Cause Of Hospital Death Research Articles

Catheter-directed interventions in acute pulmonary embolism. Position statement of SEC-Interventional Cardiology Association/SEC-Ischemic Heart Disease and Acute Cardiovascular Care Association/SEC-GT Pulmonary Hypertension Working Group

Pulmonary embolism (PE) is the leading cause of hospital death and the third most frequent cause of cardiovascular mortality. Traditionally, treatment options have included anticoagulation, thrombolysis, or surgery; however, catheter-directed interventions (CDI), including catheter-directed thrombolysis and aspiration thrombectomy, have been developed for patients with intermediate- or high-risk PE. These techniques can rapidly improve right ventricular function, hemodynamic status, and mortality in some patients, although there is a lack of evidence from randomized controlled trials. This document, prepared by the Interventional Cardiology Association, the Association of Ischemic Heart Disease and Acute Cardiovascular Care, and the Working Group on Pulmonary Hypertension of the Spanish Society of Cardiology (SEC), reviews the current recommendations and available evidence on the management of PE. It emphasizes the importance of rapid response teams, risk stratification, and early patient monitoring in identifying candidates for reperfusion. Based on existing clinical evidence on CDI, the document discusses various clinical scenarios and provides guidance on patient selection, particularly in situations of uncertainty due to insufficient evidence. Lastly, it describes periprocedural support, highlighting the necessary multidisciplinary approach to improve outcomes and reduce morbidity and mortality in patients with PE.

Intervención dirigida por catéter en la embolia aguda de pulmón. Posicionamiento SEC-Asociación de Cardiología Intervencionista/SEC-Asociación de Cardiopatía Isquémica y Cuidados Agudos Cardiovasculares/SEC-GT Hipertensión Pulmonar

Pulmonary embolism (PE) is the leading cause of hospital death and the third most frequent cause of cardiovascular mortality. Traditionally, treatment options have included anticoagulation, thrombolysis, or surgery; however, catheter-directed interventions (CDI), including catheter-directed thrombolysis and aspiration thrombectomy, have been developed for patients with intermediate- or high-risk PE. These techniques can rapidly improve right ventricular function, hemodynamic status, and mortality in some patients, although there is a lack of evidence from randomized controlled trials. This document, prepared by the Interventional Cardiology Association, the Association of Ischemic Heart Disease and Acute Cardiovascular Care, and the Working Group on Pulmonary Hypertension of the Spanish Society of Cardiology (SEC), reviews the current recommendations and available evidence on the management of PE. It emphasizes the importance of rapid response teams, risk stratification, and early patient monitoring in identifying candidates for reperfusion. Based on existing clinical evidence on CDI, the document discusses various clinical scenarios and provides guidance on patient selection, particularly in situations of uncertainty due to insufficient evidence. Lastly, it describes periprocedural support, highlighting the necessary multidisciplinary approach to improve outcomes and reduce morbidity and mortality in patients with PE.

Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis.

In 2019, 80% of the 7.4 million global child deaths occurred in low- and middle-income countries (LMICs). Global and regional estimates of cause of hospital death and admission in LMIC children are needed to guide global and local priority setting and resource allocation but are currently lacking. The study objective was to estimate global and regional prevalence for common causes of pediatric hospital mortality and admission in LMICs. We performed a systematic review and meta-analysis to identify LMIC observational studies published January 1, 2005-February 26, 2021. Eligible studies included: a general pediatric admission population, a cause of admission or death, and total admissions. We excluded studies with data before 2,000 or without a full text. Two authors independently screened and extracted data. We performed methodological assessment using domains adapted from the Quality in Prognosis Studies tool. Data were pooled using random-effects models where possible. We reported prevalence as a proportion of cause of death or admission per 1,000 admissions with 95% confidence intervals (95% CI). Our search identified 29,637 texts. After duplicate removal and screening, we analyzed 253 studies representing 21.8 million pediatric hospitalizations in 59 LMICs. All-cause pediatric hospital mortality was 4.1% [95% CI 3.4%-4.7%]. The most common causes of mortality (deaths/1,000 admissions) were infectious [12 (95% CI 9-14)]; respiratory [9 (95% CI 5-13)]; and gastrointestinal [9 (95% CI 6-11)]. Common causes of admission (cases/1,000 admissions) were respiratory [255 (95% CI 231-280)]; infectious [214 (95% CI 193-234)]; and gastrointestinal [166 (95% CI 143-190)]. We observed regional variation in estimates. Pediatric hospital mortality remains high in LMICs. Global child health efforts must include measures to reduce hospital mortality including basic emergency and critical care services tailored to the local disease burden. Resources are urgently needed to promote equity in child health research, support researchers, and collect high-quality data in LMICs to further guide priority setting and resource allocation.

Inflammation, Sepsis, and the Coagulation System.

Sepsis has been a major health problem for centuries and it is still the leading cause of hospital deaths. Several studies in the past decades have identified numerous biochemical abnormalities in severe cases, and many of these studies provide evidence of the perturbation of the hemostatic system. This can result in complications, such as disseminated intravascular coagulation that can lead to multiorgan failure. Nevertheless, large clinical studies have demonstrated that the simple approach of inhibiting the coagulation processes by any means fails to provide significant improvement in the survival of septic patients. A cause of this failure could be the fact that in sepsis the major clinical problems result not primarily from the presence of the infective agent or enhanced coagulation but from the complex dysregulated systemic host response to pathogens. If this overt reaction is not fully deciphered, appropriate interference is highly unlikely and any improvement by conventional therapeutic interventions would be limited. Cellular activation in sepsis can be targeted by novel approaches like inhibition of the heterotypic cellular interactions of blood cells by targeting surface receptors or posttranscriptional control of the hemostatic system by noncoding ribonucleic acid (RNA) molecules. Stable RNA molecules can affect the expression of several proteins. Thus, it can be anticipated that modulation of microRNA production would result in a multitude of effects that may be beneficial in septic cases. Here, we highlight some of the recent diagnostic possibilities and potential novel routes of the dysregulated host response.

IFITM3 overexpression reverses insufficient healing benefits of small extracellular vesicles from high-fat-diet BMSCs in sepsis via the HMGB1 pathway

Bone marrow mesenchymal stem cells (BMSCs) are a promising new therapy for sepsis, a common cause of death in hospitals. However, the global epidemic of metabolic syndromes, including obesity and pre-obesity, threatens the health of the human BMSC pool. The therapeutic effects of BMSCs are primarily due to the secretion of the small extracellular vesicles containing lipids, proteins, and RNA. Accordingly, studies on BMSCs, their small extracellular vesicles, and their modifications in obese individuals are becoming increasingly important. In this study, we investigated the therapeutic potential of small extracellular vesicles (sEVs) from high-fat diet BMSCs (sEVsHFD) in sepsis-induced liver-heart axis injury. We found that sEVsHFD yielded diminished therapeutic benefits compared to sEVs from chow diet BMSCs (sEVsCD). We subsequently verified that IFITM3 significantly differed in sEVsCD and sEVsHFD, alternating in septic liver tissue, and indicating its potential as a remodeling target of sEVs. IFITM3-overexpressed high-fat-diet BMSCs (HFD-BMSCs) showed that corresponding sEVs (sEVsHFD-IFITM3) markedly ameliorated liver-heart axis injury during sepsis. Lastly, we identified the protective action mechanisms of sEVsHFD-IFITM3 in sepsis-induced organ failure and HMGB1 expression and secretion was altered in septic liver and serum while HMGB1 has been demonstrated as a critical mediator of multi-organ failure in sepsis. These findings indicate that IFITM3 overexpression regenerates the therapeutic benefit of sEVs from HFD-BMSCs in sepsis via the HMGB1 pathway.

Prevalence of Carbapenemases in Carbapenem-Resistant Acinetobacter baumannii Isolates from the Kingdom of Bahrain.

Acinetobacter baumannii is regarded as a significant cause of death in hospitals. The WHO recently added carbapenem-resistant Acinetobacter baumannii (CRAB) to its global pathogen priority list. There is a dearth of information on CRAB from our region. Fifty CRAB isolates were collected from four main hospitals in Bahrain for this study. Bacterial identification and antibiotic susceptibility tests were carried out using the BD PhoenixTM and VITEK-2 compact, respectively. Using conventional PCR, these isolates were further screened for carbapenem resistance markers (blaOXA-51, blaOXA-23, blaOXA-24, blaOXA-40, blaIMP, blaNDM, blaVIM, and blaKPC). All of the isolates were resistant to imipenem (100%), meropenem (98%), and cephalosporins (96-98%), followed by other commonly used antibiotics. All these isolates were least resistant to gentamicin (64%). The detection of resistance determinants showed that the majority harbored blaOXA-51 (100%) and blaIMP (94%), followed by blaOXA-23 (82%), blaOXA-24 (46%), blaOXA-40 (14%), blaNDM (6%), blaVIM (2%), and blaKPC (2%). The study isolates showed a high level of antibiotic resistance. Class D carbapenemases were more prevalent in our CRAB isolate collection. The resistance genes were found in various combinations. This study emphasizes the importance of strengthening surveillance and stringent infection control measures in clinical settings to prevent the emergence and further spread of such isolates.

502 The Most Common Pathogens Isolated From Mechanically Ventilated Burn Patients With and Without Inhalation Injury

Abstract Introduction The lung microbiota of patients with inhalation injury (INHI) may be distinct from those who do not have INHI. Furthermore, the lung trauma from mechanical ventilation or INHI can increase the risk of ventilator-associated pneumonia (VAP), a leading cause of death in hospital acquired infections. The purpose of this study was to identify the main pathogens isolated from mechanically ventilated patients, with and without INHI, including those that develop VAP to test the hypothesis that INHI itself influences the bacterial present in airways. Methods Data was collected via a single institution retrospective review using the Burn Registry and adjacent health records from 1/1/2019 to 12/31/2021. VAP was defined as a hospital-acquired pneumonia that developed ≥ 48 hours of mechanical ventilation and positive culture was growth of any microorganism. Data were examined for the 3 most common pathogens cultured from respiratory samples obtained via bronchoalveolar lavage (BAL), mini-BAL, or sputum induction. Results The 3 most common pathogens cultured from respiratory samples are presented as the percentage of the cohort in which each pathogen was identified. In all mechanically ventilated patients (n=213), Staphylococcus aureus (15.9%), Pseudomonas aeruginosa (9.9%), and Diphtheroid (9.9%) were most commonly isolated. In all patients with INHI (n=78), S. aureus (21.3%), Diphtheroid (13.3%), and gamma hemolytic Streptococcus (10.7%) were the most common. In all patients with no INHI (n=135), S. aureus (14.1%), P. aeruginosa (10.9%) and Diphtheroid (7.0%) were the most common. In those with INHI and with VAP (n=3), S. aureus (100%) was present in addition to P. aeruginosa, Klebsiella pneumoniae, Acinetobacter baumannii, and Klebsiella aerogenes which were each in 33% of patients. In those with INHI and without VAP (n=75), S. aureus (17.3%), Diphtheroid (13.3%), and gamma hemolytic Strep. (10.7%) were the most cultured. P. aeruginosa was in 8% of patients. In those with no INHI and with VAP (n=7), the most common bacteria were S. aureus (57.1%) followed by Enterobacter cloacae, P. aeruginosa, gamma hemolytic Strep., Diphtheroid, E. coli, A. baumanii, and S. pneumoniae which were each in 28.6% of patients. In those with no INHI and no VAP (n=128), S. aureus (10.9%), P. aeruginosa (9.4%) were found and alpha hemolytic Strep., Diphtheroid, K. pneumoniae and coagulase negative Staph. were each in 7% of patients. Conclusions All VAP patients had polymicrobial infections. Differences in the most common pathogens of ventilated patients with INHI versus those without INHI were seen. P. aeruginosa was not one of the top 3 pathogens in patients with INHI and MRSA was not one of the top 3 pathogens for either group. Follow up studies with a larger VAP sample size are needed to evaluate whether these trends are significant and generalizable. Applicability of Research to Practice Understanding the microbiology of patients with and without INHI can guide targeted antibiotic treatment.

The effect of thioredoxin-1 in a rat model of traumatic brain injury depending on diurnal variation.

Traumatic brain injury (TBI) is a public health concern with limited treatment options because it causes a cascade of side effects that are the leading cause of hospital death. Thioredoxin is an enzyme with neuroprotective properties such as antioxidant, antiapoptotic, immune response modulator, and neurogenic, among others; it has been considered a therapeutic target for treating many disorders. The controlled cortical impact (CCI) model was used to assess the effect of recombinant human thioredoxin 1 (rhTrx1) (1 μg/2 μL, intracortical) on rats subjected to TBI at two different times of the light-dark cycle (01:00 and 13:00h). We analyzed the food intake, body weight loss, motor coordination, pain perception, and histology in specific hippocampus (CA1, CA2, CA3, and Dental Gyrus) and striatum (caudate-putamen) areas. Body weight loss, reduced food intake, spontaneous pain, motor impairment, and neuronal damage in specific hippocampus and striatum regions are more evident in rats subjected to TBI in the light phase than in the dark phase of the cycle and in groups that did not receive rhTrx1 or minocycline (as positive control). Three days after TBI, there is a recovery in body weight, food intake, motor impairment, and pain, which is more pronounced in the rats subjected to TBI at the dark phase of the cycle and those that received rhTrx1 or minocycline. Knowing the time of day a TBI occurs in connection to the neuroprotective mechanisms of the immune response in diurnal variation and the usage of the Trx1 protein might have a beneficial therapeutic impact in promoting quick recovery after a TBI.

Evaluation of Pattern of Lesions Depicted on Brain Computed Tomography Scan of Patients Presenting with Stroke in Zaria, Nigeria.

Stroke is a major public health problem worldwide and it is the third leading cause of death in industrialized countries and ranks among the five most common causes of hospital deaths in adults in Africa. Accurate stroke diagnosis has a high significance for patient's outcome. Computed tomography (CT) brain scan is the imaging of choice for patients presenting to the emergency department with stroke. The study aimed at evaluating the pattern of lesion depicted on CT brain of patients presenting with stroke in ABUTH, Zaria. A prospective review of CT findings in 155 patients who presented in the Radiology Department of Ahmadu Bello University Teaching Hospital (ABUTH) with clinical diagnosis of stroke was undertaken over a period of six months (from October 2017 to April 2018).. Of the 155 patients seen within the period under review, 88 (56.8%) were males while 67 (43.2%) were females. Age range was 11-90 years (mean 56, standard deviation (SD) 16, 44(28.4%) of patients were in the age group of 61-70 years. Ninety six patients (61.9%) had ischaemic stroke, 27(17.4%) had hemorrhagic stroke, eight (5.2%) was stroke mimic, six patients (3.9%) mixed lesions (ie both ischaemic and haemorrhagic). Eighteen patients (11.6%) had normal brain CT findings. The region most affected by stroke was the parietal region 52(38%). Ischaemic stroke is the most common form of stroke in this study.

Clinical outcomes and prognostic factors of patients with sepsis caused by intra-abdominal infection in the intensive care unit: a post-hoc analysis of a prospective cohort study in Korea

BackgroundSepsis is the most common cause of death in hospitals, and intra-abdominal infection (IAI) accounts for a large portion of the causes of sepsis. We investigated the clinical outcomes and factors influencing mortality of patients with sepsis due to IAI.MethodsThis post-hoc analysis of a prospective cohort study included 2126 patients with sepsis who visited 16 tertiary care hospitals in Korea (September 2019–February 2020). The analysis included 219 patients aged > 19 years who were admitted to intensive care units owing to sepsis caused by IAI.ResultsThe incidence of septic shock was 47% and was significantly higher in the non-survivor group (58.7% vs 42.3%, p = 0.028). The overall 28-day mortality was 28.8%. In multivariable logistic regression, after adjusting for age, sex, Charlson Comorbidity Index, and lactic acid, only coagulation dysfunction (odds ratio: 2.78 [1.47–5.23], p = 0.001) was independently associated, and after adjusting for each risk factor, only simplified acute physiology score III (SAPS 3) (p < 0.001) and continuous renal replacement therapy (CRRT) (p < 0.001) were independently associated with higher 28-day mortality.ConclusionsThe SAPS 3 score and acute kidney injury with CRRT were independently associated with increased 28-day mortality. Additional support may be needed in patients with coagulopathy than in those with other organ dysfunctions due to IAI because patients with coagulopathy had worse prognosis.

Impact of a multidisciplinary sepsis huddle in the emergency department

BackgroundSepsis is a leading cause of death in hospitals requiring prompt recognition and treatment. The sepsis bundle is the cornerstone of sepsis treatment. Studies have evaluated the impact of a sepsis huddle on sepsis bundle compliance but not in sepsis identification. ObjectiveMeasure the effect of a multidisciplinary sepsis bedside huddle in the Emergency Department (ED) on sepsis identification and sepsis bundle compliance. MethodsRetrospective, single-center, cohort study. Pre-huddle patients were identified via Best Practice Advisory (BPA) alert on the electronic medical record from 11/01/2019–3/31/2020. The post-huddle group were patients for whom a sepsis huddle was activated from 11/01/2020–3/31/2021. Results116 patients met inclusion criteria and 15 were determined to not have sepsis for a total of 21 pre-huddle and 80 post-huddle patients. Comparing pre-post results, sepsis huddle increased code sepsis activation (10% vs 91%, p < 0.001); sepsis bundle compliance (24% vs 80%, p < 0.001); antibiotics within one hour (33% vs 90%, p < 0.001); culture within one hour (67% vs 95%, p < 0.001), order entry <30 min. (29% vs 86%, p < 0.001); and median order entry time (48 vs. 3 min, p < 0.001). Post-huddle, 80% of order entries were ≤ 20 min. Logistic regression predicting sepsis code found huddle to be the first predictor, (p < 0.0000005). Hour-1 bundle compliance was predicted by physician/physician assistant order ≤30 min (R2 = 0.36, p < 0.0000005). ConclusionSepsis bedside huddle in the ED improves identification and sepsis bundle compliance. Results suggest increased order entry speed caused bundle improvement.

Detection of Extended-spectrum Beta-lactamases (ESBLs), Carbapenemase, Metallo-β-lactamase Production Bacteria and Antibiotic Susceptibility Pattern in Hospitalized Patients with Ventilator-associated Pneumonia

Background: Due to the increase in microbial resistance, nosocomial multidrug resistance infections, including ventilator-associated pneumonia (VAP), are presently one of the main causes of death in hospitals since they are difficult to treat. Objectives: This study aimed to investigate the bacterial etiology of VAP and their microbial resistance pattern in Dezful Hospital, southwest of Iran. Methods: In this cross-sectional study, 131 bacterial isolates were isolated from the respiratory secretions of the patients with VAP in ICU wards. Antibiotic susceptibility testing (AST) of all isolates was carried out after the identification. Then the extended-spectrum beta-lactamases (ESBLs), carbapenemase, and metallobetalactamase were identified by phenotyping and genotyping. Results: The most frequent isolates were Staphylococcus aureus (30.5%), Acinetobacter baumannii (25.2%), and Klebsiella pneumoniae (24.4%). All strains of S. aureus were sensitive to vancomycin, ticoplanin, quinupristin-dalfopristin, and linezolid. Escherichia coli and Klebsiella showed high resistance to cephalosporins. More than 93% of Acinetobacter isolates were resistant to carbapenem and quinolones. The overall prevalence of ESBLs and carbapenemase producing bacteria were 80.43% and 73.6%, respectively. The most frequent ESBLs gene was blaCTX-M gene (78.3%) followed by blaAMP-C gene (67.5%), blaSHV gene (64.8%), and blaTEM gene (54%). Conclusions: In sum, there was a possibility that the treatment of nosocomial multidrug resistant infections such as VAP would become a major challenge. Therefore, it was recommended that AST results should always be considered when selecting the appropriate treatment regimen. Furthermore, it was found important to emphasize the principles of antibiotic stewardship and to constantly monitor the pattern of microbial susceptibility.

Down-Regulation of CXCR4 in Mesenchymal Stem Cells by Septic Serum.

Sepsis is one of the main concerns of health and one of the leading causes of death in hospitals. It is essential to manage sepsis in hospitalized patients. In recent years, cell therapy has been considered as a new approach to treat sepsis. This study evaluated the effect of CXCR4 as one of the main proteins involved in the homing of mesenchymal stem cells in the sepsis serum in mice model. Mouse sepsis model was induced by injection of E.coli and biochemical analyses was done to confirm the organ failure. Mesenchymal stem cells (MSCs) derived from bone marrow were separated into sepsis and control groups. In the sepsis serum group, MSCs were treated with sepsis serum at two time points: 24 and 48h. Quantitative RT-PCR and flow cytometry were performed to determine the mRNA expression of CXCR4 in sepsis serum group compared to control group. Also, a migration assay was done to assess the migration capacity of bone marrow MSCs during inflammation and treatment in sepsis. Our result showed that treatment with sepsis serum can control migration by decrease in CXCR4 level (P ≤ 0.05) compared to control group. Moreover it was also reported that sepsis serum decreased mRNA expression of CXCR4 in MScs. In our study, MSCs treated with septic serum were no longer able to migrate . Probably many variables such as source, dose, injection time, and injection route of MSCs after sepsis induction in the animal models are key factors for successful cell therapy.

Adverse Event Reporting Priorities: An Integrative Review.

Adverse events remain the third leading cause of death in hospitals today, after heart disease and cancer. However, adverse events remain underreported. The purpose of this integrative review is to synthesize adverse event reporting priorities in acute care hospitals from quantitative, qualitative, and mixed-methods research articles. A comprehensive review of articles was conducted using nursing, medicine, and communication databases between January 1, 1999, and May 3, 2021. The literature was described using standard reporting criteria. Twenty-nine studies met the eligibility criteria. Four key priorities emerged: understanding and reducing barriers, improving perceptions of adverse event reporting within healthcare hierarchies, improving organizational culture, and improving outcomes measurement. A paucity of literature on adverse event reporting within acute care hospital settings was found. Perceptions of fear of blaming and retaliation, lack of feedback, and comfort level of challenging someone more powerful present the greatest barriers to adverse event reporting. Based on qualitative studies, obtaining trusting relationships and sustaining that trust, especially in hierarchical healthcare systems, are difficult to achieve. Given that patient safety training is a common strategy clinically to improve organizational culture, only 4 published articles examined its effectiveness. Further research in acute care hospitals is needed on all 4 key priorities. The findings of this review may ultimately be used by clinicians and researchers to reduce adverse events and develop future research questions.

Interaction Between Altered Gut Microbiota and Sepsis: A Hypothesis or an Authentic Fact?

Sepsis, as an important public health concern, is one of the leading causes of death in hospitals around the world, accounting for 25% of all deaths. Nowadays, several factors contribute to the development of sepsis. The role of the gut microbiota and the response state of the aberrant immune system is dominant. The effect of the human microbiome on health is undeniable, and gut microbiota is even considered a body organ. It is now clear that the alteration in the normal balance of the microbiota (dysbiosis) is associated with a change in the status of immune system responses. Owing to the strong association between the gut microbiota and its metabolites particularly short-chain fatty acids with many illnesses, the gut microbiota has a unique position in the research of microbiologists and even clinicians. This review aimed to analyze studies' results on the association between microbiota and sepsis, with a substantial understanding of their relationship. As a result, an extensive and comprehensive search was conducted on this issue in existing databases.

Ventricular Unloading Using the ImpellaTM Device in Cardiogenic Shock.

Cardiogenic shock (CS) remains a leading cause of hospital death. However, the use of mechanical circulatory support has fundamentally changed CS management over the last decade and is rapidly increasing. In contrast to extracorporeal membrane oxygenation as well as counterpulsation with an intraaortic balloon pump, ventricular unloading by the Impella™ device actively reduces ventricular volume as well as pressure and augments systemic blood flow at the same time. By improving myocardial oxygen supply and enhancing systemic circulation, the Impella device potentially protects myocardium, facilitates ventricular recovery and may interrupt the shock spiral. So far, the evidence supporting the use of Impella™ in CS patients derives mostly from observational studies, and there is a need for adequate randomized trials. However, the Impella™ device appears a promising technology for management of CS patients. But a profound understanding of the device, its physiologic impact and clinical application are all important when evaluating CS patients for percutaneous circulatory support. This review provides a comprehensive overview of the percutaneous assist device Impella™. Moreover, it highlights in depth the rationale for ventricular unloading in CS and describes practical aspects to optimize care for patients requiring hemodynamic support.

Outcomes after implementation of prophylactic protocol for venous thromboembolism in surgical patients: A retrospective cohort study

IntroductionVenous thromboembolism (VTE) in surgical patients is a preventable cause of hospital death. In previous studies, the prevalence of VTE decreased after implementing a prophylactic protocol. Because of the low rate of VTE prophylaxis in Thailand, we studied the outcomes after the implementation of a VTE prophylactic protocol in our hospital. MethodsA retrospective cohort single-center study was conducted from November 2019 to November 2020 in the Department of Surgery. We established the VTE prophylactic protocol using a multidisciplinary team approach and the Caprini score risk assessment model. The outcomes were the incidence of symptomatic VTE, VTE-related death, risk factors, and safety. ResultsIn total, 6983 patients were admitted to the surgical department during the study period. After excluding patients with current VTE and missing data, 4579 patients were enrolled in this study, and 1579 (34.5%) patients at high risk for VTE were identified. The use of pharmacological prophylaxis, mechanical prophylaxis, and early ambulation in the entire cohort was lower than that in high-risk patients (7.99%, 19.81%, and 21.56% vs. 15.77%, 31.10%, and 46.55%, respectively). In the comparison of before and after implementation, the prevalence of symptomatic VTE and 30-day mortality of VTE decreased from 1.20% to 0.37% and from 0.11% to 0.02%, respectively. No major bleeding occurred. ConclusionsAfter protocol implementation, the prevalence of symptomatic VTE and VTE-related death decreased. The VTE prophylaxis was safe. We highly recommended using a multidisciplinary team approach VTE prophylaxis in high-risk surgical patients.

Impact of the implementation of a Sepsis Code Program in medical patient management: a cohort study in an Internal Medicine ward.

IntroductionSepsis is the main cause of death in hospitals and the implementation of diagnosis and treatment bundles has shown to improve its evolution. However, there is a lack of evidence about patients attended in conventional units.MethodsA 3-year retrospective cohort study was conducted. Patients hospitalized in Internal Medicine units with sepsis were included and assigned to two cohorts according to Sepsis Code (SC) activation (group A) or not (B). Baseline and evolution variables were collected.ResultsA total of 653 patients were included. In 296 cases SC was activated. Mean age was 81.43 years, median Charlson comorbidity index (CCI) was 2 and 63.25% showed some functional disability. More bundles were completed in group A: blood cultures 95.2% vs 72.5% (p < 0.001), extended spectrum antibiotics 59.1% vs 41.4% (p < 0.001), fluid resuscitation 96.62% vs 80.95% (p < 0.001). Infection control at 72 hours was quite higher in group A (81.42% vs 55.18%, odds ratio 3.55 [2.48-5.09]). Antibiotic was optimized more frequently in group A (60.77% vs 47.03%, p 0.008). Mean in-hospital stay was 10.63 days (11.44 vs 8.53 days, p < 0.001). Complications during hospitalization appeared in 51.76% of patients, especially in group B (45.95% vs 56.58%, odds ratio 1.53 [1.12-2.09]). Hospital readmissions were higher in group A (40% vs 24.76%, p < 0.001). 28-day mortality was significantly lower in group A (20.95% vs 42.86%, odds ratio 0.33 [0.23-0.47]).ConclusionsImplementation of SC seems to be effective in improving short-term outcomes in IM patients, although therapy should be tailored in an individual basis.

Identifying adverse drug reactions from free-text electronic hospital health record notes.

BackgroundAdverse drug reactions (ADRs) are estimated to be the fifth cause of hospital death. Up to 50% are potentially preventable and a significant number are recurrent (reADRs). Clinical decision support systems have been used to prevent reADRs using structured reporting concerning the patient's ADR experience, which in current clinical practice is poorly performed. Identifying ADRs directly from free text in electronic health records (EHRs) could circumvent this.AimTo develop strategies to identify ADRs from free‐text notes in electronic hospital health records.MethodsIn stage I, the EHRs of 10 patients were reviewed to establish strategies for identifying ADRs. In stage II, complete EHR histories of 45 patients were reviewed for ADRs and compared to the strategies programmed into a rule‐based model. ADRs were classified using MedDRA and included in the study if the Naranjo causality score was ≥1. Seriousness was assessed using the European Medicine Agency's important medical event list.ResultsIn stage I, two main search strategies were identified: keywords indicating an ADR and specific prepositions followed by medication names. In stage II, the EHRs contained a median of 7.4 (range 0.01‐18) years of medical history covering over 35 000 notes. A total of 318 unique ADRs were identified of which 63 were potentially serious and 179 (sensitivity 57%) were identified by the rule. The method falsely identified 377 ADRs (positive predictive value 32%). However, it also identified an additional eight ADRs.ConclusionTwo key strategies were developed to identify ADRs from hospital EHRs using free‐text notes. The results appear promising and warrant further study.

Machine learning prediction of mortality in venous thromboembolism patients: the Birmingham Black Country Venous Thromboembolism (BBC-VTE) cohort

Abstract Introduction Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the main causes of preventable death in hospitals in the UK. Current clinical risk scores to predict mortality of patients with VTE are the pulmonary embolism severity index (PESI) and the simplified PESI (sPESI) which have similar predictive power. Purpose To evaluate the ability of machine learning algorithms to predict mortality in patients admitted with VTE and to compare their predictive capability with the sPESI score for 30-day mortality. Methods The BBC-VTE was a retrospective multicentre patient cohort established to determine clinical features and novel aspects of risk prediction for VTE (and VTE-related complications) in a contemporary cohort. We include a cohort of 1554 patients (mean age 65.6 years; 53% female) who represent all consecutive admissions with a final diagnosis of VTE to one of 3 regional hospitals in the West Midlands, UK during the years 2012–2014. The dataset was split into training (70%) and validation (30%) cohorts. We trained two tree-based models, Random Forests (RF) and XGBoost (XG), using 5-fold cross-validation on the training cohort to predict patient mortality. This was validated using the held-out validation cohort and compared to a simple logistic regression model. To provide a comparison with the sPESI score, we extracted a sub-group of patients (n=652) who had values for oxygen saturation, systolic blood pressure, heart rate, history of cancer, history of cardiopulmonary disease, and age. We used RF to determine the mortality prediction using: i) only the sPESI variables listed and; ii) all the clinical variables available to us. This was then compared against the standard sPESI prediction for this cohort. C-indices (AUC) were used for comparison. Results The c-indices for RF and XG using the full patient cohort were 0.85 [95% CI: 0.80 – 0.90] (Fig. 1a) and 0.82 [95% CI: 0.77 - 0.87], with the logistic regression c-index being 0.83 [95% CI: 0.78 – 0.88]. The reported sPESI c-index was significantly smaller (p&amp;lt;0.05) than the RF c-index (0.75 [95% CI: 0.69–0.80]). The most important features for prediction of mortality indicated by the RF algorithm are age, admission blood levels, discharge oral anticoagulation, and previous malignancy (Fig. 2). The sPESI score c-index for the subgroup of patients was found to be 0.72. In comparison, using RF with the same variables gives a significantly larger (p&amp;lt;0.05) c-index of 0.78 [95% CI: 0.73 – 0.83]. When using all clinical variables available the c-index increased to 0.85 [95% CI: 0.80 – 0.90] (Fig. 1b). Conclusion Application of machine learning using simple clinical variables in hospital settings can improve prediction of mortality post-VTE event above-and-beyond the current simplified PESI risk score. Prospective study is warranted to validate the algorithm on external datasets and to construct individualised risk predictions. Funding Acknowledgement Type of funding sources: None. Figure 1. ROC curve comparisons with sPESIFigure 2. Feature Importances