Higher Risk Of Mortality Research Articles

EP592 - A surgical case report of an epiploic hernia - A mobile right colon herniating through the foramen of Winslow

Abstract Introduction An Epiploic Hernia is an extremely rare type of abdominal hernia with <0.1 % incidence where the bowel or other intra-abdominal contents herniate through the Foramen of Winslow. A case of an Epiploic hernia in a middle-aged female is presented here. Presentation of case A woman in her 60s was admitted to a tertiary level hospital with severe right sided intermittent upper abdominal pain associated with nausea, bloating and constipation. The symptoms were thought to be due to biliary colic and managed conservatively. Since the symptoms persisted and a computed tomography scan of abdomen was organized. CT scan showed that the caecum was in the upper left quadrant. A laparoscopy was performed and demonstrated that her right colon was mobile herniating through the Foramen of Winslow into the lesser sac. The hernia was reduced, and the bowel was viable. The patient was discharged with no complications. Discussion There have been case reports of small bowel as the content of the hernia with lesser occurrences of caecum, ascending colon, transverse colon, gall bladder, omentum, or Meckel's diverticulum. A caecal herniation through the Foramen of Winslow is reported only with an incidence of 0.02 %. <10 % of these Epiploic hernias are diagnosed preoperatively making it a potentially life-threatening condition if not treated promptly due to high risk of bowel strangulation and mortality of up to 50 %. Conclusion A high index of suspicion is needed for the diagnosis of this internal hernia and radiological investigation is fundamental in making this diagnosis for allowing prompt surgical treatment.

WP5.7 - Do we follow-up our patients after emergency laparotomy?

Abstract Aim Emergency Laparotomy (EL) carries a high risk of major morbidity and mortality and patients can require an extended period of recovery after surgery. Within our organisation, all patients who undergo EL are supported by a dedicated 7-day service to support their mobility, motivation and goal settings as well as wellbeing needs. However, this support does not extend beyond discharge and we do not have standardised follow-up protocol. This audit aimed to review the outpatient follow-up that EL patients received. Methods EL data is recorded prospectively and submitted to the Emergency Laparotomy and Laparoscopic Audit (ELLSA). All ELLSA patients admitted between June 2021 and July 2022 were included. Electronic records were reviewed to see what follow-up they received. Results 258 patients underwent EL during this time period. Only 136 patients received follow-up (53%). Of the appointments carried out, 76% were review by Surgical Team and 45% were review by Colorectal Specialist Nurses. 70% of patients follow-up was face-to-face, with the remainder by telephone. The average time to surgical clinic follow-up was 111days (range 12-371 days). Conclusions Only half of the patients received any follow-up after EL, and even fewer received a face-to-face clinic with their consultant. There was also considerable delay for some patients. We feel this is evidence that a dedicated follow-up service for ELLSA patients is required to reduce this variation. We intend to implement a protocolised follow-up as a result of this audit.

SP1.10 - Patient Perceptions of Shared Decision-Making in Emergency Surgery

Abstract Background Shared decision-making (SDM), a concept becoming increasingly more prevalent in medical practice, is now considered the ‘gold standard’ approach. Research into patient perceptions of SDM is lacking and barriers to its implementation remain, specifically in emergency general surgery. Considering procedures with high mortality risks makes research into patients understanding of SDM here a critical step for its implementation. Aim Explore what emergency surgery patients understand about SDM and their experience of it. Methods A literature review and scoping review determined the quantity and quality of research in this area enabling long-listing of known SDM concepts. This developed questions and structured discussions for the patient and public involvement (PPI) exercise. This exercise was developed following research, patient representative input and discussions with experienced researchers. Twenty-five participants, identified from the local ELLSA database, were invited with their support-person. Small-group discussions considered how surgeons make decisions, what SDM means to patients, and improving this process. Responses were transcribed, then analysed. Results Nine patients and four supporters attended the exercise. Thematic analysis identified two key themes: patient perceptions of how surgeons make decisions, and patient experiences of emergency surgical decision-making. Subtheme analysis showed participants weren’t aware of surgeons’ use of “30-day mortality” and couldn’t quantify surgical risk, feeling time pressures and out-of-control. They relied on surgeons to make their decision. Conclusions Patients who’ve undergone emergency surgery don’t understand how surgeons make emergency surgical decisions. Many reported not experiencing SDM at all. This work provides the first patient-insights into an area requiring more research – on a larger scale.

Immunotherapy and Radiotherapy for Older Patients with Locally Advanced Non-Metastatic Non-Small-Cell Lung Cancer Who Are Not Candidates for or Decline Surgery and Chemotherapy: A Practical Proposal by the International Geriatric Radiotherapy Group.

The standard of care for locally advanced non-small-cell lung cancer (NSCLC) is either surgery combined with chemotherapy pre- or postoperatively or concurrent chemotherapy and radiotherapy. However, older and frail patients may not be candidates for surgery and chemotherapy due to the high mortality risk and are frequently referred to radiotherapy alone, which is better tolerated but carries a high risk of disease recurrence. Recently, immunotherapy with immune checkpoint inhibitors (ICIs) may induce a high response rate among cancer patients with positive programmed death ligand 1 (PD-L1) expression. Immunotherapy is also well tolerated among older patients. Laboratory and clinical studies have reported synergy between radiotherapy and ICI. The combination of ICI and radiotherapy may improve local control and survival for NSCLC patients who are not candidates for surgery and chemotherapy or decline these two modalities. The International Geriatric Radiotherapy Group proposes a protocol combining radiotherapy and immunotherapy based on the presence or absence of PD-L1 to optimize the survival of those patients.

Sarcopenia and cognitive impairment in older adults: Long-term prognostic implications based on the National Health and Nutrition Examination Survey (2011–2014)

AimsThe relationship between sarcopenia and cognitive impairment in older adults remains contentious. This study investigates this association and examines the long-term prognosis for individuals with both conditions. MethodsUtilizing data from the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2014, this study focuses on the correlation between sarcopenia and cognitive impairment, as well as the extended prognosis for individuals managing these conditions. ResultsThe study cohort comprised 2890 participants, with 648 (22.4 %) diagnosed with sarcopenia. Multivariable logistic regression analysis identified a significant association between sarcopenia and an increased risk of cognitive impairment (adjusted odds ratio [aOR]: 1.68, 95 % confidence interval [CI]: 1.30–2.17). Over a median follow-up period of 48 months, 200 individuals (6.9 %) succumbed to cardiovascular and cerebrovascular diseases (CCVDs), including hypertension, congestive heart failure, coronary artery disease, and stroke, as well as Alzheimer's disease (AD). Participants had comorbid conditions such as CCVDs and diabetes mellitus. Kaplan–Meier survival analysis and the Cox proportional hazards model indicated that individuals with both sarcopenia and cognitive impairment had the highest mortality risk from CCVDs and AD (adjusted hazard ratio [aHR]: 2.73, 95 % CI: 1.48–5.02). Individuals with sarcopenia and comorbidities exhibited a higher mortality risk from CCVDs or AD compared to those without sarcopenia but with comorbidities (aHR: 2.71, 95 % CI: 1.37–5.37). ConclusionSarcopenia is independently associated with cognitive impairment. Older adults with both sarcopenia and cognitive impairment or concurrent comorbidities face increased mortality risks from CCVDs or AD compared to their healthy counterparts. Clinical implication•Sarcopenia is associated with cognitive impairment.•Cognitive impairment and comorbidities increased the risk of mortality from CCVDs and AD for sarcopenia patients.

Developing and Verifying an Effective Diagnostic Model Linked to Immune Infiltration in Stanford Type A Aortic Dissection

Background: The deadly cardiovascular condition known as Stanford type A aortic dissection (TAAD) carries a high risk of morbidity and mortality. One important step in the pathophysiology of the condition is the influx of immune cells into the aorta media, which causes medial degeneration. The purpose of this work was to investigate the potential pathogenic significance of immune cell infiltration in TAAD and to test for associated biomarkers. Methods: The National Center for Biotechnology Information (NCBI) Gene Expression Omnibus (GEO) database provided the RNA sequencing microarray data (GSE153434, GPL20795, GSE52093). Immune cell infiltration abundance was predicted using ImmuCellAI. GEO2R was used to select differentially expressed genes (DEGs), which were then processed for Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. Additionally, hub genes linked to immune infiltration were found using functional and pathway enrichment, least absolute shrinkage and selection operator (LASSO), weighted gene co-expression network analysis (WGCNA), and differential expression analysis. Lastly, hub genes were validated and assessed using receiver operating characteristic (ROC) curves in the microarray dataset GSE52093. The hub gene expression and its connection to immune infiltration in TAAD were confirmed using both animal models and clinic data. Results: We identified the most important connections between macrophages, T helper cell 17 (Th17), iTreg cells, B cells, natural killer cells and TAAD. And screened seven hub genes associated with immune cell infiltration: ABCG2, FAM20C, ELL2, MTHFD2, ANKRD6, GLRX, and CDCP1. The diagnostic model in TAAD diagnosis with the area under ROC (AUC) was 0.996, and the sensitivity was 99.21%, the specificity was 98.67%, which demonstrated a surprisingly strong diagnostic power of TAAD in the validation datasets. The expression pattern of four hub DEGs (ABCG2, FAM20C, MTHFD2, CDCP1) in clinic samples and animal models matched bioinformatics analysis, and ABCG2, FAM20C, MTHFD2 up-regulation, and the of CDCP1 down-regulation were also linked to poor cardiovascular function. Conclusions: This study developed and verified an effective diagnostic model linked to immune infiltration in TAAD, providing new approaches to studying the potential pathogenesis of TAAD and discovering new medication intervention targets.

Impact of targeted neonatal echocardiography consultations for critically sick preterm neonates

RationalePreterm neonates needing rescue treatments with inotropes and/or inhaled nitric oxide (iNO) (acute critical illnesses, ACIs) in neonatal intensive care units (NICUs) are at high risk of mortality. While targeted...

Opioid Prescriptions for US Patients Undergoing Long-Term Dialysis or with Kidney Transplant from 2011 to 2020.

Pain is important for patients with kidney failure, but opioid medication prescriptions are associated with morbidity and mortality. The Centers for Disease Control and Prevention issued opioid prescription guidelines in 2016 and 2022, associated with dramatically decreased prescription rates in the United States. It is critical to know if nationwide opioid prescription rates for patients with kidney failure have decreased. We analyzed the USRDS database from 2011 to 2020 to describe trends in the proportion of ESKD patients who received one or more, or long-term opioid prescriptions, examined factors associated with long-term opioid prescriptions, and evaluated associations of all-cause death with short-term or long-term opioid prescriptions. From 2011-2022, the percentage of patients with kidney failure (dialysis and kidney transplant) who received at least one or more, or who had received long-term opioid medication prescriptions decreased steadily, from 60% to 42%, and from 23% to 13%, respectively (both P for trend <0.001). The largest reductions in prescription rates were for hydrocodone and oxycodone. Similar trends existed for dialysis and kidney transplant patients. Women, the poor and those in rural settings were more likely to receive long-term opioid prescriptions. Prescription rates were highest in White patients and those 45 to 64 years old. Short-term and long-term opioid medication prescriptions were associated with higher mortality in both dialysis and kidney transplant patients. ESKD patients' opioid prescription rates decreased between 2011 and 2020. Higher mortality risk was associated with both short-term and long-term opioid prescriptions. Mortality risk was monotonically associated with morphine milligram equivalents in patients with kidney failure who received long-term opioid prescriptions.

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Peripheral artery disease is a considered as one of the major macrovascular complications in diabetes mellitus type 2. It is chronic arteriosclerotic illness that mainly affects the lower limbs and is presented as narrowed or blocked blood vessels. The prevalence increases with the age, it affects 15-20% of persons older than 70 years age, 10-15% of the general population. Smoking and high cholesterol levels increase the risk for PAD progression in large blood vessels such as legs, while diabetes increases the risk for PAD in small blood vessels such as the feet. Critical ischemia, its most severe form can lead to limb amputation and the patient’s death, and even its asymptomatic forms are associated with a high risk of cardiovascular morbidity and mortality. Approximately more than half of all patients are asymptomatic and preventive therapy reduces the risk of complications and death, so it’s important to recognize the subclinical forms in time and to control risk factors of disease. The risk factors that can be modified are tobacco use, hypertension, hyperlipidemia, diabetes mellitus, obesity and some of them cannot be modified such as age, sex or family medical history. Diabetes mellitus type 2 is considered as the most important risk factor for development of peripheral artery disease. The experts suggest that is necessary to establish an HBA1C therapeutic target below 8% in patient with DM and PAD.

Echocardiographic assessment of right ventricular function and right ventriculoarterial coupling in tricuspid regurgitation.

Echocardiographic evaluation of the cardiopulmonary unit is difficult in case of tricuspid regurgitation (TR) and combined echocardiographic parameters could be useful. This study aimed to assess the variation of simple and combined echocardiographic parameters analysing the cardiopulmonary unit according to the severity of TR. TR was graded according to Hahn's classification in 179 patients. Classical morphological, function and load parameters analysing right ventricle were assessed. Combined parameters of function and load; morphology and load; and morphology-load-function index were calculated. We used ROC curve analysis to analyze the diagnostic value of echocardiographic parameters to predict potential high or low surgical risk of mortality according to TRISCORE in 82 patients. Simple parameters were significatively different among groups with a nonlinear progression between the 5 levels of severity of TR. Combined parameters were also significatively different among groups. Among them, myomechanical index (MMI = RV-RA mean pressure gradient x RVFWS/indexed RAED area × 10-2) and morphology-load-function index (MLF = RVED length/area x TR TVI x RVFWS) had a linear progression between the 5 groups and had the best predictive value for TRISCORE high and low risk. Combined parameters are relevant to evaluate cardiopulmonary unit in patients with various degrees of TR, especially when combining morphology, function, and load parameters, and are potentially interesting in their prognostic assessment, as shown by the good predictive value for TRISCORE risk.

Mortality Predictors and Neurological Outcomes Following Extracorporeal Cardiopulmonary Resuscitation (eCPR): A Single-Center Retrospective Study.

Extracorporeal cardiopulmonary resuscitation (eCPR) offers cardiorespiratory support to patients experiencing cardiac arrest. However, this technology is not yet considered a standard treatment, and the evidence on eCPR criteria and its association with survival and good neurological outcomes remains scarce. Therefore, we aimed to investigate the overall mortality and risk factors for mortality. Moreover, we provide a comparison of demographic, clinical, and laboratory characteristics of patients, including neurological outcomes and adverse events during support. This retrospective analysis included in-hospital and out-of-hospital cardiac arrest patients who received eCPR and were admitted between January 2008 and June 2022 at a tertiary and trauma one-level university hospital in Austria. In total, 90 patients fulfilled inclusion criteria, 41 (46%) patients survived until intensive care unit discharge, and 39 (43%) survived until hospital discharge. The most common cause of cardiac arrest was myocardial infarction (42, 47%), and non-shockable initial rhythm was reported in 50 patients (56%). Of 33 survivors with documented outcomes, 30 had a good recovery as measured with Cerebral Performance Category score, 2 suffered severe disability, and 1 remained in a persistent vegetative state. Finally, multivariate analysis identified asystole as initial rhythm (HR 2.88, p = 0.049), prolonged CPR (HR 1.02, p = 0.043), and CPR on the weekend (HR 2.57, p = 0.032) as factors with a higher risk of mortality. eCPR-related decision-making could be additionally supported by the comprehension of the reported risk factors for mortality and severe disability. Further studies are needed to elucidate the impact of peri-arrest variables on outcomes, aiming to improve patient selection.

PTH may predict early mortality in incident patients on hemodialysis: results from a large cohort.

Parathyroid hormone (PTH) is merit as a risk factor for mortality in patients with chronic kidney disease in prevalent hemodialysis patients in a U shape. Most studies, however, do not focus on incident patients and those who died within the first 90days of therapy. We evaluated PTH as a risk factor for mortality in a large cohort population in Brazil. This is an observational cohort study that included 4317 adult patients who initiated hemodialysis between July 1st, 2012 and June 30, 2017. The main outcome was all-cause mortality. Fine-gray sub-distribution hazard models were used to evaluate survival in the presence of a competing event (kidney transplant). Median PTH levels of 252 (118, 479) pg/mL. There were 331 deaths during the first 90days of therapy (6.7%), 430 in a 1-year follow-up (10.7%) and 1282 (32%) during the 5-year study period. Deaths according to PTH < 150, 150-600 and > 600pg/mL corresponded to 38.1%, 33.0% and 28.5%, respectively (p < 0.001). In an adjusted model, patients who started dialysis with PTH < 150pg/mL had a higher mortality risk within the first 90days, but not in 1year and 5years after starting dialysis. Analyses in a subset of patients with a repeated PTH in 1year (N = 1954) showed that although persistent PTH low levels (< 150pg/mL) at 1year were significantly associated with all-cause mortality, this result was not sustained after multiple adjustments. PTH < 150pg/mL confers a high mortality risk in the first 90days of dialysis. If this result reflects poor nutritional conditions, it deserves further investigations.

Lipid-Lowering Treatment Gaps in Patients after Acute Myocardial Infarction: Using Global Database TriNetX.

Background and Objectives: Patients with previous acute myocardial infarction are at significantly higher risk of recurrent events. Early and intensive lipid-lowering therapy targeting low-density lipoprotein cholesterol is a key strategy for reducing cardiovascular risk in post-acute myocardial infarction patients worldwide. This study aimed to assess patients' real-life lipid-lowering treatment gaps after acute myocardial infarction using a global network, TriNetX, of anonymous, real-time patient data. The uniqueness of the study was the use of the novel, evolving, and constantly improving TriNetX platform and the evaluation of its feasibility for clinical research. Materials and Methods: A retrospective study was conducted on global repository patients in 2020, diagnosed with acute myocardial infarction, with a three-year follow-up. Results: After acute myocardial infarction, the prescribing rate of lipid-lowering medication (statins, ezetimibe and PCSK9I) was insufficient to reach target LDL-C values. The mean LDL-C level decreased from 2.7 mmol/L (103 mg/dL) as measured on the day of AMI to 1.97 mmol/L (76 mg/dL) between 31D and 3M. During the second and third years, the mean LDL-C value was stable (around 2.0 mmol/L (78 mg/dL)). LDL-C goals were not sufficiently reached, as only 7-12% of patients were reported to have LDL-C values < 55 mg/dL (1.4 mmol/L) and 13-20% of patients were reported to have LDL-C values < 70 mg/dL (1.8 mmol/L) during the follow-up periods. This means that a substantial number of patients remain at a very high risk for CV complications and mortality. Most cardiovascular complications happen within three months after acute myocardial infarction. Conclusions: Gaps remain between the recommendations for managing LDL-C in guidelines and what occurs in real life. The TriNetX platform is an innovative platform with significant potential and should be further developed for clinical research, as it enables the use of valuable interinstitutional data.

Patterns of care and outcomes for hepatocellular carcinoma and pancreatic cancer based on rurality of patient’s residence in a rural midwestern state

BackgroundAlthough advancements in surgical planning and multidisciplinary care have improved the survival of patients with hepatopancreatic cancers in recent years, the impact of the rurality of patient residence on care received and survival is not well known. We aimed to assess the association between the rurality of a patient’s residence and cancer-specific survival outcomes among patients with hepatocellular carcinoma (HCC) and pancreatic cancer (PC) in Iowa, hypothesizing that patients in rural areas would experience lower survival. MethodsAdult patients diagnosed with HCC or PC between 2010 and 2020 were identified using the Iowa Cancer Registry. Chi-square tests were used to compare categorical variables by rural/urban status. Logistic regression was used to examine factors associated with receiving surgery. Multivariable-adjusted Cox proportional hazards regression was used to determine associations with cancer-specific mortality. ResultsOf 1877 patients with HCC, 58%, 27%, and 16% resided in metropolitan, micropolitan, and rural areas, respectively. Approximately 70% of patients in rural areas traveled ≥50 miles for definitive care. Additionally, those residing in rural areas had the highest proportion of patients receiving definitive care at non-Commission on Cancer (CoC) centers (12.6% metro vs 14% micro vs 22.2% rural, P < .001). In a multivariable-adjusted analysis of patients with stage I to III disease, definitive care at a non-CoC center was independently associated with lower odds of surgery (odds ratio [OR] = 0.23; 95% CI, 0.12–0.45; P < .0001) and higher mortality risk (OR = 1.39; 95% CI, 1.07–1.79; P = .01), though rural residence was not. For PC, 5465 patients were diagnosed, and 51%, 28%, and 20% resided in metropolitan, micropolitan, and rural areas, respectively. Similar to HCC, although rural residence was neither associated with odds of surgery nor with mortality risk, receiving definitive care at non-CoC accredited centers was associated with significantly lower odds of receiving surgery (OR = 0.17; 95% CI, 0.11–0.26; P < .0001) and higher mortality risk (OR = 1.48; 95% CI, 1.23–1.77; P < .0001). ConclusionRural residents with hepatopancreatic cancer have the highest proportion of patients receiving definitive care at non-CoC centers, which is associated with lower odds of receiving surgery and higher odds of mortality. This highlights the importance of standardizing complex cancer care and the need to foster collaboration between specialized and non-specialized centers.

A Single-center Experience With >200 Lung Transplant Recipients With COVID-19 Infection.

Although COVID-19 is no longer a declared global health emergency, data remain limited on the impact of COVID-19 in lung transplant recipients. We identified lung transplant recipients who were diagnosed with COVID-19 from March 2020 through August 2022 in our institutional database and investigated clinical outcomes. We then analyzed outcomes based on date of COVID-19 diagnosis (first wave March 2020-October 2020; second wave November 2020-2021; third wave December 2021-September 2022) and compared these results. Of the 210 lung transplant recipients (median age 67; 67% men) enrolled, 140 (67%) required hospital admission. Among admitted recipients, 35 (25%) were intubated and 7 (5%) were placed on extracorporeal membrane oxygenation. Overall survival was 67.1% at 1 y and 59.0% at 2 y post-COVID-19 diagnosis. COVID-19 led to mortality in all 5 patients diagnosed during their index admission for lung transplantation. Although overall survival was significantly better in recipients with COVID-19 during the third wave, in-hospital mortality remained high (first wave 28%, second wave 38%, and 28% third wave). Vaccination (partially vaccinated versus none and fully vaccinated versus none) was the only significant protective factor for hospital admission, and age 70 y and older and partially vaccinated (versus none or fully vaccinated) were independent risk factors for in-hospital mortality. Overall survival after COVID-19 infection in lung transplant recipients continues to improve; however, in-hospital mortality remains remarkably high. Vaccination appears to have been impactful in preventing hospital admission, but its impact on in-hospital mortality is still unclear. Further research is needed to better identify lung transplant recipients at high risk for mortality from COVID-19.

Retrospective analysis of Acinetobacter baumannii bacteraemia risk factors, complications and mortality in a tertiary university hospital in Saudi Arabia.

Introduction. There are many multidrug-resistant isolates of the nosocomial pathogen, Acinetobacter baumannii, causing severe healthcare-acquired infections in terminally ill patients with high mortality and morbidity rates. Aim. This study aims to retrospectively analyse A. baumannii bacteraemia (ABB) cases in Saudi Arabia, where the information is sparse regarding the prevalence, risk factors, clinical disease, antibiotic regimen, antibiotic susceptibility, treatment outcomes and mortality associated with this infection. Methods. A retrospective chart review was conducted between 1 January 2015 and 31 December 2022 to identify all patients aged 14 years and above with ABB. Demographic and clinical data, as well as results from laboratory analyses, were collected from patients' electronic charts. Statistical analyses were performed on the data to identify factors associated with 90-day mortality. Results. Of the 122 ABB cases, 71 (63.4%) died. The factors that were found to be associated with 90-day mortality were the Charlson Comorbidity Index, Pitt bacteraemia score, quick Sequential Organ Failure Assessment score (P<0.001 for each), hospital ward (P<0.02), short duration of antibiotic treatment (P<0.01) and higher age (P<0.05). The most common source of infection was central line-associated bloodstream infection in 52.7%. Also associated with mortality were inappropriate antimicrobial therapy (P<0.02) and empirical use of colistin (P<0.05). In many patients, ABB was caused by carbapenem-resistant A. baumannii [(CRAB), 69.6%], and 74.4% of those patients died. Conclusion. To prevent ABB-associated mortality, an appropriate regimen and duration of treatment are necessary. Hospitals should also practice proper hygiene to prevent the spread of ABB. CRAB is a growing threat in hospitals in Saudi Arabia, especially in the critical care setting, and carries a very high risk of mortality.

The Open Abdomen After Intra-abdominal Contamination in Emergency General Surgery

IntroductionDelayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination. MethodsThis retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality. ResultsWe identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027). ConclusionsIn the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.

Sex differences in clinical presentation, treatment response, and side effects of nutritional therapy among patients at nutritional risk: a secondary analysis of the randomized clinical trial EFFORT

BackgroundConsidering sex-specific factors has become an increasingly recognized area for research and practice, in the field of clinical nutrition, there is insufficient evidence regarding differences in clinical presentation, treatment response, and side effects of nutritional therapy among female and male patients. ObjectivesWe hypothesized that the clinical presentation, response to nutritional therapy, and side effects from the intervention would differ in the two sexes. MethodsThis secondary analysis investigated differences among female and male patients at risk for malnutrition regarding initial presentation, clinical outcomes, and treatment response in patients included in the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized controlled trial comparing individualized nutritional support to usual care. ResultsOf 2028 patients included in the trial, 964 were females and 1064 were males. The nutritional history and clinical presentation of female patients was different: they consumed less food and had a greater loss of appetite than the male population. Male patients had higher risk for mortality at 180 d [27% compared with 19%; adjusted hazards ratio (HR): 1.35; 95% CI: 1.12, 1.63] and further adverse clinical outcomes. However, there was no difference in the effect of nutritional support on mortality among female and male patients (HR: 0.76; 95% CI: 0.45, 1.27, compared with HR: 0.81; 95% CI: 0.54, 1.21, respectively; P-interaction = 0.939). ConclusionsResults of this multicenter randomized trial suggest that multimorbid female inpatients have a different clinical presentation and are more prone to loss of appetite and reduced daily dietary intake than male inpatients. Importantly, the favorable response to nutritional interventions was similar in both sexes.This trial was registered at clinicaltrials.gov as NCT02517476.

Abstract 28: A major effect of aprocitentan on albuminuria in patients with resistant hypertension

Background and Objectives: Micro- and macroalbuminuria measured by urinary albumin-to-creatinine ratio (UACR) (30–300 mg/g and &gt;300 mg/g, respectively), and high normal UACR (10–30 mg/g) are associated with higher risk of mortality, CV disease and CKD progression in patients with hypertension, diabetes, decreased renal function, or even the general population and reduction can lower these risks. The endothelin ETA/ETB receptor antagonist aprocitentan reduced albuminuria in patients with confirmed resistant hypertension (RHT). In the PRECISION trial, in addition to standard background therapy including valsartan, aprocitentan 12.5 mg reduced UACR by 30% compared to placebo (LS Geom Mean [95 CL] 0.70 [0.61, 0.80], p&lt;0.0001) and 25 mg by 34% (0.66 [0.58,0.75], p&lt;0.0001) at the end of double-blind part 1 (4 weeks) in the overall population. In this analysis, we evaluated the effect of aprocitentan on UACR at both doses according to the baseline (BL) albuminuria (30–300 mg/g and &gt;300 mg/g). Methods: 730 patients with RHT on a standardized fixed-dose combination of amlodipine/ valsartan/hydrochlorothiazide were randomized to aprocitentan (12.5 mg or 25 mg) or placebo. Of these, 174 and 90 had BL microalbuminuria or macroalbuminuria, respectively. Changes from BL in UACR and office systolic blood pressure measured at trough (SBP, the primary endpoint in PRECISION) after 4 weeks of double-blind treatment. Results: In subjects with microalbuminuria, aprocitentan reduced UACR by 43% in the 12.5 mg group (0.57 [0.42, 0.78], p=0.0005) and by 45% in the 25 mg group (0.55 [0.40,0.77], p=0.0004) compared to placebo. In subjects with macroalbuminuria, aprocitentan reduced UACR by 48% with 12.5 mg (0.52 [0.37, 0.75], p=0.0006) and by 61% with 25 mg (0.39 [0.27,0.57], p&lt;0.0001) compared to placebo. In contrast, placebo did not have any noticeable effect on albuminuria in any group. The effect of aprocitentan in lowering blood pressure, measured at trough, was independent of the level of albuminuria at baseline. After 4 weeks, 53.3% and 60% of patients achieved a decrease of ≥10 mmHg from baseline with 12.5 mg aprocitentan, respectively in the microalbuminuria and macroalbuminuria groups, compared to 64% with aprocitentan 25 mg (both cohorts) and 48% and 29% in the placebo group. Conclusion: Aprocitentan produced a major decrease of albuminuria regardless of baseline level in patients with RHT. These findings suggest substantial clinical benefit of aprocitentan in CKD patients.

Machine Learning for Targeted Advance Care Planning in Cancer Patients: A Quality Improvement Study

ContextPrognostication challenges contribute to delays in advance care planning (ACP) for patients with cancer near the end of life (EOL). ObjectivesExamine a quality improvement mortality prediction algorithm intervention's impact on ACP documentation and EOL care. MethodsWe implemented a validated mortality risk prediction machine learning model for solid malignancy patients admitted from the emergency department (ED) to a dedicated solid malignancy unit at Duke University Hospital. Clinicians received an email when a patient was identified as high-risk. We compared ACP documentation and EOL care outcomes before and after the notification intervention. We excluded patients with intensive care unit (ICU) admission in the first 24 hours. Comparisons involved chi-square/Fisher's exact tests and Wilcoxon rank sum tests; comparisons stratified by physician specialty employ Cochran-Mantel-Haenszel tests. ResultsPreintervention and postintervention cohorts comprised 88 and 77 patients, respectively. Most were White, non-Hispanic/Latino, and married. ACP conversations were documented for 2.3% of hospitalizations preintervention vs. 80.5% postintervention (P<0.001), and if the attending physician notified was a palliative care specialist (4.1% vs. 84.6%) or oncologist (0% vs. 76.3%) (P<0.001). There were no differences between groups in length of stay (LOS), hospice referral, code status change, ICU admissions or LOS, 30-day readmissions, 30-day ED visits, and inpatient and 30-day deaths. ConclusionIdentifying patients with cancer and high mortality risk via machine learning elicited a substantial increase in documented ACP conversations but did not impact EOL care. Our intervention showed promise in changing clinician behavior. Further integration of this model in clinical practice is ongoing.