Higher Hospital Mortality Research Articles

Incidence and impact of extra-pulmonary organ failures on hospital mortality in acute\xa0exacerbation\xa0of idiopathic pulmonary fibrosis

To evaluate hospital mortality and associated risk factors for acute exacerbations of idiopathic pulmonary fibrosis (AEIPF). Emphases were put on incidence and impact of extra-pulmonary organ failures. Patients diagnosed with AEIPF from July 2014 to September 2018 were enrolled. Clinical data were collected. Acute physiology and chronic health evaluation II (APACHE II) and simplified acute physiological score II (SAPS II) were calculated. Extra-pulmonary organ failures were diagnosed upon criteria of sequential organ failure assessment (SOFA). Forty-five patients with AEIPF were included. Eighteen patients (40.0%) developed extra-pulmonary organ failures, and 25 patients (55.6%) died during hospitalization. Serum C-reactive protein (CRP) (p = 0.001), SAPS II (p = 0.004), SOFA (p = 0.001) were higher, whereas arterial oxygen pressure (PaO2)/ fractional inspired oxygen (FiO2) (p = 0.001) was lower in non-survivors than survivors. More non-survivors developed extra-pulmonary organ failures than survivors (p = 0.002). After adjustment, elevated serum CRP (OR 1.038, p = 0.049) and extra-pulmonary organ failure (OR 13.126, p = 0.016) were independent predictors of hospital mortality in AEIPF. AEIPF had high hospital mortality and occurrence of extra-pulmonary organ failure was common. Elevated serum CRP and extra-pulmonary organ failure had predictive values for mortality.

Does the "Weekend Effect" Extend to Friday Admissions? An Analysis of Ischemic Stroke Hospitalizations in South Carolina.

Background: Weekend admission has been found to be associated with higher hospital mortality and longer hospital stay among patients with acute cardiovascular conditions. Whether those admitted on Fridays face similar risk as those admitted on Sundays and Saturdays remain uncertain.Methods: This study used 2012–2013 data from hospital records for nonfatal patients with ischemic stroke in the state of South Carolina. The database contained the records of all hospitalizations in South Carolina except military and federal institutions. Multilevel logistic, negative binomial, and log-linear regression models were performed to explore the temporal pattern by hospital admission on specific day of a week for three outcomes: discharge to hospice care (vs. other alive discharges), length of stay, and total charge, respectively. Each model controlled for the patient age, gender, race/ethnicity, year of hospital admission, season of admission, payer, and Charlson Comorbidity Index.Results: A total of 19,346 nonfatal ischemic stroke hospitalizations were identified. Multilevel logistic regression shows that patients admitted on non-Friday weekdays had a significantly lower odds of being discharged to hospice care as compared with those admitted on Fridays [odds ratio = 0.80, 95% confidence interval (CI) = 0.65–0.99] where there was no significant difference between Friday admissions and weekend admissions. The length of hospital stay for admission on non-Friday weekdays was significantly shorter than that of Friday admissions [incident rate ratio (IRR) = 0.87, 95% CI = 0.84–0.90], whereas longer length of hospital stay was found on weekend admission (IRR = 1.06, 95% CI = 1.02–1.11). Friday admissions were not associated with higher charges as compared with non-Friday weekday admissions.Conclusions: Some hospitalization outcomes admitted on Fridays seemed to have the “weekend effects” too. Further studies are warranted to investigate underlying mechanism for such a difference in outcomes between Friday and other weekdays. Interventions to close the weekend–weekday gap of patient outcomes need to consider the elevated risk on Friday admission.

P0564INCIDENCE AND PROGNOSIS OF ACUTE KIDNEY INJURY VERSUS ACUTE KIDNEY DISEASE AMONG 71,041 INPATIENTS

Abstract Background and Aims The current diagnostic criteria for acute kidney injury (AKI) predict the need for dialysis and early mortality, but are less useful to predict long-term outcomes. Acute kidney disease (AKD) defines patients with AKI or subacute loss of kidney function lasting for more than 7 days, which should predict better subsequent chronic kidney disease (CKD). The aim of this study was to investigate the risk factors and prognosis of AKD and to compare different types of acute/subacute renal impairment among Chinese inpatients. Method From a cohort of 450,000 patients consecutive admitted from June 1, 2012, to March 31, 2018 to five district hospitals, complete data were available from 71,041 inpatients. AKI and AKD were diagnosed based on the Acute Disease Quality Initiative Criteria 2017. Based on this diagnostic criterion of AKI and AKD, patients were classified as having (1) AKI Recover, if Scr back to baseline value within 7 days (renal impairment duration of less than 7 days or rapid recovery within 7 days), and (2) AKD with AKI, if a condition in which stage 1 or greater AKI was present ≥ 7 days after an AKI initiating event (continuous AKI progressing to AKD), (3) AKD without AKI, if Scr levels increased slowly but lasted more than 7 days (subacute AKD without meeting the AKI criterion). Results Of 71,041 inpatients, 16,098 (22.66%) patients developed AKI or AKD. 5,895 (8.30%) AKI patients recovered within 7 days (AKI Recover), 5,623 (7.91%) were followed by AKD and 4,580 (6.44%) patients developed AKD without AKI. Thus, AKI and AKD are frequent complications in Chinese inpatients (Fig 1). Compared to AKI recover or AKD without AKI, patients with AKI followed by AKD had higher hospital mortality (16.59% vs. 3.82% vs. 2.12%, P<0.05) and more de novo CKD (8.95% vs. 7.29% vs. 5.48%, P<0.05). Mortality was proportional to stages of AKI and AKD (P for trend <0.05), while AKI followed by AKD was associated with a higher risk of long-term mortality (hazard ratio (HR) 4.51, 4.32-4.71, P<0.05) as compared to AKD without AKI (HR 2.25, 2.13-2.39, P<0.05) and AKI Recover (HR 1.18, 1.09-1.26, P<0.05). The AKI criterion yielded a higher risk for overall survival and a lower risk for de novo CKD than the AKD criterion, indicating that both criteria imply persistent kidney damage but that a rapid decline in excretory kidney function implies higher mortality risks while a persistent decline may rather result in de novo CKD (Fig 2). Meanwhile, these associations between different kidney injury criteria and outcomes had good generalizability and were constant across different genders, surgeries, and comorbidities (Fig 2). The AKD criterion was robustly associated with overall survival (area under the receiver operating characteristic curve (AUROC) 0.71) and de novo CKD (AUROC 0.71), while AKI criterion showed a relatively lower ability to fitting risk of overall survival (AUROC 0.65, P<0.05) and CKD (AUROC 0.63, P<0.05). Moreover, combining AKI and AKD was strongly associated with long-term mortality (AUROC 0.725) and de novo CKD (AUROC 0.72) compared to each single criterion of AKI or AKD (Fig 3). Conclusion (1) Adding AKD as a definition for renal failure lasting >7 days up to 90 days is of clinical importance in addition to the existing definitions for AKI and CKD. (2) These findings suggest research activities and clinical practice should also focus on AKD, which is far more accurate to predict subsequent de novo CKD.

Association between biomass formation and the prognosis of infective endocarditis due to Staphylococcus aureus

IntroductionThe aim of this study was to evaluate the association between biomass formation and the clinical characteristics and prognosis of Staphylococcus aureus infective endocarditis (IE). MethodsWe prospectively studied 209 S. aureus strains causing IE. Biomass formation was examined using the crystal violet assay and quantified spectrophotometrically. The average (SD) optical density of the biomass was compared for each clinical, microbiological (methicillin-resistance, vancomycin MIC≥1.5μg/ml) and molecular (clonal complex, agr type and agr dysfunction) variable according to their presence or absence. The primary clinical endpoints studied were in-hospital death, severe sepsis, persistent bacteraemia, symptomatic peripheral embolisms and prosthetic valve IE. ResultsMean age was 66.1 years, 61.5% of patients were male and the median age-adjusted Charlson comorbidity index was 5 points (IQR 3–8). In-hospital mortality was 37.3%. Strains belonging to CC5 and CC22 had optical biomass densities [mean (SD) 1.573 (1.14) vs 0.942 (0.98) p<0.001 and 1.720 (0.94) vs 1.028 (1.04) p=0.001, respectively]. Strains belonging to CC5 and CC22 had significantly higher optical biomass densities [1.369 (1.18) vs 0.920 (0.93) p=0.008]. No statistically significant differences were found in the clinical endpoints studied. ConclusionsHigh biomass production was associated with CC5 and CC22 but not with higher hospital mortality, septic complications, type of endocarditis, methicillin-resistance, elevated vancomycin MIC or agr dysfunction.

Profile of mortality among beneficiaries of public health assurance schemes in Karnataka: a retrospective study

Background: The burden of non-communicable diseases (NCDs) that can potentially be dealt at tertiary care is increasing in developing countries including India which increase the out of pocket expenditure. Different health assurance schemes have been implemented in the state of Karnataka to provide access to quality tertiary medical care to all. The current study was undertaken to study the profile of mortality under these schemes as no information was available till date.Methods: Data of beneficiaries availing treatment in empanelled tertiary care hospitals under health assurance schemes was collected from Suvarna Arogya Suraksha Trust (SAST) online data base from April 2015 to March 2016 on 20 August 2016. Statistical analysis was done by data collection using Microsoft EXCEL 2010 and SPSS-20 version.Results: Majority of the beneficiaries (91.9%) were treated under Vajpayee Arogyashree Scheme. Deaths were more in beneficiaries of Mysore division with significant high mortality in burn patients. Nearly 63.2% of the beneficiaries were males and were in the age group of 15-60 years and higher hospital mortality was seen among infants (6.8%). Age less than one year, longer cardio pulmonary bypass time and longer aortic cross-clamp time are significantly (p&lt;0.001) associated with hospital mortality in surgeries of congenital heart disease.Conclusions: Mortality in beneficiaries of health assurance schemes was more in infants, females, burn cases and in Mysore division.

Trauma complications and in-hospital mortality: failure-to-rescue

BackgroundReducing medical errors and minimizing complications have become the focus of quality improvement in medicine. Failure-to-rescue (FTR) is defined as death after a surgical complication, which is an institution-level surgical safety and quality metric that is an important variable affecting mortality rates in hospitals. This study aims to examine whether complication and FTR are different across low- and high-mortality hospitals for trauma care.MethodsThis was a retrospective cohort study performed at trauma care hospitals registered at Japan Trauma Data Bank (JTDB) from 2004 to 2017. Trauma patients aged ≥ 15 years with injury severity score (ISS) of ≥ 3 and those who survived for > 48 h after hospital admission were included. The hospitals in JTDB were categorized into three groups by standardized mortality rate. We compared trauma complications, FTR, and in-hospital mortality by a standardized mortality rate (divided by the institute-level quartile).ResultsAmong 184,214 patients that were enrolled, the rate of any complication was 12.7%. The overall mortality rate was 3.7%, and the mortality rate among trauma patients without complications was only 2.8% (non-precedented deaths). However, the mortality rate among trauma patients with any complications was 10.2% (FTR). Hospitals were categorized into high- (40 facilities with 44,773 patients), average- (72 facilities with 102,368 patients), and low- (39 facilities with 37,073 patients) mortality hospitals, using the hospital ranking of a standardized mortality rate. High-mortality hospitals showed lower ISS than low-mortality hospitals [10 (IQR, 9–18) vs. 11 (IQR, 9–20), P < 0.01]. Patients in high-mortality hospitals showed more complications (14.2% vs. 11.2%, P < 0.01), in-hospital mortality (5.1% vs. 2.5%, P < 0.01), FTR (13.6% vs. 7.4%, P < 0.01), and non-precedented deaths (3.6% vs. 1.9%, P < 0.01) than those in low-mortality hospitals.ConclusionsUnlike reports of elective surgery, complication rates and FTR are associated with in-hospital mortality rates at the center level in trauma care.

Higher ICU Capacity Strain Is Associated With Increased Acute Mortality in Closed ICUs.

To determine whether patients admitted to an ICU during times of strain, when compared with its own norm (i.e. accommodating a greater number of patients, higher acuity of illness, or frequent turnover), is associated with a higher risk of death in ICUs with closed models of intensivist staffing. We conducted a large, multicenter, observational cohort study. Multilevel mixed effects logistic regression was used to examine relationships for three measures of ICU strain (bed census, severity-weighted bed census, and activity-weighted bed census) on the day of admission with risk-adjusted acute hospital mortality. Pooled case mix and outcome database of adult general ICUs participating in the Intensive Care National Audit and Research Centre Case Mix Programme. The analysis included 149,310 patients admitted to 215 adult general ICUs in 213 hospitals in United Kingdom, Wales, and Northern Ireland. A relative lower strain in ICU capacity as measured by bed census on the calendar day (daytime hours) of admission was associated with decreased risk-adjusted acute hospital mortality (odds ratio, 0.94; 95% CI, 0.90-0.99; p = 0.01), whereas a nonsignificant association was seen between higher strain and increased acute hospital mortality (odds ratio, 1.04; 95% CI, 1.00-1.10; p = 0.07). The relationship between periods of high ICU strain and acute hospital mortality was strongest when bed census was composed of higher acuity patients (odds ratio, 1.05; 95% CI, 1.01-1.10; p = 0.03). No relationship was seen between high strain and ICU mortality. In closed staffing models of care, variations in bed census within individual ICUs was associated with patient's predicted risk of acute hospital mortality, particularly when its standardized bed census consisted of sicker patients.

Clinical Impacts and Outcomes With Possible Donor-Derived Infection in Infected Donor Liver Transplantation: A Single-Center Retrospective Study in China.

Information on possible donor-derived transmission events in China is limited. We evaluated the impacts of liver transplantation from infected deceased-donors, analyzed possible donor-derived bacterial or fungal infection events in recipients, and evaluated the etiologic agents' characteristics and cases outcomes. A single-center observational study was performed from January 2015 to March 2017 to retrospectively collect data from deceased-donors diagnosed with infection. Clinical data were recorded for each culture-positive donor and the matched liver recipient. The microorganisms were isolated and identified, and antibiotic sensitivity testing was performed. The pathogens distribution and incidence of possible donor-derived infection (P-DDI) events were analyzed and evaluated. Information from 211 donors was collected. Of these, 82 donors were infected and classified as the donation after brain death category. Overall, 149 and 138 pathogens were isolated from 82 infected donors and 82 matched liver recipients, respectively. Gram-positive bacteria, Gram-negative bacteria, and fungi accounted for 42.3% (63 of 149), 46.3% (69 of 149), and 11.4% (17 of 149) of pathogens in infected donors. The incidence of multidrug-resistant bacteria was high and Acinetobacter baumannii was the most concerning species. Infections occurred within the first 2 weeks after liver transplantation with an organ from an infected donor. Compared with the noninfection recipient group, the infection recipient group experienced a longer mechanical ventilation time (P = .004) and intensive care unit stay (P = .003), a higher incidence of renal dysfunction (P = .026) and renal replacement therapy (P = .001), and higher hospital mortality (P = .015). Possible donor-derived infection was observed in 14.6% of cases. Recipients with acute-on-chronic liver failure were more prone to have P-DDI than recipients with other diseases (P = .007; odds ratio = 0.114; 95% confidence interval, .025-.529). When a liver recipient receives a graft from an infected deceased-donor, the postoperative incidence of infection is high and the infection interval is short. In addition, when a possible donor-derived, drug-resistant bacterial infection occurs, recipients may have serious complications and poor outcomes.

Clinical and economic impact of methicillin-resistant Staphylococcus aureus: a multicentre study in China

Methicillin-resistant Staphylococcus aureus (MRSA) has become a serious threat to global health. In China, the proportion of S. aureus isolates that were MRSA was 44.6% in 2014. The clinical and economic impact of MRSA in China remains largely uninvestigated. This study aims to compare the differences in hospital costs, length of hospital stay, and hospital mortality rate between MRSA and methicillin-susceptible S. aureus (MSSA) colonization or infection and between MRSA cases and those without an S. aureus infection. A retrospective and multicentre study was conducted in four tertiary hospitals in China between 2013 and 2015. Inpatient characteristics and hospital costs were collected from electronic medical records. We conducted propensity score matching (PSM) to eliminate selection bias by balancing the potential confounding variables between the two groups. The main indicators included hospital costs, length of hospital stay, and hospital mortality rate. A total of 1,335 inpatients with MRSA, 1,397 with MSSA, and 33,606 without an S. aureus infection were included. PSM obtained 954 and 1,313 pairs between the MRSA and MSSA groups and between the MRSA and S. aureus-free groups, respectively. After PSM, MRSA colonization or infection is associated with an increased total hospital cost ranging from $3,220 to $9,606, an excess length of hospital stay of 6 days–14 days, and an attributable hospital mortality rate of 0–3.58%. Between the MRSA and MSSA groups, MRSA colonization or infection was significantly associated with a higher total hospital cost and longer length of hospital stay among survivors but not among non-survivors; however, there were no differences in the hospital mortality rate between these two groups. Between the MRSA and the S. aureus-free groups, MRSA colonization or infection was significantly associated with an increased total hospital cost, a prolonged length of hospital stay and a higher hospital mortality rate among both survivors and non-survivors. It is critical to quantify the clinical and economic impact of MRSA to justify resource allocation for the development of strategies to improve clinical outcomes and to reduce the economic burden.

AN UPDATED EXAMINATION OF COMORBIDITIES AMONG PATIENTS PRESENTING WITH ACUTE MYOCARDIAL INFARCTION

A greater number of comorbidities is associated with higher hospital mortality rates. Knowledge of the full spectrum of comorbidities of myocardial infarction in the United States remains limited, especially for non-cardiovascular comorbidities. Using the latest National Inpatient Sample database,

Impact of corticosteroid treatment on clinical outcomes of influenza-associated ARDS: a nationwide multicenter study

BackgroundCorticosteroid treatment has been widely used in the treatment of septic shock, influenza, and ARDS, although some previous studies discourage its use in severe influenza patients. This multicenter retrospective cohort study conducted in the intensive care units (ICUs) of eight medical centers across Taiwan aims to determine the real-world status of corticosteroid treatment in patients with influenza-associated acute respiratory distress syndrome (ARDS) and its impact on clinical outcomes. Between October 2015 and March 2016, consecutive ICU patients with virology-proven influenza infections who fulfilled ARDS and received invasive mechanical ventilation were enrolled. The impact of early corticosteroid treatment (≥ 200 mg hydrocortisone equivalent dose within 3 days after ICU admission, determined by a sensitivity analysis) on hospital mortality (the primary outcome) was assessed by multivariable logistic regression analysis, and further confirmed in a propensity score-matched cohort.ResultsAmong the 241 patients with influenza-associated ARDS, 85 (35.3%) patients receiving early corticosteroid treatment had similar baseline characteristics, but a significantly higher hospital mortality rate than those without early corticosteroid treatment [43.5% (37/85) vs. 19.2% (30/156), p < 0.001]. Early corticosteroid treatment was independently associated with increased hospital mortality in overall patients [adjusted odds ratio (95% CI) = 5.02 (2.39–10.54), p < 0.001] and in all subgroups. Earlier treatment and higher dosing were associated with higher hospital mortality. Early corticosteroid treatment was associated with a significantly increased odds of subsequent bacteremia [adjusted odds ratio (95% CI) = 2.37 (1.01–5.56)]. The analyses using a propensity score-matched cohort showed consistent results.ConclusionsEarly corticosteroid treatment was associated with a significantly increased hospital mortality in adult patients with influenza-associated ARDS. Earlier treatment and higher dosing were associated with higher hospital mortality. Clinicians should be cautious while using corticosteroid treatment in this patient group.

Pseudomonas aeruginosa bloodstream infections in children: a 9-year retrospective study.

P. aeruginosa bloodstream infection (BSI) is associated with high hospital mortality. Empirical combination therapy is commonly used, but its benefit remains debated. The purpose of this study was to describe in a paediatric population, demographical characteristics and outcome of children treated for P. aeruginosa BSI receiving either a combined or single antibacterial therapy. We performed a retrospective, single-centre, cohort study of hospitalized children with P. aeruginosa BSI from 2007 to 2015. A total of 118 bloodstream infections (BSI) were analysed (102 (86.4%) hospital-acquired, including 52 (44.1%) hospitalized in intensive care unit). In immunocompromised children, 52% of BSI episodes were recorded. Recent medical history revealed that 68% were hospitalized, 31% underwent surgery and 67% had a prior antibiotic therapy within the last 3months. In-hospital mortality was similar for patients receiving single or combined anti-Pseudomonas therapy (p = 0.78). In multivariate analysis, independent risk factors for in-hospital mortality were neutropenia (OR = 6.23 [1.94-20.01], hospitalization in ICU (OR = 5.24 [2.04-13.49]) and urinary tract infection (OR = 4.40 [1.02-19.25]).Conclusion: P. aeruginosa BSI mainly occurred in immunocompromised children. Most infections were hospital-acquired and associated with high mortality. Combination therapy did not improve survival. What is Known: • P. aeruginosa bloodstream infection (BSI) is associated with high hospital mortality. Empirical combination therapy is commonly used but its benefit remains debated. What is New: • This is the largest cohort of Pseudomonas aeruginosa bacteraemia in children ever published. P. aeruginosa Bloodstream mainly occurred in immunocompromised children. Most infections were hospital-acquired and associated with high mortality. Combination therapy did not improve survival.

The optimal peripheral oxygen saturation may be 95-97% for post-cardiac arrest patients: A retrospective observational study.

Current post-resuscitation guidelines recommend oxygen titration in adults with the return of spontaneous circulation after cardiac arrest. However, the optimal peripheral oxygen saturation (SpO2) is still unclear for post-cardiac arrest care. We conducted a retrospective observational study of prospectively collected data of all cardiac arrest patients admitted to the intensive care units between 2014 and 2015. The main exposure was SpO2, which were interfaced from bedside vital signs monitors as 1-min averages, and archived as 5-min median values. The proportion of time spent in different SpO2 categories was included in separate multivariable regression models along with covariates. The primary outcome measure was hospital mortality and the proportion of discharged home as the secondary outcome was reported. 2836 post-cardiac arrest patients in ICUs of 156 hospitals were included. 1235 (44%) patients died during hospitalization and 818 (29%) patients discharged home. With multivariate regression analysis, the proportion of time spent in SpO2 of ≤89%, 90%, 91%, and 92% were associated with higher hospital mortality. The proportion of time spent in SpO2 of 95%, 96%, and 97% were associated with a higher proportion of discharged home outcome, but not associated with hospital mortality. In this retrospective observational study, the optimal SpO2 for patients admitted to the intensive care unit after cardiac arrest may be 95-97%. Further investigation is warranted to determine if targeting SpO2 of 95-97% would improve patient-centered outcomes after cardiac arrest.

Complete left bundle branch block as predictor of cardiogenic shock in patient with acute myocardial infarction on the background of diabetes mellitus type 2

Cardiogenic shock is the leading cause of death in patients with acute myocardial infarction, with high hospital mortality rates ∼80 %. The incidence of cardiogenic shock among myocardial infarction patients is approximately 7 %. Cardiogenic shock patients are found that pre-existing diabetes is associated with an increased risk of cardiogenic shock and it worsens outcomes, with a longer hospital stay. Cardiogenic shock develops approximately twice as often among diabetics as among nondiabetic patients with acute myocardial infarction. Diabetes mellitus and left bundle branch block are predictors of cardiogenic shock complicating acute myocardial infarction. Except for bad prognosis, left bundle branch block can be a marker of a slowly progressing, degenerative, ischemic or non-ischemic cardiac disease, affecting not only the muscle but also the heart conduction system. Immediate diagnosis and management are required. In this article, a clinical case of acute posterior myocardial infarction complicated by complete left bundle branch block and cardiogenic shock in the patient with concomitant diabetes mellitus type 2 is demonstrated. This article emphasizes the priority of referring patients with left bundle branch block to primary percutaneous coronary intervention, usage of more specific ECG criteria for acute coronary syndrome, the role of myocardial infarction biomarker including sensitive assays for cardiac troponins, and bedside echocardiography which may improve diagnostic accuracy and result in timely intervention in such patients. This article also underlines the role of mechanical circulatory support, urgent reperfusion therapy, and strict control of glycemia in the acute phase of myocardial infarction which may contribute to clinical stability of patients with diabetes mellitus and myocardial infarction complicated by cardiogenic shock.

The Prevalence and Outcomes of Sepsis in Adult Patients in Two Hospitals in Malawi.

There are an estimated 19.4 million sepsis cases every year, many of them in low-income countries. The newly adopted definition of sepsis uses Sequential Organ Failure Assessment Score (SOFA), a score which is not feasible in many low-resource settings. A simpler quick-SOFA (qSOFA) based solely on vital signs score has been devised for identification of suspected sepsis. This study aimed to determine in-hospital prevalence and outcomes of sepsis, as defined as suspected infection and a qSOFA score of 2 or more, in two hospitals in Malawi. The secondary aim was to evaluate qSOFA as a predictor of mortality. A cross-sectional study of adult in-patients in two hospitals in Malawi was conducted using prospectively collected single-day point-prevalence data and in-hospital follow-up. Of 1,135 participants, 81 (7.1%) had sepsis. Septic patients had a higher hospital mortality rate (17.5%) than non-septic infected patients (9.0%, p = 0.027, odds ratio 2.1 [1.1-4.3]), although the difference was not statistically significant after adjustment for baseline characteristics. For in-hospital mortality among patients with suspected infection, qSOFA ≥ 2 had a sensitivity of 31.8%, specificity of 82.1%, a positive predictive value of 17.5%, and a negative predictive value of 91.0%. In conclusion, sepsis is common and is associated with a high risk of death in admitted patients in hospitals in Malawi. In low-resource settings, qSOFA score that uses commonly available vital signs data may be a tool that could be used for identifying patients at risk-both for those with and without a suspected infection.

Predictors of postoperative prolonged mechanical ventilation after left ventricular assist device surgery

Aim: Prolonged mechanical ventilation (PMV) after cardiovascular surgeries is associated with morbidity and mortality. The aim of the study was to determine the risk factors for postoperative PMV (PPMV) after left ventricular assist device (LVAD) surgery.Material and Methods: We retrospectively analyzed the data of patients who underwent LVAD surgery between 2011 and 2016. Prolonged mechanical ventilation was defined as postoperative tracheal extubation 24 hours after the patient is admitted to the ICU. Patients were divided into two groups whether they were extubated within 24 hours of surgery or extubated after 24 hours following surgery.Results: During the study period, a total of fifty-seven patients were admitted to ICU. Fifty-seven patients’ data were screened. The mean age of the 57 patients enrolled was 44.6 ± 16.1 years. Of them, 82% were male, and 54 (95%) patients had dilated cardiomyopathy diagnosis. A total of 26 (46%) patients required PPMV. The two groups were similar in terms of demographics, duration of surgery, postoperative LVAD flow rates, presence of preoperative MV, infections, and circulatory support devices (p > 0.05). Patients who required PPMV underwent more revision surgeries [14 (54%) vs. 2 (7%), p 0.001] and had higher incidences of acute kidney injury (AKI) on the first day after the surgery [13 (50%) vs. 4 (13%), p = 0.003] compared with those who did not require PPMV. Furthermore, the patients who required PPMV also required more renal replacement therapies postoperatively [12 (46%) vs. 5 (16%), p = 0.02] and had longer intensive care unit stay (30.1±25.2 days vs. 14.0 ±11.4 days, p = 0.002) and had higher hospital mortality (58% vs. 35%, p = 0.043) and 30-day mortality (38% vs. 16%, p = 0.042) than those who did not require PPMV. Logistic regression analysis revealed postoperative AKI as an independent risk factor for PPMV (OR = 0.223, 95% CI 0.067–0.743, p = 0.015).Conclusion: Our results revealed that almost half of the patients who underwent LVAD surgery required PPMV. AKI on the first day following surgery is an independent risk factor for PPMVs.

Performance of the “GUCH morbidity and mortality scores” in cyanotic and non-cyanotic adults with congenital heart disease

Cyanotic adults with congenital heart disease (ACHD) rely on life-sustaining adaptations to their chronic cyanosis and are at risk of adverse consequences if such adaptations are out of balance. They may benefit from surgical treatment options that were not available during their childhood. The “GUCH morbidity and mortality scores” were specifically designed to predict risks after surgery in ACHD and included comorbidities and patient age. We aim to assess their performance in cyanotic compared to non-cyanotic ACHD. Data of all consecutive adults who underwent CHD surgery in 2005–2016, were collected. Mortality was defined as hospital mortality or mortality within 30 days following surgery. Morbidity was defined as occurrence of one or more of the following complications: renal failure requiring dialysis, neurological deficit persisting at discharge, atrioventricular block requiring pacemaker implantation, mechanical circulatory support, phrenic nerve injury and unplanned reoperation. The performance of the GUCH scores was assessed using the area under the receiver operating characteristics curve (C-index, 95% CI). We evaluated 824 operations including 99 performed in cyanotic ACHD. The mean age at operation was 34 ± 13 years (18–72 years). Cyanotic patients had higher hospital mortality and morbidity than non-cyanotic patients (11.1% vs. 2.4%, P < 0.0001; and 22.2% vs. 8.4%, P < 0.0001 respectively). C-index for GUCH mortality score in cyanotic and non-cyanotic ACHD were not different: 0.722 (0.536–0.907) and 0.800 (0.712-0.887) ( P = 0.44), respectively. C-index for GUCH morbidity score was lower in cyanotic than in non-cyanotic ACHD: 0.483 (0.335–0.632) vs. 0.671 (0.601–0.741) ( P = 0.027). GUCH mortality score is efficient in cyanotic ACHD patients. However, the GUCH morbidity score should be refined in these patients.

Effects of Cancer, Coronary Artery Disease and other Comorbidities on COVID-19 Related Mortality: A Meta-analysis and Meta-regression

Objective: To investigate Coronavirus Disease 2019 (COVID-19) associated mortality, the prevalence of different symptoms, and the prevalence and association between comorbidities and their effects on outcomes. Methods: We performed a systematic literature search and meta-analysis on studies that assess COVID-19 patients' symptoms, comorbidities, and outcomes using pooled event rate (PER) and pooled event means (PEM). The primary outcome was the pooled all- cause short-term mortality. The secondary outcomes were length of hospital stay and symptom presentation. Meta-regression and leave-one-out analysis were conducted for mortality. Results: 56 articles met our inclusion criteria with a total of 9074 patients. The PEM for age was 49.6 years. The PER for female gender was 46.79%. The PER for smoking, hypertension, cardiac comorbidities, diabetes was 10.96%, 24.47%, 20.30%; 12.34% respectively. The PER for CAD, COPD, history of cancer and chronic liver disease was 5.44%, 3.96%, 3.75% and 3.08%. The PER for fever, cough, sore throat and headache was 79.29%, 56.48%, 11.10%, 8.16%, respectively. The PER for diarrhea, chest pain, fatigue and vomiting was 11.32%, 13.43%, 27.72% and 11.98%, respectively. PEM for hospital stay was 10.9 days (95% CI 7.3- 16.1 days). The PER for hospital mortality was 11.17% (95% CI, 6.67% - 17.89%). Hospital mortality was significantly and positively associated with cardiac comorbidity and COPD. Age and cancer were not associated with higher hospital mortality. Conclusion: Fever and cough are the most common presenting symptoms with estimated PER of 79.29% and 56.48% respectively. Hospital mortality is significantly and positively associated with cardiac comorbidities, CAD, and COPD, while not being significantly associated with patient age or cancer.

Comparison of SAPS 3 performance in patients with and without solid tumor admitted to an intensive care unit in Brazil: a retrospective cohort study.

ObjectiveTo compare the performance of the Simplified Acute Physiology Score 3 (SAPS 3) in patients with and without solid cancer who were admitted to the intensive care unit of a comprehensive oncological hospital in Brazil.MethodsWe performed a retrospective cohort analysis of our administrative database of the first admission of adult patients to the intensive care unit from 2012 to 2016. The patients were categorized according to the presence of solid cancer. We evaluated discrimination using the area under the Receiver Operating Characteristic curve (AUROC) and calibration using the calibration belt approach.ResultsWe included 7,254 patients (41.5% had cancer, and 12.1% died during hospitalization). Oncological patients had higher hospital mortality than nononcological patients (14.1% versus 10.6%, respectively; p < 0.001). SAPS 3 discrimination was better for oncological patients (AUROC = 0.85) than for nononcological patients (AUROC = 0.79) (p < 0.001). After we applied the calibration belt in oncological patients, the SAPS 3 matched the average observed rates with a confidence level of 95%. In nononcological patients, the SAPS 3 overestimated mortality in those with a low-middle risk. Calibration was affected by the time period only for nononcological patients.ConclusionSAPS 3 performed differently between oncological and nononcological patients in our single-center cohort, and variation over time (mainly calibration) was observed. This finding should be taken into account when evaluating severity-of-illness score performance.

An Analysis of Hospital Mortality After Cardiac Operations in Children With Down Syndrome

Children with Down syndrome (DS) have lower mortality compared to nonsyndromic (NS) children after atrioventricular septal defect (AVSD) repair. Limited data exist regarding hospital mortality and utilization after other congenital heart disease (CHD) operations in DS. We compared hospital mortality and utilization after CHD operations in both populations and hypothesized that the survival benefit in children with DS is not consistent across CHD lesions. The Texas Inpatient Public Use Datafile was queried for all patients <18 years old undergoing operations for CHD between 1999 and 2016. Hospital mortality, length-of-stay and charges were compared between DS and NS groups, stratified by CHD operation using mixed-effects multivariable analyses and propensity score matching analyses adjusting for prematurity, low birth weight, age, and sex. Over the 18-year period, 2841 cases with DS underwent CHD operations compared to 25,063 NS cases. The most common types of interventions performed in DS were AVSD repair, isolated ventricular septal defect (VSD) repair and tetralogy of Fallot (TOF) repair. By multivariable analyses, DS was associated with lower mortality after isolated AVSD repair (RR 0.40 [IQR 0.20-0.79]), and higher hospital mortality after bidirectional Glenn anastomosis (BDG) (RR 5.17 [IQR 2.10-12.77]) and TOF/pulmonary atresia repair (RR 9.71 [IQR 2.16-43.68]) compared to NS children. Similar results were noted using propensity score matching. Children with DS had lower mortality after AVSD repair than NS children, but higher mortality after operations for BDG and TOF/pulmonary atresia. Further study is needed to determine if the presence of pulmonary hypertension in DS modifies the association between DS and mortality depending on cardiac lesion.