Higher Risk Of In-hospital Death Research Articles

Factors associated with in-hospital death in patients with nosocomial infections: a registry-based study using community data in western Iran.

OBJECTIVESDetermining the predictors of in-hospital death related to nosocomial infections is an essential part of efforts made in the overall health system to improve the delivery of health care to patients. Therefore, this study investigated the predictors of in-hospital death related to nosocomial infections. METHODSThis registry-based, longitudinal study analyzed data on 8,895 hospital-acquired infections (HAIs) in Hamadan Province, Iran from March 2017 to December 2019. The medical records of all patients who had been admitted to the hospitals were extracted from the Iranian Nosocomial Infections Surveillance Software. The effects of the type and site of infection, as well as age group, on in-hospital death were estimated using univariate and multivariable Cox regression models. RESULTSIn total, 4,232 (47.8%) patients with HAIs were males, and their mean age was 48.25±26.22 years. In both sexes, most nosocomial infections involved Gram-negative bacteria and the most common site of infection was the urinary tract. Older patients had a higher risk of in-hospital death (adjusted hazard ratio [aHR], 2.26; 95% confidence interval [CI], 1.38 to 3.69 for males; aHR, 2.44; 95% CI, 1.29 to 4.62 for females). In both sexes, compared with urinary tract infections, an increased risk of in-hospital death was found for ventilator-associated events (VAEs) (by 95% for males and 93% for females) and bloodstream infections (BSIs) (by 67% for males and 82% for females). CONCLUSIONSWe found that VAEs, BSIs, and fungal infections were independently and strongly associated with increased mortality.

Poor clinical outcomes for patients with cancer during the COVID-19 pandemic.

Poor clinical outcomes for patients with cancer during the COVID-19 pandemic.

Sodium status and kidney involvement during COVID-19 infection

The angiotensin-converting enzyme 2 receptor (ACE2) is expressed in epithelial cells of many tissues including the kidney, and has been identified to interact with human pathogenic coronaviruses, including SARS-CoV-2. Although diffuse alveolar damage and acute respiratory failure are the main features of COVID-19 infection, two recent studies demonstrate that kidney impairment in hospitalized COVID-19 patients is common, and that kidney involvement is associated with high risk of in-hospital death. Interestingly, studies in rats have demonstrated that high dietary sodium intake results in down-regulation of the ACE2 expression in kidney tissue. We hypothesize that low sodium status makes kidney involvement during the course of COVID-19 infection more likely due to upregulation of membrane bound ACE2 in the kidneys. We propose that sodium intake and status should be monitored carefully during severe COVID-19 infections, and that low sodium intake be corrected early in its course, despite a potential conflict regarding common dietary recommendations to restrict dietary sodium intake in patients with hypertension, diabetes, and kidney disease.

Kidney disease is associated with in-hospital death of patients with COVID-19

In December 2019, a coronavirus 2019 (COVID-19) disease outbreak occurred in Wuhan, Hubei Province, China, and rapidly spread to other areas worldwide. Although diffuse alveolar damage and acute respiratory failure were the main features, the involvement of other organs needs to be explored. Since information on kidney disease in patients with COVID-19 is limited, we determined the prevalence of acute kidney injury (AKI) in patients with COVID-19. Further, we evaluated the association between markers of abnormal kidney function and death in patients with COVID-19. This was a prospective cohort study of 701 patients with COVID-19 admitted in a tertiary teaching hospital that also encompassed three affiliates following this major outbreak in Wuhan in 2020 of whom 113 (16.1%) died in hospital. Median age of the patients was 63 years (interquartile range, 50-71), including 367 men and 334 women. On admission, 43.9% of patients had proteinuria and 26.7% had hematuria. The prevalence of elevated serum creatinine, elevated blood urea nitrogen and estimated glomerular filtration under 60 ml/min/1.73m2 were 14.4, 13.1 and 13.1%, respectively. During the study period, AKI occurred in 5.1% patients. Kaplan-Meier analysis demonstrated that patients with kidney disease had a significantly higher risk for in-hospital death. Cox proportional hazard regression confirmed that elevated baseline serum creatinine (hazard ratio: 2.10, 95% confidence interval: 1.36-3.26), elevated baseline blood urea nitrogen (3.97, 2.57-6.14), AKI stage 1 (1.90, 0.76-4.76), stage 2 (3.51, 1.49-8.26), stage 3 (4.38, 2.31-8.31), proteinuria 1+ (1.80, 0.81-4.00), 2+∼3+ (4.84, 2.00-11.70), and hematuria 1+ (2.99, 1.39-6.42), 2+∼3+ (5.56,2.58- 12.01) were independent risk factors for in-hospital death after adjusting for age, sex, disease severity, comorbidity and leukocyte count. Thus, our findings show the prevalence of kidney disease on admission and the development of AKI during hospitalization in patients with COVID-19 is high and is associated with in-hospital mortality. Hence, clinicians should increase their awareness of kidney disease in patients with severe COVID-19.

In-hospital Mortality Among Neurological Patients over the Period of 5 years — a Retrospective, Single-center Study

Introduction. Neurological disorders have been considered for many years dangerous and are associated with higher risk of in-hospital death. Brain vascular disorders are widely considered as the most severe and related to the highest mortality rate.Aim. The aim of the study was to assess the mortality rate in subjects hospitalized in the Neurology ward within 5 years, in particular the etiology, direct cause and predictability of deaths.Material and Methods. This study is retrospective. The documentation analysis concerned the last 5 years, i.e. from 2015 to 2019. From among the entire database of 8247 patients hospitalized in the Neurology Clinic of the University Hospital No. 1 in Bydgoszcz, 429 deaths were reported and analyzed.Results. The mortality rate was 5.2% among all subjects, 6.6% among all vascular patients and 1.16% among non-vascular subjects. The highest mortality was reported among hemorrhagic stroke (28.4%) and it was significantly higher compared to ischemic stroke (OR = 6.25, 95% CI 4.9–7.8, p < 0.0001). Patients with stroke had significantly higher mortality compared to other neurological disorders (OR = 11.08 95% CI 7.7–15.9, p < 0.0001). The main direct reason of death (80%) was primary cerebral as a result of baseline disease. 7% of deaths were considered as sudden, unexpected and 10.7% were related to complications developed during hospitalization.Conclusions. Stroke, especially hemorrhagic subtype, still remains the cause of the highest in-hospital mortality rate in the Neurology Ward. It is worth to notice that special attention should be paid to patients with coexisting infectious diseases, that contribute to higher mortality risk. (JNNN 2020;9(1):20–26)

Association of Low Baseline Diaphragm Muscle Mass With Prolonged Mechanical Ventilation and Mortality Among Critically Ill Adults

Low diaphragm muscle mass at the outset of mechanical ventilation may predispose critically ill patients to poor clinical outcomes. To determine whether lower baseline diaphragm thickness (Tdi) is associated with delayed liberation from mechanical ventilation and complications of acute respiratory failure (reintubation, tracheostomy, prolonged ventilation >14 days, or death in the hospital). Secondary analysis (July 2018 to June 2019) of a prospective cohort study (data collected May 2013 to January 2016). Participants were 193 critically ill adult patients receiving invasive mechanical ventilation at 3 intensive care units in Toronto, Ontario, Canada. Diaphragm thickness was measured by ultrasonography within 36 hours of intubation and then daily. Patients were classified as having low or high diaphragm muscle mass according to the median baseline Tdi. The primary outcome was time to liberation from ventilation accounting for the competing risk of death and adjusting for age, body mass index, severity of illness, sepsis, change in Tdi during ventilation, baseline comorbidity, and study center. Secondary outcomes included in-hospital death and complications of acute respiratory failure. A total of 193 patients were available for analysis; the mean (SD) age was 60 (15) years, 73 (38%) were female, and the median (interquartile range) Sequential Organ Failure Assessment score was 10 (8-13). Median (interquartile range) baseline Tdi was 2.3 (2.0-2.7) mm. In the primary prespecified analysis, baseline Tdi of 2.3 mm or less was associated with delayed liberation from mechanical ventilation (adjusted hazard ratio for liberation, 0.51; 95% CI, 0.36-0.74). Lower baseline Tdi was associated a higher risk of complications of acute respiratory failure (adjusted odds ratio, 1.77; 95% CI, 1.20-2.61 per 0.5-mm decrement) and prolonged weaning (adjusted odds ratio, 2.30; 95% CI, 1.42-3.74). Lower baseline Tdi was also associated with a higher risk of in-hospital death (adjusted odds ratio, 1.47; 95% CI, 1.00-2.16 per 0.5-mm decrement), particularly after discharge from the intensive care unit (adjusted odds ratio, 2.68; 95% CI, 1.35-5.32 per 0.5-mm decrement). In this study, low baseline diaphragm muscle mass in critically ill patients was associated with prolonged mechanical ventilation, complications of acute respiratory failure, and an increased risk of death in the hospital.

Association of Use of an Intravascular Microaxial Left Ventricular Assist Device vs Intra-aortic Balloon Pump With In-Hospital Mortality and Major Bleeding Among Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock

Acute myocardial infarction (AMI) complicated by cardiogenic shock is associated with substantial morbidity and mortality. Although intravascular microaxial left ventricular assist devices (LVADs) provide greater hemodynamic support as compared with intra-aortic balloon pumps (IABPs), little is known about clinical outcomes associated with intravascular microaxial LVAD use in clinical practice. To examine outcomes among patients undergoing percutaneous coronary intervention (PCI) for AMI complicated by cardiogenic shock treated with mechanical circulatory support (MCS) devices. A propensity-matched registry-based retrospective cohort study of patients with AMI complicated by cardiogenic shock undergoing PCI between October 1, 2015, and December 31, 2017, who were included in data from hospitals participating in the CathPCI and the Chest Pain-MI registries, both part of the American College of Cardiology's National Cardiovascular Data Registry. Patients receiving an intravascular microaxial LVAD were matched with those receiving IABP on demographics, clinical history, presentation, infarct location, coronary anatomy, and clinical laboratory data, with final follow-up through December 31, 2017. Hemodynamic support, categorized as intravascular microaxial LVAD use only, IABP only, other (such as use of a percutaneous extracorporeal ventricular assist system, extracorporeal membrane oxygenation, or a combination of MCS device use), or medical therapy only. The primary outcomes were in-hospital mortality and in-hospital major bleeding. Among 28 304 patients undergoing PCI for AMI complicated by cardiogenic shock, the mean (SD) age was 65.0 (12.6) years, 67.0% were men, 81.3% had an ST-elevation myocardial infarction, and 43.3% had cardiac arrest. Over the study period among patients with AMI, an intravascular microaxial LVAD was used in 6.2% of patients, and IABP was used in 29.9%. Among 1680 propensity-matched pairs, there was a significantly higher risk of in-hospital death associated with use of an intravascular microaxial LVAD (45.0%) vs with an IABP (34.1% [absolute risk difference, 10.9 percentage points {95% CI, 7.6-14.2}; P < .001) and also higher risk of in-hospital major bleeding (intravascular microaxial LVAD [31.3%] vs IABP [16.0%]; absolute risk difference, 15.4 percentage points [95% CI, 12.5-18.2]; P < .001). These associations were consistent regardless of whether patients received a device before or after initiation of PCI. Among patients undergoing PCI for AMI complicated by cardiogenic shock from 2015 to 2017, use of an intravascular microaxial LVAD compared with IABP was associated with higher adjusted risk of in-hospital death and major bleeding complications, although study interpretation is limited by the observational design. Further research may be needed to understand optimal device choice for these patients.

Clinical characteristics and outcomes in coronavirus disease 2019 (COVID-19) patients with and without hypertension: a retrospective study.

The novel coronavirus disease (COVID-19) has spread all over the world in a short time. Information about the differences between COVID-19 patients with and without hypertension is limited. To explore the characteristics and outcomes differences between COVID-19 patients with and without hypertension, the medical records and cardiac biomarkers of 414 patients were analyzed. A total of 149 patients had a history of hypertension, while 265 patients did not have hypertension, and the groups were compared based on their clinical characteristics and laboratory findings as well as the hazard risk for composite outcomes, including intensive care unit (ICU) admission, mechanical ventilation, or death. The results are as follows. On admission, 22.1% of patients in hypertension group had elevated high sensitivity troponin I (hs-TNI > 26 pg/mL), which was higher than the proportion in the nonhypertension group (6.4%). Median NT-proBNP levels in patients with hypertension (141.9 pg/mL) were higher than those in patients without hypertension (77.3 pg/mL). Patients in the hypertension group had a higher risk for in-hospital death [HR: 2.57, 95% CI (1.46~4.51)]. However, the impact of hypertension on the prognosis was not significant after adjusting for age and sex. Multivariate Cox hazard regression confirmed that NT-proBNP levels in the highest tertile (upper 75 % of patients with hypertension) was an independent risk factor for in-hospital death in all COVID-19 patients. Taken together, hypertension per se had a modest impact on the prognosis in COVID-19 patients. In COVID-19 patients with and without hypertension, NT-proBNP may be a better predictor of prognosis than hs-TNI.

Early risk stratification of in hospital mortality following a ground level fall in geriatric patients with normal physiological parameters.

The purpose of this study was to identify risk factors of mortality for geriatric patients who fell from ground level at home and had a normal physiological examination at the scene. Patients aged 65 and above, who sustained a ground level fall (GLF) with normal scene Glasgow Coma Scale (GCS) score 15, systolic blood pressure (SBP)>90 and <160 mmHg, heart rate≥60 and ≤100 beats per minute) from the 2012-2014 National Trauma Data Bank (NTDB) data sets were included in the study. Patients' characteristics, existing comorbidities [history of smoking, chronic kidney disease (CKD), cerebrovascular accident (CVA), diabetes mellitus (DM), and hypertension (HTN) requiring medication], injury severity scores (ISS), American College of Surgeons' (ACS) trauma center designation level, and outcomes were examined for each case. Risks factors of mortality were identified using bivariate analysis and logistic regression modeling. A total of 40,800 patients satisfied the study inclusion criteria. The findings of the logistic regression model for mortality using the covariates age, sex, race, SBP, ISS, ACS trauma level, smoking status, CKD, CVA, DM, and HTN were associated with a higher risk of mortality (p<.05). The fitted model had an Area under the Curve (AUC) measure of 0.75. Cases of geriatric patients who look normal after a fall from ground level at home can still be associated with higher risk of in-hospital death, particularly those who are older, male, have certain comorbidities. These higher-risk patients should be triaged to the hospital with proper evaluation and management.

P1653Admission high-sensitivity troponin T and NT-proBNP for outcome prediction in acute heart failure

Abstract Background High-sensitivity troponin T (hs-TnT) reflects the severity of ongoing myocardial damage and holds independent prognostic significance in chronic heart failure (HF). In acute HF (AHF), its additive prognostic value over natriuretic peptides is unclear. Methods Individual data of 1571 AHF patients with admission hs-TnT were collected from 3 cohorts. Results Patients were aged 78±10 years, and 51% were men. Median hs-TnT and N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) concentrations were 43 ng/L (interquartile interval 26–69) and 5660 (2693–12466), respectively. Patients experiencing in-hospital death (n=187, 13%) had significantly higher hs-TnT and NT-proBNP on admission (both p&lt;0.001). The risk of in-hospital death increased by 45% per each doubling of hs-TnT (HR 1.45, 95% confidence interval - CI 1.31–1.59, p&lt;0.001), and by 32% per each doubling of NT-proBNP (HR 1.32, 95% CI 1.17–1.50, p&lt;0.001). Patients with hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L had a 2.7-fold higher risk of in-hospital death (relative risk - RR 2.7, 95% CI 1.7–4.5). Among the 1262 patients discharged, 1024 deaths occurred over a median 11-month follow-up (4–22). In a model including NT-proBNP, hs-TnT ≥43 ng/L was a strong, independent predictor of all-cause death at 6, 12 and 24 months, and the composite of cardiovascular death or HF hospitalization at 6 and 24 months. hs-TnT ≥43 ng/L also improved risk reclassification. Conclusions The risk of in-hospital death is almost 3 folds higher with admission hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L, and hs-TnT ≥43 ng/L holds strong independent prognostic significance for post-discharge outcome.

Procalcitonin, white blood cell count and C-reactive protein as predictors of S. aureus infection and mortality in infective endocarditis

BackgroundInfective endocarditis (IE) is characterized by high rates of in-hospital death, and Staphylococcus aureus infection predicts a worse prognosis. We aimed to assess if admission inflammatory biomarkers (white blood cell – WBC – count, C-reactive protein — CRP, and procalcitonin) are informative on microbiological etiology and short-term outcomes. MethodsData from 236 patients admitted for IE from January 2013 to June 2018 were retrieved from a multicenter registry. ResultsFifty-two patients (22%) were infected by S. aureus. WBC, CRP and procalcitonin had area under the curve (AUC) values for S. aureus infection of 0.595, 0.675, and 0.727, respectively. Adding procalcitonin to WBC improved discrimination over WBC alone (p = 0.045), and procalcitonin predicted S. aureus infection independently from the other inflammatory biomarkers and patient characteristics. Patients with WBC ≥ 12,800/mm3, CRP ≥ 130 mg/L, and procalcitonin ≥ 1.7 ng/mL had an almost 20-fold higher risk of S. aureus infection than patients with all biomarkers < cut-offs. AUC values for in-hospital death were 0.702, 0.725 and 0.727 for the WBC, CRP, and procalcitonin, respectively. Among inflammatory biomarkers, WBC and procalcitonin independently predicted in-hospital death. Procalcitonin refined risk stratification when added to WBC, and to the combination of WBC and CRP. Patients with WBC ≥ 10,535/mm3, CRP ≥ 85 mg/dL, and procalcitonin ≥ 0.4 ng/mL had a 27-fold higher risk of in-hospital death than patients with all biomarkers < cut-offs. ConclusionsAmong patients with IE, high levels of inflammatory biomarkers on admission, particularly procalcitonin, are associated with a higher likelihood of S. aureus infection, and a higher risk of in-hospital mortality.

A Real-Time Early Warning System for Monitoring Inpatient Mortality Risk: Prospective Study Using Electronic Medical Record Data.

BackgroundThe rapid deterioration observed in the condition of some hospitalized patients can be attributed to either disease progression or imperfect triage and level of care assignment after their admission. An early warning system (EWS) to identify patients at high risk of subsequent intrahospital death can be an effective tool for ensuring patient safety and quality of care and reducing avoidable harm and costs.ObjectiveThe aim of this study was to prospectively validate a real-time EWS designed to predict patients at high risk of inpatient mortality during their hospital episodes.MethodsData were collected from the system-wide electronic medical record (EMR) of two acute Berkshire Health System hospitals, comprising 54,246 inpatient admissions from January 1, 2015, to September 30, 2017, of which 2.30% (1248/54,246) resulted in intrahospital deaths. Multiple machine learning methods (linear and nonlinear) were explored and compared. The tree-based random forest method was selected to develop the predictive application for the intrahospital mortality assessment. After constructing the model, we prospectively validated the algorithms as a real-time inpatient EWS for mortality.ResultsThe EWS algorithm scored patients’ daily and long-term risk of inpatient mortality probability after admission and stratified them into distinct risk groups. In the prospective validation, the EWS prospectively attained a c-statistic of 0.884, where 99 encounters were captured in the highest risk group, 69% (68/99) of whom died during the episodes. It accurately predicted the possibility of death for the top 13.3% (34/255) of the patients at least 40.8 hours before death. Important clinical utilization features, together with coded diagnoses, vital signs, and laboratory test results were recognized as impactful predictors in the final EWS.ConclusionsIn this study, we prospectively demonstrated the capability of the newly-designed EWS to monitor and alert clinicians about patients at high risk of in-hospital death in real time, thereby providing opportunities for timely interventions. This real-time EWS is able to assist clinical decision making and enable more actionable and effective individualized care for patients’ better health outcomes in target medical facilities.

Admission high-sensitivity troponin T and NT-proBNP for outcome prediction in acute heart failure

BackgroundHigh-sensitivity troponin T (hs-TnT) reflects the severity of ongoing myocardial damage. In acute heart failure (AHF), its additive prognostic value over B-type natriuretic peptides is unclear. MethodsIndividual data of 1499 AHF patients with admission hs-TnT were collected from 3 cohorts. ResultsPatients (78 ± 10 years, 51% men, N-terminal fragment of pro-B-type natriuretic peptide – NT-proBNP - 5660 [2693–12,466], hs-TnT 43 ng/L [26–69]) experiencing in-hospital death (n = 187, 13%) had significantly higher hs-TnT and NT-proBNP on admission (both p < 0.001). Patients with hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L had a 2.7-fold higher risk of in-hospital death (relative risk - RR 2.7, 95% confidence interval - CI 1.7–4.5). Among discharged patients, 1024 deaths (81%) occurred over 11 months (4–22). In the whole population, hs-TnT ≥43 ng/L predicted all-cause death at 6, 12 and 24 months independently from NT-proBNP ≥5660 ng/L.The best NT-proBNP cut-off for in-hospital mortality (4382 ng/L) independently predicted this endpoint, while the best hs-TnT cut-off (55 ng/L) did not. Patients with NT-proBNP ≥4382 ng/L and hs-TnT ≥55 ng/L had a 12-fold higher risk of in-hospital death (RR 11.7, 95% CI 6.9–19.7). The best hs-TnT cut-offs independently predicted all post-discharge outcomes. ConclusionsThe best NT-proBNP cut-off (4382 ng/L) independently predicts outcome, while the best hs-TnT (55 ng/L) does not; patients with both biomarkers ≥best cut-offs have a 12-fold higher risk of in-hospital mortality. Admission hs-TnT ≥43 ng/L and the best hs-TnT cut-offs hold independent prognostic significance for post-discharge outcome, while hs-TnT seems less predictive than NT-proBNP when considering absolute values.

Procalcitonin (PCT), C-reactive protein (CRP), cardiac troponin I (TNI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and prognosis in infective endocarditis

Infective endocarditis (IE) is characterized by high rates of in-hospital death, and Staphylococcus aureus infection predicts a worse prognosis. We aimed to assess if admission inflammatory biomarkers (white blood cell – WBC – count, C-reactive protein — CRP, and procalcitonin) are informative on microbiological etiology and short-term outcomes.Data from 236 patients admitted for IE from January 2013 to June 2018 were retrieved from a multicenter registry.Fifty-two patients (22%) were infected by S. aureus. WBC, CRP and procalcitonin had area under the curve (AUC) values for S. aureus infection of 0.595, 0.675, and 0.727, respectively. Adding procalcitonin to WBC improved discrimination over WBC alone (p = 0.045), and procalcitonin predicted S. aureus infection independently from the other inflammatory biomarkers and patient characteristics. Patients with WBC ≥ 12,800/mm3, CRP ≥ 130 mg/L, and procalcitonin ≥ 1.7 ng/mL had an almost 20-fold higher risk of S. aureus infection than patients with all biomarkers < cut-offs. AUC values for in-hospital death were 0.702, 0.725 and 0.727 for the WBC, CRP, and procalcitonin, respectively. Among inflammatory biomarkers, WBC and procalcitonin independently predicted in-hospital death. Procalcitonin refined risk stratification when added to WBC, and to the combination of WBC and CRP. Patients with WBC ≥ 10,535/mm3, CRP ≥ 85 mg/dL, and procalcitonin ≥ 0.4 ng/mL had a 27-fold higher risk of in-hospital death than patients with all biomarkers < cut-offs.Among patients with IE, high levels of inflammatory biomarkers on admission, particularly procalcitonin, are associated with a higher likelihood of S. aureus infection, and a higher risk of in-hospital mortality.

Relation of Admission Blood Pressure to In-hospital and 90-Day Outcomes in Patients Presenting With Transient Ischemic Attack

The association between admission blood pressure (BP) and outcomes in patients with transient ischemic attack (TIA) is not well defined. Patients in the United States national Get With The Guidelines-Stroke registry with a TIA were included. Admission systolic and diastolic BP was used to compute mean arterial pressure and pulse pressure (PP). A subset of this cohort was linked to Centers for Medicare and Medicaid claims data for postdischarge outcomes. The in-hospital outcomes of interest were: mortality, not discharged home, and inability to ambulate independently at discharge. Postdischarge, 30-day and 90-day outcomes of interest were mortality, readmission for stroke, and readmission for major cardiovascular event-composite of death, cerebrovascular, or cardiovascular readmission. Among the 218,803 patients with TIA, lower admission systolic blood pressure (SBP) was associated with worse in-hospital outcomes. Compared with patients with SBP of 150 mm Hg, a lower SBP of 120 mm Hg was associated with higher risk of in-hospital death (adjusted OR = 1.79; 95% CI = 1.50 to 2.12), not being discharged home (adjusted OR = 1.31; 95% CI = 1.27 to 1.36), or inability to ambulate independently at discharge (adjusted OR = 1.27; 95% CI = 1.23 to 1.31). Similarly, among the 64,352 patients in the Centers for Medicare and Medicaid-linked cohort, an inverse association between systolic BP and postdischarge mortality (p <0.0001), and major cardiovascular event (p = 0.0001) was observed at 30-days and at 90-days postdischarge. However, there was no relation between SBP and readmission for stroke either at 30-days (p = 0.35) or at 90-days (p = 0.11). Results were largely similar for diastolic BP, mean arterial pressure, PP, and outcomes. In conclusion, in patients with a transient ischemic attack, a BP paradox was observed, with higher admission BP associated with improved in-hospital, 30-day, and 90-day postdischarge outcomes.

Epidemiology and outcomes of acute kidney injury in hospitalized cancer patients in China.

Acute kidney injury (AKI) is a common complication in cancer patients, but the data are lacking in Asian countries. We aimed to assed the epidemiology, correlated risk factors and outcomes of AKI in cancer patients from China. We conducted a nationwide cohort study of cancer patients who were admitted to 25 general and children hospitals across China from January 1, 2013 to December 31, 2015. We obtained patient-level data from the electronic hospitalization information system and laboratory databases of all inpatients who had at least two serum creatinine tests within any 7-day window during their first 30 days of hospitalization. AKI was defined and staged according to Kidney Disease Improving Global Outcomes criteria. Incidence rate and risk factor profiles for AKI were examined. Outcomes of interest included in-hospital mortality, length of stay and daily costs. A total of 136,756 adult cancer patients were assessed in our study. The overall incidence of AKI was 7.5%, of which 1.6% were community acquired and 5.9% hospital acquired. The top three cancer types with high incidence of AKI were bladder cancer, leukemia, and lymphoma. Risk factors for community-acquired and hospital-acquired AKI were similar, including age, increased baseline serum creatinine, shock and urinary tract obstruction. In-hospital death occurred in 12.0% with AKI vs. 0.9% cancer patients without AKI. After adjustment for confounders, the severe AKI was associated with higher risk of in-hospital death, prolonged length of stay and higher daily costs. Clinicians should increase their awareness of AKI in hospitalized cancer patients.

Sodium Fluctuations and Mortality in a General Hospitalized Population

Background/Aims: Aim of our study was to describe the association between natremia (Na) fluctuation and hospital mortality in a general population admitted to a tertiary medical center. Methods: We performed a retrospective observational cohort study on the patient population admitted to the Fondazione Policlinico A. Gemelli IRCCS Hospital between January 2010 and December 2014 with inclusion of adult patients with at least 2 Na values available and with a normonatremic condition at hospital admission. Patients were categorized according to all Na values recorded during hospital stay in the following groups: normonatremia, hyponatremia, hypernatremia, and mixed dysnatremia. The difference between the highest or the lowest Na value reached during hospital stay and the Na value read at hospital admission was used to identify the maximum Na fluctuation. Cox proportional hazards models were used to estimate hazard ratios (HRs) for in-hospital death in the groups with dysnatremias and across quartiles of Na fluctuation. Covariates assessed were age, sex, highest and lowest Na level, Charlson/Deyo score, cardiovascular diseases, cerebrovascular diseases, dementia, congestive heart failure, severe kidney disease, estimated glomerular filtration rate, and number of Na measurements during hospital stay. Results: 46,634 admissions matched inclusion criteria. Incident dysnatremia was independently associated with in-hospital mortality (hyponatremia: HR 3.11, 95% CI 2.53, 3.84, p < 0.001; hypernatremia: HR 5.12, 95% CI 3.94, 6.65, p < 0.001; mixed-dysnatremia: HR 4.94, 95% CI 3.08, 7.92, p < 0.001). We found a higher risk of in-hospital death by linear increase of quartile of Na fluctuation (p trend <0.001) irrespective of severity of dysnatremia (HR 2.34, 95% CI 1.55, 3.54, p < 0.001, for the highest quartile of Na fluctuation compared with the lowest). Conclusions: Incident dysnatremia is associated with higher hospital mortality. Fluctuation of Na during hospital stay is a prognostic marker for hospital death independent of dysnatremia severity.

Performance of a Hematological Scoring System in Predicting All-Cause Mortality in Patients with Acute Myocardial Infarction

Abstract Background: The presence of nucleated red blood cells (NRBCs) and increases in mean platelet volume (MPV) and neutrophil to lymphocyte ratio (NLR) in peripheral circulation are associated with poorer prognosis in patients with acute coronary disease. Objective: We developed a scoring system for in-hospital surveillance of all-cause mortality using hematological laboratory parameters in patients with acute myocardial infarction (AMI). Methods: Patients admitted for AMI were recruited in this prospective study. Exclusion criteria were age younger than 18 years, glucocorticoid therapy, cancer or hematological diseases and readmissions. NRBCs, MPV and NLR were measured during hospitalization. The scoring system was developed in three steps: first, the magnitude of the association of clinical and laboratory parameters with in-hospital mortality was measured by odds ratio (OR), second, a multivariate logistic regression model was conducted with all variables significantly (p < 0.05) associated with the outcome, and third, a β-coefficient was estimated by multivariate logistic regression with hematological parameters with a p < 0.05. Results: A total of 466 patients (mean age were 64.2 ± 12.8 years, 61.6% male) were included in this study. A hematological scoring system ranging from 0 to 49, where higher values were associated with higher risk of in-hospital death. The best performance was registered for a cut-off value of 26 with sensitivity of 89.1% and specificity of 67.2%, positive predictive value of 26.8% (95% CI: 0.204 - 0.332) and negative predictive value of 97.9% (95% CI: 0.962 - 0.996). The area under the curve for the scoring system was 0.868 (95% CI: 0.818 - 0.918). Conclusions: Here we propose a hematological scoring system for surveillance tool during hospitalization of patients with acute myocardial infarction. Based on total blood count parameters, the instrument can evaluate inflammation and hypoxemia due to in-hospital complications and, consequently, predict in-hospital mortality.

Regional disparity in outcomes among patients hospitalized for Takotsubo cardiomyopathy in the United States✰

IntroductionTakotsubo cardiomyopathy (TTCM), an entity first described in Japan over two decades ago following myocardial stunning cases without evidence of coronary stenosis, has emerged as a unique entity with global recognition. We sought to investigate the extent and magnitude of regional variations in its outcomes. MethodWe used the National Inpatient Sample (NIS) of the Agency for Healthcare Research and Quality (2010–2014). Risk-adjusted rates of outcomes across the US geographical regions were calculated by fitting a Poisson regression model with a robust error variance under generalized estimating equations. Discrete numeric variables with over-dispersed count distributions -length of stay and continuous variables with a right skewed spread- cost of hospitalization were modeled using a generalized linear regression with a negative binomial function and gamma function respectively. ResultWe found significant regional variations in-patient mortality. While there was significantly higher risk of in-hospital death in the West (5.28 [4.34–6.44]) vs 4.40 [3.57–5.43] vs 4.10 [3.38–498] vs 4.78 [3.96–5.77]), there was a different pattern of variation in the length of days with longer hospital stay in the Northeast. Likewise, the risk-adjusted rate of non-routine home discharges was highest for Northeast. The West had the highest cost of hospitalization (West: $40,217 vs. South: $28,465) ConclusionSignificant geographic variation exists in the cost of hospitalization and in-hospital mortality of TTCM across the US. Understanding this variation requires a detailed understanding of the processes of care and identification of effective strategies to eliminate these disparities.

Ten-year trends of palliative care utilization associated with multiple sclerosis patients in the United States from 2005 to 2014

Multiple sclerosis (MS) is a chronic neuro-inflammatory disease of the central nervous system, associated with accumulation of irreversible neurological disabilities through both inflammatory relapses and progressive neurodegeneration. Patients with debilitating MS could benefit from palliative care perspectives both during relapses that lead to transient disability as well as later in the disease course when significant physical and cognitive disability have accrued. However, no data about palliative care utilization trends of MS patients are available. We examined 10-year temporal trends of palliative care and assessed independent associations of palliative care with hospital utilization and cost using the 2005–2014 national inpatient sample. The national trends of palliative care utilization in MS patients increased by 120 times from 0.2% to 6.1% during 2005–2014, particularly with the dramatic single-year increase between 2010 (1.5%) and 2011 (4.5%). Moreover, the proportion of receiving palliative care in in-hospital death gradually increased from 7.7% in 2005 to 58.8% in 2014. Palliative care in MS inpatients may affect hospital utilization and charges in different ways. Hospital palliative care was associated with increased length of stay (LOS) (β = 0.444 days, p < 0.001) and in-hospital death (OR = 15.35, 95% CI [13.76, 17.12]), but associated with decreased hospital charges (β = −$2261, p < 0.001). In conclusion, the temporal trends of palliative care use in MS inpatients gradually increased with an exponential increase between 2010 and 2011 during 2005–2014, which is mostly attributed to patients with higher risk of in-hospital death. Moreover, palliative care was associated with reduced hospital charge with increased LOS and in-hospital death.