Higher Risk Of In-hospital Death Research Articles

A novel Vascular Leak Index identifies sepsis patients with a higher risk for in-hospital death and fluid accumulation

PurposeSepsis is a leading cause of morbidity and mortality worldwide and is characterized by vascular leak. Treatment for sepsis, specifically intravenous fluids, may worsen deterioration in the context of vascular leak. We therefore sought to quantify vascular leak in sepsis patients to guide fluid resuscitation.MethodsWe performed a retrospective cohort study of sepsis patients in four ICU databases in North America, Europe, and Asia. We developed an intuitive vascular leak index (VLI) and explored the relationship between VLI and in-hospital death and fluid balance using generalized additive models (GAM).ResultsUsing a GAM, we found that increased VLI is associated with an increased risk of in-hospital death. Patients with a VLI in the highest quartile (Q4), across the four datasets, had a 1.61–2.31 times increased odds of dying in the hospital compared to patients with a VLI in the lowest quartile (Q1). VLI Q2 and Q3 were also associated with increased odds of dying. The relationship between VLI, treated as a continuous variable, and in-hospital death and fluid balance was statistically significant in the three datasets with large sample sizes. Specifically, we observed that as VLI increased, there was increase in the risk for in-hospital death and 36–84 h fluid balance.ConclusionsOur VLI identifies groups of patients who may be at higher risk for in-hospital death or for fluid accumulation. This relationship persisted in models developed to control for severity of illness and chronic comorbidities.

Early Prediction Model of Acute Aortic Syndrome Mortality in Emergency Departments.

PurposeAcute aortic syndrome is a constellation of life-threatening medical conditions for which rapid assessment and targeted intervention are important for the prognosis of patients who are at high risk of in-hospital death. The current study aims to develop and externally validate an early prediction mortality model that can be used to identify high-risk patients with acute aortic syndrome in the emergency department.Patients and MethodsThis retrospective multi-center observational study enrolled 1088 patients with acute aortic syndrome admitted to the emergency departments of two hospitals in China between January 2017 and March 2021 for model development. A total of 210 patients with acute aortic syndrome admitted to the emergency departments of Peking University Third Hospital between January 2007 and December 2021 was enrolled for model validation. Demographics and clinical factors were collected at the time of emergency department admission. The predictive variables were determined by referring to the results of previous studies and the baseline analysis of this study. The study’s endpoint was in-hospital death. To assess internal validity, we used a fivefold cross-validation method. Model performance was validated internally and externally by evaluating model discrimination using the area under the receiver-operating characteristic curve (AUC). A nomogram was developed based on the binary regression results.ResultsIn the development cohort, 1088 patients with acute aortic syndromes were included, and 88 (8.1%) patients died during hospitalization. In the validation cohort, 210 patients were included, and 20 (9.5%) patients died during hospitalization. The final model included the following variables: digestive system symptoms (OR=2.25; P=0.024), any pulse deficit (OR=7.78; P<0.001), creatinine (µmol/L)(OR=1.00; P=0.018), lesion extension to iliac vessels (OR=4.49; P<0.001), pericardial effusion (OR=2.67; P=0.008), and Stanford type A (OR=10.46; P<0.001). The model’s AUC was 0.838 (95% CI 0.784–0.892) in the development cohort and 0.821 (95% CI 0.750–0.891) in the validation cohort, and the Hosmer–Lemeshow test showed p=0.597. The fivefold cross-validation demonstrated a mean accuracy of 0.94, a mean precision of 0.67, and a mean recall of 0.13.ConclusionThis risk prediction tool uses simple variables to provide robust prediction of the risk of in-hospital death from acute aortic syndrome and validated well in an independent cohort. The tool can help emergency clinicians quickly identify high-risk acute aortic syndrome patients, although further studies are needed for verifying the prospective data and the results of our study.

Changes in ischemic stroke presentations, management and outcomes during the first year of the COVID-19 pandemic in Alberta: a population study.

Background:Pandemics may promote hospital avoidance, and added precautions may exacerbate treatment delays for medical emergencies such as stroke. We sought to evaluate ischemic stroke presentations, management and outcomes during the first year of the COVID-19 pandemic.Methods:We conducted a population-based study, using linked administrative and stroke registry data from Alberta to identify all patients presenting with stroke before the pandemic (Jan. 1, 2016 to Feb. 27, 2020) and in 5 periods over the first pandemic year (Feb. 28, 2020 to Mar. 31, 2021), reflecting changes in case numbers and restrictions. We evaluated changes in hospital admissions, emergency department presentations, thrombolysis, endovascular therapy, workflow times and outcomes.Results:The study included 19 531 patients in the prepandemic period and 4900 patients across the 5 pandemic periods. Presentations for ischemic stroke dropped in the first pandemic wave (weekly adjusted incidence rate ratio [IRR] 0.54, 95% confidence interval [CI] 0.50 to 0.59). Population-level incidence of thrombolysis (adjusted IRR 0.50, 95% CI 0.41 to 0.62) and endovascular therapy (adjusted IRR 0.63, 95% CI 0.47 to 0.84) also decreased during the first wave, but proportions of patients presenting with stroke who received acute therapies did not decline. Rates of patients presenting with stroke did not return to prepandemic levels, even during a lull in COVID-19 cases between the first 2 waves of the pandemic, and fell further in subsequent waves. In-hospital delays in thrombolysis or endovascular therapy occurred in several pandemic periods. The likelihood of in-hospital death increased in Wave 2 (adjusted odds ratio [OR] 1.48, 95% CI 1.25 to 1.74) and Wave 3 (adjusted OR 1.46, 95% CI 1.07 to 2.00). Out-of-hospital deaths, as a proportion of stroke-related deaths, rose during 4 of 5 pandemic periods.Interpretation:The first year of the COVID-19 pandemic saw persistently reduced rates of patients presenting with ischemic stroke, recurrent treatment delays and higher risk of in-hospital death in later waves. These findings support public health messaging that encourages care-seeking for medical emergencies during pandemic periods, and stroke systems should re-evaluate protocols to mitigate inefficiencies.

Prediction of in-hospital mortality by using get with the guideline-heart failure (GWTG-HF) risk scores in patients hospitalized with heart failure

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): University Grants Commission Bangladesh Background Prognostic stratification using readily available clinical data can assist clinical decision making in heart failure. Get with the Guideline- Heart Failure (GWTG-HF) score approved by American Heart Association (AHA) can be used to inform hospitals about the expected in-hospital mortality of their patients. Purpose This study aims to predict in-hospital mortality of patients with heart failure using GWTG-HF score in order to give evidence based therapy to high risk patients. Methods We have included patients who were hospitalized with a diagnosis of heart failure from February 2020 to 15 January 2021. A total of 2038 patients were admitted during this period of which 144 patients were diagnosed with heart failure (7%). The GWTG-HF risk score uses 7 clinical factors collected at admission. These are older age, low systolic blood pressure, elevated heart rate, low serum sodium, elevated BUN, presence of COPD, and ethnicity. The probability of in-hospital mortality is estimated for an individual patient by summing points assigned to the value of each predictor for a total point score within a range of 0-100. These scores were calculated for 144 heart failure patients involved in this study. Results Death occurred in 29 heart failure patients (20.13%). Mean age was 59 ±13 years. Male/female ratio was 3.65. All patients were ethnically Bangladeshi Asian. 60% of patients had left ventricular ejection fraction (LVEF) &amp;lt;40%. Overall LVEF was median (IQR) 36% (30-45). Those who died were more likely to have a prior heart failure diagnosis and an LVEF &amp;lt;40%. The observed mortality was 0% for the GWTG-HF score 0-33, 14.14% for 34-50, 42% for 51-57, 40% for 58-61 and 50% with a score of 62-65. The observed mortality of our patients were much higher than expected GWTG-HF score (20% vs 2.8%). The probable reasons for increased mortality in our study could be 1) The number of patients having LVEF &amp;lt;40% is much higher (60%), 2) surgically uncorrected/absence of intervention for underlying valvular disease/advance heart failure/ischaemic cardiomyopathy, 3) different treatment regimens and non-compliance of patients regarding long-term medication. Additionally, those who died had higher serum creatinine and BUN and lower serum sodium and haemoglobin levels at admission. Further multi-centre study involving large population is needed to clarify higher death rate in heart failure patients in our population. Conclusion The GWTG-HF risk score can identify patients at high risk of in-hospital death to aid clinical decision making. The risk score could be used to inform hospitals about the expected mortality rates of patients with heart failure admitted to their hospital. Although GWTG-HF risk score is validated in different populations, the mortality rate in this study is greater than expected mortality due to aforementioned reasons. Abstract Figure. GWTG-HF Risk Score (Reference 1) Abstract Figure. Predicted and Observed Mortality Rates

Stress hyperglycemia is associated with in-hospital mortality in patients with diabetes and acute ischemic stroke.

Background and ObjectiveStress hyperglycemia may occur in diabetic patients with acute severe cerebrovascular disease, but the results regarding its association with stroke outcomes are conflicting. This study aimed to examine the association between stress‐induced hyperglycemia and the occurrence of in‐hospital death in patients with diabetes and acute ischemic stroke.Research Design and MethodsAll data were from the Chinese Stroke Center Alliance (CSCA) database and were collected between 2016 and 2018 from >300 centers across China. Patients’ demographics, clinical presentation, and laboratory data were extracted from the database. The primary endpoint was in‐hospital death. The ratio of fasting blood glucose (FBG) to HbA1c was calculated, that is, the stress‐induced hyperglycemia ratio (SHR), to determine stress hyperglycemia following acute ischemic stroke.ResultsA total of 168,381 patients were included. The mean age was 66.2 ± 10.7, and 77,688 (43.0%) patients were female. The patients were divided into two groups: survivors (n = 167,499) and non‐survivors (n = 882), as well as into four groups according to their SHR quartiles (n = 42,090–42,099/quartile). There were 109 (0.26%), 142 (0.34%), 196 (0.47%), and 435 (1.03%) patients who died in the Q1, Q2, Q3, and Q4 quartiles, respectively. Compared with Q1 patients, the death risk was higher in Q4 patients (odds ratio (OR) = 4.02) (adjusted OR = 1.80, 95% confidence interval [CI] = 1.10–2.92, p = 0.018 after adjustment for traditional cardiovascular risk factors). The ROC analyses showed that SHR (AUC = 0.667, 95% CI: 0.647–0.686) had a better predictive value for mortality than that of fasting blood glucose (AUC = 0.633, 95% CI: 0.613–0.652) and HbA1c (AUC = 0.523, 95% CI: 0.504–0.543).ConclusionsThe SHR may serve as an accessory parameter for the prognosis of patients with diabetes after acute ischemic stroke. Hyperglycemia in stroke patients with diabetes mellitus is associated with a higher risk of in‐hospital death.

Surgical outcomes of total arch replacement with modified elephant trunk technique in type A aortic dissection: insights from single-center experience.

Total arch replacement with modified elephant trunk technique plays an important role in treating acute type A aortic dissection in China. We aim to summarize the therapeutic effects of this procedure in our center over a 17-year period. Consecutive patients treated at our hospital due to type A aortic dissection from January 2004 to January 2021 were studied. Relevant data of these patients undergoing total arch replacement with modified elephant trunk technique were collected and analyzed. A total of 589 patients were included with a mean age of 53.1 ± 12.2 years. The mean of cardiopulmonary bypass, cross-clamping, and selected cerebral perfusion time were 199.6 ± 41.9, 119.0 ± 27.2, and 25.1 ± 5.0 min, respectively. In-hospital death occurred in 46 patients. Multivariate analysis identified four significant risk factors for in-hospital mortality: preexisting renal hypoperfusion (OR 5.43; 95% CI 1.31 - 22.44; P = 0.020), cerebral malperfusion (OR 11.87; 95% CI 4.13 - 34.12; P < 0.001), visceral malperfusion (OR 4.27; 95% CI 1.01 - 18.14; P = 0.049), and cross-clamp time ≥ 130 min (OR 3.26; 95% CI 1.72 - 6.19; P < 0.001). The 5, 10, and 15 years survival rates were 86.4%, 82.6%, and 70.2%, respectively. Total arch replacement with modified elephant trunk technique is an effective treatment for acute type A aortic dissection with satisfactory perioperative results. Patients with preexisting renal hypoperfusion, cerebral malperfusion, visceral malperfusion, and long cross-clamp time are at a higher risk of in-hospital death.

Ambulation capacity, age, immunosuppression, and mechanical ventilation are risk factors of in-hospital death in severe COVID-19: a cohort study

Despite ambulation capacity being associated with a decreased level of physical activity and survival may be influenced by the functional capacity, studies have not addressed the association between ambulation capacity and death in patients hospitalized by COVID-19. To verify the functional, clinical, and sociodemographic risk factors associated with in-hospital death in individuals with severe COVID-19. It is a cohort retrospective study performed at a large tertiary hospital. Patients18years of age or more, of both sexes, hospitalized due to severe COVID-19 were included. Cases with dubious medical records and/or missing essential data were excluded. Patients were classified according to their ambulation capacity before the COVID-19 infection. Information regarding sociodemographic characteristics, in-hospital death, total hospital stays, Intensive Care Unit (ICU) stays, and the necessity of Mechanical Ventilation (MV) were collected from medical records and registered in a RedCap database. Multiple logistic regression analysis was used to identify possible factors associated with the in-hospital death rate. Data from1110participants were included in the statistical analysis. The median age of the patients was57(46‒66)years, 58.42% (n=590) were male, and 61.73% (n=602) were brown or black. The case fatality rate during hospitalization was36.0%(n=363). In-hospital death was associated with ambulation capacity; dependent ambulators (OR=2.3; CI 95%=1.2-4.4) and non-functional ambulation (OR=1.9; CI 95%= 1.1-3.3), age [older adults (OR=3.0; CI 95%=1.9‒4.), ICU stays (OR=1.4; CI 95%=1.2‒1.4), immunosuppression (OR=5.5 CI 95%=2.3‒13.5) and mechanical ventilation (OR=27.5; CI95%=12.0-62.9). Decreased ambulation capacity, age, length of ICU stay, immunosuppression, and mechanical ventilation was associated with a high risk of in-hospital death due to COVID-19.

Outcomes of transcatheter aortic valve implantation in nonagenarians compared to &lt; 90 years patients

Given that life expectancy has been improved, nonagenarians become a significant proportion of world population. As aortic stenosis is primarily a disease of the elderly, the need for invasive cardiac approaches is expected to increase in people of extreme age We compare the in-hospital adverse clinical outcomes and mortality after TAVI procedures in nonagenarians to < 90 years patients. A retrospective study was conducted on 1336 patients who underwent TAVI at Toulouse University hospital, Rangueil, France. Post-TAVI adverse clinical outcomes were defined according to Valve Academic Research Consortium-2 Criteria. The studied population was divided into 2 groups according to age. Out of 1336 patients, 250 (18.7%) were nonagenarians with a mean age of 91.8 ± 1.9 years.While comorbidities were less common in nonagenarians, the calculated scores to predict mortality were significantly higher. Pacemaker implantation (12.4% vs. 12.1%, P = 0.08), stroke (2% vs. 1.8%, P = 0.86) and major vascular complications (9.2% vs. 6.7%, P = 0.17) were more common in nonagenarians while acute kidney injury (1.2% vs. 2.7%, P = 0.15) and major bleeding events (3.2%vs3.4%, P = 0.87) were more common in < 90 year group. The rate of procedures success in nonagenarians and < 90 year group was 93.2% and 96.9%, respectively. Adjusted multivariate analysis showed that Nonagenarians are more likely to develop major vascular complications [OR = 1.76 95%CI (1.04;3)]. Survival analysis showed a significant difference in mortality during hospitalization period only ( P = 0.004) The prevalence of TAVI success is remarkably high in nonagenarians and comparable to that of younger age. The nonagenarians are significantly at higher risk for in-hospital death after TAVI and they are more likely to develop major vascular complications. The difference in mortality rate during hospitalization period was two times more but it becomes no longer significant after hospital discharge.

Beyond Chronological Age: Frailty and Multimorbidity Predict In-Hospital Mortality in Patients With COVID-19

Background: We evaluated whether frailty and multimorbidity predict in-hospital mortality in patients with COVID-19 beyond chronological age. Methods: 165 patients admitted from March 8th to April 17th, 2020, with COVID-19 in an acute geriatric ward in Italy were included. Pre-disease frailty was assessed with the Clinical Frailty Scale (CFS). Multimorbidity was defined as the co-occurrence of ≥2 of these in the same patient. The hazard (HR) of in-hospital mortality as a function of CFS score and number of chronic diseases in the whole population and in those aged 70+ years were calculated. Results Among the 165 patients, 112 were discharged, 11 were transferred to intensive care units and 42 died. Patients who died were older (81.0 vs. 65.2 years, p<0.001), more frequently multimorbid (97.6 vs. 52.8%; p<0.001) and more likely frail (37.5 vs. 4.1%; p<0.001). Less than 2.0% of patients without multimorbidity and frailty, 28% of those with multimorbidity only and 75% of those with both multimorbidity and frailty died. Each unitary increment in the CFS was associated with a higher risk of in-hospital death in the whole sample (HR=1.3; 95%CI=1.05-1.62) and in patients aged 70+ years (HR=1.29;95%CI=1.04-1.62), whereas the number of chronic diseases was not significantly associated with higher risk of death. The CFS addition to age and sex increased mortality prediction by 9.4% in those aged 70+ years. Conclusions Frailty identifies patients with COVID-19 at risk of in-hospital death independently of age. Multimorbidity contributes to prognosis because of the very low probability of death in its absence.

Abstract 13866: Quantity of Cardiovascular Risk Factors and Associated Outcomes in Young Women With ST-Elevation Myocardial Infarction

Introduction: Despite the remarkable progress in STEMI care, the mortality rates in young women with STEMI remain high. It remains unclear whether this is related to the number of cardiovascular (CV) risk factors. Methods: From 2010 to 2020, we evaluated 10,441 consecutive STEMI patients, including 3,150 (30%) women enrolled in prospective Midwest STEMI Consortium registry, constituted of Minneapolis Heart Institute, Minneapolis, MN, The Christ Hospital, Cincinnati, OH, Prairie Heart Institute, Springfield, IL, and Iowa Heart Center, Des Moines, IA. We categorized baseline CV risk factors (hypertension, dyslipidemia, diabetes, smoking, and family history of CAD) in the 477 (15%) women &lt;55 years and without previous history of CAD. Results: Smoking was the most common, and diabetes the least common CV risk factor. Of the 477 women, 161 (33.8%) had 0 or 1 CV risk factor, 132 (27.7%) had 2, and 184 (38.6%) had at least 3 CV risk factors. As the number of CV risk factors decreased, non-atherosclerotic STEMI etiologies -SCAD or Takotsubo syndrome- increased, as did the incidences of cardiogenic shock or cardiac arrest. There were no differences in reperfusion strategies or time among patients with 0 or more CV risk factors; however, as the number of CV risk factors decreased, patients were less likely to receive antiplatelet or statin at discharge. There was a trend toward higher death in the hospital with decreasing number of CV risk factors, but it did not reach statistical significance (p=0.075) (Table). Conclusions: Young women with fewer traditional CV risk factors more often presented with non-atherosclerotic causes of STEMI and higher incidences of cardiogenic shock or cardiac arrest and had a trend toward a higher risk of in-hospital death. Thus, future epidemiological studies are needed to determine if sex-specific risk enhancers, in addition to traditional CV risk factors, have a role in risk stratification among young women for future CV events.

U-Shaped Association Between Serum Uric Acid and Short-Term Mortality in Patients With Infective Endocarditis.

BackgroundIncreased uric acid (UA) levels have been reported to be associated with poor clinical outcomes in several conditions. However, the prognostic value of UA in patients with infective endocarditis (IE) is yet unknown.MethodsA total of 1,117 patients with IE were included and divided into two groups according to the current definition of hyperuricemia (UA>420 μmol/L in men and >360 μmol/L in women): hyperuricemia group (n=336) and normouricemia group (n=781). The association between the UA level and short-term outcomes were examined.ResultsThe in-hospital mortality was 6.2% (69/1117). Patients with hyperuricemia carried a higher risk of in-hospital death (9.8% vs. 4.6%, p=0.001). Hyperuricemia was not an independent risk factor for in-hospital death (adjusted odds ratio [aOR]=1.92, 95% confidence interval [CI]: 0.92-4.02, p=0.084). A U-shaped relationship was found between the UA level and in-hospital death (p<0.001). The in-hospital mortality was lower in patients with UA in the range 250–400 μmol/L. The aOR of in-hospital death in patients with UA>400 and <250 μmol/L was 3.48 (95% CI: 1.38-8.80, p=0.008) and 3.28 (95%CI: 1.27-8.51, p=0.015), respectively. Furthermore, UA>400 μmol/L (adjusted hazard ratio [aHR]=3.54, 95%CI: 1.77-7.07, p<0.001) and <250 μmol/L (aHR=2.23, 95%CI: 1.03-4.80, p=0.041) were independent risk factors for the 6-month mortality.ConclusionThe previous definition of hyperuricemia was not suitable for risk assessment in patients with IE because of the U-shaped relationship between UA levels and in-hospital death. Low and high levels of UA were predictive of increased short-term mortality in IE patients.

Do ventilatory parameters influence outcome in patients with severe acute respiratory infection? Secondary analysis of an international, multicentre14-day inception cohort study.

PurposeTo investigate the possible association between ventilatory settings on the first day of invasive mechanical ventilation (IMV) and mortality in patients admitted to the intensive care unit (ICU) with severe acute respiratory infection (SARI).Materials and methodsIn this pre-planned sub-study of a prospective, multicentre observational study, 441 patients with SARI who received controlled IMV during the ICU stay were included in the analysis.ResultsICU and hospital mortality rates were 23.1 and 28.1%, respectively. In multivariable analysis, tidal volume and respiratory rate on the first day of IMV were not associated with an increased risk of death; however, higher driving pressure (DP: odds ratio (OR) 1.05; 95% confidence interval (CI): 1.01–1.1, p = 0.011), plateau pressure (Pplat) (OR 1.08; 95% CI: 1.04–1.13, p < 0.001) and positive end-expiratory pressure (PEEP) (OR 1.13; 95% CI: 1.03–1.24, p = 0.006) were independently associated with in-hospital mortality. In subgroup analysis, in hypoxemic patients and in patients with acute respiratory distress syndrome (ARDS), higher DP, Pplat, and PEEP were associated with increased risk of in-hospital death.ConclusionsIn patients with SARI receiving IMV, higher DP, Pplat and PEEP, and not tidal volume, were associated with a higher risk of in-hospital death, especially in those with hypoxemia or ARDS.

Renal dysfunction in patients with pulmonary embolism: data from the SIRENA register

Aim. To assess the prevalence, severity and prognostic value of renal dysfunction (RD) in patients with pulmonary embolism (PE) of the Russian population, as well as to determine the RD significance as a marker that improves the predictive ability of current risk stratification systems.Material and methods. From April 2018 to April 2019, patients hospitalized due to PE were sequentially included in the Russian multicenter observational prospective registry SIRENA. RD was diagnosed at a glomerular filtration rate (GFR) &lt;60 ml/ min/1,73 m2. Risk of early (hospital or 30-day) death was stratified in accordance with the current 2019 ESC Clinical Guidelines. During the study, we analyzed inpatient mortality and complication rate.Results. A total of 604 patients (men, 293 (49%); women, 311 (51%)) were in the study. RD was detected in 320 (53%) patients, while severe dysfunction — in 63 (10%) ones. In addition, 71 (12%) patients had high death risk, 364 (61%) — intermediate, 164 (27%) — low. During hospitalization, 107 (18%) patients died, including 32% from the high-risk group, 20% — moderate, and 7% — low. RD in the deceased patients was diagnosed more often, while GFR &lt;50 ml/min/1,73 m2 reliably predicted hospital mortality (sensitivity, 67%; specificity, 72%; AUC=0,72; p&lt;0,001). In patients with simplified Pulmonary Embolism Severity Index (sPESI) of 0 and ≥ 1, the presence of RD led to at least a 2-fold increase in mortality. Multivariate Cox regression revealed that RD is a predictor of in-hospital mortality (hazard ratio (HR), 3,41; 95% confidence interval (CI): 2,15-5,41; p&lt;0,001), regardless of the presence of death risk reclassifies, such as high troponin (HR, 1,31; 95% CI: 0,80-2,14; p=0,28) and right ventricular dysfunction (HR, 1,23; 95% CI: 0,74-2,04; p=0,42).Conclusion. In patients with PE of the Russian population, there is a high incidence of RD, which is diagnosed in every second patient and is severe in 10% of cases. The presence of RD is associated with a significant increase in in-hospital mortality, while the risk of death increases with a decrease in GFR. The addition of RD, considered as a decrease in the estimated GFR &lt;60 ml/min/1,73 m2, to the sPESI improves risk stratification and allows identification of patients at high risk of in-hospital death.

Coronary artery calcification and risk of mortality and adverse outcomes in patients with COVID-19: a Chinese multicenter retrospective cohort study.

BackgroundCoronary artery calcification (CAC) is an independent risk factor of major adverse cardiovascular events; however, the impact of CAC on in-hospital death and adverse clinical outcomes in patients with coronavirus disease 2019 (COVID-19) remains unclear.ObjectiveTo explore the association between CAC and in-hospital mortality and adverse events in patients with COVID-19.MethodsThis multicenter retrospective cohort study enrolled 2067 laboratory-confirmed COVID-19 patients with definitive clinical outcomes (death or discharge) admitted from 22 tertiary hospitals in China between January 3, 2020 and April 2, 2020. Demographic, clinical, laboratory results, chest CT findings, and CAC on admission were collected. The primary outcome was in-hospital death and the secondary outcome was composed of in-hospital death, admission to intensive care unit (ICU), and requiring mechanical ventilation. Multivariable Cox regression analysis and Kaplan–Meier plots were used to explore the association between CAC and in-hospital death and adverse clinical outcomes.ResultsThe mean age was 50 years (SD,16) and 1097 (53.1%) were male. A total of 177 patients showed high CAC level, and compared with patients with low CAC, these patients were older (mean age: 49 vs. 69 years, P < 0.001) and more likely to be male (52.0% vs. 65.0%, P = 0.001). Comorbidities, including cardiovascular disease (CVD) ([33.3%, 59/177] vs. [4.7%, 89/1890], P < 0.001), presented more often among patients with high CAC, compared with patients with low CAC. As for laboratory results, patients with high CAC had higher rates of increased D-dimer, LDH, as well as CK-MB (all P < 0.05). The mean CT severity score in high CAC group was also higher than low CAC group (12.6 vs. 11.1, P = 0.005). In multivariable Cox regression model, patients with high CAC were at a higher risk of in-hospital death (hazard ratio [HR], 1.731; 95% CI 1.010–2.971, P = 0.046) and adverse clinical outcomes (HR, 1.611; 95% CL 1.087–2.387, P = 0.018).ConclusionHigh CAC is a risk factor associated with in-hospital death and adverse clinical outcomes in patients with confirmed COVID-19, which highlights the importance of calcium load testing for hospitalized COVID-19 patients and calls for attention to patients with high CAC.Supplementary InformationThe online version contains supplementary material available at 10.1007/s42058-021-00072-4.

Outcomes and risk factors for death in patients with coronavirus disease-2019 (COVID-19) pneumonia admitted to the intensive care units of an Egyptian University Hospital. A retrospective cohort study

BackgroundThe characteristics, outcomes, and risk factors for in-hospital death of critically ill intensive care unit (ICU) patients with coronavirus disease-2019 (COVID-19) have been described in patients from Europe, North America and China, but there are few data from COVID-19 patients in Middle Eastern countries. The aim of this study was to investigate the characteristics, outcomes, and risk factors for in-hospital death of critically ill patients with COVID-19 pneumonia admitted to the ICUs of a University Hospital in Egypt. MethodsRetrospective analysis of patients with COVID-19 pneumonia admitted between April 28 and July 29, 2020 to two ICUs dedicated to the isolation and treatment of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in Cairo University Hospitals. Diagnosis was confirmed in all patients using real-time reverse transcription polymerase chain reaction on respiratory samples and radiologic evidence of pneumonia. ResultsOf the 177 patients admitted to the ICUs during the study period, 160 patients had COVID-19 pneumonia and were included in the analysis (mean age: 60 ± 14 years, 67.5% males); 23% of patients had no known comorbidities. The overall ICU and hospital mortality rates were both 24.4%. The ICU and hospital lengths of stay were 7 (25–75% interquartile range: 4–10) and 10 (25–75% interquartile range: 7–14) days, respectively. In a multivariable analysis with in-hospital death as the dependent variable, ischemic heart disease, history of smoking, and secondary bacterial pneumonia were independently associated with a higher risk of in-hospital death, whereas greater PaO2/FiO2 ratio on admission to the ICU was associated with a lower risk. ConclusionIn this cohort of critically ill patients with COVID-19 pneumonia, ischemic heart disease, history of smoking, and secondary bacterial pneumonia were independently associated with a higher risk of in-hospital death.

Neutrophil-to-Lymphocyte Ratio as an Independent Predictor of In-Hospital Mortality in Patients with Acute Intracerebral Hemorrhage.

Background and Objectives: Neutrophil-to-lymphocyte ratio (NLR), a very low cost, widely available marker of systemic inflammation, has been proposed as a potential predictor of short-term outcome in patients with intracerebral hemorrhage (ICH). Methods: Patients with ICH admitted to the Neurology Department during a two-year period were screened for inclusion. Based on eligibility criteria, 201 patients were included in the present analysis. Clinical, imaging, and laboratory characteristics were collected in a prespecified manner. Logistic regression models and receiver operating characteristics (ROC) curves were used to assess the performance of NLR assessed at admission (admission NLR) and 72 h later (three-day NLR) in predicting in-hospital death. Results: The median age of the study population was 70 years (IQR: 61–79), median admission NIHSS was 16 (IQR: 6–24), and median hematoma volume was 13.7 mL (IQR: 4.6–35.2 mL). Ninety patients (44.8%) died during hospitalization, and for 35 patients (17.4%) death occurred during the first three days. Several common predictors were significantly associated with in-hospital mortality in univariate analysis, including NLR assessed at admission (OR: 1.11; 95% CI: 1.04–1.18; p = 0.002). However, in multivariate analysis admission, NLR was not an independent predictor of in-hospital mortality (OR: 1.04; 95% CI: 0.9–1.1; p = 0.3). The subgroup analysis of 112 patients who survived the first 72 h of hospitalization showed that three-day NLR (OR: 1.2; 95% CI: 1.09–1.4; p < 0.001) and age (OR: 1.05; 95% CI: 1.02–1.08; p = 0.02) were the only independent predictors of in-hospital mortality. ROC curve analysis yielded an optimal cut-off value of three-day NLR for the prediction of in-hospital mortality of ≥6.3 (AUC = 0.819; 95% CI: 0.735–0.885; p < 0.0001) and Kaplan–Meier analysis proved that ICH patients with three-day NLR ≥6.3 had significantly higher odds of in-hospital death (HR: 7.37; 95% CI: 3.62–15; log-rank test; p < 0.0001). Conclusion: NLR assessed 72 h after admission is an independent predictor of in-hospital mortality in ICH patients and could be widely used in clinical practice to identify the patients at high risk of in-hospital death. Further studies to confirm this finding are needed.

Early vs. Late Onset Cardiac Injury and Mortality in Hospitalized COVID-19 Patients in Wuhan.

Background: Increasing evidence points to cardiac injury (CI) as a common coronavirus disease 2019 (COVID-19) related complication. The characteristics of early CI (occurred within 72 h of admission) and late CI (occurred after 72 h of admission) and its association with mortality in COVID-19 patients is unknown.Methods: This retrospective study analyzed patients confirmed with COVID-19 in Union Hospital (Wuhan, China) from Jan 29th to Mar 15th, 2020. Clinical outcomes (discharge, or death) were monitored to April 15, 2020, the latest date of follow-up. Demographic, clinical, laboratory, as well as treatment and prognosis were collected and analyzed in patients with early, late CI and without CI.Results: A total of 196 COVID-19 patients were included for analysis. The median age was 65 years [interquartile range (IQR) 56–73 years], and 112 (57.1%) were male. Of the 196 COVID-19 patients, 49 (25.0%) patients had early and 20 (10.2%) patients had late CI, 56.6% developed Acute-Respiratory-Distress-Syndrome (ARDS) and 43 (21.9%) patients died. Patients with any CI were more likely to have developed ARDS (87.0 vs. 40.2%) and had a higher in-hospital mortality than those without (52.2 vs. 5.5%, P < 0.001). Among CI subtypes, a significantly higher risk of in-hospital death was found in patients with early CI with recurrence [19/49 patients, adjusted odds ratio (OR) = 7.184, 95% CI 1.472–35.071] and patients with late CI (adjusted OR = 5.019, 95% CI 1.125–22.388) compared to patients with early CI but no recurrence.Conclusions: CI can occur early on or late after, the initial 72 h of admission and is associated with ARDS and an increased risk of in-hospital mortality. Both late CI and recurrent CI after the initial episode were associated with worse outcomes than patients with early CI alone. This study highlights the importance of early examination and periodical monitoring of cardiac biomarkers, especially for patients with early CI or at risk of clinical deterioration.

Burden and causes of hospital admissions and readmissions in patients undergoing hemodialysis and peritoneal dialysis: a nationwide study.

High rates of hospitalization in dialysis patients impose an increasing healthcare burden. We explored and compared hospital admission rates among patients starting hemodialysis (HD) and peritoneal dialysis (PD), and investigated causes of admission/readmission in search of potentially preventable risks. Observational study recruiting8902 patients (3101 on PD) who started maintenance dialysis in Sweden between 2006 and 2016 and were followed-up for 2years. We compared the Hazard Ratios (HR) for hospital admission and in-hospital death, and calculated the odds ratios (OR) of readmission within 30days after discharge. Six thousand four hundred ninety-three (73%) patients were hospitalized at least once, and 246 admissions ended with in-hospitaldeath. Compared with HD, patients on PD had a higher risk of hospitalization (HR 1.07; 95% CI 1.01-1.13), longer length of stay (mean difference of 2.06; 1.39-2.73days), and higher risk of in-hospital death (HR 1.18; 1.03-1.37). Peritonitis and cardiovascular events were the most frequent causes of admission. Of 5810 patients discharged from the hospital, 1447 (25%) were readmitted and 124 (2%) died within 30days. No differences in readmission risk were observed between dialysis modalities. There was frequently discordance between the cause of hospital admission and readmission, and we identified a consistent pattern of readmission attributed to complications from infections and their interplay with cardiovascular diseases. Our study illustrates a high burden of hospitalization in patients on dialysis, suggests the risk of longerhospitalizations for patients on PD, and identifies cardiovascular events and infections as complications that may benefit from closer post-discharge monitoring.

History of heart failure in patients with coronavirus disease 2019: Insights from a French registry

BackgroundAlthough cardiovascular comorbidities seem to be strongly associated with worse outcomes in patients with coronavirus disease 2019 (COVID-19), data regarding patients with preexisting heart failure are limited.AimsTo investigate the incidence, characteristics and clinical outcomes of patients with COVID-19 with a history of heart failure with preserved or reduced ejection fraction.MethodsWe performed an observational multicentre study including all patients hospitalized for COVID-19 across 24 centres in France from 26 February to 20 April 2020. The primary endpoint was a composite of in-hospital death or need for orotracheal intubation.ResultsOverall, 2809 patients (mean age 66.4 ± 16.9 years) were included. Three hundred and seventeen patients (11.2%) had a history of heart failure; among them, 49.2% had heart failure with reduced ejection fraction and 50.8% had heart failure with preserved ejection fraction. COVID-19 severity at admission, defined by a quick sequential organ failure assessment score > 1, was similar in patients with versus without a history of heart failure. Before and after adjustment for age, male sex, cardiovascular comorbidities and quick sequential organ failure assessment score, history of heart failure was associated with the primary endpoint (hazard ratio [HR]: 1.41, 95% confidence interval [CI]: 1.06–1.90; P = 0.02). This result seemed to be mainly driven by a history of heart failure with preserved ejection fraction (HR: 1.61, 95% CI: 1.13–2.27; P = 0.01) rather than heart failure with reduced ejection fraction (HR: 1.19, 95% CI: 0.79–1.81; P = 0.41).ConclusionsHistory of heart failure in patients with COVID-19 was associated with a higher risk of in-hospital death or orotracheal intubation. These findings suggest that patients with a history of heart failure, particularly heart failure with preserved ejection fraction, should be considered at high risk of clinical deterioration.

Chronic Kidney Disease Is Associated with High Mortality Risk in Patients with Diabetes after Primary Shoulder Arthroplasty: A Nationwide Population-Based Cohort Study.

The number of diabetic patients with chronic kidney disease (CKD) undergoing shoulder arthroplasty is growing. This study aims to compare perioperative outcomes of shoulder arthroplasty in diabetic patients at different renal function stages. Between 1998 and 2013, a total of 4443 diabetic patients with shoulder arthroplasty were enrolled: 1174 (26%) had CKD without dialysis (CKD group), 427 (9%) underwent dialysis (dialysis group), and 3042 (68%) had no CKD (non-CKD group). Compared with the non-CKD group, the CKD (odds ratio [OR], 4.69; 95% confidence interval [CI], 2.02–10.89) and dialysis (OR, 6.71; 95% CI, 1.63–27.73) groups had a high risk of in-hospital death. The dialysis group had a high risk of infection after shoulder arthroplasty compared with the CKD (subdistribution hazard ratio [SHR], 1.69; 95% CI, 1.07–2.69) and non-CKD (SHR, 1.76; 95% CI, 1.14–2.73) groups. The dialysis group showed higher risks of all-cause readmission and mortality than the CKD and non-CKD groups after a 3-month follow-up. In conclusion, CKD was associated with worse outcomes after shoulder arthroplasty. Compared with those without CKD, CKD patients had significantly increased readmission and mortality risks but did not have an increased risk of surgical complications, including superficial infection or implant removal.