Higher Hospital Mortality Research Articles

Role of central venous oxygen saturation in prognostication of patients with severe sepsis and septic shock in emergency medical services.

Introduction:All the components of early goal-directed therapy, especially central venous oxygen saturation (ScvO2) as one of the endpoints of resuscitation, may not have mortality benefit, more so after results of the Australasian Resuscitation of Sepsis Evaluation, A Randomized Trial of Protocol-Based Care for Early Septic Shock, and The Protocolised Management in Sepsis trials. However, extrapolating results from trials undertaken in the developed world may not be entirely appropriate.Materials and Methods:In this prospective observational study conducted in the emergency medical services, we aimed to find out the mean baseline ScvO2 in a cohort of 200 patients presenting with severe sepsis/septic shock and its prognostic significance. The measurement of ScvO2 was performed by sampling blood from the superior vena cava through the central venous catheter.Results:The mean age of patients was 46.70 ± 17.64 years. The mean ScvO2 at baseline of the study cohort was 65.95 ± 20.70%. Based on initial ScvO2 values, 104 (52%) patients had a lower ScvO2 level, a priori classified as the hypoxic group. Sixty-five (32.5%) patients had an initial ScvO2 level in between 70 and 89%, categorized as normoxic group, and the remaining 31 (15.5%) patients had high ScvO2, leveled as the hyperoxic group. Sixty-six (33%) patients had hospital mortality. Of 104 hypoxemic patients, 28 (26.9%) had hospital mortality. In this group, the mean ScvO2 value in 28 nonsurvivors at baseline and after 6 h of resuscitation was 46.21 ±16.66% and 48.82 ±18.81%, respectively. Twenty-five (38.5%) patients had hospital mortality among 65 patients with baseline ScvO2 value in the normoxic range. Hospital mortality figure stood at 13 (41.9%) patients in the hyperoxic group. Among patients in the hyperoxic group, the mean serum lactate value at baseline in nonsurvivors was 4.52 ± 2.95 mmol/L, significantly higher as compared to the mean value of 2.89 ± 1.55 mmol/L in survivors. The hyperoxia group had higher hospital mortality though it was not statistically significant.Conclusion:The mean baseline ScvO2 was lower in our study cohort. In the hypoxic group, patients with hospital mortality had persistently lower ScvO2 level during the first 6 h of resuscitation. Importantly, higher mortality in the hyperoxic group with high serum lactate emphasizes the point that ScvO2 value should be analyzed along with serum lactate levels as complimentary resuscitation endpoints.

ТУБЕРКУЛЕЗ КАК РЕЗУЛЬТАТ СИНДРОМА ВОССТАНОВЕНИЯ ИММУННОЙ СИСТЕМЫ ПОСЛЕ НАЧАЛА АНТИРЕТРОВИРУСНОЙ ТЕРАПИИ

Начало антиретровирусной терапии у ВИЧ-инфицированных лиц несет в себе высокий риск развития синдрома восстановления иммунной системы с проявлением ранее не диагностированных инфекций, в том числе туберкулеза.Целью исследования было оценить клинико-рентгенологические особенности и эффективность лечения туберкулеза, развившегося в результате СВИС после начала АРТ у ВИЧ-инфицированных пациентов. Материал и методы. Изучены 24 медицинские карты стационарных больных ко-инфекцией туберкулез/ВИЧ, находившихся на лечении в Республиканской клинической туберкулезной больнице г. Донецка, у которых туберкулез развился в течение первых трех месяцев после начала антиретровирусной терапии. На догоспитальном этапе всем пациентам перед началом противовирусного лечения проводили объективный осмотр, рентгенографию органов грудной клетки, определяли содержание CD4-лимоцитов крови. Результаты и обсуждение. Перед началом антиретровирусной терапии медианы содержания CD4 в крови пациентов составляли 35 кл/мкл и 4,7%, не имели жалоб 7 человек (29,2%)%, 13 (54,2%) отмечали повышение температуры тела, 12 (50,0%) – слабость, 8 (33,3%) – кашель с мокротой, 4 (16,7%) – снижение массы тела, и у 2 лиц (8,3%) имелась неврологическая симптоматика. Рентгенологически нормальная картина органов грудной клетки определялась у 11 больных (45,8%), у 13 (54,2%) имелось усиление легочного рисунка, у 6 (25,0%) – увеличение внутригрудных лимфатических узлов. Первые симптомы туберкулеза появлялись в сроки от 3 до 60 дней, медиана – 19 дней, все больные отмечали лихорадку и слабость, у 9 (37,5%) наблюдались признаки туберкулезного менингита, у 17 (70,8%) – генерализованного туберкулеза. За стационарный период лечения умерло 14 человек (58,3%). Из 9 больных туберкулезным менингитом погибло семеро (77,8%). Успешно закончили стационарный этап противотуберкулезной химиотерапии и были выписаны для продолжения лечения в амбулаторных условиях 8 человек (33,3%). Выводы. Туберкулез, развивающийся в результате синдрома восстановления иммунной системы, возникает у ВИЧ-инфицированных лиц с глубокой иммуносупрессией при назначении антиретровирусной терапии без антимикобактериальных препаратов, характеризуется быстрым развитием, склонностью к генерализации и неблагоприятным прогнозом. Особо злокачественным течением отличается туберкулезный менингит, при котором летальность достигает 77,8%. У 54,2% больных перед началом противовирусного лечения отмечались лихорадка, у такого же количества – усиление легочного рисунка, у 25,0% – увеличение внутригрудных лимфатических узлов. Наличие указанных симптомов является основанием для отсрочки антиретровирусной терапии и детального обследования пациентов. При невозможности верифицировать причину патологии целесообразно начинать противовирусное лечение под прикрытием противотуберкулезной химиотерапии, однако ее схема и продолжительность нуждаются в четкой регламентации.

High Visceral Adipose Tissue to Subcutaneous Adipose Tissue Ratio as a Predictor of Mortality in Acute Respiratory Distress Syndrome

We aimed to further determine the relationship between the areas of visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and the ratio of VAT to SAT (VAT/SAT) with the outcomes of acute respiratory distress syndrome (ARDS) patients. A retrospective study was performed on patients with ARDS in 7 intensive care units (ICU) of West China Hospital, Sichuan University. A total of 169 patients were included in the analysis. Abdominal computed tomography scans of each patient within 24 hours of being admitted to the ICU were assessed by at least 2 investigators. Higher VAT/SAT was related with higher hospital mortality (22% vs. 44%, P = 0.003; adjusted odds ratio [aOR] 0.699, 95% CI 0.530-0.922 ([P = 0.011]). On the contrary, higher SAT and VAT were related to lower hospital mortality in ARDS (aOR 1.077, 95% CI 1.037-1.119 [P < 0.001]; aOR 1.017, 95% CI 1.004-1.030 [P = 0.011], respectively). Patients with higher SAT and VAT had shorter length of ICU stay (ICU LOS) (26.26 vs. 15.83 days, P = 0.031; 25.16 vs. 14.19 days, P = 0.007, respectively), while VAT/SAT was not related with ICU LOS. Moreover, we did not find any significant relationship either between VAT/SAT and mechanical ventilation-free days or between SAT and mechanical ventilation-free days. This study suggests that VAT/SAT can contribute to adverse outcomes of patients with ARDS. However, higher SAT and VAT were related to better prognosis of ARDS patients.

2191. Hepatitis A Outbreak in Southeast Michigan: No Longer a Third World Disease

BackgroundHepatitis A (Hep A) is a self-limiting diarrheal illness occurring in underdeveloped countries. August 2016 marked the onset of an outbreak in Southeast Michigan. Our study characterizes the presentation and clinical course of Hep A patients that presented to our healthcare system.MethodsThis study included all Hep A positive cases that presented to Henry Ford Health System from August 2016 to December 2017. Electronic medical records were reviewed for demographics, sexual history, travel history, food exposure, illicit drug use, signs, symptoms and outcomes. Data were also collected on healthcare units of presentation, screening, and care including emergency department, clinic, inpatient hospitalization, or transfer from another facility. Outcomes included hospitalization, consultations with hepatology and transplant, re-admission, and death.ResultsA total of 166 cases were reviewed; Figure 1 displays the cases per month. The average age was 51 years and 54% were male. The most common symptoms were abdominal pain (47%) and nausea (42.8). Underlying conditions included illicit drug use (23%), alcohol abuse (22%), and diabetes (18.6%). Three percent of cases traveled outside of the state within 2 weeks prior to diagnosis. Twenty-three percent had history of illicit drug use and 4.2% were food handlers. Table 1 displays the healthcare unit where Hep A serology was ordered. One hundred Twenty-two (73.5%) cases were hospitalized, 44 (26.5%) required ICU admission and seven (4.2%) were readmitted within 30 days. Ninety-two cases (55%) required hepatology evaluation, 25 were evaluated for transplantation and one (0.6%) received a liver transplant. Eighteen (10.8%) patients died, two of which were never hospitalized).Figure 1.Number of cases per month and year.Table 1.Healthcare Unit Where Hep A Serology Was OrderedAdmission114 (68.6%)Office visit31 (18.7)Lab encounter13 (7.8)ED8 (4.8)Total166ConclusionHigh clinical suspicion is crucial during an outbreak. Most of our cases were diagnosed with Hep A during inpatient admission after presenting with abdominal pain and nausea. In an outbreak setting, consider testing for immunity from history of previous exposure or vaccination. High hospital admission, morbidity and mortality were seen.Disclosures All authors: No reported disclosures.

Procedure-Specific Volume and Nurse-to-Patient Ratio: Implications for Failure to Rescue Patients Following Liver Surgery.

The effect of various hospital characteristics on failure to rescue (FTR) after liver surgery has not been well examined. We sought to examine the relationship between hospital characteristics and FTR after liver surgery. The 2013-2015 Medicare-Provider Analysis and Review (MEDPAR) database was used to identify Medicare beneficiaries who underwent liver surgery. The effect of various hospital characteristics on FTR was compared among the highest mortality hospitals (HMH) and the lowest mortality hospitals (LMH). Among 4902 patients undergoing hepatectomy, patients treated at HMH had a higher risk of FTR (OR 3.08, 95% CI 2.03-4.66). Hospital factors such as total number of beds (OR 0.80, 95% 0.56-1.15), operating rooms (OR 0.81, 95% 0.57-1.14), and overall hospital surgical volume (OR 0.88, 95% 0.61-1.25) were not associated with FTR (all p > 0.05). In contrast, hospitals with a greater nurse-to-patient ratio had a markedly lower risk of FTR following a complication (OR 0.70, 95% CI 0.54-0.91; p = 0.007) (Table3). As volume of liver operations and nurse-to-patient ratio decreased the risk of FTR increased (p > 0.001). After risk-adjusting for patient characteristics, both the effect of surgical volume (adjusted OR 0.66, 95% CI 0.46-0.94; p = 0.022) and nurse-to-patient ratio (adjusted OR 0.68, 95% CI 0.51-0.90; p = 0.008) remained strongly associated with FTR. FTR rates varied considerably among hospital performing hepatectomy. Higher procedure-specific hepatectomy volume, as well as a higher nurse-to-patient ratio, accounted for a reduction in the FTR rates. These data highlight the importance of not only procedure volume, but also adequate nurse staffing in reducing FTR and improving mortality following complex procedures such as hepatectomy.

Factors limiting physical activity after acute typeA aortic dissection.

SummaryBackgroundAcute type A aortic dissection (AAD) leads to high hospital mortality rates in the first 48 h after the onset of symptoms. Survivors, however, have good long-term perspectives and enhanced survival especially if regaining moderate amounts of physical activity.MethodsThis study analyzed 131 survivors (from 180 consecutive patients, aged 60 years (rande 30–84 years, 71% male) of acute AAD after a median time of 44 months (range 1–147 months). The hospital mortality was 13.5%. The group of physically active patients was compared with those with a sedentary life style. The qualitative and quantitative data on physical activity were correlated with data from an aortic registry.ResultsOverall 87% of patients reported 1 or more types of physical activities after hospital discharge. The most common types were walking (51%), biking (29%), hiking (15%) and gymnastics (14%). Patients with a sedentary life style underwent longer hypothermic circulatory arrest times (39 min, range 8–167 min vs. 47 min, range 27–79 min, p = 0.009), had a longer intensive care unit (ICU) stay (Pearsons r = −0.226 [between length of ICU stay and hours of physical activity after hospital discharge], p = 0.033) and suffered more frequently from postoperative paresis (33.3% vs. 3.8%, p < 0.001) compared with physically active patients. Binary logistic regression analysis showed female gender (p = 0.026) and higher body mass index (p = 0.019) to be independently associated with a reduced amount of physical activity.ConclusionsThis study demonstrate that the majority of survivors of acute aortic dissection type A regain a physically active life including the practice of a variety of sports. Factors predictive of a sedentary life style can be identified. Female patients deserve special attention.

Relationship between height and outcomes among critically ill adults: a cohort study.

Many diagnostic and therapeutic interventions for critically ill adult patients are not performed according to patient size, but are standardized for an idealized 174-cm man (ideal body weight 70kg). This study aims to determine whether critically ill patients with heights significantly different from a standardized patient have higher hospital mortality or greater resource utilization. Retrospective cohort study of consecutive patients admitted to 210 intensive care units (ICUs) in the United Kingdom participating in the Intensive Care National Audit and Research Centre's Case Mix Programme Database from April 1, 2009, to March 31, 2015. Primary outcome was hospital mortality, adjusted for age, comorbid disease, severity of illness, socioeconomic status and body mass index, using hierarchical modeling to account for clustering by ICU. Data were stratified by sex, and the effect of height was modeled continuously using restricted cubic splines. The cohort included 233,308 men and 184,070 women, with overall hospital mortality of 22.5% and 20.6%, respectively. After adjustment for potential confounders, hospital mortality decreased with increasing height; predicted mortality (holding all other covariates at their mean value) decreased from 24.1 to 17.1% for women and from 29.2 to 21.0% for men across the range of heights. Similar patterns were observed for ICU mortality and several additional secondary outcomes. Short stature may be a risk factor for mortality in critically ill patients. Further work is needed to determine which unmeasured patient characteristics and processes of care may contribute to the increased risk observed.

End-stage renal disease is associated with increased post endoscopic retrograde cholangiopancreatography adverse events in hospitalized patients.

AIMTo determine if end-stage renal disease (ESRD) is a risk factor for post endoscopic retrograde cholangiopancreatography (ERCP) adverse events (AEs).METHODSWe performed a retrospective cohort study using the Nationwide Inpatient Sample (NIS) 2011-2013. We identified adult patients who underwent ERCP using the International Classification of Diseases 9th Revision (ICD-9-CM). Included patients were divided into three groups: ESRD, chronic kidney disease (CKD), and control. The primary outcome was post-ERCP AEs including pancreatitis, bleeding, and perforation determined based on specific ICD-9-CM codes. Secondary outcomes were length of hospital stay, in-hospital mortality, and admission cost. AEs and mortality were compared using multivariate logistic regression analysis.RESULTSThere were 492175 discharges that underwent ERCP during the 3 years. The ESRD and CKD groups contained 7347 and 39403 hospitalizations respectively, whereas the control group had 445424 hospitalizations. Post-ERCP pancreatitis (PEP) was significantly higher in the ESRD group (8.3%) compared to the control group (4.6%) with adjusted odd ratio (aOR) = 1.7 (95%CI: 1.4-2.1, aP < 0.001). ESRD was associated with significantly higher ERCP-related bleeding (5.1%) compared to the control group 1.5% (aOR = 1.86, 95%CI: 1.4-2.4, aP < 0.001). ESRD had increased hospital mortality 7.1% vs 1.15% in the control OR = 6.6 (95%CI: 5.3-8.2, aP < 0.001), longer hospital stay with adjusted mean difference (aMD) = 5.9 d (95%CI: 5.0-6.7 d, aP < 0.001) and higher hospitalization charges aMD = $+82064 (95%CI: $68221-$95906, aP < 0.001).CONCLUSIONESRD is a risk factor for post-ERCP AEs and is associated with higher hospital mortality. Careful selection and close monitoring is warranted to improve outcomes.

Recovery of Kidney Dysfunction After Transcatheter Aortic Valve Implantation (from the Northern New England Cardiovascular Disease Study Group)

Acute Kidney Recovery (AKR) is a potential benefit of transcatheter aortic valve implantation (TAVI). We determined the incidence and predictors of AKR in a multicenter prospective registry of TAVI. After excluding patients on dialysis or who died within 48 hours postprocedure, we reviewed 1,502 consecutive patients underwent TAVI in Northern New England from 2012 to 2017. Patients were categorized into 3 groups based on the change in postprocedure estimated glomerular filtration rate (eGFR): Acute Kidney Injury (AKI, decrease in eGFR >25%), AKR (increase in eGFR >25%) or no change in kidney function on discharge creatinine following TAVI. We then focused in patients with baseline chronic kidney disease (CKD defined as eGFR ≤60 ml/min; n = 755) and developed multivariate predictor models to determine the clinical and procedural variables associated with AKR. For the TAVI cohort (n = 1,502), the overall incidence of AKR was 17.8%. AKR was threefold higher in patients with eGFR ≤60 ml/min as compared to those with eGFR >60 ml/min (26.6% vs 8.9%, p < 0.001). In the CKD population, hospital complications were similar among patients with no change in renal function and AKR; patients with AKI had a higher rate of hospital mortality, pacemaker implantation, length of hospitalization, and transfusions. Using multivariable logistic regression, moderate to severe lung disease, eGFR < 50 ml/min and previous aortic valve surgery were found to be independent predictors of AKR. Patients with diabetes mellitus, baseline anemia, and Society of thoracic surgeons score >6.1 were less likely to develop AKR. In conclusion, AKR occurred in 1 of 4 of all TAVI patients with baseline CKD and was a more frequent phenomena than AKI. Patients with decreased lung function, previous aortic valve surgery and worse baseline renal function were more likely to demonstrate AKR, whereas patients with diabetes mellitus, baseline anemia, and higher Society of thoracic risk scores were less likely to see improvements in renal function after TAVI.

Abstract 341: Urine Output and Blood Urea Nitrogen Predict Mortality After Out-of-Hospital Cardiac Arrest

Introduction: Renal dysfunction, as defined by elevated serum creatinine, is associated with decreased survival among patients resuscitated after out-of-hospital cardiac arrest (OHCA). Less is known about other measures of renal function and outcomes after OHCA. Hypothesis: BUN and urine output will predict mortality after OHCA. Methods: Retrospective single-center cohort study of 276 adult OHCA patients treated with targeted temperature management after OHCA between December 2005 and September 2016. Fluid balance and urine output were recorded for the first 6, 12 and 24 hours. Initial laboratory values were determined from electronic records. Hospital survivors and non-survivors were compared using the Wilcoxon test, and multivariate analysis was performed to determine predictors of hospital death. Results: Mean age was 63±12 years, and 204 (73%) were male; shockable rhythm occurred in 241 (87%). Inpatient death occurred in 111 (40%). Hospital survivors had lower initial BUN (13 vs. 20 mg/dL) and creatinine (1.1 vs. 1.5 mg/dL); all p &lt;.001. Hospital survivors had higher (p &lt;.001) urine output during the first 6 hours (1,091 vs. 559 ml), 12 hours (1,583 vs. 843 ml), and 24 hours (2,215 vs. 1,294 ml). Higher initial BUN (OR 1.12, 95% CI 1.07-1.18) and creatinine (OR 3.036, 95% CI 1.65-5.59) predicted hospital mortality; all p &lt;.001. Urine output during the first 24 hours was associated with hospital mortality (OR 0.57 per each 1 L, 95% CI 0.45-0.72, p &lt;.001; AUROC 0.73, optimal cut-off 1 L). Patients with 24-hour urine output &lt;1 L were at increased risk of hospital death (66.3% vs. 26.0%, unadjusted OR 5.61, 95% CI 3.27-9.63, p &lt;.001). Initial BUN (adjusted OR 1.09, 95% CI 1.01-1.16, p=.02) and urine output during the first 24 hours (adjusted OR 0.71 per each 1 L; 95% CI 0.52-0.97, p=.03) remained predictive of hospital mortality after adjustment for patient characteristics and illness severity. Conclusions: Lower 24-hour urine output and higher initial BUN were associated with higher hospital mortality among patients resuscitated from OHCA, even after adjustment for illness severity. Serum creatinine was not a significant predictor of mortality. This emphasizes the importance of low urine output as a prognostic marker and therapeutic target after OHCA.

DELAYED ADMISSION TO ICU OVER 6 HOURS WAS ASSOCIATED WITH HIGHER HOSPITAL MORTALITY IN PATIENTS WITH SEPSIS

DELAYED ADMISSION TO ICU OVER 6 HOURS WAS ASSOCIATED WITH HIGHER HOSPITAL MORTALITY IN PATIENTS WITH SEPSIS

Clinical features and outcome of patients with acute respiratory failure revealing anti-synthetase or anti-MDA-5 dermato-pulmonary syndrome: a French multicenter retrospective study

BackgroundAnti-synthetase (AS) and dermato-pulmonary associated with anti-MDA-5 antibodies (aMDA-5) syndromes are near one of the other autoimmune inflammatory myopathies potentially responsible for severe acute interstitial lung disease. We undertook a 13-year retrospective multicenter study in 35 French ICUs in order to describe the clinical presentation and the outcome of patients admitted to the ICU for acute respiratory failure (ARF) revealing AS or aMDA-5 syndromes.ResultsFrom 2005 to 2017, 47 patients (23 males; median age 60 [1st–3rd quartiles 52–69] years, no comorbidity 85%) were admitted to the ICU for ARF revealing AS (n = 28, 60%) or aMDA-5 (n = 19, 40%) syndromes. Muscular, articular and cutaneous manifestations occurred in 11 patients (23%), 14 (30%) and 20 (43%) patients, respectively. Seventeen of them (36%) had no extra-pulmonary manifestations. C-reactive protein was increased (139 [40–208] mg/L), whereas procalcitonine was not (0.30 [0.12–0.56] ng/mL). Proportion of patients with creatine kinase ≥ 2N was 20% (n = 9/47). Forty-two patients (89%) had ARDS, which was severe in 86%, with a rate of 17% (n = 8/47) of extra-corporeal membrane oxygenation requirement. Proportion of patients who received corticosteroids, cyclophosphamide, rituximab, intravenous immunoglobulins and plasma exchange were 100%, 72%, 15%, 21% and 17%, respectively. ICU and hospital mortality rates were 45% (n = 21/47) and 51% (n = 24/47), respectively. Patients with aMDA-5 dermato-pulmonary syndrome had a higher hospital mortality than those with AS syndrome (n = 16/19, 84% vs. n = 8/28, 29%; p = 0.001).ConclusionsIntensivists should consider inflammatory myopathies as a cause of ARF of unknown origin. Extra-pulmonary manifestations are commonly lacking. Mortality is high, especially in aMDA-5 dermato-pulmonary syndrome.

Comparison of Mortality Risk Prediction Among Patients ≥70 Versus

Older adults account for an increasing number of cardiac intensive care unit (CICU) admissions. This study sought to determine the predictive value of illness severity scores for mortality in CICU patients ≥70 years of age. Adult patients admitted to the CICU from 2007 to 2015 at one tertiary care hospital were reviewed. Severity of illness scores were calculated on the first CICU day. Area under the receiver-operator characteristic curve (AUROC) values were used to assess discrimination for hospital mortality in patients ≥70 versus <70 years of age. We included 10,004 patients with a mean age of 67.4 ± 15.2 years (37.4% female); 4,771 patients (47.7%) were ≥70 years of age. Patients ≥70 years of age had greater illness severity and more extensive co-morbidities compared with patients <70 years of age. Patients ≥70 years of age had higher hospital mortality (11.6% vs 6.8%, odds ratio 1.80, 95% confidence interval 1.57 to 2.07, p <0.001), with a progressive increase in mortality as a function of decade. Severity of illness scores had lower AUROC values for hospital mortality in patients ≥70 years of age compared with patients <70 years of age (all p <0.05 by DeLong test). The Braden skin score on CICU admission predicted hospital mortality with an AUROC value only slightly lower than these scores. Increasing age decade was associated with decreased postdischarge survival by Kaplan-Meier analysis (p <0.001 by log-rank). In conclusion, contemporary CICU patients ≥70 years of age have greater illness severity, more co-morbidities and higher mortality than patients <70 years of age, yet severity of illness scores are less accurate for predicting mortality in CICU patients ≥70 years of age, emphasizing the need for more effective risk-stratification methods in this population.

Abstract 230: Repair of Aortic Coarctation in Neonates Less than Two Kilogram

Objective: Though a significant number of low birth weight and premature neonates are born with aortic coarctation, waiting for the child to grow before intervening rarely permits significant useful weight gain and puts the child at risk of interim complications. Previous studies of early operation on these patients have shown a high hospital mortality up to 25% (25 out of 100) and 30% (30 out of 100) recurrence in one year. We reviewed our data to ascertain whether modern approaches allow better outcomes for these children. Methods: All patients weighing less than 2 kg with isolated coarctation between August 2008 and November 2015 were studied by retrospective chart review to ensure greater than 24 months follow-up. Eleven patients underwent extended end-to side surgical repair. In-hospital and medium term follow-up data were collected. Data are expressed as median (range). Results: Weight at time of surgery was 1.8kg (1.6-1.9). There were no deaths, in-hospital or during follow-up. One patient developed postoperative chylothorax. In-hospital stay was 18 days (4-47). At follow-up of 68 months (28-115) echocardiographic velocity across the repair was 1.6m/sec (1.4-4.5). One patient with William’s syndrome had evidence of recoarctation and required balloon coarctoplasty followed by stenting. This patient had grossly abnormal vessels at the time of initial surgery with aortic wall thickness greater than 3mm. Conclusions: Neonates below 2kg can undergo coarctation repair safely with low incidence of recurrence. Waiting for growth in this cohort of patients cannot therefore be justified.

Optimisation of nutritional screening tool CIPA: are two parameters of protein really necessary?

the preliminary nutritional screening tool CIPA (food intake, proteins, anthropometry) is positive when it fulfills one of the following: control food intake (CI) 48-72 h < 50%, albumin < 3 g/dl, total protein < 5 g/dl, body mass index (BMI) < 18,5 kg/m2 or mid-upper arm circumference (MUAC) ≤ 22,5 cm. The use of two protein parameters increases costs and difficulty; one of them can be suppressed without affecting validity. to evaluate the effectiveness of screening CIPA after exclusion of total protein. prospective study of hospitalized patients; prevalence or risk of malnutrition was evaluated through CIPA and Subjective Global Assessment (SGA). Hospital malnutrition according to complete CIPA screening (with total proteins and albumin, [CIPAc] and without total proteins [CIPAw/p]) and concordance between both methods were analyzed, as well as the association of the positive screening result with clinical outcomes. three hundred and forty-three patients were analyzed. The prevalence or risk of malnutrition identified by complete CIPA (c) was 38.19% (33.02-43.36); by CIPA without protein (w/p), 37.32% (32.17-42.46); and SGA was 29.15% (24.32-33.99). Kappa index: 0.981 between both CIPAs, p < 0.001. Both CIPA and SGA detect patients with higher mortality in hospital and one month after discharge. Early readmission was higher in positive CIPA, statistical significantly in CIPAw/p (screening with positive results 21.88% vs screening with negative results 13.49%, p = 0.044), SGA 20.01% vs 15.23%, p = 0.28. Length of stay was higher in patients with positive screening in CIPAc, CIPAw/p and SGA. CIPAw/p is equally or more effective than the previously validated full CIPA; therefore, it could replace the latter saving costs. The prevalence of malnutrition is high in both variants and they are able to predict which patient has worse clinical prognosis.

Non-invasive positive pressure ventilation in lung transplant recipients with acute respiratory failure: Beyond the perioperative period

PurposeThe purpose of this study is to evaluate outcomes in MICU lung transplant recipients with acute respiratory failure treated with non-invasive positive pressure ventilation (NPPV) and identify factors associated with NPPV failure (need for intubation). MethodsRetrospective chart review of all lung transplant recipients who were admitted with acute respiratory failure to the MICU from January 2009–August 2016 was completed. Logistic regression analysis was performed to determine which factors were independently associated with NPPV failure. ResultsOf 156 patients included in the study, 125 (80.1%) were tried on NPPV. Sixty-eight (54.4%) were managed successfully with NPPV with a hospital survival rate of 94.1%. Subjects who failed NPPV had higher hospital mortality, similar to those intubated from the outset (15 [48.3%]; 22 [38.6%], p = .37). In multivariate analyses, APACHE III scores >78 (9.717 [3.346, 28.22]) and PaO2/FiO2 ≤ 151 (4.54 [1.72, 11.99]) were associated with greater likelihood of NPPV failure. There was no difference in NPPV failure based on the presence of BOS. In patients with high severity of illness, there was no difference in mortality between initial IMV and NPPV failure when stratified on the basis of hypoxemia (PaO2/FiO2 > 151, p-value 0.34; PaO2/FiO2 ≤ 151, p-value 0.99). ConclusionsNPPV is a viable option for lung transplant recipients with acute respiratory failure. Extreme caution should be exercised when used in patients with high severity of illness (APACHE III >78) and/or severe hypoxemia (PaO2/FiO2 ≤ 151).

The relationship of hospital market concentration, costs, and quality for major surgical procedures

BackgroundOur objective was to determine the association between indicators of surgical quality – incidence of major complications and failure-to-rescue – and hospital market concentration in light of differences in costs of care. MethodsPatients undergoing coronary artery bypass graft (CABG), colon resection, pancreatic resection, or liver resection in the 2008–2011 Nationwide Inpatient Sample were identified. The effect of hospital market concentration on major complications, failure-to-rescue, and inpatient costs was estimated at the lowest and highest mortality hospitals using multivariable regression techniques. ResultsA weighted total of 527,459 patients were identified. Higher market concentration was associated with between 4% and 6% increased odds of failure-to-rescue across all four procedures. Across procedures, more concentrated markets had decreased inpatient costs (average marginal effect ranging from -$3064 (95% CI: -$5812 - -$316) for CABG to -$4876 (-$7773 - -$1980) for liver resection. ConclusionIn less competitive (more concentrated) hospital markets, higher overall risk of failure-to-rescue after complications was accompanied by lower inpatient costs, on average. These data suggest that market controls may be leveraged to influence surgical quality and costs.

Intestinal Mucosal Barrier Disruption and Microfold Cells Impairment were Required for Invasive Fungal Infection after Living Donor Liver Transplantation.

Introduction and Objective Post-transplant invasive fungal infection (IFI) is a critical problem with high mortality for patients receiving living donor liver transplantation (LDLT), however, the underlying mechanism stays unclear. Hence, identifying the risk factors and understanding the mechanisms of IFIs are essential to improve outcome of LDLT patients. Materials and Methods Clinical characteristics of patients diagnosed with opportunistic fungal infections compared with non-infected patients after living donor liver transplantation were analyzed in a retrospective cohort from 1994 to 2017. The correlation between marginal graft injury and incidence of IFIs was investigated by 1, 3-β-D-Glucan assay in rat orthotopic liver transplantation models using marginal grafts. And intestinal mucosal structural integrity as well as microfold cells of intestinal Peyer’s patches were also investigated in animal models. Results and Discussion 44 out of 584 patients were diagnosed with opportunistic fungal infections after LDLT, and they were presented with higher hospital mortality (15% vs 2.8%, p=0.002) as well as long term graft failure compared with patients without infections (Fig. 1A, HR=2.394, p<0.001). In addition, prolonged cold ischemic time and warm ischemic time were identified associated with post-transplant opportunistic infection occurrence (Fig. 1BC). In rat orthotopic liver transplantation models, incidence of IFIs and median serum β-D-Glucan value were higher in small-for-size graft, as well as in graft with prolonged ischemic time compared to whole-size graft and sham operation groups (Fig. 2AB). Furthermore, disruption of intestinal villi structure and loss of tight junctions were found associated with more severe liver graft injury (Fig. 2C). And damage to tight junctions of intestinal follicle associated epithelium covering Peyer’s patches as well as deletion of functional microfold cells (M cells) were also found in liver graft after transplantation, whilst the situation was even worse after ischemic time was extended (Fig. 2D). Conclusion Small-for-size and ischemic injury of liver graft rendered LDLT patients more vulnerable to gut derived invasive fungal infections by disrupting intestinal mucosal barrier and impairing intestinal innate immunity.

Rapid urine-based screening for tuberculosis in HIV-positive patients admitted to hospital in Africa (STAMP): a pragmatic, multicentre, parallel-group, double-blind, randomised controlled trial

SummaryBackgroundCurrent diagnostics for HIV-associated tuberculosis are suboptimal, with missed diagnoses contributing to high hospital mortality and approximately 374 000 annual HIV-positive deaths globally. Urine-based assays have a good diagnostic yield; therefore, we aimed to assess whether urine-based screening in HIV-positive inpatients for tuberculosis improved outcomes.MethodsWe did a pragmatic, multicentre, double-blind, randomised controlled trial in two hospitals in Malawi and South Africa. We included HIV-positive medical inpatients aged 18 years or more who were not taking tuberculosis treatment. We randomly assigned patients (1:1), using a computer-generated list of random block size stratified by site, to either the standard-of-care or the intervention screening group, irrespective of symptoms or clinical presentation. Attending clinicians made decisions about care; and patients, clinicians, and the study team were masked to the group allocation. In both groups, sputum was tested using the Xpert MTB/RIF assay (Xpert; Cepheid, Sunnyvale, CA, USA). In the standard-of-care group, urine samples were not tested for tuberculosis. In the intervention group, urine was tested with the Alere Determine TB-LAM Ag (TB-LAM; Alere, Waltham, MA, USA), and Xpert assays. The primary outcome was all-cause 56-day mortality. Subgroup analyses for the primary outcome were prespecified based on baseline CD4 count, haemoglobin, clinical suspicion for tuberculosis; and by study site and calendar time. We used an intention-to-treat principle for our analyses. This trial is registered with the ISRCTN registry, number ISRCTN71603869.FindingsBetween Oct 26, 2015, and Sept 19, 2017, we screened 4788 HIV-positive adults, of which 2600 (54%) were randomly assigned to the study groups (n=1300 for each group). 13 patients were excluded after randomisation from analysis in each group, leaving 2574 in the final intention-to-treat analysis (n=1287 in each group). At admission, 1861 patients were taking antiretroviral therapy and median CD4 count was 227 cells per μL (IQR 79–436). Mortality at 56 days was reported for 272 (21%) of 1287 patients in the standard-of-care group and 235 (18%) of 1287 in the intervention group (adjusted risk reduction [aRD] −2·8%, 95% CI −5·8 to 0·3; p=0·074). In three of the 12 prespecified, but underpowered subgroups, mortality was lower in the intervention group than in the standard-of-care group for CD4 counts less than 100 cells per μL (aRD −7·1%, 95% CI −13·7 to −0·4; p=0.036), severe anaemia (−9·0%, −16·6 to −1·3; p=0·021), and patients with clinically suspected tuberculosis (−5·7%, −10·9 to −0·5; p=0·033); with no difference by site or calendar period. Adverse events were similar in both groups.InterpretationUrine-based tuberculosis screening did not reduce overall mortality in all HIV-positive inpatients, but might benefit some high-risk subgroups. Implementation could contribute towards global targets to reduce tuberculosis mortality.FundingJoint Global Health Trials Scheme of the Medical Research Council, the UK Department for International Development, and the Wellcome Trust.

Mortality and long-term dialysis requirement among elderly continuous renal replacement therapy patients in a tertiary referral intensive care unit.

Elderly patients are frequently considered poor candidates for continuous renal replacement therapy in intensive care units, but with little evidence base. We gathered data regarding patients requiring continuous renal replacement therapy at our institution's intensive care unit during 2012-2014, and compared outcomes between patients of 75 years or older, and younger patients. Older patients had similar intensive care unit mortality to younger patients (41.5% vs. 36.1%, p = 0.21), but higher hospital mortality (54.2% vs. 44.0%, p = 0.02), and one-year mortality (63.6% vs. 50.6%, p = 0.005). There were no significant differences in dialysis-dependence rates between older and younger patients at intensive care unit discharge (31.9% vs. 35.8%, p = 0.50), and hospital discharge (18.5% vs. 24.2%, 0.32). Rates of new dialysis-dependence between older and younger patients at time of hospital discharge were similar (10.2% vs. 6.0%, p = 0.20). Intensivists should not withhold continuous renal replacement therapy based on age alone. Other factors should be considered in triage of patients for intensive care unit and continuous renal replacement therapy.