Independent Predictors Of Hospital Mortality Research Articles

Acute myocardial infarction complicated by cardiogenic shock in Ukraine: multicentre registry analysis 2021-2022.

Data on the results and management strategies in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) in the Low and Lower-Middle Income Countries (LLMICs) are limited. This lack of understanding of the situation partially hinders the development of effective cardiogenic shock treatment programs in this part of the world. The Ukrainian Multicentre Cardiogenic Shock Registry was analyzed, covering patient data from 2021 to 2022 in 6 major Ukrainian reperfusion centres from different parts of the country. Analysis was focusing on outcomes, therapeutic modalities and mortality predictors in AMI-CS patients. We analyzed data from 221 consecutive patients with CS from 6 hospitals across Ukraine. The causes of CS were ST-elevated myocardial infarction (85.1%), non-ST-elevated myocardial infarction (5.9%), decompensated chronic heart failure (7.7%) and arrhythmia (1.3%), with a total in-hospital mortality rate for CS of 57.1%. The prevalence of CS was 6.3% of all AMI with reperfusion rate of 90.5% for AMI-CS. In 23.5% of cases, CS developed in the hospital after admission. Mechanical circulatory support (MCS) utilization was 19.9% using intra-aortic balloon pump alone. Left main stem occlusion, reperfusion deterioration, Charlson Comorbidity Index >4, and cardiac arrest were found to be independent predictors for hospital mortality in AMI-СS. Despite the wide adoption of primary percutaneous coronary intervention as the main reperfusion strategy for AMI, СS remains a significant problem in LLMICs, associated with high in-hospital mortality. There is an unmet need for the development and implementation of a nationwide protocol for CS management and the creation of reference CS centers based on the country-wide reperfusion network, equipped with modern technologies for MCS.

Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study

BackgroundClinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches.MethodsThis was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality.ResultsThere were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987–19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351–60.298) were both found to be independent predictors of hospital mortality on multivariable analysis.ConclusionsDifferences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.

Candidemia in critically ill COVID-19 patients: Risk factors and impact on mortality

BackgroundRisk factors of candidemia are well-described in intensive care units (ICUs) before the Coronavirus disease 2019 (COVID-19) pandemic. The increased rates of admission to ICUs have appeared during the pandemic. MethodsPatient characteristics and laboratory data of 80 candidemia with COVID-19, 101 candidemia without COVID-19, and 100 non-candidemia with COVID-19 patients were evaluated, in this study. ResultsSystemic inflammatory response syndrome (SIRS) ≥ 2, solid malignancy, total parenteral nutrition (TPN), central venous catheterization (CVC), hypotension, fever, urea, alanine aminotransferase (ALT), D-dimer, procalcitonin, ferritin, and delta neutrophil index (DNI) was found to be associated with candidemia in COVID-19 patients. TPN, hypotension, and fever were identified as independent predictors of candidemia in COVID-19, and candidemia in COVID-19 is characterized by significantly high mortality rates. Urea, lactate, and procalcitonin were defined as independent predictors of hospital mortality in candidemia patients with COVID-19. ConclusionThe presence of candidemia increases mortality in COVID-19. TPN, fever, and hypotension werefound to be the most powerful predictors of candidemia in COVID-19. Overall, these data show that candidemia in COVID-19 is characterized by significantly high mortality rates. Determination of distinctive features can prevent candidemia and mortality.

Clinical characteristics and mortality prediction of patients admitted to the Hong Kong East Cluster intensive care units in the COVID‐19 fifth wave

AbstractIntroductionCOVID‐19 has been threatening global public health since 2019. To address the overwhelming caseload, several tools were developed to predict prognosis and aid triage of critically ill patients for intensive care. Currently, there is a lack of local data on the validity of such tools.ObjectiveThe objective of this study is to identify the predictors of intensive care unit (ICU) mortality in COVID‐19 patients in Hong Kong and externally validate the different scoring systems.MethodsA retrospective cohort analysis of patients admitted to the HKEC ICUs from 1 January 2022 to 30 April 2022 was performed. We collected data on patient demographics, vaccination status, laboratory parameters, and clinical outcomes including need for organ support and mortality. Clinical severities were estimated by Sequential Organ Failure Score, 4C Mortality Score, COVID‐Gram score, and Acute Physiology and Chronic Health Evaluation (APACHE) IV score based on the original studies. Comparison between individual scoring systems' performance on hospital mortality was conducted and summarized.ResultsIn these four months, 137 patients with COVID‐19 admitted to ICUs of Ruttonjee Hospital and Pamela Youde Nethersole Eastern Hospital were recruited. 64 patients (46.7%) were admitted for COVID‐19 related respiratory failure, among which mortality was 66.7%. The overall hospital and ICU mortality were 21.9% and 13.1%, respectively. Invasive mechanical ventilation (IMV) (OR 3.221, p 0.034), high flow nasal cannula (HFNC) oxygen therapy (OR 3.107, p 0.039), and higher APACHE IV score (OR 1.043, p &lt; 0.001) were independent predictors of hospital mortality using multivariate analysis. The scoring systems had good performance in mortality prediction in our population. The APACHE IV score (AUROC 0.79, 95% CI 0.698–0.894) and 4C Mortality Score (AUROC 0.751, 95% CI 0.657–0.844) outperformed other scoring systems in predicting hospital mortality.ConclusionIn patients with COVID‐19, the use of IMV or HFNC and APACHE IV score were independent risk factors for hospital mortality. The APACHE IV and the 4C Mortality Score were most useful in our population for predicting ICU and hospital mortality.

Prognostic Value of Neutrophils-to-Lymphocytes Ratio and Platelets-to-Lymphocytes Ratio in Sepsis Patients With Lymphopenia.

Inflammation plays a critical role in sepsis. The integration of neutrophil-to-lymphocyte ratio (NLR) and platelets-to-lymphocytes ratio (PLR) from multiple cell types offers a novel approach to rapidly assess inflammation status. However, the predictive role of NLR and PLR in sepsis with lymphopenia remains uncertain. The purpose of this study was to explore the prognostic value of NLR and PLR in sepsis patients with lymphopenia. In this observational retrospective study, we included 172 sepsis patients with lymphopenia and collected clinical characteristics for analysis. Through binary logistic regression analysis, we identified independent factors. Receiver-operating characteristic curves (ROC) and areas under the curves (AUC) were employed to assess the ability to predict hospital mortality risk. Our results showed a total hospital mortality rate of 53.49%. Multivariate analysis demonstrated that NLR (OR = 1.11, P < .001) and PLR (OR = 1.01, P = .003) were independent predictors associated with hospital mortality in sepsis patients with lymphopenia. The AUCs of NLR and PLR were 0.750 (95% CI: 0.634-0.788, P < .001) and 0.662 (95% CI: 0.580-0.743, P < .001), respectively. Notably, an optimal cut-off value of 18.93 for NLR displayed a sensitivity of 75.0% and specificity of 63.0% in discriminating hospital mortality in sepsis patients with lymphopenia, while the optimal cut-off value for PLR was 377.50, with a sensitivity of 67.5% and specificity of 64.1%. NLR and PLR serve as independent predictors of hospital mortality in sepsis patients with lymphopenia.

Hyperglycemia and elevated C-reactive protein are independent predictors of hospital mortality in hospitalized COVID-19 patients in South-Kivu, eastern Democratic Republic of the Congo: A cross-sectional study.

The coronavirus disease 2019 (COVID-19) pandemic was a priority public health problem because of its high mortality rate. This study mainly aimed to determine factors associated with a poor outcome in COVID-19 hospitalized patients in South-Kivu, an eastern province of the Democratic Republic of the Congo (DRC). This observational study retrospectively evaluated medical records of patients consecutively admitted for probable or confirmed COVID-19 between May 01 and July 31, 2020 at the Hôpital Provincial Général de Référence de Bukavu (HPGRB), a tertiary hospital located in South-Kivu. A binary logistic regression model was performed to determine the predictors of mortality. A total of 157 hospitalized COVID-19 patients aged 57.7 (13.2) years were included in this study. Male gender (69.4%), older age (52.9%), medical history of diabetes (38.2%), and arterial hypertension (35.1%) were the most frequent risk factors. Most patients presented with fever (73.3%), cough (72.6%), and dyspnea (66.2%). Overall, 45.1% of patients died. Intrahospital mortality was significantly associated with advanced age [odds ratio, OR (95% confidence interval, CI) = 2.34 (1.06-5.38)], hypoxemia [OR (95% CI) = 4.67 (2.02-10.77)], hyperglycemia [OR (95% CI) = 2.14 (1.06-4.31)], kidney failure [OR (95% CI) = 2.82 (1.4-5.68)], hyperleukocytosis [OR (95% CI) = 3.33 (1.67-6.66)], and higher C-reactive protein (CRP) levels [OR (95% CI) = 3.93 (1.93-8.01)]. After adjustment for various covariates, only higher CRP levels [OR (95% CI) = 3.23 (1.23-8.5)] and hyperglycemia [OR (95% CI) = 2.5 (1.02-6.11)] at admission were independently associated with mortality. Hyperglycemia and marked inflammatory syndrome were the major predictors of poor outcomes in patients hospitalized for COVID-19 in South-Kivu. These two factors should be quantified at hospital admission to establish the patient's prognosis.

Relationship of Hospital Mortality with Metabolic Acidosis Severity in Critically Ill Patients

Background: Metabolic acidosis (MA) is a common pathologic process with fatal consequences in critically ill (CI) patients. The more the severity of acidosis the more mortality rate is expected. To evaluate the relationship of hospital mortality with MA severity in CI patients admitted to emergency department (ED).&#x0D; Methods: In this prospective cohort study, we enrolled CI patients (based on physician clinical assumption), most at level 1 or 2 emergency severity index triage system. Patients were followed and evaluated in 2 parallel groups, one with and the other without MA. The severity of acidosis, chief complaints, final diagnosis, demographic data, acute physiologic assessment and chronic health evaluation II (APACHE II) score, serum lactate and bicarbonate level, need for intubation and mechanical ventilation, admission ward, hospital length of stay and in hospital mortality were compared between the 2 groups.&#x0D; Results: A total of 1811 CI patients including 60.2% males and 39.8% females with and without MA were evaluated. The most common age range was 65-55 years old (31.7%) with the meanSD of 61.348.23. The most common complaints and diagnoses were weakness (40.5%) and pneumosepsis (35.1%), respectively. Patients with severe acidosis had higher lactate level and APACHE II score (p&lt;0.05). Mortality rate was 10.4%. Most of our cases had severe MA. Expired cases had higher lactate level and APACHE II score (p&lt;0.05).&#x0D; Conclusion: Lactate level, bicarbonate level and APACHE II score were all significant independent predictors of hospital mortality in CI patients.

Predictors of hospital mortality in older adults with and without dementia: a necessary step towards personalized prognostication

AbstractBackgroundDementia has been associated with increased risk of hospital mortality (1). However, predictors of hospital mortality for patients with dementia have not been widely addressed. We aimed to investigate predictors of hospital mortality according to preexisting clinical dementia in older adults.MethodsWe analyzed data from a prospective cohort study in Sao Paulo, Brazil. We included acutely ill patients aged ≥60 years admitted to a tertiary university hospital between 2009 and 2020. Candidates underwent comprehensive geriatric assessments in the first 24 hours of hospitalization. Preexisting clinical dementia (after this, referred to as dementia) was determined by a Clinical Dementia Rating (CDR) ≥1 (2). We investigated independent predictors of hospital mortality according to dementia using multivariable Poisson regressions. We further analyzed our multivariable models' accuracy in predicting hospital mortality using area under the ROC curves (AUC).ResultsWe included 3,863 participants (mean age = 80; female = 62%). Overall, 1,761 participants (46%) had dementia. Mortality was 11% in participants without dementia and 21% in those with dementia (p&lt;0.001). In participants without dementia, mortality was independently predicted by age, multimorbidity, functional status, delirium, nutritional status, and serum albumin (Table 1). However, in participants with dementia, mortality was also predicted by illness acuity and creatinine. Finally, we observed that our multivariable model had an AUC = 0.88 (95%CI = 0.86‐0.90) in participants without dementia and 0.80 (0.78‐0.83) in those with dementia (Figure 1).ConclusionOlder adults with dementia were twice as likely to die in the hospital than those without dementia. Moreover, independent predictors of hospital mortality were not necessarily shared between patients with and without dementia. Given the importance of prognostic assessments for decision‐making processes, researchers should consider exploring new algorithms that differ according to baseline cognition.

Primary or Delayed Repair for Complete Atrioventricular Septal Defect, Tetralogy of Fallot, and Ventricular Septal Defect: Relationship to Country Economic Status.

Primary repair in the first six months of life is routine for tetralogy of Fallot, complete atrioventricular septal defect, and ventricular septal defect in high-income countries. The objective of this analysis was to understand the utilization and outcomes of palliative and reparative procedures in high versus middle-income countries. The World Database of Pediatric and Congenital Heart Surgery identified patients who underwent surgery for: tetralogy of Fallot, complete atrioventricular septal defect, and ventricular septal defect. Patients were categorized as undergoing primary repair, repair after prior palliation, or palliation only. Country economic status was categorized as lower middle, upper middle, and high, defined by the World Bank. Multiple logistic regression models were utilized to identify independent predictors of hospital mortality. Economic categories included high (n = 571, 5.3%), upper middle (n = 5,342, 50%), and lower middle (n = 4,793, 49.7%). The proportion of patients and median age with primary repair were: tetralogy of Fallot, 88.6%, 17.7 months; complete atrioventricular septal defect, 83.4%, 7.7 months; and ventricular septal defect, 97.1%, ten months. Age at repair was younger in high income countries (P < .0001). Overall mortality after repair was lowest in high income countries. Risk factors for hospital mortality included prematurity, genetic syndromes, and urgent or emergent operations (all P < .05). Primary repair was selected in >90% of patients, but definitive repair was delayed in lower and upper middle income countries compared with high-income countries. Repair after prior palliation versus primary repair was not a risk factor for hospital mortality. Initial palliation continues to have a small but important role in the management of these three specific congenital heart defects.

Sex-Based Differences in Early Outcomes Following Mitral Valve Surgery for Degenerative Disease

Objectives: To determine whether sex-based differences exist following surgery for degenerative mitral valve disease. Methods: Using a national database, we analysed data on mitral valve surgery for degenerative disease (n = 22,658) between January 2000 and March 2019 in the UK. We split the cohort into men (n = 14,681) and women (n = 7977) and compared background characteristics, intraoperative variables and early postoperative outcomes. Our primary outcome was hospital mortality; secondary outcomes included re-exploration for bleeding, prolonged admission (&gt;10 days) and mitral replacement. We used binary logistic regression models for all outcomes, with multiplicative interaction terms to determine the nature of any differences. Results: Women presented older (70 ± 11 years vs. 67 ± 11 years, p &lt; 0.001) with worse symptom profiles (New York Heart Association Class III–IV 57% vs. 44%, p &lt; 0.001). They had higher rates of preoperative atrial fibrillation (39% vs. 35%, p &lt; 0.001) and tricuspid disease requiring surgery (21% vs. 15%, p &lt; 0.001). They had lower repair rates (66% vs. 76%, p &lt; 0.001), higher mortality (3% vs. 2%, p &lt; 0.001) and were more likely to have a prolonged admission (48% vs. 40%, p &lt; 0.001). Female sex was an independent predictor of mortality (odds ratio (OR): 1.52, 95% CI: 1.21–1.90, p &lt; 0.001). Age and Canadian Cardiovascular Society (CCS) score showed significant interactions with sex. The relationship between advancing age and mortality was found to be more pronounced in women. Conclusions: (1) Female sex is an independent predictor of hospital mortality, prolonged hospital admission and mitral valve replacement. (2) The relationship between female sex and mortality is exacerbated by worsening CCS score and advancing age. (3) Women have significantly lower repair rates.

An enigma of hypothyroidism and hyponatremia coexistence: a nationwide population-based retrospective study

IntroductionHypothyroidism is a rare and possible cause of hyponatremia. However, the clinical epidemiology and risk of mortality (ROM) when they coexist still remain elusive.ObjectivesWe assessed the epidemiology and ROM among index patients with coexisting hypothyroidism and hyponatremia via a national population database.Patients and methodsThis retrospective cohort study utilized Taiwan’s National Health Insurance program database. Distributions of definite sociodemographic factors were analyzed. The annual incidence among the overall group and sex-subgroups was investigated. In addition, potential factors influencing the ROM were also evaluated.ResultsOf 4,549,226 patients from 1998 to 2015, a total of 3,140 index patients with concurrent hypothyroidism and hyponatremia were analyzed. The incidence rate increased tenfold from 1998 to 2015; average annual incidence rate was 174. Among the total participants, 57.1% were women; mean age was 72.6 ± 14.7 years and 88.8% were aged > 55 years. Although average length of stay (LOS) was 13.1 ± 15.4 days, the mortality group had significantly longer LOS than that in the survival group (12.9 days vs 22.2 days). Old age, catastrophic illness, cardiac dysrhythmia, and low hospital hierarchy were independent predictors of hospital mortality. The optimal LOS cutoff value for ROM prediction was 16 days. Index patients with LOS > 16 days increased ROM by 2.3-fold.ConclusionsCoexistent hypothyroidism and hyponatremia is rare, although the incidence increased gradually. Factors influencing the ROM, such as old age, underlying catastrophic status, cardiac dysrhythmia, hospital hierarchy, and LOS should be considered in clinical care.

Impact of Chronic Kidney Disease on Clinical Outcomes during Hospitalization and Five-Year Follow-Up after Coronary Artery Bypass Grafting.

Chronic kidney disease (CKD) is often associated with multiple comorbidities including diabetes mellitus, and each has its own complications and impact after cardiac surgery including coronary revascularization. The objective of this work was to study the impact of CKD on clinical outcomes after coronary artery bypass grafting (CABG) and to compare outcomes in patients with different grades of renal functions. We retrospectively reviewed all patients who underwent CABG from January 2016 to August 2020 at our tertiary care hospital using electronic medical records. The study included 410 patients with a median age of 60 years, and 28.6% of them had CKD and hospital mortality of 2.7%. About 71.4% of the patients had GFR > 60 mL/min per 1.73 m2, 18.1% had early CKD (GFR 30-60), 2.7% had late CKD (GFR < 30), and 7.8% of them had end-stage renal disease (ESRD) requiring dialysis. The CKD group had significantly more frequent hospital mortality (p = 0.04), acute cerebrovascular stroke (p = 0.03), acute kidney injury (AKI) (p < 0.001), longer ICU stay (p = 0.002), post-ICU stay (p = 0.001), and sternotomy wound debridement (p = 0.03) compared to the non-CKD group. The frequencies of new need for dialysis were 2.4% vs. 14.9% vs. 45.5% (p < 0.001) in the patients with GFR > 60 mL/min per 1.73 m2, early CKD, and late CKD, respectively. Acute cerebral stroke (OR: 10.29, 95% CI: 1.82-58.08, and p = 0.008), new need for dialysis (OR: 25.617, 95% CI: 13.78-85.47, and p < 0.001), and emergency surgery (OR: 3.1, 95% CI: 1.82-12.37, and p = 0.036) were the independent predictors of hospital mortality after CABG. The patients with CKD had an increased risk of strokes (HR: 2.14, 95% CI: 1.20-3.81, and p = 0.01) but insignificant mortality increase (HR: 1.44, 95% CI: 0.42-4.92, and p = 0.56) during follow-up. The patients with CKD, especially the late grade, had worse postoperative early and late outcomes compared to non-CKD patients after CABG. Patients with dialysis-independent CKD had increased risks of needing dialysis, hospital mortality, and permanent dialysis after CABG.

CAUSES OF AN UNFRIENDLY CLINICAL OUTCOME OF MYOCARDIAL INFARCTION AGGRAVATED BY CARDIOGENIC SHOCK: A SINGLE-CENTER RETROSPECTIVE STUDY

Summary. Aim. Search for risk factors of adverse clinical outcome of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS).&#x0D; Materials and methods. 1,292 consecutive patients with AMI treated by emergent percutaneous coronary intervention (PCI) in the reperfusion center of Zaitsev V.T. Institute for General and Emergency Surgery NAMS of Ukraine were selected. 54 out of 1292 patients (4.2%) matched the Society for Cardiovascular Angiography and Interventions (SCAI) criteria of CS stage C and higher either on admission or during hospitalization.&#x0D; Results. The overall hospital mortality in patients with CS due to AMI in our series was 59.3%. Univariant analysis revealed that the age of 65 and higher, left ventricular ejection fraction &lt;40%, a single-vessel coronary lesion, absence of concomitant chronic total occlusion (CTO), reperfusion deterioration and cardiac arrest were the only risk factors for hospital death in CS patients. The risk of CS progression was independently associated with anemic syndrome (Hb &lt; 118 g/l), chronic total occlusion, and multivessel coronary disease. In a multivariant logistic regression the preexisting LV EF&#x0D; &lt;40%, single-vessel disease and absence of CTO were found as the independent predictors of hospital mortality in СS.&#x0D; Conclusions. СS in patients with AMI still be a significant challenge even after successful PCI, associated with high in-hospital mortality (59.3%). There is an unmet need for development and implementation of an adjusted registry-based national protocol for CS management in order to improve patient survival.

Occurrence, Risk Factors, and Outcomes of Pulmonary Barotrauma in Critically Ill COVID-19 Patients: A Retrospective Cohort Study.

Pulmonary barotrauma has been frequently observed in patients with COVID-19 who present with acute hypoxemic respiratory failure. This study evaluated the prevalence, risk factors, and outcomes of barotrauma in patients with COVID-19 requiring ICU admission. This retrospective cohort study included patients with confirmed COVID-19 who were admitted to an adult ICU between March and December 2020. We compared patients who had barotrauma with those who did not. A multivariable logistic regression analysis was performed to determine the predictors of barotrauma and hospital mortality. Of 481 patients in the study cohort, 49 (10.2%, 95% confidence interval: 7.6-13.2%) developed barotrauma on a median of 4 days after ICU admission. Barotrauma manifested as pneumothorax (N = 21), pneumomediastinum (N = 25), and subcutaneous emphysema (N = 25) with frequent overlap. Chronic comorbidities and inflammatory markers were similar in both patient groups. Barotrauma occurred in 4/132 patients (3.0%) who received noninvasive ventilation without intubation, and in 43/280 patients (15.4%) who received invasive mechanical ventilation. Invasive mechanical ventilation was the only risk factor for barotrauma (odds ratio: 14.558, 95% confidence interval: 1.833-115.601). Patients with barotrauma had higher hospital mortality (69.4% versus 37.0%; p < 0.0001) and longer duration of mechanical ventilation and ICU stay. Barotrauma was an independent predictor of hospital mortality (odds ratio: 2.784, 95% confidence interval: 1.310-5.918). s. Barotrauma was common in critical COVID-19, with invasive mechanical ventilation being the most prominent risk factor. Barotrauma was associated with poorer clinical outcomes and was an independent predictor of hospital mortality.

Utility of the National Emergency Laparotomy Audit prognostic model in predicting outcomes in an Australian health system.

The Royal College of Anaesthetists was commissioned by the United Kingdom Health Quality Partnership to conduct the National Emergency Laparotomy Audit of England and Wales (NELA), to compare outcomes of patients undergoing emergency laparotomy in order to promote quality improvement. Prior to 2016 there were minimal data for emergency laparotomy patients in Australia. The aim of this cohort study was to assess the utility and applicability of the NELA model in a tertiary centre in Western Australia. NELA-related data of patients who underwent emergency laparotomy, between June 2018 and May 2020, were merged with other administrative databases and clinical records. The discriminative ability and calibration of the model were assessed by the area under the receiver operating characteristic (AUROC) curve and calibration plot, respectively. Cox proportional hazards regression was used to assess whether the NELA-predicted risks were an independent predictor of hospital mortality. Of the 502 patients included, 168 (33.5%) patients had a NELA-predicted risk >10%, and of these, 93 (55.4%) were admitted to a critical care unit in a planned fashion immediately after surgery. The NELA model had a good ability to discriminate between survivors and non-survivors (AUROC 0.892, 95% confidence intervals 0.854 to 0.93, P <0.001). However, the model was not perfectly calibrated, with the predicted risks tending to overestimate the observed risks of mortality, especially when the predicted risks were >50%. A high NELA-predicted risk remained significantly associated with mortality after adjusting for other covariates, including sepsis and plasma lactate concentration, suggesting that it is a reliable screening tool for identifying high-risk patients requiring emergency laparotomy.

Prognostic Value of Arterial Lactate Metabolic Clearance Rate in Moderate and Severe Acute Pancreatitis.

High lactate levels at hospital admission are significantly associated with poor prognosis in acute pancreatitis patients. Early high lactate clearance is a vital marker for predicting persistent organ failure and mortality in critical illness; however, its value in acute pancreatitis remains unclear. Data were collected from patients who were diagnosed with moderately severe acute pancreatitis and severe acute pancreatitis from January 2017 to December 2020. Initial lactate (within 2 hours after admission) and repeat lactate at 24 hours after admission were measured to determine lactate clearance. Low clearance was defined as a reduction in repeat lactate of less than 30% compared to the first measurement. High clearance was defined as a repeat lactate decrease ≥30% of the first measurement or both first and second lactate levels <2 mmol/L. Baseline data, laboratory data, mortality rate, persistent organ failure rate, and other outcomes such as the incidence of septic pancreatic necrosis and sepsis and the length of hospital stay and intensive care unit (ICU) stay were compared in the low and high lactate clearance groups. Multivariate logistic regression analyses were used to assess the value of lactate clearance for predicting death. Among 4425 acute pancreatitis patients, 3040 patients were diagnosed with moderate or severe acute pancreatitis, and 1028 patients had initial lactate measured. Finally, 390 patients who had initial and 24-hour repeat lactate data were included in the study. Patients who had elevated initial lactate had poor outcomes, and 51 patients in the initial elevated lactate group died. In the lactate normalization group analysis, 293 patients had 24-hour lactate normalization; compared with patients in the nonnormalization group, they had a lower rate of mortality (12.6% vs. 33%). In the lactate clearance group analysis, 70 (21.9%) patients had a low clearance after 24 hours; compared with patients in the high clearance group, they had a higher rate of developing persistent multiorgan failure (P = 0.045), and the incidence of death was higher (15% vs. 28.6%, P = 0.007). Multivariate logistic analysis showed that 24-hour lactate clearance (OR: 2.007; 95% CI:1.032-3.903, P = 0.04), elevated initial lactate (OR: 2.011; 95% CI:1.023-3.953, P = 0.043), blood urea nitrogen (OR: 2.316; 95% CI:1.061-5.056, P = 0.035), and white blood count (OR: 1.982; 95% CI:1.026-3.829, P = 0.042) were independent predictors of hospital mortality. The 24-hour clearance of lactate is a reliable marker to predict the outcome of moderate and severe acute pancreatitis, and low lactate clearance may indicate that the patient's condition will worsen, requiring aggressive treatments to improve patient outcomes.

Long-term results after simultaneous carotid and coronary revascularisation.

The revascularisation strategy for concomitant carotid and coronary disease is unknown. Simultaneous or stage coronary artery stenting and carotid endarterectomy are the most common revascularisation approach in the CABG population. This study aimed to evaluate long-term results after simultaneous carotid artery stenting or carotid endarterectomy in patients who underwent coronary artery bypass surgery. This is a prospective cohort non-randomised single-institution study. During the period from 2012 to 2015, sixty consecutive patients (65.9 ± 7.41 mean) underwent simultaneous carotid artery stenting and coronary artery bypass surgery (n = 30) or simultaneous carotid endarterectomy and coronary artery bypass surgery (n = 30). The primary endpoints were short- and long-term rates of adverse events (transient ischemic attack, stroke, myocardial infarction, and death). The mean follow-up was 62.05 ± 11.12 months. In-hospital mortality was insignificantly higher in the carotid endarterectomy, and coronary artery bypass surgery group (6.6% vs. 0%), the rate of stroke and myocardial infarction was similar (13.3% and 0% in the carotid endarterectomy and coronary artery bypass surgery group vs. 6.6% and 3.3% in the carotid artery stenting and coronary artery bypass surgery group, respectively). The intensive care unit readmission was significantly higher in the surgical revascularisation approach; it was an independent predictor of hospital mortality. The overall mortality during the follow-up period was 14.28% in both groups. Freedom of the composite adverse outcomes (stroke, myocardial infarction, and death) was 78.55%. Comparing two revascularisation strategies is not straightforward due to different anatomical indications for carotid artery stenting and endarterectomy. We consider that each technique has an essential role in carotid revascularisation. Good selection of patients, according to indications, contributes to satisfactory short- and long-term results.

Predictors of in-hospital mortality in a cohort of people living with HIV (PLHIV) admitted to an academic medical intensive care unit from 2009 to 2014: A retrospective cohort study.

Outcomes for critically ill people living with human immunodeficiency virus (PLHIV) have changed with the use of antiretroviral therapy (ART). To identify these outcomes and correlates of mortality in a contemporary critically ill cohort in an urban academic medical center in Baltimore, a city with a high burden of HIV, we conducted a retrospective cohort study of individuals admitted to a medical intensive care unit (MICU) at a tertiary care center between 2009 and 2014. PLHIV who were at least 18 years of age with an index MICU admission of ≥24 hours during the 5-year study period were included in this analysis. Data were obtained for participants from the time of MICU admission until hospital discharge and up to 180 days after MICU admission. Logistic regression was used to identify independent predictors of hospital mortality. Between June 2009 and June 2014, 318 PLHIV admitted to the MICU met inclusion criteria. Eighty-six percent of the patients were non-Hispanic Blacks. Poorly controlled HIV was very common with 70.2% of patients having a CD4 cell count <200 cells/mm3 within 3 months prior to admission and only 34% of patients having an undetectable HIV viral load. Hospital mortality for the cohort was 17%. In a univariate model, mortality did not differ by demographic variables, CD4 cell count, HIV viral load, or ART use. Regression analysis adjusted by relevant covariates revealed that MICU patients admitted from the hospital ward were 6.4 times more likely to die in hospital than those admitted from emergency department. Other positive predictors were a diagnosis of end-stage liver disease, cardiac arrest, ventilator-dependent respiratory failure, vasopressor requirement, non-Hodgkin lymphoma, and symptomatic cytomegalovirus disease. In conclusion, in this critically ill cohort with HIV infection, most predictors of mortality were not directly related to HIV and were similar to those for the general population.

Admission rate-pressure product as an early predictor for in-hospital mortality after aneurysmal subarachnoid hemorrhage.

Early prediction of in-hospital mortality in aneurysmal subarachnoid hemorrhage (aSAH) is essential for the optimal management of these patients. Recently, a retrospective cohort observation has reported that the rate-pressure product (RPP, the product of systolic blood pressure and heart rate), an objective and easily calculated bedside index of cardiac hemodynamics, was predictively associated with in-hospital mortality following traumatic brain injury. We thus wondered whether this finding could also be generalized to aSAH patients. The current study aimed to examine the association of RPP at the time of emergency room (ER) admission with in-hospital mortality and its predictive performance among aSAH patients. We retrospectively included 515 aSAH patients who had been admitted to our ER between 2016 and 2020. Their baseline heart rate and systolic blood pressure at ER presentation were extracted for the calculation of the admission RPP. Meanwhile, we collected relevant clinical, laboratory, and neuroimaging data. Then, these data including the admission RPP were examined by univariate and multivariate analyses to identify independent predictors of hospital mortality. Eventually, continuous and ordinal variables were selected from those independent predictors, and the performance of these selected predictors was further evaluated and compared based on receiver operating characteristic (ROC) curve analyzes. We identified both low (< 10,000; adjusted odds ratio (OR) 3.49, 95% CI 1.93-6.29, p < 0.001) and high (> 15,000; adjusted OR 8.42, 95% CI 4.16-17.06, p < 0.001) RPP on ER admission to be independently associated with in-hospital mortality after aSAH. Furthermore, after centering the admission RPP by its median, the area under its ROC curve (0.761, 95% CI 0.722-0.798, p < 0.001) was found to be statistically superior to any of the other independent predictors included in the ROC analyzes (all p < 0.01). In light of the predictive superiority of the admission RPP, as well as its objectivity and easy accessibility, it is indeed a potentially more applicable predictor for in-hospital death in aSAH patients.

Predictors of Mortality Following Aortic Valve Replacement in Aortic Stenosis Patients.

Background: Understanding of the risk factors for the development of adverse outcomes after aortic valve replacement is necessary to develop timely preventive measures and to improve the results of surgical treatment. Methods: We analyzed patients with aortic stenosis (n = 742) who underwent surgical treatment in the period 2014–2020. The average age was 63 (57;69) years—men 58%, women 42%. Results: The hospital mortality rate was 3% (22 patients). The following statistically significant threshold values (cut-off points) were obtained in the ROC analysis: aortic cross-clamp time > 93 min AUC (CI) 0.676 (0.640–0.710), p = 0.010; cardiopulmonary bypass time > 144 min AUC (CI) 0.809 (0.778–0.837), p < 0.0001, hemoglobin before op <120 g/L. AUC (CI) 0.762 (0.728–0.793), p < 0.0001, hematocrit before op <39% AUC (CI) 0.755 (0.721–0.786), p < 0.001, end-diastolic dimension index >2.39 AUC (CI) 0.647 (0.607–0.686), p = 0.014, end-systolic dimension index > 1.68 AUC (CI) 0.657 (0.617–0.695), p = 0.009. Statistically significant independent predictors of hospital mortality were identified: BMI > 30 kg/m2 (OR 2.84; CI 1.15–7.01), ischemic heart disease (OR 3.65; CI 1.01–13.2), diabetes (OR 3.88; CI 1.38–10.9), frequent ventricular ectopy before operation (OR 9.78; CI 1.91–50.2), mitral valve repair (OR 4.47; CI 1.76–11.3), tricuspid valve repair (OR 3.06; CI 1.09–8.58), 3 and more procedures (OR 4.44; CI 1.67–11.8). Conclusions: The hospital mortality rate was 3%. The main indicators associated with the risk of death were: diabetes, overweight (body mass index more than 30 kg/m2), frequent ventricular ectopy before surgery, hemoglobin level below 120 g/L, hematocrit level below 39%, longer cardiopulmonary bypass time and aortic cross-clamp time, additional mitral and tricuspid valve interventions.