Greater Odds Of Mortality Research Articles

Peripheral Perfusion Index in Ugandan Children With Plasmodium falciparum Severe Malaria: Secondary Analysis of Outcomes in a 2014-2017 Cohort Study.

Continuous, noninvasive tools to monitor peripheral perfusion, such as perfusion index (PI), can detect hemodynamic abnormalities and assist in the management of critically ill children hospitalized with severe malaria. In this study of hospitalized children with severe malaria, we aimed to assess whether PI correlates with clinical markers of perfusion and to determine whether combining PI with these clinical measures improves identification of children with greater odds of mortality. Post hoc analysis of a prospective, multicenter, cohort study conducted between 2014 and 2017. Two referral hospitals in Central and Eastern Uganda. Six hundred children younger than 5 years old with severe malaria and 120 asymptomatic community children. None. PI was measured at 6-hour intervals for the first 24 hours of hospitalization. We compared PI to standard clinical perfusion measures such as capillary refill time, presence of cold peripheral limbs, or temperature gradient. Admission PI was highly correlated with clinical measures of perfusion. Admission PI was lower in children with severe malaria compared with asymptomatic community children; and, among the children with severe malaria, PI was lower in those with clinical features of poor perfusion or complications of severe malaria, such as shock and hyperlactatemia (all p < 0.02). Among children with severe malaria, lower admission PI was associated with greater odds of mortality after adjustment for age, sex, and severe malaria criteria (adjusted odds ratio, 2.4 for each log decrease in PI [95% CI, 1.0-5.9]; p = 0.045). Diagnostically, the presence of two consecutive low PI measures (< 1%) predicted mortality, with a sensitivity of 50% and a specificity of 76%. In severe malaria, PI correlates with clinical complications (including shock and elevated serum lactate) and may be useful as an objective, continuous explanatory variable associated with greater odds of later in-hospital mortality.

WP5.5 - Investigating the Optimal Timing for Definitive Treatment in Sigmoid Volvulus: A Retrospective Cohort Study

Abstract Aims The evidence base is replete of guidance on the optimal timing for definitive surgical management of acute sigmoid volvulus (ASV), with limited understanding or long-term outcomes for those managed conservatively. This study aimed to assess the management and outcomes of this understudied patient population. Methods A retrospective cohort study was conducted in a UK tertiary centre between January 2018 and December 2022. Results 69 patients presented with ASV (54M:15F, age 73.7 SD +/- 15.0 years). The median number of acute admissions per patient was 2 (IQR 1-4.5), with 29 patients (42.0%) presenting only once. 44 patients (63.8%) were managed conservatively. Of those patients, 22 (50.0%) were readmitted within the study period. 25 patients (26.2%) underwent operative management, with 18 (72.0%) of these patients undergoing emergency surgery (6 during their index admission, 33.3%). Elective surgical management was performed in 7 patients after an average of 3 previous admissions. All-cause mortality amongst the cohort was 47.8% (n=33), with a median life span of 1.1 years from index admission (IQR 0.3-2.6); 24.0% in the operative group (5 acute, 1 elective) versus 61.4% in the conservatively managed group. Conservatively managed patients were at greater odds of mortality compared to acutely operated patients (OR 4.129, 95% CI 1.25-13.67, p=0.02) and electively operated patients (OR 9.529, 95% CI 1.05-86.20, p=0.045). Acute operations had no significant greater odds of mortality compared to elective operations (p=0.49). Conclusions Conservative management of ASV was associated with greater odds of all-cause mortality compared to patients who received an operation. Operations performed in the acute setting had no greater mortality odds than in the elective setting.

Association of Frailty With Clinical and Financial Outcomes Following Liver Transplantation.

Frailty, a measure of physiological aging and reserve, has been validated as a prognostic indicator of mortality in patients with cirrhosis. However, large-scale analyses of the independent association of frailty with clinical and financial outcomes following liver transplantation (LT) are lacking. Adults (≥18 years) undergoing LT were identified in the 2016-2020 National Readmissions Database. Frailty was defined using the binary Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable linear and logistic regression models were developed to evaluate the independent association of frailty with in-hospital mortality, perioperative complications, and costs. Of an estimated 34 442 patients undergoing LT, 8265 (24%) were frail. After adjustment, frailty was associated with greater odds of mortality (adjusted odds ratio [AOR] 1.80; 95% Confidence Interval [CI]: 1.49-1.18), postoperative length of stay (β+11 days; 95% CI:+10,+12), and hospitalization costs (+$86 880; 95% CI:+75 660,+98 100), as well as a two-fold increase in relative risk of nonhome discharge (AOR 2.17, 95% CI: 1.90-2.49). Frailty is associated with an increased risk of in-hospital mortality, complications, and resource utilization among LT recipients. As the proportion of frail LT patients continues to rise, our findings underscore the need for novel risk-stratification and individualized care protocols for such vulnerable patients.

Severe Pneumonia in PICU Admissions: The Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) Observational Cohort Study, 2020-2022.

Mortality from pneumonia is three times higher in Asia compared with industrialized countries. We aimed to determine the epidemiology, microbiology, and outcome of severe pneumonia in PICUs across the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN). Prospective multicenter observational study from June 2020 to September 2022. Fifteen PICUs in PACCMAN. All children younger than 18 years old diagnosed with pneumonia and admitted to the PICU. None. Clinical, microbiologic, and outcome data were recorded. The primary outcome was PICU mortality. Univariate and multivariable logistic regression was performed to investigate associations between PICU mortality and explanatory risk factors on presentation to the PICU. Among patients screened, 846 of 11,778 PICU patients (7.2%) with a median age of 1.2 years (interquartile range, 0.4-3.7 yr) had pneumonia. Respiratory syncytial virus was detected in 111 of 846 cases (13.1%). The most common bacteria were Staphylococcus species (71/846 [8.4%]) followed by Pseudomonas species (60/846 [7.1%]). Second-generation cephalosporins (322/846 [38.1%]) were the most common broad-spectrum antibiotics prescribed, followed by carbapenems (174/846 [20.6%]). Invasive mechanical ventilation and noninvasive respiratory support was provided in 438 of 846 (51.8%) and 500 of 846 (59.1%) patients, respectively. PICU mortality was 65 of 846 (7.7%). In the multivariable logistic regression model, age (adjusted odds ratio [aOR], 1.08; 95% CI, 1.00-1.16), Pediatric Index of Mortality 3 score (aOR, 1.03; 95% CI, 1.02-1.05), and drowsiness (aOR, 2.73; 95% CI, 1.24-6.00) were associated with greater odds of mortality. In the PACCMAN contributing PICUs, pneumonia is a frequent cause for admission (7%) and is associated with a greater odds of mortality.

Prehospital Post-Resuscitation Vital Sign Phenotypes are Associated with Outcomes Following Out-of-Hospital Cardiac Arrest

Objectives The use of machine learning to identify patient ‘clusters’ using post-return of spontaneous circulation (ROSC) vital signs may facilitate the identification of patient subgroups at high risk of rearrest and mortality. Our objective was to use k-means clustering to identify post-ROSC vital sign clusters and determine whether these clusters were associated with rearrest and mortality. Methods The ESO Data Collaborative 2018–2022 datasets were used for this study. We included adult, non-traumatic OHCA patients with >2 post-ROSC vital sign sets. Patients were excluded if they had an EMS-witnessed OHCA or were encountered during an interfacility transfer. Unsupervised (k-means) clustering was performed using minimum, maximum, and delta (last minus first) systolic blood pressure (BP), heart rate, SpO2, shock index, and pulse pressure. The assessed outcomes were mortality and rearrest. To explore the association between rearrest, mortality, and cluster, multivariable logistic regression modeling was used. Results Within our cohort of 12,320 patients, five clusters were identified. Patients in cluster 1 were hypertensive, patients in cluster 2 were normotensive, patients in cluster 3 were hypotensive and tachycardic (n = 2164; 17.6%), patients in cluster 4 were hypoxemic and exhibited increasing systolic BP, and patients in cluster 5 were severely hypoxemic and exhibited a declining systolic BP. The overall proportion of patients who experienced mortality stratified by cluster was 63.4% (c1), 68.1% (c2), 78.8% (c3), 84.8% (c4), and 86.6% (c5). In comparison to the cluster with the lowest mortality (c1), each other cluster was associated with greater odds of mortality and rearrest. Conclusions Unsupervised k-means clustering yielded 5 post-ROSC vital sign clusters that were associated with rearrest and mortality.

Association between Insurance Status and Outcomes of Hospitalizations for Necrotizing Soft Tissue Infections.

Background: Lack of insurance is associated with poorer outcomes in hospitalized patients. However, few studies have explored this association in hospitalizations for necrotizing soft tissue infections (NSTIs). This study examined the impact of insurance status on the outcome of NSTI admissions. Methods: All adult hospitalizations for necrotizing fasciitis, gas gangrene, and Fournier gangrene between 2016 and 2018 were examined using the Nationwide Inpatient Sample database. Insurance status was categorized as insured (including Medicare, Medicaid, and Private, including Health maintenance organization (HMO) or uninsured (Self-pay). Outcome measures included mortality rates, limb loss, length of hospital stay, prolonged hospital stay, and critical care admissions. Statistical analysis included weighted sample analysis, chi-square tests, multivariate regression analysis, and negative binomial regression modeling. Results: Approximately 29,705 adult hospitalizations for NSTIs were analyzed. Of these, 57.4% (17,065) were due to necrotizing fasciitis, 22% (6,545) to gas gangrene, and 20.5% (6,095) to Fournier gangrene. Approximately 9.7% (2,875) were uninsured, whereas 70% (26,780) had insurance coverage. Among the insured, Medicare covered 39.6% (10,605), Medicaid 29% (7,775), and private insurance 31.4% (8,400). After adjustments, Medicare insurance was associated with greater odds of mortality (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: 1.33-2.47; p = 0.001). Medicaid insurance was associated with increased odds of amputation (aOR: 1.81; 95% CI: 1.33-2.47; p < 0.001), whereas private insurance was associated with lower odds of amputation (aOR: 0.70; 95% CI: 0.51-0.97; p = 0.030). Medicaid insurance was associated with greater odds of prolonged hospital stay (aOR: 1.34; 95% CI: 1.09-1.64; p < 0.001). No significant association was observed between the lack of insurance or self-pay and the odds of primary or secondary outcomes. Conclusion: Medicare insurance was correlated with greater odds of mortality, whereas Medicaid insurance was associated with increased odds of amputation and longer hospital stay. Uninsured status was not associated with significant differences in NSTI outcomes.

Prevalence, Associated Factors, and Outcomes of Severe Acute Kidney Injury in Pediatric Acute Liver Failure: Single-Center Retrospective Study, 2003-2017.

Our aim was to determine the prevalence and explanatory factors associated with outcomes in children with acute liver failure (ALF) admitted to the PICU, who also develop severe acute kidney injury (AKI). Retrospective cohort, 2003 to 2017. Sixteen-bed PICU in a university-affiliated tertiary care hospital. Admissions to the PICU with ALF underwent data review of the first week and at least 90-day follow-up. Patients with stages 2-3 AKI using the British Association of pediatric Nephrology definitions, or receiving continuous renal replacement therapy (CRRT) for renal indications, were defined as severe AKI. We excluded ALF cases on CRRT for hepatic-only indications. None. Baseline characteristics, proportion with severe AKI, illness severity and interventions, and outcomes (i.e., transplant, survival with native liver, overall survival, duration of PICU stay, and mechanical ventilation). Ninety-four children with ALF admitted to the PICU were included. Over the first week, 29 had severe AKI, and another eight received CRRT for renal/mixed reno-hepatic indications; hence, the total severe AKI cohort was 37 of 94 (39.4%). In a multivariable logistic regression model, peak aspartate aminotransferase (AST) and requirement for inotropes on arrival were associated with severe AKI. Severe AKI was associated with longer PICU stay and duration of ventilation, and lower spontaneous survival with native liver. In another model, severe AKI was associated with greater odds of mortality (odds ratio 7.34 [95% CI, 1.90-28.28], p = 0.004). After 90 days, 3 of 17 survivors of severe AKI had serum creatinine greater than the upper limit of normal for age. Many children with ALF in the PICU develop severe AKI. Severe AKI is associated with the timecourse of PICU admission and outcome, including survival with native liver. Future work should look at ALF goal directed renoprotective strategies at the time of presentation.

Noninvasive Surrogate for Physiologic Dead Space Using the Carbon Dioxide Ventilatory Equivalent: Testing in a Single-Center Cohort, 2017-2023.

We sought to evaluate the association between the carbon dioxide ( co2 ) ventilatory equivalent (VEq co2 = minute ventilation/volume of co2 produced per min), a marker of dead space that does not require a blood gas measurement, and mortality risk. We compared the strength of this association to that of physiologic dead space fraction (V D /V t = [Pa co2 -mixed-expired P co2 ]/Pa co2 ) as well as to other commonly used markers of dead space (i.e., the end-tidal alveolar dead space fraction [AVDSf = (Pa co2 -end-tidal P co2 )/Pa co2 ], and ventilatory ratio [VR = (minute ventilation × Pa co2 )/(age-adjusted predicted minute ventilation × 37.5)]). Retrospective cohort data, 2017-2023. Quaternary PICU. One hundred thirty-one children with acute respiratory distress syndrome. None. All dead space markers were calculated at the same 1-minute timepoint for each patient within the first 72 hours of using invasive mechanical ventilation. The 131 children had a median (interquartile range, IQR) age of 5.8 (IQR 1.4, 12.6) years, oxygenation index (OI) of 7.5 (IQR 4.6, 14.3), V D /V t of 0.47 (IQR 0.38, 0.61), and mortality was 17.6% (23/131). Higher VEq co2 ( p = 0.003), V D /V t ( p = 0.002), and VR ( p = 0.013) were all associated with greater odds of mortality in multivariable models adjusting for OI, immunosuppressive comorbidity, and overall severity of illness. We failed to identify an association between AVDSf and mortality in the multivariable modeling. Similarly, we also failed to identify an association between OI and mortality after controlling for any dead space marker in the modeling. For the 28-day ventilator-free days outcome, we failed to identify an association between V D /V t and the dead space markers in multivariable modeling, although OI was significant. VEq co2 performs similarly to V D /V t and other surrogate dead space markers, is independently associated with mortality risk, and may be a reasonable noninvasive surrogate for V D /V t .

Trends and associated outcomes of fat embolism after trauma surgery

BackgroundFat embolism is a life-threatening complication often occurring in patients with traumatic injuries. However, temporal trends and perioperative outcomes of fat embolism remain understudied. Using a nationally representative cohort, we aimed to characterize temporal trends of fat embolism and its associated resource utilization in operatively managed trauma patients. MethodsAll patients (≥18 years) undergoing any major operations after traumatic injuries were tabulated using the 2005 to 2020 National Inpatient Sample. Patients were stratified into those with fat embolism and those without. Multivariable logistic and linear regressions were developed to assess the association between fat embolism and outcomes of interest. ResultsOf an estimated 10,600,000 hospitalizations, 7,479 (0.07%) patients had fat embolism. Compared to the non-fat embolism cohort, the fat embolism cohort was younger (55 [26–79] vs 69 [49–82] years, standard mean difference = 0.46) and more likely to receive treatment at a high-volume trauma center (42.9 vs 33.7%, standard mean difference = 0.19). Over the study period, there was an increase in annual mortality and hospitalization costs among the fat embolism group (nptrend <0.001). After risk adjustment, fat embolism was associated with greater odds of mortality (adjusted odds ratio: 2.65, 95% confidence interval: 2.24–3.14) compared to others. Additionally, fat embolism was associated with increased odds of cerebrovascular, infectious, and renal complications. ConclusionAmong all operatively managed trauma patients, those who developed fat embolism had increased mortality, rates of complications, length of stay, and costs. Optimization of early and accurate identification of fat embolism is warranted to mitigate complications and improve resource allocation among trauma patients.

Mechanical Ventilation and Outcomes of Children Who Undergo Ventricular Assist Device Placement: 2014-2020 Linked Analysis From the Advanced Cardiac Therapies Improving Outcomes Network and Pediatric Cardiac Critical Care Consortium Registries.

Placement of a ventricular assist device (VAD) improves outcomes in children with advanced heart failure, but adverse events remain important consequences. Preoperative mechanical ventilation (MV) increases mortality, but it is unknown what impact prolonged postoperative MV has. Advanced Cardiac Therapies Improving Outcomes Network (ACTION) and Pediatric Cardiac Critical Care Consortium (PC 4 ) registries were used to identify and link children with initial VAD placement admitted to the cardiac ICU (CICU) from August 2014 to July 2020. Demographics, cardiac diagnosis, preoperative and postoperative CICU courses, and outcomes were compiled. Univariable and multivariable statistics assessed association of patient factors with prolonged postoperative MV. Multivariable logistic regression sought independent associations with outcomes. Thirty-five pediatric CICUs across the United States and Canada. Children on VADs included in both registries. None. Two hundred forty-eight ACTION subjects were linked to a matching patient in PC 4 . Median (interquartile) age 7.7 years (1.5-15.5 yr), weight 21.3 kg (9.1-58 kg), and 56% male. Primary diagnosis was congenital heart disease (CHD) in 35%. Pre-VAD explanatory variables independently associated with prolonged postoperative MV included: age (incidence rate ratio [IRR], 0.95; 95% CI, 0.93-0.96; p < 0.01); preoperative MV within 48 hours (IRR, 2.76; 95% CI, 1.59-4.79; p < 0.01), 2-7 days (IRR, 1.82; 95% CI, 1.15-2.89; p = 0.011), and greater than 7 days before VAD implant (IRR, 2.35; 95% CI, 1.62-3.4; p < 0.01); and CHD (IRR, 1.96; 95% CI, 1.48-2.59; p < 0.01). Each additional day of postoperative MV was associated with greater odds of mortality (odds ratio [OR], 1.09 per day; p < 0.01) in the full cohort. We identified an associated greater odds of mortality in the 102 patients with intracorporeal devices (OR, 1.24; 95% CI, 1.04-1.48; p = 0.014), but not paracorporeal devices (77 patients; OR, 1.04; 95% CI, 0.99-1.09; p = 0.115). Prolonged MV after VAD placement is associated with greater odds of mortality in intracorporeal devices, which may indicate inadequacy of cardiopulmonary support in this group. This linkage provides a platform for future analyses in this population.

Cardiac Surgery-Associated Acute Kidney Injury in Neonates Undergoing the Norwood Operation: Retrospective Analysis of the Multicenter Neonatal and Pediatric Heart and Renal Outcomes Network Dataset, 2015-2018.

Cardiac surgery-associated acute kidney injury (CS-AKI) is associated with adverse outcomes. Single-center studies suggest that the prevalence of CS-AKI is high after the Norwood procedure, or stage 1 palliation (S1P), but multicenter data are lacking. A secondary analysis of the Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) multicenter cohort who underwent S1P. Using neonatal modification of Kidney Disease Improving Global Outcomes (KDIGO) criteria, perioperative associations between CS-AKI with morbidity and mortality were examined. Sensitivity analysis, with the exclusion of prophylactic peritoneal dialysis (PD) patients, was performed. Twenty-two hospitals participating in the Pediatric Cardiac Critical Care Consortium (PC 4 ) and contributing to NEPHRON. Three hundred forty-seven neonates (< 30 d old) with S1P managed between September 2015 and January 2018. None. Of 347 patients, CS-AKI occurred in 231 (67%). The maximum stages were as follows: stage 1, in 141 of 347 (41%); stage 2, in 51 of 347 (15%); and stage 3, in 39 of 347 (11%). Severe CS-AKI (stages 2 and 3) peaked on the first postoperative day. In multivariable analysis, preoperative feeding was associated with lower odds of CS-AKI (odds ratio [OR] 0.48; 95% CI, 0.27-0.86), whereas prophylactic PD was associated with greater odds of severe CS-AKI (OR 3.67 [95% CI, 1.88-7.19]). We failed to identify an association between prophylactic PD and increased creatinine (OR 1.85 [95% CI, 0.82-4.14]) but cannot exclude the possibility of a four-fold increase in odds. Hospital mortality was 5.5% ( n = 19). After adjusting for risk covariates and center effect, severe CS-AKI was associated with greater odds of hospital mortality (OR 3.67 [95% CI, 1.11-12.16]). We failed to find associations between severe CS-AKI and respiratory support or length of stay. The sensitivity analysis using PD failed to show associations between severe CS-AKI and outcome. KDIGO-defined CS-AKI occurred frequently and early postoperatively in this 2015-2018 multicenter PC 4 /NEPHRON cohort of neonates after S1P. We failed to identify associations between resource utilization and CS-AKI, but there was an association between severe CS-AKI and greater odds of mortality in this high-risk cohort. Improving the precision for defining clinically relevant neonatal CS-AKI remains a priority.

Pediatric Sepsis Phenotypes and Outcome: 5-Year Retrospective Cohort Study in a Single Center in India (2017-2022).

To describe mortality associated with different clinical phenotypes of sepsis in children. Retrospective study. PICU of a tertiary care center in India from 2017 to 2022. Six hundred twelve children (from 2 mo to 17 yr old) with a retrospectively applied diagnosis of sepsis using 2020 guidance. The main outcome was mortality associated with sepsis subtypes. Other analyses included assessment of risk factors, requirement for organ support, and PICU resources used by sepsis phenotype. Clinical data were recorded on a predesigned proforma. None. Of the 612 children identified, there were 382 (62%) with sepsis but no multiple organ failure (NoMOF), 48 (8%) with thrombocytopenia-associated MOF (TAMOF), 140 (23%) with MOF without thrombocytopenia, and 40 (6.5%) with sequential MOF (SMOF). Mortality was higher in the SMOF (20/40 [50%]), MOF (62/140 [44%]) and TAMOF (20/48 [42%]) groups, compared with NoMOF group (82/382 [21%] [ p < 0.001]). The requirement for organ support and PICU resources was higher in all phenotypes with MOF as compared with those without MOF. On multivariable analysis elevated lactate and having MOF were associated with greater odds of mortality. In this single-center experience of sepsis in India, we found that sepsis phenotypes having MOF were associated with mortality and the requirement of PICU resources. Prospective studies in different regions of the world will help identify a classification of pediatric sepsis that is more widely applicable.

Balloon atrial septostomy versus left atrial cannulation for left heart decompression in children with dilated cardiomyopathy and myocarditis on extracorporeal membrane oxygenation: An ELSO registry analysis.

In children with myocarditis or dilated cardiomyopathy (DCM) on extracorporeal membrane oxygenation (ECMO) for cardiogenic shock, it is often necessary to decompress the left heart to minimize distension and promote myocardial recovery. We compare outcomes in those who underwent balloon atrial septostomy (BAS) versus direct left atrial (LA) drainage for left heart decompression in this population. Retrospective study of the Extracorporeal Life Support Organization (ELSO) multicenter registry of patients ≤ 18years with myocarditis or DCM on ECMO who underwent LA decompression. Descriptive and univariate statistics assessed association of patient factors with decompression type. Multivariable logistic regression sought independent associations with outcomes. 369 pediatric ECMO runs were identified. 52% myocarditis, 48% DCM, overall survival 74%. 65% underwent BAS and 35% LA drainage. Patient demographics including age, weight, gender, race/ethnicity, diagnosis, pre-ECMO pH, mean airway pressure, and arrest status were similar. 89% in the BAS group were peripherally cannulated onto ECMO, versus 3% in the LA drainage group (p < .001). On multivariable analysis, LA drainage (OR 3.96; 95% CI, 1.47-10.711; p = .007), renal complication (OR 2.37; 95% CI, 1.41-4.01; p = .001), cardiac complication (OR 3.14; 95% CI, 1.70-5.82; p < .001), and non-white race/ethnicity (OR 1.75; 95% CI, 1.04-2.94; p = .035) were associated with greater odds of mortality. There was a trend toward more episodes of pulmonary hemorrhage in BAS (n = 17) versus LA drainage group (n = 3), p = .08. Comparing only those with central cannulation, LA drainage group was more likely to be discontinued from ECMO due to recovery (72%) versus the BAS group (48%), p = .032. In children with myocarditis or DCM, there was a three times greater likelihood for mortality with LA drainage versus BAS for LA decompression. When adjusted for central cannulation groups only, there was better recovery in the LA drainage group and no difference in mortality. Further prospective evaluation is warranted.

COVID-19: An evaluation of predictive scoring systems in South Africa

Background| The Coronavirus Disease 2019 (COVID-19) pandemic, caused by SARS-CoV-2, has resulted in more than 700 million cases worldwide. Sepsis and pneumonia severity scores assist in risk assessment of critical outcomes in patients with COVID-19. This allows healthcare workers to triage patients, by using clinical parameters and limited special investigations, thus offering the most appropriate level of care. Methods| A retrospective cohort study of 605 adult patients hospitalised with moderate to severe COVID-19, at a tertiary state hospital in South Africa. Evaluating the utility of the CURB65, NEWS2 and ISARIC-4C Mortality Score, in predicting critical outcomes, using clinical characteristics on admission. Outcomes included in-hospital mortality, invasive mechanical ventilation, and intensive care unit admission (ICU). Performance of severity scores and risk factors was assessed by area under the receiver operator characteristics (AUROC) analysis and logistic regression. Findings |A total of 605 records were used, 129 (21 %) non-survivors, 101 (17 %) ICU admissions and 77 (13 %) requiring invasive ventilation. Greater odds of mortality was associated with moderate and severe risk groups of the CURB65, ISARIC-4C and NEWS2 score. Mortality AUROC curve analysis for the CURB65 score was 0·76 (95 % CI: 0·71–0·8), 0·77 (95 % CI: 0·73–0·81) for the ISARIC-4C and 0·77 (95 % CI: 0·73–0·82) for the NEWS2 score. The CURB65 score had a sensitivity of 86 % with 12·8 % mortality, ISARIC-4C score a sensitivity of 87·6 % with 8 % mortality and NEWS2 score a sensitivity of 92·2 % with 8·6 % mortality. Interpretation |In 605 hospitalised patients with moderate to severe COVID-19, predominantly infected by the ancestral strain, good performance of the NEWS2 and ISARIC-4C score in predicting in-hospital mortality was noted. The CURB65 score had a high mortality rate in its low-risk group suggesting unexplained risk factors, not accounted for in the score, thus limiting its utility in the South African setting.

Prevalence and outcomes of type 2 myocardial infarction in patients with cancer: A retrospective analysis from the National Inpatient Sample dataset

BackgroundThis study aimed to investigate the prevalence, clinical characteristics and outcomes of type 2 myocardial infarction (T2AMI) in patients with versus without cancer. MethodsAll hospitalizations with a primary discharge diagnosis of T2AMI were stratified according to cancer status (secondary diagnosis of any-cancer vs cancer-free) using data from the US National Inpatient Sample (2016–2019). The primary outcome was in-hospital all-cause mortality while secondary outcomes were in-hospital major adverse cardiovascular and cerebrovascular events (MACCE). ResultsAmong 61,305 included hospitalizations with primary diagnosis of T2AMI, 3745 (6.1%) were associated with a diagnosis of cancer. Patients with T2AMI and cancer presented more frequently with acute respiratory failure (23.2% vs 18.1%), acute pulmonary embolism (3.7% v 1.3%), major bleeding (6.8% vs 4.1%) and renal failure (51.0% vs 46.8%), compared to patients without. On adjusted analysis, diagnosis of cancer was associated with lower odds of invasive coronary angiography (aOR 0.75, 95% CI 0.60 to 0.93, p = 0.009) but greater odds of mortality (aOR 1.95, 95% C.I. 1.26–2.99 p = 0.002). Among the different types of cancer, adjusted risk of all-cause mortality was higher in patients with colorectal (aOR 4.17 95% CI 1.68–10.32, p = 0.002), lung (aOR 3.63, 95% CI 1.83–7.18, p < 0.001) and haematologic (aOR 2.48, 95% CI 1.22–5.05, p = 0.001) cancer. ConclusionsPatients with cancer presenting with T2AMI have lower odds of management with invasive diagnostic coronary angiography and have higher rates of in-hospital all-cause death. Further studies are warranted to improve overall care and outcomes of cancer patients and cardiovascular diseases.

Outcomes of Gastrostomy and Tracheostomy in Infants Undergoing Truncus Arteriosus Repair: Database Study Using the Pediatric Health Information System.

We sought to determine the prevalence of and factors associated with gastrostomy tube placement and tracheostomy in infants undergoing truncus arteriosus repair, and associations between these procedures and outcome. Retrospective cohort study. Pediatric Health Information System database. Infants less than 90 days old who underwent truncus arteriosus repair from 2004 to 2019. None. Multivariable logistic regression models were used to identify factors associated with gastrostomy tube and tracheostomy placement and to identify associations between these procedures and hospital mortality and prolonged postoperative length of stay (LOS; > 30 d). Of 1,645 subjects, gastrostomy tube was performed in 196 (11.9%) and tracheostomy in 56 (3.4%). Factors independently associated with gastrostomy tube placement were DiGeorge syndrome, congenital airway anomaly, admission age less than or equal to 2 days, vocal cord paralysis, cardiac catheterization, infection, and failure to thrive. Factors independently associated with tracheostomy congenital airway anomaly, truncal valve surgery, and cardiac catheterization. Gastrostomy tube was independently associated with prolonged postoperative LOS (odds ratio [OR], 12.10; 95% CI, 7.37-19.86). Hospital mortality occurred in 17 of 56 patients (30.4%) who underwent tracheostomy versus 147 of 1,589 patients (9.3%) who did not ( p < 0.001), and median postoperative LOS was 148 days in patients who underwent tracheostomy versus 18 days in those who did not ( p < 0.001). Tracheostomy was independently associated with mortality (OR, 3.11; 95% CI, 1.43-6.77) and prolonged postoperative LOS (OR, 9.85; 95% CI, 2.16-44.80). In infants undergoing truncus arteriosus repair, tracheostomy is associated with greater odds of mortality; while gastrostomy and tracheostomy are strongly associated with greater odds of prolonged postoperative LOS.

PEDS7: Balloon Atrial Septostomy versus Left Atrial Cannulation for Left Heart Decompression in Children with Dilated Cardiomyopathy and Myocarditis on Extracorporeal Membrane Oxygenation

Purpose: To describe the association of left heart decompression with balloon atrial septostomy (BAS) compared to left atrial (LA) cannulation with survival in children with myocarditis or dilated cardiomyopathy (DCM) on veno-arterial extracorporeal membrane oxygenation (ECMO). Methods: Retrospective study of the Extracorporeal Life Support Organization (ELSO) multicenter registry of patients ≤ to 18 years old with myocarditis or DCM on ECMO who underwent LA decompression. Only index ECMO run within a hospitalization was included. Descriptive and univariate statistics assessed association of patient factors with decompression type. Multivariable logistic regression sought independent associations with outcomes. Results: 321 pediatric ECMO runs were identified. 57% myocarditis (n=183) and 43% DCM (n=138). Survival overall was 74%. 67% underwent balloon atrial septostomy (BAS) and 33% underwent left atrial cannulation. Patient demographics including age, weight, gender, race/ethnicity, diagnosis, pre-ECMO pH, mean airway pressure, and arrest status were similar between groups. Median ECMO duration was longer in the BAS group compared to LA cannulation (7.2 versus 5.7 days respectively, p=0.002). 82 (78%) were centrally versus peripherally (22%, n=23) cannulated on ECMO in the LA cannulation group, versus 19 (9%) centrally versus 194 (91%) peripherally cannulated in the BAS group. On multivariable analysis, we found LA cannulation (OR 3.68; 95% CI, 1.86-7.31; p<0.001), neurologic complication (OR 5.25; 95% CI, 2.38-11.58; p<0.001), renal complication (OR 2.74; 95% CI, 1.41-5.29; p=0.003), and cardiac complication (OR 2.64; 95% CI, 1.30-5.38; p=0.007) were associated with greater odds of mortality. There were more episodes of pulmonary hemorrhage in the BAS group (n=17) compared to the LA cannulation group (n=2). Conclusions: Our findings indicate better left heart decompression with an LA cannula compared to BAS given a lower incidence of pulmonary hemorrhage in the LA cannulation group. There was a three times greater likelihood for mortality in children with myocarditis and DCM on ECMO who undergo LA cannulation compared to BAS, however, they appear to be fundamentally different cohorts. Further prospective evaluation with adjustment for severity of illness is warranted.

National Trends and Clinical Outcomes of Type B Aortic Dissection Management at Safety-Net Hospitals.

Patients with type B aortic dissection (TBAD) are often underinsured and urgently admitted for open or thoracic endovascular aortic repair (TEVAR). The present study evaluated the association of safety-net status with outcomes among patients with TBAD. The 2012-2019 National Inpatient Sample was queried to identify all adults admitted with type B aortic dissection. Safety-net hospitals (SNHs) were defined as institutions in the top 33% for the annual proportion of uninsured or Medicaid patients. Multivariable regression models were utilized to assess the association of SNH with in-hospital mortality, perioperative complications, length of stay (LOS), hospitalization cost, and non-home discharge. Of an estimated 172 595 patients, 61 000 (35.3%) were managed at SNH. Compared to others, patients admitted to SNH were younger, more commonly non-white, and more frequently non-electively admitted. From 2012 to 2019, the annual incidence of type B aortic dissection increased in the overall cohort. Additionally, utilization of TEVAR at non-SNH increased significantly (2012: 6.5% vs 2019: 9.8%), while that of SNH remained similar (2012: 7.4% vs 2019: 7.9%). Patients undergoing open repair had higher mortality at both SNH (12.4 vs 7.8%, P < .001) and non-SNH (13.1 vs 6.1%, P < .001) compared to those receiving TEVAR. After risk adjustment, compared to non-SNH, SNH status was associated with greater odds of mortality, perioperative complications and non-home discharge. Our finding suggests that SNH have inferior clinical outcomes for TBAD as well as reduced adoption of endovascular management strategies. Future studies to identify barriers to optimal aortic repair and ameliorate disparities at SNH are warranted.

An Ounce of Prevention is the Only Cure: Nationwide Clinical and Financial Outcomes of Self-Inflicted Firearm Injuries.

Self-inflicted gunshot wounds (SIGSWs) remain a leading, preventable cause of death in the United States. The present study evaluated patient demographics, operative characteristics, in-hospital outcomes, and resource utilization between patients with SIGSW and other GSW. The 2016-2020 National Inpatient Sample was queried for patients ≥16years old admitted following gunshot wounds. Patients were categorized as SIGSW if they were injured through self-harm. Multivariable logistic regression was used to evaluate the association of SIGSW on outcomes. The primary endpoint was in-hospital mortality with complications, costs, and length of stay secondarily considered. Of an estimated 157,795 surviving to hospital admission, 14,670 (9.30%) were SIGSW. Self-inflicted gunshot wounds were more commonly female (18.1 vs 11.3%), insured by Medicare (21.1 vs 5.0%), and white (70.8 vs 22.3%) (all P < .001) compared to non-SIGSW. Psychiatric illness was more prevalent in SIGSW (46.0 vs 6.6%, P < .001). Additionally, SIGSW more frequently underwent neurologic (10.7 vs 2.9%) and facial operations (12.5 vs 3.2%) (both P < .001). After adjustment, SIGSW was associated with greater odds of mortality (AOR: 12.4, 95% CI: 10.4-14.7). Length of stay (β: +1.5days, 95% CI: .8-2.1) and costs (β: +$3.6K, 95% CI: 1.4-5.7) were significantly greater in SIGSW. Self-inflicted gunshot wounds are associated with increased mortality compared to other GSW, likely due to the increased proportion of injuries in the head and neck region. This lethality, coupled with the high prevalence of psychiatric illness in this population, indicates that efforts must be made to intervene through primary prevention, including enhanced screening and weapon safety considerations for those at risk.

Mortality and functional outcomes in patients with post-stroke epileptic seizures: a systematic review and meta-analysis (S45.006)

<h3>Objective:</h3> To conduct a meta-analysis of published data to comprehensively investigate clinical and functional outcomes in post-stroke epilepsy (PSE) patients. <h3>Background:</h3> It is critical to highlight the burden of PSE on patient outcomes. Whereas PSE has been reported to worsen outcomes in stroke patients, published data are inconclusive. <h3>Design/Methods:</h3> We used Covidence to conduct a literature search of studies published until 1-March-2022. We used Joanna Briggs Institute tool for cohort studies to assess the risk of bias. Our outcome measures include mortality and poor outcomes (Rankin Scale score 3–6). We report Odds ratio (OR) and 95% Confidence Intervals (CI) using a random-effect meta-analysis. Publication bias was assessed using Egger’s test. We conducted the statistical analyses in R version 4.2.0. (PROSPERO ID: CRD42022308648) <h3>Results:</h3> We screened 3721 studies and included 71 articles (N= 29,759 patients with PSE; 17,42,083 patients without PSE). Articles reported 3938 early and 13,067 late seizures; 12,754 seizures were not classified as early/late. Risk of bias was high in two studies, moderate in 36 and low in 33. PSE was associated with greater odds of mortality (OR 2.09; CI 1.78–2.45; N= 52 studies) and poor outcomes (OR 2.39; CI 1.91–3.00; N= 19 studies). In subgroup analyses, post-ischemic stroke epilepsy was associated with mortality (OR 2.31; CI 1.88–2.83) and poor outcome (OR 2.60; CI 1.91–3.52). Post-hemorrhagic stroke epilepsy showed consistently significant OR for the poor outcome (OR 2.04; CI 1.33–3.13) but failed to reach statistical significance for mortality (OR 1.29; CI 0.96–1.74). No significant publication bias was observed for mortality (p=0.93) and poor outcome (p=0.17). <h3>Conclusions:</h3> Our meta-analysis suggests that PSE is associated with a doubled risk of death and severe disability. Prevention of PSE should be a high research priority. The role of stroke severity or lesion volume also requires further study. <b>Disclosure:</b> Mr. Misra has nothing to disclose. Juan Vazquez, MD has nothing to disclose. Ms. Eldem has nothing to disclose. Lucas Silva has nothing to disclose. Dr. Mohadat has nothing to disclose. Dr. Hickman has nothing to disclose. Ms. Khan has nothing to disclose. Mrs. Funaro has nothing to disclose. Clarissa Yasuda has nothing to disclose. Dr. Liebeskind has received research support from Cerenovus. Dr. Liebeskind has received research support from Genentech . Dr. Liebeskind has received research support from Medtronic. Dr. Liebeskind has received research support from Stryker. Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Bristol-Myers Squibb. Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Diamedica. Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Abbvie. Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Medtronic. Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for AstraZeneca. Dr. Kasner has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Javelin. Dr. Kasner has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for UpToDate. The institution of Dr. Kasner has received research support from Bristol-Myers Squibb. The institution of Dr. Kasner has received research support from Medtronic. The institution of Dr. Kasner has received research support from WL Gore. Dr. Mishra has nothing to disclose.