Greater Risk Of Adverse Outcomes Research Articles

Inpatient mortality and outcomes of COVID-19 among patients with non-ischemic cardiomyopathy: A propensity matched analysis

BackgroundPatients with chronic medical conditions, particularly cardiovascular diseases, are at a greater risk of adverse outcomes due to COVID-19. The effect of COVID-19 on patients with non-ischemic cardiomyopathy (NICM) is not known well. ObjectivesTo study the impact of COVID-19 infection on NICM hospital mortality and other outcomes. MethodsThis study included a cohort of patients from the 2020 and 2021 National Inpatient Sample databases. Patients hospitalized for COVID-19 with and without NICM were matched using a 1:1 propensity score-matching ratio. Outcomes analyzed were in-hospital mortality, rates of acute kidney injury (AKI), acute myocardial infarction (AMI), cardiogenic shock, cardiac arrest, mechanical ventilation, tracheal intubation, pulmonary embolism (PE), ventricular tachycardia (VT), ventricular fibrillation (VF), length of stay (LOS), and total hospitalization charges. ResultsA total of 2,532,652 patients met the inclusion criteria (1,199,008 females [47.3 %], predominantly white 1,456,203 (57.5 %); mean [SD] age 63 [5.4] years), including 64,155 (2.5 %) patients with a history of NICM. Following propensity matching, 10,258 COVID-19 patients with and without NICM were matched. Patients with NICM had higher rates of AMI (11.1 vs. 7.1 %, p < 0.001), cardiogenic shock (2 vs. 0.6 %, p < 0.001), cardiac arrest (4.4 vs. 3.2 %, p < 0.01), mechanical ventilation (13.7 vs 12 %, p < 0.01), VT (8.5 vs. 2.2 %, p < 0.001), and VF (1.0 vs 0.25 %, p < 0.001). The odds ratios for in-hospital mortality, AKI, and PE did not differ significantly. ConclusionA History of NICM does not affect COVID-19 mortality but increases the risk of cardiovascular complications.

Persistent Racial Disparities in Morbidity Following Major Elective Operations.

Introduction: Despite considerable national attention, racial disparities in surgical outcomes persist. We sought to consider whether race-based inequities in outcomes following major elective surgery have improved in the contemporary era. Methods: All adult hospitalization records for elective coronary artery bypass grafting, abdominal aortic aneurysm repair, colectomy, and hip replacement were tabulated from the 2016-2020 National Inpatient Sample. Patients were stratified by Black or White race. To consider the evolution in outcomes, we included an interaction term between race and year. We designated centers in the top quartile of annual procedural volume as high-volume hospitals (HVH). Results: Of ∼2,838,485 patients, 245,405 (8.6%) were of Black race. Following risk-adjustment, Black race was linked with similar odds of in-hospital mortality, but increased likelihood of major complications (Adjusted Odds Ratio [AOR] 1.41, 95%Confidence Interval [CI] 1.36-1.47). From 2016-2020, overall risk-adjusted rates of major complications declined (patients of White race: 9.2% to 8.4%; patients of Black race 11.8% to 10.8%, both P < .001). Yet, the delta in risk of adverse outcomes between patients of White and Black race did not significantly change. Of the cohort, 158,060 (8.4%) were treated at HVH. Following adjustment, Black race remained associated with greater odds of morbidity (AOR 1.37, CI 1.23-1.52; Ref:White). The race-based difference in risk of complications at HVH did not significantly change from 2016 to 2020. Conclusion: While overall rates of complications following major elective procedures declined from 2016 to 2020, patients of Black race faced persistently greater risk of adverse outcomes. Novel interventions are needed to address persistent racial disparities and ensure acceptable outcomes for all patients.

Problems in Conducting Multivariate Logistic Regression Analysis

We read with great interest the original article “The Relationship Between Procalcitonin Level and Short Term Mortality in Emergency Department” by Cehreli et al. (1). A high initial level of procalcitonin (PCT) is a sensitive marker of bacterial infection, and the degree of PCT elevation can determine which patients are at greater risk of adverse outcomes. In this study, the authors wanted to analyse whether there was an association between PCT levels and seven-day mortality in patients whom PCT levels were measured in the emergency department. However, we think that there are some serious methodological mistakes.

Abstract P130: Higher Circulating Angiotensin Converting Enzyme 2 (ACE2) and ACE2 to ACE Ratio Are Associated With Lower COVID-19 Mortality: A Mechanistic Substudy of the ACTIV-4 Host Tissue Trials

Background: SARS-Cov-2 targets the peptidase ACE2, a key component of the renin-angiotensin system (RAS), which directly regulates the balance of the vasoconstrictor/inflammatory peptide Ang II and the vasodilator/anti-inflammatory peptide Ang-(1-7). Few studies have quantified the circulating elements of the RAS longitudinally in SARS-Cov-2 infection and their association with COVID-19 outcomes. Objective: Evaluate the association of circulating RAS enzymes with mortality in critically ill patients with COVID-19. Methods: We quantified serum ACE and ACE2 concentrations by ELISA among 111 patients hospitalized for confirmed SARS-Cov-2 infection with new onset hypoxemia who were randomized to the placebo arm of the ACTIV-4 Host Tissue trials investigating RAS pathway interventions. Serum was collected at baseline/randomization (Day 0) and 1, 3, and 5 days after randomization. We used multivariable Cox regression to estimate the association of baseline and longitudinal ACE and ACE2 with 90-day mortality. Hazard ratios (HR) for RAS enzyme concentrations were adjusted for age, sex, race/ethnicity, baseline level of O 2 support, obesity, hypertension, RAS inhibitor use prior to admission, and vasopressor use within 7 days of admission. Results: Participants were aged 18-90 (mean [SD] = 55 [14]) years, 62% male, 42% non-White, with 58% and 48% prevalence of obesity and hypertension, respectively. There were 22 (20%) deaths over 90 days of follow-up (median [25%, 75%] time to event = 16 [9, 29] days). Relative to participants with values below the sample median, those with higher Day 0 ACE2 (&gt;4.9 pM; adjusted HR [95% CI] = 0.07 [0.02, 0.33]) and ACE2/ACE ratio (&gt;6.0*10 -3 ; adjusted HR = 0.08 [0.01, 0.39]) had significantly lower mortality. Similarly, when analyzed as continuous, log 2 -normalized, time-varying predictors from Day 0 to Day 5, two-fold increments in ACE2 (adjusted HR = 0.81 [0.69, 0.96]) and ACE2/ACE ratio (adjusted HR = 0.78 [0.64, 0.96]) over this period were associated with lower mortality. Results did not differ by hypertension status (interaction p=0.385 and 0.278 for Day 0 ACE2 and ACE2/ACE ratio, respectively, and p=0.714 and 0.457 for time-varying ACE2 and ACE2/ACE ratio, respectively). In contrast, neither ACE levels at Day 0 (&gt;1.3 nM; adjusted HR = 1.23 [0.41, 3.67]) nor time-varying ACE (adjusted HR = 1.21 [0.75, 1.95]) were associated with mortality. Conclusions: Higher baseline and longitudinal serum ACE2 levels, but not ACE, were associated with markedly reduced mortality among hospitalized patients with COVID-19, consistent with a protective role for ACE2. Whether serum ACE2 levels arise from tissue ACE2 shedding, thus binding less virus to tissue, should be explored further. A better understanding of the RAS timecourse in severe COVID-19 illness could identify patients at greater risk for adverse outcomes and inform targeted treatment strategies.

Evaluating caregiver-child interactions in low- and middle-income countries: a systematic review of tools and methods.

The United Nations Sustainable Development Goals (SDGs) has placed emphasis on improving early child development globally. This is supported through the Nurturing Care Framework which includes responsive caregiving. To evaluate responsive caregiving, tools to assess quality of caregiver-child interactions are used, however there is little information on how they are currently employed and/or adapted particularly in low- and middle-income countries (LMICs) where children have a greater risk of adverse outcomes. The aim of this review is to provide a comprehensive guide on methodologies used to evaluate caregiver-child interaction - including their feasibility and cultural adaptation. We conducted a systematic review of studies over 20years in LMICs which assessed caregiver-child interactions. Characteristics of each tool, their validity (assessed with COSMIN Risk of Bias checklist), and the quality of the study (Mixed Methods Appraisal Tool) are reported. We identified 59 studies using 34 tools across 20 different LMICs. Most tools (86.5%) employed video-recorded observations of caregiver-child interactions at home (e.g. Ainsworth's Sensitivity Scale, OMI) or in the laboratory (e.g. PICCOLO) with a few conducting direct observations in the field (e.g. OMCI, HOME); 13.5% were self-reported. Tools varied in methodology with limited or no mention of validity and reliability. Most tools are developed in Western countries and have not been culturally validated for use in LMIC settings. There are limited caregiver-child interaction measures used in LMIC settings, with only some locally validated locally. Future studies should aim to ensure better validity, applicability and feasibility of caregiver-child interaction tools for global settings.

Caring for Older People As a Social Determinant of Health: Findings from a Scoping Review of Observational Studies

Background: Unpaid care is a critical source of support for people with health and social care needs. Unpaid carers are a group facing increasing demands and are at risk of adverse outcomes. Objectives: To assess the breadth of evidence on older carers/carers of older people in UK cohort studies. Methods: Using scoping review methods, we developed a targeted search strategy in three bibliographic databases (Medline, PsycInfo and CINAHL) for studies reporting carer characteristics and outcomes. Data were mapped using Evidence for Policy and Practice Information (EPPI) Reviewer, a web-based programme for managing and analysing data in reviews. The impacts of caring were explored and synthesised. Findings: Eighty-five studies were included. Where studies examined the impact of caring, outcomes were typically health-related; findings were inconsistent. Fewer studies reported the socioeconomic, disability-related, quality of life, or social impacts of caring. Fewer than half of studies reported subgroup analyses or care recipient information, and only five studies stratified carers’ outcomes by a measure of socioeconomic status. Limitations: Relying on data from observational studies means that key outcomes or caring pathways may be overlooked due to data collection methods. We therefore cannot infer causation/reverse causation regarding caring and carer outcomes. Implications: Our work highlights specific gaps in evidence regarding the social, economic, health and quality of life outcomes for carers. We also suggest methodological considerations to improve our understanding of care recipients, carers’ trajectories, and those at greatest risk of adverse outcomes. This information is vital to the development of research design, policies and interventions to support carers’ wellbeing.

Race, Genotype, and Prognosis in Black Patients With Transthyretin Cardiac Amyloidosis

Previous studies suggest worse outcomes in patients with variant transthyretin cardiac amyloidosis due to V122I (ATTRv-CA) compared to patients with wild-type disease (ATTRwt-CA). Given V122I is almost exclusively found in Black patients, it is unclear if this is attributable to the biology of genotype or racial differences. Patients with transthyretin cardiac amyloidosis (ATTR-CA) diagnosed between January 2001 and August 2021 were characterized into 3 categories: (1) White with ATTRwt-CA (White- WT); (2) Black with V122I ATTRv-CA (Black-V122I), and (3) Black with ATTRwt-CA (Black-WT). Event-free survival (composite of death, left ventricular assist device (LVAD), or cardiac transplant) was evaluated using univariable and multivariable analyses over a median follow-up of 1.6 (0.7-2.90) years. Of 694 ATTR-CA patients, 502 (72%) were White-WT, 139 (20%) Black-V122I, and 53 (8%) Black- WT. Notably, 28% of Black patients with ATTR-CA had wild-type disease and not the V122I variant. Using multivariable modeling to adjust for several prognostic features, Black-V122I had higher risk of the composite adverse outcome compared with a grouped cohort of patients with WT disease (White-WT and Black-WT) [hazard ratio (HR) 1.82, CI 1.30-2.56, p<0.001). Furthermore, the Black cohort as a whole (Black- V122I and Black-WT) demonstrated greater risk of adverse outcomes compared to White-WT (HR 1.63, CI 1.19-2.24, p=0.002). Black-V122I had greater risk of the primary endpoint compared to White-WT (HR 1.80, CI 1.27-2.56, p=0.001). Black patients with ATTR-CA have worse event-free survival than White-WT despite risk adjustment. However, it remains unclear whether this is driven by differences in race or genotype given the smaller number of Black-WT patients. Approximately one-quarter of Black patients had WT, of which a greater proportion were female compared to White-WT.

Characteristics and clinical outcomes of patients with pre-delta, delta and omicron SARS-CoV-2 infection in Indonesia (2020–2023): a multicentre prospective cohort study

Limited data exist from southeast Asia on the impact of SARS-CoV-2 variants and inactivated vaccines on disease severity and death among patients hospitalised with COVID-19. A multicentre hospital-based prospective cohort was enrolled from September 2020 through January 2023, spanning pre-delta, delta, and omicron periods. The participant hospitals were conveniently sampled based on existing collaborations, site willingness and available study resources, and included six urban and two rural general hospitals from East Nusa Tenggara, Jakarta, and North Sumatra provinces. Factors associated with severe disease and day-28 mortality were examined using logistic and Cox regression. Among 822 participants, the age-adjusted percentage of severe disease was 26.8% (95% CI 22.7-30.9) for pre-delta, 50.1% (44.0-56.2) for delta, and 15.2% (9.7-20.7) for omicron. The odds of severe disease were 64% (18-84%) lower for omicron than delta (p<0.001). One or more vaccine doses reduced the odds of severe disease by 89% (65-97%) for delta and 98% (91-100%) for omicron. Age-adjusted mortality was 11.9% (8.8-15.0) for pre-delta, 24.4% (18.8-29.9) for delta and 9.6% (5.2-14.0) for omicron. The day-28 cumulative incidence of death was lower for omicron (9.2% [5.6-13.9%]) than delta (28.6% [22.0-35.5%]) (p<0.001). Severe disease on admission was the predominant prognostic factor for death (aHR34.0 [16.6-69.9] vs mild-or-moderate; p<0.001). After controlling for disease severity on admission as an intermediate, the risk of death was 48% (32-60%) lower for omicron than delta (p<0.001); and 51% (38-61%; p<0.001) lower for vaccinated participants than unvaccinated participants overall, and 56% (37-69%; p<0.001) for omicron, 46% (-5 to 73%; p=0.070) for pre-delta (not estimable for delta). Infections by omicron variant resulted in less severe and fatal outcomes than delta in hospitalised patients in Indonesia. However, older, and unvaccinated individuals remained at greater risk of adverse outcomes. University of Oxford and Wellcome Trust.

2012 The long-term clinical outcomes of older adults with frailty following acute hospital admission in Tanzania

Abstract Background Non-communicable disease, multimorbidity and frailty are posing considerable challenges as global populations age. Healthcare systems in Low- and Middle-Income Countries are having to rapidly adapt services to meet the needs of older people. Objective This study, the first of its kind in sub-Saharan Africa, aimed to establish whether screening older people for frailty on admission to hospital could be used to identify those at greatest risk of adverse outcomes. Methods At baseline assessment, 308 participants aged ≥60 years, admitted to medical wards at four hospitals in the Kilimanjaro Region of Tanzania, were screened for frailty using the Clinical Frailty Scale (CFS). After 10-12 months, participants, and their informants, were contacted by telephone to establish clinical outcomes. The primary outcome was all-cause mortality. Cox regression was used to estimate hazard ratios ( 95% confidence interval) for mortality, with dichotomised CFS frailty status (frail if ≥5) as the independent variable. Results Primary outcome data were obtained for 194 (63.0%) of the original participants after a mean follow-up period of 10.8 ( 0.9) months. Mean age was 75.1 years and 99 (51%) of respondents were female. A total of 100 (51.5%) respondents were deceased and hazard ratios for all-cause mortality demonstrate that those with frailty were at significantly greater risk of mortality (HR 2.27 [CI 1.39 – 3.69], p&amp;lt;0.01), an effect that persisted even after adjustment for age, baseline Barthel Index, education and number of chronic conditions. Conclusion For older people living in Tanzania, unplanned admission to hospital is associated with high mortality and frailty is a strong independent predicator. In accurately identifying which older people are at the greatest risk, frailty screening using the CFS could provide a starting point for the development of targeted care pathways and interventions.

Clinical phenogroup diversity and multiplicity: Impact on mechanisms of exercise intolerance in heart failure with preserved ejection fraction.

We aimed to clarify the extent to which cardiac and peripheral impairments to oxygen delivery and utilization contribute to exercise intolerance and risk for adverse events, and how this relates to diversity and multiplicity in pathophysiologic traits. Individuals with heart failure with preserved ejection fraction (HFpEF) and non-cardiac dyspnoea (controls) underwent invasive cardiopulmonary exercise testing and clinical follow-up. Haemodynamics and oxygen transport responses were compared. HFpEF patients were then categorized a priori into previously-proposed, non-exclusive descriptive clinical trait phenogroups, including cardiometabolic, pulmonary vascular disease, left atrial myopathy, and vascular stiffening phenogroups based on clinical and haemodynamic profiles to contrast pathophysiology and clinical risk. Overall, patients with HFpEF (n = 643) had impaired cardiac output reserve with exercise (2.3 vs. 2.8 L/min, p = 0.025) and greater reliance on peripheral oxygen extraction augmentation (4.5 vs. 3.8 ml/dl, p < 0.001) compared to dyspnoeic controls (n = 219). Most (94%) patients with HFpEF met criteria for at least one clinical phenogroup, and 67% fulfilled criteria for multiple overlapping phenogroups. There was greater impairment in peripheral limitations in the cardiometabolic group and greater cardiac output limitations and higher pulmonary vascular resistance during exertion in the other phenogroups. Increasing trait multiplicity within a given patient was associated with worse exercise haemodynamics, poorer exercise capacity, lower cardiac output reserve, and greater risk for heart failure hospitalization or death (hazard ratio 1.74, 95% confidence interval 1.08-2.79 for 0-1 vs. ≥2 phenogroup traits present). Though cardiac output response to exercise is limited in patients with HFpEF compared to those with non-cardiac dyspnoea, the relative contributions of cardiac and peripheral limitations vary with differing numbers and types of clinical phenotypic traits present. Patients fulfilling criteria for greater multiplicity and diversity of HFpEF phenogroup traits have poorer exercise capacity, worsening haemodynamic perturbations, and greater risk for adverse outcome.

Predictors of fibrogenesis in children with JIA: a single-center pilot study

BackgroundPatients with rheumatological diseases are at high risk of developing irreversible fibrotic changes, both articular and extra-articular, as a result of tissue damage caused by the chronic phase of persistent inflammation. Thus, our purpose was to study early markers of fibrosis formation in children with juvenile idiopathic arthritis (JIA).MethodsSeventy patients with juvenile idiopathic arthritis, namely, polyarthritis (64.29%) and oligoarthritis (35.71%) variant JIA (mean age 13.3 years, 64.29% girls, 35.71% boys), were included in this 4-year prospective study. Basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) levels were determined by ELISA kits.ResultsWe evaluated bFGF (mean: 7478.21 pg/ml; min: 4171.56 pg/ml; max: 18,011.25 pg/ml) and VEGF (mean: 342.47 pg/ml; min: 23.68 pg/ml; max: 2158.91 pg/ml) levels in children with JIA. Children with JIA had a higher VEGF level when JIA onset occurred after 15 years of age and they had a high disease activity; additionally, a higher bFGF level was observed in children older than 14 years and in those with a JIA onset after 15 years of age, the oligoarticular variant, a moderate disease activity and regardless of MTX administration but more often when MTX was administered at a dosage from 10 to 12.5 mg/m2/week.ConclusionsLaboratory screening of fibrosis formation predictors could help identify patients who may be at greater risk of adverse outcomes. Children with JIA had higher bFGF and VEGF levels when JIA onset occurred after 15 years of age, depending on disease activity.

Inside the ‘imperfect mosaic’: Minority ethnic women’s qualitative experiences of race and ethnicity during pregnancy, childbirth, and maternity care in the United Kingdom

BackgroundPersistent, high rates of maternal mortality amongst ethnic minorities is one of the UK’s starkest examples of racial disparity. With greater risks of adverse outcomes during maternity care, ethnic minority women are subjected to embedded, structural and systemic discrimination throughout the healthcare service.MethodsFourteen semi-structured interviews were undertaken with minority ethnic women who had recent experience of UK maternity care. Data pertaining to ethnicity and race were subject to iterative, inductive coding, and constant comparison through Grounded Theory Analysis to test a previously established theory: The ‘Imperfect Mosaic’.Analysis & findingsA related theory emerged, comprising four themes: ‘Stopping Short of Agentic Birth’; ‘Silenced and Stigmatised through Tick-Box Care’; ‘Anticipating Discrimination and the Need for Advocacy’; and ‘Navigating Cultural Differences’. The new theory: Inside the ‘Imperfect Mosaic’, demonstrates experiences of those who received maternity care which directly mirrors experiences of those who provide care, as seen in the previous theory we set-out to test. However, the current theory is based on more traditional and familiar notions of racial discrimination, rather than the nuanced, subtleties of socio-demographic-based micro-aggressions experienced by healthcare professionals.ConclusionsOur findings suggest the need for the following actions: Prioritisation of bodily autonomy and agency in perinatal physical and mental healthcare; expand awareness of social and cultural issues (i.e., moral injury; cultural safety) within the NHS; and undertake diversity training and support, and follow-up of translation of the training into practice, across (maternal) health services.

Biatrial myopathy in heart failure with preserved ejection fraction.

Left atrial (LA) myopathy is increasingly recognized as an important phenotypic trait in heart failure (HF) with preserved ejection fraction (HFpEF). Right atrial (RA) remodelling and dysfunction also develop in HFpEF, but little data are available regarding the clinical characteristics and pathophysiology among patients with isolated LA, RA, or biatrial myopathy. Patients with HFpEF underwent invasive haemodynamic exercise testing, comprehensive imaging including speckle tracking strain echocardiography, and clinical follow-up at Mayo Clinic between 2006 and 2018. LA myopathy was defined as LA volume index >34 ml/m2 and/or LA reservoir strain ≤24% and RA myopathy by RA volume index >39 ml/m2 in men and >33 ml/m2 in women and/or RA reservoir strain ≤19.8%. Of 476 consecutively evaluated patients with HFpEF defined by invasive exercise testing with evaluable atrial structure/function, 125 (26%) had no atrial myopathy, 147 (31%) had isolated LA myopathy, 184 (39%) had biatrial myopathy, and 20 (4%) had isolated RA myopathy. Patients with HFpEF and biatrial myopathy had more atrial fibrillation, poorer left ventricular systolic and diastolic function, more severe pulmonary vascular disease, tricuspid regurgitation, ventricular interdependence and right ventricular dysfunction, and poorer cardiac output reserve with exercise. There were 94 patients with events over a median follow-up of 2.9 (interquartile range 1.4-4.6) years. Individuals with biatrial myopathy had an 84% higher risk of HF hospitalization or death as compared to those with isolated LA myopathy (hazard ratio 1.84; 95% confidence interval 1.16-2.92, p = 0.01). Biatrial myopathy identifies patients with more advanced HFpEF characterized by more severe pulmonary vascular disease, right HF, poorer cardiac reserve, and a greater risk for adverse outcomes. Further study is required to define optimal strategies to treat and prevent biatrial myopathy in HFpEF.

Incidence and Perinatal Outcomes of Twin Pregnancy in Tertiary Healthcare Facility, Odisha, India

Background: Assisted reproductive technology has resulted in a progressive rise in the incidence of twin pregnancies, which affect both mother and child in terms of antepartum complications. Objective: To assess the perinatal outcomes of twin pregnancies and the influence of chorionicity on them in a tertiary healthcare facility. Methods: It is a hospital-based cross-sectional study that was carried out in the Obstetrics and Gynecology Department of S.C.B. Medical College Hospital, Cuttack, during the period from 2013 to 2015. All mothers having twin pregnancies (with 28 weeks of completed gestation) admitted to the antenatal (ANC) ward and labor room during this period were taken as a study group, and written informed consent was taken after explaining the details of the study. Results: A total of 150 cases are identified; among them, 98 cases (65.33%) are dichorionic diamniotic, 50 cases (33.33%) are monochorionic diamniotic, and 2 cases (1.33%) are monochorionic and monoamniotic pregnancies. The majority (66%) of the twin pregnancies were between 35-38 wks of gestational age at the onset of labor. It is also observed that macerated births, stillbirths, and neonatal deaths are higher in mono-chorionic twins as compared to dichorionic twins. Conclusions: Twin pregnancies carry a greater risk of adverse outcomes, especially perinatal mortality and neonatal morbidity, in monochorionic twins than dichorionic twins. Good antenatal care, early diagnosis of chorionicity, and antepartum assessment of placentation will prevent mortality and morbidity.

Abstract 17509: Gender-Specific Differences in Patients Undergoing Coronary Artery Bypass Grafting

Background: Several studies suggested that females undergoing coronary artery bypass grafting (CABG) have poorer outcomes than males. However, we noted contradicting findings regarding short and long-term mortalities among females. Our aim is to assess gender-specific differences in pre and post -operative CABG risk factors and outcomes. Methods: Our cohort included 7,687 adult patients who underwent CABG surgery between 2006 and 2022 in a large rural healthcare system. Patients were grouped by gender and continuous variables were summarized using median and inter-quartile range. Appropriate statistical tests were conducted to assess differences. Results: There were 1827 (23.8%) females and 5860 (76.2%) males. Females were slightly older ((68, 60.5, 75) vs (67, 65, 73), p&lt;0.0001), with higher total number of Elixhauser comorbidities ((6, 3, 8) vs (4, 3, 7), p&lt;0.0001), higher cha2ds2vasc scores ((4, 3, 5) vs (3, 2, 4), p&lt;0.0001) and higher prevalence of stroke history (12.4% vs 10.3%, p=0.013). Analysis of risk factors used for computing the Society of Thoracic (STS) scores revealed several significant differences (with p&lt;0.001) between females and males including sleep apnea (12.1% vs 15.7%), diabetes (52.7% vs 43.4%), depression (25.5% vs 13.9%), and BMI ((31.6, 14.4, 35.5) vs (28.8, 25.8, 33.7)). Compared to males, females had greater need for blood transfusions (49.8% vs 33.6%), prolonged post-operative pulmonary ventilation (33.8% vs 24.4%), mediastinal drainage (13.4% vs 6.4%) and more frequent acute cardiac arrests (7.2% vs 4.8%). In addition females had higher 30-day mortality (0.93% vs 0.84%, p=0.014), 1-year mortality (4.2% vs 2.9%, p=0.0003), 1-year incident stroke (2.2% vs 1.5%, p=0.05), longer hospital length of stay (LoS) in hours ((143.4, 116.9, 191.6) vs (120.7, 96.9, 167.2), p&lt;0.0001), ICU LOS in hours ((96, 48.8, 143.9) vs (77.9, 39.4, 120), p&lt;0.0001), and duration from discharge to all-time mortality in days ((1513, 523.5, 2723.5) vs (1740, 622, 2921), p=0.008). Conclusions: Female gender is linked to several pre-operative and post-operative risk factors and are at greater risk of adverse outcomes following CABG surgery. Further work is needed to understand the causes of these discrepancies and to limit their effect on outcomes.

50 Pain severity as a predictor of verbal fluency functioning after COVID-19 illness

Objective:Published results focusing on language assessment in acutely recovered COVID-19 patients have shown communication problems in this group, including significant cognitive-linguistic disruptions in verbal fluency (Cummings, 2022). Extant research also indicates that poorer health-related outcomes, such as reduced physical functioning and quality of life, co-occur with cognitive difficulties post-COVID-19 infection (Mendez et al., 2021; Tabacof et al., 2022). Understanding what factors may worsen the impact of COVID-19 on cognition, and aspects of language function specifically, is necessary to determine who is at greatest risk of adverse outcomes following infection. Our goal was to examine the effect of health-related outcomes on language abilities, specifically verbal fluency, post-COVID-19 infection.Participants and Methods:37 adults 19 years and older (M age = 38.78, 67.5% female, 92.5%&gt; high school education) were recruited from British Columbia and Ontario, Canada. Participants provided documentation indicating they had had a COVID-19 infection at least 3 months prior to participation. Participants completed a series of online questionnaires, including the Short Form Health Survey (SF-20), to measure aspects of health-related quality of life. The SF-20 measures dimensions of functioning (physical, social, role) and well-being (mental health, health perception, pain). For each parameter except pain, higher scores indicate better functioning/well-being; for pain higher scores indicate greater pain levels. Participants also completed neuropsychological tests, including measures of verbal fluency, via teleconference. Animals and F-A-S total scores were combined to represent verbal fluency (semantic and phonemic, respectively) performance. To assess the impact of health outcomes on verbal fluency performance, hierarchical regression analyses were conducted. The six SF-20 subscale scores were entered as predictors and verbal fluency score (sum) as the outcome. Age and sex (Male/Female) were controlled for in the model.Results:Age and sex were not significantly related to verbal fluency scores in our sample. After controlling for these demographics, the overall model including SF-20 subscales did not significantly predict fluency performance (F (8, 28) = 1.04, p = .433). However, Pain scores did individually predict verbal fluency performance (B = 5.60, t = 2.53, p = &lt;.05). Unexpectedly, pain ratings were positively associated with fluency scores, such that each increase in pain rating (e.g., “none” to “mild”) was associated with a fluency score increase of 5.60 points (i.e., 5.6 more words stated across administered tasks).Conclusions:These preliminary findings suggest that participants’ self-reported pain severity was positively associated with verbal fluency task performance in our sample (i.e., greater pain severity predicting better fluency). These findings are contrary to substantial evidence showing the deleterious effects of pain on cognitive functions in other populations (Khera &amp; Rangasamy, 2021). It is possible that findings may be explained by a potential unknown intervening variable not included in our model. This is the first study to our knowledge to examine associations between experienced pain and verbal fluency performance post-COVID-19 infection. It will be important for future work to not only utilize more robust measures of pain experiences and explore more areas of cognition and language, but also to employ larger samples and examine a broader set of covariates.

Immunoglobulin A vasculitis nephritis: Current understanding of pathogenesis and treatment.

The clinical spectrum of immunoglobulin A vasculitis nephritis (IgAVN) ranges from the relatively common transitory microscopic hematuria and/or low-grade proteinuria to nephritic or nephrotic syndrome, rapidly progressive glomerulonephritis, or even renal failure. Clinical and experimental studies have shown a multifactor pathogenesis: Infection triggers, impaired glycosylation of IgA1, complement activation, Toll-like-receptor activation and B cell proliferation. This knowledge can identify IgAVN patients at a greater risk for adverse outcome and increase the evidence for treatment recommendations.

Time-dependent changes of platelet and D-dimer parameters in vaccinated &lt;i&gt;versus&lt;/i&gt; non-immunized COVID-19 patients

There are increasing data concerning changes in hematological (clinical) and biochemical blood tests in patients with COVID-19 infection, which indicate the severity of the manifestations of the infectious process. Coagulopathy often correlates with the severity of COVID-19 disease and the risk of death. In this regard, prediction of developing coagulopathy and its prevention remain quite relevant. The aim of our study was to identify differences in the content of platelets and D-dimer in patients with COVID-19. The study included cohorts of patients vaccinated against SARS-CoV-2, and those not immunized against this infection.&#x0D; A prospective, randomized, observational study of the patients’ response was performed in cohorts of 588/52.2% vaccinated (vaccinated) and 588/52.2% non-immunized (non-vaccinated) patients with diagnosed COVID-19 over the period from 23.06.2021 to 01.05.2022. The levels of blood platelets and D-dimer, as well as clinical outcomes of the disease in patients with COVID-19, were studied in dynamics on days 1-2, 5-6 and 10-12 of hospitalization.&#x0D; Upon admission, the normal value of the blood platelet counts did not differ between the compared groups, being 206.58 × 109 in vaccinated group and 204.85 × 109 in the unvaccinated group, respectively. a moderate increase in the concentration of D-dimer was noted in both groups upon admission, i.e., 2838.60 ng/mL in the group of vaccinated patients and 3242.08 ng/mL among the unvaccinated patients. In the course of the study, we have shown that the dynamics of D-dimer index in vaccinated versus non-immunized persons was similar according to the days of disease, showing an increase from the first day and a trend towards an higher values, starting from 5-6 days. At the same time, the dynamics in the vaccinated patients was somewhat less favorable than that of the non-immunized subjects. In the patients who were not immunized throughout the entire observation period, the platelet count exceeds the levels found in vaccinated subjects, thus suggesting higher risk of thrombosis and cytokine storm.&#x0D; The data obtained show that the dynamics of D-dimer and platelet counts in vaccinated and non-immunized people is similar on appropriate terms of the illness. However, the changes are more pronounced in vaccinated cohort, but it does not indicate a greater risk of adverse outcomes.

Factors impacting resident outcomes from COVID-19 outbreaks in Residential Aged Care Facilities in Sydney Local Health District: testing an infection prevention and control scoring system

BackgroundCOVID-19 outbreaks have disproportionately affected Residential Aged Care Facilities (RACFs) around the world, with devastating impacts for residents and their families. Many factors such as community prevalence, facility layout, and infection control practices have been linked to resident outcomes. At present, there are no scoring systems designed to quantify these factors and assess their level of association with resident attack rates and mortality rates.MethodsWe constructed a novel Infection Prevention and Control (IPC) scoring system to quantify facility layout, ability to cohort residents, and IPC practices in RACFs. We conducted a retrospective observational cohort study of COVID-19 outbreaks, applying our IPC scoring system to all COVID-19 outbreaks occurring in RACFs in Sydney Local Health District during the Delta and Omicron waves of the COVID-19 pandemic in New South Wales, Australia.ResultsTwenty-six COVID-19 outbreaks in 23 facilities in the Delta wave, and 84 outbreaks in 53 facilities in the Omicron wave were included in the study. A linear Generalised Estimating Equation model was fitted to the Omicron data. Higher IPC scores were associated with higher attack rates and mortality rates. Facilities with IPC scores greater than 75.0% had attack rates 19.6% higher [95% CI: 6.4%-32.8%] and mortality rates 1.7% higher [95% CI: 0.6%-2.7%] than facilities with an IPC score of less than 60.0%.ConclusionsThe results of this study suggest the utility of the IPC scoring system for identifying facilities at greater risk of adverse outcomes from COVID-19 outbreaks. While further validation and replication of accuracy is required, the IPC scoring system could be used and adapted to improve planning, policy, and resource allocation for future outbreaks.

Management of complications after skin surgery relevant for melanoma in the trunk and extremities during the COVID-19 pandemic: a case series report

BackgroundPatients with melanoma have been found to be at greater risk of adverse outcomes including mortality after contacting COVID-19. Management of postsurgical complications presented additional challenges by potentially increasing exposure to COVID-19 through repeated inpatient admissions to hospital during the pandemic. We report four cases for which skin flaps, lymph ligation, and split-thickness skin graft (STSG) were successfully used in the treatment of complications in the trunk and extremities after wide local excision (WLE). This study details the operative experience in management of postsurgical complications for melanoma in the trunk and extremities during a 6-month period at the height of the COVID-19 pandemic.Case presentationWe present 4 cases detailing management of complications that occurred after wide local excisions performed for melanoma during Feb. to Oct. 2020. Case 1: A 90-year-old man who experienced wound dehiscence and necrosis on the shoulder after non-radical excision for an aggressive melanoma and underwent the side-to-side closure after ellipse formed WLE with modified tangent-to-circle method. Case 2: An 80-year-old man who had undergone excision for melanoma in his left upper arm and histopathology did not show radically. Two weeks after the excision, he underwent a WLE and direct reconstruction with double rotation skin flap. Case 3: A 55-year-old man that experienced a large wound dehiscence on his back due to WLE. He underwent an advanced double skin flap operation. Case 4: A 36-year-old woman who had a lymphorrhea and graft necrosis after WLE and STSG on the right lower leg. A combination of micro lymph ligation and re-STSG was performed. One month after the operation, all wounds had healed. There was no clinical evidence of tumor recurrence after 8 months post procedure.ConclusionsSevere complications (e.g., large wound dehiscence, necrosis, or lymphorrhea) following wide local excision of melanoma are infrequent but must be swiftly and appropriately managed, especially during the COVID-19 pandemic to decrease the likelihood of COVID-19 infection and impaired oncology outcomes from delaying systemic cancer therapy due to the complications in primary interventions.