Higher Risk Of In-hospital Death Research Articles

Development and validation of a nomogram for predicting in-hospital death in cirrhotic patients with acute kidney injury

BackgroundThe purpose of this study was to develop a nomogram for predicting in-hospital mortality in cirrhotic patients with acute kidney injury (AKI) in order to identify patients with a high risk of in-hospital death early.MethodsThis study collected data on cirrhotic patients with AKI from 2008 to 2019 using the Medical Information Mart for Intensive Care IV. Multivariate logistic regression was used to identify confounding factors related to in-hospital mortality, which were then integrated into the nomogram. The concordance index (C-Index) was used to evaluate the accuracy of the model predictions. The area under the curve (AUC) and decision curve analysis (DCA) was used to assess the predictive performance and clinical utility of the nomogram.ResultsThe final study population included 886 cirrhotic patients with AKI, and 264 (29.8%) died in the hospital. After multivariate logistic regression, age, gender, cerebrovascular disease, heart rate, respiration rate, temperature, oxygen saturation, hemoglobin, blood urea nitrogen, serum creatinine, international normalized ratio, bilirubin, urine volume, and sequential organ failure assessment score were predictive factors of in-hospital mortality. In addition, the nomogram showed good accuracy in estimating the in-hospital mortality of patients. The calibration plots showed the best agreement with the actual presence of in-hospital mortality in patients. In addition, the AUC and DCA curves showed that the nomogram has good prediction accuracy and clinical value.ConclusionsWe have created a prognostic nomogram for predicting in-hospital death in cirrhotic patients with AKI, which may facilitate timely intervention to improve prognosis in these patients.

Frailty on in-hospital death in older patients with acute exacerbation of chronic obstructive pulmonary disease: a real-world prospective cohort study

Few evidence exists for the effect of frailty on the patients admitted with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We explored the link of frailty and in-hospital death, and whether laboratory indicators mediate this association. This was a real-world prospective cohort study including older patients with AECOPD, consisting of two cohorts, training set (n=1356) and validation set (n=478). The independent prognostic factors including frail status were determined by multivariate logistic regression analysis. The relationship between frailty and in-hospital mortality was estimated by multivariable Cox regression. A nomogram was developed to provide the clinician with a quantitative tool to predict the risk of in-hospital death. Mediation analyses for frailty and in-hospital death were conducted. The training set included 1356 patients(aged 86.7±6.6), and 25.0% of them were frail. A nomogram model was created, including ten independent variables: age, sex, frailty, chronic obstructive pulmonary disease grades (COPD grades), severity of exacerbation, mean arterial pressure (MAP), Charlson Comorbidity Index (CCI), Interleukin-6 (IL-6), albumin, and troponin T (TPN-T). The area under the receiver operating characteristic curve (ROCs) was 0.862 and 0.845 for the training set and validation set, respectively. Patients with frailty had higher risk of in-hospital death than those without frailty (HR,1.83, 95%CI: 1.14-2.94; p=0.013). Furthermore, CRP and albumin mediated the associations between frailty with in-hospital death. Frailty may be an adverse prognostic factor for older patients admitted with an AECOPD. CRP and albumin may be parts of the immunoinflammatory mechanism between frailty and in-hospital death.

Comparative analysis of the prognostic significance of the CURB-65 and CRB-65 scores and their modifications in hospital mortality assessment in patients with community-acquired pneumonia

Background. Mortality associated with community-acquired pneumonia (CAP) continues to be a crucial health problem worldwide. Correct assessment of CAP severity and the level of care is pivotal in the disease outcome.Aim. To evaluate the prognostic value of the CURB-65 and CRB-65 scores and their modifications in determining the risk of in-hospital mortality in patients with CAP.Materials and methods. The retrospective study included 1,412 patients with CAP aged over 18 years. In a population of 1,020 patients, which was subsequently split into test (n = 676) and training (n = 344) samples in the ratio 2 : 1, we compared the predictive value of the CURB-65 (confusion, urea > 7 mmol / l, respiratory rate ≥ 30 / min, low blood pressure (BP), and age ≥ 65 years) and CRB-65 (confusion, respiratory rate ≥ 30 / min, low blood pressure (BP), and age ≥ 65 years) scores in identifying patients at high risk of in-hospital death. The specified scoring systems were modified by changing the cut-offs for each criterion to increase their accuracy. For comparison, we used the ROC analysis with the calculation of the area under the curve (AUC).Results. The modified CURB-65 score with new cut-off values (age > 72 years, respiratory rate > 21 / min, urea level > 9.5 mmol / l, systolic blood pressure ≤ 105 mm Hg, and diastolic blood pressure ≤ 65 mm Hg) was more accurate than the original one in predicting death and was named CURB-72. The AUC for CURB-72 and CURB-65 was 0.946 (95% confidence interval (CI): 0.916–0.967) and 0.905 (95% CI: 0.869–0.934), respectively (p = 0.0034). The modified CRB-65 (CRB-72) score also outperformed the original model, but showed no statistically significant difference. While comparing the modified scoring systems, the new CURB-72 score surpassed the CRB-72 score and demonstrated maximum accuracy in identifying CAP patients at risk of in-hospital mortality (p = 0.0347).Conclusion. The modified CURB-65 (CURB-72) and CRB-65 (CRB-72) scores demonstrated potential for assessing the prognosis of CAP and are superior to classical scoring systems. CURB-72 showed the highest sensitivity and specificity.

Sex Differences in Epidemiological Distribution and Outcomes of Surgical Mitral Valve Disease.

Mitral valve (MV) disease is the most common form of valvular heart disease. Findings that indicate women have a higher risk for unfavorable outcomes than men remain controversial. This study aimed to determine the sex-based differences in epidemiological distributions and outcomes of surgery for MV disease.Methods and Results: Overall, 18,572 patients (45.3% women) who underwent MV surgery between 2001 and 2018 were included. Outcomes included in-hospital death and all-cause mortality during follow up. Subgroup analysis was conducted across different etiologies, including infective endocarditis (IE), degenerative, ischemic, and rheumatic mitral pathology. The overall MV repair rate was lower in women than in men (20.5% vs. 30.6%). After matching, 6,362 pairs (woman : man=1 : 1) of patients were analyzed. Women had a slightly higher risk for in-hospital death than men (10.8% vs. 9.8%; odds ratio [OR]: 1.11, 95% confidence interval [CI]: 0.99-1.24; P=0.075). Women tended to have a higher incidence of de novo dialysis (9.8% vs. 8.6%; P=0.022) and longer intensive care unit stay (8 days vs. 7.1 days; P<0.001). Women with IE had poorer in-hospital outcomes than men; however, there were no sex differences in terms of all-cause mortality. Sex-based differences of MV intervention still persist. Although long-term outcomes were comparable between sexes, women, especially those with IE, had worse perioperative outcomes than men.

Abstract 6480: In-hospital mortality risk factors for uveal melanoma patients in the emergency department

Abstract Purpose: A considerable amount of uveal melanoma patients present to the emergency department (ED) for a complication related to their primary tumor. However, there is not much research into the primary reasons for these patients to present to the ED and their outcomes. Methods: The Nationwide Emergency Department Sample was queried from the last quarter of 2015 to 2019 to identify patients with a diagnosis of uveal melanoma. Multivariable logistic regression, with patient- and hospital-level characteristics as covariates, was used to identify factors associated with increased risk of in-hospital death. Results: From the last quarter of 2015 to 2019, there were 7,561 ED encounters with a secondary diagnosis of uveal melanoma. Most patients were at least 65 years of age (43.5%), male (52.5%), and a Medicare beneficiary (44.2%), or belong to a family in the 3rd income quartile (25.6%). The median age of these patients was 61 years (IQR: 32-74). Most patients presented to hospitals in the South (40.8%), with a Trauma Level I designation (47.2%), and to a metropolitan teaching hospital (72.6%). The most common diagnosis for presentation to the ED were the following general clinical categories: blood disorders (7.1%), genitourinary tract disorders (5.1%), infections (6.0%), respiratory diseases (9.0%), nervous system disorders (4.8%), endocrine/nutrition disorders (4.3%), and vascular disorders (8.3%). The rate of metastatic uveal melanoma was 5.8%. The rate of in-hospital mortality was 3.6%. In a multivariable logistic regression identified the following clinical categories as factors associated with a higher risk of in-hospital death: infections (odds ratio [OR]=10.22; p&amp;lt;0.001), metastases (OR=10.22; p&amp;lt;0.001), genitourinary tract disorders (OR=7.05; p&amp;lt;0.001), respiratory diseases (OR=3.31; p=0.031), and vascular disorders (OR=3.14; p=0.044). Nervous system, blood, and endocrine/nutrition disorders were not associated with a higher rate of in-hospital mortality. The only demographic variable associated with a higher risk of in-hospital death was being part of the top income quartile (OR=3.10; p=0.14). Conclusion: Physicians have to be mindful of different complications associated with uveal melanoma that can lead to presentation to the ED and possible in-hospital death. Specifically, physicians need to be mindful of infections, metastases, genitourinary tract disorders, respiratory diseases, and vascular disorders in these patients. Citation Format: Alice A. Beneke, Kamil Taneja, Lauren Ladehoff, Kevin Root, Eric Toloza. In-hospital mortality risk factors for uveal melanoma patients in the emergency department [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6480.

Timing of Initiation of Extracorporeal Membrane Oxygenation Support and Outcomes Among Patients With Cardiogenic Shock.

Venoarterial extracorporeal membrane oxygenation (ECMO) provides full hemodynamic support for patients with cardiogenic shock, but optimal timing of ECMO initiation remains uncertain. We sought to determine whether earlier initiation of ECMO is associated with improved survival in cardiogenic shock. We analyzed adult patients with cardiogenic shock who received venoarterial ECMO from the international Extracorporeal Life Support Organization (ELSO) registry from 2009 to 2019, excluding those cannulated following an operation. Multivariable logistic regression evaluated the association between time from admission to ECMO initiation and in-hospital death. Among 8619 patients (median, 56.7 [range, 44.8-65.6] years; 33.5% women), the median duration from admission to ECMO initiation was 14 (5-32) hours. Patients who had ECMO initiated within 24 hours (n=5882 [68.2%]) differed from those who had ECMO initiated after 24 hours, with younger age, more preceding cardiac arrest, and worse acidosis. After multivariable adjustment, patients with ECMO initiated >24 hours after admission had higher risk of in-hospital death (adjusted odds ratio, 1.20 [95% CI, 1.06-1.36]; P=0.004). Each 12-hour increase in the time from admission to ECMO initiation was incrementally associated with higher adjusted in-hospital mortality rate (adjusted odds ratio, 1.06 [95% CI, 1.03-1.10]; P<0.001). The association between longer time to ECMO and worse outcomes appeared stronger in patients with lower shock severity. Longer delays from admission to ECMO initiation were associated with higher a mortality rate in a large-scale, international registry. Our analysis supports optimization of door-to-support time and the avoidance of inappropriately delayed ECMO initiation.

Acute respiratory failure prognosis in prolonged ICU stays

Objective: This study aimed to assess the outcome of patients with acute respiratory failure and need of mechanical ventilation who stayed for more than 21 days in the ICU. Methods: All acute respiratory failure patients in King Saud Medical City, Riyadh Saudi Arabia and adults ICU who required a lengthy intensive care unit stay of more than 21 days between January 2022 and August 2023 were identified in this retrospective study. Information was extracted from the hospital database by trained physicians. Results: Total 121 patients (mean age 61.2±15.8 years) were included. Of which, 24.1% patients were more than 70 years. Sepsis was the most common cause of prolonged ICU stay both in survivors and non-survivors with 77.8% and 76.1%, respectively. Compared to patients who survived, non-survivors had higher acute physiology and chronic health evaluation (APACHE 4) scores were considerably older. Moreover, non-survivors were more likely than survivors to have renal failure, arrhythmia, hepatic failure, or significant gastrointestinal tract bleeding as reasons for a lengthy ICU stay. Patients who were admitted to ICU because they needed further surgery were more likely to survive. Conclusion: When acute respiratory fever (ARF) patients needed a lengthy stay in the ICU, their prognosis was not good. A high risk of in-hospital death was linked to older ages, more than 28 days ICU stay, more than 25 APACHE 4 score, unstable hemodynamic condition, hepatic failure, renal failure, major gastrointestinal tract bleeding, and needing FiO2 &amp;ge;40%.

Фактори несприятливого прогнозу в жінок із високим ризиком гострої тромбоемболії легеневої артерії

The aim – to determine the risk factors of an unfavorable prognosis in patients with pulmonary embolism (PE) depending on gender.Materials and methods. A retrospective analysis of the data of 635 patients with a verified diagnosis of PE according to multispiral computed tomographic angiography (MSCT-angiography) of pulmonary vessels and/or according to autopsy results, who were consecutively hospitalized at Kharkiv City Clinical Hospital No. 8 for the period from January 1, 2017 to January 1, 2023. Patients were divided into two groups: IA group included patients with high-risk acute PE who were discharged from the hospital, IВ group – patients with high-risk acute PE who died during the hospital period. Clinical and anamnestic, laboratory and instrumental indicators were analyzed, statistical processing of data depending on gender was carried out.Results and discussion. When analyzing the obtained data, it was established that in the group of deceased patients with a high risk there was probably a higher proportion of women (72 % at p=0.014). Deceased males had more severe clinical manifestations than deceased females, as evidenced by significantly lower SpO2 values (p=0.022) and larger right ventricular dimensions on echocardiography (p=0.036). In turn, such a risk factor of PE as obesity was more common in women than in men (61.1 % vs. 28.6 % at p=0.039). In order to determine independent factors associated with in-hospital mortality in high-risk PE patients in women, we conducted uni- and multifactorial logistic regression analysis of the influence of the studied factors. Since the small number of deceased men in the sample (n=14) does not allow us to draw reasonable conclusions, the analysis of factors affecting mortality is given only for the group of women. Factors associated with in-hospital death were the presence of arterial hypertension in the anamnesis (p=0.043), a decrease in systolic blood pressure (p=0.0003) in the acute period, and the localization of a thrombus at the bifurcation of the pulmonary arteries (p=0.012). After performing the regression analysis, we derived a formula for individual prediction of the risk of in-hospital death for gender with high-risk PE. Using the ROC analysis, it was established that the sensitivity of the obtained prognostic formula is 75.0 %; specificity – 83.9 (area under the ROC curve 0.867; 95 % confidence interval 0.762–0.938, p&lt;0.0001). The formula developed by us includes available general clinical indicators and allows specifying the individual risk of in-hospital mortality for female patients with high-risk PE.Conclusions. The results of a comparative analysis of two subgroups of patients with high-risk PE who died, depending on gender, showed that men were more likely to have lower SpO2 values and larger right ventricular sizes according to echocardiography. In turn, such risk factors as obesity were more common in women than in men. According to multivariate logistic regression analysis, additional independent factors that are associated with the development of death during the hospital period in women with high-risk PE are the presence of arterial hypertension in the anamnesis, a decrease in systolic blood pressure in the acute period, and the localization of a thrombus at the bifurcation of the pulmonary arteriesof. Proposed formula, according to which Y&gt;0.5 establishes an additional high risk of in-hospital death in women with high-risk PE.

Serial Assessment of Shock Severity in Cardiac Intensive Care Unit Patients.

One-time assessment of the Society for Cardiovascular Angiography and Interventions (SCAI) shock classification robustly predicts mortality in the cardiac intensive care unit (CICU). We sought to determine whether serial SCAI shock classification could improve risk stratification. Unique admissions to a single academic level 1 CICU from 2015 to 2018 were included in this retrospective cohort study. Electronic health record data were used to assign the SCAI shock stage during 4-hour blocks of the first 24 hours of CICU admission. Shock was defined as hypoperfusion (SCAI shock stage C, D, or E). In-hospital death was evaluated using logistic regression. Among 2918 unique CICU patients, 1537 (52.7%) met criteria for shock during ≥1 block, and 266 (9.1%) died in the hospital. The SCAI shock stage on admission was: A, 37.6%; B, 31.5%; C, 25.9%; D, 1.8%; and E, 3.3%. Patients who met SCAI criteria for shock on admission (first 4 hours) and those with worsening SCAI shock stage after admission were at higher risk for in-hospital death. Each higher admission (adjusted odds ratio, 1.36 [95% CI, 1.18-1.56]; area under the receiver operating characteristic curve, 0.70), maximum (adjusted odds ratio, 1.59 [95% CI, 1.37-1.85]; area under the receiver operating characteristic curve, 0.73) and mean (adjusted odds ratio, 2.42 [95% CI, 1.99-2.95]; area under the receiver operating characteristic curve, 0.78) SCAI shock stage was incrementally associated with a higher in-hospital mortality rate. Discrimination was highest for the mean SCAI shock stage (P<0.05). Each additional 4-hour block meeting SCAI criteria for shock predicted a higher mortality rate (adjusted odds ratio, 1.15 [95% CI, 1.07-1.24]). Dynamic assessment of shock using serial SCAI shock classification assignment can improve mortality risk stratification in CICU patients by quantifying the magnitude and duration of shock.

Abstract 16440: Gender Differences of In-Hospital Outcomes in Acute Myocardial Infarction and Cardiogenic Shock Patients Using Impella: From the Nation Inpatient Sample 2016-2019

Background: There is a lack of independent studies on gender differences in hospital outcomes with Impella in patients with acute myocardial infarction (AMI) combined with cardiogenic shock (CS). Our study aims to provide evidence on the impact of gender differences on AMI-CS patients receiving Impella with a nationally representative sample. Methods: Data were obtained from the National Inpatient Sample (NIS) from 2016 to 2019. Patients with AMI and CS were searched in the NIS using ICD-10 CM codes, and those with Impella were screened using ICD-10PCS codes. Patients treated with Impella were then stratified by gender. We used multivariate regression analysis with inverse probability weighting(IPTW) based on propensity scores to compare the risk of in-hospital death after Impella among patients of different genders. Results: From 2016-2019, a total of 2,953 inpatients with AMI combined with CS using Impella were identified. Of these, 28.5% were women. Women treated with Impella were older (mean age 68.42 versus 64.68 years, P&lt;0.0001). Male inpatients on Impella had a higher proportion of NSTEMI, and were more likely to have smoking, congestive heart failure, cardiac arrhythmias, and acute renal failure. Female inpatients were more likely to have STEMI and were more likely to have Chronic pulmonary disease, uncomplicated hypertension, hypothyroidism, and valvular disease. After IPTW-adjusted baseline clinical covariates, women using Impella had a higher risk of in-hospital death than men, while length of stay and total hospital cost did not differ significantly between genders (OR, 1.33 [95%CI, 1.10-1.60]; Beta, -0.05 [95%CI, -0.80-0.71]; and Beta, 8105.24 [95%CI, -25376.84-9166.35]; respectively). Conclusions: Impella use was lower in women. However, in-hospital mortality was significantly higher in women among AMI-CS patients using Impella. Further studies are needed to explore the reasons for higher mortality in female patients using Impella.

Elevated International Normalized Ratio and Mortality in Hospitalized Patients Treated with Direct Oral Anticoagulants

BackgroundDirect oral anticoagulants (DOACs) are associated with a prolongation of the prothrombin time and an increased international normalized ratio (INR). The clinical significance of these changes is unclear. This study aimed to examine the association between an elevated INR on admission and in-hospital death and long-term survival in patients treated with DOACs. MethodsData were retrospectively retrieved from records of hospitalized patients at the Sheba Medical Center between November 2008 and July 2023. Patients were selected based on DOAC treatment, coagulation profile, and INR test done within 48 hours of hospitalization. The outcomes were in-hospital mortality and mortality in the year following hospitalization. ResultsThe study included 11,399 hospitalized patients treated with DOACs. Patients with elevated INR had a 180% higher risk of in-hospital mortality (adjusted odds ratio 2.80; 95% confidence interval, 2.30-3.39) and a 57% increased risk of death during the following year (adjusted hazard ratio 1.57; 95% confidence interval, 1.44-1.71). Similar results were observed in subgroup analyses for each DOAC. ConclusionsAn elevated INR on admission is associated with a higher risk for in-hospital death and increased risk for mortality during the first year following hospitalization in hospitalized patients treated with DOACs. This highlights that elevated INR levels in patients on DOACs should not be dismissed as laboratory variations due to DOAC treatment, as they may serve as a prognostic marker.

Prevalence of Antimicrobial Resistance in Gram-Negative Bacteria Bloodstream Infections in Peru and Associated Outcomes: VIRAPERU Study.

Surveillance of antimicrobial resistance among gram-negative bacteria (GNB) is of critical importance, but data for Peru are not available. To fill this gap, a non-interventional hospital-based surveillance study was conducted in 15 hospitals across Peru from July 2017 to October 2019. Consecutive unique blood culture isolates of key GNB (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter spp.) recovered from hospitalized patients were collected for centralized antimicrobial susceptibility testing, along with linked epidemiological and clinical data. A total of 449 isolates were included in the analysis. Resistance to third-generation cephalosporins (3GCs) was present in 266 (59.2%) GNB isolates. Among E. coli (n = 199), 68.3% showed 3GC resistance (i.e., above the median ratio for low- and middle-income countries in 2020 for this sustainable development goal indicator). Carbapenem resistance was present in 74 (16.5%) GNB isolates, with wide variation among species (0% in E. coli, 11.0% in K. pneumoniae, 37.0% in P. aeruginosa, and 60.8% in Acinetobacter spp. isolates). Co-resistance to carbapenems and colistin was found in seven (1.6%) GNB isolates. Empiric treatment covered the causative GNB in 63.3% of 215 cases. The in-hospital case fatality ratio was 33.3% (92/276). Pseudomonas aeruginosa species and carbapenem resistance were associated with higher risk of in-hospital death. In conclusion, an important proportion of bloodstream infections in Peru are caused by highly resistant GNB and are associated with high in-hospital mortality.

Protective Effects of Home T2DM Treatment with Glucagon-Like Peptide-1 Receptor Agonists and Sodium-Glucose Co-transporter-2 Inhibitors Against Intensive Care Unit Admission and Mortality in the Acute Phase of the COVID-19 Pandemic: A Retrospective Observational Study in Italy.

Type 2 diabetes mellitus (T2DM) is a relevant risk factor for severe forms of COVID-19 (SARS coronavrus 2 [SARS-CoV-2] disease 2019), and calls for caution because of the high prevalence of T2DM worldwide and the high mortality rates observed in patients with T2DM who are infected with SARS-CoV-2. People with T2DM often take dipeptidyl peptidase-4 inhibitors (DPP-4is), glucagon-like peptide-1 receptor agonists (GLP-1ras), or sodium-glucose co-transporter-2 inhibitors (SGLT-2is), all of which have clear anti-inflammatory effects. The study aimed to compare (i) the severity and duration of hospital stay between patients with T2DM categorized by pre-hospitalization drug class utilization and (ii) the COVID-19-related death rates of those three groups. We designed an observational, retrospective, multi-center, population-based study and extracted the hospital admission data from the health care records of 1916 T2DM patients over 18years old who were previously on GLP-1ra, SGLT-2i, or DPP-4i monotherapy and were hospitalized for COVID-19 (diagnosis based on ICD.9/10 codes) between January 2020 and December 2021 in 14 hospitals throughout Italy. We analyzed general data, pre-admission treatment schedules, date of admission or transfer to the intensive care unit (ICU) (i.e., the index date; taken as a marker of increased COVID-19 disease severity), and death (if it had occurred). Statistics analyzed the impact of drug classes on in-hospital mortality using propensity score logistic regressions for (i) those admitted to intensive care and (ii) those not admitted to intensive care, with a random match procedure used to generate a 1:1 comparison without diabetes cohort replacement for each drug therapy group by applying the nearest neighbor method. After propensity score matching, we checked the balance achieved across selected variables if a balance was ever achieved. We then used propensity score matching between the three drug classes to assemble a sample in which each patient receiving an SGLT-2i was matched to one on a GLP-1ra, and each patient on a DPP-4i was matched to one on a GLP-1ra, adjusting for covariates. We finally used GLP-1ras as references in the logistic regression. The overall mortality rate (MR) of the patients was 14.29%. The MR in patients with COVID was 53.62%, and it was as high as 42.42% in the case of associated T2DM, regardless of any glucose-lowering therapy. In those on DPP-4is, there was excess mortality; in those treated with GLP-1ras and SGLT-2is, the death rate was significantly lower, i.e., almost a quarter of the overall mortality observed in COVID-19 patients with T2DM. Indeed, the odds ratio (OR) in the logistic regression resulted in an extremely high risk of in-hospital death in individuals previously treated with DPP-4is [incidence rate (IR) 4.02, 95% confidence interval (CI) 2.2-5.7) and only a slight, nonsignificantly higher risk in those previously treated with SGLT-2is (IR 1.42, 95% CI 0.6-2.1) compared to those on GLP-1ras. Moreover, the longer the stay, the higher the death rate, which ranged from 22.3% for ≤ 3-day stays to 40.3% for 4- to 14-day stays (p < 0.01 vs. the former) and 77.4% for over-14-day stays (p < 0.001 vs. both the others). Our data do not support a protective role of DPP-4is; indeed, this role has already been questioned due to previous observations. However, the data do show a strong protective effect of SGLT-2is and GLP-1ras. Beyond lowering circulating glucose levels, those two drug classes were found to exert marked anti-phlogistic effects: SGLT-2is increased adiponectin and reduced urate, leptin, and insulin concentrations, thus positively affecting overall low-grade inflammation, and GLP-1ras may also greatly help at the lung tissue level, meaning that their extra-glycemic effects extend well beyond those acknowledged in the cardiovascular and renal fields. The aforedescribed observational clinical data relating to a population of Italian inpatients with T2DM suggest that GLP-1ras and SGLT-2is can be considered antidiabetic drugs of choice against COVID-19, and might even prove beneficial in the event of any upcoming pandemic that has life-threatening effects on the pulmonary and cardiovascular systems.

Risks of Adverse Outcomes for Hospitalized COVID-19 Patients during the Four Waves in Brazil According to SARS-CoV-2 Variants, Age Group, and Vaccine Status.

Brazil was hit with four consecutive waves of COVID-19 until 2022 due to the ancestral SARS-CoV-2 (B.1 lineage), followed by the emergence of variants/subvariants. Relative risks of adverse outcomes for COVID-19 patients hospitalized during the four waves were evaluated. Data were extracted from the largest Brazilian database (SIVEP-Gripe), and COVID-19 patients who were hospitalized during the peak of each of the four waves (15-week intervals) were included in this study. The outcomes of in-hospital death, invasive (IMV) and non-invasive (NIV) ventilation requirements, and intensive care unit (ICU) admission were analyzed to estimate the relative risks. A higher risk of in-hospital death was found during the second wave for all age groups, but a significant reduction was observed in the risk of death for the elderly during the third and fourth waves compared to patients in the first wave. There was an increased risk of IMV requirement and ICU admissions during the second wave for patients aged 18-59 years old compared to the first wave. Relative risk analysis showed that booster-vaccinated individuals have lower risks of in-hospital death and IMV requirement in all age groups compared to unvaccinated/partially vaccinated patients, demonstrating the relevance of full/booster vaccination in reducing adverse outcomes for patients who were hospitalized during the variant prevalence.

Development and validation of a prediction model based on comorbidities to estimate the risk of in-hospital death in patients with COVID-19.

Most existing prognostic models of COVID-19 require imaging manifestations and laboratory results as predictors, which are only available in the post-hospitalization period. Therefore, we aimed to develop and validate a prognostic model to assess the in-hospital death risk in COVID-19 patients using routinely available predictors at hospital admission. We conducted a retrospective cohort study of patients with COVID-19 using the Healthcare Cost and Utilization Project State Inpatient Database in 2020. Patients hospitalized in Eastern United States (Florida, Michigan, Kentucky, and Maryland) were included in the training set, and those hospitalized in Western United States (Nevada) were included in the validation set. Discrimination, calibration, and clinical utility were evaluated to assess the model's performance. A total of 17 954 in-hospital deaths occurred in the training set (n = 168 137), and 1,352 in-hospital deaths occurred in the validation set (n = 12 577). The final prediction model included 15 variables readily available at hospital admission, including age, sex, and 13 comorbidities. This prediction model showed moderate discrimination with an area under the curve (AUC) of 0.726 (95% confidence interval [CI]: 0.722-0.729) and good calibration (Brier score = 0.090, slope = 1, intercept = 0) in the training set; a similar predictive ability was observed in the validation set. An easy-to-use prognostic model based on predictors readily available at hospital admission was developed and validated for the early identification of COVID-19 patients with a high risk of in-hospital death. This model can be a clinical decision-support tool to triage patients and optimize resource allocation.

Alternatives to Dual Antiplatelet Therapy Are Not Recommended After Transcarotid Revascularization

Inadequate compliance with dual antiplatelet therapy (DAPT) in the setting of transcarotid revascularization (TCAR) is often encountered due to poor tolerance, bleeding, or need for anticoagulation. We aim to define the risks associated with the replacement of DAPT for an alternate medication regimen. All patients undergoing TCAR in the Vascular Quality Initiative from September 2016 to March 2022 were included into the study population comparing DAPT to alternative medication regimens via univariable, multivariable, and propensity score matching techniques. We captured 29,802 total TCAR procedures consisting of 24,651 (82.7%) maintained on DAPT and 5151 (17.3%) on alternative regimens (Table I). Patients on alternative medications were more likely to experience in-hospital death (0.4% vs 0.7%; P < .01), ipsilateral stroke (1.0% vs 1.7%; P < .01), any stroke (1.2% vs 1.9%; P < .01), and transient ischemic attack (0.4% vs 0.7%; P < .01). Additionally, the mortality rate was higher at 1-year postprocedure in the alternative cohort (4.7% vs 7.0%; P < .01). On the multivariable analysis, we noted a higher risk of in-hospital death (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.9-2.5; P < .01), ipsilateral stroke (OR, 1.5; 95% CI, 1.2-2.0) and transient ischemic attack (OR, 1.7; 95% CI, 1.2-2.4) in the alternate medication group. The higher incidence of mortality at one-year postprocedure persisted as well despite adjustment (OR, 1.4; 95% CI, 1.2-1.6). A propensity score match with respect to 29 variables generated 4876 unique pairs (Table II). Compared to patients on DAPT, in-hospital ipsilateral stroke was significantly higher in patients receiving alternative antiplatelet regimens (1.7% vs 1.1%, OR, 1.54; 95% CI, 1.10-2.16; P = .01), while no statistically significant difference was noted with respect to mortality (0.6% vs 0.5%; OR, 1.35; 95% CI, 0.72-2.54; P = .35). A composite of stroke/death was also more likely in patients receiving an alternative regimen (2.4% vs 1.7%; OR, 1.47; 95% CI, 1.12-1.93; P = .01). Immediate stent thrombosis (OR, 2.75; 95% CI, 1.16-6.51) and a nonsignificant trend toward increased return to the operating room was more common in the alternative patients. Conversely, the incidence of perioperative myocardial infarction was slightly lower in the alternative regimen group (0.4% vs 0.7%; OR, 0.53; 95% CI, 0.31-0.90; P = .02). At 1 year postprocedure, we observed an increased risk of mortality (hazard ratio, 1.34; 95% CI, 1.11-1.63; P < .01), but not stroke (hazard ratio, 0.52; 95% CI, 0.27-0.99; P = .06), in patients treated with an alternative medication regimen. Increased surgeon vigilance is required to ensure TCAR patients are maintained on DAPT as alternatives are associated with an increased rate of adverse events.Table IPerioperative and 1-year outcomesDAPT (n = 24,651)Alternate regimen (n = 5151)P valueIn-hospital outcomes Death93 (0.4)35 (0.7)<.01 Ipsilateral stroke256 (1.0)85 (1.7)<.01 Stroke299 (1.2)97 (1.9)<.01 Myocardial infarction135 (0.6)19 (0.4).10 Transient ischemic attack108 (0.4)38 (0.7)<.01 Stroke/death355 (1.4)124 (2.4)<.01 Stroke/death/myocardial infarction470 (1.9)140 (2.7)<.01 Length of stay, median (IQR)1 (1-2)1 (1-3)<.01 Postop length of stay >1 day6968 (28.3)1681 (32.6)<.01 Cranial nerve injury61 (0.3)12 (0.3).90 Bleeding requiring intervention180 (0.7)55 (1.1).01 Immediate occlusion35 (0.1)20 (0.4)<.01Return to operating room181 (0.7)58 (1.1)<.01 Reason.48Bleeding162 (89.5)48 (82.8)Occlusion17 (9.4)8 (13.8)Infection1 (0.6)1 (1.7)Pseudoaneurysm1 (0.6)1 (1.7)One-year outcomes Mortality4.7% (4.4-5.0)7.0% (6.2-8.0)<.01 Stroke0.9% (0.8-1.1)0.7% (0.4-1.1).20DAPT, Dual antiplatelet therapy.Values are number (%) unless otherwise indicated. Open table in a new tab Table IIIn-hospital outcomesAlternate therapy vs DAPT (C-Statistic 0.66-0.68)OR [95% CI]P valueDeath1.5 [0.9-2.5].12Ipsilateral stroke1.5 [1.2-2.0]<.01Total stroke1.5 [1.2-1.9]<.01Transient ischemic attack1.7 [1.2-2.4].01Stroke/death1.6 [1.2-2.0]<.01Stroke/death/myocardial infarction1.3 [1.1-1.6].01Bleeding1.3 [1.0-1.8].06Immediate occlusion2.8 [1.6-4.8]<.01Return to operating room1.4 [1.1-2.0].02One-year outcomesHazard ratio [95% CI]Mortality1.4 [1.2-1.6]<.01Stroke0.7 [0.4-1.2].15Stroke/death1.2 [1.0-1.5].03CI, Confidence interval; DAPT, dual antiplatelet therapy; OR, odds ratio.Values are number (%) unless otherwise indicated.Final variables included in the model: age, gender, symptomatic status, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, active smoking status, prior ipsilateral carotid endarterectomy and carotid artery stenting, contralateral carotid occlusion, elective status, protamine use, and surgeon volume with clustering by institutional centers. Open table in a new tab

Development and validation of multivariable prediction models for in-hospital death, 30-day death, and change in residence after hip fracture surgery and the 'stratify-hip' algorithm.

To develop and validate the stratify-hip algorithm (multivariable prediction models to predict those at low, medium, and high risk across in-hospital death, 30-day death, and residence change after hip fracture). Multivariable Fine-Gray and logistic regression of audit data linked to hospital records for older adults surgically-treated for hip fracture in England/Wales 2011-2014 (development n=170,411) and 2015-2016 (external validation, n=90,102). Outcomes included time to in-hospital death, death at 30-days, and time to residence change. Predictors included: age, sex, pre-fracture mobility, dementia, and pre-fracture residence (not for residence change). Model assumptions, performance, and sensitivity to missingness were assessed. Models were incorporated into the stratify-hip algorithm assigning patients to overall low (low risk across outcomes), medium (low death risk, medium/high risk of residence change), or high (high risk of in-hospital death, high/medium risk of 30-day death) risk. For complete-case analysis, 6,780 of 141,158 patients (4.8%) died in-hospital, 8,693 of 149,258 patients (5.8%) died by 30-days, and 4,461 of 119,420 patients (3.7 %) had residence change. Models demonstrated acceptable calibration (observed:expected ratio 0.90, 0.99, and 0.94), and discrimination (area under curve 73.1, 71.1 and 71.5; Brier score 5.7, 5.3, 5.6) for in-hospital death, 30-day death, and residence change, respectively. Overall, 31%, 28%, and 41% of patients were assigned to overall low-, medium-, and high- risk. External validation and missing data analyses elicited similar findings. The algorithm is available at https://stratifyhip.co.uk. The current study developed and validated the stratify-hip algorithm as a new tool to risk stratify patients after hip fracture.

A prediction model for in-hospital mortality in intensive care unit patients with metastatic cancer.

To identify predictors for in-hospital mortality in patients with metastatic cancer in intensive care units (ICUs) and established a prediction model for in-hospital mortality in those patients. In this cohort study, the data of 2,462 patients with metastatic cancer in ICUs were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Least absolute shrinkage and selection operator (LASSO) regression analysis was applied to identify the predictors for in-hospital mortality in metastatic cancer patients. Participants were randomly divided into the training set (n = 1,723) and the testing set (n = 739). Patients with metastatic cancer in ICUs from MIMIC-IV were used as the validation set (n = 1,726). The prediction model was constructed in the training set. The area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were employed for measuring the predictive performance of the model. The predictive performance of the model was validated in the testing set and external validation was performed in the validation set. In total, 656 (26.65%) metastatic cancer patients were dead in hospital. Age, respiratory failure, the sequential organ failure assessment (SOFA) score, the Simplified Acute Physiology Score II (SAPS II) score, glucose, red cell distribution width (RDW) and lactate were predictors for the in-hospital mortality in patients with metastatic cancer in ICUs. The equation of the prediction model was ln(P/(1 + P)) = -5.9830 + 0.0174 × age + 1.3686 × respiratory failure + 0.0537 × SAPS II + 0.0312 × SOFA + 0.1278 × lactate - 0.0026 × glucose + 0.0772 × RDW. The AUCs of the prediction model was 0.797 (95% CI,0.776-0.825) in the training set, 0.778 (95% CI, 0.740-0.817) in the testing set and 0.811 (95% CI, 0.789-0.833) in the validation set. The predictive values of the model in lymphoma, myeloma, brain/spinal cord, lung, liver, peritoneum/pleura, enteroncus and other cancer populations were also assessed. The prediction model for in-hospital mortality in ICU patients with metastatic cancer exhibited good predictive ability, which might help identify patients with high risk of in-hospital death and provide timely interventions to those patients.

Hospitalized Coronavirus Disease 2019 (Covid-19) with Pre-existing Diabetes Mellitus: Comparison between Survived and Deceased Patients

Patients with pre-existing diabetes mellitus (DM) are at high risk of severe outcomes from coronavirus disease 2019 (COVID-19). However, there is limited data on these patients from South Asia, especially Bangladesh. Besides, comparative studies between survived and deceased patients with DM and COVID-19 are rare in literature. This retrospective cross-sectional study was conducted among RT-PCR confirmed COVID-19 patients with pre-existing DM in a specialized COVID-19 hospital in Bangladesh. Data from hospital records were analyzed. Among 921 RT-PCR confirmed patients with COVID-19 admitted during the study period, 231 (~25%) patients had pre-existing DM. The overall mortality and intensive care unit (ICU) mortality rate among patients with DM was 11.3% (26/231) and 46.2% (12/26), respectively. The median age of the deceased patients was slightly higher (63.5 vs. 59 years, p 0.21). The most common comorbidity in both groups was hypertension. The clinical features were not significantly different between survived and deceased. However, deceased patients had significantly lower blood oxygen level (85% vs. 93%, p &lt;0.001), and higher neutrophil-lymphocyte ratio (7.9 vs. 4.5, p 0.003) and serum ferritin levels (946.0 vs. 425.0 ng/mL, p 0.03). Glycemic status was poor in both groups. This study would help identify a subgroup of diabetic patients with COVID-19 who are at higher risk of in-hospital death requiring rigorous clinical management.&#x0D; Bangladesh J Microbiol, Volume 39, Number 1, June 2022, pp 1-6

Trends in clinical characteristics and outcomes of all critically ill COVID-19 adult patients hospitalized in France between March 2020 and June 2021: a national database study

IntroductionStudies regarding coronavirus disease 2019 (COVID-19) were mainly performed in the initial wave, but some small-scale data points to prognostic differences for patients in successive waves. We therefore aimed to study the impact of time on prognosis of ICU-admitted COVID-19 patients.MethodWe performed a national retrospective cohort study, including all adult patients hospitalized in French ICUs from March 1, 2020 to June 30, 2021, and identified three surge periods. Primary and secondary outcomes were in-hospital mortality and need for invasive mechanical ventilation, respectively.Results105,979 critically ill ICU-admitted COVID-19 patients were allocated to the relevant three surge periods. In-hospital mortality for surges 1, 2, and 3 was, respectively, 24%, 27%, and 24%. Invasive mechanical ventilation was the highest level of respiratory support for 42%, 32%, and 31% (p < 0.001) over the whole period, with a decline in the use of vasopressors over time. Adjusted for age, sex, comorbidities, and modified Simplified Acute Physiology Score II at ICU admission, time period was associated with less invasive mechanical ventilation and a high risk of in-hospital death. Vaccination against COVID-19 was associated with a lower likelihood of invasive mechanical ventilation (adjusted sub-hazard ratio [aSHR] = 0.64 [0.53–0.76]) and intra-hospital death (aSHR = 0.80, [0.68–0.95]).ConclusionIn this large database of ICU patients admitted for COVID-19, we observed a decline in invasive mechanical ventilation, vasopressors, and RRT use over time but a high risk of in-hospital death. Vaccination was identified as protective against the risk of invasive mechanical ventilation and in-hospital death.