Higher 30-day Mortality Research Articles

Association between red cell distribution width and 30-day mortality in patients with sepsis-associated liver injury: a retrospective cohort study

BackgroundSepsis-associated liver injury (SALI) is a critical component of sepsis-induced multiple organ dysfunction with high mortality. Identifying biomarkers for risk stratification is essential. Red cell distribution width (RDW), indicating variation in red blood cell volume, has been linked to adverse outcomes in various diseases. This study aimed to evaluate the association between RDW and 30-day mortality in SALI patients.MethodsA retrospective cohort study was conducted using data from the Medical Information Mart for Intensive Care-IV database. Patients admitted to the intensive care unit (ICU) with SALI were included. RDW was recorded within the initial 24 h. The primary outcome was 30-day mortality. A multivariable Cox regression analysis was performed to examine the relationship between RDW and mortality.ResultsAmong 529 SALI patients (mean age 68.7 years, 61.8% male), 46.1% had RDW > 15.5%. The 30-day mortality rate was 35.5%. RDW was significantly higher in non-survivors compared to survivors (17.2 ± 3.0 vs. 15.4 ± 2.3, P < 0.001). Cox regression identified RDW as an independent risk factor for 30-day mortality (HR 1.14, 95% CI 1.09 to 1.19, P < 0.001). Subgroup analyses demonstrated that the findings were consistent across the various groups.ConclusionElevated RDW is independently associated with higher 30-day mortality in patients with SALI, suggesting its potential role in risk stratification and clinical management.

Reintervention for Acute Aortic Prosthesis Endocarditis: Early and Mid-Term Outcomes

Objective: This study aimed to analyze the outcomes and challenges associated with surgical redo procedures following aortic valve replacement for acute infective endocarditis. While transcatheter aortic valve implantation is growing in terms of its utilization for degenerative bioprostheses failure, valve-in-valve procedures are limited in acute aortic endocarditis. Surgical interventions for aortic prosthesis endocarditis carry a significant risk, with a higher mortality and morbidity, often requiring concomitant complex procedures. Methods: This was a retrospective, monocentric, observational study. We identified 352 patients with infective endocarditis from the institutional database. After applying the inclusion and exclusion criteria, 54 patients who underwent surgical re-operation between 2016 and 2023 were included. Endpoints included early and late mortality, complications, and major adverse cardiac and cerebrovascular events (MACCEs). Results: From the cohort, predominantly male and with an average age of 71.9 ± 12.1 years old (79.6%), the following notable findings were derived: isolated aortic valve replacement was feasible only in 34 patients (63%) while more complex procedures were demanded in the other cases; the overall 30-day mortality rate was 18.5%, post-operative ECMO occurred in 9.3% of cases, and post-operative new stroke in 2.7%; the 5-year overall survival rate was 58.3 ± 18.6%, while freedom from MACCEs was 41.7 ± 19.7%. Another re-intervention was required in three patients during follow-up, with one case attributed to re-endocarditis. Conclusions: Despite advancements in surgical and perioperative care, redo procedures for acute infective endocarditis pose significant risks, as evidenced by the high 30-day mortality rate. However, the 5-year survival suggests a relatively acceptable outcome, underscoring the complexities and challenges inherent in managing this condition surgically.

Hypoalbuminemia is Associated with Higher 90-Day Mortality and Poor Prognosis in Patients with Esophageal Squamous Cell Carcinoma and Liver Cirrhosis Receiving Radiotherapy-Based Therapy.

Liver cirrhosis (LC) is common among patients with esophageal squamous cell carcinoma (ESCC) due to shared etiologic factor, alcohol. For non-metastatic ESCC (nmESCC) patients with cirrhosis, surgery is often contraindicated or associated with high morbidity, therefore radiotherapy-based therapy was commonly applied. This study aims to investigate prognosticators for overall survival (OS) in nmESCC and cirrhotic patients receiving radiotherapy-based therapy. Furthermore, we will also evaluate the predictors for the 90-day mortality rate to reduce avoidable treatment-related toxic effects, and prevent medical waste. Between January 2001 and December 2021, we retrospectively reviewed medical records of 1298 ESCC patients. Total 78 patients with nmESCC and liver cirrhosis identified based on abdominal ultrasonography, computerized tomography, or liver biopsy were enrolled. Clinicopathologic parameters were collected and correlated with OS and 90-day mortality. Univariate analysis revealed that Child-Pugh classification B/C (P<0.001, versus A), radiotherapy alone (P=0.03, versus chemoradiotherapy), prothrombin time (PT) prolonged≧2seconds (P=0.024), albumin≦3.5g/dl (P<0.001), controlled/refractory ascites (P=0.01, versus none of ascites), and total bilirubin≧1.5mg/dl (P=0.004) were significantly associated with inferior OS. In multivariate analyses, albumin≦3.5g/dl (P=0.001, odds ratio (OR): 2.500) and total bilirubin≧1.5mg/dl (P=0.019, OR: 2.012) were independent adverse prognosticators. The 90-day mortality in these 78 patients receiving radiotherapy-based therapy was 10.3% (n=8), including ESCC progression in 4 patients, liver failure in 1 patient, and others in 3. Clinical 8th AmericanJoint Committee on Cancer (AJCC) stage IVA (P=0.02), clinical T classification T3/4 (P=0.049), PT prolonged≧4seconds (P=0.009), and albumin≦3.5g/dl (P=0.027) were significantly correlated with higher 90-day mortality. Logistic model showed albumin≦3.5g/dl (P=0.015, OR: 16.129) and clinical 8th AJCC stage IVA (P=0.012, OR: 17.544) were independently correlated with higher 90-day mortality. Hypoalbuminemia is associated with higher 90-day mortality and poor prognosis in nmESCC and liver cirrhosis patients receiving radiotherapy-based therapy.

Machine learning-based model for predicting the occurrence and mortality of nonpulmonary sepsis-associated ARDS

Objective: The objective was to establish a machine learning-based model for predicting the occurrence and mortality of nonpulmonary sepsis-associated ARDS. Methods: 80% of sepsis patients selected randomly from the MIMIC-IV database, without prior pulmonary conditions and with nonpulmonary infection sites, were used to construct prediction models through machine learning techniques (including K-nearest neighbour, extreme gradient boosting, support vector machine, deep neural network, and decision tree methods). The remaining 20% of patients were utilized to validate the model’s accuracy. Additionally, local data were employed for further model validation. Results: A total of 11,409 patients were included, with the most common type of infection being bloodstream infection. A total of 7,632 (66.9%) patients developed nonpulmonary sepsis-associated ARDS (NPS-ARDS). Patients with NPS-ARDS had significantly longer ICU stays (6.2 ± 5.2 days vs. 4.4 ± 3.7 days, p < 0.01) and higher 28-day mortality rates (19.5% vs. 14.9%, p < 0.01). Both internal and external validation demonstrated that the model constructed with the extreme gradient boosting method had high accuracy. In the internal validation, the model predicted NPS-ARDS and mortality in such patients with accuracies of 77.5% and 71.8%, respectively. In the external validation, the model predicted NPS-ARDS and mortality in these patients with accuracies of 78.0% and 81.4%, respectively. Conclusion: The model established via the extreme gradient boosting method can predict the occurrence and mortality of nonpulmonary sepsis-associated ARDS to a certain extent.

Abstract 4135726: Prospective validation and implementation pilot study of an emergency department heart failure risk stratification tool: STRIDE-HF

Background: We previously found the STRIDE-HF emergency department (ED) risk tool accurately predicted risk of a 30-day serious adverse event (SAE), including 30-day mortality, cardiopulmonary resuscitation, intra-aortic balloon pump insertion, intubation, new dialysis, myocardial infarction, or coronary revascularization. Research question: We sought to prospectively validate STRIDE-HF and describe safety of the deployed model in a clinical pilot. We hypothesized that performance would decrease slightly with prospective evaluation and that real-time risk display would contribute to safe disposition decisions. Goals: 1) To prospectively validate KPCARES-HF across 21 community EDs among ED patients with acute heart failure (AHF) from January 1, 2023 – December 31 st , 2023; and 2) to describe outcomes among patients predicted to be very low risk and discharged home in the clinical pilot. Methods: For prospective validation, we report 30-day mortality rates by risk strata. We assess model performance using area under the receiver operator curve (AUROC) and sensitivity at a key clinical threshold. We describe rates of 30-day SAE among patients predicted to be very low risk and discharged after ED or observation unit care in the clinical pilot. Results: There were 13,274 ED patients in the prospective validation; median age was 76, 50.8% were female, and 44.5% were non-White. We found 11.4%, 24.8%, 31.9%, and 31.9% of patients were very low, low, moderate, and high risk, respectively, while 21.6%, 15.2% and 63.0% were discharged, observed, and admitted, respectively. Among discharged patients, 29.2% and 13.3% were moderate or high risk, respectively, and 30-day mortality rates among these patients were 2.2% and 8.4%, respectively. Among 8,363 admitted patients, 27.7% were very low or low risk. Conclusions: STRIDE-HF maintained high predictive accuracy with prospective validation in this diverse, multi-center cohort. Our findings suggest that use of STRIDE-HF might help better align risk with admission decision and can be safely used to assist providers in identifying patients who may be stable for outpatient care.

Clostridioides difficile infections caused by hypervirulent strains: a single-centre real-life study.

Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated infections worldwide, with hypervirulent strains linked to severe disease and higher mortality. This study aims to analyze the epidemiology of CDI at a tertiary-care hospital in Italy and compare clinical outcomes between patients infected with hypervirulent and non-hypervirulent strains. A retrospective comparative study was conducted on patients diagnosed with CDI at ASST Spedali Civili di Brescia, Italy, from January 2015 to June 2023. Hypervirulent strains were identified using the GeneXpert assay as positive for cytotoxin gene (tcdB), binary toxin genes (tcdA and tcdB) and a single nucleotide deletion at position 117 in the tcdC gene and compared to a randomized matched control group with non-hypervirulent CDI. Clinical data were collected and analyzed, with multivariate logistic regression employed to identify risk factors for hypervirulent CDI. Of 1,059 positive C. difficile specimens, a statistically significant trend between January 2015 to June 2023 was found in the increasing incidence of CDI cases per 1,000 hospital admissions and 10,000 bed-days. Notably, a remarkable increase of hypervirulent strains was recorded in 2021 and 2022 when compared to previous years. A total of 130 patients were analyzed: 62 (47.7%) with hypervirulent CDI and 68 (52.3%) controls. Hypervirulent CDI was associated with higher 30-day mortality (18% vs. 5.8%, p = 0.03). Multivariate analysis showed that hypervirulent CDI significantly increased 30-day mortality risk (OR = 9.915, CI = 2.37-61.05, p = 0.005) and that prior antibiotic therapy was a significant risk factor (OR = 5.49, CI = 1.19-39.96, p = 0.047). Our epidemiological data, while suggesting a potential resurgence in CDI transmission during COVID-19 pandemic, are derived from a single-center experience with limited generalizability to the broader population. Nonetheless, they highlight the need for strengthened antimicrobial stewardship and national surveillance systems to effectively monitor and manage these strains.

Association between serum glucose potassium ratio and mortality in critically ill patients with intracerebral hemorrhage

The effect of serum glucose-to-potassium ratio (GPR) on cerebrovascular diseases has been previously validated. However, the value of the GPR in patients with severe intracerebral hemorrhage (ICH) requiring ICU admission remains unclear. This study aimed to investigate the association between the GPR and the clinical prognosis of critically ill patients with ICH. This study identified patients with severe ICH requiring ICU admission from the Medical Information Mart for Intensive Care (MIMIC-IV) database and divided them into quartiles based on GPR levels. Outcomes included 30-day, 90-day, and 1-year mortality rates. The association between the GPR and clinical outcomes in critically ill patients with ICH was elucidated using Cox proportional hazards regression analysis and restricted cubic splines. In total, 2018 patients (53.8% male), with a median age of 70 years, were enrolled in the study. The 30-day, 90-day, and 1-year mortality rates were 23.9%, 30.1%, and 38.4%, respectively. Per multivariate Cox proportional hazards analysis, an elevated GPR was significantly associated with all-cause mortality. After adjusting for age, sex, Charlson Comorbidity Index, white blood cell count, red blood cell count, platelet count, and Glasgow Coma Scale, patients with an elevated GPR had a higher 30-day mortality (hazard ratio [HR]: 1.32; 95% confidence interval [CI]: 1.22–1.42; P < 0.001), 90-day mortality (HR: 1.27; 95% CI: 1.18–1.37; P < 0.001) and 1-year mortality (HR: 1.22; 95% CI: 1.14–1.31; P < 0.001) when analyzed as a continuous variable. Furthermore, analysis using restricted cubic splines demonstrated a consistent and progressive escalation in the risk of all-cause mortality with an elevated GPR. The GPR was significantly associated with short- and long-term all-cause mortality in critically ill patients with ICH. This finding demonstrates that GPR may be useful in identifying patients with ICH at a high risk of all-cause mortality.

Seroprevalence and prognostic value of Aspergillus-specific IgG among non-neutropenic invasive pulmonary aspergillosis patients: a prospective multicenter study

BackgroundThis study aimed to assess the diagnostic and prognostic value of Aspergillus-specific IgG (Asp-IgG) for invasive pulmonary aspergillosis (IPA) in non-neutropenic non-hematologic patients.MethodsBetween November 2019 and February 2022, we recruited 40 non-neutropenic, non-hematologic IPA patients from Taiwan and measured serum Asp-IgG levels using Phadia, Thermofisher. A positive Asp-IgG test was defined as a level > 40 mgA/L. We evaluated the association between Asp-IgG levels and overall survival, as well 90-day mortality rate of IPA patients.ResultsOf the 40 participants, 11 (27.5%) tested positive for Asp-IgG, while 16 (40%) had positive galactomannan antigen (optical density > 1). Higher Asp-IgG levels were associated with improved overall survival (HR: 0.22, 95% CI: 0.05–0.99, p = 0.035) in multivariable Cox regression. The overall 90-day mortality rate was 65% (26/40). We found that patients with low Asp-IgG levels (≤ 40 mgA/L) had a borderline higher 90-day mortality rate compared to patients with high Asp-IgG levels (OR: 3.15, 95% CI: 0.75–13.28, p = 0.118). Stratifying by serum galactomannan and Aspergillus IgG levels, patients with elevated serum GM and low Asp-IgG had the highest 90-day mortality (80%, 8/10), followed by patients with low serum GM and low Asp-IgG (68.4%, 13/19).ConclusionsAsp-IgG was positive in approximately one-fourth of non-neutropenic IPA patients. Asp-IgG may hold potential as a clinical prognostic factor for IPA. Further studies are required to validate this finding.

Predictive factors for shunt dependency in patients with spontaneous intraventricular hemorrhage

Intraventricular hemorrhage (IVH) occurs in approximately 30–50% patients with spontaneous intracerebral hemorrhage (ICH), with a high 30-day mortality rate. Excess accumulation of parenchymal or ventricular blood associated with the development of acute hydrocephalus leads to poor outcomes. The prediction of shunt dependency is important to identify patients susceptible to requiring permanent shunt placement and benefit from the diversion. This retrospective analytical study aimed to establish a predictive model of shunt dependency in patients with IVH. This study included 179 patients with primary IVH with supratentorial origin or spontaneous ICH with extension into the ventricles between 2015 and 2021. Patients were grouped into “shunt required” and “shunt not required” groups. Variables, including age, sex, preexisting hypertension and diabetes, initial Glasgow Coma Scale scores, ICH location and volume, urokinase administration, modified Graeb score (mGraeb score), and bicaudate index, were analyzed. The shunt required group had significantly higher mGraeb scores (12.0 (6.5–15.0) vs. 7.0 (4.0–12.0), p = 0.001) and higher bicaudate index (0.20 (0.17–0.23) vs. 0.16 (0.13–0.18), P < 0.001) than the shunt not required group. The receiver operating characteristic curve (ROC curve) analysis revealed that a cut-off value of 0.16 of the bicaudate index was significantly related to shunt dependency. The subgroup statistical analysis revealed that neither urokinase administration (p = 0.533) nor urokinase dosage (p = 0.117) showed significant relevance in shunt dependency in patients who received external ventricular drainage. In logistic regression adjusted for the confounders, thalamic ICH (odds ratio (OR) 3.55; 95% confidence interval [(95%CI), 1.13–11.18], an mGraeb score greater than 8 (OR, 3.93; 95%CI, 1.84–8.38), and a bicaudate index greater than 0.16 (OR, 9.87; 95%CI, 3.79–25.73) were factors associated with a higher tendency for shunting. The findings of this study may help identify patients at risk for a permanent shunt after IVH.

Age-specific differences of Impella support in Japanese patients: The Japanese registry for percutaneous ventricular assist device (J-PVAD) registry analysis on outcomes and adverse events

BackgroundThe association between the clinical significance and prognostic impact of catheter-based micro-axial ventricular assist device Impella (Abiomed, Danvers, MA, USA) support and age has not been sufficiently investigated. Methods and ResultsA total of 5282 patients treated with Impella were analyzed from the Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD). Patients were categorized into four age groups: <50 years old (Group A, n = 670), 50–69 years old (Group B, n = 2009), 70–79 years old (Group C, n = 1716), and ≥ 80 years old (Group D, n = 887). Kaplan–Meier curve analysis demonstrated that the prognosis, including 30-day all-cause mortality, was significantly poorer in Group D compared to the other groups. A multivariate Cox regression model identified Group D as an independent predictor of 30-day all-cause death (HR: 2.173, 95 % CI: 1.699–2.779) relative to Group A. The multivariate logistic regression analysis indicated that estimated glomerular filtration rate, lactate levels, and systolic blood pressure were independently associated with 30-day mortality across all age categories. The presence of more than two major adverse events was independently associated with 30-day mortality specifically in the cohort aged ≥80 years (OR: 1.492, 95 % CI: 1.037–2.148, p = 0.031). ConclusionIncreasing age was identified as a significant factor associated with higher 30-day mortality rates in J-PVAD. While the incidence of major adverse events did not differ significantly across age categories, the occurrence of two or more additional adverse events was linked to increased 30-day mortality among older individuals. Therefore, an appropriate mechanical support strategy may be necessary for elderly Japanese patients based on their age.

Delirium and Weakness Acquired in the Intensive Care Unit: Individual and Combined Effects on 90-Day Mortality in Survivors of Critical Illness.

To compare the individual and combined effects on 90-day mortality among four critically ill survivor groups: normal (without ICU-acquired delirium or ICU-acquired weakness), delirium-only (with ICU-acquired delirium only), weakness-only (with ICU-acquired weakness only) and delirium-weakness (combined ICU-acquired delirium and weakness). A prospective cohort study consecutively recruited delirium-free critically ill patients admitted to six medical ICUs at a university hospital. Delirium was assessed once daily for 14 days (or until death or ICU discharge) using the Confusion Assessment Method for the ICU. Participants who were discharged from the ICUs were assessed for weakness using the Medical Research Council scale. A summed score below 48 defines ICU-acquired weakness. These survivors were evaluated again for 90-day mortality. The study is reported using the STROBE checklist. Delirium developed in 107 (43.2%) participants during their first 14 days of ICU stay; 55 (22.2%) met criteria for weakness by ICU discharge. Participants with delirium were at increased risk for also developing ICU-acquired weakness, and the 90-day mortality was 18.2%. Independent of age and Acute Physiology and Chronic Health Evaluation II score at ICU admission, delirium-only and weakness-only were not associated with higher 90-day mortality, while participants in the delirium-weakness group had a 3.69-fold higher risk of death, compared to those who were normal during the ICU stay. A non-significant interaction was found, suggesting the joint effect of delirium and weakness on mortality is not higher than the sum of both effects individually. Mortality is substantially high among critically ill survivors who experience both delirium and weakness, although no additive effect on mortality was observed when these conditions occur together. Our findings highlight the urgent need to optimise ICU care by prioritising the prevention, early identification and management of these two common ICU-acquired conditions. Study participation and completion of all assessments. ClinicalTrials.gov identifier: NCT04206306.

Standard modifiable risk factors (SMuRF) paradox for the prognosis in the patients with acute myocardial infarction

Abstract Background Hypertension, diabetes, dyslipidemia and smoking are recognized as standard modifiable risk factors (SMuRFs) for adverse cardiovascular events such as acute myocardial infarction (AMI). Recent studies have shown that AMI patients without SMuRFs are associated with increased mortality compared to those with SMuRFs. However, the relationship between the number of SMuRFs in patients with AMI and mortality has not been well evaluated. Purpose The purpose of this study was to evaluate the clinical characteristics and prognosis of AMI patients stratified by the number of SMuRFs. Methods We studied 6,706 AMI patients between 2013 and 2021 using data from the Mie ACS registry, a retrospective and multicenter registry. For the purpose of this study, only AMI patients as their first cardiovascular events were included in this analysis. Therefore, after excluding patients with a known history of coronary artery disease (n=982), 5724 AMI patients were included in the current analysis. All-cause mortality was compared with 30-day and after 30-day mortality in AMI patients stratified by the number of SMuRFs as the primary outcome. In addition, all-cause mortality rate was compared in AMI patients without and with SMuRFs after propensity score matching on age, sex, body mass index, Killip classification, cardiac arrest before presentation, multivessel disease, left main truck disease, hemoglobin and emergent percutaneous coronary intervention. Results Among 5,724 AMI patients, 672 patients (11.7%) did not have SMuRFs. The median age of patients without SMuRFs was higher than that of patients with any SMuRFs (73 y.o. vs. 70 y.o, P&amp;lt;0.001), and higher prevalence of female and severe Killip class was observed in patients without SMuRFs compared with those with any SMuRFs (P&amp;lt;0.001, respectively). According to the KM survival curves stratified by number of SMURFs, an increased number of SMURFs was associated with higher 30-day survival rates (P=0.035), and the 30-day landmark analysis showed a trend toward higher survival in patients with the highest number of SMURFs, although not statistically significant (Figure1). Multivariate Cox regression analysis showed that 0 SMuRF was an independent prognostic factor for 30-day mortality with hazard ratio of 1.55 (95%CI; 1.13-2.13, P&amp;lt;0.001). In addition, KM survival curves after propensity score matched analysis showed the poor 30-day mortality in 0 SMuRF group (P=0.036), there was no significant difference in after 30-day mortality between the two groups (Figure 2). Conclusions Patients without SMuRFs had a high 30-day mortality rate, but once they survived the acute phase, their prognosis was comparable to patients with SMuRFs. Moreover, the SMuRF paradox was recognized in the acute phase. This finding highlights the need for early identification of the individuals at risk of developing MI despite the absence of SMuRFs and strict acute management regardless of the number of SMuRFs.

Timing of inopressor initiation in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract Introduction Inotropes and vasopressors (inopressors) are commonly used in the treatment of acute myocardial infarction complicated by cardiogenic shock (AMICS). The characteristics of patients subjected to early or late initiation of inopressors are not yet described, and the impact of timing on outcomes remains uncertain. Purpose This retrospective real-world data study aims to identify patient-, treatment-, and outcome characteristics of AMICS patients treated with early- or late initiated inopressors. Methods The Netherlands Heart Registration (NHR) prospectively records baseline, procedural, and outcome data for PCI patients. Between 2017-2021, additional retrospective data on CS patients were collected by fourteen Dutch hospitals. Patients were categorized based on the timing of inopressor initiation, either early (pre PCI) or solely late (at the cathlab or within 24 hours after PCI). Patients presenting with an out of hospital cardiac arrest were excluded. Missing data were imputed through multiple imputation (30x). Multivariable logistic regression analysis was performed to evaluate the association between the timing of inopressor initiation and 30-day mortality, adjusting for univariate significant confounders among variables known at admission. Results A total of 956 consecutive CS patients were included of whom 418 (43.7%) and 538 (57.3%) patients were subjected to early and late initiation of inopressors respectively. The most frequently used drug in both groups was noradrenaline. At baseline, patients in the early initiation group were younger (67.4 vs. 70.0 years, p &amp;lt;0.001), presented with a lower mean arterial pressure (MAP) (72.5 vs. 76.3, p = 0.048) and higher lactate (4.2 vs. 3.6, p = 0.012), and presented with a NSTEMI more often (36.0% vs. 14.2%, p &amp;lt;0.001). They also had a higher prevalence of previous myocardial infarction (33.9% vs. 22.9%, p &amp;lt;0.001) and previous CABG (14.3% vs. 6.2%, p &amp;lt;0.001). Moreover, 30-day mortality rates were higher in the early initiated group (48.6% vs. 37.6%, pLogrank &amp;lt;0.001). After multivariate adjustment for age, admission MAP and lactate, early inopressor initiation remained independently associated with 30-day mortality (OR 1.44, 95%-CI 1.08-1.98) compared to late initiation. Conclusion In this Dutch cohort of CS patients undergoing PCI, baseline- treatment- and outcome characteristics differed between patient categories receiving either early or late initiated inopressors. Patients who were subjected to early initiated inopressors were younger, presented with worse hemodynamics, had a more extensive cardiovascular medical history and higher 30-day mortality rates. The results of this study reemphasize the importance of identifying patients who benefit from inopressors.30-day mortality late vs. earlyTable patient characteristics

Microaxial Flow Pump Use and Renal Outcomes in Infarct-Related Cardiogenic Shock - a Secondary Analysis of the DanGer Shock Trial.

In the Danish-German Cardiogenic Shock (DanGer Shock) trial, use of a microaxial flow pump (mAFP) in patients with ST-segment elevation myocardial infarction (STEMI)-related CS led to lower all-cause mortality but higher rates of renal replacement therapy (RRT). In this prespecified analysis, rates and predictors of acute kidney injury (AKI) and RRT were assessed. In this international, randomized, open label, multicenter trial, 355 adult patients with STEMI-CS were randomized to mAFP (N=179) or standard care alone (N=176). AKI was defined according to Risk, Injury, and Failure, sustained Loss and End-stage kidney disease (RIFLE) criteria and assessed using logistic regression models. Use of RRT was assessed accounting for the competing risk of death using Fine-Gray subdistribution hazard models. AKI (RIFLE≥1) was recorded in 110 patients (61%) in mAFP group and 79 (45%) in control group (p<0.01); RRT was used in 75 (42%) and 47 (27%) patients, respectively (p<0.01). About 2/3 of the RRTs were initiated within the first 24h from admission (n=48 (64%) in mAFP group, n=31 (66%) in control group). Occurrence of AKI and RRT were associated with higher 180-day mortality in both study arms. At 180 days, all patients alive were free of RRT. mAFP use was associated with higher rates of RRT, even when accounting for competing risk of death (subdistribution hazard: 1.67 [1.18-2.35]). This association was largely consistent among prespecified subgroups. Allocation to mAFP was associated with lower 180-day mortality irrespective of AKI or RRT (p=0.8 for interaction). Relevant predictors of AKI in both groups comprised reduced left ventricular ejection fraction, baseline kidney function, shock severity, bleeding events, and positive fluid balance. In addition, predictors of AKI specific to mAFP were suction events, higher pump speed, and longer duration of support. Shock severity, allocation to mAFP, and device-related complications were associated with an increased risk of AKI. AKI was generally associated with higher mortality, but the allocation to mAFP consistently led to lower mortality rates at 180 days irrespective of the occurrence of AKI with or without RRT initiation.

Sublingual microcirculatory assessment on admission independently predicts the outcome of old intensive care patients suffering from shock

Shock is a life-threatening condition. This study evaluated if sublingual microcirculatory perfusion on admission is associated with 30-day mortality in older intensive care unit (ICU) shock patients. This trial prospectively recruited ICU patients (≥ 80 years old) with arterial lactate above 2 mmol/L, requiring vasopressors despite adequate fluid resuscitation, regardless of shock cause. All patients received sequential sublingual measurements on ICU admission (± 4 h) and 24 (± 4) hours later. The primary endpoint was 30-day mortality. From September 4th, 2022, to May 30th, 2023, 271 patients were screened, and 44 included. Patients were categorized based on the median percentage of perfused small vessels (sPPV) into those with impaired and sustained microcirculation. 71% of videos were of good or acceptable quality without safety issues. Patients with impaired microcirculation had significantly shorter ICU and hospital stays (p = 0.015 and p = 0.019) and higher 30-day mortality (90.0% vs. 62.5%, p = 0.036). Cox regression confirmed the independent association of impaired microcirculation with 30-day mortality (adjusted hazard ratio 3.245 (95% CI 1.178 to 8.943, p = 0.023). Measuring sublingual microcirculation in critically ill older patients with shock on ICU admission is safe, feasible, and provides independent prognostic information about outcomes.Trial registration NCT04169204.

Procedural Volume and Outcomes After Septal Reduction Therapies in Hypertrophic Obstructive Cardiomyopathy.

Septal myectomy and alcohol septal ablation (ASA) are septal reduction therapies for patients with symptomatic obstructive hypertrophic cardiomyopathy. Operator and hospital volume may influence outcomes, but contemporary data on this relationship are limited. This retrospective cohort study used data from the Vizient Clinical Data Base (2016-2022). Patients with undergoing septal myectomy and ASA were identified using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and stratified into low-, medium-, and high-volume groups based on annualized operator and hospital volumes. The outcomes were 30-day in-hospital mortality and 90-day readmission, analyzed using multivariable adjusted logistic and Cox models. Among 5725 patients with hypertrophic cardiomyopathy (3990 septal myectomy; 1735 ASA), most operators and hospitals performed <10 procedures annually. For septal myectomy, low-volume operators were associated with higher odds of 30-day mortality (adjusted odds ratio [aOR], 1.86 [95% CI, 1.11-3.15]) and greater risk for 90-day readmission (aOR, 1.51 [95% CI, 1.22-1.88]), and medium-volume operators had higher odds of 30-day mortality (aOR, 1.93 [95% CI, 1.05-3.55]). Medium-volume hospitals had higher 30-day mortality (aOR, 2.29 [95% CI, 1.32-3.99]), with low-volume hospitals showing greater risk for 90-day readmission (aOR, 1.60 [95% CI, 1.14-2.23]). For ASA, low- and medium-volume operators had increased 30-day mortality (aOR, 2.99 [95% CI, 1.15-7.75] and aOR, 3.86 [95% CI, 1.30-11.46]), but the risk of 90-day readmission was similar. Hospital volumes did not significantly impact outcomes for ASA. Low operator and hospital volumes were associated with worse outcomes for septal reduction therapies, emphasizing the need to refer patients with hypertrophic cardiomyopathy to high-volume centers with experienced operators.

Vascular Resection for Pancreas Cancer - 10-year Experience from a Single High Volume-center.

Combined pancreatic and vascular resections are increasingly performed for pancreatic ductal adenocarcinoma (PDAC). We evaluated the outcomes after pancreatectomy with non-vascular resection (NVR), venous resection (VR), and arterial resection (AR). Retrospective review (2011-2023) of 715 PDAC patients treated with curative-intent surgery. Associations among clinicopathological data, perioperative therapy, time to recurrence (TTR), and overall survival (OS) were evaluated. Initial staging revealed 533 resectable, 98 borderline, and 84 locally advanced PDAC cases. Pancreaticoduodenectomy was the most common procedure (n=467). NVR was performed in 351 (58.2%) patients, VR in 181 (30.0%), and AR in 70 (11.8%). The median TTR and OS did not significantly differ according to the initial staging or type of pancreas resection. Median TTR and OS were significantly shorter for VR (14.5 and 22.7mo) compared to NVR (18.6 and 30.5mo, P<0.001) and AR (20.6 and 30.9mo, P=0.004 and P=0.017). Chemotherapy or chemoradiation significantly prolonged TTR (20.1 vs. 10.2mo, P<0.001 and 25.3 vs. 16.4mo, P<0.001) and OS (31.5 vs. 17.2mo, P<0.001 and 35.5 vs. 27.5mo, P=0.030). AR was associated with higher 90-day mortality rates. In the multivariable analysis, vascular resection was not associated with OS. Perioperative therapy, pathological N0 status, and absence of perineural invasion were the key predictors of longer TTR and OS. Pancreatectomy with AR was not associated with worse oncological outcomes when controlling for perioperative therapy. However, AR was associated with higher 90-day mortality rates. Patient selection is crucial when performing AR in patients with PDAC.

Failure to Rescue Female Patients Undergoing High-Risk Surgery

Female patients have higher mortality rates after high-risk surgery than male patients. It is unknown whether this mortality gap is due to different rates of postoperative complications or if complications are addressed differently by sex, causing complications to lead to death-so-called failure to rescue. To evaluate sex differences in failure to rescue across high-risk surgical procedures. This retrospective cohort study was conducted using data from Medicare beneficiaries from October 2015 to February 2020 who underwent high-risk vascular or cardiac surgical procedures, including abdominal aortic aneurysm repair, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement or repair. Data analysis was performed from August 2023 to March 2024. The primary exposure was patient sex. The primary outcomes were risk-adjusted rates of complications, 30-day mortality, and failure to rescue, which was defined as a death occurring after a serious complication. Categorical variables are presented as frequencies and proportions and compared using χ2 analysis. Continuous variables were tested for normality and compared using a t test. A total of 863 305 Medicare beneficiaries were included in this study cohort, of whom 304 176 (35.2%) were female. Mean (SD) age was slightly higher in female patients (74.8 [9.3] years) than male patients (73.4 [8.5] years), and female patients had more comorbidities than male patients (≥2 Elixhauser comorbidities, female: 262 809 [86.4%] vs male: 465 231 [83.2%]). Female patients were more likely to receive care at large hospitals and hospitals with a higher surgical case volume. Overall, female and male patients had similar rates of complications (female: 14.98% vs male: 14.37%; adjusted relative risk [aRR], 1.04; 95% CI, 1.03-1.05; P < .001). However, female patients had higher rates of 30-day mortality (female: 4.22% vs male: 3.34%; aRR, 1.26; 95% CI, 1.23-1.29; P < .001) and higher rates of failure to rescue (female: 10.71% vs male: 8.58%; aRR, 1.25; 95% CI, 1.22-1.28; P < .001). A similar pattern was observed when stratified by each procedure. In this cohort study among Medicare beneficiaries undergoing high-risk surgery, male and female patients experienced similar rates of serious complications, but female patients with complications were more likely to die. In other words, clinicians fail to rescue female patients with complications after high-risk surgery more often than male patients. Improving the recognition and management of female patients' complications postoperatively may narrow the sex disparity after high-risk surgery.

Trans-arterial embolization for treatment of acute lower gastrointestinal bleeding-a multicenter analysis.

To assess the technical feasibility, safety, and clinical success rate of trans-arterial embolization (TAE) as an emergency treatment for acute lower gastrointestinal bleeding (LGIB). Consecutive patients who received urgent TAE due to active LGIB at five academic centers in Germany were retrospectively analyzed. LGIB was confirmed and localized using contrast-enhanced computed tomography (CT) or endoscopy. Outcome parameters including technical and clinical success rates as well as ischemia-related adverse events were analyzed. Furthermore, treatment-related variables that may affect technical and clinical success were analyzed using a regression model. One hundred and forty-one patients were included. TAE was performed in 91% (128/141) of patients. In 81% (114/141) of patients, TAE was performed due to active bleeding visible at angiography, the remaining 10% (14/141) underwent empiric embolization based on pre-interventional imaging. In 9% (13/141) of patients, no TAE was performed. Microcoils were the most used embolic 48.5% (62/128), followed by glue 23.5% (30/128) and Microparticles (8%; 10/128). In the case of bleeding visible in angiography, the technical success rate was 100% (114/114); the clinical success rate was 93.6% (120/128). Severe ischemia-related adverse events necessitating bowel surgery occurred in 14% (18/128) of all patients after embolization. Thirty-day mortality was 14% (21/141). Regression analysis revealed no significant correlations but a statistical trend toward a higher incidence of bowel resection when glue was used (p = 0.090) and toward a higher 30-day mortality when an unselective embolization was performed (p = 0.057). TAE for LGIB has a high technical and clinical success rate. Severe ischemia-related adverse events necessitating bowel surgery occurred in 14% of patients without identifying a significant correlation to the embolization technique or an embolic. Question Is trans-arterial embolization (TAE) viable as an emergency treatment for acute lower gastrointestinal bleeding (LGIB)? Findings TAE demonstrated a 100% technical and 93.6% clinical success rate in treating acute LGIB, with severe ischemia-related adverse events occurring in 14% of patients. Clinical relevance TAE is highly effective and has an acceptable complication rate in treating lower gastrointestinal bleeding, emphasizing the need for a direct head-to-head comparison between endovascular and endoscopic therapy.

Analysis of risk factors and different treatments for infections caused by carbapenem-resistant Acinetobacter baumannii in Shaanxi, China

BackgroundThe global threat of Carbapenem-resistant Acinetobacter baumannii (CRAB) has intensified as resistance to carbapenems continues to rise in recent decades. We aimed to explore risk factors, molecular epidemiology, and antimicrobial therapy of CRAB infection.MethodsThe clinical data of 110 patients infected with A. baumannii from December 2021 to December 2022 were retrospectively analyzed. Patients were divided into a carbapenem-resistance group (55 patients) and carbapenem-sensitive group (CSAB; 55 patients) based on resistance to carbapenem, and the risk factors of patients infected with CRAB were analyzed. Fifty-five patients with CRAB infection who received antimicrobial therapy were divided into a combination therapy group (45 patients) and a monotherapy group (10 patients), and differences between the two groups were compared. Whole-genome sequencing analysis was performed to assess resistance genes. Phylogenetic analysis was performed to explore the characteristics of CRAB isolates.ResultsAmong the total 110 patients, the rate of poor prognosis in the CRAB group was 43.6% (24/55). Mechanical ventilation (odds ratio [OR] = 5.364, 95% confidence interval [CI] 1.462–19.679, P = 0.011) and puncture (OR = 19.935, 95% CI 1.261–315.031, P = 0.012) were independent risk factors for CRAB infection. Of 55 patients in the antimicrobial regimen study, 45 received combination therapy (including dual, triple, or quadruple antibiotic therapy) and 10 received monotherapy. Univariate analysis revealed significant differences between the combination group and monotherapy group for admission to the intensive care unit and wound infection (P < 0.05). The CRAB strains of 26 patients taking carbapenem-based combination therapy were mainly ST208, ST1968, and ST195, among which patients with ST1968 strains had higher 28-day mortality. Furthermore, the blaOXA−23 gene was harbored in ST1968, ST195, and ST208.ConclusionsMortality was significantly higher in patients infected with CRAB than with CSAB. Mechanical ventilation and puncture were independent risk factors in predicting CRAB infections. The distribution of CRAB was dominated by ST208, ST1968, and ST195, among which patients with ST1968 had higher 28-day mortality. The blaOXA−23 gene appears to be widely disseminated.