Lower 30-day All-cause Mortality Research Articles

Clinical outcomes for Clostridioides difficile associated diarrhea in inflammatory bowel disease patients versus non-IBD population: A retrospective cohort study.

Patients with inflammatory bowel disease (IBD) have a higher incidence of Clostridioides difficile infection (CDI). Previous studies have demonstrated negative clinical outcomes in IBD patients with CDI compared to patients without CDI. The clinical presentation of CDI is indistinguishable from IBD exacerbation, thus posing a frequent clinical dilemma on the role of Clostridioides infection in the testing, diagnosis, and treatment of these patients. To compare clinical outcomes of CDI in patients with IBD to those without IBD. Retrospective cohort of adult patients admitted to Rabin Medical Center Israel between the years 2014 and 2020 with a concurrent diagnosis of IBD and CDI. Matching 1:2 was performed between the IBD patients and the non-IBD population with respect to age and sex. Sixty-seven patients with IBD and 134 patients without IBD were included in the study. The groups' median age was 40.6 (interquartile range [IQR] of 29.8-68.9), with 45.8% male and 54.2% female. The non-IBD group had a higher Charlson score with 2 (IQR 0; 5) versus 0 (IQR 0; 4) in the IBD group (P value <.01). Patients with IBD had more exposure to systemic antibiotics, 71.1% versus 26.3% (P value <.01). In a multivariable analysis we found no difference in 90-day mortality and rate of relapse between the 2 study groups with an odds ratio of 1.709 (95% confidence interval 0.321-9.905) and odds ratio of 0.209 (95% confidence interval 0.055-1.513) respectively. In our cohort patients with IBD who present with diarrhea and concomitant CDI have similar rates of relapse and mortality compared with patients without IBD.

Abstract WP34: Collaboration Between Acute Care Hospitals And Rehabilitation Hospitals Reduces 30-day Readmission And Mortality After Ischemic Stroke Hospital Discharge

Background: To improve transitions of care from an acute hospital to an acute rehabilitation hospital, monthly multidisciplinary case review meetings among these hospitals' staff were implemented in 2020. This study aimed to determine whether this effort improved the outcomes of stroke patients. Methods: Monthly online meetings among the acute stroke care team and 3 rehabilitation hospital team leaders were implemented in a large healthcare system. The goal of these meetings was to review all readmissions in-depth, promote communication, and establish best practice protocols to reduce adverse events. We compared patient outcomes before (2018-2019, n=360) and after (2020-2021, n=264) the intervention using multivariate logistic regression models. The primary outcomes were all-cause mortality and readmission within 30 days after acute hospital discharge. Secondary outcomes were 30-day mortality, readmission, and ED visits. The models were adjusted for patient demographics, comorbidities, stroke severity assessed with the National Institute of Health Stroke Scale (NIHSS), and hospital stroke certification status. Results: The median patient age was 70 (interquartile range [IQR]: 60;79), and 297 (48%) were females. The patients in the post-intervention period had longer hospital stays (median 6 vs. 5 days, p&lt;.0001) and higher median NIHSS scores (6 vs. 4, p=0.03). The intervention was associated with lower 30-day all-cause mortality and readmission (12% vs. 22%, Adjusted odds ratio [aOR], 0.562; 95% confidence interval [CI], 0.344-0.920). Readmissions alone were reduced (11% vs. 22%, aOR, 0.557; 95% CI, 0.338-0.918). No significant associations between the intervention and mortality (aOR, 1.00; 95% CI, 0.21-4.85) or ED visits (aOR, 0.86; 95% CI, 0.52-1.40) were found. Conclusion: The multidisciplinary case review meetings among neurology and rehabilitation staff may greatly reduce 30-day hospital readmissions and mortality after acute stroke hospital discharge.

Effect of timing of coronary revascularization in patients with post-infectious myocardial infarction.

ObjectivesAcute infection is a well-known provocative factor of acute myocardial infarction (AMI). Prognosis is worse when it is associated with sepsis. Coronary revascularization is reported to provide benefit in these patients; however, the optimal timing remains uncertain.MethodsThis retrospective study was performed at a tertiary center in Taipei from January 2010 to December 2017. 1931 patients received coronary revascularization indicated for AMI. Among these, 239 patients were hospitalized for acute infection but later developed AMI. Patients with either an ST-elevation myocardial infarct or the absence of obstructive coronary artery disease were excluded. Revascularization was performed via either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). We defined early and delayed revascularization groups if it was performed within or after 24 hours of the diagnosis of AMI, respectively. We evaluated whether the timing of revascularization altered 30-day and one-year all-cause mortality.ResultsAt one month, 24 (26%) patients died in early revascularization group and 32 (22%) patients in delayed revascularization group. At one year, 40 (43%) and 59 (40%) patients died on early and delayed revascularization groups respectively. Early revascularization did not result in lower 30-day all-cause mortality (P = 0.424), and one-year all-cause mortality (Hazard ratio (HR): 0.935; 95% confidence interval (CI): 0.626–1.397, P = 0.742) than delay revascularization.ConclusionsTiming of coronary revascularization of post infectious acute coronary syndrome may be arranged according to individual risk category as those without sepsis.

A Randomized, Single-Blind, Group Sequential, Active-Controlled Study to Evaluate the Clinical Efficacy and Safety of α-Lipoic Acid for Critically Ill Patients With Coronavirus Disease 2019 (COVID-19).

ObjectTo evaluate the clinical efficacy and safety of α-Lipoic acid (ALA) for critically ill patients with coronavirus disease 2019 (COVID-19).MethodsA randomized, single-blind, group sequential, active-controlled trial was performed at JinYinTan Hospital, Wuhan, China. Between February 2020 and March 2020, 17 patients with critically ill COVID-19 were enrolled in our study. Eligible patients were randomly assigned in a 1:1 ratio to receive either ALA (1200 mg/d, intravenous infusion) once daily plus standard care or standard care plus equal volume saline infusion (placebo) for 7 days. All patients were monitored within the 7 days therapy and followed up to day 30 after therapy. The primary outcome of this study was the Sequential Organ Failure Estimate (SOFA) score, and the secondary outcome was the all-cause mortality within 30 days.ResultNine patients were randomized to placebo group and 8 patients were randomized to ALA group. SOFA score was similar at baseline, increased from 4.3 to 6.0 in the placebo group and increased from 3.8 to 4.0 in the ALA group (P = 0.36) after 7 days. The 30-day all-cause mortality tended to be lower in the ALA group (3/8, 37.5%) compared to that in the placebo group (7/9, 77.8%, P = 0.09).ConclusionIn our study, ALA use is associated with lower SOFA score increase and lower 30-day all-cause mortality as compared with the placebo group. Although the mortality rate was two-folds higher in placebo group than in ALA group, only borderline statistical difference was evidenced due to the limited patient number. Future studies with larger patient cohort are warranted to validate the role of ALA in critically ill patients with COVID-19.Clinical Trial Registrationhttp://www.chictr.org.cn/showproj.aspx?proj=49534.

Abstract 11816: Combined Use of VA-ECMO and IMPELLA (ECPELLA) Reduces Myocardial Damage and Mortality in Lethal Cardiogenic Shock Patients Due to Acute Coronary Syndrome

Background: Short-term mortality of lethal cardiogenic shock (CS) patients due to acute coronary syndrome (ACS) remains to be improved. The veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been applied as the effective lifesaving modality for CS patients. While VA-ECMO maintains end-organ perfusion, it increases the damaged left ventricular (LV) afterload. Combined treatment of VA-ECMO and a micro-axial Impella pump, ECPELLA, simultaneously provides the systemic circulatory support and LV unloading. However, it remains unknown whether LV unloading effect by ECPELLA can reduce the myocardial damage and the mortality. Purpose: This study was to assess whether ECPELLA reduces myocardial damage and improves the mortality of CS patients due to ACS. Methods: From January 2012 to May 2021, 66 consecutive patients with lethal CS (SCAI stage-E) due to ACS were enrolled. All patients received VA-ECMO support prior to or after the percutaneous coronary intervention. Among them, 34 patients received ECPELLA and 32 patients received VA-ECMO + IABP. We assessed serum CK-MB levels and the cumulative 30-day mortality. Results: There were no significant difference in age, rate of male sex, coronary risk factors, ST elevated ACS, left main trunk (LMT) lesion, and the time from onset to reperfusion between two treatment groups. The ECPELLA group had significantly lower peak CK-MB and lower 30-day all-cause mortality compared to the VA-ECMO + IABP group [Peak CPK level: median (IQR); 295 (92-507) vs.580 (219-1090): p=0.002, the 30-day mortality rate: 50% vs. 76%: p=0.02, respectively]. Multivariate Cox proportional hazard analysis including age, the time form onset to reperfusion, LMT lesion, E-CPR, and ECPELLA revealed that the ECPELLA (HR: 0.30 95% confidence interval:0.13-0.64; p=0.002) was independently associated with the 30-day all-cause mortality. Conclusion: Results suggest that the ECPELLA reduces the myocardial damage shown by peak CK-MB and improves the 30-day mortality.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Statins in the perioperative period.

In this review, we discuss clinical evidence-based data regarding the potential benefit of statin therapy in the perioperative period of non-cardiac surgery. Results from meta-analyses of prospective observational studies have provided conflicting evidence. Moreover, comparison among studies is complicated by varying data sources, outcome definitions, types of surgery, and preoperative versus perioperative statin therapy. However, results of two recent large prospective cohort studies showed that statin use on the day of or the day after non-cardiac surgery (or both) is associated with lower 30-day all-cause mortality and reduction in a variety of postoperative complications, predominantly cardiac, compared with non-use during this period. There is a paucity of data from randomized controlled trials assessing the benefit of statin therapy in non-cardiac surgery. No randomized controlled trials have shown that initiating a statin in statin-naïve patients may reduce the risk of cardiovascular complications in non-cardiac surgeries. One randomized clinical trial demonstrated that the use of a preoperative statin in patients with stable coronary heart disease treated with long-term statin therapy had a significant reduction in the incidence of myocardial necrosis and major adverse cardiovascular events after non-cardiac surgery. In conclusion, it is important that all health-care professionals involved in the care of the surgical patient emphasize the need to resume statin therapy, particularly in patients with established atherosclerotic cardiovascular disease. However, initiating a statin in statin-naïve patients undergoing non-cardiac surgery needs more evidence-based data.

The Effect of Metformin Use on Left Ventricular Ejection Fraction and Mortality Post-Myocardial Infarction.

Animal studies showed that the use of metformin after myocardial infarction (MI) resulted in a protective effect on cardiac myocytes. In this study, we examined the effect of metformin in patients with diabetes mellitus (DM) on left ventricular ejection fraction (LVEF) and post-MI mortality. We reviewed charts of patients with MI admitted to the UAMS medical center. Baseline characteristics and 12-month follow up data were collected. Patients were classified into three groups: Control group- no DM (n = 464), Metformin group- DM + MI (n = 88) and No-Metformin group- DM + MI (n = 168). First, we compared Metformin and No-Metformin groups to the Control group. Second, we performed propensity-score matching in patients with DM, and compared Metformin to No-Metformin groups. All-cause 30-day and 12-month mortality was significantly higher in the No-Metformin group compared to controls (13.5 vs 9.3% p = 0.03 at 30 days, 23.7 vs 15.9 % p = 0.03 at 12 months). However, all-cause 30-day and 12-month mortality were similar in the Controls and Metformin group (9.3 vs 6.8 % p = 0.93 at 30 days, 15.9 vs 11.4 % p = 0.97 at 12 months). Mean LVEF on presentation (45 % in the three groups) and at follow up (47.84, 46.38 and 43.62 % in Control, Metformin, and No-Metformin groups, respectively) were not statistically different. There were no significant differences in regard to re-hospitalization, re-intervention, new stroke, CHF development, new MI, or identifiable arrhythmias. Metformin was an independent predictor of lower 30-day and 12-month all-cause mortality in patients with DM (HR 0.25, p = 0.02 and HR 0.32, p = 0.01, respectively). In the matched analysis, 30-day all-cause mortality was significantly higher in the No-Metformin compared to the Metformin group (21.1 vs 8.8 %, p = 0.05). However the difference in 12-month all-cause mortality did not reach statistical significance (24.6 vs 15.8 %, p = 0.15). This proof-of-concept study shows that use of metformin in patients with DM is associated with lower 30-day all-cause mortality and tendency for a lower 12-month all-cause mortality following MI without discernible improvement in LVEF.

Beta-blocker Use and 30-day All-cause Readmission in Medicare Beneficiaries with Systolic Heart Failure

BackgroundBeta-blockers improve outcomes in patients with systolic heart failure. However, it is unknown whether their initial negative inotropic effect may increase 30-day all-cause readmission, a target outcome for Medicare cost reduction and financial penalty for hospitals under the Affordable Care Act. MethodsOf the 3067 Medicare beneficiaries discharged alive from 106 Alabama hospitals (1998-2001) with a primary discharge diagnosis of heart failure and ejection fraction <45%, 2202 were not previously on beta-blocker therapy, of which 383 received new discharge prescriptions for beta-blockers. Propensity scores for beta-blocker use, estimated for each of the 2202 patients, were used to assemble a matched cohort of 380 pairs of patients receiving and not receiving beta-blockers who were balanced on 36 baseline characteristics (mean age 73 years, mean ejection fraction 27%, 45% women, 33% African American). ResultsBeta-blocker use was not associated with 30-day all-cause readmission (hazard ratio [HR] 0.87; 95% confidence interval [CI], 0.64-1.18) or heart failure readmission (HR 0.95; 95% CI, 0.57-1.58), but was significantly associated with lower 30-day all-cause mortality (HR 0.29; 95% CI, 0.12-0.73). During 4-year postdischarge, those in the beta-blocker group had lower mortality (HR 0.81; 95% CI, 0.67-0.98) and combined outcome of all-cause mortality or all-cause readmission (HR 0.87; 95% CI, 0.74-0.97), but not with all-cause readmission (HR 0.89; 95% CI, 0.76-1.04). ConclusionsAmong hospitalized older patients with systolic heart failure, discharge prescription of beta-blockers was associated with lower 30-day all-cause mortality and 4-year combined death or readmission outcomes without higher 30-day readmission.

Prospective Study Examining Clinical Outcomes Associated with a Negative Pressure Wound Therapy System and Barker’s Vacuum Packing Technique

BackgroundThe open abdomen has become a common procedure in the management of complex abdominal problems and has improved patient survival. The method of temporary abdominal closure (TAC) may play a role in patient outcome.MethodsA prospective, observational, open-label study was performed to evaluate two TAC techniques in surgical and trauma patients requiring open abdomen management: Barker’s vacuum-packing technique (BVPT) and the ABTheraTM open abdomen negative pressure therapy system (NPWT). Study endpoints were days to and rate of 30-day primary fascial closure (PFC) and 30-day all-cause mortality.ResultsAltogether, 280 patients were enrolled from 20 study sites. Among them, 168 patients underwent at least 48 hours of consistent TAC therapy (111 NPWT, 57 BVPT). The two study groups were well matched demographically. Median days to PFC were 9 days for NPWT versus 12 days for BVPT (p = 0.12). The 30-day PFC rate was 69 % for NPWT and 51 % for BVPT (p = 0.03). The 30-day all-cause mortality was 14 % for NPWT and 30 % for BVPT (p = 0.01). Multivariate logistic regression analysis identified that patients treated with NPWT were significantly more likely to survive than the BVPT patients [odds ratio 3.17 (95 % confidence interval 1.22–8.26); p = 0.02] after controlling for age, severity of illness, and cumulative fluid administration.ConclusionsActive NPWT is associated with significantly higher 30-day PFC rates and lower 30-day all-cause mortality among patients who require an open abdomen for at least 48 h during treatment for critical illness.

Association Between Stroke Center Hospitalization for Acute Ischemic Stroke and Mortality

Context Although stroke centers are widely accepted and supported, little is known about their effect on patient outcomes. Objective To examine the association between admission to stroke centers for acute ischemic stroke and mortality. Design, Setting, and Participants Observational study using data from the New York Statewide Planning and Research Cooperative System. We compared mortality for patients admitted with acute ischemic stroke (n = 30 947) between 2005 and 2006 at designated stroke centers and nondesignated hospitals using differential distance to hospitals as an instrumental variable to adjust for potential prehospital selection bias. Patients were followed up for mortality for 1 year after the index hospitalization through 2007. To assess whether our findings were specific to stroke, we also compared mortality for patients admitted with gastrointestinal hemorrhage (n = 39 409) or acute myocardial infarction (n = 40 024) at designated stroke centers and nondesignated hospitals. Main Outcome Measure Thirty-day all-cause mortality. Results Among 30 947 patients with acute ischemic stroke, 15 297 (49.4%) were admitted to designated stroke centers. Using the instrumental variable analysis, admission to designated stroke centers was associated with lower 30-day all-cause mortality (10.1% vs 12.5%; adjusted mortality difference, −2.5%; 95% confidence interval [CI], −3.6% to −1.4%; P Conclusion Among patients with acute ischemic stroke, admission to a designated stroke center was associated with modestly lower mortality and more frequent use of thrombolytic therapy.

Association Between Stroke Center Hospitalization for Acute Ischemic Stroke and Mortality

Although stroke centers are widely accepted and supported, little is known about their effect on patient outcomes. To examine the association between admission to stroke centers for acute ischemic stroke and mortality. Observational study using data from the New York Statewide Planning and Research Cooperative System. We compared mortality for patients admitted with acute ischemic stroke (n = 30,947) between 2005 and 2006 at designated stroke centers and nondesignated hospitals using differential distance to hospitals as an instrumental variable to adjust for potential prehospital selection bias. Patients were followed up for mortality for 1 year after the index hospitalization through 2007. To assess whether our findings were specific to stroke, we also compared mortality for patients admitted with gastrointestinal hemorrhage (n = 39,409) or acute myocardial infarction (n = 40,024) at designated stroke centers and nondesignated hospitals. Thirty-day all-cause mortality. Among 30,947 patients with acute ischemic stroke, 15,297 (49.4%) were admitted to designated stroke centers. Using the instrumental variable analysis, admission to designated stroke centers was associated with lower 30-day all-cause mortality (10.1% vs 12.5%; adjusted mortality difference, -2.5%; 95% confidence interval [CI], -3.6% to -1.4%; P < .001) and greater use of thrombolytic therapy (4.8% vs 1.7%; adjusted difference, 2.2%; 95% CI, 1.6% to 2.8%; P < .001). Differences in mortality also were observed at 1-day, 7-day, and 1-year follow-up. The outcome differences were specific for stroke, as stroke centers and nondesignated hospitals had similar 30-day all-cause mortality rates among those with gastrointestinal hemorrhage (5.0% vs 5.8%; adjusted mortality difference, +0.3%; 95% CI, -0.5% to 1.0%; P = .50) or acute myocardial infarction (10.5% vs 12.7%; adjusted mortality difference, +0.1%; 95% CI, -0.9% to 1.1%; P = .83). Among patients with acute ischemic stroke, admission to a designated stroke center was associated with modestly lower mortality and more frequent use of thrombolytic therapy.