.4%); hypertension (61.4%) and ischemic heart disease (53.8%) were the most common comorbidities, and infection the most common precipitant of decompensation (60.6%). There were optimal adherence rates to routine orders, which included referrals to Internal Medicine and Cardiology, baseline vital signs monitoring, fluid intake and output monitoring, chest radiograph, complete blood count, blood urea nitrogen, sodium, potassium, prothrombin time, partial thromboplastin time, arterial blood gas, urinalysis, and N-terminal pro b-type natriuretic peptide. Conditional orders, such as oxygen support, focused echocardiography, thyroid - stimulating hormone, and the use of vasopressors, diuretics, and venous thromboembolism prophylactic agents, were optimally performed when warranted. However, we noted suboptimal adherence to certain resource-intensive conditional orders, such as hourly monitoring of urine output (61.4%), hooking to cardiac monitor (53.8%), and performance of 12-lead ECG within 10 minutes (56.8%). Further, only 43.9% of patients were referred to the intensive care unit. Troponin I, calcium, magnesium, and albumin were ordered in excess.

CONCLUSION

Overall adherence rate of physicians to the hospital’s Acute Heart Failure Pathway was satisfactory. Work is needed to improve adherence to hourly urine output monitoring, consistent hooking to cardiac monitor, and timely performance of 12-lead ECG – an effort that begins with expanding in-hospital diagnostic equipment and human resource supply. We recommend continuous pathway implementation with periodic evaluation and stakeholder feedback to further improve quality of care.

Human ; Male ; Female ; Middle Aged: 45-64 Yrs Old ; Adult ; Albumins ; Blood ; Blood Urea Nitrogen ; Calcium ; Cardiology ; Chart ; Charts ; Cohort Studies ; Critical Care ; Critical Pathways ; Diagnostic Equipment ; Disease ; Diuretics ; Echocardiography ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Equipment And Supplies ; Evaluation Studies As Topic ; Feedback ; Heart ; Heart Diseases ; Heart Failure ; Hormones ; Hospitals ; Hospitals, General ; Humans ; Hypertension ; Indicators And Reagents ; Infection ; Infections ; Inpatients ; Intensive Care Units ; Internal Medicine ; Lead ; Magnesium ; Male ; Medicine ; Myocardial Ischemia ; Natriuretic Peptide, Brain ; Natriuretic Peptides ; Nitrogen ; Overall ; Oxygen ; Partial Thromboplastin Time ; Patients ; Peptides ; Philippines ; Physicians ; Potassium ; Prothrombin ; Prothrombin Time ; Quality Of Health Care ; Referral And Consultation ; Sodium ; Statistics ; Tertiary Care Centers ; Thorax ; Thromboembolism ; Thromboplastin ; Thyroid Gland ; Time ; Troponin ; Troponin I ; Universities ; Urea ; Urinalysis ; Urine ; Venous Thromboembolism ; Vital Signs ; Work ; Workforce

OBJECTIVE: This study summarizes and compares clinical and laboratory characteristics of 34 patients admitted to the intensive care unit (ICU) for complications from coronavirus disease 2019 (COVID-19) at the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China from Jan. 22 to Mar. 5, 2020. METHODS: A total of 34 patients were divided into two groups, including those who required noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) with additional extracorporeal membrane oxygenation (ECMO) in 11 patients. Clinical features of COVID-19 patients were described and the parameters of clinical characteristics between the two groups were compared. RESULTS: The rates of the acute cardiac and kidney complications were higher in IMV cases than those in NIV cases. Most patients had lymphocytopenia on admission, with lymphocyte levels dropping progressively on the following days, and the more severe lymphopenia developed in the IMV group. In both groups, T lymphocyte counts were below typical lower limit norms compared to B lymphocytes. On admission, both groups had higher than expected amounts of plasma interleukin-6 (IL-6), which over time declined more in NIV patients. The prothrombin time was increased and the levels of platelet, hemoglobin, blood urea nitrogen (BUN), D-dimer, lactate dehydrogenase (LDH), and IL-6 were higher in IMV cases compared with NIV cases during hospitalization. CONCLUSIONS Data showed that the rates of complications, dynamics of lymphocytopenia, and changes in levels of platelet, hemoglobin, BUN, D-dimer, LDH and IL-6, and prothrombin time in these ICU patients were significantly different between IMV and NIV cases.
Acute Kidney Injury ; virology ; Aged ; Aged, 80 and over ; Betacoronavirus ; Blood Urea Nitrogen ; China ; Coronavirus Infections ; complications ; therapy ; Extracorporeal Membrane Oxygenation ; Female ; Fibrin Fibrinogen Degradation Products ; analysis ; Heart Diseases ; virology ; Hemoglobins ; analysis ; Hospitalization ; Humans ; Intensive Care Units ; Interleukin-6 ; blood ; L-Lactate Dehydrogenase ; blood ; Lymphopenia ; virology ; Male ; Middle Aged ; Noninvasive Ventilation ; Pandemics ; Pneumonia, Viral ; complications ; therapy ; Positive-Pressure Respiration ; Prothrombin Time ; Retrospective Studies

blood glucose, blood urea nitrogen, hematocrit, and hemoglobin), and enzyme-linked immunosorbent assay kits (calcium, magnesium, creatinine, aspartate aminotransferase, alanine aminotransferase, bilirubin, and albumin). Similar trends were found for the parameters of biochemistries, electrolytes, and blood gas, and they revealed no significant changes after blood withdrawal-induced hemorrhagic shock. However, the TBS group showed more effective ability to correct metabolic acidosis than the NS and RS groups. TBS was a feasible and safe resuscitation solution in this study and may be an alternative to NS and RS for resuscitation in hemorrhagic shock patients without liver damage.]]>
Acidosis ; Alanine Transaminase ; Animals ; Aspartate Aminotransferases ; Bilirubin ; Blood Glucose ; Blood Urea Nitrogen ; Carbon Dioxide ; Creatinine ; Electrolytes ; Enzyme-Linked Immunosorbent Assay ; Hematocrit ; Hemodynamics ; Humans ; Hydrogen-Ion Concentration ; Liver ; Magnesium ; Male ; Oxygen ; Potassium ; Rats ; Resuscitation ; Shock, Hemorrhagic ; Sodium

OBJECTIVE: To study the clinical effect and complications of continuous blood purification (CBP) in the treatment of multiple organ dysfunction syndrome (MODS) in neonates. METHODS: A retrospective analysis was performed for the clinical data of 21 neonates with MODS who were admitted to the neonatal intensive care unit from November 2015 to April 2019 and were treated with CBP. Clinical indices were observed before treatment, at 6, 12, 24, and 36 hours of CBP treatment, and at the end of treatment to evaluate the clinical effect and safety of CBP treatment. RESULTS: Among the 21 neonates with MODS undergoing CBP, 17 (81%) had response to treatment. The neonates with response to CBP treatment had a significant improvement in oxygenation index at 6 hours of treatment, a significant increase in urine volume at 24 hours of treatment, a stable blood pressure within the normal range at 24 hours of treatment, and significant reductions in the doses of the vasoactive agents epinephrine and dopamine at 6 hours of treatment (P<0.05), as well as a significant reduction in serum K+ level at 6 hours of treatment, a significant improvement in blood pH at 12 hours of treatment, and significant reductions in blood lactic acid, blood creatinine, and blood urea nitrogen at 12 hours of treatment (P<0.05). Among the 21 neonates during CBP treatment, 6 experienced thrombocytopenia, 1 had membrane occlusion, and 1 experienced bleeding, and no hypothermia, hypotension, or infection was observed. CONCLUSIONS CBP is a safe, feasible, and effective method for the treatment of MODS in neonates, with few complications.
Blood Gas Analysis ; Blood Urea Nitrogen ; Hemofiltration ; Humans ; Infant, Newborn ; Multiple Organ Failure ; Retrospective Studies

OBJECTIVE: Unperforated and perforated acute appendicitis need to be differentiated because appendicitis with a free perforation requires an emergency operation to prevent contamination inside the bowel from spreading into the peritoneal cavity. The sensitivity of imaging tests is not reliable enough alone for determining the existence of a perforation. The aim of this study was to determine the differences in laboratory values between unperforated and perforated acute appendicitis to help distinguish perforated acute appendicitis. METHODS: The laboratory values and demographic data of a total of 175 patients who visited the emergency room and were diagnosed with acute appendicitis were collected. The time elapsed from symptom presentation to the ER visit, length of admission, patient demographics, and laboratory values, including sex, age, leukocyte count, neutrophil %, neutrophil count, C-reactive protein (CRP), platelet count, prothrombin time (PT), activated partial thromboplastin time, international normalized ratio (INR), serum glucose, blood urea nitrogen, creatinine, total and direct bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma-glutamyltransferase were analyzed. RESULTS: The factors associated with appendix perforations were an elevated leukocyte count, neutrophil count, neutrophil %, CRP, serum glucose and total bilirubin; and delayed PT and INR. CONCLUSION: Acute appendicitis patients without definite imaging evidence of the perforation but with the laboratory values suggesting a perforation, such as elevated leukocyte count, neutrophil count, neutrophil %, CRP, serum glucose, and total bilirubin; and delayed PT, and INR should raise concern for a possible undiscovered perforation.
Abdomen, Acute ; Alanine Transaminase ; Alkaline Phosphatase ; Appendicitis ; Appendix ; Aspartate Aminotransferases ; Bilirubin ; Blood Glucose ; Blood Urea Nitrogen ; C-Reactive Protein ; Creatinine ; Demography ; Diagnosis, Differential ; Emergencies ; Emergency Service, Hospital ; gamma-Glutamyltransferase ; Humans ; International Normalized Ratio ; Leukocyte Count ; Neutrophils ; Partial Thromboplastin Time ; Patient Admission ; Peritoneal Cavity ; Platelet Count ; Prothrombin Time

BACKGROUND: Compared to the general population, patients with end-stage renal disease have more gastrointestinal symptoms and a higher prevalence of peptic ulcer. Risk factors for peptic ulcer disease in patients with end-stage renal disease, however, remain poorly defined. This study aims to better identify those risk factors. METHODS: We analyzed 577 patients with end-stage renal disease from 2004 to 2016. We excluded patients with life-threatening conditions. All patients underwent upper endoscopy. We analyzed patient medical records, medication history, and endoscopic findings. Independent sample t test, chi-square test, Fisher’s exact test, and multiple logistic regression analysis were used in statistical analyses. RESULTS: Of the 577 patients with end-stage renal disease, 174 had peptic ulcer disease (gastric or duodenal ulcer). Patients on hemodialysis had a higher prevalence of peptic ulcer disease than those on peritoneal dialysis. Patients with peptic ulcer disease had lower serum albumin level and higher blood urea nitrogen level than those without peptic ulcer disease. Positive scores on two or more nutritional indices (albumin, serum cholesterol, uric acid, and creatinine levels) were associated with peptic ulcer disease in end-stage renal disease. CONCLUSION: Hemodialysis, hypoalbuminemia, and multiple malnutrition indices were associated with the prevalence of peptic ulcer disease in patients with end-stage renal disease receiving dialysis.
Blood Urea Nitrogen ; Cholesterol ; Creatinine ; Dialysis ; Endoscopy ; Humans ; Hypoalbuminemia ; Kidney Failure, Chronic ; Logistic Models ; Malnutrition ; Medical Records ; Nutrition Assessment ; Peptic Ulcer ; Peritoneal Dialysis ; Prevalence ; Renal Dialysis ; Risk Factors ; Serum Albumin ; Uric Acid

Autophagy is a fundamental cellular process that maintains homeostasis and cell integrity, under stress conditions. Although the involvement of autophagy in various conditions has been elucidated, the role of autophagy in renal structure is not completely clarified. Our aim was to investigate the cytoprotective effect of autophagy against acute kidney injury (AKI) through cisplatin deteriorative pathway, which leads to AKI via renal cell degradation. For in vivo experiments, male Sprague Dawley rats were divided in to 2 groups (n = 6/group) as control, Cis-5D. Following a single intraperitoneal injection of cisplatin, rats were sacrificed after 5 days. Blood urea nitrogen (BUN), creatinine (Cr) and histological alterations were examined. Further, expression of key regulators of autophagy, light-clain 3 (LC3), p62, and Beclin1, was evaluated by immunohistochemistry (IHC). The rats exhibited severe renal dysfunction, indicated by elevated BUN, Cr. Hematoxylin and eosin staining revealed histological damages in cisplatin-treated rats. Furthermore, IHC analysis revealed increased expression of LC3, Beclin1 and decreased expression of p62. Furthermore, expression of aforementioned autophagy markers was restricted to proximal tubule. Taken together, our study demonstrated that cisplatin can cause nephrotoxicity and lead to AKI. This phenomenon accelerated autophagy in renal proximal tubules and guards against AKI.
Acute Kidney Injury ; Animals ; Autophagy ; Blood Urea Nitrogen ; Cisplatin ; Creatinine ; Eosine Yellowish-(YS) ; Hematoxylin ; Homeostasis ; Humans ; Immunohistochemistry ; Injections, Intraperitoneal ; Male ; Rats ; Rats, Sprague-Dawley

OBJECTIVE: The purpose of this study was to determine the effect of quercetin on the antitumor activity of cisplatin and its side-effects. METHODS: EMT6 cells, a mouse breast cancer cell line, were injected subcutaneously in mice to generate a breast tumor-bearing mouse model. Experimental groups were divided into four groups: control (C), quercetin (Q), cisplatin (CP), and cisplatin+quercetin (CP+Q). RESULTS: The tumor volume of the CP+Q group was significantly lower than that of the CP group. Serum blood urea nitrogen and creatinine levels in the CP+Q group were lower than those in the CP group. Renal γ-glutamyltranspeptidase and alkaline phosphatase activities were significantly higher in the CP+Q group than in the CP group, and the content of renal thiobarbituric acid reactive substance was significantly lower in the CP+Q group than that in the CP group. These results suggested that quercetin and cisplatin synergistically increased cellular toxicity in breast cancer cells and mediated cancer growth inhibition, thereby enhancing the antitumor effect of cisplatin compared to when only cisplatin was administered. Quercetin also reduced renal toxicity, which arose as a potential a side effect of cisplatin. CONCLUSION: The enhanced antitumor effect of cisplatin and decreased renal toxicity after quercetin treatment suggested the applicability of quercetin as an adjuvant for chemotherapeutic agents.
Alkaline Phosphatase ; Animals ; Blood Urea Nitrogen ; Breast Neoplasms ; Breast ; Cell Line ; Cisplatin ; Creatinine ; Mice ; Quercetin ; Tumor Burden

BACKGROUND: Despite major progress in stem cell therapy, our knowledge of the characteristics and tissue regeneration potency of long-term transported cells is insufficient. In a previous in vitro study, we established the optimal cell transport conditions for amniotic fluid stem cells (AFSCs). In the present study, the target tissue regeneration of long-term transported cells was validated in vivo. METHODS: For renal regeneration, transported AFSCs were seeded on a poly(lactide-co-glycolide) scaffold and implanted in a partially resected kidney. The target tissue regeneration of the transported cells was compared with that of freshly harvested cells in terms of morphological reconstruction, histological microstructure reformation, immune cell infiltration, presence of induced cells, migration into remote organs, expression of inflammation/fibrosis/renal differentiation-related factors, and functional recovery. RESULTS: The kidney implanted with transported cells showed recovery of total kidney volume, regeneration of glomerular/renal tubules, low CD4/CD8 infiltration, and no occurrence of cancer during 40 weeks of observation. The AFSCs gradually disappeared and did not migrate into the liver, lung, or spleen. We observed low expression levels of proinflammatory cytokines and fibrotic factors; enhanced expression of the genes Wnt4, Pax2, Wt1, and Emx2; and significantly reduced blood urea nitrogen and creatinine values. There were no statistical differences between the performance of freshly harvested cells and that of the transported cells. CONCLUSION: This study demonstrates that long-term transported cells under optimized conditions can be used for cell therapy without adverse effects on stem cell characteristics, in vivo safety, and tissue regeneration potency.
Amniotic Fluid ; Blood Urea Nitrogen ; Cell- and Tissue-Based Therapy ; Creatinine ; Cytokines ; Female ; In Vitro Techniques ; Kidney ; Liver ; Lung ; Polyglactin 910 ; Regeneration ; Spleen ; Stem Cells

PURPOSE: This study compared and analyzed the risk factors that affect a wound healing group and healing failure group. MATERIALS AND METHODS: From 2010 to 2018, 39 patients who had suffered a single toe amputation were evaluated retrospectively. The patients were divided into two groups (wound healing group and healing failure group - within at least 3 months following the amputation). Regarding the possible risk factors, age, gender, Wagner and Brodsky classifications, duration of diabetes mellitus, whether the patient had peripheral arterial occlusive disease (PAOD) or cardiovascular disease, body mass index, HbA1c, total cholesterol, estimated glomerular filtration rate (eGFR), blood urea nitrogen (BUN), smoking, and alcohol were investigated. RESULTS: The mean duration of diabetes mellitus was 140 months in the healing group and 227 months in the healing failure group, and the duration of diabetes was significantly longer in the failure group (p=0.009). A significant difference in eGFR was observed between the two groups (59.17 mL/min/1.73 m2 in the healing group and 31.1 mL/min/1.73 m2 in the failure group) (p=0.022). Sixteen patients with PAOD were found, all 10 patients in the healing failure group were PAOD patients. CONCLUSION: To reduce the additional complications in single toe amputation patients, the underlying disease and appropriate treatment are the most important factors. In addition, a more proximal level of amputation also should be considered in cases of patients with PAOD, high BUN and low eGFR, and patients with long-term diabetes.
Amputation ; Arterial Occlusive Diseases ; Blood Urea Nitrogen ; Body Mass Index ; Cardiovascular Diseases ; Cholesterol ; Classification ; Diabetes Mellitus ; Glomerular Filtration Rate ; Humans ; Retrospective Studies ; Risk Factors ; Smoke ; Smoking ; Toes ; Wound Healing ; Wounds and Injuries