Clinical characteristics and mortality risk factors in enterococcal bloodstream infections: a 9-year retrospective cohort study in Japan.

42. Are telemedicine cardiac clearance visits safe prior to lumbar fusion?

Comparison of clinical outcomes and risk factors in polymicrobial versus monomicrobial enterococcal bloodstream infections

Introduction: The incidence of device infection is constantly increasing; requiring transvenous lead extraction (TLE). Data regarding predictors of short and long-term mortality after TLE for infection are limited. Methods: We collected data regarding 30-day and 1-year mortality of patients undergoing TLE at a university hospital between April 2004 and June 2015. Patients with less than 30-day follow up were excluded. Results: Out of total 1223 TLE procedures, 700 were performed for infectious indications. 30-day follow-up was available for 620 patients (88.6%) and 1-year follow up was available for 541 patients (77.3%). Overall 30-day mortality was 9% (4.3% for pocket infection, 12.3% for systemic infection) and 1-year mortality was 27.5% (16% for pocket infection, 35.8% for systemic infection). Patient age, end-stage renal disease, history of valve replacement, atrial fibrillation, Staphylococcus aureus infection, systemic infection, any procedural complication, elevated WBC count, low hemoglobin, need for CCU admission, need for pressor support, acute kidney injury, cardiogenic shock and need for blood transfusion were predictors of both 30-day and 1-year mortality in univariate analysis. Any retained fragment was predictor of 30-day mortality. Peripheral vascular disease and low platelet count were predictors of 1-year mortality. Patient age, history of valve replacement, need for pressor support and low hemoglobin were independent predictors of 30-day as well as 1-year mortality in multivariate analysis. End-stage renal disease, atrial fibrillation, elevated WBC count and need for CCU admission were independent predictors of 30-day mortality. Systemic infection, low platelet count and need for blood transfusion were predictors of 1-year mortality. Strongest predictor of 30-day mortality was history of valve replacement (Odds ratio 4.23) and strongest predictor of 1-year mortality was need for pressor support (Odds ratio 3.12). Conclusions: In conclusion, 30-day and 1-year mortality after device infection remains high despite successful TLE. Patient age, history of valve replacement, need for pressor support and low hemoglobin are independent predictors of both short and long-term mortality in multivariate analysis.

BackgroundFulminant myocarditis (FM) is a critical disease with high early mortality. Low triiodothyronine syndrome (LT3S) was a strong predictor of poor prognosis of critical diseases. This study investigated whether LT3S was associated with 30-day mortality in FM patients.MethodsNinety-six FM patients were divided into LT3S (n=39, 40%) and normal free triiodothyronine (FT3) (n=57, 60%) groups based on serum FT3 level. Univariable and multivariable logistic regression analyses were performed to identify independent predictors of 30-day mortality. Kaplan–Meier curve was used to compare 30-day mortality between two groups. Receiver operating characteristic (ROC) curve and decision curve analysis (DCA) were used to assess the value of FT3 level for 30-day mortality prediction.ResultsCompared to normal FT3 group, LT3S group had higher incidence of ventricular arrhythmias, worse hemodynamics, worse cardiac function, more severe kidney impairment, and higher 30-day mortality (48.7% vs. 12.3%, P<0.001). In univariable analysis, LT3S (odds ratio [OR]:6.786, 95% confidence interval [CI]:2.472-18.629, P<0.001) and serum FT3 (OR:0.272, 95%CI:0.139-0.532, P<0.001) were significant strong predictors of 30-day mortality. After adjustment for confounders in multivariable analysis, LT3S (OR:3.409, 95%CI:1.019-11.413, P=0.047) and serum FT3 (OR:0.408, 95%CI:0.199-0.837, P=0.014) remained independent 30-day mortality predictors. The area under the ROC curve of FT3 level was 0.774 (cut-off: 3.58, sensitivity: 88.46%, specificity: 62.86%). In DCA, FT3 level showed good clinical-application value for 30-day mortality prediction.ConclusionIn FM patients, LT3S could independently predict 30-day mortality. FT3 level was a strong 30-day mortality predictor and a potentially useful risk-stratification biomarker.

Although patients receiving extracorporeal life support (ECLS) as a bridge to transplantation have demonstrated worse outcomes than those without ECLS, we investigated the key factors in the improvement of their posttransplant outcome. From December 2003 to December 2018, 257 adult patients who underwent heart transplantation (HTx) at our institution were included. We identified 100 patients (38.9%) who underwent HTx during ECLS (ECLS group). The primary outcome was 30-day mortality after HTx. The median duration of ECLS was 10.0 days. The 30-day mortality rate was 3.9% (9.2% in peripheral ECLS, 2.9% in central ECLS, and 1.9% in non-ECLS). The use of ECLS was not an independent predictor of 30-day and 1-year mortality (p = 0.248 and p = 0.882, respectively). Independent predictors of 30-day mortality were found to be higher ejection fraction (p < 0.001), Sequential Organ Failure Assessment score (p < 0.001), and total bilirubin level (p = 0.005). In a subgroup analysis, cannulation type was not a predictor of 30-day mortality (p = 0.275). Early ECLS application to prevent organ failure and sophisticated management of acute heart failure may be important steps in achieving favorable survival after HTx.

Meta-Analysis of Predictors of All-Cause Mortality After Transcatheter Aortic Valve Implantation

Background:Enterococcus faecium bloodstream infections (EF-BSI) cause significant morbidity and mortality in solid organ transplant (SOT) recipients, with the role of vancomycin resistance (VR) remaining controversial as an independent driver. Methods: This was a retrospective cohort study including SOT recipients with EF-BSI at our institution from 2019 to 2023. We used Cox proportional hazards regression to identify predictors of 30-day all-cause mortality. A time-dependent covariate was used to model the effects of receiving targeted, effective antibiotic therapy. Results: A total of 79 patients were included (26.6%, with VR). The overall 30-day mortality was 12.7% (10/79). In univariable analysis, septic shock (Hazard Ratio, HR: 17.1, 95% CI: 3.64-80.8, p < 0.001), the need for Continuous Venovenous Hemofiltration (HR: 6.40, 95% CI: 1.85-22.1, p = 0.003), and a Pitt Bacteremia Score ≥ 2 (HR: 5.17, 95%CI: 1.10-24.3, p = 0.038) were associated with increased mortality, while source control was protective (HR: 0.20, 95% CI: 0.05-0.76, p = 0.018). In the final multivariable model, only septic shock remained an independent predictor of 30-day mortality (HR: 11.4, 95% CI: 1.63-79.5, p = 0.014). VR was not significantly associated with mortality, though the confidence interval was wide and included clinically meaningful effects (HR: 2.07, 95% CI: 0.40-10.6, p = 0.4). Conclusions: In SOT recipients with EF-BSI, 30-day mortality is overwhelmingly driven by the host's physiological response, manifested as septic shock, rather than the VR profile of the pathogen. The early recognition of severe sepsis/septic shock and the aggressive implementation of supportive care and source control measures in this setting are crucial.

268 Study of 30 Days Mortality in a Contemporary Population Of Elderly Patients Undergoing Primary Percutaneous Intervention in Acute ST Elevation MI

The most commonly used parameter of right ventricular (RV) systolic function - tricuspid annular plane systolic excursion (TAPSE) - is unavailable for some patients. Subcostal echocardiographic assessment of tricuspid annular kick (SEATAK) has been proposed as its alternative. The study aimed to assess the feasibility of SEATAK use in patients with acute pulmonary embolism (PE) and its value in prognosis after PE. The observational study included 164 consecutive patients (45.7% men; average age, 70 years) with a high clinical probability of PE referred for computed tomography pulmonary angiography. SEATAK was unavailable due to inadequate quality of echocardiogram in 2.8% of patients, whereas TAPSE could not be calculated in 4.9%, both parameters were not estimated only in 0.6%. SEATAK and TAPSE values did not differ between groups of patients with PE (n = 82) and without (n = 82). In the whole study, SEATAK correlated positively with TAPSE (r = 0.71; 95% confidence interval [CI], 0.62-0.78; P < 0.001), fractional area change of the RV, left ventricular ejection fraction, and peak systolic tricuspid annular velocity assessed with tissue Doppler imaging. There were only 3 echocardiographic predictors of 30-day all-cause mortality in patients with with PE (n = 10): SEATAK, pulmonary acceleration time, and the 60/60 sign. SEATAK predicted 30-day all-cause mortality with AUC (area under the curve) 0.726 (95% CI, 0.594-0.858; P = 0.01) and 30-day PE-related mortality (n = 4) with AUC, 0.772 (95% CI, 0.506-0.998; P = 0.03). SEATAK is a promising practicable echocardiographic parameter reflecting RV systolic function and might be an accurate alternative to TAPSE. Moreover, SEATAK could be an independent predictor of all-cause and PE-related 30-day mortality in patients with acute PE.

Background: Ventricular assist devices (VADs) are increasingly common, and their surgical implantation predisposes patients to an increased risk of acute kidney injury (AKI). We sought to evaluate the incidence, risk factors and short- and long-term all-cause mortality of patients with AKI following VAD implantation. Methods: We identified all patients who underwent VAD implantation at the University of Chicago between January 1, 2008, and January 31, 2012. We evaluated the incidence of AKI, defined as a ≥50% increase in serum creatinine over the first 7 postoperative days (RIFLE Risk-Creatinine). A logistic regression model was used to identify risk factors for the development of AKI, and a Cox proportional hazards model was used to examine factors associated with 30-day and 365-day all-cause mortality. Results: A total of 157 eligible patients had VAD implantations with 44 (28%) developing postimplantation AKI. In a multivariate analysis, only diabetes mellitus [odds ratio = 2.25 (1.03-4.94), p = 0.04] was identified as a significant predictor of postoperative AKI. Using a multivariable model censored for heart transplantation, only AKI [hazard ratio, HR = 3.01 (1.15-7.92), p = 0.03] and cardiopulmonary bypass time [HR = 1.01 (1.001-1.02), p = 0.02] were independent predictors of 30-day mortality. Preoperative body mass index [HR = 0.95 (0.90-0.99), p = 0.03], preoperative diabetes mellitus [HR = 1.89 (1.07-3.35), p = 0.03] and postimplantation AKI [HR = 1.85 (1.06-3.21), p = 0.03] independently predicted 365-day mortality. Conclusion: AKI is common following VAD implantation and is an independent predictor of 30-day and 1-year all-cause mortality.

Background: Community acquired pneumonia (CAP) is an important cause for death in the elderly. We aimed to determine the predictors of 30-day mortality in elderly patients with CAP. Methods: This retrospective cohort study was performed in a tertiary-care university hospital. A total of 393 consecutive patients with age ≥65 years who were immunocompetent and hospitalized due to CAP during a 24-month period were enrolled. Clinical characteristics and laboratory data were collected. Logistic regression analysis was used to determine the independent predictors of 30-day mortality. Results: The mean age was 76.0 ± 7.0 years (range 65–98 years), and 61.3% of the patients were male. The mean length of hospital stay was 14.3 ± 11.8 days. Intensive care unit admission rate was 5.1%. The 30-day mortality was 7.4%, and hospital mortality was 9.2%. In multivariate analysis, independent predictors of 30-day mortality in elderly patients with CAP were: requirement for invasive mechanical ventilation (OR 46.7, p = 0.000, 95% CI 10.2-213.6), altered mental status (OR 11.2, p = 0.000, 95% CI 3.7-33.5), congestive heart failure (OR 7.8, p = 0.000, 95% CI 2.5-24.8), and chronic renal insufficiency (OR 5.2, p = 0.001, 95% CI 2.0 -13.8). Conclusions: In this cohort of elderly patients with CAP, requirement for invasive mechanical ventilation, altered mental status, congestive heart failure, and chronic renal insufficiency were independent predictors of 30-day mortality. Our findings suggest that both pneumonia severity and comorbidities might predict 30-day mortality in elderly patients hospitalized with CAP.

Risk factors and outcomes of carbapenem-resistant and multidrug-resistant klebsiella pneumoniae bloodstream infection in patients with acute leukemia

Deprivation in the general population predicts mortality. We have investigated its relevance to an acute medical admission, using a database of all emergency admissions to St James' Hospital, Dublin, over a 10-year period (2002-11). All emergency admissions, based on geocoding of residence, were allocated to a Small Area Health Research Unit division, with a corresponding deprivation index. We then examined this index as a univariate (unadjusted) and independent (adjusted) predictor of 30-day in-hospital mortality. The 30-day in-hospital mortality, over the 10-year period, was higher for those in the upper half of the deprivation distribution (9.6 vs. 8.6%; P = 0.002). Indeed, there was a stepwise increase in 30-day mortality over the quintiles of deprivation from 7.3% (Quintile 1) to 8.8, 10.0, 10.0 and 9.3%, respectively. Univariate logistic regression of the deprivation indices (quintiles) against outcome showed an increased risk (P = 0.002) of a 30-day death with odds ratios (ORs), respectively (compared with lowest deprivation quintile) of 1.39 [95% confidence intervals (CI) 1.21, 1.58], 1.47 (95% CI 1.29, 1.68), 1.44 (95% CI 1.26, 1.64) and 1.39 (95% CI 1.22, 1.59). The deprivation index was an independent predictor of outcome in a model when adjusted for illness severity and co-morbidity. The fully adjusted OR for a 30-day death was increased by 31% (P = 0.001) for patients in the upper half of the deprivation index distribution (OR 1.35; 95% CI 1.23, 1.48; P < 0.001). Deprivation, independent of co-morbidity or acute illness severity, is an independent predictor of 30-day mortality in acute medical admissions.

Can mean platelet volume predict the prognosis of patients with acute kidney injury requiring continuous renal replacement therapy?

Current risk scores used for patients undergoing transcatheter aortic valve implantation (TAVI) do not reliably predict adverse events after TAVI. Procalcitonin (PCT) is associated with increased atherosclerotic burden and adverse outcomes in patients with cardiovascular disease. The aim of our study is to assess the predictive value of preprocedural serum PCT levels in comparison with established risk scores in TAVI patients. A total of 243 patients undergoing transfemoral TAVI at our institution were included prospectively in the study and 230 of these patients participated in the follow-up 1 year after TAVI. The primary endpoints were mortality at 30days and 1year. Multivariable analysis revealed that preprocedural PCT was the only independent predictor of 30-day mortality (HR 2.84; 95% CI 1.59-5.06; p < 0.001) and 1-year mortality (HR 1.90; 95% CI 1.17-3.11; p = 0.01), whereas high-sensitivity C-reactive protein showed no association with procedural outcomes. The results of ROC analysis showed good predictive power of PCT for both outcomes (AUC 0.75; p = 0.0003 for 30-day mortality and AUC 0.71; p < 0.0001 for 1-year mortality). An optimal cut-off value for PCT of 0.06ng/ml for short- and long-term mortality was determined with the Youden index. A significantly higher mortality rate was observed in the high-PCT group (≥ 0.06ng/ml) based on Kaplan-Meier analysis (log rank = 12.1; p = 0.001 at 30days and log rank = 14.2; p = 0.0002 at 1year). Patients in the high-PCT group also had a considerably worse clinical pro6file. In conclusion, preprocedural PCT is an independent predictor of 30-day and 1-year mortality after TAVI. In particular, a cut-off value of 0.06ng/ml discriminates patients at higher risk of mortality within 30days and 1year of TAVI.