Higher In-hospital Case Fatality Research Articles

Optimal Timing for Resumption of Anticoagulation After Intracranial Hemorrhage in Patients With Mechanical Heart Valves.

Anticoagulation in patients with intracranial hemorrhage (ICH) and mechanical heart valves is often held for risk of ICH expansion; however, there exists a competing risk of acute ischemic stroke (AIS). Optimal timing to resume anticoagulation remains uncertain. We retrospectively studied patients with ICH and mechanical heart valves from 2000 to 2018. The primary outcome was a composite end point of symptomatic hematoma expansion or new ICH, AIS, and intracardiac thrombus up to 30 days post-ICH. The exposure was timing of reinitiation of anticoagulation classified as early (resumed up to 7 days after ICH), late (≥7 and up to 30 days after ICH), and never if not resumed or resumed after 30 days post-ICH. We included 184 patients with ICH and mechanical heart valves (65 anticoagulated early, 100 late, 19 not resumed by day 30 post-ICH). Twelve patients had AIS, 16 new ICH, and 6 intracardiac thromboses. The mean time from ICH to anticoagulation was 12.7 days. Composite outcomes occurred in 12 patients resumed early (18.5%), 14 resumed late (14.0%), and 4 never resumed (21.1%). There was no increased hazard of the composite outcome (hazard ratio [HR], 1.1 [95% CI, 0.2-6.0]), AIS, or worsening or new ICH among patients resumed early versus late. There was no difference in the composite among patients never resumed versus resumed. Patients who never resumed anticoagulation had significantly more severe ICH (median Glasgow Coma Scale: 10.6, 13.9, and 13.9 among those who resumed never, early, and late, respectively; P=0.0001), higher in-hospital mortality (56.5%, 0%, and 0%, respectively; P<0.0001), and an elevated 30-day AIS risk (HR, 15.9 [95% CI, 1.9-129.7], P=0.0098). In this study of patients with ICH and mechanical heart valves, there was no difference in 30-day thrombotic and hemorrhagic brain-related outcomes when anticoagulation was resumed within 7 versus 7 to 30 days after ICH. Withholding anticoagulation >30 days was associated with severe baseline ICH, higher in-hospital case fatality, and elevated AIS risk.

Clinical usefulness of Edinburgh CT criteria in patients with lobar intracerebral hemorrhage

Identifying the cause of intracerebral hemorrhage (ICH) is relevant to optimize its management. We aimed to assess the applicability and utility of the Edinburgh CT criteria for cerebral amyloid angiopathy (CAA) in an unselected cohort of hospitalized patients. We retrospectively applied the Edinburgh criteria to the first available brain CTs of patients hospitalized for a first-ever lobar ICH in the district of L'Aquila from 2011 to 2017. ICH characteristics and outcomes were compared according to the presence of the Edinburgh CT criteria, including associated subarachnoid hemorrhage (aSAH) and finger-like projections (FLPs). The outcome of ICH in-hospital mortality was assessed with multivariate logistic regression analysis. We adopted the Edinburgh criteria, age, NIHSS and Glasgow Coma Scale scores, systolic blood pressure, antiplatelet treatment, ICH volume, and intraventricular extension on admission as covariates. Of 178 patients with lobar ICH, 52 (29.2%) had aSAH+FLPs, 60 (33.7%) aSAH only, 1 (0.6%) FLPs, and 65 (36.5%) none. Patients with aSAH+FLPs were older (79.0 ± 9.2 years) than those with only one criterion or none (74.0 ± 15.3 and 72.2 ± 13.8 years, respectively; P = 0.020). Patients with aSAH+FLPs also had more severe ICH at onset, higher in-hospital case-fatality (log rank test P = 0.003) and higher mRS scores at discharge (P < 0.001) as compared to those fulfilling one or none of the Edinburgh criteria. Low Glasgow Coma Scale score was the only factor independently associated to in-hospital case-fatality (odds ratio per point increase 0.51; 95% confidence interval, 0.32-0.91; P = 0.021). Our data suggest the applicability of the Edinburgh CT criteria in a hospital setting. The presence of those criteria reflects ICH clinical severity. Applying the Edinburgh CT criteria might help refining the diagnosis and improving the management of patients with lobar ICH.

Abstract 13615: Weekdays versus Weekends: Outcomes of Cardiogenic Shock in the Setting of Acute Myocardial Infarction

Introduction: Acute myocardial infarction (AMI) accounts for the majority of patients with cardiogenic shock (CS). The high case fatality justifies the need for an optimal hospital care system that is available 24 hours, 7 days a week. It is unclear whether the “weekend effect” has an impact on the outcome of CS associated with AMI. Hypothesis: Weekend CS-AMI admissions have a higher in-hospital case fatality than weekday admissions. Methods: A total of 22,632 patients with ST segment elevation AMI complicated with CS between the years 1986 to 2015 were identified in the Myocardial Infarction Data Acquisition System, a statewide database of all admissions to non-federal hospitals in NJ. Trend analysis was performed using a logistic regression model with admission year as a continuous variable. Case fatality rates between weekend vs weekday admissions were compared using the Cochran–Mantel–Haenszel test, stratifying by admission year. Results: From 1986 to 2015 there was a steady decline in the rates of in-hospital case fatality of AMI complicated with CS, from 79% to 33% (p&lt; 0.001). The overall CS death rate for admissions on weekends was 61% and for weekdays 59% (Common-Odds Ratio = 1.10 (95% CI (1.02-1.17) p= 0.006) (figure). The use of mechanical circulatory support (MCS) was lower on weekends (p&lt;0.001) and was associated with a higher case fatality rate 48 hours from admission (p&lt;0.001). Conclusion: Deaths related to CS complicating AMI have steadily declined and this applies for both, patients admitted on weekends and weekdays. There was a higher hospital death rate in patients admitted over weekends compared to weekdays. The underutilization of MCS devices during weekends likely contributes to the difference in case fatality between weekends and weekdays.

Brain Injury as a Risk Factor for Fever Upon Admission to the Intensive Care Unit and Association With In-Hospital Case Fatality

To test the hypothesis that fever was more frequent in critically ill patients with brain injury when compared to nonneurological patients and to study its effect on in-hospital case fatality. Retrospective matched cohort study utilizing a single-center prospectively compiled registry. Critically ill neurological patients ≥18 years and consecutively admitted to the intensive care unit (ICU) with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and traumatic brain injury (TBI) were selected. Patients were matched by sex, age, and Acute Physiology and Chronic Health Evaluation II (APACHE-II) to a cohort of nonneurological patients. Fever was defined as any temperature ≥37.5°C within the first 24 hours upon admission to the ICU. The primary outcome measure was in-hospital case fatality. Mean age among neurological patients was 65.6 ± 15 years, 46% were men, and median APACHE-II was 15 (interquartile range 11-20). There were 18% AIS, 27% ICH, and 6% TBI. More neurological patients experienced fever than nonneurological patients (59% vs 47%, P = .007). The mean hospital length of stay was higher for nonneurological patients (18 ± 20 vs 14 ± 15 days, P = .007), and more neurological patients were dead at hospital discharge (29% vs 20%, P < .0001). After risk factor adjustment, diagnosis (neurological vs nonneurological), and the probability of being exposed to fever (propensity score), the following variables were associated with higher in-hospital case fatality: APACHE-II, neurological diagnosis, mean arterial pressure, cardiovascular and respiratory dysfunction in ICU, and fever (odds ratio 1.9, 95% confidence interval 1.04-3.6, P = .04). These data suggest that fever is a frequent occurrence after brain injury, and that it is independently associated with in-hospital case fatality.

Significance of arterial hyperoxia and relationship with case fatality in traumatic brain injury: a multicentre cohort study

ObjectiveIn this retrospective multi-centre cohort study, we tested the hypothesis that hyperoxia was not associated with higher in-hospital case fatality in ventilated traumatic brain injury (TBI) patients admitted to the...

Prevalence and Characteristics Associated with Malnutrition at Hospitalization among Patients with Acquired Immunodeficiency Syndrome in Brazil

BackgroundBrazil’s National STD/AIDS Program is considered a model of success worldwide. However, AIDS-associated malnutrition continues in subgroups of Brazilian patients despite access to free highly active antiretroviral therapy (HAART). We aimed to identify the prevalence of malnutrition and associated factors among patients hospitalized with AIDS.MethodsWe conducted a cross-sectional nutritional assessment among 127 adults hospitalized with AIDS in Brazil’s third largest city. Using anthropometric measurements, we determined the prevalence of malnutrition (body mass index <18.5 kg/m2) at hospitalization. Prevalence ratios of malnutrition by demographic, socioeconomic, and clinical conditions were estimated using log-binomial regression.ResultsOne-third of participants were first informed of their HIV disease during the current hospitalization and recent treatment interruption was common (71%) among those on HAART. Forty-three percent were malnourished and 35% had severe weight loss at admission. Patient characteristics independently associated with malnutrition were older age (2% increased prevalence for each year; 95% confidence interval [CI] 0–4%) and very low daily per capita household income. Living on <USD 2.00, USD 2.00–4.99 or USD 5.00–9.99 increased the prevalence of malnutrition by 2.01 (95% CI 1.06–3.81), 1.75 (95% CI 0.92–3.35) and 1.42 (95% CI 0.76–2.65) times, respectively, compared to ≥USD 10.00 per day. Chronic diarrhea was marginally associated with malnutrition (RR 1.42; 95% CI 0.99–2.04). Overall, 16% of the patients died during hospitalization. We observed a trend toward higher in-hospital case fatality among malnourished patients (22% vs. 12% for patients with and without malnutrition, respectively; chi square P = 0.14).ConclusionsUnacceptably high rates of malnutrition persist in Brazilians hospitalized with AIDS and our results reinforce the importance of nutritional evaluations in these patients. Improved early testing and treatment adherence strategies may continue to help reduce AIDS-related morbidity and mortality in Brazil, yet novel interventions to disrupt the cycle of poverty, HIV, and malnutrition are also urgently needed.

183 Hypothermia After Out-of-Hospital Cardiac Arrest: Perspectives From Hamilton, Ontario

age groups, and more female than male hospitalizations after 80 years of age. The average LOS was 15.3 days over the three years, with females staying longer than males (16.5 vs. 14.1 days). Longer LOS was seen in PEI (22.3 days), NS (21.3 days), and MB (19.9 days); shorter LOS was seen in NB (13.5 days), ON (13.9 days), and SK (14.6 days). The average rate of discharge home was 41.4% over the three years (males: 45.6%; females: 36.8%). Higher rates of discharge home were seen in PEI (57.2%), NT (50.3%), and BC (48.5%); lower rates were seen in NL (22.8%), ON (33.7%), and SK (38.8%). The average in-hospital case-fatality rate was 15.5% (males: 13.6%; females: 17.5%). Higher rates of case-fatality were in NL (18.2%) and NS (17.8%); lower rates were in AB (13.2%), PEI (13.8%), and NB (13.9%). Further, the overall rate for transfer to another health care facility was 43.2% (males: 40.8%; females: 45.7%). In comparison, hospitalized cardiovascular diseases (I00-I99) over the three years had a shorter LOS (8.6 days, males: 7.9; females: 9.7), and a higher discharge home rate (61.6%, males: 64.3%; females: 57.6%), a lower in-hospital case fatality rate (6.6%, males: 5.7%; females: 7.7%). CONCLUSION: This study provides an overall picture of hospitalized stroke across Canada. In general, stroke hospitalizations have a longer hospital stay, higher in-hospital case fatality, and lower rate of discharge home, which increases the burden per case on the Canadian health care system. Further, characteristics of stroke hospitalizations varied across Canadian provinces and territories. Significant differences in stroke management in Canada need to be addressed.

182 The Burden of Hospitalized Stroke in Canada

Hospitalizations and mortality for stroke have been declining. However, stroke remains a leading cause of death and disability for Canadians. This study provides an overall picture of the burden of hospitalized stroke in Canada. Acute care hospital separations from the most recent three fiscal years (2007/08 to 2009/10) with a primary diagnosis of stroke (ICD-10-CA: I60-I69) were identified. The number of stroke hospitalizations, average length of stay (LOS), and discharge dispositions, by age, gender, and province/territory were calculated using IBM/Cognos Data Cubes. The number of stroke hospitalizations remained steady over the three years. The proportion by gender was similar, with males accounting for 51.7% of stroke hospitalizations in 2007/08, 52.3% in 2008/09, and 52.2% in 2009/10. There were more male than female stroke hospitalizations in younger age groups, and more female than male hospitalizations after 80 years of age. The average LOS was 15.3 days over the three years, with females staying longer than males (16.5 vs. 14.1 days). Longer LOS was seen in PEI (22.3 days), NS (21.3 days), and MB (19.9 days); shorter LOS was seen in NB (13.5 days), ON (13.9 days), and SK (14.6 days). The average rate of discharge home was 41.4% over the three years (males: 45.6%; females: 36.8%). Higher rates of discharge home were seen in PEI (57.2%), NT (50.3%), and BC (48.5%); lower rates were seen in NL (22.8%), ON (33.7%), and SK (38.8%). The average in-hospital case-fatality rate was 15.5% (males: 13.6%; females: 17.5%). Higher rates of case-fatality were in NL (18.2%) and NS (17.8%); lower rates were in AB (13.2%), PEI (13.8%), and NB (13.9%). Further, the overall rate for transfer to another health care facility was 43.2% (males: 40.8%; females: 45.7%). In comparison, hospitalized cardiovascular diseases (I00-I99) over the three years had a shorter LOS (8.6 days, males: 7.9; females: 9.7), and a higher discharge home rate (61.6%, males: 64.3%; females: 57.6%), a lower in-hospital case fatality rate (6.6%, males: 5.7%; females: 7.7%). This study provides an overall picture of hospitalized stroke across Canada. In general, stroke hospitalizations have a longer hospital stay, higher in-hospital case fatality, and lower rate of discharge home, which increases the burden per case on the Canadian health care system. Further, characteristics of stroke hospitalizations varied across Canadian provinces and territories. Significant differences in stroke management in Canada need to be addressed.

Mortalidad poblacional por infarto agudo de miocardio. Estudio IBERICA

The magnitude of the problem of myocardial infarction (MI) is better understood by assessing the population case-fatality than by analyzing only the number of patients attending hospitals. Our data come from the IBERICA Study (Investigation, Specific Search and Registry of Acute Myocardial Ischemic Syndrome). Twenty eight-day MI population case-fatality is described in the population aged 25 to 74 years during 1997 and 1998 in the following Spanish autonomous communities: Castilla-La Mancha (Toledo and Albacete), Catalonia (Girona), Valencia Community (Valencia), Balearic Islands (Majorca), Murcia, Navarra and Basque Country. The relationship between case-fatality and other variables such as sex, age and geographic area is also analyzed. A total of 10,660 MI cases were registered, 4,106 of whom died within the period of 28 days following the onset of symptoms (38.5%; CI 95%, 37.6-39.4%). The overall case-fatality was 37.0% (CI 95%, 35.9-38.0%) in men and 44.3% (CI 95%, 42.3-46.4%) in women. Death occurred out of hospitals in 2,869 (69.9%) cases. An increased case-fatality in women was associated with a higher in-hospital case-fatality (45% higher than men). The proportion of patients who died before reaching a hospital was similar in both genders. Classical symptoms of MI were more common among men than women (82.7% vs. 77.6%, p < 0,001). The interval between symptoms' onset and hospitalization was 30 minute longer among hospitalized women as compared with men (p < 0,001). Population MI case-fatality is high in the seven Spanish autonomous communities studied. Approximately 2 out of 3 deaths occur without patients being able to reach a hospital. These results emphasize the importance of primary and secondary prevention measures and the necessity to design ready-access systems to defibrillation and resuscitation manoeuvres for patients with cardiopulmonary arrest.