In-hospital Death Research Articles

Hospital referrals, exclusions from hospital care, and deaths among long-term care residents in the Community of Madrid during the March–April 2020 COVID-19 epidemic period: a multivariate time series analysis

BackgroundFrom March 7 to April 7, 2020, the Community of Madrid (CoM), Spain, issued interventions in response to the COVID-19 epidemic, including hospital referral triage protocols for long-term care facility (LTCF) residents (March 18–25). Those with moderate to severe physical disability and cognitive impairment were excluded from hospital referral. This research assesses changes in the association between daily hospital referrals and the deaths of LTCF residents attributable to the triage protocols.MethodsDaily hospital referrals and all-cause mortality from January to June 2020 among LTCF residents and the CoM population aged 65 + were obtained. Significant changes in LTCF resident daily hospital referrals time series, and in-LTCF and in-hospital daily deaths, were examined with tests for breaks and regimes in time series. Multivariate time series analyses were conducted to test changes in the associations between LTCF resident hospital referrals with daily deaths in-hospital and in-LTCF, and in the CoM population aged 65 + when the triage protocols were implemented.ResultsAmong LTCF residents, hospital referrals declined sharply from March 6 to March 23, 2020. Increases in LTCF residents' daily deaths occurred from March 7 to April 1, followed by a decrease reaching pre-epidemic levels after April 28. The daily ratio of in-hospital deaths to in-LTCF deaths reached its lowest values from March 9 to April 19, 2020. The four versions of the triage protocol, published from March 18 to March 25 had no impact on further changes in the association of hospital referrals with daily deaths of LTCF residents in-hospital or in-LTCF.ConclusionsWhile LTCF residents’ deaths increased, hospital referrals of LTCF residents decreased with the introduction of the CoM governmental interventions on March 7. They were implemented before the enactment of the triage protocols, protecting hospitals from collapse while overlooking the need for standards of care within LTCFs. The CoM triage protocols sanctioned the existing restrictions on hospital referrals of LTCF residents.

Daily steps are a predictor of, but perhaps not a modifiable risk factor for Parkinson's Disease: findings from the UK Biobank.

Higher physical activity levels have been suggested as a potential modifiable risk factor for lowering the risk of incident Parkinson's disease (PD). This study uses objective measures of physical activity to investigate the role of reverse causation in the observed association. To investigate the association between accelerometer-derived daily step count and incident PD, and to assess the impact of reverse causation on this association. This prospective cohort study involved a follow-up period with a median duration of 7.9 years, with participants who wore wrist-worn accelerometers for up to 7 days. The study was conducted within the UK Biobank, a large, population-based cohort. The analysis included 94,696 participants aged 43-78 years (56% female) from the UK Biobank who provided valid accelerometer data and did not have prevalent PD. Daily step counts were derived using machine learning models to determine the median daily step count over the monitoring period. The primary outcome was incident PD, identified through hospital admission and death records. Cox proportional hazards regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) for the association between daily step count and incident PD, with adjustments for various covariates and evaluation of reverse causation by splitting follow-up periods. During a median follow-up of 7.9 years (IQR: 7.4-8.4), 407 incident PD cases were identified. An inverse linear association was observed between daily step count and incident PD. Participants in the highest quintile of daily steps (>12,369 steps) had an HR of 0.41 (95% CI 0.31-0.54) compared to the lowest quintile (<6,276 steps; HR 1.00; 95% CI 0.84-1.19). A per 1,000 step increase was associated with an HR of 0.92 (95% CI 0.89-0.94). However, after excluding the first six years of follow-up, the association was not significant (HR 0.96, 95% CI 0.92-1.01). The observed association between higher daily step count and lower incident PD is likely influenced by reverse causation, suggesting changes in physical activity levels occur years before PD diagnosis. While step counts may serve as a predictor for PD, they may not represent a modifiable risk factor. Further research with extended follow-up periods is warranted to better understand this relationship and account for reverse causation.

Use of Neutrophil-to-Lymphocyte Ratio to Predict In-Hospital Mortality in Patients Admitted with Acute Decompensation of Atrial Fibrillation.

Background/Objectives: The prevalence of atrial fibrillation (AF) has been on the rise over the last 20 years. It is considered to be the most common cardiac arrhythmia and is associated with significant morbidity and mortality. The need for in-hospital management of patients having AF is increasing. Acute decompensation of cardiac rhythm is an indication for hospital admission. In the existing literature, several studies on different pathologies have observed that the risk of death was greater for patients with an increased neutrophil-to-lymphocyte ratio (NLR) and suggested that the NLR can be a useful biomarker to predict in-hospital mortality. This study aims to evaluate the link between the neutrophil-to-lymphocyte ratio at admission and death among the patients admitted to the medical ward for the acute manifestation of AF, and to gain a better understanding of how we can predict in-hospital all-cause death based on the NLR for these patients. Methods: A single-center retrospective study in an academic medical clinic was conducted. We analyzed if the NLR at in-hospital admission can be related to in-hospital mortality among the patients admitted for AF at the Medical Ward of Municipal Emergency University Hospital Timisoara between 2015 and 2016. After identifying a total of 1111 patients, we divided them into two groups: in-hospital death patients and surviving patients. We analyzed the NLR in both groups to determine if it is related to in-hospital mortality or not. One patient was excluded because of missing data. Results: Our analysis showed that patients who died during in-hospital admission had a significantly higher NLR compared to those who survived (p < 0.0001, 95% CI (1.54 to 3.48)). The NLR was found to be an independent predictor of in-hospital death among patients with AF, even for the patients with no raised level of blood leukocytes (p < 0.0001, 95% CI (0.6174 to 3.0440)). Additionally, there was a significant correlation between the NLR and the risk of in-hospital death for patients admitted with decompensated AF (p < 0.0001), with an area under the ROC curve of 0.745. Other factors can increase the risk of death for these patients (such as the personal history of stroke, HAS-BLED score, and age). Conclusions: The NLR is a useful biomarker to predict in-hospital mortality in patients with AF and can predict the risk of death with a sensitivity of 72.8% and a specificity of 70.4%. Further studies are needed to determine the clinical utility of the NLR in risk stratification and management of patients with AF.

Relationship Between CHA₂DS₂-VASc Score on Admission and In-Hospital Major Adverse Cardiovascular Events in Patients Diagnosed With ST-Elevation Myocardial Infarction.

The CHA₂DS₂-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, sex) scoring system, which includes conventional risk factors of coronary artery disease, was originally created to quantify the risk of thromboembolism in patients with atrial fibrillation. This study evaluated the usefulness of this score to predict adverse outcomes in STEMI (ST-elevation myocardial infarction) patients without atrial fibrillation. Primary end points were identified as MACE (major adverse cardiovascular events) which included in-hospital death or cerebrovascular accident. MACE rate was 10% (193 patients). The CHA₂DS₂-VASc score was an independent predictor of MACE (95% CI, 2.31 [1.37-3.9]; P = .0016). Other independent predictors of MACE included heart rate (95% CI, 1.56 [0.97-2.50]; P = .0242), admission Killip class (95% CI, 24.19 [10.74-54.46]; P < .0001), admission creatinine level (95% CI, 1.54 [1.10-2.16]; P = .0024), peak CK-MB level (95% CI, 1.63 [0.98-2.70]; P = .0001), and no-reflow (95% CI, 2.45 [1.25-4.80]; P = .0085). A nomogram was developed to estimate the risk of in-hospital adverse outcomes for STEMI patients. The CHA₂DS₂-VASc score was an independent predictor of MACE in STEMI patients. Linear analysis of CHA₂DS₂-VASc score without dichotomization was the main difference of this study from others.

The Etiology of Non-traumatic Loss of Consciousness in Patients Admitted to the Emergency Department

Background: Loss of consciousness (LOC) is one of the most common complaints in the emergency department (ED). This disorder can result from a wide range of clinical conditions, such as structural brain damage, infection, shock, respiratory failure, or psychiatric disorders. Objectives: This study was conducted with the aim of investigating the cause and prognosis of patients with non-traumatic LOC referred to two referral hospitals of Mashhad University. Methods: This prospective cohort study was conducted on 1000 patients presenting with complaints of LOC at Ghaem and Imam Reza hospitals in Mashhad in 2020. All patients with a decreased level of consciousness and a Glasgow Coma Scale (GCS) score of less than 14 were included in the investigation. Results: A total of 1037 patients participated in this study, while 37 patients were excluded. Of the participants, 524 (52.4%) were men and 476 (47.6%) were women. The average age was 59.85 ± 16.06 years, ranging from 18 to 95 years. The relatively common causes of LOC included sepsis (38.3%), stroke (9.2%), heart failure (8%), myocardial infarction (7.3%), meningitis (7.2%), hepatic encephalopathy (6.5%), and toxic alcohol ingestion (5.8%). Deceased patients were older, had higher respiratory rates and temperatures, and had lower blood sugar and blood pressure upon admission. A previous history of stroke, hyperlipidemia, hypertension, and diabetes were associated with death. The relationships between different study outcomes were assessed using multivariate binary logistic regression; a two-sided P &lt; 0.05 was considered significant. Conclusions: Patients presenting to the ED with LOC are more likely to die, making LOC a potential prognostic factor for in-hospital death.

Global Leadership Initiative on Malnutrition criteria using calf and upper arm circumference as phenotypic criteria for assessing muscle mass demonstrate satisfactory validity for diagnosing malnutrition in hospitalized patients: A prospective cohort study.

Hospitalized individuals present high rates of malnutrition and loss of muscle mass (MM). Imaging techniques for assessing MM are expensive and scarcely available in hospital practice. The Global Leadership Initiative on Malnutrition (GLIM) proposed a framework for malnutrition diagnosis that includes simple measurements to assess MM, such as calf circumference (CC) and mid-upper arm circumference (MUAC). This study aimed to analyze the validity of the GLIM criteria with CC and MUAC for malnutrition diagnosis, using Subjective Global Assessment (SGA) as the reference standard, in inpatients. A prospective cohort study was conducted on 453 inpatient adults in a university hospital. The presence of malnutrition was assessed within 48 h of hospital admission using SGA and GLIM criteria using CC and MUAC as phenotypic criteria for malnutrition diagnosis. Accuracy, agreement tests, and logistic regression analysis adjusted for confounders were performed to test the validity of the GLIM criteria for malnutrition diagnosis. The patients were aged 59 (46-68) years, 51.4% were male, and 67.8% had elective surgery. Compared with SGA, the GLIM criteria using the two MM assessment measures showed good accuracy (area under the curve > 0.80) and substantial agreement (κ > 0.60) for diagnosing malnutrition. The highest sensitivity was obtained with GLIMCC (89%), whereas GLIMMUAC showed high specificity (>90%). Also, malnutrition identified by GLIMCC and GLIMMUAC was significantly associated with prolonged hospitalization and in-hospital death. In the absence of imaging techniques to assess MM, the use of CC and MUAC measurements from the GLIM criteria demonstrated satisfactory validity for diagnosing malnutrition in hospitalized patients.

Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study

BackgroundCerebral perfusion may change depending on arterial cannulation site and may affect the incidence of neurologic adverse events in post-cardiotomy extracorporeal life support (ECLS). The current study compares patients' neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillary vs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications.MethodsThis retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models.ResultsThis study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02–2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan–Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar.ConclusionsIn this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.Graphical abstract

Sex Differences in Profile and In-Hospital Death for Acute Stroke in Chile: Data From a Nationwide Hospital Registry.

Knowledge of local contextual sex differences in the profile and outcome for stroke can improve service delivery. We aimed to determine sex differences in the profile of patients with acute stroke and their associations with in-hospital death in the national hospital database of Chile. We present a retrospective cohort based on the analysis of the 2019 Chilean database of Diagnosis-Related Groups, which represents 70% of the operational expenditure of the public health system. Random-effects multiple logistic regression models were used to determine independent associations of acute stroke (defined by main diagnosis International Classification of Diseases, Tenth Revision [ICD-10] codes) and in-hospital death, and reported with odds ratios (ORs) and 95% CIs. Of 1 048 575 hospital discharges, 15 535 were for patients with acute stroke (7074 [45.5%] in women), and 2438 (15.6%) of them died during hospitalization. Differences by sex in sociodemographic and clinical characteristics were identified for stroke and main subtypes. After fully adjusted model, women with ischemic stroke had lower in-hospital death (OR, 0.79 [95% CI, 0.69-0.91]) compared with men; other independent predictors included age per year increase (OR, 1.03 [95% CI, 1.03-1.04]), chronic kidney disease (OR, 1.47 [95% CI, 1.20-1.80]), atrial fibrillation (OR, 1.50 [95% CI, 1.26-1.80]), and other risk factors. Conversely, for intracerebral hemorrhage, women had a higher in-hospital mortality rate than men (OR, 1.19 [95% CI, 1.02-1.40]); other independent predictors included age per year increase (OR, 1.009 [95% CI, 1.003-1.01]), chronic kidney disease (OR, 1.55 [95% CI, 1.23-1.97]), oral anticoagulant use (OR, 1.88 [95% CI, 1.37-2.58]), and other risk factors. Sex differences in characteristics and in-hospital death of hospitalized patients exist for acute stroke in Chile. In-hospital death is higher for acute ischemic stroke in men and higher for intracerebral hemorrhage in women. Future research is needed to better identify contributing factors.

Did the Palliative Care Outcomes Collaboration (PCOC) program lead to improved end-of-life care quality and reduced non-beneficial treatments?

Palliative Care Outcomes Collaboration (PCOC) is an internationally recognized program developed in Australia. Taiwan became the first country in Asia to implement PCOC in 2020. There is little research on the impact of PCOC in Asia. We sought to examine the effects of the Taiwan PCOC on palliative outcomes. The study analyzed the impact of PCOC with a retrospective cohort design. The hypotheses were that PCOC could improve end-of-life care quality and reduce non-beneficial treatments. The study enrolled patients with terminal illnesses from the inpatient palliative care units. General characteristics of participants were collected. Exclusion criteria were people without a diagnosis of terminal illness, aged 20 and younger, or with missing data. The study collected 1,121 patients, 555 in the PCOC comparison group and 566 in the intervention group. Most patients were with terminal cancer (88.58%). The rates of hospital deaths in the PCOC and non-PCOC groups were 68.73% vs. 74.95% (P = 0.021). A multivariable logistic regression model, adjusting for age, sex, Charlson comorbidity index, and terminal cancer status, was utilized. The PCOC intervention significantly decreased hospital deaths (OR = 0.26, 95%CI 0. 16-0.41, P < 0.001). PCOC in Taiwan significantly reduced hospital deaths among terminal patients, possibly due to effective symptom management and improved communication via the use of patient-reported outcomes. Further research is needed to support PCOC implementation in Asia and investigate collaboration programs' impact on end-of-life care quality and non-beneficial treatments.

Restrictions on Pesticides and Deliberate Self-Poisoning in Sri Lanka

Deliberate self-poisoning using pesticides as a means of suicide is an important public health problem in low- and middle-income countries. Three highly toxic pesticides-dimethoate, fenthion, and paraquat-were removed from the market in Sri Lanka between 2008 and 2011. In 2015, less toxic pesticides (chlorpyrifos, glyphosate, carbofuran, and carbaryl) were restricted. Subsequent outcomes have not been well described. To explore the association of pesticide bans with pesticide self-poisonings and in-hospital deaths. In this cross-sectional study with an interrupted time series design, data were prospectively collected on all patients with deliberate self-poisonings presenting to 10 Sri Lankan hospitals between March 31, 2002, and December 31, 2019, and analyzed by aggregated types of poisoning. The correlates of pesticide bans were estimated within the pesticide group and on self-poisonings within other substance groups. The data analysis was performed between April 1, 2002, and December 31, 2019. Implementation of 2 sets of pesticide bans. The main outcomes were changes in hospital presentations and in-hospital deaths related to pesticide self-poisoning as measured using segmented Poisson regression. A total of 79 780 patients (median [IQR] age, 24 [18-34] years; 50.1% male) with self-poisoning from all causes were admitted to the study hospitals, with 29 389 poisonings (36.8%) due to pesticides. A total of 2859 patients died, 2084 (72.9%) of whom had ingested a pesticide. The first restrictions that targeted acutely toxic, highly hazardous pesticides were associated with an abrupt and sustained decline of the proportion of poisonings with pesticides (rate ratio [RR], 0.85; 95% CI, 0.78-0.92) over the study period and increases in poisonings with medications (RR, 1.11; 95% CI, 1.02-1.21) and household and industrial chemicals (RR, 1.20; 95% CI, 1.05-1.36). The overall case fatality of pesticides significantly decreased (RR, 0.33; 95% CI, 0.26-0.42) following the implementation of the 2008 to 2011 restrictions of highly hazardous pesticides. Following the 2015 restrictions of low-toxicity pesticides, hospitalizations were unchanged, and the number of deaths increased (RR, 1.98; 95% CI, 1.39-2.83). These findings support the restriction of acutely toxic pesticides in resource-poor countries to help reduce hospitalization for and deaths from deliberate self-poisonings and caution against arbitrary bans of less toxic pesticides while more toxic pesticides remain available.

Midterm Outcomes of Percutaneous Intramyocardial Septal Radiofrequency Ablation for Hypertrophic Cardiomyopathy: A Single-Center, Observational Study.

Percutaneous intramyocardial septal radiofrequency ablation (PIMSRA) has been reported to be safe and effective at midterm follow-up to treat drug-refractory hypertrophic obstructive cardiomyopathy in a single center. However, data from other centers are lacking. This retrospective cohort study aimed to investigate the efficacy and safety of PIMSRA from another independent center. PIMSRA was performed in 76 patients with hypertrophic obstructive cardiomyopathy in our center from April 2020 to June 2023. The primary outcome was the reduction of left ventricular outflow tract gradient after 6 months or more post-PIMSRA. Secondary outcomes were periprocedural major adverse clinical events. Sixty-one patients returned to the hospital for follow-up 6 to 30 (median, 14) months after the procedure. At the last follow-up of the 61 patients, the maximum septal thickness decreased from a median of 23.6 (interquartile range, 20.5-26.4) to 19.1 (interquartile range, 16.0-22.1) mm (P<0.001) and the left ventricular outflow tract peak gradient at rest decreased from a median of 70.0 (interquartile range, 29.1-107.5) to 20.0 (interquartile range, 10.8-48.8) mm Hg (P<0.001). The percentage of patients with symptoms of New York Heart Association functional class III/IV decreased from 51% to 0%. Of all 76 patients, there was no in-hospital or 30-day death, no right or left branch block, and no permanent pacemaker implantation. Six (8%) patients had pericardial effusion, with 1 experiencing cardiac tamponade and ventricular fibrillation, and 1 (1%) patient developed septal branch aneurysm that was treated with coil occlusion. PIMSRA allows for the reduction in the left ventricular outflow tract gradient and enhances symptomatic improvement, with a limited incidence of adverse events and complications among patients with hypertrophic obstructive cardiomyopathy.

SARS-CoV-2 seroepidemiology in Cape Town, South Africa, and implications for future outbreaks in low-income communities.

In low- and middle-income countries where SARS-CoV-2 testing is limited, seroprevalence studies can help describe and characterise the extent of the pandemic, as well as elucidate protection conferred by prior exposure. We conducted repeated cross-sectional serosurveys (July 2020 -November 2021) using residual samples from patients from Cape Town, South Africa, sent for routine laboratory studies for non-COVID-19 conditions. SARS-CoV-2 anti-nucleocapsid antibodies and linked clinical information were used to investigate: (1) seroprevalence over time and risk factors associated with seropositivity, (2) ecological comparison of seroprevalence between subdistricts, (3) case ascertainment rates, and (4) the relative protection against COVID-19 associated with seropositivity and vaccination statuses. Among the subset sampled, seroprevalence of SARS-CoV-2 in Cape Town increased from 39.19% (95% confidence interval [CI] 37.23-41.19) in July 2020 to 67.8% (95%CI 66.31-69.25) in November 2021. Poorer communities had both higher seroprevalence and COVID-19 mortality. Only 10% of seropositive individuals had a recorded positive SARS-CoV-2 test. Using COVID-19 hospital admission and death data at the Provincial Health Data Centre, antibody positivity before the start of the Omicron BA.1 wave (28 November 2021) was strongly protective for severe disease (adjusted odds ratio [aOR] 0.15; 95%CI 0.05-0.46), with additional benefit in those who were also vaccinated (aOR 0.07, 95%CI 0.01-0.35). The high population seroprevalence in Cape Town was attained at the cost of substantial COVID-19 mortality. At the individual level, seropositivity was highly protective against subsequent infections and severe COVID-19 disease. In low-income communities, where diagnostic testing capacity is often limited, surveillance systems dependent on them will underestimate the true extent of an outbreak. Rapidly conducted seroprevalence studies can play an important role in addressing this.

Time to intravenous diuretic administration in patients hospitalized with heart failure: An observational study.

To help establish optimized treatment strategies for congestion in patients with acute heart failure, this study aimed to provide a detailed summary of real-world diuretic use in hospitalized patients with heart failure requiring urgent therapy in Japan. This observational study used a Japanese medical records database to extract data of patients admitted to hospital with a heart failure diagnosis and an intravenous diuretic prescription from the day before admission to 2days after. Time from hospital visit to first dose, second dose, and maximum dose of intravenous diuretics were determined. Patients were grouped according to whether they received diuretic modification, defined as an intravenous diuretic dose increase or concomitant use of other diuretics. Overall, 1577 patients were included in the study (without diuretic modification, n=1140 [72.3%]; with diuretic modification, n=437 [27.7%]). The study population was 49.5% female (n=780) and the mean age±standard deviation was 80.1±12.7years. Intravenous diuretic treatment was received within 1h of their hospital visit in 43.5% of patients (686/1577) and ≤2h in 16.4% of patients (258/1577). Among 437 patients with an inadequate response following their first dose, 42.1% received an intravenous dose titration, 56.5% received combination diuretics, and 1.4% received both. Over half of the patients (59.0% [258/437]) with diuretic modification received it after the first 24h of the hospital visit. The median time from hospital visit to first dose titration was similar to time to first combination diuretic use (18.6h and 17.0h, respectively). The mean±standard deviation duration of intravenous diuretic use was significantly longer for patients with versus without diuretic modification (6.3±5.2 vs. 3.7±3.2days), and a significantly greater proportion of patients (44.6% [195/437] vs. 35.0% [399/1140]) received repeated intravenous diuretic administration. Other characteristics/outcomes of intravenous diuretic use were similar with versus without diuretic modification, including in-hospital death (15.6% [68/437] vs. 13.9% [159/1140]) and mean±standard deviation length of hospitalization (21.9±14.7days vs. 22.1±21.2days). In Japan, real-world patterns of intravenous diuretic administration for patients with heart failure remains far from the time-sensitive approach recommended in Japanese, European, and United States guidelines.

Fetal autopsy: Clinicopathologic correlation in consecutive cases

Background: Fetal and neonatal mortality serves as the most sensitive index of maternal and neonatal care. Congenital malformations remain a common cause of perinatal deaths and account for 10–15% in developing countries. Antenatal anomaly scan has become a standard element of obstetric care and their time for a fetal malformation is about 18 weeks. Fetal autopsy serves as a methodology to confirm the sonogram findings with regard to fetal anomalies. Aims and Objectives: The aim of our present study is to review and evaluate fetal autopsy of stillbirth/fetal losses and to confirm the malformations that were diagnosed by ultrasound. Materials and Methods: A cross-sectional study of a total of 10 cases received during the period of September 2023–October 2023 at the Institute of Obstetrics and Gynaecology. All the cases were spontaneous fetal losses. A standard protocol of autopsy procedure was followed which included external, internal, and histopathological examination. In fetuses with prenatally diagnosed malformations, ultrasound findings were compared with autopsy findings. Results: We analyzed a total of 10 fetuses, which included one chromosomal abnormality, four cardiac anomalies, one multiple anomaly, three central nervous system (CNS) anomalies, and one lethal skeletal dysplasia. The fetal autopsy confirmed the prenatal ultrasound findings in eight cases. Fetuses with CNS abnormality were not appreciated grossly due to early autolysis of the brain in the post-mortem. Conclusion: Prenatal imaging and screening are considered milestone development which detects fetal anomalies. However, the time-tested clinical autopsy which used to be conducted for all hospital deaths to find the cause of death was the norm of yesteryears which threw light on many unidentified causes and many syndromic associations not detected antemortem. Likewise, this case highlights the importance of autopsy correlation with prenatal imaging to highlight the same findings and to detect findings not picked up during imaging.

Correlation of Cause of Death Issued in Medico Legal Deaths in Hospitals and Cause of Death Found at Autopsy

Background:The death certificate is essential for legal investigations and public health planning. This study examines theaccuracy of causes of death reported by hospitals versus post-mortem findings and evaluates the completeness of deathcertificates.Method: A prospective, descriptive study was conducted in 99 cases, with hospital-issued death certificates, broughtfor medico-legal autopsy to the Department of Forensic Medicine, Institute of Medicine, Maharajgunj Medical Campus.Cases which were brought dead to the hospital but still were issued with death certificates and cases where the cause ofdeath remained undetermined even after autopsy were excluded. Data was recorded in a pro-forma and analyzed using theSPSS software Version 20.Result: The study involved individuals aged 13 to 30 years, mostly male. Private hospitals issued 66.7% of death certificates,with 55.6% by house officers. Only 62.6% met WHO standards. Autopsies were performed within 24 hours in 67.7% ofcases, revealing blunt force head injury as the leading cause of death (26.3%). There was a 67.7% discrepancy betweenhospital and autopsy causes of death, with house officers and government hospitals showing notable inconsistencies.Conclusion: Factors like the use of standard or non-standard death certificates, the designation of doctors, and the typeof hospital issuing the certificates influence the discrepancies between the causes of death listed by hospitals and thosedetermined after autopsies. This study aims to enhance the existing knowledge on the accuracy of death certificates and islikely the first systematic study of its kind in Nepal, laying the groundwork for future research.

Hospital admissions in adolescents with mental disorders in Spain over the last two decades: a mental health crisis?

Mental disorders account for a large and increasing health burden worldwide. Characterizing the spectrum of mental disorders and trends over time in adolescents should influence education policies and support preventative strategies at schools. Retrospective study of all hospitalizations in Spain in adolescents 11-18-years old, including mental disorders as diagnosis using the Spanish National Registry of Hospital Discharges. Information was retrieved from 2000 to 2021. During the 22-year study period there were 2,015,589 hospitalizations in adolescents in Spain, of which 118,609 (5.9%) had mental disorders. The rate of psychiatric diagnoses significantly increased from 3.9% in 2000 to 9.5% in 2021. Females accounted for 55.1% of admissions. Mean age at admission declined from 17 to 15 years-old from 2000 to 2021. Mean hospital stay was 10.6 days. Mean in-hospital mortality was 0.24%. By rate order, diagnoses were: substance use disorders (SUD) (40%) > eating disorders (15%) > anxiety/posttraumatic stress disorder (PTSD) (13%) > attention deficit hyperactivity disorder (ADHD) (9%) > major depression (8%) > schizophrenia/psychosis (6%) > autism spectrum disorder (ASD) (6%) > sleep disorder (3%) > suicidal behavior (2%) > sexual disorders (1%). A significant gender dichotomy was noticed, with female predominance for internalizing disorders (i.e., anxiety, depression, suicidal behavior and eating disorders) whereas externalizing disorders (i.e., SUD, ADHD, ASD, schizophrenia and other psychoses) predominated in males. Suicidal behavior and male sex were independent predictors of in-hospital death in multivariate analysis. After the first year of the COVID-19 pandemic, hospitalizations due to mental disorders in adolescents increased by 51% in 2021. There is a growing crisis of mental health among adolescents in Spain. Although the COVID-19 pandemic has unveiled the high rate and severity of psychiatric disorders among youth, a steadily increase has occurred since the beginning of the millennium. Primary preventative strategies should be adapted to distinct and more prevalent mental disorders in adolescents.

Impact of peptic ulcer bleeding on the in-hospital outcomes of cirrhotic patients with acute gastrointestinal bleeding: an international multicenter study

ABSTRACT Objectives Peptic ulcer is the most common source of non-variceal bleeding. However, it remains controversial whether the outcomes of cirrhotic patients with peptic ulcer bleeding differ from those with variceal bleeding. Methods Cirrhotic patients with acute gastrointestinal bleeding (AGIB) who underwent endoscopy and had an identifiable source of bleeding were retrospectively screened from an international multicenter cohort. Logistic regression analyses were performed to explore the impact of peptic ulcer bleeding on in-hospital death and 5-day failure to control bleeding. Propensity score matching (PSM) analysis was performed by matching age, gender, Child-Pugh score, and model for end-stage liver disease score between the peptic ulcer bleeding and variceal bleeding groups. Results Overall, 1535 patients were included, of whom 73 (4.7%) had peptic ulcer bleeding. Multivariate logistic regression analyses showed that peptic ulcer bleeding was not independently associated with in-hospital death (OR = 2.169, p = 0.126) or 5-day failure to control bleeding (OR = 1.230, p = 0.680). PSM analyses demonstrated that both in-hospital mortality (9.7% vs. 6.3%, p = 0.376) and rate of 5-day failure to control bleeding (6.9% vs. 5.4%, p = 0.787) were not significantly different between the two groups. Conclusions The impact of peptic ulcer bleeding on the in-hospital outcomes of cirrhotic patients is similar to that of variceal bleeding.

Unveiling the performance of the prehospital Rapid Emergency Medicine Score (pREMS): How the predictive score impacts in-hospital outcomes in traumatic brain injury (TBI): A retrospective observational cohort study

IntroductionThis study aimed to evaluate the predictive accuracy of the prehospital rapid emergency medicine score (pREMS) for predicting the outcomes of hospitalized patients with traumatic brain injury (TBI) who died, were discharged, were admitted to the intensive care unit (ICU), or were admitted to the operating room (OR) within 72 h.MethodsA retrospective cohort analysis was performed on a sample of 513 TBI patients admitted to the emergency department (ED) of Besat Hospital in 2023. Only patients of both sexes aged 18 years or older who were not pregnant and had adequate documentation of vital signs were included in the analysis. Patients who died during transport and patients who were transferred from other hospitals were excluded. The predictive power of the pREMS for each outcome was assessed by calculating the sensitivity and specificity curves and by analyzing the area under the receiver operating characteristic curve (AUROC).ResultsThe mean pREMS scores for hospital discharge, death, ICU admission and OR admission were 11.97 ± 3.84, 6.32 ± 3.15, 8.24 ± 5.17 and 9.88 ± 2.02, respectively. pREMS accurately predicted hospital discharge and death (AOR = 1.62, P < 0.001) but was not a good predictor of ICU or OR admission (AOR = 1.085, P = 0.603). The AUROCs for the ability of the pREMS to predict outcomes in hospitalized TBI patients were 0.618 (optimal cutoff point = 7) for ICU admission and OR and 0.877 (optimal cutoff point = 9.5) for hospital discharge and death at 72 h.ConclusionThe results indicate that the pREMS, a new preclinical trauma score for traumatic brain injury, is a useful tool for prehospital risk stratification (RST) in TBI patients. The pREMS showed good discriminatory power for predicting in-hospital mortality within 72 h in patients with traumatic brain injury.

Out of hospital cardiac arrest - new insights and a call for a worldwide registry and guidelines

IntroductionOut of hospital cardiac arrest (OHCA) is a major public health problem with substantial mortality rates worldwide. Genetic diseases and primary electrical disorders are the most common etiologies at younger ages, while ischemic heart disease and cardiomyopathies are common causes at older ages. Despite improvement in prevention and treatment in recent years, OHCA is still a major cause of cardiovascular death.MethodWe report prospective data regarding etiology, characteristics, clinical course, and outcomes of patients with OHCA who were admitted to a tertiary care center intensive cardiac care unit (ICCU) between 2020–2023.ResultsA total of 92 patients admitted after OHCA were included in the cohort. Mean age was 63.8 ± 13.8 years and 75 (82%) were males. The most common etiology of OHCA was acute coronary syndrome (ACS) in 54 (59%) patients, of whom 46 (85%) patients had ST elevation myocardial infarction and 8 (15%) had non-ST elevation myocardial infarction. During hospitalization, 42 (46%) patients underwent targeted temperature management and 13 (14%) received mechanical circulatory support. Interestingly, 77 (84%) patients underwent coronary angiography, while only 51 (55%) received percutaneous coronary intervention (PCI). Neurologic status was favorable in 49 (53%) patients with Cerebral Performance Category score of 1–2. Overall, mortality rates were relatively low, with 15 (16%) in-hospital deaths and 24 (26%) deaths at 30-day follow-up.ConclusionAlthough ACS was the most common etiology for OHCA, only 55% of patients underwent PCI. Most OHCA patients admitted to the ICCU survived hospitalization and were discharged. Increased awareness, public education, worldwide registries, and specific evidence-based guidelines for the treatment of OHCA patients may lead to improved outcomes for these patients who often carry poor prognoses.

Leveraging independence and mental fitness - keys to reducing in-hospital mortality among geriatric COVID-19 patients in the intensive care unit: A cross-sectional study in Poland.

Coronavirus disease 2019 (COVID-19) quickly reached the pandemic status, with 765.22 million confirmed cases of COVID-19 and 6.92 million COVID-19 deaths reported worldwide by May 2023. Due to its sudden and global nature, the COVID-19 pandemic has had a significant impact on the emotional and mental health of many people. A group of COVID-19 patients who frequently require intensive care are geriatric patients. The cognitive performance of these patients and their independence in instrumental activities of daily living (IADL) may be crucial to their prognosis and risk of in-hospital death. The present study aimed to assess the level of independence in activities of daily living (ADL), mental fitness, the level of fear of COVID-19, and cognitive functions to determine their impact on in-hospital mortality in geriatric COVID-19 patients. A total of 300 intensive care unit (ICU) patients with COVID-19 were included in the cross-sectional study, using the following questionnaires: the Lawton IADL scale, the Katz ADL index of independence, the fear of COVID-19 scale (FCV-19S), the abbreviated mental test score (AMTS), and the 15-item geriatric depression scale (GDS15). Patients aged 64 or below reported significantly greater independence on the IADL scale and the basic ADL scale, and showed a significantly higher level of mental fitness (Mann-Whitney U test; p = 0.001). Patient survival and in-hospital mortality were influenced by independence in basic and complex ADL. The level of independence is an important prognostic indicator for in-hospital mortality in geriatric COVID-19 patients. The higher the level of mental fitness, the higher the level of independence in basic and instrumental activities of daily living. Patients aged ≥65 years are less independent in basic and instrumental activities of daily living. Moreover, they show a significantly lower level of cognitive functions.