All-cause In-hospital Mortality Research Articles

#1259 Relationship between renal dysfunction, non-obstructive ACS and in-hospital prognosis: findings from the CCC-ACS project

Abstract Background and Aims Acute coronary syndrome (ACS) is an acute and critical condition of coronary heart disease (CHD) with high mortality and poor prognosis. The prevalence of non-obstructive ACS is about 5% ∼ 15%. Among patients with non-obstructive ACS, which patients are more prone to poor prognosis is a concern. Chronic kidney disease (CKD) is an important risk factor for cardiovascular disease, and due to its special pathophysiological mechanism, non-obstructive ACS may not be uncommon in CKD patients. Therefore, the aim of this study was to investigate the relationship between renal function, the occurrence and prognosis of non-obstructive ACS. Method Improving Care for Cardiovascular Disease in China - Acute Coronary Syndrome (CCC-ACS), a hospital-based medical quality improvement project, is a hospital-based medical quality improvement project to improve the compliance of ACS guidelines in China and improve the prognosis of patients. It was jointly sponsored by the American Heart Association (AHA) and the Chinese Society of Cardiology (CSC) in 2014, with 240 hospitals participating, representing different levels of ACS management in Chinese hospitals. We analyzed patients who underwent coronary angiography from November 2014 to July 2019 in CCC-ACS. Patients were divided into eGFR <60 ml/min·1.73 m² and eGFR≥60 ml/min·1.73 m² groups according to estimated glomerular filtration rate (eGFR) calculated by the EPI formula. According to the results of coronary angiography, the patients were divided into obstructive ACS group and non-obstructive ACS group (obstructive ACS group was defined as at least one coronary artery stenosis ≥ 50%; the others were non-obstructive ACS group). Outcome was defined as in-hospital all-cause mortality and in-hospital MACEs. Results A total of 77 586 patients were included, including 2 292 patients (3.0%) with non-obstructive ACS and 75 294 patients (97.0%) with obstructive ACS. After adjusting for confounding factors using a multivariate logistic regression model, patients with eGFR<60 ml/min·1.73 m² had an approximately 20% increased risk of non-obstructive ACS compared with patients with eGFR≥60 ml/min·1.73 m². The comparison of in-hospital outcomes between the patients with non-obstructive ACS and obstructive ACS is shown in Fig. 1. In-hospital outcomes showed that although the obstructive ACS group had a worse in-hospital prognosis than the non-obstructive ACS group, and the eGFR<60 ml/min·1.73 m² group had a worse in-hospital prognosis than the eGFR≥60 ml/min·1.73 m² group, further grouping of patients showed that the non-obstructive ACS group with eGFR<60 ml/min·1.73 m² had a worse prognosis than the obstructive ACS group with eGFR≥60 ml/min·1.73 m². Confounding factors adjusted for non-obstructive ACS showed that lower eGFR was associated with a higher risk of in-hospital MACEs. After analyzing the in-hospital medication and discharge medication of patients, it was found that the standardized cardiovascular drug therapy was inadequate in patients with non-obstructive ACS. Conclusion Patients with non-obstructive ACS have worse renal function than patients with obstructive ACS, and the proportion of patients with eGFR<60 ml/min·1.73 m² is higher. In patients with non-obstructive ACS, the risk of in-hospital MACEs significantly increased as eGFR decreased. This suggests that we may consider giving standardized cardiovascular drug therapy to patients with non-obstructive ACS, especially those with non-obstructive ACS combined with abnormal renal function, in order to improve the prognosis of patients. This needs to be confirmed by more randomized controlled trial results.

Frequency and mortality rate following antimicrobial-resistant bloodstream infections in tertiary-care hospitals compared with secondary-care hospitals.

There are few studies comparing proportion, frequency, mortality and mortality rate following antimicrobial-resistant (AMR) infections between tertiary-care hospitals (TCHs) and secondary-care hospitals (SCHs) in low and middle-income countries (LMICs) to inform intervention strategies. The aim of this study is to demonstrate the utility of an offline tool to generate AMR reports and data for a secondary data analysis. We conducted a secondary-data analysis on a retrospective, multicentre data of hospitalised patients in Thailand. Routinely collected microbiology and hospital admission data of 2012 to 2015, from 15 TCHs and 34 SCHs were analysed using the AMASS v2.0 (www.amass.website). We then compared the burden of AMR bloodstream infections (BSI) between those TCHs and SCHs. Of 19,665 patients with AMR BSI caused by pathogens under evaluation, 10,858 (55.2%) and 8,807 (44.8%) were classified as community-origin and hospital-origin BSI, respectively. The burden of AMR BSI was considerably different between TCHs and SCHs, particularly of hospital-origin AMR BSI. The frequencies of hospital-origin AMR BSI per 100,000 patient-days at risk in TCHs were about twice that in SCHs for most pathogens under evaluation (for carbapenem-resistant Acinetobacter baumannii [CRAB]: 18.6 vs. 7.0, incidence rate ratio 2.77; 95%CI 1.72-4.43, p<0.001; for carbapenem-resistant Pseudomonas aeruginosa [CRPA]: 3.8 vs. 2.0, p = 0.0073; third-generation cephalosporin resistant Escherichia coli [3GCREC]: 12.1 vs. 7.0, p<0.001; third-generation cephalosporin resistant Klebsiella pneumoniae [3GCRKP]: 12.2 vs. 5.4, p<0.001; carbapenem-resistant K. pneumoniae [CRKP]: 1.6 vs. 0.7, p = 0.045; and methicillin-resistant Staphylococcus aureus [MRSA]: 5.1 vs. 2.5, p = 0.0091). All-cause in-hospital mortality (%) following hospital-origin AMR BSI was not significantly different between TCHs and SCHs (all p>0.20). Due to the higher frequencies, all-cause in-hospital mortality rates following hospital-origin AMR BSI per 100,000 patient-days at risk were considerably higher in TCHs for most pathogens (for CRAB: 10.2 vs. 3.6,mortality rate ratio 2.77; 95%CI 1.71 to 4.48, p<0.001; CRPA: 1.6 vs. 0.8; p = 0.020; 3GCREC: 4.0 vs. 2.4, p = 0.009; 3GCRKP, 4.0 vs. 1.8, p<0.001; CRKP: 0.8 vs. 0.3, p = 0.042; and MRSA: 2.3 vs. 1.1, p = 0.023). In conclusion, the burden of AMR infections in some LMICs might differ by hospital type and size. In those countries, activities and resources for antimicrobial stewardship and infection control programs might need to be tailored based on hospital setting. The frequency and in-hospital mortality rate of hospital-origin AMR BSI are important indicators and should be routinely measured to monitor the burden of AMR in every hospital with microbiology laboratories in LMICs.

Mortality in Community-Acquired Sepsis and Infections in the Faroe Islands-A Prospective Observational Study.

The aim of this study was to collect data and analyze mortality among patients hospitalized with community-acquired infections in the Faroe Islands. A prospective observational study was conducted in the Medical Department of the National Hospital of the Faroe Islands from October 2013 to April 2015. Cumulative all-cause, in-hospital, short-term, intermediate-term and long-term mortality rates were calculated. Kaplan-Meier survival curves comparing infection-free patients with infected patients of all severities and different age groups are presented. A log-rank test was used to compare groups. Mortality hazard ratios were calculated for subgroups using Cox regression multivariable models. There were 1309 patients without infection and 755 patients with infection. There were 51% female and 49% male patients. Mean age was 62.73 ± 19.71. Cumulative all-cause mortality and in-hospital mortality were highest in more severe forms of infection. This pattern remained the same for short-term mortality in the model adjusted for sex and age, while there were no significant differences among the various infection groups in regard to intermediate- or long-term survival after adjustment. Overall and short-term mortality rates were highest among those with severe manifestations of infection and those with infection compared to infection-free patients.

Machine learning derived serum creatinine trajectories in acute kidney injury in critically ill patients with sepsis

BackgroundCurrent classification for acute kidney injury (AKI) in critically ill patients with sepsis relies only on its severity-measured by maximum creatinine which overlooks inherent complexities and longitudinal evaluation of this heterogenous syndrome. The role of classification of AKI based on early creatinine trajectories is unclear.MethodsThis retrospective study identified patients with Sepsis-3 who developed AKI within 48-h of intensive care unit admission using Medical Information Mart for Intensive Care-IV database. We used latent class mixed modelling to identify early creatinine trajectory-based classes of AKI in critically ill patients with sepsis. Our primary outcome was development of acute kidney disease (AKD). Secondary outcomes were composite of AKD or all-cause in-hospital mortality by day 7, and AKD or all-cause in-hospital mortality by hospital discharge. We used multivariable regression to assess impact of creatinine trajectory-based classification on outcomes, and eICU database for external validation.ResultsAmong 4197 patients with AKI in critically ill patients with sepsis, we identified eight creatinine trajectory-based classes with distinct characteristics. Compared to the class with transient AKI, the class that showed severe AKI with mild improvement but persistence had highest adjusted risks for developing AKD (OR 5.16; 95% CI 2.87–9.24) and composite 7-day outcome (HR 4.51; 95% CI 2.69–7.56). The class that demonstrated late mild AKI with persistence and worsening had highest risks for developing composite hospital discharge outcome (HR 2.04; 95% CI 1.41–2.94). These associations were similar on external validation.ConclusionsThese 8 classes of AKI in critically ill patients with sepsis, stratified by early creatinine trajectories, were good predictors for key outcomes in patients with AKI in critically ill patients with sepsis independent of their AKI staging.

Rising Trends in Metabolically Healthy Obesity in Cancer Patients and Its Impact on Cardiovascular Events: Insights from a Contemporary Nationwide Analysis in the USA (2016-2020).

Background: Obesity or overweight raises the risk of developing 13 types of cancer, representing 40% of all cancers diagnosed in the United States annually. Given the ongoing debate surrounding the impact of metabolically healthy obesity (MHO) on cardiovascular outcomes, it is crucial to comprehend the incidence of Major Adverse Cardiovascular and Cerebrovascular Events (MACCEs) and the influence of MHO on these outcomes in cancer patients. Methods: Data of hospitalized cancer patients with and without obesity were analyzed from the National Inpatient Sample 2016-2020. Metabolically healthy patients were identified by excluding diabetes, hypertension, and hyperlipidemia using Elixhauser comorbidity software, v.2022.1. After that, we performed a multivariable regression analysis for in-hospital MACCEs and other individual outcomes. Results: We identified 3,111,824 cancer-related hospitalizations between 2016 and 2020. The MHO cohort had 199,580 patients (6.4%), whereas the MHnO (metabolically healthy non-obese) cohort had 2,912,244 patients (93.6%). The MHO cohort had a higher proportion of females, Blacks, and Hispanics. Outcomes including in-hospital MACCEs (7.9% vs. 9.5%; p < 0.001), all-cause mortality (6.1% vs. 7.5%; p < 0.001), and acute myocardial infarction (AMI) (1.5% vs. 1.6%; p < 0.001) were lower in the MHO cohort compared to the MHnO cohort. Upon adjusting for the baseline characteristics, the MHO group had lower odds of in-hospital MACCEs [adjusted odds ratio (AOR) = 0.93, 95% CI (0.90-0.97), p < 0.001], all-cause mortality [AOR = 0.91, 95% CI (0.87-0.94); p < 0.001], and acute ischemic stroke (AIS) [AOR = 0.76, 95% CI (0.69-0.84); p < 0.001], whereas there were higher odds of acute myocardial infarction (AMI) [AOR = 1.08, 95% CI (1.01-1.16); p < 0.001] and cardiac arrest (CA) [AOR = 1.26, 95% CI (1.01-1.57); p = 0.045] in the MHO cohort compared to the MHnO cohort. Conclusions: Hospitalized cancer patients with MHO exhibited a lower prevalence of in-hospital MACCEs than those with MHnO. Additional prospective studies and randomized clinical trials are imperative to validate these findings, particularly in stratifying MHO across various cancer types and their corresponding risks of in-hospital MACCEs.

CHA2DS2-VASc score predicts periprocedural complications and mortality of percutaneous coronary intervention irrespective of atrial fibrillation: a systematic review and meta-analysis

Abstract Funding Acknowledgements None. Background Periprocedural complications of Percutaneous Coronary Intervention (PCI) are dreaded as they negatively impact prognosis, but they are hard to predict especially in resource-limited settings. CHA2DS2-VASc Score, apart from predicting thromboembolic risk in atrial fibrillation, has been reported to be associated with several complications of PCI. Purpose We aimed to assess the predictive value of CHA2DS2-VASc score for periprocedural complications and mortality in Acute Coronary Syndrome (ACS) patients treated with PCI. Methods Systematic search of the literature was conducted through Pubmed and Embase for all articles published from inception until 24th September 2023. Studies were included if they were observational studies conducted in ACS patients who received PCI during index hospital stay and evaluated the value of CHA2DS2-VASc score to predict at least one outcome of interest. Studies were excluded if they only used modified CHA2DS2-VASc score or did not conduct a separate analysis for ACS patients. Results Out of 1,783 manually reviewed unique studies, 34 studies involving a total of 342,141 ACS patients were included. Only 2 studies exclusively included patients with atrial fibrillation. Random effect meta-analyses found a significant association between high CHA2DS2-VASc score and Contrast-Induced Nephropathy/CIN (11 studies; OR 5.35; 95%CI 3.56–8.03; I2=94%), no-reflow phenomenon (14 studies; OR 3.21; 95%CI 2.20–4.68; I2 = 91%), acute stent thrombosis (3 studies; OR 5.23; 95%CI 3.85–7.10; I2=0%), in-hospital all-cause mortality (9 studies; OR 3.25; 95%CI 1.65–6.44; I2=91%), in-hospital cardiovascular mortality (3 studies; 3.05; 95%CI 1.58–5.87; I2=38%), post-discharge all-cause mortality (4 studies; 3.35; 95%CI 2.24–5.02; I2=0%), and post-discharge cardiovascular mortality (3 studies; 3.65; 95%CI 2.65–5.01; I2=35%). The CHA2DS2-VASc score cut-off with the highest OR for each outcome was used in bivariate random-effects meta-analysis model for diagnostic test accuracy. CHA2DS2-VASc score cut-off of ≥4 is a good predictor of CIN/AKI (5 studies) with AUC 0.81 (0.77–0.84), sensitivity 0.70 (0.51–0.84), specificity of 0.81 (0.54–0.94), while CHA2DS2-VASc score cut-off of ≥2 is good for screening no-reflow phenomenon (5 studies) with AUC 0.70 (0.66–0.74), sensitivity 0.86 (0.56–0.97), specificity 0.44 (0.20–0.71), and for screening in-hospital all-cause mortality (5 studies) with AUC 0.77 (0.73–0.81), sensitivity 0.88 (0.77–0.94), and specificity 0.35 (0.19–0.55). Conclusion CHA2DS2-VASc score is a rapid, non-invasive, and easily measurable tool that provides a good prediction of CIN/AKI, as well as a useful screening tool for no-reflow phenomenon and in-hospital all-cause mortality in ACS patients who received PCI regardless of their atrial fibrillation diagnosis.CHA2DS2-VASc score cut-off 4 for CIN/AKICHA2DS2-VASc cut-off 2 for no-reflow

Association between the stress hyperglycemia ratio and 28-day all-cause mortality in critically ill patients with sepsis: a retrospective cohort study and predictive model establishment based on machine learning

BackgroundSepsis is a severe form of systemic inflammatory response syndrome that is caused by infection. Sepsis is characterized by a marked state of stress, which manifests as nonspecific physiological and metabolic changes in response to the disease. Previous studies have indicated that the stress hyperglycemia ratio (SHR) can serve as a reliable predictor of adverse outcomes in various cardiovascular and cerebrovascular diseases. However, there is limited research on the relationship between the SHR and adverse outcomes in patients with infectious diseases, particularly in critically ill patients with sepsis. Therefore, this study aimed to explore the association between the SHR and adverse outcomes in critically ill patients with sepsis.MethodsClinical data from 2312 critically ill patients with sepsis were extracted from the MIMIC-IV (2.2) database. Based on the quartiles of the SHR, the study population was divided into four groups. The primary outcome was 28-day all-cause mortality, and the secondary outcome was in-hospital mortality. The relationship between the SHR and adverse outcomes was explored using restricted cubic splines, Cox proportional hazard regression, and Kaplan‒Meier curves. The predictive ability of the SHR was assessed using the Boruta algorithm, and a prediction model was established using machine learning algorithms.ResultsData from 2312 patients who were diagnosed with sepsis were analyzed. Restricted cubic splines demonstrated a "U-shaped" association between the SHR and survival rate, indicating that an increase in the SHR is related to an increased risk of adverse events. A higher SHR was significantly associated with an increased risk of 28-day mortality and in-hospital mortality in patients with sepsis (HR > 1, P < 0.05) compared to a lower SHR. Boruta feature selection showed that SHR had a higher Z score, and the model built using the rsf algorithm showed the best performance (AUC = 0.8322).ConclusionThe SHR exhibited a U-shaped relationship with 28-day all-cause mortality and in-hospital mortality in critically ill patients with sepsis. A high SHR is significantly correlated with an increased risk of adverse events, thus indicating that is a potential predictor of adverse outcomes in patients with sepsis.

Epidemiology and Outcomes of Hospitalized Chimeric Antigen Receptor T-Cell (CAR-T) Therapy Patients Who Developed Acute Respiratory Failure.

Objectives:The aim of the study was to examine the incidence, baseline characteristics, and outcomes of Chimeric Antigen Receptor T-cell (CAR-T) therapy admissions in individuals who developed acute respiratory failure (ARF). The study utilized the National Inpatient Sample (NIS) database for the years 2017 to 2020. Methods: The study identified CAR-T cell therapy hospitalizations through the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) codes. Patients with acute respiratory failure (ARF) were further classified using specific International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Descriptive statistics were performed to analyze baseline characteristics, comorbidities, complications, and outcomes. Results: Analysis of the NIS Database identified 5545 CAR-T therapy admissions between 2017 and 2020, revealing a rising trend over time. In our study, we found that hypertension (39%), dyslipidemia (21.7%), and venous thromboembolism (13%) were the most frequently observed comorbidities in CAR-T cell therapy admissions. Acute respiratory failure (ARF) was reported in 7.1% of admissions, and they had higher all-cause in-hospital mortality than CAR-T cell therapy admissions without ARF (32.9% vs 1.3%, P < 0.001). ARF admissions that required invasive mechanical ventilation (IMV) also had higher all-cause in-hospital mortality compared to admissions not requiring IMV (48.9% vs 11.8%, P = 0.001). There was no difference in the mortality rate among admissions with non-Hodgkin's Lymphoma, Multiple Myeloma, and Leukemia that utilized CAR-T therapy. Conclusions: In this largest study to date, we illuminate the incidence and outcomes of CAR-T cell therapy admissions with ARF. Higher mortality rates were observed in CAR-T cell therapy admissions with ARF. The study emphasizes the crucial role of interdisciplinary collaboration in CAR-T patient management and calls for additional research to clarify ARF's etiology and inform effective management strategies.

Exposure to hyperoxemia and mortality in cardiac intensive care unit patients

Abstract Funding Acknowledgements None. Background Hyperoxemia (a high PaO2, i.e. &amp;gt;200-300 mmHg) has been associated with adverse outcomes in general critical care settings as well as in acute cardiovascular care conditions. The association between hyperoxemia and mortality has not been characterized in the heterogeneous population admitted to the cardiac intensive care unit (CICU). We aimed to examine the association between hyperoxemia on CICU admission with in-hospital mortality. Methods We retrospectively analyzed Mayo Clinic CICU patients from January 2007 to April 2018. PaO2 closest on admission was analyzed as a continuous variable (per 100 mmHg) and categorized as: 60-100 mmHg (51.9%), 101-150 mmHg (28.6%), 151-200 mmHg (10.6%), 201-300 mmHg (6.4%), and &amp;gt;300 mmHg (2.5%). Those without PaO2 on admission and those with hypoxemia were excluded. The primary outcome was all-cause in-hospital mortality evaluated using logistic regression, after adjusting for age, Charlson Comorbidity Index, M-CARS, and use of IMV and NIPPV. Results A total of 3,368 patients were included (median 70.3 years, 39.4% women). Admission diagnoses included ACS (37.0%, with 19.8% STEMI), HF (67.8%), shock (33.0%) and cardiac arrest (25.3%). Median admission PaO2 was 99 (IQR 78, 136) mmHg, with no difference in median PaO2 between hospital survivors and inpatient deaths (99 versus 98, p = 0.38). A J-shaped relationship was observed between admission PaO2 and in-hospital mortality (Figure A), with slightly higher mortality below 100 mmHg and incrementally higher mortality above this threshold (esp. at &amp;gt;200 mmHg). The incremental association between higher PaO2 and mortality (adjusted OR 1.17 per 100 mmHg higher, 95% CI 1.01-1.34, P = 0.03) was focused in the highest PaO2 group (i.e., &amp;gt;300 mmHg; Figure B). Conclusion Hyperoxia (esp. PaO2 &amp;gt;300 mmHg) on CICU admission is associated with increased in-hospital mortality, demonstrating a J-shaped association with an inflection point of lowest mortality around 100 mmHg. Further studies are warranted to assess if specific oxygen targets influence outcomes in critically ill cardiac patients.

Impact of removing ESBL status labelling from culture reports on the use of carbapenems for non-bacteraemic patients diagnosed with ESBL-positive urinary tract infections.

To evaluate carbapenem prescribing rates for initial definitive treatment of urinary tract infections and clinical outcomes before and after removing ESBL status labels on antibiotic susceptibility reports. This was a retrospective cohort study of adult patients treated for at least 48 h for an ESBL-producing/ceftriaxone-resistant Enterobacterales urinary tract infection. ESBL status reporting ceased in September 2022 for a network of seven community hospitals within the USA. The primary endpoint was the rate of carbapenem prescribing for initial definitive treatment of urinary tract infections. Secondary endpoints included total days of therapy for initial definitive treatment with carbapenems, clinical cure rates, time to transition to oral antibiotic therapy for initial definitive treatment, rate of guideline-compliant therapy, rate of relapsed infection within 30 days, 30 day readmission rate, and 30 day all-cause in-hospital mortality. Of 3055 patients screened, 199 were included in the pre group and 153 were included in the post group. The rate of carbapenem prescribing for initial definitive treatment was 156 patients (78%) in the pre group, compared with 93 patients (61%) in the post group (P = <0.01). Days of therapy for initial definitive therapy with carbapenem was 620 in the pre group compared with 372 in the post group (P < 0.01). There was no difference between other secondary outcomes. Removing ESBL status labels from laboratory reports reduced carbapenem use for initial definitive treatment of urinary tract infections from 78% to 61% (P < 0.01) without impacting clinical outcomes.

The significance of metabolic alkalosis on acute decompensated heart failure: the ALCALOTIC study.

To determine the prevalence and the impact on prognosis of metabolic alkalosis (MA) in patients admitted for acute heart failure (AHF). The ALCALOTIC is a multicenter, observational cohort study that prospectively included patients admitted for AHF. Patients were classified into four groups according to their acid-base status on admission: acidosis, MA, respiratory alkalosis, and normal pH (reference group for comparison). Primary endpoint was all-cause in-hospital mortality, and secondary endpoints included 30/90-day all-cause mortality, all-cause readmission, and readmission for HF. Associations between endpoints and acid-base alterations were estimated in a multivariate Cox regression model including sex, age, comorbidities, and Barthel index and expressed as hazard ratio (HR) with 95% confidence interval (95% CI). Six hundred sixty-five patients were included (84years and 57% women), and 40% had acid-base alterations on admission: 188 (28%) acidosis and 78 (12%) alkalosis. The prevalence (95% CI) of MA was 9% (6.8-11.2%). Patients with MA were more women; had fewer comorbidities, better renal function, and higher left ventricle ejection fraction values; and received more treatment with oral acetazolamide during hospitalization and at discharge. MA was not associated with a higher risk of in-hospital mortality and 30/90-day all-cause mortality or readmissions but was associated with a significant increase in readmissions for HF at 30 and 90days (adjusted HR [95% CI] 3.294 [1.397-7.767], p = 0.006 and 2.314 [1.075-4.978], p = 0.032). The prevalence of MA in patients admitted for AHF was 9%, and its presence was associated with more readmissions for HF but not with all-cause mortality.

Pre-hospital glycemia as a biomarker for in-hospital all-cause mortality in diabetic patients - a pilot study

BackgroundType 2 Diabetes Mellitus (T2DM) presents a significant healthcare challenge, with considerable economic ramifications. While blood glucose management and long-term metabolic target setting for home care and outpatient treatment follow established procedures, the approach for short-term targets during hospitalization varies due to a lack of clinical consensus. Our study aims to elucidate the impact of pre-hospitalization and intra-hospitalization glycemic indexes on in-hospital survival rates in individuals with T2DM, addressing this notable gap in the current literature.MethodsIn this pilot study involving 120 hospitalized diabetic patients, we used advanced machine learning and classical statistical methods to identify variables for predicting hospitalization outcomes. We first developed a 30-day mortality risk classifier leveraging AdaBoost-FAS, a state-of-the-art ensemble machine learning method for tabular data. We then analyzed the feature relevance to identify the key predictive variables among the glycemic and routine clinical variables the model bases its predictions on. Next, we conducted detailed statistical analyses to shed light on the relationship between such variables and mortality risk. Finally, based on such analyses, we introduced a novel index, the ratio of intra-hospital glycemic variability to pre-hospitalization glycemic mean, to better characterize and stratify the diabetic population.ResultsOur findings underscore the importance of personalized approaches to glycemic management during hospitalization. The introduced index, alongside advanced predictive modeling, provides valuable insights for optimizing patient care. In particular, together with in-hospital glycemic variability, it is able to discriminate between patients with higher and lower mortality rates, highlighting the importance of tightly controlling not only pre-hospital but also in-hospital glycemic levels.ConclusionsDespite the pilot nature and modest sample size, this study marks the beginning of exploration into personalized glycemic control for hospitalized patients with T2DM. Pre-hospital blood glucose levels and related variables derived from it can serve as biomarkers for all-cause mortality during hospitalization.

Gender, racial and ethnic disparities in acute coronary syndromes with coronary in-stent restenosis

BackgroundCoronary in-stent restenosis (ISR) is a major clinical challenge of contemporary percutaneous revascularization and portends adverse cardiovascular outcomes. ObjectivesWe aimed to evaluate gender, race, and ethnicity related outcomes in acute coronary syndromes (ACS) with ISR. MethodsPrimary hospitalizations for ACS and ISR in the National Inpatient Sample database from 2016 to 2019 were included. Patients were stratified by gender, race, and ethnicity. The primary end points were all cause in-hospital mortality and coronary revascularization defined as composite of percutaneous coronary intervention (PCI), balloon angioplasty and/or coronary artery bypass grafting (CABG). ResultsDuring the study period, a nationally weighted total of 97,680 patients with ACS and ISR were included. There was substantial variation in comorbidities, with greatest burden among Black and Hispanic women. All-cause in-hospital mortality was 2.4 % in the study cohort, but significantly higher in women (2.1 % vs. 2.1 %; aOR: 1.282, 95 % CI: 1.174–1.4; p < 0.001) and revascularization rates were significantly lower in women (77 % vs 80.2 %; aOR: 0.891, 95 % CI: 0.862–0.921; p < 0.001). Compared to White men, all women except Hispanic women, had significantly higher likelihood of in-hospital mortality, while White women, Black men and women, and Hispanic men had lower odds of revascularization. ConclusionsThere are significant gender, racial, and ethnic related differences in revascularization practices and clinical outcomes in patients with ACS and ISR with an adverse impact on women, racial and ethnic minorities in the U.S.

In-hospital and long-term all-cause mortality in 75 years and older hospitalized patients with and without COVID-19

In-hospital and long-term all-cause mortality in 75 years and older hospitalized patients with and without COVID-19

Characteristics Associated with Ventricular Tachyarrhythmias and Their Prognostic Impact in Heart Failure with Mildly Reduced Ejection Fraction.

Background: The occurrence of ventricular tachyarrhythmias represents an established risk factor of mortality in heart failure (HF). However, data concerning their prognostic impact in heart failure with mildly reduced ejection fraction (HFmrEF) is limited. Therefore, the present study aims to investigate patient characteristics associated with ventricular tachyarrhythmias and their prognostic impact in patients with HFmrEF. Methods: Consecutive patients hospitalized with HFmrEF (i.e., left ventricular ejection fraction 41-49% and signs and/or symptoms of HF) were retrospectively included at one institution from 2016 to 2022. The prognosis of patients with HFmrEF and different types of ventricular tachyarrhythmias (i.e., non-sustained ventricular tachycardia (nsVT), sustained VT (sVT), and ventricular fibrillation (VF) was investigated for the primary endpoint of long-term all-cause mortality at 30 months. Secondary endpoints included in-hospital all-cause mortality and long-term HF-related rehospitalization at 30 months. Results: From a total of 2184 patients with HFmrEF, 4.4% experienced ventricular tachyarrhythmias (i.e., 2.0% nsVT, 0.7% sVT, and 1.6% VF). The occurrence of nsVT was associated with higher New York Heart Association (NYHA) functional class, whereas the incidence of sVT/VF was associated with acute myocardial infarction and ischemic heart disease. However, nsVT (25.0%; HR = 0.760; 95% CI 0.419-1.380; p = 0.367) and sVT/VF (28.8%; HR = 0.928; 95% CI 0.556-1.549; p = 0.776) were not associated with a higher risk of long-term all-cause mortality compared to patients with HFmrEF without ventricular tachyarrhythmias (31.5%). In-hospital cardiovascular mortality was more frequently observed in patients with HFmrEF and sVT/VF compared to those with HFmrEF but without sustained ventricular tachyarrhythmias (7.7% vs. 1.5%; p = 0.004). Finally, the risk of rehospitalization for worsening HF was not affected by the presence of ventricular tachyarrhythmias. Conclusions: The occurrence of ventricular tachyarrhythmias in patients hospitalized with HFmrEF was low and not associated with long-term prognosis.

Direct Bilirubin, but not Indirect Bilirubin, is Associated with Short-term Adverse Events in HFpEF.

Abnormal live function tests have been identified as independent risk factors for ominous prognosis in patients with heart failure. However, most of the previous studies have failed to determine the contribution of direct bilirubin (DBIL) and indirect bilirubin (IBIL) separately. Hence, we aimed to explore whether DBIL or IBIL is correlated with the prognosis of heart failure with preserved ejection fraction (HFpEF). <p> Methods: A total of 19837 patients were hospitalized for HFpEF between January 2012 and January 2022 in Fuqing City Hospital affiliated with Fujian Medical University. The primary endpoint was in-hospital all-cause mortality. Secondary endpoints included in-hospital cardiovascular mortality and 30-day re-admission for heart failure. <p> Results: Univariable analysis indicated that patients with elevated DBIL or IBIL were exposed to a higher risk of mortality and re-admission. However, in multivariable models, both ln-transformed DBIL and TBIL, but not IBIL, were independent risk factors for in-hospital all-cause mortality [hazard ratio (HR)=1.796, 95% confidential interval (CI)=1.477-2.183, P＜0.001; HR=1.854, 95% CI=1.461-2.352, P＜0.001; HR=1.161, 95% CI=0.959-1.407, P=0.126] and in-hospital cardiovascular mortality (HR=1.831, 95% CI=1.345-2.492, P＜0.001; HR=1.899, 95% CI=1.300-2.773, P=0.001; HR=1.145, 95% CI=0.841-1.561, P=0.389). Only DBIL remained independently associated with 30-day readmission for heart failure (HR=1.361, 95% CI=1.036-1.787, P=0.027). Adding ln-transformed DBIL to model 1 increased its discriminatory capacity (C-statistic: 0.851 to 0.869, respectively), whereas adding ln-transformed IBIL yielded little increment (C-statistic: 0.851 to 0.852, respectively). <p> Conclusion: DBIL, but not IBIL, was associated with short-term ominous prognosis in patients with HFpEF. Hence, DBIL may be the superior predictor for prognosis in HFpEF.

Is the fluoroquinolone combination necessary for empirical antibiotic regimen in severe community-acquired pneumonia?

ABSTRACT Objectives This study aimed to assess whether superior clinical outcomes can be attained through piperacillin/tazobactam (TZP)+fluoroquinolone (FQ) combination therapy for severe community-acquired pneumonia (CAP) compared to TZP monotherapy. Methods This retrospective study was conducted at a tertiary care hospital in Korea. Adult inpatients diagnosed with pneumonia within 48 hours of hospitalization were included. Severe CAP was defined as a CURB-65 score of ≥ 3 or based on the 2007 guidelines of the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) definition. Only patients who received either TZP and FQ combination or TZP as initial empirical therapy were included. Results The final analysis included 145 patients; 57.9% received combination therapy and 42.1% received monotherapy. In the combination therapy group, body mass index (20.67 ± 3.28 vs. 22.26 ± 4.80, p = 0.030) and asthma prevalence (0 vs 8.3%, p = 0.022) were significantly higher; initial symptoms, clinical severity, and causative pathogens were not significantly different between groups. White blood cell counts (12,641.64 ± 6,544.66 vs. 12491.67 ± 10,528.24, p = 0.008), and C-reactive protein levels (18.78 ± 11.47 vs. 26.58 ± 14.97, p < 0.001) were significantly higher in the combination therapy group. Clinical outcomes, including all-cause in-hospital mortality rate (26.2 vs. 33.3%, p = 0.358), were not significantly different between the groups. Multivariate analysis identified no significant association between FQ combination and all-cause in-hospital mortality. Conclusion In patients with severe CAP, there were no differences in the clinical outcomes, including mortality, between the TZP and FQ combination therapy and TZP monotherapy. FQ combination was not significantly associated with in-hospital mortality.

A COVID-19 specific multiparametric and ECG-based score for the prediction of in-hospital mortality: ELCOVID score.

We aimed to develop and validate a COVID-19 specific scoring system, also including some ECG features, to predict all-cause in-hospital mortality at admission. Patients were retrieved from the ELCOVID study (ClinicalTrials.gov identifier: NCT04367129), a prospective, multicenter Italian study enrolling COVID-19 patients between May to September 2020. For the model validation, we randomly selected two-thirds of participants to create a derivation dataset and we used the remaining one-third of participants as the validation set. Over the study period, 1014 hospitalized COVID-19 patients (mean age 74years, 61% males) met the inclusion criteria and were included in this analysis. During a median follow-up of 12 (IQR 7-22) days, 359 (35%) patients died. Age (HR 2.25 [95%CI 1.72-2.94], p < 0.001), delirium (HR 2.03 [2.14-3.61], p = 0.012), platelets (HR 0.91 [0.83-0.98], p = 0.018), D-dimer level (HR 1.18 [1.01-1.31], p = 0.002), signs of right ventricular strain (RVS) (HR 1.47 [1.02-2.13], p = 0.039) and ECG signs of previous myocardial necrosis (HR 2.28 [1.23-4.21], p = 0.009) were independently associated to in-hospital all-cause mortality. The derived risk-scoring system, namely EL COVID score, showed a moderate discriminatory capacity and good calibration. A cut-off score of ≥ 4 had a sensitivity of 78.4% and 65.2% specificity in predicting all-cause in-hospital mortality. ELCOVID score represents a valid, reliable, sensitive, and inexpensive scoring system that can be used for the prognostication of COVID-19 patients at admission and may allow the earlier identification of patients having a higher mortality risk who may be benefit from more aggressive treatments and closer monitoring.

Multidrug-resistant pathogens and ventilator-associated pneumonia in critically ill COVID-19 and non-COVID-19 patients: a prospective observational monocentric comparative study

BackgroundThe COVID-19 pandemic has increased the incidence of ventilator-associated pneumonia (VAP) among critically ill patients. However, a comparison of VAP incidence in COVID-19 and non-COVID-19 cohorts, particularly in a context with a high prevalence of multidrug-resistant (MDR) organisms, is lacking.Material and MethodsWe conducted a single-center, mixed prospective and retrospective cohort study comparing COVID-19 patients admitted to the intensive care unit (ICU) of the “Città della Salute e della Scienza” University Hospital in Turin, Italy, between March 2020 and December 2021 (COVID-19 group), with a historical cohort of ICU patients admitted between June 2016 and March 2018 (NON-COVID-19 group). The primary objective was to define the incidence of VAP in both cohorts. Secondary objectives were to evaluate the microbial cause, resistance patters, risk factors and impact on 28 days, ICU and in-hospital mortality, duration of ICU stay, and duration of hospitalization).ResultsWe found a significantly higher incidence of VAP (51.9% - n = 125) among the 241 COVID-19 patients compared to that observed (31.2% - n = 78) among the 252 NON-COVID-19 patients. The median SOFA score was significantly lower in the COVID-19 group (9, Interquartile range, IQR: 7–11 vs. 10, IQR: 8–13, p < 0.001). The COVID-19 group had a higher prevalence of Gram-positive bacteria-related VAP (30% vs. 9%, p < 0.001), but no significant difference was observed in the prevalence of difficult-to-treat (DTR) or MDR bacteria. ICU and in-hospital mortality in the COVID-19 and NON-COVID-19 groups were 71% and 74%, vs. 33% and 43%, respectively. The presence of COVID-19 was significantly associated with an increased risk of 28-day all-cause hospital mortality (Hazard ratio, HR: 7.95, 95% Confidence Intervals, 95% CI: 3.10-20.36, p < 0.001). Tracheostomy and a shorter duration of mechanical ventilation were protective against 28-day mortality, while dialysis and a high SOFA score were associated with a higher risk of 28-day mortality.ConclusionCOVID-19 patients with VAP appear to have a significantly higher ICU and in-hospital mortality risk regardless of the presence of MDR and DTR pathogens. Tracheostomy and a shorter duration of mechanical ventilation appear to be associated with better outcomes.

Perioperative Transfusion and Mortality for Cardiovascular Surgery: A Cohort Study Based on Population in Republic of Korea.

Objective:This study aimed to evaluate the rate of transfusion for cardiovascular surgeries between 2010 and 2019 in Republic of Korea and the association between blood transfusion and postoperative mortality. Methods: Data were extracted from the National Health Insurance Service database in Republic of Korea. This study includes adult patients who underwent cardiovascular surgery between 1 January 2010 and 31 December 2019. The endpoints were in-hospital mortality and the 1-year all-cause mortality. Results: The analysis included 62,794 cases, with transfusions used in 88.8% of cases. Multivariable logistic regression revealed that older age, comorbidities, hospital admission through the emergency room, aortic procedures (versus coronary artery bypass grafting), cardiopulmonary bypass, repeat procedures, and supportive therapies during the intensive care (extracorporeal membrane oxygenation and mechanical ventilation) were risk factors for blood transfusion. Female sex was associated with a lower risk of transfusion. Perioperative blood transfusion was associated with a 6.87-fold increased risk of in-hospital mortality (odds ratio [OR]: 6.87, 95% confidence interval [CI]: 3.95, 11.93; p < 0.001) and a 3.20-fold increased risk of 1-year all-cause mortality (OR: 3.35, 95% CI: 2.75, 3.93; p < 0.001). Conclusions: Blood transfusion is used at a high rate in cardiovascular surgeries, and it was associated with increases in the risk of in-hospital and 1-year all-cause mortality. However, these correlations should be viewed with caution as emergent phenomena rather than causative. Understanding factors associated with the need for blood transfusion can assist surgeons in predicting the outcomes of cardiovascular surgery and in tailoring procedures as needed to optimize outcomes.