Higher 30-day Mortality Research Articles

Value of serum tryptophan in stratified management of 90-day mortality risk in patients with hepatitis B virus-related acute-on-chronic liver failure: a multicenter retrospective study.

To explore the correlation of serum tryptophan level with 90-day mortality risk in patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF). This retrospective study was conducted among 108 patients with HBV-ACLF, whose survival outcomes within 90 days after diagnosis were recorded. The correlation of baseline serum tryptophan levels measured by high-performance liquid chromatography with 90-day mortality of the patients was analyzed, and the predictive value of serum tryptophan for 90-day mortality was explored. Within 90 days after diagnosis, 53 (29.4%) of the patients died and 127 (70.6%) survived. The deceased patients had significantly lower baseline serum tryptophan levels than the survivors (7.31±3.73 pg/mL vs 13.32±7.15 pg/mL, P<0.001). Multivariate analysis suggested that serum tryptophan level was an independent factor correlated with mortality of HBV-ACLF after adjustment for confounding variables. The patients with serum tryptophan levels below the median level (10.14 pg/mL) at admission had significantly higher 90-day mortality risks than those with higher tryptophan levels (43.3% vs 15.6%, HR: 3.157, 95% CI: 1.713-5.817), and the complication by kidney dysfunction further increased the risk to 73.3% as compared with patients with higher serum tryptophan levels with normal kidney function (15.0%; HR: 7.558, 95% CI: 3.369-16.960). Serum tryptophan levels had an area under the receiver operating characteristic curve of 0.771 (95% CI: 0.699-0.844) for predicting 90-day mortality. Serum tryptophan level is closely correlated with the survival outcomes of patients with HBV-ACLF, and a decreased tryptophan level indicates a high 90-day mortality risk, which can be further increased by the complication by kidney dysfunction.

Circle of Willis Variants and Their Association with Outcome after Successful Revascularization of Anterior Large Vessel Occlusion.

Leptomeningeal collaterals have been associated with better outcomes in large-vessel stroke, but little is known about how the Circle of Willis (CoW) collaterals affect stroke outcomes. We aimed to determine the relationship between three anatomically distinct CoW subtypes and 90-day outcomes in acute ischemic stroke patients after successful revascularization via endovascular thrombectomy (EVT). We performed a retrospective analysis of patients treated with successful EVT for large-vessel occlusion at a comprehensive stroke center between May 2016 and November 2023. The CoW anatomy was trichotomized using baseline computed tomography angiography as follows: (I) complete CoW (C-CoW), (II) non-isolating incomplete CoW (NI-CoW), and (III) isolating incomplete CoW (I-CoW). Chi-squared and logistic regression analyses were utilized to determine the association of the CoW subtype with two co-primary outcomes: the 90-day modified Rankin Scale and 90-day mortality. A total of 465 patients were included in the analysis. Multivariable logistic regression analysis demonstrated a significant association between I-CoW and 90-day mRS compared to NI-CoW [OR (95% CI), 1.83 (1.08-3.09); p=0.02]. Additionally, I-CoW anatomy was associated with a higher 90-day mortality than C-CoW [OR (95%CI), 2.58 (1.01-6.60); p=0.04] and NI-CoW [OR (95% CI), 1.89 (1.13-3.18); p=0.01]. CoW variants are associated with functional and mortality outcomes in patients treated with endovascular thrombectomy for anterior circulation large vessel occlusion. Further research is needed to determine how CoW vessel anatomy may impact clinical assessment, triage, and treatment in acute ischemic stroke. CoW = Circle of Willis; EVT = endovascular thrombectomy; C-CoW = complete Circle of Willis; NI-CoW = non-isolating incomplete Circle of Willis; I-CoW = isolating Circle of Willis; AIS = acute ischemic stroke; LVO = large vessel occlusion; ACom = anterior communicating artery; PCom = posterior communicating artery; Tan CS = Tan collateral scores; ACA = anterior cerebral artery; PCA = posterior cerebral artery.

Postoperative Outcomes Following Lung Resection Performed at Private Equity-Acquired Hospitals.

Private equity acquisition of hospitals performing complex operations is increasingly prevalent in the United States healthcare landscape. While comparative health outcomes for common medical conditions have been investigated, the quality of thoracic surgical care in private equity-acquired hospitals is unknown. Medicare Beneficiaries, aged 65-99 years, undergoing elective lung resection between 2016 to 2020 were included. Private equity-acquired hospitals were identified using the Agency for Healthcare Research and Quality Health System Compendium. Postoperative outcomes, including 30-day mortality, complications, failure to rescue, readmission, and postoperative length of stay were risk-adjusted and compared to non-acquired hospitals using logistic regression considering patient age, sex, comorbidities, procedure type, and year of procedure. Of 144,223 beneficiaries undergoing lung resection, 11,140 (7.7%) received care at private equity-acquired hospitals. Private equity-acquired hospitals performed fewer lung resections annually (mean = 4.2) than non-acquired hospitals (mean = 10.5; p<0.001). Compared to non-acquired hospitals, patients treated at private equity-acquired hospitals demonstrated higher rates of 30-day mortality (2.1% vs 1.9%, OR 1.17 (1.03-1.33); p=0.019), serious complications (8.1% vs 6.8%, OR 1.29 (1.19-1.39); p<0.001), 30-day readmission (10.6% vs 9.9%, OR 1.08 (1.01-1.15); p=0.028), and longer postoperative length of stay (5.9 vs 5.3 days; p<0.001). Failure to rescue rates were not significantly different (9.8% vs 9.4%, OR 1.05 (0.90-1.23); p=0.518). These findings raise concern that private equity-acquired hospitals may provide lower-quality care for patients undergoing common thoracic procedures. Underlying structural factors may contribute to these differences. This motivates further investigation of specialty surgical care performed at private equity-acquired health institutions.

Serial Procalcitonin Measurements for Determining Bacterial Infection and Mortality in Cirrhotic Patients With Systemic Inflammatory Response Syndrome.

The utility of serial procalcitonin (PCT) measurements in cirrhotic patients with systemic inflammatory response syndrome (SIRS) is not well understood. The aim of this study was to assess the effectiveness of serial PCT measurements for diagnosing bacterial infections and predicting 30-day mortality in this population. We prospectively studied 120 cirrhotic patients with SIRS, 64.2% of whom had bacterial infections. Serial PCT levels were measured within the first 72 hours of admission. Patients with bacterial infections had significantly higher PCT levels at admission, 24 hours, and 72 hours compared with those without infections. PCT values >0.5 ng/mL within 72 hours demonstrated high sensitivity (81.8-87.5%) but moderate specificity (27.9-44.2%) for diagnosing bacterial infections. Serial PCT monitoring, including the 72-hr/baseline ratio and changes in PCT over 72 hours, provided insights into the evolution of bacterial infections and short-term mortality. Patients with a PCT 72-hour/baseline ratio >0.8 had higher 30-day mortality than those with a ratio <0.5 (50.0% vs 25.6%; odds ratio 3.91, 95% CI 1.40-10.97). Patients whose PCT levels decreased by >50% had lower 30-day mortality than those with increasing levels (23.3% vs 46.7%; odds ratio 0.25, 95% CI 0.08-0.74). Patients with Model for End-Stage Liver Disease scores >15 and bacterial infections who experienced a PCT decrease of <50% had higher 30-day mortality than those with greater reductions (57.7% vs 25.0%, P = 0.021). Serial PCT measurements within 72 hours of admission are useful for determining bacterial infections and mortality in cirrhotic patients with SIRS. PCT monitoring may optimize antibiotic use and enhance early risk stratification, potentially improving patient outcomes.

Predictive Potential of ECMO Blood Flow for Hemolysis and Outcome of Patients with Severe ARDS.

Background: Treatment with veno-venous extracorporeal membrane oxygenation (VV ECMO) has become a frequently considered rescue therapy in patients with severe acute respiratory distress syndrome (ARDS). Hemolysis is a common complication in patients treated with ECMO. Currently, it is unclear whether increased ECMO blood flow (Q̇EC) contributes to mortality and might be associated with increased hemolysis. Methods: A total of 441 patients with ARDS and VV ECMO, treated in a tertiary ARDS center, were included. The Q̇EC value for a significant increase in ICU mortality was determined by binary recursive partitioning. Linear regression analysis was performed to analyze a correlation between mean Q̇EC and mean plasma concentrations of cell-free hemoglobin (CFH). Results: A Q̇EC of 4 L/min divided the cohort into two groups with significantly different ICU mortality (Q̇EC ≤ 4 L/min: 39.3% (n = 300) versus Q̇EC > 4 L/min: 71.6% (n = 141), p < 0.001). Patients with Q̇EC > 4 L/min had a higher 28-day mortality. Furthermore, a higher mean Q̇EC was associated with increased CFH and decreased haptoglobin plasma concentrations. Conclusion: In patients with ARDS and VV ECMO, a mean Q̇EC > 4 L/min is associated with increased mortality, increased CFH and decreased haptoglobin plasma concentrations. Whether increased hemolysis determines the poorer outcome associated with higher Q̇EC should be the subject of future research.

Association of the geriatric nutritional risk index with poor outcomes in patients with coronary revascularization: a cohort study.

Poor nutritional status may affect outcomes after coronary revascularization, but the association between nutritional status and outcomes in patients undergoing coronary revascularization has not been fully evaluated. This study was based on the MIMIC-IV database to analyze the impact of baseline nutritional status on poor outcomes in patients with coronary revascularization. Patients with coronary revascularization were screened from the MIMIC-IV database. A geriatric nutritional risk index (GNRI) was calculated and used to divide patients into 4 groups: no malnutrition (Q4: ≥96.79), mild malnutrition (Q3: 90.85-96.78), moderate malnutrition (Q2: 86.37-90.84), and severe malnutrition (Q1: 86.37). The primary outcome measure was 28-day mortality, and the secondary outcome measures were AKI and length of hospital stay. Cox proportional hazards model, Kaplan-Meier survival analysis, restricted cubic spline (RCS), and multiple linear regression model were used for statistical analysis, respectively, to ensure the robustness of study results. A total of 1,168 patients with coronary revascularization were included. The GNRI demonstrated a significant association with 28-day mortality in patients undergoing coronary revascularization. As a continuous variable, the GNRI exhibited a notable inverse correlation with mortality across unadjusted, partially adjusted, and fully adjusted Cox regression models [hazard ratios (HRs): 0.93, 0.94, 0.96, respectively; all P < 0.001]. When considered as a categorical variable, a low GNRI (first quartile, Q1) was significantly associated with elevated mortality risks (HRs: 2.64, 2.30, 1.82 in the unadjusted, partially adjusted, and fully adjusted models, respectively; all P < 0.05). Subgroup analysis revealed a more pronounced association in patients under 65 years of age (P for interaction = 0.014). Furthermore, reduced GNRI levels were also associated with an increased incidence of AKI and extended hospital lengths of stay. GNRI is associated with prognosis in patients with coronary revascularization. Patients with lower GNRI had higher 28-day mortality, greater risk of AKI, and longer hospital stays.

Reintervention for Acute Aortic Prosthesis Endocarditis: Early and Mid-Term Outcomes.

Objective: This study aimed to analyze the outcomes and challenges associated with surgical redo procedures following aortic valve replacement for acute infective endocarditis. While transcatheter aortic valve implantation is growing in terms of its utilization for degenerative bioprostheses failure, valve-in-valve procedures are limited in acute aortic endocarditis. Surgical interventions for aortic prosthesis endocarditis carry a significant risk, with a higher mortality and morbidity, often requiring concomitant complex procedures. Methods: This was a retrospective, monocentric, observational study. We identified 352 patients with infective endocarditis from the institutional database. After applying the inclusion and exclusion criteria, 54 patients who underwent surgical re-operation between 2016 and 2023 were included. Endpoints included early and late mortality, complications, and major adverse cardiac and cerebrovascular events (MACCEs). Results: From the cohort, predominantly male and with an average age of 71.9 ± 12.1 years old (79.6%), the following notable findings were derived: isolated aortic valve replacement was feasible only in 34 patients (63%) while more complex procedures were demanded in the other cases; the overall 30-day mortality rate was 18.5%, post-operative ECMO occurred in 9.3% of cases, and post-operative new stroke in 2.7%; the 5-year overall survival rate was 58.3 ± 18.6%, while freedom from MACCEs was 41.7 ± 19.7%. Another re-intervention was required in three patients during follow-up, with one case attributed to re-endocarditis. Conclusions: Despite advancements in surgical and perioperative care, redo procedures for acute infective endocarditis pose significant risks, as evidenced by the high 30-day mortality rate. However, the 5-year survival suggests a relatively acceptable outcome, underscoring the complexities and challenges inherent in managing this condition surgically.

Sex difference in outcomes after coronary artery bypass grafting: follow-up data of the Netherlands Heart Registration.

Controversies exist regarding sex differences in outcomes after coronary artery bypass grafting (CABG). This study assessed sex differences in early and mid-term outcomes after CABG and factors associated with these differences. Outcomes were based on data from the Netherlands Heart Registration (NHR). Data of patients undergoing CABG in the Netherlands between 2013 and 2019 were retrieved from the NHR database. Primary outcomes were early mortality, morbidity and mid-term survival. The population was divided into subgroups based on age (≥ 70years and < 70years). Regression analyses investigated the correlation between sex and both early and mid-term mortality. This study included 41,705 male and 10,048 female patients. Median follow-up was 3.6 (1.8-4.8) years. Female patients were less likely to receive ≥ 2 arterial grafts (15.9% vs 23.2%, p < 0.001), had fewer anastomoses (3.2 ± 1.1 vs 3.5 ± 1.1, p < 0.001), higher 30-day mortality (1.9% vs 1.0%; p < 0.001) and alower mid-term survival rate (91.3% vs 93.1%, p < 0.001). Perioperative complications, including myocardial infarction and stroke, were more common in female patients (all p < 0.001). Women aged < 70years had alower mid-term survival rate than men < 70years (94.5% vs 96.0%, p < 0.001). Cox regression analysis showed that female sex was not significantly associated with mid-term mortality in the total cohort [hazard ratio (HR) 1.03; p = 0.45] but was associated with mid-term mortality in patients aged < 70years (HR 1.19; p < 0.001). Women undergoing CABG in our cohort presented with more complex risk profiles, received different surgical strategies and had worse early and mid-term outcomes compared to men. Female sex was associated with mid-term mortality only in patients < 70years of age.

Hypoalbuminemia is Associated with Higher 90-Day Mortality and Poor Prognosis in Patients with Esophageal Squamous Cell Carcinoma and Liver Cirrhosis Receiving Radiotherapy-Based Therapy.

Liver cirrhosis (LC) is common among patients with esophageal squamous cell carcinoma (ESCC) due to shared etiologic factor, alcohol. For non-metastatic ESCC (nmESCC) patients with cirrhosis, surgery is often contraindicated or associated with high morbidity, therefore radiotherapy-based therapy was commonly applied. This study aims to investigate prognosticators for overall survival (OS) in nmESCC and cirrhotic patients receiving radiotherapy-based therapy. Furthermore, we will also evaluate the predictors for the 90-day mortality rate to reduce avoidable treatment-related toxic effects, and prevent medical waste. Between January 2001 and December 2021, we retrospectively reviewed medical records of 1298 ESCC patients. Total 78 patients with nmESCC and liver cirrhosis identified based on abdominal ultrasonography, computerized tomography, or liver biopsy were enrolled. Clinicopathologic parameters were collected and correlated with OS and 90-day mortality. Univariate analysis revealed that Child-Pugh classification B/C (P<0.001, versus A), radiotherapy alone (P=0.03, versus chemoradiotherapy), prothrombin time (PT) prolonged≧2seconds (P=0.024), albumin≦3.5g/dl (P<0.001), controlled/refractory ascites (P=0.01, versus none of ascites), and total bilirubin≧1.5mg/dl (P=0.004) were significantly associated with inferior OS. In multivariate analyses, albumin≦3.5g/dl (P=0.001, odds ratio (OR): 2.500) and total bilirubin≧1.5mg/dl (P=0.019, OR: 2.012) were independent adverse prognosticators. The 90-day mortality in these 78 patients receiving radiotherapy-based therapy was 10.3% (n=8), including ESCC progression in 4 patients, liver failure in 1 patient, and others in 3. Clinical 8th AmericanJoint Committee on Cancer (AJCC) stage IVA (P=0.02), clinical T classification T3/4 (P=0.049), PT prolonged≧4seconds (P=0.009), and albumin≦3.5g/dl (P=0.027) were significantly correlated with higher 90-day mortality. Logistic model showed albumin≦3.5g/dl (P=0.015, OR: 16.129) and clinical 8th AJCC stage IVA (P=0.012, OR: 17.544) were independently correlated with higher 90-day mortality. Hypoalbuminemia is associated with higher 90-day mortality and poor prognosis in nmESCC and liver cirrhosis patients receiving radiotherapy-based therapy.

Evolution in the Management of Left-Sided Obstructive Colon Cancer in the Netherlands During a 9-Year Period.

There is growing evidence that bridge to surgery with stent or decompressing stoma for left-sided obstructive colon cancer (LSOCC) is better than emergency resection (ER), especially in elderly patients (age ≥70 years). This was already incorporated in Dutch guideline recommendations in 2014. The aim of this study was to evaluate time trends and interhospital variability in treatment approaches for LSOCC, and to compare short-term outcomes between approaches. Data of patients undergoing resection for LSOCC between 2012 and 2020 were extracted from the Dutch ColoRectal Audit. A total of 4,535 patients were included (3,155 ER, 573 semielective resection [SER], 807 resection after stent or stoma [RSS]). A decrease in ER over time was observed (79.7% in 2012-2014, 68.8% in 2015-2017, and 54.7% in 2018-2020) in favor of RSS (9.2%, 17.9%, and 31.2%, respectively). Compared with SER and RSS, ER was associated with higher 30-day mortality (6.2% ER, 2.8% SER, and 1.0% RSS; P<.001) and complication rates (45.4%, 31.2%, 31.5%, respectively; P<.001). There were still 19 hospitals with >75% ER in 2018-2020. For hospitals with >75% ER, mortality was significantly higher compared with hospitals mainly performing SER and RSS (5.6% vs 4.2%; P=.038). The proportion of ER in patients (age ≥70 years) decreased from 80.7% in 2012-2014 to 54.3% in 2018-2020 (P<.001). Mortality in patients aged ≥70 years was significantly lower after RSS than after ER (1.6% vs 9.5%; P<.001). A significant decrease in ER for LSOCC at a national level was observed, although with a variable degree of adherence to revised guidelines among hospitals. The high risk of mortality after ER, especially in elderly patients, strongly supports the guideline recommendations to perform bridge to surgery in these patients.

Machine learning-based model for predicting the occurrence and mortality of nonpulmonary sepsis-associated ARDS

Objective: The objective was to establish a machine learning-based model for predicting the occurrence and mortality of nonpulmonary sepsis-associated ARDS. Methods: 80% of sepsis patients selected randomly from the MIMIC-IV database, without prior pulmonary conditions and with nonpulmonary infection sites, were used to construct prediction models through machine learning techniques (including K-nearest neighbour, extreme gradient boosting, support vector machine, deep neural network, and decision tree methods). The remaining 20% of patients were utilized to validate the model’s accuracy. Additionally, local data were employed for further model validation. Results: A total of 11,409 patients were included, with the most common type of infection being bloodstream infection. A total of 7,632 (66.9%) patients developed nonpulmonary sepsis-associated ARDS (NPS-ARDS). Patients with NPS-ARDS had significantly longer ICU stays (6.2 ± 5.2 days vs. 4.4 ± 3.7 days, p < 0.01) and higher 28-day mortality rates (19.5% vs. 14.9%, p < 0.01). Both internal and external validation demonstrated that the model constructed with the extreme gradient boosting method had high accuracy. In the internal validation, the model predicted NPS-ARDS and mortality in such patients with accuracies of 77.5% and 71.8%, respectively. In the external validation, the model predicted NPS-ARDS and mortality in these patients with accuracies of 78.0% and 81.4%, respectively. Conclusion: The model established via the extreme gradient boosting method can predict the occurrence and mortality of nonpulmonary sepsis-associated ARDS to a certain extent.

Abstract 4135726: Prospective validation and implementation pilot study of an emergency department heart failure risk stratification tool: STRIDE-HF

Background: We previously found the STRIDE-HF emergency department (ED) risk tool accurately predicted risk of a 30-day serious adverse event (SAE), including 30-day mortality, cardiopulmonary resuscitation, intra-aortic balloon pump insertion, intubation, new dialysis, myocardial infarction, or coronary revascularization. Research question: We sought to prospectively validate STRIDE-HF and describe safety of the deployed model in a clinical pilot. We hypothesized that performance would decrease slightly with prospective evaluation and that real-time risk display would contribute to safe disposition decisions. Goals: 1) To prospectively validate KPCARES-HF across 21 community EDs among ED patients with acute heart failure (AHF) from January 1, 2023 – December 31 st , 2023; and 2) to describe outcomes among patients predicted to be very low risk and discharged home in the clinical pilot. Methods: For prospective validation, we report 30-day mortality rates by risk strata. We assess model performance using area under the receiver operator curve (AUROC) and sensitivity at a key clinical threshold. We describe rates of 30-day SAE among patients predicted to be very low risk and discharged after ED or observation unit care in the clinical pilot. Results: There were 13,274 ED patients in the prospective validation; median age was 76, 50.8% were female, and 44.5% were non-White. We found 11.4%, 24.8%, 31.9%, and 31.9% of patients were very low, low, moderate, and high risk, respectively, while 21.6%, 15.2% and 63.0% were discharged, observed, and admitted, respectively. Among discharged patients, 29.2% and 13.3% were moderate or high risk, respectively, and 30-day mortality rates among these patients were 2.2% and 8.4%, respectively. Among 8,363 admitted patients, 27.7% were very low or low risk. Conclusions: STRIDE-HF maintained high predictive accuracy with prospective validation in this diverse, multi-center cohort. Our findings suggest that use of STRIDE-HF might help better align risk with admission decision and can be safely used to assist providers in identifying patients who may be stable for outpatient care.

Clostridioides difficile infections caused by hypervirulent strains: a single-centre real-life study.

Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated infections worldwide, with hypervirulent strains linked to severe disease and higher mortality. This study aims to analyze the epidemiology of CDI at a tertiary-care hospital in Italy and compare clinical outcomes between patients infected with hypervirulent and non-hypervirulent strains. A retrospective comparative study was conducted on patients diagnosed with CDI at ASST Spedali Civili di Brescia, Italy, from January 2015 to June 2023. Hypervirulent strains were identified using the GeneXpert assay as positive for cytotoxin gene (tcdB), binary toxin genes (tcdA and tcdB) and a single nucleotide deletion at position 117 in the tcdC gene and compared to a randomized matched control group with non-hypervirulent CDI. Clinical data were collected and analyzed, with multivariate logistic regression employed to identify risk factors for hypervirulent CDI. Of 1,059 positive C. difficile specimens, a statistically significant trend between January 2015 to June 2023 was found in the increasing incidence of CDI cases per 1,000 hospital admissions and 10,000 bed-days. Notably, a remarkable increase of hypervirulent strains was recorded in 2021 and 2022 when compared to previous years. A total of 130 patients were analyzed: 62 (47.7%) with hypervirulent CDI and 68 (52.3%) controls. Hypervirulent CDI was associated with higher 30-day mortality (18% vs. 5.8%, p = 0.03). Multivariate analysis showed that hypervirulent CDI significantly increased 30-day mortality risk (OR = 9.915, CI = 2.37-61.05, p = 0.005) and that prior antibiotic therapy was a significant risk factor (OR = 5.49, CI = 1.19-39.96, p = 0.047). Our epidemiological data, while suggesting a potential resurgence in CDI transmission during COVID-19 pandemic, are derived from a single-center experience with limited generalizability to the broader population. Nonetheless, they highlight the need for strengthened antimicrobial stewardship and national surveillance systems to effectively monitor and manage these strains.

Association between serum glucose potassium ratio and mortality in critically ill patients with intracerebral hemorrhage

The effect of serum glucose-to-potassium ratio (GPR) on cerebrovascular diseases has been previously validated. However, the value of the GPR in patients with severe intracerebral hemorrhage (ICH) requiring ICU admission remains unclear. This study aimed to investigate the association between the GPR and the clinical prognosis of critically ill patients with ICH. This study identified patients with severe ICH requiring ICU admission from the Medical Information Mart for Intensive Care (MIMIC-IV) database and divided them into quartiles based on GPR levels. Outcomes included 30-day, 90-day, and 1-year mortality rates. The association between the GPR and clinical outcomes in critically ill patients with ICH was elucidated using Cox proportional hazards regression analysis and restricted cubic splines. In total, 2018 patients (53.8% male), with a median age of 70 years, were enrolled in the study. The 30-day, 90-day, and 1-year mortality rates were 23.9%, 30.1%, and 38.4%, respectively. Per multivariate Cox proportional hazards analysis, an elevated GPR was significantly associated with all-cause mortality. After adjusting for age, sex, Charlson Comorbidity Index, white blood cell count, red blood cell count, platelet count, and Glasgow Coma Scale, patients with an elevated GPR had a higher 30-day mortality (hazard ratio [HR]: 1.32; 95% confidence interval [CI]: 1.22–1.42; P < 0.001), 90-day mortality (HR: 1.27; 95% CI: 1.18–1.37; P < 0.001) and 1-year mortality (HR: 1.22; 95% CI: 1.14–1.31; P < 0.001) when analyzed as a continuous variable. Furthermore, analysis using restricted cubic splines demonstrated a consistent and progressive escalation in the risk of all-cause mortality with an elevated GPR. The GPR was significantly associated with short- and long-term all-cause mortality in critically ill patients with ICH. This finding demonstrates that GPR may be useful in identifying patients with ICH at a high risk of all-cause mortality.

Seroprevalence and prognostic value of Aspergillus-specific IgG among non-neutropenic invasive pulmonary aspergillosis patients: a prospective multicenter study

BackgroundThis study aimed to assess the diagnostic and prognostic value of Aspergillus-specific IgG (Asp-IgG) for invasive pulmonary aspergillosis (IPA) in non-neutropenic non-hematologic patients.MethodsBetween November 2019 and February 2022, we recruited 40 non-neutropenic, non-hematologic IPA patients from Taiwan and measured serum Asp-IgG levels using Phadia, Thermofisher. A positive Asp-IgG test was defined as a level > 40 mgA/L. We evaluated the association between Asp-IgG levels and overall survival, as well 90-day mortality rate of IPA patients.ResultsOf the 40 participants, 11 (27.5%) tested positive for Asp-IgG, while 16 (40%) had positive galactomannan antigen (optical density > 1). Higher Asp-IgG levels were associated with improved overall survival (HR: 0.22, 95% CI: 0.05–0.99, p = 0.035) in multivariable Cox regression. The overall 90-day mortality rate was 65% (26/40). We found that patients with low Asp-IgG levels (≤ 40 mgA/L) had a borderline higher 90-day mortality rate compared to patients with high Asp-IgG levels (OR: 3.15, 95% CI: 0.75–13.28, p = 0.118). Stratifying by serum galactomannan and Aspergillus IgG levels, patients with elevated serum GM and low Asp-IgG had the highest 90-day mortality (80%, 8/10), followed by patients with low serum GM and low Asp-IgG (68.4%, 13/19).ConclusionsAsp-IgG was positive in approximately one-fourth of non-neutropenic IPA patients. Asp-IgG may hold potential as a clinical prognostic factor for IPA. Further studies are required to validate this finding.

Predictive factors for shunt dependency in patients with spontaneous intraventricular hemorrhage

Intraventricular hemorrhage (IVH) occurs in approximately 30–50% patients with spontaneous intracerebral hemorrhage (ICH), with a high 30-day mortality rate. Excess accumulation of parenchymal or ventricular blood associated with the development of acute hydrocephalus leads to poor outcomes. The prediction of shunt dependency is important to identify patients susceptible to requiring permanent shunt placement and benefit from the diversion. This retrospective analytical study aimed to establish a predictive model of shunt dependency in patients with IVH. This study included 179 patients with primary IVH with supratentorial origin or spontaneous ICH with extension into the ventricles between 2015 and 2021. Patients were grouped into “shunt required” and “shunt not required” groups. Variables, including age, sex, preexisting hypertension and diabetes, initial Glasgow Coma Scale scores, ICH location and volume, urokinase administration, modified Graeb score (mGraeb score), and bicaudate index, were analyzed. The shunt required group had significantly higher mGraeb scores (12.0 (6.5–15.0) vs. 7.0 (4.0–12.0), p = 0.001) and higher bicaudate index (0.20 (0.17–0.23) vs. 0.16 (0.13–0.18), P < 0.001) than the shunt not required group. The receiver operating characteristic curve (ROC curve) analysis revealed that a cut-off value of 0.16 of the bicaudate index was significantly related to shunt dependency. The subgroup statistical analysis revealed that neither urokinase administration (p = 0.533) nor urokinase dosage (p = 0.117) showed significant relevance in shunt dependency in patients who received external ventricular drainage. In logistic regression adjusted for the confounders, thalamic ICH (odds ratio (OR) 3.55; 95% confidence interval [(95%CI), 1.13–11.18], an mGraeb score greater than 8 (OR, 3.93; 95%CI, 1.84–8.38), and a bicaudate index greater than 0.16 (OR, 9.87; 95%CI, 3.79–25.73) were factors associated with a higher tendency for shunting. The findings of this study may help identify patients at risk for a permanent shunt after IVH.

Age-specific differences of Impella support in Japanese patients: The Japanese registry for percutaneous ventricular assist device (J-PVAD) registry analysis on outcomes and adverse events

BackgroundThe association between the clinical significance and prognostic impact of catheter-based micro-axial ventricular assist device Impella (Abiomed, Danvers, MA, USA) support and age has not been sufficiently investigated. Methods and ResultsA total of 5282 patients treated with Impella were analyzed from the Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD). Patients were categorized into four age groups: <50 years old (Group A, n = 670), 50–69 years old (Group B, n = 2009), 70–79 years old (Group C, n = 1716), and ≥ 80 years old (Group D, n = 887). Kaplan–Meier curve analysis demonstrated that the prognosis, including 30-day all-cause mortality, was significantly poorer in Group D compared to the other groups. A multivariate Cox regression model identified Group D as an independent predictor of 30-day all-cause death (HR: 2.173, 95 % CI: 1.699–2.779) relative to Group A. The multivariate logistic regression analysis indicated that estimated glomerular filtration rate, lactate levels, and systolic blood pressure were independently associated with 30-day mortality across all age categories. The presence of more than two major adverse events was independently associated with 30-day mortality specifically in the cohort aged ≥80 years (OR: 1.492, 95 % CI: 1.037–2.148, p = 0.031). ConclusionIncreasing age was identified as a significant factor associated with higher 30-day mortality rates in J-PVAD. While the incidence of major adverse events did not differ significantly across age categories, the occurrence of two or more additional adverse events was linked to increased 30-day mortality among older individuals. Therefore, an appropriate mechanical support strategy may be necessary for elderly Japanese patients based on their age.

Delirium and Weakness Acquired in the Intensive Care Unit: Individual and Combined Effects on 90-Day Mortality in Survivors of Critical Illness.

To compare the individual and combined effects on 90-day mortality among four critically ill survivor groups: normal (without ICU-acquired delirium or ICU-acquired weakness), delirium-only (with ICU-acquired delirium only), weakness-only (with ICU-acquired weakness only) and delirium-weakness (combined ICU-acquired delirium and weakness). A prospective cohort study consecutively recruited delirium-free critically ill patients admitted to six medical ICUs at a university hospital. Delirium was assessed once daily for 14 days (or until death or ICU discharge) using the Confusion Assessment Method for the ICU. Participants who were discharged from the ICUs were assessed for weakness using the Medical Research Council scale. A summed score below 48 defines ICU-acquired weakness. These survivors were evaluated again for 90-day mortality. The study is reported using the STROBE checklist. Delirium developed in 107 (43.2%) participants during their first 14 days of ICU stay; 55 (22.2%) met criteria for weakness by ICU discharge. Participants with delirium were at increased risk for also developing ICU-acquired weakness, and the 90-day mortality was 18.2%. Independent of age and Acute Physiology and Chronic Health Evaluation II score at ICU admission, delirium-only and weakness-only were not associated with higher 90-day mortality, while participants in the delirium-weakness group had a 3.69-fold higher risk of death, compared to those who were normal during the ICU stay. A non-significant interaction was found, suggesting the joint effect of delirium and weakness on mortality is not higher than the sum of both effects individually. Mortality is substantially high among critically ill survivors who experience both delirium and weakness, although no additive effect on mortality was observed when these conditions occur together. Our findings highlight the urgent need to optimise ICU care by prioritising the prevention, early identification and management of these two common ICU-acquired conditions. Study participation and completion of all assessments. ClinicalTrials.gov identifier: NCT04206306.

Standard modifiable risk factors (SMuRF) paradox for the prognosis in the patients with acute myocardial infarction

Abstract Background Hypertension, diabetes, dyslipidemia and smoking are recognized as standard modifiable risk factors (SMuRFs) for adverse cardiovascular events such as acute myocardial infarction (AMI). Recent studies have shown that AMI patients without SMuRFs are associated with increased mortality compared to those with SMuRFs. However, the relationship between the number of SMuRFs in patients with AMI and mortality has not been well evaluated. Purpose The purpose of this study was to evaluate the clinical characteristics and prognosis of AMI patients stratified by the number of SMuRFs. Methods We studied 6,706 AMI patients between 2013 and 2021 using data from the Mie ACS registry, a retrospective and multicenter registry. For the purpose of this study, only AMI patients as their first cardiovascular events were included in this analysis. Therefore, after excluding patients with a known history of coronary artery disease (n=982), 5724 AMI patients were included in the current analysis. All-cause mortality was compared with 30-day and after 30-day mortality in AMI patients stratified by the number of SMuRFs as the primary outcome. In addition, all-cause mortality rate was compared in AMI patients without and with SMuRFs after propensity score matching on age, sex, body mass index, Killip classification, cardiac arrest before presentation, multivessel disease, left main truck disease, hemoglobin and emergent percutaneous coronary intervention. Results Among 5,724 AMI patients, 672 patients (11.7%) did not have SMuRFs. The median age of patients without SMuRFs was higher than that of patients with any SMuRFs (73 y.o. vs. 70 y.o, P&amp;lt;0.001), and higher prevalence of female and severe Killip class was observed in patients without SMuRFs compared with those with any SMuRFs (P&amp;lt;0.001, respectively). According to the KM survival curves stratified by number of SMURFs, an increased number of SMURFs was associated with higher 30-day survival rates (P=0.035), and the 30-day landmark analysis showed a trend toward higher survival in patients with the highest number of SMURFs, although not statistically significant (Figure1). Multivariate Cox regression analysis showed that 0 SMuRF was an independent prognostic factor for 30-day mortality with hazard ratio of 1.55 (95%CI; 1.13-2.13, P&amp;lt;0.001). In addition, KM survival curves after propensity score matched analysis showed the poor 30-day mortality in 0 SMuRF group (P=0.036), there was no significant difference in after 30-day mortality between the two groups (Figure 2). Conclusions Patients without SMuRFs had a high 30-day mortality rate, but once they survived the acute phase, their prognosis was comparable to patients with SMuRFs. Moreover, the SMuRF paradox was recognized in the acute phase. This finding highlights the need for early identification of the individuals at risk of developing MI despite the absence of SMuRFs and strict acute management regardless of the number of SMuRFs.

Timing of inopressor initiation in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract Introduction Inotropes and vasopressors (inopressors) are commonly used in the treatment of acute myocardial infarction complicated by cardiogenic shock (AMICS). The characteristics of patients subjected to early or late initiation of inopressors are not yet described, and the impact of timing on outcomes remains uncertain. Purpose This retrospective real-world data study aims to identify patient-, treatment-, and outcome characteristics of AMICS patients treated with early- or late initiated inopressors. Methods The Netherlands Heart Registration (NHR) prospectively records baseline, procedural, and outcome data for PCI patients. Between 2017-2021, additional retrospective data on CS patients were collected by fourteen Dutch hospitals. Patients were categorized based on the timing of inopressor initiation, either early (pre PCI) or solely late (at the cathlab or within 24 hours after PCI). Patients presenting with an out of hospital cardiac arrest were excluded. Missing data were imputed through multiple imputation (30x). Multivariable logistic regression analysis was performed to evaluate the association between the timing of inopressor initiation and 30-day mortality, adjusting for univariate significant confounders among variables known at admission. Results A total of 956 consecutive CS patients were included of whom 418 (43.7%) and 538 (57.3%) patients were subjected to early and late initiation of inopressors respectively. The most frequently used drug in both groups was noradrenaline. At baseline, patients in the early initiation group were younger (67.4 vs. 70.0 years, p &amp;lt;0.001), presented with a lower mean arterial pressure (MAP) (72.5 vs. 76.3, p = 0.048) and higher lactate (4.2 vs. 3.6, p = 0.012), and presented with a NSTEMI more often (36.0% vs. 14.2%, p &amp;lt;0.001). They also had a higher prevalence of previous myocardial infarction (33.9% vs. 22.9%, p &amp;lt;0.001) and previous CABG (14.3% vs. 6.2%, p &amp;lt;0.001). Moreover, 30-day mortality rates were higher in the early initiated group (48.6% vs. 37.6%, pLogrank &amp;lt;0.001). After multivariate adjustment for age, admission MAP and lactate, early inopressor initiation remained independently associated with 30-day mortality (OR 1.44, 95%-CI 1.08-1.98) compared to late initiation. Conclusion In this Dutch cohort of CS patients undergoing PCI, baseline- treatment- and outcome characteristics differed between patient categories receiving either early or late initiated inopressors. Patients who were subjected to early initiated inopressors were younger, presented with worse hemodynamics, had a more extensive cardiovascular medical history and higher 30-day mortality rates. The results of this study reemphasize the importance of identifying patients who benefit from inopressors.30-day mortality late vs. earlyTable patient characteristics