An insidious presentation of thrombotic thrombocytopenic purpura: A case report and brief literature review

Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy with an estimated incidence of 11 cases/million population per year. Early treatment is essential and is curative in this disease where lack of treatment results in 90% mortality. We describe an atypical case of a patient with TTP who presented to the Emergency Department for headache, and was found to have thrombocytopenia but only mild anemia that was explained by another disease process. Case: A 44-year-old female presented to the Emergency Department for worsening headache and weakness over the last week. She had no fever and no focal neurological deficits but was pale and complained of severe headache. A blood test showed her to be anemic and thrombocytopenic. She explained that she had been having prolonged heavy menses over the last year. She was treated with blood and platelet transfusions, and seen by the Gynecology service who treated her for uterine fibroids after which she was discharged. She returned 1 week later with the same complaint, and was found to have a stable hemoglobin level but recurrence of thrombocytopenia. A TTP diagnosis was entertained and the workup confirmed it. The patient was treated with plasmapheresis and discharged home with no sequalae. Conclusion: Emergency physicians should keep TTP in mind when approaching cases of thrombocytopenia with mild anemia, even if an alternative diagnosis exists

Autosomal dominant polycystic kidney disease and minimal trauma: medical review and case report

Abstract Background Blunt abdominal trauma in the setting of polycystic kidney disease is still scantly described in the literature and management guidelines of such patients are not well-established. Case presentation The authors herein present a case of hypovolemic shock secondary to segmental renal artery bleed in a 75-year-old man with polycystic kidney disease after minimal blunt abdominal trauma, who underwent successful selective arterial embolization, and provide a thorough review of similar cases in the literature, while shedding the light on important considerations when dealing with such patients. Conclusions It is important to suspect renal injury in patients with pre-existing renal lesions irrespective of the mechanism of injury; and, vice-versa to suspect an underlying abnormality in patients with a clinical deterioration that’s out of proportion to the mechanism of injury

Mitral valve velocity time integral and passive leg raise as a measure of volume responsiveness

Abstract Background Fluid responsiveness is an important topic for clinicians. Aggressive hydration has been shown to lead to worse outcomes. The aim of this study was to investigate the sensitivity and specificity of mitral valve (MV) velocity time integral (VTI) as a non-invasive marker of volume responsiveness. Methods This was a prospective observational study conducted in a tertiary emergency department. End-stage renal disease patients presenting to the emergency department requiring emergent hemodialysis were enrolled. A focused echocardiogram was done on enrolled patients. Two sets of measurements were obtained before and after hemodialysis. During each scanning session, the left ventricular outflow tract and the mitral valve VTI were obtained before and after a passive leg raise maneuver. Results 54 patients were enrolled, of which, 30 (55%) were male. The mean age was 47.4 years. The mean volume of fluid removed was 3.89 ± 0.91 L. All patients had a diagnosis of hypertension, 22 (41%) patients were diabetic, 14 (26%) patients had coronary artery disease, and 19 (35%) patients had congestive heart failure. The mean change in LVOT VTI was 1.83% (95% CI 0.12–3.55) in the pre-dialysis group and 15.05% (95% CI 12.76–17.34) in the post-hemodialysis cohort. The mean change in MV VTI was 3.74% (95% CI 2.84–4.65) in the pre-dialysis cohort and 12.95% (95% CI 11.50–14.39) in the post-dialysis cohort. For patients who had  4 L removed, the mean delta LVOT VTI was 16.84% (95% CI 13.47–20.22) and the mean MV VTI was 14.77% (95% CI 13.03–16.51). Mitral valve VTI with PLR was found to have a sensitivity of 89.18% and a specificity of 94.11% in detecting volume responsiveness. Conclusion Mitral valve velocity time integral in conjunction with passive leg raise seem to correlate with volume responsiveness in hemodialysis patients

Sepsis in hemodialysis patients.

BACKGROUND: Bacterial infections are very common in End Stage Renal Disease (ESRD) patients. The diagnosis of sepsis in such patients is often challenging and requires a high index of suspicion. The aim of this study is to report on a series of patient with ESRD on hemodialysis (HD) diagnosed with sepsis. METHODS: Single center retrospective study looking at ESRD on HD who presented to our tertiary hospital were retrieved. Inclusion criteria included a discharge diagnosis of sepsis, septic shock or bacteremia. RESULTS: Our sample was composed of 41 females and 49 males, with a mean age of 70 ± 15 years. Infections from the HD catheters followed by lower respiratory tract infections were the most common cause of bacteremia. IV fluid replacement for the first 6 and 24 h were 0.58 and 1.27 l respectively. Vasopressors were used in 30 patients with norepinephrine, dopamine and dobutamine used in 22, nine and one patients respectively. Out of 90 subjects, 24 (26.6 %) were dead within the same hospital visit. the 28 days out of hospital mortality was 25.6 %. There was no significant difference in mortality in patients who presented with less than two SIRS or two or more SIRS criteria. CONCLUSION: This is the first study looking at an in depth analysis of sepsis in the specific dialysis population and examining the influence of fluid resuscitation, role of SIRS criteria and vasopressor use on their mortality

Sepsis in patients with haematological versus solid cancer: a retrospective cohort study

Objectives This study aims to examine the outcome of haematological and patients with solid cancer presenting with sepsis to the emergency department (ED).Design Single-centred, retrospective cohort study. Setting conducted at an academic emergency department of a tertiary hospital.Participants All patients >18 years of age admitted with sepsis were included.Interventions Patients were stratified into two groups: haematological and solid malignancy.Primary and secondary outcome The primary outcome of the study was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) mortality, ICU and hospital lengths of stay and mechanical ventilation duration.Results 442 sepsis cancer patients were included in the study, of which 305 patients (69%) had solid tumours and 137 patients (31%) had a haematological malignancy. The mean age at presentation was 67.92 (±13.32) and 55.37 (±20.85) (p<0.001) for solid and liquid tumours, respectively. Among patients with solid malignancies, lung cancer was the most common source (15.6%). As for the laboratory workup, septic solid cancer patients were found to have a higher white blood count (12 576.90 vs 9137.23; p=0.026). During their hospital stay, a total of 158 (51.8%) patients with a solid malignancy died compared with 57 (41.6%) patients with a haematological malignancy (p=0.047). There was no statistically significant association between cancer type and hospital mortality (OR 1.15 for liquid cancer p 0.58). There was also no statistically significant difference regarding intravenous fluid administration, vasopressor use, steroid use or intubation.Conclusion Solid tumour patients with sepsis or septic shock are at the same risk of mortality as patients with haematological tumours. However, haematological malignancy patients admitted with sepsis or septic shock have higher rates of bacteraemia

Serum lactate is an independent predictor of hospital mortality in critically ill patients in the emergency department: a retrospective study

Abstract Background Elevated lactate has been found to be associated with a higher mortality in a diverse patient population. The aim of the study is to investigate if initial serum lactate level is independently associated with hospital mortality for critically ill patients presenting to the Emergency Department. Methods Single-center, retrospective study at a tertiary care hospital looking at patients who presented to the Emergency Department (ED) between 2014 and 2016. A total of 450 patients were included in the study. Patients were stratified to lactate levels: 4 mmol/L. The primary outcome was in-hospital mortality. Secondary outcomes included 72-h hospital mortality, ED and hospital lengths of stay. Results The mean age was 64.87 ± 18.08 years in the 4 mmol/L group. All 3 groups were comparable in terms of age, gender and comorbidities except for diabetes, with the 2-4 mmol/L and >4 mmol/L groups having a higher proportion of diabetic patients. The mean lactate level was 1.42 ± 0.38 (4 mmol/L). In-hospital mortality was found to be 4 (2.7%), 18(12%) and 61(40.7%) patients in the low, intermediate and high lactate groups respectively. ED and hospital length of stay were longer for the >4 mmol/L group as compared to the other groups. While adjusting for all variables, patients with intermediate and high lactate had 7.13 (CI 95% 2.22–22.87 p = 0.001) and 29.48 (CI 95% 9.75–89.07 p = <0.001) greater odds of in-hospital mortality respectively. Discussion Our results showed that for all patients presenting to the ED, a rising lactate value is associated with a higher mortality. This pattern was similar regardless of patients’ age, presence of infection or blood pressure at presentation. Conclusion Higher lactate values are associated with higher hospital mortalities and longer ED and hospital lengths of stays. Initial ED lactate is a useful test to risk-stratify critically ill patients presenting to the ED

Data_heart_failure

Raw data of the systolic heart failure and sepsi

Propuesta de implementación de sistema de costos abc para los procesos de captación de clientes y prestación de servicios y su efecto en la rentabilidad de la empresa Inicia, Fútbol y Valores Asociación Civil, Lima 2017

Trabajo de Suficiencia ProfesionalEl presente proyecto está orientado a proporcionar información relevante sobre la elaboración e implementación de un sistema de costos ABC en los procesos de captación de clientes y prestación de servicios en la empresa Inicia, Fútbol y Valores Asociación Civil. El sistema de costos ABC, es una herramienta muy útil para la determinación y el control de los costos de una empresa y la gestión de ellos, debido a que proporciona información importante sobre el costo de cada proceso y actividad de la misma, contribuyendo en la toma de decisiones, reducir costos y en muchos casos mejora la prestación de servicios, permitiendo generar valor y mejorar la rentabilidad, generando el éxito desde una pequeña bodega en nuestra comunidad, hasta una multinacional

Data from: Outcomes of systolic heart failure patients presenting with sepsis to the emergency department of a tertiary hospital: a retrospective chart review study from Lebanon

Objectives: Congestive heart failure (CHF) patients may be at a higher risk of mortality from sepsis than patients without CHF due to insufficient cardiovascular reserves during systemic infections. . The aim of this study is to compare sepsis-related mortality between CHF and non-CHF patients in patients presenting to a tertiary medical center. Design: A single centre, retrospective, cohort study. Setting: Conducted in an academic ED between January 2010 and January 2015. Patients’ charts were queried via the hospital’s electronic system. Patients with a diagnosis of sepsis were included. Descriptive analysis was performed on the demographics, characteristics, and outcomes of septic patients of the study population. Participants: A total of 174 patients, of which 87 (50%) were CHF patients. Primary and secondary outcomes: The primary outcome of the study was in-hospital mortality. Secondary outcomes included intensive care unit (ICU), and hospital lengths of stay, and differences in interventions between the two groups. Results: CHF patients had a higher in-hospital mortality (57.5% vs 34.5%). Septic CHF patients had higher odds of death as compared to the control population (OR, 2.45; 95% CI, 1.22-4.88). Secondary analyses showed that CHF patients had lower instances of bacteremia upon presentation to the ED (31.8% vs 46.4%). They had less IV fluid requirements in first 24 hours (2.75 ± 2.28 L vs 3.67 ± 2.82 L, p-value=0.038), had a higher rate of intubation in the ED (24.2% vs 10.6%, p-value=0.025) and required more dobutamine in the first 24 hours (16.1% vs 1.1%, p-value<0.001). Emergency department length of stay was found to be lower in CHF patients (15.12 ± 24.45 hours vs 18.17 ± 26.13 hours, p-value=0.418) and they were more likely to be admitted to the ICU (59.8% vs 48.8%, p-value=0.149). Conclusion: Septic patients with CHF experienced an increased hospital mortality compared to patients without CHF