Higher Risk Of In-hospital Mortality Research Articles

Is Mean Platelet Volume a Useful Predictor of Hospital Mortality in Covid-19 Patients?

Background: Elevated Mean Platelet Volume (MPV) can indicate the activation of platelets and the coagulation cascade, which has been suggested as a predictor of mortality in some diseases. The aim of this study was to investigate the role of MPV in predicting hospital mortality in patients with Covid-19.
 Methods: This was a cross-sectional single-center retrospective study. The data of all patients with a PCR-confirmed diagnosis of Covid-19 hospitalized within a 3-month period were analyzed. The patients’ files were reviewed, and the data were recorded into a checklist, including demographic characteristics, underlying diseases, and laboratory test results. Hospital mortality was designated as the main outcome of the study.
 Results: A total of 201 Covid-19 patients, confirmed by PCR, were included in this study. In-hospital mortality was observed in 28 patients (13.9%). The results of univariate regression analysis revealed that the triage level, history of chronic pulmonary disease, age, oxygen saturation, lymphocyte count, BUN, Cr, and CRP were significantly related to in-hospital mortality. However, MPV showed no significant relationship with in-hospital mortality.
 Conclusion: Low triage level, advanced age and hypoxia predicted a higher risk of in-hospital mortality in Covid-19 patients. The role of MPV as a predictor of patient outcome in Covid-19 remains inconclusive, necessitating further studies with larger sample sizes.

Association of patient age and insurance status with in-hospital mortality for patients with lung cancer.

e13669 Background: In 2022, the National Cancer Institute estimated that more than 240,000 individuals will be diagnosed with lung cancer. Furthermore, over 130,000 patients will die. To help minimize this death rate, it is important to identify death risk factors. Methods: We utilized the 2006-2012 Nationwide Emergency Department Sample to identify risk risk factors for death in lung cancer patients. A multivariate logistic regression was used to identify patient and hospital characteristics that were significantly associated with a higher chance of in-hospital death. The top 20 primary diagnoses of these patients were included in the analysis to take into account the reason to visit the ED. A p-value less than 0.05 was considered significant. Results: During this time period, 1,344,817 lung cancer patients presented to the emergency departments (ED) across the US. The majority of patients at least 70 years old (50.8%), male (51.1%), Medicare beneficiaries (67.5%), of the lowest income quartile (28.1%), living in the South (40.3%), presented to non-trauma hospitals (54.3%), and presented to metropolitan non-teaching hospitals (43.3%). Out of the 1,344,817 lung cancer patients that presented to the ED, 6.1% died in the hospital. The primary diagnoses associated with increased mortality are the following: respiratory failure (odds ratio (OR): 9.05, 95% confidence interval (CI): 8.47-9.67, p < 0.001), septicemia (OR: 8.46, 95% CI: 7.98-8.97,p < 0.001), acute cerebrovascular disease (OR: 3.04, 95% CI: 2.71-3.35,p < 0.001), secondary malignancy (OR: 2.00, 95% CI: 1.88-2.13,p < 0.001), pulmonary heart disease (OR: 1.97, 95% CI: 1.75-2.20,p < 0.001), and pneumonia (OR: 1.90, 95% CI: 1.80-2.01, p < 0.001). Patients at least 70 years old (OR: 3.09, 95% CI: 1.72-5.53, p < 0.001), males (OR: 1.28, 95% CI: 1.24-1.32,p < 0.001), and uninsured patients (OR: 1.29, 95% CI: 1.15-1.46, p < 0.001) are patient groups at higher risk for in-hospital mortality. 5 primary diagnoses associated with decreased risk of death are the following: fluid/electrolyte disorder (OR: 0.81, 95% CI:0.70-0.93), p = 0.003), central nervous system disease (OR: 0.76, 95% CI: 0.640.91, p = 0.002), arrhythmia (OR: 0.74, 0.65-0.83, p < 0.001), anemia (OR:0.68, 95% CI: 0.55-0.83, < 0.001), complication related to previous surgery of medical therapy (OR:0.64, 95% CI:0.51-0.80, < 0.001), and chronic obstructive pulmonary disease (OR: 0.45, 95% CI: 0.39-0.62, p < 0.001). Conclusions: Older, uninsured, and male lung cancer patients are at high risk for in-hospital mortality. Patients presenting to the ED with respiratory failure and septicemia are at the highest risk for mortality.

COMORBIDITIES AND MORTALITY IN PATIENTS WITH COVID-19 AMONG AGED 18 YEARS AND OLDER IN DILCHORA HOSPITAL-DIRE DAWA, EASTERN ETHIOPIA, 2022

Objective: To describe the outcome and assess factors associated with mortality among hospitalized COVID-19 adult patients with chronic diseases in Dilchora hospital, Dire Dawa, Eastern Ethiopian, 2022 Design and method: A retrospective cohort study was used. Data was collected using a data extraction form by reviewing medical records of all hospitalized adult COVID-19 patients from May 3, 2021-January 26, 2022. The data extraction form consists of demographic and clinical information. Descriptive statistics were used to summarize data, mean, frequency, and percentages were used. Multivariate binary logistic regression was applied to assess the factors associated with mortality. Adjusted Odds ratio (AOR) with 95% CIs were used. Variables with a p-value of <0.05 were considered statistically significant. Results: A total of 196 COVID-19 positive patients were included in the study. More than half, 107 (54.6%) were male. The mean age of the patients was 51 (SD = 17). 154 (78.6%) were urban residents. Of these, 46 (23.5%) patients died. Only 3 (1.5%) of them were fully vaccinated. Nearly half, 92 (47%) of patients had preexisting comorbidity. The most common comorbidities were diabetes 26 (28.3%), hypertension 23 (25%), and congestive heart failure 18 (19.6%). 33 (71.7%) of dead patients had comorbidity. Factors that were associated with higher odds of mortality were advanced age > = 60 years (AOR 5.3, 95% CI 1.63-17.38), urban residence (AOR 5.2, 95% CI 1.21-22.43), presence of comorbidities (AOR 2.66, 95% CI 1.02-6.99), and severity (AOR 12.93, 95% CI 4.26-39.30). Conclusions: COVID-19 patients with chronic non-communicable diseases faced a higher risk of in-hospital mortality. We recommend implementing aggressive preventive strategies including vaccination to combat COVID-19 targeting older adults, urban areas, and patients with chronic diseases comorbidity as a priority.

Association between coagulation disorder scores and in-hospital mortality in ARF patients: a retrospective analysis from the MIMIC-IV database.

Acute respiratory failure (ARF) has a high mortality rate, and currently, there is no convenient risk predictor. The coagulation disorder score was proven to be a promising metric for predicting in-hospital mortality, but its role in ARF patients remains unknown. In this retrospective study, data were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Patients diagnosed with ARF and hospitalized for more than 2 days at their first admission were included. The coagulation disorder score was defined based on the sepsis-induced coagulopathy score and was calculated by parameters, namely, additive platelet count (PLT), international normalized ratio (INR), and activated partial thromboplastin time (APTT), based on which the participants were divided into six groups. Overall, 5,284 ARF patients were enrolled. The in-hospital mortality rate was 27.9%. High levels of additive platelet score, INR score, and APTT score were significantly associated with increased mortality in ARF patients (P < 0.001). Binary logistic regression analysis showed that a higher coagulation disorder score was significantly related to the increased risk of in-hospital mortality in ARF patients (Model 2: coagulation disorder score = 6 vs. coagulation disorder score = 0: OR, 95% CI: 7.09, 4.07-12.34, P < 0.001). The AUC of the coagulation disorder score was 0.611 (P < 0.001), which was smaller than that of sequential organ failure assessment (SOFA) (De-long test P = 0.014) and simplified acute physiology score II (SAPS II) (De-long test P < 0.001) but larger than that of additive platelet count (De-long test P < 0.001), INR (De-long test P < 0.001), and APTT (De-long test P < 0.001), respectively. In subgroup analysis, we found that in-hospital mortality was markedly elevated with an increased coagulation disorder score in ARF patients. No significant interactions were observed in most subgroups. Of note, patients who did not administrate oral anticoagulant had a higher risk of in-hospital mortality than those who administrated oral anticoagulant (P for interaction = 0.024). This study found a significant positive association between coagulation disorder scores and in-hospital mortality. The coagulation disorder score was superior to the single indicators (additive platelet count, INR, or APTT) and inferior to SAPS II and SOFA for predicting in-hospital mortality in ARF patients.

Risk of in-hospital Deterioration for Children with Single Ventricle Physiology.

Children with single ventricle physiology (SV) are at high risk of in-hospital morbidity and mortality. Identifying children at risk for deterioration may allow for earlier escalation of care and subsequently decreased mortality.We conducted a retrospective chart review of all admissions to the pediatric cardiology non-ICU service from 2014 to 2018 for children < 18 years old. We defined clinical deterioration as unplanned transfer to the ICU or inpatient mortality. We selected children with SV by diagnosis codes and defined infants as children < 1 year old. We compared demographic, vital sign, and lab values between infants with and without a deterioration event. We evaluated vital sign and medical therapy changes before deterioration events.Among infants with SV (129 deterioration events over 225 admissions, overall 25% with hypoplastic left heart syndrome), those who deteriorated were younger (p = 0.001), had lower baseline oxygen saturation (p = 0.022), and higher baseline respiratory rate (p = 0.022), heart rate (p = 0.023), and hematocrit (p = 0.008). Median Duke Pediatric Early Warning Score increased prior to deterioration (p < 0.001). Deterioration was associated with administration of additional oxygen support (p = 0.012), a fluid bolus (p < 0.001), antibiotics (p < 0.001), vasopressor support (p = 0.009), and red blood cell transfusion (p < 0.001).Infants with SV are at high risk for deterioration. Integrating baseline and dynamic patient data from the electronic health record to identify the highest risk patients may allow for earlier detection and intervention to prevent clinical deterioration.

Clinical outcomes and procedural characteristics of ventricular tachycardia ablation in patients with or without electrical storm

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Electrical storm (ES) is a life-threatening clinical condition characterized by the recurrence of three or more episodes of ventricular tachycardia (VT) and/or ventricular fibrillation within 24 hours, leading to ICD therapy. Catheter ablation of VT in patients with ES is a high-risk procedure but has been shown to reduce VT recurrence and the number of appropriate ICD therapies in patients with structural heart disease. Purpose Our study aimed to compare the characteristics and outcomes of VT ablation in patients with or without ES. Methods Our single-center study included a cohort of 39 consecutive patients (31 men, mean age=60.9±18.4 years) who underwent VT ablation between January 2020 and January 2022, 21 of them (53.8%) due to ES and 18 patients (46.2%) had an elective procedure. Clinical and procedural characteristics, VT recurrence, and mortality rates were compared between the two groups. Results Patients with ES were older than patients without ES (67.8 vs 54.2 years, p=0.004), they were mainly presented with ischaemic cardiomyopathy (85.7% vs 27.8%, p&amp;lt;0.0001), had a higher prevalence of congestive heart failure (90.5% vs 44.4%, p=0.001) and a more severe left ventricular dysfunction (LVEF: 30.8% vs 46.9%, p=0.002). During the procedure, in the ES group, all of the patients had left-sided ablation (transaortic: 80.9%, transseptal: 19.1%), while in patients without ES, 72.2% of the procedures were left-sided (p=0.04). In 8/39 patients (20.5%) endo-epicardial access was needed. The number of RF ablation points was significantly higher in the ES group (64.1 vs 36.1 points, p=0.01). Complications were detected only in the ES group: intraprocedural death occurred in one case due to an ES and consequently cardiogenic shock, and one patient had a dissection of the right femoral artery. There was no significant difference regarding procedure time, fluoroscopy time, and radiation exposure. The in-hospital 30-day mortality was 8/21 (28.6%) in patients with ES, while no patients died in the non-ES group. During longer clinical follow-up, there was no significant difference in the recurrence of VT episodes and mortality. Conclusion Patients presented with ES are a more vulnerable population with many comorbidities. Catheter ablation of VT in patients with ES is a more complex procedure with a higher complication rate and these patients have a higher risk of in-hospital mortality. Further studies are needed to determine the optimal timing of VT ablation in this patient population.

Trends in aetiology-based hospitalisation for cirrhosis before and during the COVID-19 pandemic in the United States.

Patients with pre-existing cirrhosis and exposure to coronavirus disease-19 (COVID-19) may portend a poor prognosis. We evaluated the temporal trends in aetiology-based hospitalisations and potential predictors of in-hospital mortality in hospitalisation with cirrhosis before and during the COVID-19 pandemic. Based on the US National Inpatient Sample 2019-2020, we determined quarterly trends in aetiology-based hospitalisations with cirrhosis and decompensated cirrhosis and identified predictors of in-hospital mortality in hospitalisation with cirrhosis. We analysed 316,418 hospitalisations, representing 1,582,090 hospitalisations with cirrhosis. Hospitalisations for cirrhosis increased at a relatively higher rate during the COVID-19 era. Hospitalisation rates for alcohol-related liver disease (ALD)-related cirrhosis increased significantly (quarterly percentage change [QPC]: 3.6%, 95% CI: 2.2%-5.1%), with a notably higher rate during the COVID-19 era. In contrast, hospitalisation rates for hepatitis C virus (HCV)-related cirrhosis decreased steadily with a trend of -1.4% of QPC (95% CI: -2.5% to -0.1%). Quarterly trends in the proportion of ALD- (QPC: 1.7%, 95% CI: 0.9%-2.6%) and nonalcoholic fatty liver disease-related (QPC: 0.7%, 95% CI: 0.1%-1.2%) hospitalisations with cirrhosis increased significantly but declined steadily for viral hepatitis. The COVID-19 era and COVID-19 infection were independent predictors of in-hospital mortality during hospitalisation with cirrhosis and decompensated cirrhosis. Compared with HCV-related cirrhosis, ALD-related cirrhosis was associated with a 40% higher risk of in-hospital mortality. In-hospital mortality in cirrhosis was higher in the COVID-19 era than in the pre-COVID-19 era. ALD is the leading aetiology-specific cause of in-hospital mortality in cirrhosis with an independent detrimental impact of the COVID-19 infection.

Predictors of delirium in patients with acute decompensated heart failure at a cardiac intensive care unit

Abstract Funding Acknowledgements Type of funding sources: None. Background Delirium is commonly observed in critically ill patients and is associated with a worse overall prognosis in patients hospitalized with acute decompensated heart failure. However, in patients with acute decompensated heart failure (ADHF), the impact of delirium on prognosis and the factors that influence it have not been thoroughly examined. Objective To study the predictors of delirium in patients hospitalized in the cardiac intensive care unit (CICU) due to acute decompensated heart failure. Methods We retrospectively analyzed 105 patients admitted to a CICU due to ADHF. Delirium was diagnosed based on the Confusion Assessment Method for ICU (CAM­-ICU) during CICU stay. Echocardiography and laboratory measurements were performed during hospitalization. A logistic regression analysis was performed, looking for independent predictors of delirium development. Results Delirium was observed in 25 patients (23.8%) during CICU hospitalization. Multivariable analysis revealed that older age (odds ratio [OR]: 7.6; 95% confidence interval [CI]: 3.2-21.2; p&amp;lt;0.001), previous diagnosis of dementia (OR: 7.31, 95% CI: 3.65­-14.91, p&amp;lt;0.001), high plasma level of C reactive protein &amp;gt; 79 mg/L (OR: 1.26, 95% CI: 1.09-­1.61, p=0.031), and prior alcohol misuse (OR: 5.4; 95% CI: 2.76-13.40; p=0.003) as significant independent determinants of delirium. Furthermore, we determined that delirium was an independent predictor of in-hospital mortality (OR: 1.93, 95% CI 1.1-3.4.1, p=0.033). There was no relationship to the previous medical history of arterial hypertension, diabetes mellitus, or left ventricular ejection fraction. Conclusions In patients with ADHF, the development of delirium during CICU stay is associated with a higher risk of in-hospital mortality. Older age, dementia, high levels of C reactive protein, and alcohol misuse were identified as predictors of delirium. Therefore, this clinical entity's early diagnosis and proper management are essential.

B-40 | Impact of Congenital Heart Diseases in Adults Undergoing Transcatheter Aortic Valve Replacement: Insight from the National Inpatient Database

ACHD patients undergoing TAVR have a higher risk of in-hospital mortality, cardiogenic shock, and use of MCS. Current guidelines do not differentiate TAVR treatment based on ACHD, and more prospective trials could help us identify a suitable approach. We utilized the national inpatient sample (NIS) database using ICD-10 codes to extract all the patients undergoing TAVR between 2016-2019 and stratified them based on the presence or absence of ACHD ( >18 years old). Multivariate logistic regression analysis was used to calculate the adjusted odds (aOR) ratio of in-hospital outcomes. A total of 221,530 patients underwent TAVR, of which 3,640 (1.6%) had ACHD. On adjusted analysis, ACHD patients who underwent the TAVR procedure had a significantly higher risk of in-hospital mortality (aOR 1.84, 95% CI 1.15-2.94), cardiogenic shock (aOR 2.19, 95%CI 1.59-3.02), and cardiac arrest (aOR 2.04, 95% CI 1.10-3.76) with higher use of mechanical circulatory support (MCS) (aOR 1.79, 95% CI 1.06-3.02) than non-ACHD patients. The length of stay (5.57±6.74 vs. 4.06±5.30, p<0.001) and total hospitalization charge ($239,935 vs. $215,195, p<0.0001) were higher in the ACHD group than the non-ACHD group. There was no significant difference in the odds of acute kidney injury (AKI), stroke, acute MI, heart failure, bleeding, and pacemaker implantation between the two groups. ACHD patients undergoing TAVR have a higher risk of in-hospital mortality, cardiogenic shock, and use of MCS. Current guidelines do not differentiate TAVR treatment based on ACHD, and more prospective trials could help us identify a suitable approach.

A High De Ritis Ratio is Associated with Mortality in Adult Trauma Patients.

The De Ritis ratio, which is the ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT), has been suggested as a potential prognostic marker for various diseases. This study aimed to investigate the association between the De Ritis ratio and in-hospital mortality in adult trauma patients. A total of 17,472 adult trauma patients hospitalized between January 1, 2009, and December 31, 2020, were allocated into groups according to the De Ritis ratio. The normal range of the De Ritis ratio was calculated from 3320 individuals in the National Taiwan Biobank. Statistical analyses were performed using SPSS software. Patients with a De Ritis ratio >1.6 had a significantly higher in-hospital mortality rate (7.3% vs 1.5%, odds ratio 5.29; Q1-Q3 2.72-10.30; p < 0.001) and a 2.71-fold higher in-hospital mortality rate (Q1-Q3 1.24-5.92; p = 0.012), after adjusting for sex, age, comorbidities, consciousness level, and injury severity, than those with a De Ritis ratio within the reference values. This study revealed that a De Ritis ratio >1.6 may serve as an early prognostic tool to identify adult trauma patients at high risk of in-hospital mortality.

Abstract #1403761: The Impact of COVID-19 Infection on Diabetic Ketoacidosis Acidosis Hospitalization: A Nationwide Analysis

One of the potentially fatal consequences for diabetic patients is diabetic ketoacidosis acidosis (DKA), which is also linked to poor hospital outcomes. There is no much information in literature about COVID-19 and how it relates to other hospitalizations. The impact of COVID-19 on in-hospital mortality and other clinically relevant outcomes for DKA patients is being investigated for the first time in this study. Patients admitted with a primary diagnosis of DKA with or without a subsequent diagnosis of COVID-19 Infection were found in the National Inpatient Sample (NIS) Database 2020. Patients were divided into two groups: those who have COVID-19 and those who don't. Univariate and multivariate logistic regression models were utilized to account for frequent confounders and assess the risk of mortality and in-hospital outcomes between the two groups. The total of 110,130 DKA admissions were identified between Jan and Dec 2020. COVID-19 Infection was diagnosed in 2,504 patients (2.2%). The average age of the cohort sample was 35 years old, 51% were male, and 60% were white. The average length of stay (LOS) was 3 days, and the average total hospital charges were 33,132 US dollars. The total number of patients who died was 225 patients. When the two groups were compared, COVID-19 Infection was associated with an increased risk of in-hospital mortality among DKA patients (OR 5.3, 95% CI 1.7–15.9, p=0.003). COVID-19 patients had a higher risk of acute respiratory failure (OR 2.9, 95% CI 1.7–3.9, p< 0.001) and septic shock (OR 3.9, 95% CI 1.5–9.8, p=0.003). There was no significant difference between the COVID-19 and non-COVID-19 groups in the risk of acute coronary syndrome (OR 1.2, 95% CI 0.49–3, p=0.66), cardiac arrest (OR 2, 95% CI 0.5–7.9, p=0.31), hypokalemia (OR 1.14, 95% CI 0.92–1.4, p=0.214), deep vein thrombosis (OR 0.59, 95% CI 0.14–2.4, p=0.47), or pulmonary embolism (OR 3.6, 95% CI 0.84 – 15.4, p=0.083). COVID-19 patients had a longer mean LOS (4.2 vs 2.9 days, p< 0.001) and higher mean total hospital charges (41,216 vs 32,973 $, p=0.004). Patients admitted with DKA and concomitant COVID-19 infection found to have a higher risk of in-hospital mortality and worse hospital outcomes, particularly acute respiratory failure and septic shock. In comparison to non-COVID patients, COVID-19 patients have a longer mean LOS and a higher mean of total hospital charges.

Data Modeling Using Vital Sign Dynamics for In-hospital Mortality Classification in Patients with Acute Coronary Syndrome.

This study compared feature selection by machine learning or expert recommendation in the performance of classification models for in-hospital mortality among patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI). A dataset of 1,123 patients with ACS who underwent PCI was analyzed. After assigning 80% of instances to the training set through random splitting, we performed feature scaling and resampling with the synthetic minority over-sampling technique and Tomek link method. We compared two feature selection. recursive feature elimination with cross-validation (RFECV) and selection by interventional cardiologists. We used five simple models: support vector machine (SVM), random forest, decision tree, logistic regression, and artificial neural network. The performance metrics were accuracy, recall, and the false-negative rate, measured with 10-fold cross-validation in the training set and validated in the test set. Patients' mean age was 66.22 ± 12.88 years, and 33.63% had ST-elevation ACS. Fifteen of 34 features were selected as important with the RFECV method, while the experts chose 11 features. All models with feature selection by RFECV had higher accuracy than the models with expert-chosen features. In the training set, the random forest model had the highest accuracy (0.96 ± 0.01) and recall (0.97 ± 0.02). After validation in the test set, the SVM model displayed the highest accuracy (0.81) and a recall of 0.61. Models with feature selection by RFECV had higher accuracy than those with feature selection by experts in identifying patients with ACS at high risk for in-hospital mortality.

Unsupervised clustering identifies sub-phenotypes and reveals novel outcome predictors in patients with dialysis-requiring sepsis-associated acute kidney injury

Introduction Heterogeneity exists in sepsis-associated acute kidney injury (SA-AKI). This study aimed to perform unsupervised consensus clustering in critically ill patients with dialysis-requiring SA-AKI. Patients and Methods This prospective observational cohort study included all septic patients, defined by the Sepsis-3 criteria, with dialysis-requiring SA-AKI in surgical intensive care units in Taiwan between 2009 and 2018. We employed unsupervised consensus clustering based on 23 clinical variables upon initializing renal replacement therapy. Multivariate-adjusted Cox regression models and Fine–Gray sub-distribution hazard models were built to test associations between cluster memberships with mortality and being free of dialysis at 90 days after hospital discharge, respectively. Results Consensus clustering among 999 enrolled patients identified three sub-phenotypes characterized with distinct clinical manifestations upon renal replacement therapy initiation (n = 352, 396 and 251 in cluster 1, 2 and 3, respectively). They were followed for a median of 48 (interquartile range 9.5–128.5) days. Phenotypic cluster 1, featured by younger age, lower Charlson Comorbidity Index, higher baseline estimated glomerular filtration rate but with higher severity of acute illness was associated with an increased risk of death (adjusted hazard ratio of 3.05 [95% CI, 2.35–3.97]) and less probability to become free of dialysis (adjusted sub-distribution hazard ratio of 0.55 [95% CI, 0.38–0.8]) than cluster 3. By examining distinct features of the sub-phenotypes, we discovered that pre-dialysis hyperlactatemia ≥3.3 mmol/L was an independent outcome predictor. A clinical model developed to determine high-risk sub-phenotype 1 in this cohort (C-static 0.99) can identify a sub-phenotype with high in-hospital mortality risk (adjusted hazard ratio of 1.48 [95% CI, 1.25–1.74]) in another independent multi-centre SA-AKI cohort. Conclusions Our data-driven approach suggests sub-phenotypes with clinical relevance in dialysis-requiring SA-AKI and serves an outcome predictor. This strategy represents further development toward precision medicine in the definition of high-risk sub-phenotype in patients with SA-AKI.

Combining a Frailty Index Based on Laboratory Data and Pneumonia Severity Assessments to Predict In-Hospital Outcomes in Older Adults with Community-Acquired Pneumonia.

Due to the increased morbidity, mortality, and cost of community-acquired pneumonia (CAP) in older people, strategies directed at improving disease evaluation and prevention are imperative. We independently compared the 30-day in-hospital mortality prediction ability of a frailty index based on laboratory data (FI-Lab) with that of the CURB-65 and the Pneumonia Severity Index (PSI) and then proposed combining them to further improve prediction efficiency. Retrospective cohort study. Patients aged ≥ 65 years (n = 2039) with CAP who were admitted to Jiangsu Provincial People's Hospital of Nanjing Medical University and Jiangsu Provincial Hospital of Chinese Medicine from January 2019 to June 2022. The 29-item FI-Lab, PSI and, CURB-65 were administered at admission. We defined frailty by the cut-off value of the FI-Lab score (> 0.43). Multivariable logistic regression analysis, together with the calculation of the area under the receiver operating characteristic curve (ROC-AUC), was conducted to identify stratified risks and relationships between the three indices and 30-day mortality. Participants were divided into the following three groups based on age: 65-74 years, 75-84 years, and ≥ 85 years. Hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality due to frailty were calculated. A total of 495 participants ranging from 65 to 100 years of age were ultimately included and divided into age groups (65-74 years, n = 190, 38.4%; 75-84 years, n = 183, 37.0%; ≥ 85 years, n = 122, 24.6%). A total of 142 (28.7%) of the 495 patients were defined as having frailty. All three scores tested in this study were significantly associated with 30-day mortality in the total sample. The ORs were as follows: 1.06 (95% CI: 1.03-1.09, P < 0.001) and 2.33 (95% CI: 1.26-4.31, P = 0.007) for the FI-Lab when the score was treated as a continuous and categorical variable, respectively; 1.04 (95% CI: 1.02-1.05, P < 0.001) for the PSI; and 3.70 (95% CI: 2.48-5.50, P < 0.001) for the CURB-65. In the total sample, the ROC-AUCs were 0.783 (95% CI: 0.744-0.819) for the FI-Lab, 0.812 (95% CI: 0.775-0.845) for the PSI, and 0.799 (95% CI: 0.761-0.834) for the CURB-65 (P < 0.001). The ROC-AUC slightly improved when the FI-Lab was added to the PSI (AUC 0.850, 95% CI: 0.809-0.892, P = 0.031) and to the CURB-65 (AUC 0.839, 95% CI: 0.794-0.885, P = 0.002). Older patients with frailty showed a higher risk of in-hospital mortality, with an HR of 2.25 (95% CI: 1.14-3.58, P < 0.001). The FI-Lab seems to generate simple and readily available data, suggesting that it could be a useful complement to the CURB-65 and the PSI as effective predictors of 30-day mortality due to CAP in older populations.

Valor pronóstico de la fibrosis hepática valorada por el índice FIB4 en pacientes ingresados por síndrome coronario agudo

Introduction and objectivesLiver fibrosis is present in nonalcoholic liver disease (NAFLD) and both precede liver failure. Subclinical forms of liver fibrosis might increase the risk of cardiovascular events. The objective of this study was to describe the prognostic value of the FIB-4 index on in-hospital mortality and postdischarge outcomes in patients with acute coronary syndrome (ACS). MethodsRetrospective study including all consecutive patients admitted for ACS between 2009 and 2019. According to the FIB-4 index, patients were categorized as <1.30, 1.30-2.67 or> 2.67. Heart failure (HF) and major bleeding (MB) were assessed taking all-cause mortality as a competing event and subhazard ratios (sHR) are presented. Recurrent events were evaluated by the incidence rate ratio (IRR). ResultsWe included 3106 patients and 6.66% had a FIB-4 index ≥ 1.3. A multivariate analysis verified a higher risk of in-hospital mortality associated with the FIB-4 index (OR, 1.24; P=.016). Patients with a FIB-4 index> 2.67 had a 2-fold higher in-hospital mortality risk (OR, 2.35; P=.038). After discharge (median follow-up 1112 days), the FIB-4 index had no prognostic value for mortality. In contrast, patients with FIB-4 index ≥ 1.3 had a higher risk of first (sHR, 1.61; P=.04) or recurrent (IRR, 1.70; P=.001) HF readmission. Similarly, FIB-4 index ≥ 1.30 was associated with a higher MB risk (sHR, 1.62; P=.030). ConclusionsThe assessment of liver fibrosis by the FIB-4 index identifies ACS patients not only at higher risk of in-hospital mortality but also at higher risk of HF and MB after discharge.Full English text available from:www.revespcardiol.org/en

Outcomes of Bioprosthetic Valve Fracture in Patients Undergoing Valve-in-Valve TAVR

BackgroundValve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) is increasingly used to treat degenerated surgical bioprostheses. Bioprosthetic valve fracture (BVF) has been shown to improve hemodynamic status in VIV TAVR in case series. However, the safety and efficacy of BVF are unknown. ObjectivesThe primary objective of this study was to assess the safety and efficacy of VIV TAVR using SAPIEN 3 and SAPIEN 3 Ultra valves with or without BVF using data from the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry. MethodsThe primary outcome was in-hospital mortality. Secondary outcomes included echocardiography-derived valve gradient and aortic valve area. Inverse probability of treatment weighting was used to adjust for baseline characteristics. ResultsA total of 2,975 patients underwent VIV TAVR from December 15, 2020, to March 31, 2022. BVF was attempted in 619 patients (21%). In adjusted analyses, attempted BVF was associated with higher in-hospital mortality (OR: 2.51; 95% CI: 1.30-4.84) and life-threatening bleeding (OR: 2.55; 95% CI: 1.44-4.50). At discharge, VIV TAVR with attempted BVF was associated with larger aortic valve area (1.6 cm2 vs 1.4 cm2; P < 0.01) and lower mean gradient (16.3 mm Hg vs 19.2 mm Hg; P < 0.01). When BVF was compared with no BVF according to timing (before vs after transcatheter heart valve implantation), BVF after transcatheter heart valve implantation was associated with improved hemodynamic status and similar mortality. ConclusionsBVF as an adjunct to VIV TAVR with the SAPIEN 3 and SAPIEN 3 Ultra valves is associated with a higher risk for in-hospital mortality and significant bleeding and modest improvements in echocardiography-derived hemodynamic status. The timing of BVF is an important determinant of safety and efficacy.

Mortality and differential predictive factors of transient and persistent sepsis-associated acute kidney injury.

The clinical outcomes and differential predictive factors for transient and persistent sepsis-associated AKI (SA-AKI) currently remain unclear. Therefore, using a large international database, this study aimed to compare the in-hospital mortality outcomes and determine the clinical factors for differentiating transient and persistent SA-AKI. Patients with SA-AKI were identified from the Medical Information Mart for Intensive Care IV (MIMIC IV) database and divided into a persistent SA-AKI group and a transient SA-AKI group. In-hospital mortality rates between the two groups were compared. Logistic regression was performed to explore the risk factors, with the establishment of a clinical predictive model for transient or persistent SA-AKI. Mortality rate of the persistent SA-AKI group was higher than of the transient SA-AKI group (p < 0.001). Persistent SA-AKI was an independent risk factor for in-hospital mortality. Factors including creatinine level at inclusion (OR 1.49, 95% CI 1.43-1.56, p < 0.001), changes of creatinine level (mg/dL) within 24 hours (OR 4.25, 95% CI 3.74-4.86, p < 0.001), continuous renal replacement therapy (CRRT) performed within 48 hours (OR 4.20, 95% CI 2.87-6.17), lactate level (mmol/L) (OR 1.18, 95% CI 1.05-1.12, p < 0.001) were independent risk factors for persistent SA-AKI. When incorporating these factors, the predictive model for persistent SA-AKI demonstrated good C-indexes of 0.80 (95% CI: 0.80-0.82) and 0.81 (95% CI: 0.79-0.83) in the training and validation cohorts, respectively, though the goodness-of-fit was poor. Persistent SA-AKI has a higher risk of in-hospital mortality than transient SA-AKI, whereby persistent SA-AKI is also an independent predictor of in-hospital mortality. The nomogram established by predictive factors can be applied in clinical practice to predict persistent SA-AKI.

CLINICAL PHENOTYPES OF SEPSIS-ASSOCIATED ENCEPHALOPATHY: A RETROSPECTIVE COHORT STUDY.

Background: Sepsis-associated encephalopathy (SAE) is a dysfunction of the central nervous system experienced during sepsis with variable clinical and pathophysiologic features. We sought to identify distinct SAE phenotypes in relation to clinical outcomes. Methods: The Medical Information Mart for Intensive Care IV (MIMIC-IV) database and the eICU database were used to conduct a retrospective cohort study. Adult sepsis patients were included and SAE was defined as having a Glasgow Coma Scale (GCS) score ˂15 or delirium. The following our clinical phenotypes were defined as: ischemic-hypoxic, metabolic, mixed (ischemic-hypoxic and metabolic), and unclassified. The primary outcome was in-hospital mortality. Results: The study enrolled 4,120 sepsis patients, 2,239 from MIMIC-IV (including 1,489 patients with SAE, 67%), and 1,881 from eICU (1,291, 69%). For the SAE cohort, 2,780 patients in total were enrolled (median age, 67 years; interquartile range, 56-76.8; 1,589 (57%) were male; median GCS score was 12 [8-14]; median Sequential Organ Failure Assessment score was 6 [4-9]). The SAE phenotype distributions between the MIMIC-IV and eICU cohorts were as follows (39% vs. 35% ischemic-hypoxic, P = 0.043; 38% vs. 40% metabolic, P = 0.239; 15% vs. 15% mixed, P = 0.972; 38% vs. 40% unclassified, P = 0.471). For the overall cohort, the in-hospital mortality for patients with ischemic-hypoxic, metabolic, mixed, or unclassified phenotypes was 33.9% (95% confidence interval, 0.3-0.37), 28.4% (0.26-0.31), 41.5% (0.37-0.46), and 14.2% (0.12-0.16), respectively. In the multivariable logistic analysis, the mixed phenotype was associated with the highest risk of in-hospital mortality after adjusting for age, sex, GCS, and modified Sequential Organ Failure Assessment score (adjusted odds ratio, 2.11; 95% confidence interval, 1.67-2.67; P < 0.001). Conclusions: Four SAE phenotypes had different clinical outcomes. The mixed phenotype had the worst outcomes. Further understanding of these phenotypes in sepsis may improve trial design and targeted SAE management.

Influences of Initial Empiric Antibiotics with Ampicillin plus Cefotaxime on the Outcomes of Neonates with Respiratory Failure: A Propensity Score Matched Analysis

Background: Empiric antibiotics are often prescribed in critically ill and preterm neonates at birth until sepsis can be ruled out. Although the current guideline suggests narrow-spectrum antibiotics, an upgrade in antibiotics is common in the neonatal intensive care unit. The impacts of initial broad-spectrum antibiotics on the outcomes of critically ill neonates with respiratory failure requiring mechanical intubation have not been well studied. Methods: A total of 1162 neonates from a tertiary level neonatal intensive care unit (NICU) in Taiwan who were on mechanical ventilation for respiratory distress/failure at birth were enrolled, and neonates receiving ampicillin plus cefotaxime were compared with those receiving ampicillin plus gentamicin. Propensity score-matched analysis was used to investigate the effects of ampicillin plus cefotaxime on the outcomes of critically ill neonates. Results: Ampicillin plus cefotaxime was more frequently prescribed for intubated neonates with lower birth weight, higher severity of illness, and those with a high risk of early-onset sepsis. Only 11.1% of these neonates had blood culture-confirmed early-onset sepsis and/or congenital pneumonia. The use of ampicillin plus cefotaxime did not significantly contribute to improved outcomes among neonates with early-onset sepsis. After propensity score-matched analyses, the critically ill neonates receiving ampicillin plus cefotaxime had significantly worse outcomes than those receiving ampicillin plus gentamicin, including a higher risk of late-onset sepsis caused by multidrug-resistant pathogens (11.2% versus 7.1%, p = 0.027), longer duration of hospitalization (median [IQR], 86.5 [47-118.8] days versus 78 [45.0-106.0] days, p = 0.002), and a significantly higher risk of in-hospital mortality (14.2% versus 9.6%, p = 0.023). Conclusions: Ampicillin plus cefotaxime should not be routinely prescribed as the empiric antibiotics for critically ill neonates at birth because they were associated with a higher risk of infections caused by multidrug-resistant pathogens and final worse outcomes.

Non-communicable disease burden among inpatients at a rural district hospital in Malawi

BackgroundThe burden of non-communicable diseases (NCDs) is high in Malawi. However, resources and training for NCD care remain scarce, especially in rural hospitals. Current care for NCDs in the developing world focuses on the WHO’s traditional 4 × 4 set. However, we do not know the full burden of NCDs outside of that scope, like neurological disease, psychiatric illness, sickle cell disease, and trauma. The goal of this study was to understand the burden of NCDs among inpatients in a rural district hospital in Malawi. We broadened our definition of NCDs beyond the traditional 4 × 4 set of NCDs, and included neurological disease, psychiatric illness, sickle cell disease, and trauma.MethodsWe conducted a retrospective chart review of all inpatients who were admitted to the Neno District Hospital between January 2017 and October 2018. We broke patients down by age, date of admission, type, and number of NCD diagnoses, and HIV status, and constructed multivariate regression models for length of stay and in-hospital mortality.ResultsOf 2239 total visits, 27.5% were patients with NCDs. Patients with NCDs were older (37.6 vs 19.7 years, p < 0.001) and made up 40.2% of total hospital time. We also found two distinct populations of NCD patients. The first were patients 40 years and older with primary diagnoses of hypertension, heart failure, cancer, and stroke. The second were patients under 40 years old with primary diagnoses of mental health conditions, burns, epilepsy, and asthma. We also found significant trauma burden, accounting for 40% of all NCD visits. In multivariate analysis, carrying a medical NCD diagnosis was associated with longer length of stay (coefficient 5.2, p < 0.001) and a higher risk of in-hospital mortality (OR 1.9, p = 0.03). Burn patients also had significantly longer length of stay (coefficient 11.6, p < 0.001).ConclusionsThere is a significant burden of NCDs in a rural hospital in Malawi, including those outside of the traditional 4 × 4 set. We also found high rates of NCDs in the younger population (under 40 years of age). Hospitals must be equipped with adequate resources and training to meet this burden of disease.