In-hospital Death In Patients Research Articles

Mortality in patients with intracerebral hemorrhage associated with antiplatelet agents, oral anticoagulants or no antithrombotic therapy

The association between preceding treatment with antiplatelet agents (APs), vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) and mortality after intracerebral hemorrhage (ICH) remains unclear.The aim of this multicenter, prospective cohort study was to assess the risk for death after ICH in consecutive patients who were on treatment with APs, VKAs, DOACs, or no antithrombotic agent. The primary outcome was in-hospital death by day 30. ICH volume at admission and volume expansion were centrally assessed.Out of 598 study patients, in-hospital death occurred in 21% of patients who were on treatment with APs, 25% with VKAs, 30% with DOACs, and 13% with no antithrombotics. Crude death rate was higher in patients on antithrombotics as compared to patients receiving no antithrombotic agent. At multivariate analysis, age (HR 1.07; 95% CI 1.04–1.10), previous stroke (HR 1.83; 95% CI 1.14–2.93), GCS ≤8 at admission (HR 6.06; 95% CI 3.16–9.74) and GCS 9–12 (HR 3.38; 95% CI 1.81–6.33) were independent predictors of death. Treatment with APs (HR 1.29; 95% CI 0.61–2.76), VKAs (HR 1.42; 95% CI 0.70–2.88) or DOACs (HR 1.28; 95% CI 0.61–2.73) were not predictors of death in the overall study population, in non-trauma associated ICH as well as when GCS was not included in the model. ICH volume and volume expansion were independent predictors of death.In conclusion, preceding treatment with antithrombotic is associated with the severity of ICH. Age, previous stroke and clinical severity at presentation were independent predictors of in-hospital death in patients with ICH.

Preoperative uric acid predicts in-hospital death in patients with acute type a aortic dissection

BackgroundThe present study aimed to evaluate the value of admission serum uric acid (UA) level in predicting in-hospital risk of death in patients with acute type A aortic dissection (AAAD).MethodsFrom January 2016 to June 2019, 186 consecutive patients with AAAD who underwent thoracic aortic surgery were retrospectively studied. Serum UA levels were measured on admission. Forward conditional logistic regression was performed to identify independent risk factors for in-hospital death. Receiver operating characteristic (ROC) analysis was performed to assess the most clinical useful level of serum UA for predicting postoperative in-hospital mortality.ResultsIncreased level of serum UA was found in non-survivors compared with those survived (446 ± 123 vs 371 ± 111 umol/L, p < 0.001). Age (OR = 1.063, 95% CI 1.016–1.112, p = 0.009), UA (OR = 1.006, 95% CI 1.002–1.010, p = 0.002), D-dimer (OR = 1.025, 95% CI 1.005–1.013, p = 0.012), operation time (OR = 1.009, 95% CI 1.005–1.013, p < 0.001) and extent of aortic replacement (OR = 0.412, 95% CI 0.220–0.768, p = 0.005) were identified as independent risk factors of in-hospital mortality in AAAD patients. The best cut-off value of admission serum UA in predicting in-hospital mortality was determined to be 415 umol/L. Subgroup analysis showed that in the subgroup of total arch replacement, UA was significantly associated with in-hospital death (OR = 1.010, 95% CI 1.005–1.015, p < 0.001), while in patients underwent ascending aorta replacement or hemiarch replacement, the relationship was no longer significant (OR = 1.001, 95% CI 0.996–1.006, p = 0.611).ConclusionsElevated serum UA level on admission is an independent predictor of in-hospital mortality in patients with AAAD.

Mortality and risk assessment for anorexia nervosa in acute-care hospitals: a nationwide administrative database analysis

BackgroundAnorexia nervosa (AN) is a common eating disorder with the highest mortality rate of all psychiatric diseases. However, few studies have examined inpatient characteristics and treatment for AN. This study aimed to characterise the association between mortality and risk factors in patients with AN in acute-care hospitals.MethodsWe conducted a nationwide, retrospective analysis of the Japanese Diagnosis and Procedure Combination inpatient database. Data extraction occurred from April 2010 to March 2016. We estimated in–hospital mortality and identified independent risk factors, using multivariate logistic regression analysis to examine patient characteristics and physical and psychological comorbidities.ResultsWe identified 6937 patients with AN aged ≥12 years in 885 acute-care hospitals. Of these, 361 (5.2%) were male. Male and female participants’ median ages at first admission were 34 (17–65) and 28 (17–41) years, respectively. In total, 195 in-hospital patient deaths, including 22 (6.1%) men and 173 (2.6%) women, it was observed that the unadjusted odds ratio of mortality for male patients was more than twice that for female patients (OR: 2.40, 95% CI: 1.45–3.81). Multivariate logistic regression analysis demonstrated an adjusted odds ratio of 2.19 (95% CI: 1.29–3.73). Age at first hospital admission, percentage of ideal body weight, comorbidities, and hypotension were significantly associated with increased mortality risk, but the frequency of hospitalization, bradycardia, and other psychiatric disorders were not. Treatment in a university hospital was associated with lower mortality risk (odds ratio: 0.45, 95% CI: 0.30–0.67).ConclusionThe results highlighted sex differences in mortality rates. Potential risk factors could contribute to improved treatment and outcomes. These retrospective findings indicate a need for further longitudinal examination of these patients.

P38 Developing a model for predicting in-hospital death in patients with the use of extracorporeal membrane oxygenation

Abstract Funding Acknowledgements Minister of Science and Technology Background The objective of this study was to develop a predicting model for estimating the odds of in-hospital death in the patients who receive extracorporeal membrane oxygenation (ECMO). Methods Adult patients who received ECMO for a variety of etiologies in our National University Hospital from 2005 and 2016 were included. The demographic, anthropometric, hemodynamic, and laboratory data when ECMO was instituted were recorded for each individual. A logistic regression model was applied to find the risk variables that were independently associated with in-hospital mortality. The predicted probability derived from the model was used to plot a receiver-operating-characteristic (ROC) curve, and area under curve (AUC) was found to represent the differentiating capacity of this approach. Results A total of 919 patients (659 men and 260 women) were included in the analysis. The mean age was 53.7[SD 15.9] years. The analysis showed that age (odds ratio [OR]: 1.018, 95% confidence interval [CI]: 1.008-1.028 per year), blood urea nitrogen (1.008 [1.001-1.014] per mg/dL), use of inotropic agent in terms of inotropic equivalent (1.007 [1.002-1.013]), the presence of cardiogenic shock (1.910 [1.097-3.327]), and the need of hemodialysis (2.262 [1.304-3.926]) were positively associated with mortality. In addition, body surface area (OR: 0.414 [0.204-0.840] per square meter), systolic blood pressure (0.995 [0.990-0.999] per mmHg), Glasgow Coma Scale (0.928 [0.899-0.957] per unit), pH value (0.395 [0.158-0.988] for each unit), and urine output (OR: 0.974 [0.964-0.985] per dL) were negatively associated with the probability of in-hospital death. The AUC in ROC analysis was 0.754 (95% CI: 0.722-0.787). Conclusion The predicting model that used a simple set of physiological parameters could substantially discriminate whether the patients receiving ECMO could survive the in-hospital course. Further studies are needed to examine why false positive and false negative predictions took place. Abstract P38 Figure.

Urologic Disorders are Still the Leading Cause of In-hospital Death in Patients With Spina Bifida

ObjectiveTo assess and analyze the contemporary causes of in-hospital deaths of spina bifida patients. MethodsIt was a cross-sectional observational study of the longitudinal national cohort of all patients hospitalized in French public and private hospitals. We analyzed the data from the French hospital discharge database (Programme de Médicalisation des Systemes d'Information, PMSI) from 2009 to 2014. The number of in-hospital deaths was extracted using the combination of the ICD-10 codes "Q05" or "Q760" and a discharge code = 9. ResultsThere were 138 in-hospital deaths of spina bifida patients over the 6-year study period. The median age at death was 41 years (IQR: 25-52). The median age at death was significantly lower in patients with vs without hydrocephalus (26.6 vs 45.5 years; P <.0001). The leading cause of in-hospital death was urologic disorders (n = 24; 17.3%). Other main causes of death were pulmonary disorders (n = 23; 16.7%), neurologic disorders (n = 19; 13.8%), and bowel disorders (n = 15; 10.9%). Upper urinary tract damage accounted for most of the urologic causes of death: 8 patients died from urinary tract infections (33.3%), 7 patients died from renal failure (29.2%), 4 died from bladder cancer (16.7%), and 5 from other urologic causes. The only variable significantly associated with a death from urologic causes was the absence of hydrocephalus (OR = 0.26; P = .009). ConclusionUrologic disorders remain the leading cause of in-hospital death in spina bifida patients in France. The present study highlights that efforts to improve the urologic management of the spina bifida population are still greatly needed.

Analysis of coagulation function and prognostic factors of acute aortic dissection

Objective To investigate the clinical characteristics, coagulation function and associated prognostic factors of acute aortic dissection. Methods The clinical data of 119 patients with acute aortic dissection (AAD) admitted to Beijing University People's Hospital from November 2008 to January 2016 were analyzed. All the participants were confirmed by computed tomography angiography, and the onset time was less than 14 days. Data of blood routine test, coagulation function at the first admission were collected, and surgical intervention and prognosis were recorded. All the patients, according to the prognosis, or whether disseminated intravascular coagulation (DIC) occurred, were divided into two groups, and the differences between the two groups were compared. Logistic regression analysis was applied to analyze independent risk factors related to in-hospital death in AAD patients. Results In 119 patients with AAD, the average age was (52.9±14.2) years, with a male/female ratio of 5.3:1. Pain was the most common clinical manifestation in patients with AAD, accounting for more than 90.0%. The nature of pain was mostly expansible and/or transitive pain. Dominant DIC occurred in 13 cases (10.9%), and 7 patients died (53.8%). There were significant differences between the DIC group and non-DIC group in neutrophil/lymphocyte ratio (NLR), platelet count, fibrinogen, D-dimer, FDP, PT, APTT and mortality rate (P<0.05). All the 16 patients in the death group were type A AAD, among which, 7 patients (43.8%) developed with DIC. There were significant differences between the death group and survival group in NLR, platelet count, fibrinogen, D-dimer, FDP, PT, APTT, DIC proportion and surgical operation rate (P<0.05).Logistic regression analysis showed that NLR and platelet count were independent risk factors of in-hospital death (P<0.05). Conclusions D-dimer has a high diagnostic and prognosis value for AAD. The mortality increased with the activation and depletion of platelet. Once DIC occurs, the prognosis is extremely poor. NLR and platelet count are independent risk factors for in-hospital death in patients with AAD. Key words: Acute aortic dissection; D-dimer; Neutrophil to lymphocyte ratio; Disseminated intravascular coagulation; Prognosis

A New Recalibrated Four-Category Child-Pugh Score Performs Better than the Original Child-Pugh and MELD Scores in Predicting In-Hospital Mortality in Decompensated Alcoholic Cirrhotic Patients with Acute Variceal Bleeding: a Real-World Cohort Analysis.

There currently is no consensus on how to accurately predict early rebleeding and death after a major variceal bleed. This study investigated the relative predictive performances of the original Child-Pugh (CP), model for end-stage liver disease (MELD) and a four-category recalibrated Child-Pugh (rCP). This prospective study included all adult patients admitted to Groote Schuur Hospital with acute esophageal variceal bleeding secondary to alcoholic cirrhosis, between January 2000 and December 2017. CP and rCP grades and MELD score were calculated on admission, and the predictive ability in discriminating in-hospital rebleeding and death was compared by area under receiver-operating characteristic (AUROC) curves. During the study period, 403 consecutive adult patients were treated for bleeding esophageal varices of whom 225 were secondary to alcoholic cirrhosis. Twenty-four (10.6%) patients were CP grade A, 88 (39.1%) grade B and 113 (50.2%) grade C on hospital admission. MELD scores ranged from 6 to 40. Thirty-one (13.8%) patients rebleed, and 41 (18.2%) patients died. There was no difference in the discriminatory capacity of the CP (AUROC 0.59, 95% CI 0.50-0.670) and MELD (AUROC 0.62, 95% CI 0.51-0.73) to predict rebleeding (p = 0.72), or between the Child-Pugh (AUROC 0.75, 95% CI 0.71-0.81) and MELD (AUROC 0.71, 95% CI 0.62-0.80) to predict death (p = 0.35). The rCP classification (A-D) had a significantly improved discriminatory capacity (AUROC 0.83 95% CI 0.77-0.89) compared to the CP score (A-C) and MELD to predict death (p = 0.004). A recalibrated Child-Pugh score outperforms the original Child-Pugh grade and MELD score in predicting in-hospital death in patients with bleeding esophageal varices secondary to alcoholic cirrhosis.

P5588Early versus delayed oral anticoagulation in patients with acute pulmonary embolism: determinants and outcome

Abstract Background Whether early oral anticoagulant treatment is appropriate for patients with acute pulmonary embolism (PE) regardless of PE severity is undefined. The aim of this study in patients with acute PE at intermediate risk of death were: I) to assess the determinants for the use of early vs delayed vs no oral anticoagulants in patients with acute PE and II) to assess the association between timing of oral anticoagulation and in-hospital mortality. Methods Prospective cohorts of patients with acute PE at intermediate risk of death according to the European Society of Cardiology Guidelines 2014 were merged in a collaborative database. The initiation of oral anticoagulation was classified as early (≤3 days) or delayed (between day 3 and 10 from diagnosis). Patients treated with parenteral anticoagulants for longer than 10 days were also included. In-hospital death was the primary study outcome. Results Overall, 557 patients were included in the study, 23 received thrombolytic treatment during the hospital stay. The mean duration of parenteral anticoagulation was 7±8 days (5 median), 348 patients were initiated on a direct oral anticoagulant and 79 on a vitamin K antagonist during the hospital stay. Initiation of oral anticoagulants occurred early or delayed in 209 (37%) and 218 (39%) patients, respectively and never occurred during the first 30 days in 130 (23%). Intermediate-low risk patients more commonly received early and intermediate high delayed oral anticoagulation. Simplified PESI score of zero (OR 1.9, 95% CI 1.3–2.7) was independently associated with early oral anticoagulation; among sPESI components absence of cancer (OR 5.9, 95% CI 3.3–10) and heart rate &lt;110 (OR 1.8, 95% CI 1.01–3.16) were independent predictors of early initiation of oral anticoagulants. The presence of both right ventricle dysfunction and injury was associated with delayed initiation of oral anticoagulants. The incidence of death was 5.5%. Death occurred in 32 patients and was not related to the duration of parenteral anticoagulation (OR 1.01 per day, 95% CI 0.98–1.06) nor to right ventricle dysfunction but to sPESI 1 (OR 3.32, 95% CI 1.14–9.66). These results were partially confirmed in the 435 intermediate risk patients without cancer (OR 1.03, 95% CI 0.99–1.08 for days of parenteral treatment; OR 4.17, 95% CI 0.95–18 for sPESI 1). Conclusion The clinical severity of PE and not the timing of initiation of oral anticoagulants are associated with in-hospital death in patients with intermediate risk PE. Randomized studies are needed to definitively assess the role of heparin lead-in in patients with PE at intermediate risk for death.

High hemoglobin is associated with increased in-hospital death in patients with chronic obstructive pulmonary disease and chronic kidney disease: a retrospective multicenter population-based study

BackgroundChronic kidney disease (CKD) is a common comorbidity of chronic obstructive pulmonary disease (COPD). Although high hemoglobin (Hb) is detrimental to CKD patients, its relationship with poor outcomes in the COPD population has not been reported. This study aimed to investigate the relationship between high Hb and in-hospital mortality and to explore reference Hb intervals in patients with COPD and CKD.MethodsThis retrospective study was multicenter population-based. A total of 47,209 patients who presented with COPD between January 2012 and December 2016 were included. The average Hb level during hospitalization was used as the Hb level. CKD and advanced CKD were defined as estimated glomerular filtration rates < 60 and < 30 ml/min/1.73 m2, respectively. The association between Hb level (measured in 1 g/dL intervals) and in-hospital mortality was analyzed in different multivariable logistic regression models by CKD stratification.ResultsThe Hb level was decreased in the CKD subgroup. In the non-CKD group, a higher Hb level was not associated with an increased risk of in-hospital death. However, the Hb level and mortality showed a U-shaped relationship in the CKD group. After adjusting for age and Charlson Comorbidity Index, multivariable regression analysis showed that an Hb level > 17 g/dL was associated with an increased risk of death in the CKD group with an odds ratio (OR) of 2.085 (95% CI, 1.019–4.264). Hb > 14 g/dL was related to an increased risk of death in advanced CKD patients (OR, 4.579 (95% CI, 1.243–16.866)).ConclusionsHigh Hb is associated with an increased risk of in-hospital death in COPD patients with CKD, especially among those with advanced CKD. In this group of patients, attention should be paid to those with high Hb levels.

Predicting in-hospital death in patients with type B acute aortic dissection.

The outcome of patients with acute type B aortic dissection (BAAD) is largely dictated by whether or not the case is “complicated.” The purpose of this study was to investigate the risk factors leading to in-hospital death among patients with BAAD and then to develop a predictive model to estimate individual risk of in-hospital death.A total of 188 patients with BAAD were enrolled. Risk factors for in-hospital death were investigated with univariate and multivariable logistic regression analysis. Significant risk factors were used to develop a predictive model.The in-hospital mortality rate was 9% (17 of 188 patients). Univariate analysis revealed 7 risk factors to be statistically significant predictors of in-hospital death (P < .1). In multivariable analysis, the following variables at admission were independently associated with increased in-hospital mortality: hypotension (odds ratio [OR], 4.85; 95% confidence interval [CI], 1.12–18.90; P = .04), ischemic complications (OR, 8.24; 95% CI, 1.25–33.85; P < .001), renal dysfunction (OR, 12.32; 95% CI, 10.63–76.66; P < .001), and neutrophil percentage ≥80% (OR, 5.76; 95% CI, 2.58–12.56; P = .03). Based on these multivariable results, a reliable and simple prediction model was developed, a total score of 4 offered the best point value.Independent risk factors associated with in-hospital death can be predicted in BAAD patients. The prediction model could be used to identify the prognosis for BAAD patients and assist physicians in their choice of management.

Risk stratification model for in-hospital death in patients undergoing percutaneous coronary intervention: a nationwide retrospective cohort study in Japan

ObjectivesTo provide an accurate adjustment for mortality in a benchmark, developing a risk prediction model from its own dataset is mandatory. We aimed to develop and validate a risk model...

Can the leukocyte`s parameters in peripheral blood smear predict risk of in-hospital death of patients undergoing high-risk gastrointestinal surgery?

White blood cell (WBC) count constitutes a part of routine peripheral blood examination (FBC, full blood count). Precise analysis of leukocytes' parameters in blood smear is usually performed only when leukopenia or leukocytosis is found. We aimed to assess the usefulness of leukocytes' smear test in predicting in-hospital death of patients undergoing high-risk gastrointestinal (GI) surgery. Materials &amp; Methods. We prospectively enrolled 101 subjects undergoing high-risk GI surgery from 01.01.2017 till 31.12.2017. Blood tests were performed preoperatively, with analysis focused on the assessment of total WBC count, as well as the count of neutrophils (NEUT), lymphocytes (LYM), monocytes (MONO), eosinophils (EOS) and basophils (BASO). Indices of NEUT/LYM (NLR) and MONO/LYM (MLR) were calculated. In-hospital mortality was considered the outcome. Mortality reached 5%. There was no significant difference in WBC count between survivors and the deceased (p=0.2) and WBC failed to predict the outcome (AUC=0.69; p=0.3). MONO (p=0.009) and BASO (p=0.02) counts, as well as MLR (p=0.007) were significantly higher in patients who died. MONO count and MLR index predicted in-hospital death with good accuracy, respectively: AUC[MONO]=0.85 (p&lt;0.001) and AUC[MLR]=0.86 (p&lt;0.001). Other investigated parameters played no significant role in outcome prediction. Routine peripheral blood smear evaluation should be considered in all patients undergoing high-risk GI surgery, because the number of monocytes can be a valuable predictor of in-hospital death.

Outcomes of Hospitalized Patients with Myocardial Infarction and Immune Thrombocytopenic Purpura: A Cross Sectional Study over 15 Years

Background:Immune Thrombocytopenic Purpura (ITP) is an autoimmune disorder characterized by low platelet counts and mucocutaneous bleeding. Antiplatelet agents are an essential component in the treatment of acute myocardial infarction (MI). Patients with ITP are not exempt from succumbing to acute myocardial infarction. Myocardial infraction in these patients is rare but poses a significant management challenge. The outcomes of hospitalized patients with ITP and acute MI have not been previously described and may help identify risk factors associated with adverse outcomes in this unique patient population.Methods:The International Classification of Diseases, 9th Edition, Clinical Modification codes were used to identify patients with ITP who were admitted with acute myocardial infarction. All data regarding such hospitalization was extracted from the National Inpatient Database for the years 2000 to 2014. Patient demographics of age, race and gender; hospital characteristics such as geographical location, teaching status, rural vs. urban location and bed size, medical comorbidities such as hypertension, hyperlipidemia, diabetes and coronary artery disease were studied. The Chi square test was used to determine associations with statistical significance and logistic regression was used to determine independent predictors of mortality.Results:A total of 753,732 hospitalized patients with ITP were identified over the time period of 2000 to 2014 of which 37695 patients had both ITP and acute MI. There were more females with ITP in general (60% females vs 40% males), but more males with ITP and acute MI (55.8% males vs 44.2% females; p =0.0000). Caucasians were affected the most (5.5%) amongst all races and the age group of 65-79 years had the highest percentage of patients with ITP and MI (7.3%). While hospitals located in the Northeast region of the country had the highest prevalence of MI in ITP, there was no statistical difference between prevalence in hospitals of different sizes (small vs. medium vs. large). A majority of patients with MI and ITP were covered by Medicare and were discharged home. 5572 patients received a stent and 3353 patients underwent coronary artery bypass grafting. The classical risk factors of hypertension, hyperlipidemia, and diabetes were also noted to be highly prevalent in patients with ITP and MI. 10.05% of patients with ITP and acute MI died during hospitalization, while 4% of all patients with ITP died during hospitalization (p<0.05). Multiple regression showed that stent placement, female gender, blood transfusions, platelet transfusion, 80+ age group and higher Charlson's score were independent predictors of mortality in patients with ITP who have MI (ORs: 0.3, 0.8, 1.9, 1.3, 5.9 and 5.5 respectively).Conclusions:ITP patients with MI have poor outcomes. Known risk factors for acute MI in the general population are also applicable to patients with ITP. Acute MI is associated with an increased rate of in-hospital death in patients with ITP. Both blood transfusions and platelet transfusions adversely affect outcomes and should be considered in the management of MI in ITP patients. DisclosuresKota:Novartis: Honoraria; Xcenda: Honoraria; Incyte: Honoraria; BMS: Honoraria; Pfizer: Honoraria.

484. A Severity Score for Predicting In-Hospital Death in Patients With Clostridium difficile Infection: A Hospital-Based Cohort Study

BackgroundCurrent definitions for severe C. difficile infection (CDI) are based on populations of Western countries. We examined the predicting performance of existing definitions in Taiwanese population and developed a new severity score.MethodsWe included adult patients who were admitted to China Medical University Hospital and had first-time positive C. difficile culture or toxin test during 2012–2016. The index date was the sampling date of the specimen. Data were pulled from the electronic medical records. The primary outcome was in-hospital death during the index admission. Variables that were significantly associated with in-hospital death in the bivariable analyses were included in a multivariable logistic regression model. We assigned weight for each variable using the adjusted odds ratio (aOR) and summed up the weights to obtain a severity score.ResultsOf 544 patients, median age was 71 years old and 70 patients (12.9%) died during the index admission. Patients did not differ in: gender, age, prior infection (−30 to 0 day of index date), prior admission, prior anti-peptic ulcer medication use, index (−3 to 3 days) glucose and kidney function except for blood urea nitrogen (BUN). Variables included in the multivariable model were: complicated diabetes (aOR 2.0; 0.8–5.2), malignancy (2.0; 1.1–3.7), prior use of second-generation cephalosporins (1.8; 0.9–3.7), use of loperamide (1.8; 1.0–3.4) or probiotics within −14 to 14 days (2.4; 1.0–5.5), index white blood cell count (WBC) > 15,000 cells/μL (1.9; 1.0–3.6), index serum creatinine (sCr) ≥1.5 times premorbid level (1.1; 0.6–2.1), index BUN >30 mg/dL (1.7; 0.9–3.5), and index BUN/sCr ratio > 20 (1.3; 0.7–2.5). The severity score was significantly higher among patients who died during admission than those who survived (median 6 vs. 4). A score of ≥4 was defined as severe. The performance of severity score was better than that of SHEA-IDSA or ESCMID definition (see figure). PPV = positive predictive value; NPV = negative predictive value.ConclusionCurrent guidelines use WBC, sCr increase, sCr, or albumin to define the severity of CDI. Our severity scoring system improved the predictive performance by adding novel indicators of comorbidities, BUN, BUN/sCr, and anti-diarrhea medications use.Disclosures All authors: No reported disclosures.

Effect of an intra-aortic balloon pump with venoarterial extracorporeal membrane oxygenation on mortality of patients with cardiogenic shock: a systematic review and meta-analysis†.

An intra-aortic balloon pump (IABP) concomitant with venoarterial extracorporeal membrane oxygenation (VA-ECMO) is frequently used to support patients with refractory cardiogenic shock (CS). Because of the lack of evidence of the adjunctive benefit, the goal of the study was to compare the effect of VA-ECMO plus IABP with that of VA-ECMO alone. Systematic searches were conducted to identify studies using PubMed, Embase, the Cochrane Library and the International Clinical Trials Registry Platform. Studies reporting on patients with adult CS treated with VA-ECMO plus IABP or VA-ECMO alone were identified and included. The primary outcome was in-hospital death. The secondary outcomes included neurological, gastrointestinal and limb-related complications. The study protocol was registered at PROSPERO (CRD42017069259). A total of 29 studies comprising 4576 patients were included. The pooled in-hospital deaths of patients on VA-ECMO were 1441/2285 (63.1%) compared with 1339/2291 (58.4%) for patients with adjunctive IABP. VA-ECMO plus IABP was associated with decreased in-hospital deaths [risk ratio (RR) 0.90; 95% confidence interval (CI) 0.85-0.95; P < 0.0001]. Moreover, IABP was related to decreased in-hospital deaths of patients with extracorporeal cardiopulmonary resuscitation, postcardiotomy CS and ischaemic heart disease (RR 0.78; 95% CI 0.64-0.95; P = 0.01; RR 0.91; 95% CI: 0.85-0.98; P = 0.008; RR 0.83; 95% CI 0.73-0.96, P = 0.009). Neurological, gastrointestinal and limb-related complications did not differ significantly between patients on ECMO with and without concurrent IABP. VA-ECMO plus IABP was associated with decreased in-hospital deaths in patients with CS.

A Low Early High-density Lipoprotein Cholesterol Level Is an Independent Predictor of In-hospital Death in Patients with Acute Coronary Syndrome.

Objective In patients with acute coronary syndrome (ACS), low high-density lipoprotein cholesterol (HDL-C) levels in samples collected after an overnight fast are diagnostic indicators and well-established predictors of adverse outcomes. However, the relationship between the HDL-C levels in samples collected just after arrival (early HDL-C) and in-hospital mortality remains unknown. The purposes of the present ACS study were to (1) evaluate the association between the early HDL-C levels of patients and in-hospital mortality and (2) compare the early HDL-C level with other well-known determinants associated with in-hospital mortality.Methods This retrospective study surveyed 638 consecutive ACS patients and then assessed the possible determinants of in-hospital mortality. All initial blood samples, including that for early HDL-C, were drawn within one hour of arrival.Results In the present study, the overall in-hospital mortality was 5.9%. A multivariable analysis showed that a low early HDL-C [odds ratio (OR) 2.53, 95% confidence interval (CI) 1.14-5.62], elevated troponin T (OR 4.40, 95% CI 1.26-15.29) and high Killip class (OR 15.41, 95% CI 7.29-32.59) were independent predictors of in-hospital mortality. A Kaplan-Meier survival analysis indicated that there the in-hospital outcome for the low early HDL-C group was significantly worse than that for the high early HDL-C group (age- and gender-adjusted hazard ratio 2.40, 95% CI 1.15-5.00, p=0.02).Conclusion ACS patients with low early HDL-C levels had higher in-hospital mortalities than those who did not have low early HDL-C levels. In addition to the already well-known determinants, low early HDL-C should also be considered as an independent predictor of in-hospital mortality in ACS patients who present to a cardiac care unit.

Factors Associated With in-Hospital Death in Patients with Acute Mesenteric Artery Ischemia

ABSTRACT Objective: The aim of the study was to assess the factors associated with increased mortality in patients with acute mesenteric ischemia, emphasizing the importance of an early diagnosis and a prompt surgical intervention in order to avoid lesion progression. Materials and method: A retrospective analytical study was conducted on a study population of 50 male and female patients with acute ischemia of the mesenteric arteries, aged between 36-92 years. Demographic and pathological history characteristics were assessed, together with presented symptoms, laboratory and CT findings, as well as surgical outcome and time-related aspects between presentation in the emergency department and time of surgery, as well as the hospitalization period until discharge or death. Results: Muscular defense (OR = 23.05) and shock (OR = 13.24) as symptoms were strongly associated with a poor prognosis, while elevated values of lactate dehydrogenase (p = 0.0440) and creatine kinase (p = 0.0025) were associated with higher death rates. The time elapsed during investigations in the emergency room was significantly higher in patients who deceased (p = 0.0023), similarly to the total time from the onset of symptoms to the beginning of surgery (p = 0.0032). Surgical outcomes showed that patients with segmental ischemia of the small bowel had significantly higher chances of survival (p &lt;0.0001). Conclusion: Increased mortality rates in patients presenting in the emergency department for acute mesenteric ischemia were observed in patients with occlusion of the superior mesenteric artery, with higher levels of CK and LDH, as well as with longer periods of stay in the emergency department for diagnostic procedures until the commencement of the surgical intervention. Therefore, proper investigations in a timely manner followed by a specific and prompt surgical intervention may avoid unfavorable evolution of patients towards death.

Effect of Hangeshashin-To (Japanese Herbal Medicine Tj-14) on Tolerability of Irinotecan: Propensity Score and Instrumental Variable Analyses.

Irinotecan hydrochloride (CPT-11) is used to treat a wide spectrum of malignant tumors. Hangeshashin-to (Japanese herbal medicine TJ-14) is reportedly effective in preventing and controlling diarrhea associated with CPT-11. However, the effect of TJ-14 on tolerability of chemotherapy with CPT-11 has not been fully investigated. We used the Japanese Diagnosis Procedure Combination inpatient database to retrospectively identify patients who had received CPT-11 on their first admission with and without TJ-14. Patients who did receive TJ-14 (N = 7092) received CPT-11 more often and in larger doses than those who did not receive TJ-14 (N = 82,019). The incidence rate ratio of CPT-11 administration was 1.34 for frequency (95% confidence interval [CI], 1.31–1.38; p < 0.001), and 1.16 for total dose (95% CI, 1.14–1.19; p < 0.001) according to stabilized inverse probability treatment weighting using propensity scores. Instrumental variable analysis showed similar trends. In-hospital mortality was significantly lower in patients who received TJ-14 than in those who did not. Odds ratios of in-hospital death in patients receiving TJ-14 was 0.81 (95% CI, 0.71–0.93; p = 0.002) according to stabilized inverse probability treatment weighting using propensity scores and 0.42 (95% CI, 0.22–0.81; p = 0.009) according to instrumental variable analysis. Our findings indicate that TJ-14 improve the tolerability of CPT-11.

Prognostic Value of Electrocardiography in Patients With Fulminant Myocarditis Supported by Percutaneous Venoarterial Extracorporeal Membrane Oxygenation - Analysis From the CHANGE PUMP Study.

Fulminant myocarditis (FM) presents various abnormal findings on ECG, the prognostic impact of which has not been not fully elucidated. The aim of this study was therefore to clarify the prognostic value of ECG data in FM patients supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO).Methods and Results:In this multicenter chart review, we investigated 99 patients with FM supported by VA-ECMO. The final cohort consisted of 87 patients (mean age, 52±16 years; female, 42%) after 12 patients who required conversion to other forms of mechanical circulatory support were excluded. The median LVEF was 14.5%. At the time of VA-ECMO initiation, 38 patients (44%) had arrhythmias including atrial fibrillation (6%), complete atrioventricular block (CAVB; 17%), and ventricular tachycardia or fibrillation (VT/VF; 15%). Of the 49 patients with sinus rhythm (SR), 26 had QRS duration ≥120 ms (wide QRS). On logistic regression analysis, wide QRS predicted in-hospital death in patients with SR (OR, 3.6; 95% CI: 1.07-13.61, P=0.04). Compared with SR with narrow QRS (QRS duration <120 ms), CAVB and VT/VF had a higher risk of in-hospital death (CAVB: OR, 7.20; 95% CI: 1.78-34.15, P=0.005; VT/VF: OR, 8.10; 95% CI: 1.86-42.31, P=0.005). In patients with FM, CAVB and VT/VF carried a higher risk of in-hospital death. Wide QRS also predicted a higher risk of in-hospital death in patients with SR.

Is There an Influence of Surgeon’s Experience on the Clinical Course in Patients With a Proximal Femoral Fracture?

Teaching of surgical procedures is of paramount importance. However, it can affect patients outcome. The aim of this study was to evaluate if teaching of hip fracture surgery is an independent predictor for negative in-hospital outcome. Retrospectively, we analyzed all hip fracture patients between 2008 and 2013 recorded in a national quality measurement database (AQC). Inclusion criteria were proximal femoral fracture (ICD-10 diagnostic codes S72.00-S72.11), surgical care of those fracture and a documented teaching status of the intervention. Variables were sought in bivariate and multivariate analyses. Teaching status was entered in multiple regression analysis models for in-hospital death, complications and length of stay while controlling for confounders. In the 6-year study period, a total of 4397 patients at a mean age of 80 years met the inclusion criteria. Totally, 48% (n = 2107) of the procedures were conducted as teaching interventions. The rest of our examined cases (n = 2290) were conducted as nonteaching procedures. There was no association between teaching and mortality, but complications (odds ratio = 1.3; 95% CI: 1.04-1.5; p = 0.018) and prolonged hospitalization (standardized beta = 0.045, p = 0.002) were more likely to occur in the teaching group while controlling for confounders. There appears to be no effect of the educational status on the in-hospital death in patients with a proximal femoral fracture. However, teaching was an independent predictor of complications and longer length of stay. Although the differences were significant, the clinical outcome was comparable in both groups, thus justifying the benefits of resident teaching.