In-hospital Death Research Articles

Hospital case fatality and mortality related to Chagas disease in Brazil over two decades

ObjectiveTo analyse hospital case fatality and mortality related to Chagas disease (CD) in Brazil, 2000–2019.MethodThis is a mixed ecological study with spatial and temporal trends, based on national population data from the Brazilian Ministry of Health - hospital admissions (HA) and death certificates (DC). Records with CD as a primary or secondary cause of death in HA and/or as an underlying or associated cause of death in DC were evaluated. Temporal trends were analysed by Joinpoint regression and the spatial distribution of age- and gender-adjusted rates, spatial moving averages, and standardized morbidity ratios.ResultsThere were a total of 4,376 HA due to CD resulting in death in Brazil, with a hospital case fatality rate of 0.11/100,000 inhabitants. The Southeast region had the highest rate (63.9%, n = 2,796; 0.17/100,000 inhabitants). The general trend for this indicator in Brazil is upwards (average annual percentage change [AAPC] 7.5; 95% confidence interval [CI] 5.3 to 9.9), with increases in the North, Northeast and Southeast regions. During the same period 122,275 deaths from CD were registered in DC, with a mortality rate of 3.14/100,000 inhabitants. The highest risk of CD-related death was found among men (relative risk [RR] 1.27) and Afro-Brazilians (RR 1.63). There was a downward trend in CD mortality in the country (AAPC − 0.7%, 95%CI -0.9 to -0.5), with an increase in the Northeast region (AAPC 1.1%, 95%CI 0.6 to 1.6). Municipalities with a very high Brazilian Deprivation Index tended to show an increase in mortality (AAPC 2.1%, 95%CI 1.6 to 2.7), while the others showed a decrease.ConclusionHospital case fatality and mortality due to CD are a relevant public health problem in Brazil. Differences related to gender, ethnicity, and social vulnerability reinforce the need for comprehensive care, and to ensure equity in access to health in the country. Municipalities, states, and regions with indicators that reveal higher morbidity and mortality need to be prioritized.

Impact of the COVID-19 Pandemic on Influenza Hospital Admissions and Deaths in Wales: Descriptive National Time Series Analysis.

The COVID-19 pandemic and the ensuing implementation of control measures caused widespread societal disruption. These disruptions may also have affected community transmission and seasonal circulation patterns of endemic respiratory viruses. We aimed to investigate the impact of COVID-19-related disruption on influenza-related emergency hospital admissions and deaths in Wales in the first 2 years of the pandemic. A descriptive analysis of influenza activity was conducted using anonymized pathology, hospitalization, and mortality data from the Secure Anonymised Information Linkage Databank in Wales. The annual incidence of emergency hospitalizations and deaths with influenza-specific diagnosis codes between January 1, 2015, and December 31, 2021, was estimated. Case definitions of emergency hospitalization and death required laboratory confirmation with a polymerase chain reaction test. Trends of admissions and deaths were analyzed monthly and yearly. We conducted 2 sensitivity analyses by extending case definitions to include acute respiratory illnesses with a positive influenza test and by limiting admissions to those with influenza as the primary diagnosis. We also examined yearly influenza testing trends to understand changes in testing behavior during the pandemic. We studied a population of 3,235,883 Welsh residents in 2020 with a median age of 42.5 (IQR 22.9-61.0) years. Influenza testing in Wales increased notably in the last 2 months of 2020, and particularly in 2021 to 39,720 per 100,000 people, compared to the prepandemic levels (1343 in 2019). The percentage of influenza admissions matched to an influenza polymerase chain reaction test increased from 74.8% (1890/2526) in 2019 to 85.2% (98/115) in 2021. However, admissions with a positive test per 100,000 population decreased from 17.0 in 2019 to 2.7 and 0.6 in 2020 and 2021, respectively. Similarly, deaths due to influenza with a positive influenza test per 100,000 population decreased from 0.4 in 2019 to 0.0 in 2020 and 2021. Sensitivity analyses showed similar patterns of decreasing influenza admissions and deaths in the first 2 years of the COVID-19 pandemic. Nonpharmaceutical interventions to control COVID-19 were associated with a substantial reduction in the transmission of the influenza virus, with associated substantial reductions in hospital cases and deaths observed. Beyond the pandemic context, consideration should be given to the role of nonpharmaceutical community-driven interventions to reduce the burden of influenza.

Factors Influencing Discharges to Hospice for Patients With Late-Stage Huntington's Disease.

Background: Hospice services for patients with Huntington's disease (HD) are likely beneficial in relieving significant burdens and minimizing costly hospitalizations at the end of life, though there has been little study or clinical guidance on hospice enrollment for patients with HD. Objectives: The primary objective of this study was to identify clinical, sociodemographic, and system-level factors associated with discharges to hospice compared to other dispositions for hospitalized patients with late-stage HD. Methods: These analyses used data from the Nationwide Inpatient Sample between the years 2007 and 2011. Weighted logistic regression with a forward selection approach was performed to identify factors associated with discharge to hospice compared to discharge to home, facility, other locations, and death in hospital. Results: These analyses included 6544 hospitalizations of patients with late-stage HD. There was a significant increasing trend in discharges to hospice over the study period (P < 0.001). After adjustment, multiple clinical, sociodemographic, and system-level variables were identified as being associated with discharges to hospice. Patients with aspiration pneumonia and non-aspiration pneumonias had lower odds of being discharged to hospice compared to dying in the hospital. When comparing to discharges to facilities and home, weight loss and palliative care consultation were associated with greater odds of discharge to hospice. Conclusions: Our findings serve as a foundation for future studies on these factors, and thus help clinician decision-making on when to start advance care planning or end-of-life care for patients with HD. These results also support studies developing hospice referral criteria specific to patients with HD.

Association between new insertion of a long-term enteral feeding tube and mortality in adults admitted to the hospital with aspiration: A retrospective cohort study.

We aimed to describe the association between insertion of a new long-term enteral feeding tube during admission for aspiration and in-hospital mortality. This retrospective cohort study across 28 Canadian hospitals from 2015 to 2022 included consecutive patients who were admitted for aspiration. Patients were categorized based on new long-term enteral feeding tube insertion during hospital stay or not. The primary outcome was the time to death in hospital. Secondary outcomes included time to discharge alive and hospital readmission for aspiration within 90 days. We used propensity score weighting to balance covariates, and a competing risk model to describe in-hospital death and discharge. Of 12,850 patients admitted for aspiration, 852 (6.6%) patients received a long-term enteral feeding tube. In the hospital, 184 (21.6%) and 2489 (20.8%) patients in the enteral feeding tube group and no enteral feeding tube group died, respectively. Within 90 days of discharge, 127 (14.9%) and 1148 (9.6%) patients in the enteral feeding tube and no enteral feeding tube group were readmitted for aspiration, respectively. After balancing covariates, an enteral feeding tube was associated with a similar in-hospital mortality risk (subdistribution hazard ratio [sHR] = 1.05, 95% CI = 0.89-1.23; P = 0.5800), longer time to discharge alive (sHR = 0.58, 95% CI = 0.54-0.63; P < 0.0001), and a higher risk of readmission (risk difference = 5.0%, 95% CI = 2.4%-7.6%; P = 0.0001). Initiation of long-term enteral tube feeding was not uncommon after admission for aspiration and was not associated with an improvement in the probability of being discharged alive from the hospital or readmitted for aspiration.

Pro-adrenomedullin associates with congestion in acute heart failure patients.

Congestion is a major determinant of outcomes in acute heart failure. Its assessment is complex, making sufficient decongestive therapy a challenge. Residual congestion is frequent at discharge, increasing the risk of re-hospitalization and death. Mid-regional pro-adrenomedullin mirrors vascular integrity and may therefore be an objective marker to quantify congestion and to guide decongestive therapies in patients with acute heart failure. Observational, prospective, single-centre study in unselected patients presenting with acute heart failure. This study aimed to assess adrenomedullin's association with congestion and clinical outcomes: in-hospital death, post-discharge mortality and in-hospital worsening heart failure according to RELAX-AHF-2 trial criteria. Pro-adrenomedullin was quantified at baseline and at discharge. Congestion was assessed applying clinical scores. Cox and logistic regression models with adjustment for clinical features were fitted. N=233, median age 77years (IQR 67, 83), 148 male (63.5%). Median pro-adrenomedullin 2.0nmol/L (IQR 1.4, 2.9). Eight patients (3.5%) died in hospital and 100 (44.1%) experienced in-hospital worsening heart failure. After discharge, 60 patients (36.6%) died over a median follow-up of 1.92years (95% CI: 1.76, 2.46). Pro-adrenomedullin concentrations (logarithmized) were significantly associated with congestion, both at enrolment (β=0.36 and 0.81 depending on score, each P<0.05) and at discharge (β=1.12, P<0.001). Enrolment of pro-adrenomedullin was associated with in-hospital worsening heart failure [OR 4.23 (95% CI: 1.87, 9.58), P<0.001], and pro-adrenomedullin at discharge was associated with post-discharge death [HR 3.93 (1.86, 8.67), P<0.001]. Elevated pro-adrenomedullin is associated with in-hospital worsening heart failure and with death during follow-up in patients with acute heart failure. Further research is needed to validate this finding and to explore the ability of pro-adrenomedullin to guide decongestive treatment.

Tadalafil for Treatment of Combined Postcapillary and Precapillary Pulmonary Hypertension in Patients With Heart Failure and Preserved Ejection Fraction: A Randomized Controlled Phase 3 Study.

We assessed the efficacy and safety of tadalafil, a phosphodiesterase type 5 inhibitor, in patients with heart failure with preserved ejection fraction and combined postcapillary and precapillary pulmonary hypertension. In the double-blind PASSION study (Phosphodiesterase-5 Inhibition in Patients With Heart Failure With Preserved Ejection Fraction and Combined Post- and Pre-Capillary Pulmonary Hypertension), patients with heart failure with preserved ejection fraction and combined postcapillary and precapillary pulmonary hypertension were randomized 1:1 to receive tadalafil at a target dose of 40 mg or placebo. The primary end point was the time to the first composite event of adjudicated heart failure hospitalization or all-cause death. Secondary end points included all-cause mortality and improvements in New York Heart Association functional class or ≥10% improvement in 6-minute walking distance from baseline. Initially targeting 372 patients, the study was terminated early because of disruption in study medication supply. At that point, 125 patients had been randomized (placebo: 63; tadalafil: 62,). Combined primary end-point events occurred in 20 patients (32%) assigned to placebo and 17 patients (27%) assigned to tadalafil (hazard ratio, 1.02 [95% CI, 0.52-2.01]; P=0.95). There was a possible signal of higher all-cause mortality in the tadalafil group (hazard ratio, 5.10 [95% CI, 1.10-23.69]; P=0.04). No significant between-group differences were observed in other secondary end points. Serious adverse events occurred in 29 participants (48%) in the tadalafil group and 35 (56%) in the placebo group. The PASSION trial, terminated prematurely due to study medication supply disruption, does not support tadalafil use in patients with heart failure with preserved ejection fraction and combined postcapillary and precapillary pulmonary hypertension, with potential safety concerns and no observed benefits in primary and secondary end points. URL: https://www.clinicaltrialsregister.eu/; Unique identifier: 2017-003688-37. URL: https://drks.de; Unique identifier: DRKS -DRKS00014595.

Evaluation of the COVID-19 vaccine effectiveness on the outcomes of COVID 19 disease in Iran: a test-negative case-control study.

This study measures the COVID-19 vaccine effectiveness (CVE) against hospital admission and severe COVID-19. This study is a test-negative case-control design using data from eight provinces in April, 2021 until March, 2022. The individuals were classified as cases and controls based on the results of the RT-PCR test for SARS-CoV-2 and matched based on the timing of the test being conducted as well as the timing of hospital admission. The measure of association was an odds ratio (OR) by univariate and multiple logistic regression. The multiple logistic regression has been carried out to take confounding factors and potential effect modifiers into account. The CVE was computed as CVE = (1 - OR)*100 with 95% confidence interval. Among 19314 admitted patients, of whom 13216 (68.4%) were cases and 6098 (31.6%) were controls, 1313 (6.8%) died. From total, 5959 (30.8%) patients had received the vaccine in which one, two, and booster doses were 2443 (12.6%), 2796 (14.5٪), and 720 (3.7٪), respectively. The estimated adjusted effectiveness of only one dose, two doses and booter vaccination were 22% (95% CI: 14%-29%), 35% (95% CI: 29%-41%) and 33% (95% CI: 16%-47%), respectively. In addition, the adjusted vaccine effectiveness against severe outcome was 33% (95% CI: 19%- 44%), 34% (95% CI: 20%- 45%) and 20% (95% CI: -29%- 50%) for those who received one, two and booster vaccinations, respectively. Our study concluded that full vaccination, though less effective compared to similar studies elsewhere, decreased hospital admissions and deaths from COVID-19 in Iran, particularly during the Delta variant period, with an observed decline during the Omicron variant dominance.

Preventability of Hospital Deaths in Patients with Non-Ventilator Hospital-Acquired Pneumonia.

Crude and adjusted mortality rates for patients with non-ventilator hospital-acquired pneumonia (NV-HAP) are amongst the highest of all healthcare-associated infections, leading to calls for greater prevention. Patients prone to NV-HAP, however, tend to be severely ill at baseline making it unclear whether their high mortality rates are due to NV-HAP, underlying conditions, or both. Two infectious disease physicians conducted detailed medical record reviews on 150 randomly selected adults from 4 hospitals who died in-hospital following an NV-HAP event between April 2016 and May 2021. Reviewers abstracted risk factors, estimated the preventability of NV-HAP, identified causes of death, and adjudicated the preventability of death. Patients' median age was 69.3 (IQR 60.7-77.4) and 43.3% were female. Comorbidities were common: 57% had cancer, 30% chronic kidney disease, 29% chronic lung disease, and 27% heart failure. At least one hospice-eligible condition was present before NV-HAP in 54% and "Do Not Resuscitate" orders in 24%. Most (99%) had difficult-to-modify NV-HAP risk factors: 76% altered mental status, 35% dysphagia, and 27% nasogastric/orogastric tubes. NV-HAP was deemed possibly or probably preventable in 21% and hospital death likely or very likely preventable in 8.6%. Most patients who die following NV-HAP have multiple, severe underlying comorbidities and difficult-to-modify risk factors for NV-HAP. Only 1 in 5 NV-HAPs that culminated in death and 1 in 12 deaths following NV-HAP were judged potentially preventable. This does not diminish the importance of NV-HAP prevention programs but informs expectations about the potential magnitude of their impact on hospital deaths.

ARE COGNITIVELY IMPAIRED PATIENTS SUITABLE CANDIDATES FOR HIP ARTHROPLASTY? A PROPENSITY SCORE-MATCHED COHORT STUDY

The growth of life expectancy during the last decades has led to an increment in age-related conditions such as hip arthritis and fractures. On the other hand, these elderly patients will present a higher incidence of mental diseases which, in some studies, have been associated with inferior results.This study aims to evaluate the differences in early complication rates between patients with cognitive impairment compared with those without this condition following total hip replacement for osteoarthritis or fracture in the context of contemporary perioperative care protocols.We conducted a retrospective cohort study where cognitively-impaired patients who required primary hip arthroplasty were compared to a propensity-score matched cohort of patients without cognitive alterations. Early major complications were measured and analyzed in order to determine significant differences.Screening and matching. 1196 patients were identified during the study period. After screening for inclusion and exclusion criteria and matching, two cohorts comprising 65 patients each were compared. After performing the propensity-score match, no significant differences were found in covariates between the two groups.Outcomes. The occurrence of delirium was more frequent in patients with cognitive deficit (27.5%) than in the control group (9%), p&lt;0.001. No significant differences were found among groups regarding myocardial infarction, venous thromboembolism, blood transfusion requirement, 30-day readmission, in-hospital death, 90-days death, dislocation or surgical site infection. The composite outcome of any adverse event did not exhibit a significant difference either.To our knowledge, this is the first study which demonstrates similar outcomes between patients with cognitive impairment and those without these alterations. Our results might indicate that contemporary protocols and implants are bridging the traditional gap between these two populations. These findings support the use of total hip arthroplasty in patients with mental alterations when indicated, especially in those institutions with strict perioperative protocols.

Evaluation of the Impact of a Less-Invasive Trunk and Pelvic Trauma Protocol on Mortality in Patients with Severe Injury by Interrupted Time-Series Analysis.

Background and Objectives: Minimally invasive trauma management, including interventional radiology and non-operative approaches, has proven effective. Consequently, our hospital established a trauma IVR protocol called "Ohta Nishinouchi Hospital trauma protocol (ONH trauma protocol) in 2013, mainly for trunk trauma. However, the efficacy of the ONH trauma protocol has remained unverified. We aimed to assess the protocol's impact using interrupted time-series analysis (ITSA). Materials and Methods: This retrospective cohort study was conducted at Ohta Nishinouchi hospital, a tertiary emergency hospital, from January 2004 to December 2019. We included patients aged ≥ 18 years who presented to our institution due to severe trauma characterized by an Abbreviated Injury Scale of ≥3 in any region. The primary outcome was the incidence of in-hospital deaths per 100 transported patients with trauma. Multivariable logistic regression analysis was conducted with in-hospital mortality as the outcome, with no exposure before protocol implementation and with exposure after protocol implementation. Results: Overall, 4558 patients were included in the analysis. The ITSA showed no significant change in in-hospital deaths after protocol induction (level change -1.49, 95% confidence interval (CI) -4.82 to 1.84, p = 0.39; trend change -0.044, 95% CI -0.22 to 0.14, p = 0.63). However, the logistic regression analysis revealed a reduced mortality effect following protocol induction (odds ratio: 0.50, 95% CI: 0.37 to 0.66, p < 0.01, average marginal effects: -3.2%, 95% CI: -4.5 to -2.0, p < 0.01). Conclusions: The ITSA showed no association between the protocol and mortality. However, before-and-after testing revealed a positive impact on mortality. A comprehensive analysis, including ITSA, is recommended over before-and-after comparisons to assess the impact of the protocol.

Bereaved parent preferences on quality end-of-life care for children with cancer in the South.

The authors sought to understand bereaved family preferences for end-of-life (EOL) care, particularly among Black families and those in the South. Semi-structured interviews were conducted with parents of children who died of cancer ≥6 months before at Children's of Alabama. Themes were identified via content analysis. Quotes related to medical intensity, chemotherapy, and location of death (LOD) were scored on 5-point Likert scales, ranging from 1 (comfort care, chemotherapy, or home death) to 5 (medically intense care, avoidance of chemotherapy, or hospital death). Twenty-seven bereaved parents (12 Black) were interviewed. Children died at a mean of 13.1 years (SD=6.1 years) and a median of 3 years before the interview (range=1-12 years). Ten children (42%) had central nervous system tumors and the majority (63%) died in the hospital. Family decision-making involved maintaining hope, not causing harm, doing what was best for their child and themselves, and religious beliefs. There was no clear preference for home versus hospital death (3.0 [1.8-4.0]). Instead, parents considered their child's desires and/or medical needs, siblings, and prior experiences with death. To have a comfortable death, parents highlighted the need for comprehensive education about their child's EOL, a caring and comfortable environment, and 24/7 access to their care team. Families expressed a dual preference for comfort care (1.8 [1.3-2.8]) and chemotherapy (3.5 [2.7-4.1]) at EOL. Families did not see chemotherapy and comfort care as conflicting goals. They sought quality care emphasizing flexibility, quality time with their child, and open access to their care team, regardless of LOD.

Effects of pulmonary surfactant combined with noninvasive positive pressure ventilation in neonates with respiratory distress syndrome.

Neonatal respiratory distress syndrome (NRDS) is one of the most common diseases in neonatal intensive care units, with an incidence rate of about 7% among infants. Additionally, it is a leading cause of neonatal death in hospitals in China. The main mechanism of the disease is hypoxemia and hypercapnia caused by lack of surfactant. To explore the effect of pulmonary surfactant (PS) combined with noninvasive positive pressure ventilation on keratin-14 (KRT-14) and endothelin-1 (ET-1) levels in peripheral blood and the effectiveness in treating NRDS. Altogether 137 neonates with respiratory distress syndrome treated in our hospital from April 2019 to July 2021 were included. Of these, 64 control cases were treated with noninvasive positive pressure ventilation and 73 observation cases were treated with PS combined with noninvasive positive pressure ventilation. The expression of KRT-14 and ET-1 in the two groups was compared. The deaths, complications, and PaO2, PaCO2, and PaO2/FiO2 blood gas indexes in the two groups were compared. Receiver operating characteristic curve (ROC) analysis was used to determine the diagnostic value of KRT-14 and ET-1 in the treatment of NRDS. The observation group had a significantly higher effectiveness rate than the control group. There was no significant difference between the two groups in terms of neonatal mortality and adverse reactions, such as bronchial dysplasia, cyanosis, and shortness of breath. After treatment, the levels of PaO2 and PaO2/FiO2 in both groups were significantly higher than before treatment, while the level of PaCO2 was significantly lower. After treatment, the observation group had significantly higher levels of PaO2 and PaO2/FiO2 than the control group, while PaCO2 was notably lower in the observation group. After treatment, the KRT-14 and ET-1 levels in both groups were significantly decreased compared with the pre-treatment levels. The observation group had a reduction of KRT-14 and ET-1 levels than the control group. ROC curve analysis showed that the area under the curve (AUC) of KRT-14 was 0.791, and the AUC of ET-1 was 0.816. Combining PS with noninvasive positive pressure ventilation significantly improved the effectiveness of NRDS therapy. KRT-14 and ET-1 levels may have potential as therapeutic and diagnostic indicators.

Burden of Disease Due to Respiratory Syncytial Virus in Adults in Five Middle-Income Countries.

Respiratory syncytial virus (RSV) is an important cause of severe respiratory disease in older adults. Understanding the disease burden is crucial for guiding vaccination policy and raising disease awareness. We estimated the burden of RSV hospitalizations and deaths in adults in five middle-income countries: Argentina, Brazil, Chile, Mexico, and Malaysia. Hospital discharge and death statistics due to any respiratory disease (ICD-10 codes: J00-99) from 2010 to 2022 were obtained. The RSV attributable burden on hospitalizations and deaths by age group was determined for 2019 using previously published estimates. Latin American countries showed distinct annual peaks in respiratory-related hospitalizations and deaths during winter months that were absent in Malaysia. Among ≥20-year-olds in 2019, there were 14,604 RSV-attributable hospitalizations nationally in Argentina, 44,323 in Brazil, 4529 in Chile, 7416 in Malaysia, and 8651 in Mexico, and 60-74% in ≥65-year-olds. There were also 3518 RSV-attributable deaths in Argentina, 9115 in Brazil, 801 in Chile, 704 in Malaysia, and 3806 in Mexico 79-88% in ≥65-year-olds. Incidences of RSV-attributable hospitalizations in ≥75-year-olds ranged between 256.3 and 294.3 per 100,000 population, and deaths between 33.6 and 112.9 per 100,000 population. RSV is associated with a substantial disease burden beyond pediatric age groups, and preventive vaccines could have a major impact on this burden, especially in older adults.

Blood product transfusion practices in neonates with hypoxic-ischemic encephalopathy.

Blood product transfusion is a common practice in infants with hypoxic-ischemic encephalopathy (HIE) undoing therapeutic hypothermia (TH). The advantages and disadvantages of conservative or liberal transfusion practices in this fragile population are unknown. Study aims to characterize the transfusion practices in infants with HIE and investigate the association with outcome. We conducted a retrospective cohort study at a single level IV NICU, evaluating transfusion thresholds, as well as the association between hematological abnormalities or blood product transfusions and outcomes in infants admitted with HIE. By univariate analysis, FFP transfusion was associated with increased in-hospital death. However, multivariate analysis adjusting for HIE severity demonstrated no association between hematological abnormality or blood product transfusion and death, nor with neurodevelopmental impairment. No association was found between hematological blood product transfusion and death or neurodevelopmental impairment in a retrospective single NICU study of infants with HIE.

Under-Five Mortality and Associated Risk Factors in Children Hospitalized at David Bernardino Pediatric Hospital (DBPH), Angola: A Hierarchical Approach.

Reducing under-five mortality is a crucial indicator of overall development in a country. However, in Angola, understanding the factors contributing to hospital deaths in this vulnerable demographic remains incomplete despite improvements in healthcare infrastructure and public health policies. With one of the highest under-five mortality rates in sub-Saharan Africa, Angola faces significant challenges such as malaria, malnutrition, pneumonia, neonatal conditions, and intestinal infectious diseases, which are the leading causes of death among children. This study aimed to identify factors associated with hospital deaths among children aged 28 days to five years admitted to DBPH in Luanda between May 2022 and June 2023. Using a hospital-based case-control design, the study included 1020 children, among whom 340 experienced hospital deaths. Distal and intermediate determinants emerged as primary predictors of hospital mortality, showing significant associations with: mother without schooling (OR [95%CI] 4.3 [1.2-15.7], p < 0.027); frequent alcohol consumption during pregnancy (OR [95%CI] 3.8 [2.5-5.9], p < 0.001); hospital stay ≤24 h (OR [95%CI] 13.8 [6.2-30.8], p < 0.001); poor nutritional status (OR [95%CI] 2.1 [1.4-3.2], p < 0.001); short interbirth interval (OR [95%CI] 1.7 [1.1-2.5], p < 0.014); maternal age ≤19 years (OR [95%CI] 5.6 [3.0-10.8], p < 0.001); and maternal age ≥35 years (OR [95%CI] 2.1 [1.2-3.7], p < 0.006). These findings highlight the preventable nature of most under-five hospital deaths and underscore the urgent need to address social inequities and improve the quality of primary healthcare services to effectively reduce child mortality in Angola.

Impact of comorbidity on complication rates and life expectancy in patients with a leadless pacemaker

BackgroundKnowledge about impact of age and comorbidities on outcome in patients with leadless pacemakers (LPM) is limited. ObjectivesTo analyse outcome in LPM patients according to age and comorbidities. MethodsThis Swiss, multi-centre, retrospective analysis includes all patients with LPM implanted between 2015 and 2022. Charlson-Comorbidity-Index (CCI) was determined and patients were divided into a low- (CCI ≤ 5) and high-comorbidity (CCI > 5) group. Peri-procedural complications, in-hospital death, and all-cause mortalities were assessed. Finally, all-cause mortality according to three groups (CCI ≤ 3, 4–5, >5) was compared to age and sex-adjusted mortality in the general Swiss population. Results863 patients (median age 81 years, 65% male, 42% with CCI > 5) were included. Peri-procedural/long-term complication rates did not differ between the low- vs. high-comorbidity groups (2.6% vs. 1.7%, p = 0.48 and 1.2% vs. 2.8%, p = 0.12, respectively). In-hospital (3.6% vs. 0.6%, p = 0.002) and all-cause mortality (HR 2.9, 95%CI 2.2–3.8, p < 0.001) were significantly higher in the high-comorbidity group resulting in a three-year mortality of 58% (95%CI 51–65%) vs. 22% (95%CI 17–27%) in the low-comorbidity group. In patients with a CCI ≤ 3, all-cause mortality was comparable to the age- and sex-adjusted mortality of the general Swiss population. ConclusionsIn elderly patients with high comorbidity, LPM implantation was not associated with increased peri-procedural/long-term complications. All-cause mortality in LPM patients with a CCI ≤ 3 was comparable to age- and sex-adjusted mortality in the general Swiss population. Despite a relatively high three-year mortality due to competing risk factors, LPM implantation is safe, even in elderly patients with high comorbidity. Condensed abstractIn this Swiss, multi-centre, retrospective cohort analysis, 863 patients implanted with a leadless pacemaker were included and divided into a high-comorbidity (with a CCI > 5) and low-comorbidity (with a CCI ≤ 5) group. There was no between group difference in terms of implantation outcomes and peri-operative or long-term complications. Furthermore, all-cause mortality during follow-up in patients with a CCI ≤ 3 was comparable to age- and sex-adjusted mortality in the general Swiss population. These data indicate that LPM implantation is a safe procedure, even in elderly patients with high comorbidity.

Hospital referrals, exclusions from hospital care, and deaths among long-term care residents in the Community of Madrid during the March–April 2020 COVID-19 epidemic period: a multivariate time series analysis

BackgroundFrom March 7 to April 7, 2020, the Community of Madrid (CoM), Spain, issued interventions in response to the COVID-19 epidemic, including hospital referral triage protocols for long-term care facility (LTCF) residents (March 18–25). Those with moderate to severe physical disability and cognitive impairment were excluded from hospital referral. This research assesses changes in the association between daily hospital referrals and the deaths of LTCF residents attributable to the triage protocols.MethodsDaily hospital referrals and all-cause mortality from January to June 2020 among LTCF residents and the CoM population aged 65 + were obtained. Significant changes in LTCF resident daily hospital referrals time series, and in-LTCF and in-hospital daily deaths, were examined with tests for breaks and regimes in time series. Multivariate time series analyses were conducted to test changes in the associations between LTCF resident hospital referrals with daily deaths in-hospital and in-LTCF, and in the CoM population aged 65 + when the triage protocols were implemented.ResultsAmong LTCF residents, hospital referrals declined sharply from March 6 to March 23, 2020. Increases in LTCF residents' daily deaths occurred from March 7 to April 1, followed by a decrease reaching pre-epidemic levels after April 28. The daily ratio of in-hospital deaths to in-LTCF deaths reached its lowest values from March 9 to April 19, 2020. The four versions of the triage protocol, published from March 18 to March 25 had no impact on further changes in the association of hospital referrals with daily deaths of LTCF residents in-hospital or in-LTCF.ConclusionsWhile LTCF residents’ deaths increased, hospital referrals of LTCF residents decreased with the introduction of the CoM governmental interventions on March 7. They were implemented before the enactment of the triage protocols, protecting hospitals from collapse while overlooking the need for standards of care within LTCFs. The CoM triage protocols sanctioned the existing restrictions on hospital referrals of LTCF residents.

Daily steps are a predictor of, but perhaps not a modifiable risk factor for Parkinson's Disease: findings from the UK Biobank.

Higher physical activity levels have been suggested as a potential modifiable risk factor for lowering the risk of incident Parkinson's disease (PD). This study uses objective measures of physical activity to investigate the role of reverse causation in the observed association. To investigate the association between accelerometer-derived daily step count and incident PD, and to assess the impact of reverse causation on this association. This prospective cohort study involved a follow-up period with a median duration of 7.9 years, with participants who wore wrist-worn accelerometers for up to 7 days. The study was conducted within the UK Biobank, a large, population-based cohort. The analysis included 94,696 participants aged 43-78 years (56% female) from the UK Biobank who provided valid accelerometer data and did not have prevalent PD. Daily step counts were derived using machine learning models to determine the median daily step count over the monitoring period. The primary outcome was incident PD, identified through hospital admission and death records. Cox proportional hazards regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) for the association between daily step count and incident PD, with adjustments for various covariates and evaluation of reverse causation by splitting follow-up periods. During a median follow-up of 7.9 years (IQR: 7.4-8.4), 407 incident PD cases were identified. An inverse linear association was observed between daily step count and incident PD. Participants in the highest quintile of daily steps (>12,369 steps) had an HR of 0.41 (95% CI 0.31-0.54) compared to the lowest quintile (<6,276 steps; HR 1.00; 95% CI 0.84-1.19). A per 1,000 step increase was associated with an HR of 0.92 (95% CI 0.89-0.94). However, after excluding the first six years of follow-up, the association was not significant (HR 0.96, 95% CI 0.92-1.01). The observed association between higher daily step count and lower incident PD is likely influenced by reverse causation, suggesting changes in physical activity levels occur years before PD diagnosis. While step counts may serve as a predictor for PD, they may not represent a modifiable risk factor. Further research with extended follow-up periods is warranted to better understand this relationship and account for reverse causation.

Use of Neutrophil-to-Lymphocyte Ratio to Predict In-Hospital Mortality in Patients Admitted with Acute Decompensation of Atrial Fibrillation.

Background/Objectives: The prevalence of atrial fibrillation (AF) has been on the rise over the last 20 years. It is considered to be the most common cardiac arrhythmia and is associated with significant morbidity and mortality. The need for in-hospital management of patients having AF is increasing. Acute decompensation of cardiac rhythm is an indication for hospital admission. In the existing literature, several studies on different pathologies have observed that the risk of death was greater for patients with an increased neutrophil-to-lymphocyte ratio (NLR) and suggested that the NLR can be a useful biomarker to predict in-hospital mortality. This study aims to evaluate the link between the neutrophil-to-lymphocyte ratio at admission and death among the patients admitted to the medical ward for the acute manifestation of AF, and to gain a better understanding of how we can predict in-hospital all-cause death based on the NLR for these patients. Methods: A single-center retrospective study in an academic medical clinic was conducted. We analyzed if the NLR at in-hospital admission can be related to in-hospital mortality among the patients admitted for AF at the Medical Ward of Municipal Emergency University Hospital Timisoara between 2015 and 2016. After identifying a total of 1111 patients, we divided them into two groups: in-hospital death patients and surviving patients. We analyzed the NLR in both groups to determine if it is related to in-hospital mortality or not. One patient was excluded because of missing data. Results: Our analysis showed that patients who died during in-hospital admission had a significantly higher NLR compared to those who survived (p < 0.0001, 95% CI (1.54 to 3.48)). The NLR was found to be an independent predictor of in-hospital death among patients with AF, even for the patients with no raised level of blood leukocytes (p < 0.0001, 95% CI (0.6174 to 3.0440)). Additionally, there was a significant correlation between the NLR and the risk of in-hospital death for patients admitted with decompensated AF (p < 0.0001), with an area under the ROC curve of 0.745. Other factors can increase the risk of death for these patients (such as the personal history of stroke, HAS-BLED score, and age). Conclusions: The NLR is a useful biomarker to predict in-hospital mortality in patients with AF and can predict the risk of death with a sensitivity of 72.8% and a specificity of 70.4%. Further studies are needed to determine the clinical utility of the NLR in risk stratification and management of patients with AF.

Relationship Between CHA₂DS₂-VASc Score on Admission and In-Hospital Major Adverse Cardiovascular Events in Patients Diagnosed With ST-Elevation Myocardial Infarction.

The CHA₂DS₂-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, sex) scoring system, which includes conventional risk factors of coronary artery disease, was originally created to quantify the risk of thromboembolism in patients with atrial fibrillation. This study evaluated the usefulness of this score to predict adverse outcomes in STEMI (ST-elevation myocardial infarction) patients without atrial fibrillation. Primary end points were identified as MACE (major adverse cardiovascular events) which included in-hospital death or cerebrovascular accident. MACE rate was 10% (193 patients). The CHA₂DS₂-VASc score was an independent predictor of MACE (95% CI, 2.31 [1.37-3.9]; P = .0016). Other independent predictors of MACE included heart rate (95% CI, 1.56 [0.97-2.50]; P = .0242), admission Killip class (95% CI, 24.19 [10.74-54.46]; P < .0001), admission creatinine level (95% CI, 1.54 [1.10-2.16]; P = .0024), peak CK-MB level (95% CI, 1.63 [0.98-2.70]; P = .0001), and no-reflow (95% CI, 2.45 [1.25-4.80]; P = .0085). A nomogram was developed to estimate the risk of in-hospital adverse outcomes for STEMI patients. The CHA₂DS₂-VASc score was an independent predictor of MACE in STEMI patients. Linear analysis of CHA₂DS₂-VASc score without dichotomization was the main difference of this study from others.