Comparison of the characteristics and clinical course of patients with bacteraemia due to Burkholderia pseudomallei, Staphylococcus aureus and Escherichia coli in tropical Australia.

Clinical course of patients with chronic limb-threatening ischemia developing COVID-19

The characteristics and clinical course of patients with COVID-19 who received invasive mechanical ventilation in Osaka, Japan

This study aimed to investigate the association between the systemic immune-inflammation index (SII) and 28-day all-cause mortality in patients with acute heart failure (AHF) and to evaluate the potential of SII as a prognostic biomarker for early risk stratification. A retrospective cohort study was conducted using the Medical Information Mart for Intensive Care IV database. Patients with an AHF diagnosis on first intensive care unit admission were included, while those with intensive care unit stays <24 hours or missing key laboratory data were excluded. The SII was calculated using the formula: (platelet count × neutrophil count)/lymphocyte count from initial admission laboratory values. Patients were categorized into tertiles based on their SII values. Kaplan–Meier survival analysis and multivariable Cox proportional hazards models were used to assess the association between SII and 28-day mortality, adjusting for demographic, clinical, and laboratory covariates. A total of 5482 patients were included. Kaplan–Meier analysis showed significant differences in 28-day mortality across SII tertiles (log-rank P < .001). In multivariable Cox models, compared with the lowest tertile, the middle and highest SII tertiles were associated with higher 28-day mortality (hazard ratio = 1.485, 95% confidence interval: 1.193–1.849 and hazard ratio = 2.497, 95% confidence interval: 2.060–3.028; both P < .01). Similar associations were observed for 90-, 180-, and 365-day mortality. Restricted cubic spline analyses suggested a dose–response relationship between SII and 28-day mortality. In addition, adding SII to Acute Physiology Score III and Sequential Organ Failure Assessment improved discrimination for 28-day mortality in receiver operating characteristic analyses. Elevated SII is an independent predictor of increased 28-day all-cause mortality in AHF patients. As a readily available and cost-effective marker, SII could be integrated into early risk stratification protocols to guide personalized therapeutic strategies in acute care settings.

This study aims to investigated the associations between estimated plasma volume status (ePVS) and 30-day and 1-year mortality in intracerebral hemorrhage (ICH) patients, providing insights into the management in ICH. Data of adult ICH patients were extracted from both the Medical Information Mart for Intensive Care IV (MIMIC-IV) database and the Hospital Information System (HIS) in this retrospective cohort study. Univariate and multivariate Cox regression analyses, and restricted cubic spline plots (RCS) were conducted to explore the associations between ePVS levels and both 30-day and 1-year mortality, with hazard ratios (HR) and 95% confidence intervals (CI) used for evaluation. Subgroup analyses were performed to further investigate these associations. Among 2,512 eligible patients from the MIMIC-IV database, 655 (26.07%) died within 30 days, with 1,254 (49.92%) had died by the 1-year follow-up. After adjusting for covariates, elevated ePVS was independently associated with both 30-day mortality (HR = 1.05, 95%CI: 1.01-1.09) and 1-year mortality (HR = 1.09, 95% CI: 1.06-1.13). Compared to patients with ePVS levels of [4.63-5.79), those with ePVS levels ≥5.79 had a higher risk of 30-day mortality (HR: 1.36, 95%CI: 1.12-1.64) and 1-year mortality (HR = 1.24, 95% CI: 1.08-1.42). Among 515 eligible patients from the HIS, 132 (25.60%) died within 30 days, with 288 (55.90%) mortality observed at 1-year follow-up. After adjusting for covariates, elevated ePVS was independently associated with both 30-day mortality (HR = 1.33, 95%CI: 1.23-1.43) and 1-year mortality (HR = 1.26, 95% CI: 1.18-1.35). Comparing to patients with ePVS levels of [4.63-5.79), those with ePVS levels of ≥5.79 had a higher risk of 30-day mortality (HR:2.21, 95%CI: 1.48-3.30) and 1-year mortality (HR = 2.75, 95% CI: 2.04-3.72). Additionally, subgroup analyses demonstrated that ePVS was significantly associated with 30-day mortality or 1-year mortality derived from MIMIC-IV and HIS in most subgroups (p < 0.05). And RCS analysis indicates that, whether using MIMIC-IV or HIS data, ePVS was linearly associated with 30-day or 1-year mortality. Higher ePVS levels may be a potential risk factor for 30-day and 1-year mortality in ICH patients, suggesting that timely monitoring and stabilization of ePVS could improve prognosis in this population. However, further studies are needed to validate these fingings.

BackgroundDialysis-requiring acute kidney injury (AKI-D) is a potentially serious complication associated with high in-hospital mortality among patients with coronary artery disease (CAD) after coronary angiography (CAG). Patients with existing advanced kidney disease (AKD) have an increased risk of developing AKI-D. However, few studies have investigated the prognosis of AKI-D in patients with both CAD and AKD.MethodsIn this observational study, 603 CAD patients with AKD (estimated glomerular filtration rate, eGFR <30 mL/min/1.73 m2) were enrolled. AKI-D was defined as acute or worsening renal failure requiring the initiation of renal dialysis. The primary endpoint was 90-day all-cause mortality. Kaplan-Meier and Cox regression analyses were used to assess the association of AKI-D and 90-day all-cause mortality among CAD patients complicated with AKD.ResultsOverall, among 603 CAD patients complicated with AKD, 83 patients (13.8%) required AKI-D. Patients underwent AKI-D had a significantly higher rate of 90-day mortality than those who did not (13.3% vs. 6.5%, log rank P=0.028), with an unadjusted hazard ratio (HR) of 1.28 [95% confidence interval (CI): 1.02–1.61, P=0.032]. After adjustment for cardiac and renal impairment, however, AKI-D was no longer associated with 90-day mortality (HR: 1.08, 95% CI: 0.84–1.39, P=0.559). The attenuation analysis showed that after adjustment for cardiac and renal function, the residual effect of 90-day mortality was as low as 30% of the unadjusted effect.ConclusionsThe incidence of AKI-D is high among patients with CAD complicated by AKD. The high 90-day mortality rate of patients undergoing AKI-D is mainly attributable to cardio-renal impairment.

The effect of serum glucose-to-potassium ratio (GPR) on cerebrovascular diseases has been previously validated. However, the value of the GPR in patients with severe intracerebral hemorrhage (ICH) requiring ICU admission remains unclear. This study aimed to investigate the association between the GPR and the clinical prognosis of critically ill patients with ICH. This study identified patients with severe ICH requiring ICU admission from the Medical Information Mart for Intensive Care (MIMIC-IV) database and divided them into quartiles based on GPR levels. Outcomes included 30-day, 90-day, and 1-year mortality rates. The association between the GPR and clinical outcomes in critically ill patients with ICH was elucidated using Cox proportional hazards regression analysis and restricted cubic splines. In total, 2018 patients (53.8% male), with a median age of 70 years, were enrolled in the study. The 30-day, 90-day, and 1-year mortality rates were 23.9%, 30.1%, and 38.4%, respectively. Per multivariate Cox proportional hazards analysis, an elevated GPR was significantly associated with all-cause mortality. After adjusting for age, sex, Charlson Comorbidity Index, white blood cell count, red blood cell count, platelet count, and Glasgow Coma Scale, patients with an elevated GPR had a higher 30-day mortality (hazard ratio [HR]: 1.32; 95% confidence interval [CI]: 1.22–1.42; P < 0.001), 90-day mortality (HR: 1.27; 95% CI: 1.18–1.37; P < 0.001) and 1-year mortality (HR: 1.22; 95% CI: 1.14–1.31; P < 0.001) when analyzed as a continuous variable. Furthermore, analysis using restricted cubic splines demonstrated a consistent and progressive escalation in the risk of all-cause mortality with an elevated GPR. The GPR was significantly associated with short- and long-term all-cause mortality in critically ill patients with ICH. This finding demonstrates that GPR may be useful in identifying patients with ICH at a high risk of all-cause mortality.

Retrospective, multicenter cohort study. Assess for differences in short- and long-term mortality between operative and nonoperative treatment for elderly patients with type II odontoid fractures. There is controversy regarding whether operative or nonoperative management is the best treatment for elderly patients with type II odontoid fractures. This is a retrospective study of consecutive patients aged 65 years or older with type II odontoid fracture from 3 level I trauma centers from 2003-2009. Demographics, comorbidities, and treatment were abstracted from medical records. Mortality outcomes were obtained from medical records and a public database. Hazard ratios (HRs) and 95% confidence intervals (CI) were calculated. A total of 322 patients were included (mean age, 81.8 yr; range, 65.0-101.5 yr). Compared with patients treated nonoperatively (n = 157), patients treated operatively (n = 165) were slightly younger (80.4 vs. 83.2 yr, P = 0.0014), had a longer hospital (15.0 vs. 7.4 d, P < 0.001) and intensive care unit (1.5 vs. 1.1 d, P = 0.008) stay, and were more likely to receive a feeding tube (18% vs. 5%, P = 0.0003). Operative and nonoperative treatment groups had similar sex distribution (P = 0.94) and Charlson comorbidity index (P = 0.11). Within 30 days of presentation, 14% of patients died, and at maximal follow-up (average = 2.05 yr; range = 0 d-7.02 yr), 44% had died. On multivariate analysis, nonoperative treatment was associated with higher 30-day mortality (HR = 3.00, 95% CI = 1.51-5.94, P = 0.0017), after adjusting for age (HR = 1.10, 95% CI = 1.05-1.14; P < 0.0001), male sex (P = 0.69), and Charlson comorbidity index (P = 0.16). At maximal follow-up, there was a trend toward higher mortality associated with nonoperative treatment (HR = 1.35, 95% CI = 0.97-1.89, P = 0.079), after adjusting for age (HR = 1.07, 95% CI = 1.05-1.10; P < 0.0001), male sex (HR = 1.55, 95% CI = 1.10-2.16; P = 0.012), and Charlson comorbidity index (HR = 1.28, 95% CI = 1.16-1.40; P < 0.0001). Surgical treatment of type II odontoid fracture in this elderly population did not negatively impact survival, even after adjusting for age, sex, and comorbidities. The data suggest a significant 30-day survival advantage and a trend toward improved longer-term survival for operatively treated over nonoperatively treated patients. 4.

Background Infections with carbapenem-resistant (CR) organisms are more likely in patients with comorbidities and are associated with worse prognosis. The effect of specific and multiple comorbidities on the outcomes of patients with CR infections is not known. Age-adjusted Charlson Comorbidity Index calculation. The Charlson Comorbidity Index (CCI) scores for patients were calculated according to weights for respective comorbid conditions, as defined by the original CCI scoring system. Age adjustment was consecutively done to obtain the final age-adjusted CCI score. Methods A secondary analysis was conducted on patients enrolled into MDRO Network studies (CRACKLE-2, SNAP, POP), between December 2018 and November 2019, who had blood and respiratory infections with CR Enterobacterales (CRE), Acinetobacter baumannii (CRAb), or Pseudomonas aeruginosa (CRPa). Respiratory cultures were physician-adjudicated. Patients were stratified into 4 groups according to their age-adjusted Charlson Comorbidity Index (CCI) score: 0-2, 3-4, 5-6, and 7+ (Figure 1). Primary outcome was 30-day all-cause mortality; absolute mortality differences comparing presence and absence of comorbidities and 95% score confidence intervals were calculated. Age-adjusted Charlson Comorbidity Index and 30-day mortality. 30-day mortality for patients with carbapenem-resistant Gram-negative bloodstream and respiratory infections increases progressively with increasing age-adjusted Charlson Comorbidity Index score groups. Results 2468 patients were included, of which 66% had CRE, 17% had CRAb, and 17% had CRPa. We found a progressive increase in 30-day mortality rates with rising age-adjusted CCI scores (p &amp;lt; 0.001, Mantel Haenszel Chi-square); 18% (CCI 0-2) to 25% (3-4), further to 28% (5-6), and peak at 35% (7+) (Figure 2). Patients with lower CCI acquired infections later during hospitalization [Median (IQR) days (CCI 0-2: 11 (2, 24.5); 3-4: 10 (2, 26); 5-6: 8 (1, 24); 7+: 9 (1, 25) (Kruskal Wallis p=0.025)], and tended to have a longer length of stay [Median (IQR) days (CCI 0-2: 32 (16, 60); 3-4: 29 (15, 48); 5-6: 25 (13, 50); 7+: 24 (13, 47) (Kruskal Wallis p &amp;lt; 0.001)]. Diabetes was associated with higher 30-day mortality: 23% in non-diabetics, 27% in diabetics without end-organ damage, and 38% in diabetics with end-organ damage (p &amp;lt; 0.001). Diseases with the highest mortality difference when present were cirrhosis with portal hypertension (14.9% [3.2%, 27.8%] 95% CI, p=0.01), diabetes with end-organ damage (14.7% [8.2%, 21.6%], p&amp;lt; 0.001), and lymphoma (12.1% [0%, 25.9%], p=0.05) (Table 1). 30-day mortality differences of Charlson Score components among blood and respiratory infections. 30-day mortality for individual comorbid conditions in the Charlson Comorbidity Index (CCI) is observed using unadjusted risk difference. Each component was compared to patients without each respective comorbidity. The highest risk differences are observed in diabetes with end-organ damage, chronic kidney disease, lymphoma, and cirrhosis with portal hypertension. Conclusion Increasing comorbidities as measured by age-adjusted CCI are associated with worse outcomes in the setting of CR Gram-negative bacterial blood and respiratory infections. Diabetes contributes to this association to a great extent. This may help identify patients at-risk for poor outcomes. Disclosures Yohei Doi, MD, PHD, AbbVie: Honoraria|Entasis: Grant/Research Support|Gilead: Advisor/Consultant|GSK: Advisor/Consultant|Meiji Seika: Advisor/Consultant|Moderna: Advisor/Consultant|Pfizer: Advisor/Consultant|Shionogi: Advisor/Consultant|Shionogi: Honoraria David Paterson, bioMerieux: Grant/Research Support|bioMerieux: Honoraria|Merck: Advisor/Consultant|Merck: Grant/Research Support|Merck: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Pfizer: Honoraria|Shionogi: Grant/Research Support|Shionogi: Honoraria Michael J. Satlin, MD, AbbVie: DSMB participant|bioMerieux: Grant/Research Support|Merck: Grant/Research Support|Selux Diagnostics: Grant/Research Support|SNIPRBiome: Grant/Research Support Vance G. Fowler, MD, MHS, Affinergy: Advisor/Consultant|ArcBio: Stocks/Bonds (Private Company)|Armata: Advisor/Consultant|Astra Zeneca: Advisor/Consultant|Astra Zeneca: Grant/Research Support|Basilea: Advisor/Consultant|Basilea: Grant/Research Support|ContraFect: Advisor/Consultant|ContraFect: Grant/Research Support|Debiopharm: Advisor/Consultant|Destiny: Advisor/Consultant|EDE: Grant/Research Support|Genentech: Advisor/Consultant|Genentech: Grant/Research Support|GSK: Advisor/Consultant|Janssen: Advisor/Consultant|Karius: Grant/Research Support|MedImmune: Grant/Research Support|Merck: Grant/Research Support|sepsis diagnostics: Patent pending|UptoDate: Royalties|Valanbuio: Stocks/Bonds (Private Company)|Valanbuio: Stocks/Bonds (Private Company) David van Duin, MD, PhD, Merck: Advisor/Consultant|Merck: Grant/Research Support|Pfizer: Advisor/Consultant|Qpex: Advisor/Consultant|Roche: Advisor/Consultant|Shionogi: Advisor/Consultant|Shionogi: Grant/Research Support

Pre-operative factors associated with increased mortality in elderly patients with a hip fracture: A cohort study in a developing country

BackgroundChronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide, and acute kidney injury (AKI) is one of the most common comorbidities in patients with COPD. However, the impact of AKI occurring within 2 days of COPD diagnosis is unclear. Therefore, this study aimed to assess the impact of a 2-day onset of AKI on COPD patient outcomes using the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database.MethodsThis retrospective study is based on version 2.2 of the MIMIC-IV database. We collected clinical data and 30-day all-cause mortality data for patients with COPD in the intensive care unit (ICU), who met the diagnostic criteria for COPD upon admission between 2008 and 2019. We used the International Classification of Diseases, 10th Revision (ICD-10) (codes J44, J440, J441, and J449) to identify COPD. Kaplan-Meier analysis was used to compare 30-day all-cause mortality in COPD patients with and without 2-day AKI. A Cox proportional hazards model was employed to investigate risk factors associated with 30-day all-cause mortality in COPD patients.ResultsThis study included 2,609 patients with COPD, of whom 1,514 (58.03%) developed AKI within 2 days, while 1,095 (41.97%) did not. Patients with COPD, those who developed AKI within 2 days were older than those who did not develop AKI within 2 days [median: 72.7 (65.1, 80.0) vs. 70.6 (63.2, 79.6), P=0.005] and had a higher Simplified Acute Physiology Score III (SAPSIII) score [median: 50.0 (37.0, 67.8) vs. 37.0 (28.0, 48.0), P<0.001], at the same time, the scores of Simplified Acute Physiology Score II (SAPSII), Sequential Organ Failure Assessment (SOFA) score, and Outcome and Assessment Information Set (OASIS) Charlson Comorbidity Index were also higher (all P<0.001). In our study, 30-day all-cause mortality [hazard ratio (HR) =2.07, 95% confidence interval (CI): 1.6–2.69, P<0.001] was higher in COPD patients with a 2-day onset of AKI than in patients without a 2-day onset of AKI. After adjusting for covariates, results showed that 2-day AKI was an independent risk factor for 30-day all-cause mortality in COPD patients (HR =11.02, 95% CI: 1.8–67.39, P=0.009).ConclusionsThe occurrence of 2-day AKI was an independent risk factor for 30-day all-cause mortality in patients with COPD. Clinically, these findings highlight the importance of providing early kidney protection for patients with COPD.

To investigate the effect of circadian heart rate variation on short-term and long-term mortality in intensive care unit (ICU) patients. A retrospective cohort study was conducted. A total of 32 536 ICU patients were recorded from 2001 to 2008 published by Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II v2.6) in April 2011. The circadian heart rate variation was defined as the ratio of mean nighttime (23:00 to 07:00) heart rate to mean daytime (07:00 to 23:00) heart rate. The 28-day mortality and 1-year mortality were defined as outcome events. The information such as age, gender, ethnicity, first sequential organ failure assessment (SOFA) score, first simplified acute physiology score I (SAPS I), usage of sedatives and catecholamines within 24 hours admission of ICU, clinical complications [hypertension, chronic obstructive pulmonary disease (COPD), diabetes with or without complications, congestive heart failure, liver disease, renal failure, etc.], and the complete heart rate records within 24 hours after ICU admission were collected. Cox proportional risk regression models were used to investigate the association between circadian heart rate variation and 28-day mortality and 1-year mortality in ICU patients. Besides, subgroup analysis was also performed in patients with different first SOFA scores. Totally 15 382 ICU patients in MIMIC-II database were enrolled, excluding the patients without heart rate records or death records, using pacemaker with arrhythmia, without SOFA or SAPS I score records. Finally, 9 439 patients were enrolled in the study cohort. (1) Cox regression analysis of the whole patient showed that the higher circadian heart rate variation was correlated with the increased 28-day mortality [hazard ratio (HR) = 1.613, 95% confidence interval (95%CI) was 1.338-1.943, P < 0.001] and 1-year mortality (HR = 1.573, 95%CI was 1.296-1.908, P < 0.001). After adjustment for demographic factors (age, gender and ethnicity), severity of illness (SOFA and SAPS I scores), clinical complications (hypertension, COPD, diabetes with or without complications, congestive heart failure, liver disease, renal failure, etc.), and influence of medications (sedatives and catecholamines), the night-day heart rate ratio was also correlated with 28-day mortality (HR = 1.256, 95%CI was 1.018-1.549, P = 0.033) and 1-year mortality (HR = 1.249, 95%CI was 1.010-1.545, P = 0.040). (2) According to the SOFA score (median value of 5), the patients were divided into two subgroups, in which 5 478 patients with SOFA score ≤ 5 and 3 961 patients with SOFA score > 5. Cox regression subgroup analysis showed that circadian heart rate variation was related with higher 28-day mortality (HR = 1.430, 95%CI was 1.164-1.756, P = 0.001) and 1-year mortality (HR = 1.393, 95%CI was 1.123-1.729, P = 0.003) in patients with SOFA score > 5. After adjustment for covariates, the 28-day mortality (HR = 1.279, 95%CI was 1.032-1.584, P = 0.025) and 1-year mortality (HR = 1.255, 95%CI was 1.010-1.558, P = 0.040) also increased with the increasing of night-day heart rate ratio in patients with SOFA score > 5. However, the relationships did not exist in patients with SOFA score ≤ 5. In ICU patients, the 28-day mortality and 1-year mortality increase with the higher circadian heart rate variation, which indicates that the circadian heart rate variation in ICU patients is positively correlated with the short-term and long-term mortality, especially in patients with relatively severe illness.

BackgroundEscherichia coli is the most common cause of bloodstream infections (BSIs) and mortality is an important aspect of burden of disease. Using a multinational population-based cohort of E. coli BSIs, our objectives were to evaluate 30-day case fatality risk and mortality rate, and determine factors associated with each.MethodsDuring 2014–2018, we identified 30-day deaths from all incident E. coli BSIs from surveillance nationally in Finland, and regionally in Sweden (Skaraborg) and Canada (Calgary, Sherbrooke, western interior). We used a multivariable logistic regression model to estimate factors associated with 30-day case fatality risk. The explanatory variables considered for inclusion were year (2014–2018), region (five areas), age (< 70-years-old, ≥70-years-old), sex (female, male), third-generation cephalosporin (3GC) resistance (susceptible, resistant), and location of onset (community-onset, hospital-onset). The European Union 28-country 2018 population was used to directly age and sex standardize mortality rates. We used a multivariable Poisson model to estimate factors associated with mortality rate, and year, region, age and sex were considered for inclusion.ResultsFrom 38.7 million person-years of surveillance, we identified 2961 30-day deaths in 30,923 incident E. coli BSIs. The overall 30-day case fatality risk was 9.6% (2961/30923). Calgary, Skaraborg, and western interior had significantly increased odds of 30-day mortality compared to Finland. Hospital-onset and 3GC-resistant E. coli BSIs had significantly increased odds of mortality compared to community-onset and 3GC-susceptible. The significant association between age and odds of mortality varied with sex, and contrasts were used to interpret this interaction relationship. The overall standardized 30-day mortality rate was 8.5 deaths/100,000 person-years. Sherbrooke had a significantly lower 30-day mortality rate compared to Finland. Patients that were either ≥70-years-old or male both experienced significantly higher mortality rates than those < 70-years-old or female.ConclusionsIn our study populations, region, age, and sex were significantly associated with both 30-day case fatality risk and mortality rate. Additionally, 3GC resistance and location of onset were significantly associated with 30-day case fatality risk. Escherichia coli BSIs caused a considerable burden of disease from 30-day mortality. When analyzing population-based mortality data, it is important to explore mortality through two lenses, mortality rate and case fatality risk.

ObjectiveThis study explored the association between serum bicarbonate levels and mortality risk among patients with acute respiratory distress syndrome (ARDS) admitted to the intensive care unit (ICU).MethodsThis was a retrospective cohort study utilizing data extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Cox proportional hazards models and restricted cubic splines (RCS) were deployed for elucidating the association between the baseline bicarbonate levels and the risk of 28-day mortality while utilizing the Kaplan-Meier method to estimate survival curves, with hazard ratio (HR) and 95% confidence interval (CI). Subgroup analyses were conducted based on age, gender, Charlson Comorbidity Index (CCI) score, ARDS severity and bicarbonate administration.ResultsTotally, 6,377 patients (15.38% deaths) were included. Baseline bicarbonate was significantly associated with 28-day mortality (HR: 0.98, 95% CI: 0.97–1.00, P = 0.011) in patients with ARDS. This association was particularly evident in female patients (HR: 1.16, 95% CI: 1.14–1.87, P = 0.003), those with a CCI of 2 or higher (HR: 1.27, 95% CI: 1.05–1.53, P = 0.013), among those with a PaO2/FiO2 ratio ranging from 200 to 300 mmHg (HR: 1.39, 95% CI: 1.08–1.78, P = 0.011), and those without bicarbonate administration (HR = 1.26, 95%CI: 1.07–1.48, P = 0.004), where bicarbonate levels falling below 23 mEq/L were linked to a heightened risk of not surviving the first 28 days in ARDS patients. RCS analysis revealed that the bicarbonate levels were non-linear associated with the 28-day mortality in ARDS patients (P for non-linear <0.001).ConclusionLower serum bicarbonate levels are significantly associated with an increased 28-day mortality risk in ARDS patients, with particular emphasis on female patients, those with higher CCI scores, and those with milder ARDS. Baseline bicarbonate levels of ARDS patients in ICU have certain clinical reference value for the development of clinical management and the assessment of prognostic risk during the ICU admission.

Australians have around 19 000 hip fractures each year,1 and the estimated cost to the health care system was $445 million in 2015–16.2 Surgery within 48 hours of initial presentation to hospital is widely accepted as a clinically meaningful indicator of best practice care, and is supported by the Australian Hip Fracture Care Clinical Care Standard when there are no clinical contraindications.3 However, timely access to emergency orthopaedic hip fracture surgery is difficult in a country as large and geographically diverse as Australia; patients admitted to remote or regional hospitals that do not provide orthopaedic surgery must be transferred to larger regional centres. In a retrospective population study, we evaluated the impact of pre-surgery hospital transfer and time to surgery on 30-day mortality for people aged 65 years or more who underwent surgical interventions for fall-related hip fractures in NSW public hospitals during 1 January 2011 – 31 December 2018. Hospitalisation data from the NSW Admitted Patient Data Collection and deaths data from the NSW Registry of Births, Deaths and Marriages were linked to provide person-level records. Time to surgery (in calendar days) was estimated from the date of admission for the first episode of care to the date of surgery. Comorbid conditions during the preceding year were identified with the Charlson Comorbidity Index (CCI). Multilevel multivariable logistic regression models were fitted to assess the influence of patient-level factors (age, sex, comorbidity) and process factors (transfer status, time to surgery) on 30-day mortality. Operating hospitals were included as a random effect to account for variation between hospitals. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated and residual variation (variance partition coefficient) assessed. All analyses were performed in SAS Enterprise Guide 7.1 and MLwiN 3.02 (http://www.bristol.ac.uk/cmm/software/mlwin). The NSW Population and Health Services Research Ethics Committee approved the study (HREC/17/CIPHS/45). Of 36 956 patients who underwent hip fracture repair procedures in 36 hospitals, 3916 (10.6%) were transferred from peripheral hospitals to operating hospitals for surgery; 1579 were transferred on the day of presentation (40.3%), 1875 the following day (47.9%), and 462 patients (11.8%) spent at least two days at the admitting hospital before being transferred. Larger proportions of transferred patients than of patients admitted directly to operating hospitals were men (29.4% v 27.8%), under 85 years of age (50.9% v 48.4%), or had CCI scores of 1 or more (60.2% v 56.3%). The proportion of transferred patients who underwent surgery within 48 hours of presentation was smaller than for directly admitted patients (53.9% v 72.4%) (Box). In multilevel models adjusted for inter-hospital variation, transfer was associated with higher risk of 30-day mortality than direct admission (aOR, 1.15; 95% CI, 1.01–1.32), but after adjusting for age, sex, and comorbidity, neither transfer (aOR, 1.10; 95% CI, 0.95–1.28) nor delayed surgery (> 2 days v ≤ 2 days: aOR, 0.99; 95% CI, 0.89–1.11) significantly influenced mortality. The most influential factor was comorbidity (CCI ≥ 3 v CCI < 3: aOR, 4.89; 95% CI, 4.32–5.54). The discrimination of our fully adjusted model was adequate (area under the curve, 0.73), and 1.8% of residual variation in 30-day mortality was attributable to differences between hospitals. In our large study of NSW people with hip fractures, we found that transfer from non-operating to operating hospitals, after adjusting for patient and hospital characteristics, was not associated with higher 30-day mortality, despite increasing the time between initial presentation and surgery. This is contrary to the findings of earlier, single centre studies in Australia.4-6 However, our study was the first to control for several key person-level factors that increase the risk of death, and our findings suggest that time to surgery may be less important for health outcomes than these factors when other dimensions of care quality are equal. More research is required to understand the interplay between the effects of patient demographic characteristics, pre-injury health status, and the quality of hip fracture care on 30-day mortality for patients. Our investigation was supported by an NSW Agency of Clinical Innovation Research Support Grant and by the National Health and Medical Research Council (1147353). We thank the NSW Ministry of Health and the NSW Register of Births, Death and Marriages for providing the hospital and death data, and the Centre for Health Record Linkage (CHeReL) for providing the unique patient identifiers for linking the datasets. No relevant disclosures.

BackgroundCoagulase-negative staphylococci, including Staphylococcus epidermidis, are the most common cause of bloodstream infection in cancer patients. Linezolid resistance is increasingly identified in S. epidermidis, but whether such resistance alters the clinical course of S. epidermidis infections is unknown. The purpose of this study was to assess the clinical impact of linezolid resistance in leukemia patients with S. epidermidis bloodstream infection.MethodsThis was a retrospective, single-center cohort study of all adult leukemia patients with S. epidermidis bacteremia treated with empiric linezolid between 2012 and 2015. The primary end point was adverse clinical outcome on day 3, defined as a composite of persistent bacteremia, fever, intensive care unit admission, or death. Fourteen- and 30-day mortality were also assessed.ResultsEighty-two unique leukemia patients with S. epidermidis were identified. Linezolid resistance was identified in 33/82 (40%). Patients with linezolid-resistant S. epidermidis were significantly more likely to have persistent bacteremia (41% vs 7%; adjusted relative risk [aRR], 5.15; 95% confidence interval [CI], 1.63–16.30; P = .005); however, adverse short-term clinical outcomes overall were not more common among patients with linezolid-resistant S. epidermidis (61% vs 33%; aRR, 1.46; 95% CI, 0.92–2.32; P = .108). No differences were observed in 14- or 30-day mortality.ConclusionsLeukemia patients with linezolid-resistant S. epidermidis bacteremia who were treated with linezolid were significantly more likely to have persistent bacteremia compared with those with linezolid-sensitive isolates. Interventions to limit the clinical impact of linezolid-resistant S. epidermidis are warranted.