Lower In-hospital Mortality Research Articles

The outcomes of the obesity paradox in pulmonary embolism: a study of the national inpatient sample database from 2016 to 2020.

The "obesity paradox" suggests that, despite a higher baseline risk for adverse health outcomes, obese patients can experience a lower complication and mortality rate in conditions such as pulmonary embolisms (PE). This study aims to examine the association between obesity and inpatient outcomes of PE patients, utilizing the data from the National Inpatient Sample (NIS) database. We conducted a retrospective study analysis of obese adult PE patients (aged ≥ 18) using the NIS database from 2016 to 2020. Patients were categorized as either obese (body mass index (BMI) ≥ 30) or non-obese, excluding those with cancer diagnosis and age > 75 years to reduce confounding factors. Multivariable logistic regression, adjusted for confounders, compared the inpatient outcomes, including mortality, length of stay, need for mechanical invasive ventilation (MIV), incidence of shock requiring vasopressor use and use of reperfusion therapies. Our results showed obese patients had a lower in-hospital mortality and reduced risk for certain adverse outcomes when compared to non-obese patients. Limitations in our data, such as the lack of imaging confirmation and inability to track certain risk indicators in real time, affected precision in outcome severity classification. Our findings support the existence of an obesity paradox, particularly in PE patients, with obese patients experiencing better inpatient outcomes relative to their non-obese counterparts. This study advances the understanding of obesity's complex role in PE outcomes. However, further research is needed to further elucidate potential protective mechanisms to address our study limitations.

Trends, Characteristics and Outcomes in Breast Cancer Survivors With STEMI.

Breast cancer is the most common malignancy among women. While advances in detection and treatment have improved survival, breast cancer survivors face an increased risk of cardiovascular disease. However, limited data exist on cardiac outcomes after ST-elevation myocardial infarction (STEMI) in this population. This retrospective cohort study analyzed the National Inpatient Sample (NIS) database (2016-2021). Adult women hospitalized with STEMI were categorized as breast cancer survivors or without a history of breast cancer. The primary outcome was in-hospital mortality, with multivariable logistic regression used to adjust for confounders. A total of 369,070 adult females were included (breast cancer survivors, n = 13,890; without breast cancer, n = 355,180). Breast cancer survivors were older with more cardiovascular comorbidities. After adjustment, breast cancer survivors had lower odds of in-hospital mortality (adjusted odds ratio [aOR] 0.82, 95% CI 0.72-0.93), cardiogenic shock (aOR 0.88, 95% CI 0.77-0.99), and acute kidney injury (aOR 0.85, 95% CI 0.76-0.95). Breast cancer survivors hospitalized for STEMI had lower in-hospital mortality and complications, compared with those without breast cancer. These hypothesis-generating findings suggest that advances in oncology and cardiovascular care may contribute to improved outcomes.

Intravenous beta-blockers versus amiodarone on in-hospital mortality and safety profile in adult septic patients.

In the present study, we aimed to compare in-hospital mortality and safety of intravenous beta-blockers and amiodarone in septic patients with new-onset atrial fibrillation (NOAF). The null hypothesis is that there is no significant difference in in-hospital mortality and safety of Beta-blocker (BBs) and amiodarone in treating NOAF in patients with sepsis. We conducted a retrospective analysis based on the MIMIC-IV database. Septic patients with NOAF were screened. Patients admitted to adult mixed ICU for septic patients with NOAF. A total of 34,789 patients were screened of whom 1394 patients were included for the analysis: 286 in the amiodarone group and 1108 in the BBs group. None. Cox proportional hazard model was used to examine the in-hospital mortality, ventilator-free days and duration of atrial fibrillation in patients receiving either amiodarone or intravenous BBs. Propensity score matching was applied to determine any association. After Propensity Score (PS) matching, a total of 244 patients were included in both the BB and amiodarone groups. In this cohort, BBs was significantly associated with lower in-hospital mortality [adjusted hazard ratio (HR) of 0.70 (95% CI 0,54-0,91; P = 0.008)]. On the other hand, patients who received amiodarone had a shorter duration of atrial fibrillation (54.17 h vs 72.81 h; P = 0.003). There was no significant difference in ventilator-free days between the BB group and the amiodarone group. In septic patients with NOAF, patients receiving BBs had lower in-hospital mortality than those who received amiodarone. On the other hand, amiodarone group had a shorter duration of atrial fibrillation. There was no significant difference in ventilator-free days between the BB group and the amiodarone group.

Extracorporeal membrane oxygenation is associated with decreased mortality in non-acute respiratory distress syndrome patients following severe blunt thoracic trauma.

Extracorporeal membrane oxygenation (ECMO) has emerged as a critical intervention in the management of patients with trauma-induced cardiorespiratory failure. This study aims to compare outcomes in patients with severe thoracic injuries with and without venovenous extracorporeal membrane oxygenation (VV-ECMO). We performed a retrospective cohort study on Trauma Quality Improvement Program (2017-2021) and included all patients with isolated blunt thoracic injuries with Abbreviated Injury Scale score of ≥4 who required intubation. Patients were divided into two groups based on VV-ECMO and were compared using propensity score matching with the primary outcome of mortality. A total of 14,106 patients with severe thoracic injuries were identified. Propensity score matching resulted in two groups of 812 VV-ECMO and 812 non-VV-ECMO groups. Venovenous ECMO group had significantly lower in-hospital mortality rates (22.3% vs. 37.3%, p < 0.001). However, VV-ECMO group had significantly higher rates of complications including cardiac arrest (27.7% vs. 10.6%), pulmonary embolism (7.6% vs. 2.1%), ventilator-associated pneumonia (16.7% vs. 4.2%), unplanned intubation (11.9% vs. 8.5%), unplanned intensive care unit (ICU) admission (8.4% vs. 4.9%), and unplanned return to operation room (10.1% vs. 2.6%) (p < 0.001, for all). Patients in VV-ECMO group had significantly higher hospital (29.46 ± 26.37 vs. 13.59 ± 13.3 days) and ICU (22.96 ± 19.38 vs. 9.38 ± 9.05 days) length of stay (p < 0.001, for both). In VV-ECMO group, the mean ± SD time to perform VV-ECMO was 5.54 ± 5.91 days. Each day earlier initiation of VV-ECMO resulted in decreased hospital and ICU length of stay by 67.1% and 59.9%, respectively (p < 0.001 for both). Among patients without acute respiratory distress syndrome (n = 435 in each group after repeated PS matching), we observed significantly lower mortality rates in VV-ECMO group (26.9% vs. 40%, p < 0.001). While VV-ECMO in isolated blunt thoracic trauma patients is associated with higher survival rates even in non-acute respiratory distress syndrome cases, it is associated with higher incidence of complications. These findings emphasize earlier consideration of VV-ECMO in severe blunt thoracic trauma. Retrospective Study; Level III.

Impact of Dialysis Modality on Mortality and Complications in Cardiovascular Surgery

Background: Patients receiving maintenance dialysis face high mortality and complication rates following cardiovascular (CV) surgery. With the growing utilization of peritoneal dialysis (PD), it is important to understand the impact of modality (PD vs. center-based hemodialysis [HD]) on outcomes following CV surgery. Methods: This retrospective cohort study used data from the National Inpatient Sample (2016-2020) to compare outcomes of PD and HD patients undergoing coronary artery bypass grafting and surgical valve procedures. Multivariable logistic regression, negative binomial regression, and linear regression models were used, adjusting for demographic factors, comorbidities, and hospital characteristics. The primary outcome was in-hospital mortality, and secondary outcomes included prolonged ventilation, length of stay, and hospital charges. Results: A total of 30,155 patients were included in the study, with 28,015 (92.9%) receiving HD and 2,140 (7.1%) receiving PD. Compared to HD, PD was associated with lower in-hospital mortality (OR 0.61, 95% CI 0.38-0.97), reduced prolonged ventilation (OR 0.51, 95% CI 0.32-0.81), shorter length of stay (IRR 0.85, 95% CI 0.80-0.91), and decreased hospital charges (mean difference -$87,172 USD, 95% CI -$113,523 to -$60,820) compared to HD. Among PD patients, post-operative transition to HD was associated with worse outcomes. Conclusions: Maintaining PD during the perioperative period may confer benefits over HD, including lower hospital charges and improved patient outcomes. Careful consideration of dialysis modality in the management of CV surgery patients is needed to optimize clinical outcomes and reduce healthcare costs.

Bridging thrombolysis versus direct endovascular treatment in acute vertebrobasilar artery complex occlusion.

Endovascular treatment (EVT) is an effective treatment for patients with acute vertebrobasilar artery complex occlusion (VBAO). However, the benefit of bridging thrombolysis prior to EVT remains controversial. The purpose of the present study is to explore the best treatment strategy between bridging treatment (BT) and direct EVT in patients with acute VBAO. Patients with acute VBAO who underwent EVT within 24 hours of estimated occlusion in a nationwide retrospective registry at 65 stroke centers in 15 provinces in China from December 2015 to June 2022 were retrospectively analyzed. The outcomes of the BT and direct EVT groups were compared using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). The primary outcome was favorable functional outcome, defined as a 90-day modified Rankin Scale (mRS) score of 0-3. Secondary outcomes included 90-day functional independence (mRS score 0-2), mRS score shift, in-hospital mortality, successful reperfusion, and symptomatic intracranial hemorrhage (sICH). In addition, a meta-analysis integrating currently available evidence was performed to make a systematic comparison between the two treatment strategies. A total of 2353 patients were ultimately included; 447 of these patients received BT and 1906 received direct EVT. In both the original cohort and in the 1:1 PSM analysis, patients in the BT group had a significantly higher rate of favorable functional outcome (adjusted odds ratio [aOR] 1.41, 95% CI 1.14-1.76 for the original cohort and aOR 1.44, 95% CI 1.07-1.92 for 1:1 PSM). Regarding secondary outcomes, patients with BT had a significantly lower rate of in-hospital mortality (aOR 0.67, 95% CI 0.51-0.88 for the original cohort and aOR 0.69, 95% CI 0.48-0.99 for 1:1 PSM) and a shift toward better outcomes on the mRS (aOR 1.35, 95% CI 1.12-1.63 for the original cohort and aOR 1.31, 95% CI 1.03-1.69 for 1:1 PSM). However, there were no significant differences in functional independence, successful reperfusion, and sICH between the two groups. A meta-analysis, which included 22 studies involving 6579 patients, also revealed the superiority of BT over direct EVT on favorable functional outcome (OR 1.19, 95% CI 1.03-1.37, I2 = 0.00%; p = 0.02). This matched-control study and meta-analysis suggest that compared with direct EVT, BT may be associated with better functional outcomes in patients with acute VBAO treated within 24 hours of estimated occlusion.

Valve-sparing versus bio-Bentall aortic root replacement in patients aged 60-75 years: Survival, Reintervention and Aortic Regurgitation.

Valve-sparing root replacement(VSRR) with the David technique is an established therapy for aortic root pathology in young patients. The aim of this study was to evaluate short and long-term outcomes between VSRR and aortic root replacement(ARR) with a biological-valved conduit in sexagenarians. A multicenter retrospective review from 2002-2022 identified 299-sexagenarians undergoing aortic root surgery, among whom 82(27.4%) underwent VSRR and 217(72.6%) bio-Bentall. Inverse probability of treatment weighting(IPTW) was applied to balance clinical variables. Median follow-up was 15-years[12-18 years]. Endpoints of the study were in-hospital mortality, long-term survival, freedom from reintervention and recurrence of at-least-moderate AR. There were no major differences in baseline characteristics. The incidence of bicuspid valves(VSRR 4.9% vs ARR 19%), severe AR(42% vs 51%), type-A aortic dissection(1.2% vs 6.9%), and reoperation(4% vs 23%) were higher in ARR. Following IPTW, there was no difference in in-hospital mortality(VSRR 1.2% vs ARR 4.6%,p=0.3). The incidence of neurologic complications(p=0.003), and permanent pacemaker(PPM) implantation(p=0.022) were significantly higher in the bio-Bentall group. After IPTW, 10-year survival did not differ between VSRR(87%) and ARR(80%)(p=0.176). However, cardiac-survival was significantly higher in VSRR patients(98% vs 92%,p=0.018), with deaths mainly due to infective endocarditis and end-stage heart failure(HF). Regarding reoperation/recurrence of at-least-moderate AR, no difference was reported among groups at 10-years, with only 1-patient undergoing reintervention following bio-Bentall(p=0.117). David and bio-Bentall procedures have low in-hospital mortality and good long-term survival in sexagenarians. VSRR is associated with improved long-term cardiac-survival, lower rates of infective endocarditis, PPM-implantation and HF-episodes, with similar rates of reintervention/recurrence of moderate AR.

Preoperative Hematocrit Is Not Associated With Stroke After Surgery for Acute Type A Aortic Dissection.

To determine the impact of hematocrit on adverse neurologic events after acute type A aortic dissection (ATAAD) repair under deep hypothermic circulatory arrest. Retrospective study of consecutive aortic surgeries from 2010 to 2021. Single institution. Patients undergoing open ATAAD repairs, excluding those with preoperative cerebral malperfusion syndrome (defined as neurologic deficit with radiographic evidence of cerebral branch vessel malperfusion). Patients were split into three groups: normal, low, and high hematocrit. A total of 527 patients were included, of which 355 (67.3%) had normal hematocrit, 143 (27.1%) had low hematocrit, and 29 (5.5%) had high hematocrit. Overall, 20 (3.8%) patients had a postoperative stroke, which was comparable across groups (p = 0.59). Patients with normal hematocrit had lower in-hospital mortality (p = 0.02) and lower transfusion rates (p < 0.001), while re-exploration for bleeding was similar across groups (p = 0.68). After multivariable adjustment, there was no association between hematocrit and postoperative stroke (odds ratio [OR]: 1.00, 95% confidence interval [CI]: 0.99, 1.00, p = 0.79). Compared with normal hematocrit, there was no association between low hematocrit (OR: 1.59, 95% CI: 0.77, 3.28, p = 0.21) or high hematocrit (OR: 2.48, 95% CI: 0.74, 8.29, p = 0.14) and in-hospital mortality. Preoperative hematocrit was not associated with stroke or mortality after ATAAD repair. The rheologic effect of hematocrit on cerebral perfusion under deep hypothermia may be minimal.

Trends in the Clinical Characteristics and Outcome of Infective Endocarditis: ANationwide Study From 2016 to 2021.

Infective endocarditis (IE) is still a fatal disease, and given its rarity, ongoing updates to patient characteristics and outcomes of IE are essential for providing precision diagnoses and effective treatments. This study sought to examine temporal trends in the clinical characteristics and in-hospital occurrence of adverse outcomes of IE. Using the Japan nationwide administrative database, we identified patients with IE in Japan from 2016 to 2021. A total of 17 407 patients with IE (37.8% women; median age, 72 [interquartile range, 59-81] years) were identified. The incidence of IE increased from 2.02 per 100 000 population in 2016 to 2.59 per 100 000 population in 2021. The median age of the patients increased from 70 years in 2016 to 73 years in 2021, and patient backgrounds were becoming more complex. The in-hospital mortality rate was 14.5%, which significantly increased from 14.1% in 2016 to 15.4% in 2021. Higher age (odds ratio [OR], 1.34 [95% CI, 1.29-1.40]), heart failure (OR, 1.37 [95% CI, 1.18-1.59]), cerebrovascular complications (OR, 1.78 [95% CI, 1.59-1.99]), renal failure (OR, 2.36 [95% CI, 2.06-2.70]), and sepsis (OR, 2.79 [95% CI, 2.48-3.13]), were independently associated with an increased in-hospital mortality rate. In contrast, cardiac surgery (OR, 0.47 [95% CI, 0.41-0.55]), and a higher number of total cardiac surgeries (OR, 0.77 [95% CI, 0.65-0.92]) independently predicted a lower in-hospital mortality rate. The characterization and comprehensive analysis of IE in Japan provides valuable insights into the epidemiology, risk factors, and outcomes of IE, which may inform health service planning and treatment strategies.

Impact of board-certified intensive care training facilities on choice of adjunctive therapies and prognosis of severe respiratory failure: a nationwide cohort study

BackgroundPatients with severe respiratory failure have high mortality and need various interventions. However, the impact of intensivists on treatment choices, patient outcomes, and optimal intensivist staffing patterns is unknown. In this study, we aimed to evaluate treatments and clinical outcomes for patients at board-certified intensive care training facilities compared with those at non-certified facilities.MethodsThis retrospective cohort study used Japan’s nationwide in-patient database from 2016 to 2019 and included patients with non-operative severe respiratory failure who required mechanical ventilation for over 4 days. Treatments and in-hospital mortality were compared between board-certified intensive care facilities requiring at least one intensivist and non-certified facilities using propensity score matching.ResultsOf the 66,905 patients in this study, 30,588 were treated at board-certified facilities, and 36,317 were not. The following differed between board-certified and non-certified facilities: propofol (35% vs. 18%), dexmedetomidine (37% vs. 19%), fentanyl (50% vs. 20%), rocuronium (8.5% vs. 2.6%), vecuronium (1.9% vs. 0.6%), noradrenaline (35% vs. 19%), arginine vasopressin (8.1% vs. 2.0%), adrenaline (2.3% vs. 1.0%), dobutamine (8.7% vs. 4.8%), phosphodiesterase inhibitors (1.0% vs. 0.3%), early enteral nutrition (29% vs. 14%), early rehabilitation (34% vs. 30%), renal replace therapy (15% vs. 6.7%), extracorporeal membrane oxygenation (1.6% vs. 0.3%), critical care unit admission (74% vs. 30%), dopamine (9.0% vs. 15%), sivelestat (4.1% vs. 7.0%), and high-dose methylprednisolone (13% vs. 15%). After 1:1 propensity score matching, the board-certified group had lower in-hospital mortality than the non-certified group (31% vs. 38%; odds ratio, 0.75; 95% confidence interval, 0.72–0.77; P < 0.001). Subgroup analyses showed greater benefits in the board-certified group for older patients, those who required vasopressors on the first day of mechanical ventilation, and those treated in critical care units.ConclusionsBoard-certified intensive care training facilities implemented several different adjunctive treatments for severe respiratory failure compared to non-board-certified facilities, and board-certified facilities were associated with lower in-hospital mortality. Because various factors may contribute to the outcome, the causal relationship remains uncertain. Further research is warranted to determine how best to strengthen patient outcomes in the critical care system through the certification of intensive care training facilities.

Antibiotics versus Non-Antibiotic in the treatment of Aspiration Pneumonia: analysis of the MIMIC-IV database

BackgroundAspiration pneumonia (AP) is a common complication in the intensive care unit (ICU), which is associated with significantly increased morbidity and mortality and has a significant impact on patient prognosis. Antibiotics are commonly used in the clinical treatment of AP. However, the prognostic impact of antibiotics on patients with AP has not been adequately characterized. The purpose of this study is to illustrate the relationship between the use of antibiotics and in-hospital mortality of AP patients, as well as to analyze the effects of different antibiotic treatment regimens on the prognosis of the patients, and to further understand the distribution of pathogens and drug resistance in AP patients, so as to provide guidance information for the rational use of medication for patients in the clinic.MethodsClinical data of AP patients were extracted from the MIMIC-IV database. Statistical methods included multivariate logistic regression, propensity score matching (PSM), and inverse probability weighting (IPW) based on propensity scores to ensure the robustness of the findings. In addition, the characteristics of the medications used by patients with AP were described using statistical graphs and tables.ResultsA total of 4132 patients with AP were included. In-hospital mortality was significantly lower in the group using antibiotics compared to the group not using antibiotics (odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.27- 0.71, P = 0.001). Furthermore, in the group using mechanical ventilation (MV), antibiotics use significantly reduced in-hospital mortality (OR = 0.30, 95% CI 0.15–0.57, P < 0.001).Vancomycin and cephalosporins are the most commonly used antibiotics to treat AP. Specifically, vancomycin in combination with piperacillin-tazobactam was used most frequently with 396 cases. The highest survival rate (97.6\\%) was observed in patients treated with levofloxacin combined with metronidazole. Additionally, vancomycin combined with piperacillin-tazobactam had many inflammation related features that differed significantly from those in patients who did not receive medication.ConclusionsAntibiotics use is closely associated with lower in-hospital mortality in ICU patients with AP. Moreover, understanding antibiotics use, the composition of pathogenic bacteria, and the rates of drug resistance in patients with AP can aid in disease prevention and prompt infection control.

Ramelteon exposure and survival of critically Ill sepsis patients: a retrospective study from MIMIC-IV

BackgroundThe effect of ramelteon, a melatonin receptor agonist, on survival in septic patients remains unknown. The purpose of this retrospective cohort study was to explore the relationship between ramelteon exposure and survival outcomes in septic patients.MethodsData from septic patients admitted to the intensive care unit (ICU) were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database, with patients categorized into ramelteon exposure and non-exposure groups based on the use of ramelteon. The primary outcome was 30-day mortality, and secondary outcomes included 90-day mortality, in-hospital mortality, length of ICU stay, and hospital stay. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were employed to address confounding variables. Kaplan–Meier (K-M) analysis and Cox proportional hazards regression models for stepwise regression were utilized to assess the impact of ramelteon exposure on survival.ResultsThis study included 22,152 unexposed patients and 2,708 exposed patients, resulting in 2,607 matched pairs after PSM. Following PSM, ramelteon exposure was associated with significantly lower in-hospital mortality (11.6% vs.19.7%, p < 0.001), 30-day mortality (13.4% vs. 23.2%, p < 0.001), and 90-day mortality (22.1% vs. 30%, p < 0.001).K-M curves demonstrated a significant difference in 30-day and 90-day mortality between the two groups (P < 0.001), irrespective of PSM application. Both PSM (hazard ratio [HR] = 0.53, 95% confidence intervals [CIs] 0.47–0.61, p < 0.001) and IPTW models (HR = 0.59, 95% CI 0.50–0.70, p < 0.001) indicated a significant positive effect of ramelteon usage on 30-day mortality among septic patients compared to the non-exposure group.ConclusionsThis exploratory, retrospective study suggests an association between ramelteon exposure and reduced 30-day and 90-day mortality in septic patients compared with the non-exposure group. Considering the limitations of the retrospective design and the potential for unmeasured confounding, well-designed prospective studies and randomized controlled trials will be needed to confirm these findings.

Door-to-Diuretic Time and Outcomes in Acute Heart Failure: A Scoping Review.

Inadequate decongestion remains an unmet need in the management of patients with heart failure. The concept of door-to-diuretic (D2D) time to improve outcomes has been proposed for patients with heart failure (HF), but the trial results have been mixed. We utilized Preferred Reporting Instrument for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) for scoping reviews with an extensive a priori search strategy for databases: PubMed and Scopus between January 2015 and November 2023. We used the key search terms "door-to-diuretic time" OR "door-to-furosemide time" OR "acute heart failure decongestion". Early D2D time was defined as intravenous (IV) diuretic administration within 30-120 min of patient arrival to the healthcare facility. Articles were included if they met our criteria, were written in the English language, and investigated door-to-diuretic or furosemide time as a decongestive strategy to improve outcomes in patients with acute HF. From 588 articles, 13 articles fulfilled the inclusion criteria after excluding duplicates and articles that did not meet our inclusion criteria. Of these studies, there was 1 meta-analysis and 12 observational cohort/registry-based studies (10 were positive trials and 2 were neutral). The most common outcomes examined were mortality and rehospitalization with early diuretic administration. First, early treatment was associated with lower in-hospital mortality and shorter hospital length of stay. Second, higher doses of furosemide were associated with improved HF symptoms and decreased hospitalization, at the cost of transiently worsening renal function. Third, the evidence is mixed for long-term mortality benefits. Although the impact of early D2D time on HF outcomes is mixed, early diuretic administration appears to be an effective and safe strategy that warrants further investigation in large-scale pragmatic comparative effectiveness trials. Future trials should consider utilizing diuretic efficiency-guided dose escalation and augmented diuresis using high-dose or combination diuretic therapy.

Electronic Sepsis Screening Among Patients Admitted to Hospital Wards

Sepsis screening is recommended among hospitalized patients but is supported by limited evidence of effectiveness. To evaluate the effect of electronic sepsis screening, compared with no screening, on mortality among hospitalized ward patients. In a stepped-wedge, cluster randomized trial at 5 hospitals in Saudi Arabia, 45 wards (clusters) were randomized into 9 sequences, 5 wards each, to have sepsis screening implemented at 2-month periods. The study was conducted between October 1, 2019, and July 31, 2021, with follow-up through October 29, 2021. An electronic alert, based on the quick Sequential Organ Failure Assessment score, was implemented in the electronic medical record in a silent mode that was activated to a revealed mode for sepsis screening. The primary outcome was 90-day in-hospital mortality. There were 11 secondary outcomes, including code blue activation, vasopressor therapy, incident kidney replacement therapy, multidrug-resistant organisms, and Clostridioides difficile. Among 60 055 patients, 29 442 were in the screening group and 30 613 in the no screening group. They had a median age of 59 years (IQR, 39-68), and 30 596 were male (51.0%). Alerts occurred in 4299 of 29 442 patients (14.6%) in the screening group and 5394 of 30 613 (17.6%) in the no screening group. Within 12 hours of the alert, patients in the screening group were more likely to have serum lactate tested (adjusted relative risk [aRR], 1.30; 95% CI, 1.16-1.45) and intravenous fluid ordered (aRR, 2.17; 95% CI, 1.92-2.46) compared with those in the no screening group. In the primary outcome analysis, electronic screening resulted in lower 90-day in-hospital mortality (aRR, 0.85; 95% CI, 0.77-0.93; P < .001). Screening reduced vasopressor therapy and multidrug-resistant organisms but increased code blue activation, incident kidney replacement therapy, and C difficile. Among hospitalized ward patients, electronic sepsis screening compared with no screening resulted in significantly lower in-hospital 90-day mortality. ClinicalTrials.gov Identifier: NCT04078594.

Retrospective Analysis of the Thai Percutaneous Coronary Intervention Registry: Impacts of Center Volume and Operator Experience on Outcomes.

Percutaneous coronary intervention (PCI) outcomes can vary due to various factors, including patient clinical condition, complexity of coronary lesions, expertise of operators, and quality of the PCI center. This study evaluated the influence of PCI center volume and operator experience on patient outcomes after the procedure. Retrospective data on demographic, clinical details, and outcomes for all patients undergoing PCI across 39 hospitals in Thailand from 2018 to 2019 were retrieved. PCI center volume was categorized based on annual number of interventions: low (< 200), intermediate (200-499), and high (≥ 500). Operator experience was assessed by years of practice (low [< 5] and high [≥ 5]) and the number of PCI cases performed annually (low [< 75] and high [≥ 75]). The evaluated PCI outcomes were: PCI failure; procedural complications; PCI-related in-hospital mortality; 1 year post-intervention all-cause mortality. A total of 19,701 patients who underwent PCI were included in the analysis, of whom 17,432 had follow-up data available after 1 year. Of these, 58.1% presented with either ST-elevation or non-ST elevation myocardial infarction/unstable angina, while 41.9% had stable CAD. Nearly half of the patients had triple-vessel or left-main disease, and 8.7% presented with cardiogenic shock. The percent with PCI failure, procedural complications, PCI-related in-hospital death, and 1-year all-cause mortality were 4.9%, 5.1%, 2.7%, and 11.8%, respectively. Despite patients in higher-risk profiles being treated at high-volume PCI centers and by experienced operators, there were no significant differences in PCI failure, PCI-related in-hospital mortality nor 1-year all-cause mortality compared to those treated at low or intermediate volume PCI centers. However, high-volume PCI centers had procedural complications more frequently (4.7%) than did intermediate (3.9%) and low-volume (2.5%) centers (p < 0.001). After adjusting for confounding factors, no significant associations were found between PCI center volume and PCI outcome. Similarly, no significant relationship was found between operator experience and procedural complications, nor 1-year all-cause mortality. Nevertheless, operators with more years of practice were associated with lower PCI-related in-hospital mortality (odds ratio [95% CI] of 0.75 (0.57, 0.98); p < 0.038). Additionally, operators conducting a higher number of PCIs annually tended to have less PCI failures (odds ratio [95% CI] of 0.76 (0.57, 1.01); p = 0.062). A center's PCI volume did not significantly impact PCI outcome. In contrast, operator experience did impact outcomes. This result highlights areas for improvement and can help reform strategies for national PCI systems at both center and operator levels.

The relationship between conference presentations and in-hospital mortality in patients admitted with acute myocardial infarction: A retrospective analysis using a Japanese administrative database.

Clinicians' research activities reportedly improve their healthcare performance. Presenting research at conferences may be related to improved patient care outcomes; however, few studies have investigated this relationship. Thus, we examined the association between presenting at conferences and the mortality of patients hospitalized for acute myocardial infarction. We analyzed an administrative database of acute care hospitals in Japan. The study compared patients admitted to hospitals in which physicians made at least one conference presentation during the patient's admission year (Presentation Group) with those admitted to hospitals with no conference presentations (Control group). We performed multivariable logistic regression analyses to estimate the risk of all-cause in-hospital mortality. Five models were fitted: a Crude model, unadjusted; Model 1, adjusted for personal factors, including sex, age, Killip classification, and so on; Model 2, adjusted for Model 1 plus hospital factors; Model 3 was a multilevel analysis clustered by hospital codes and adjusted for the same variables as Model 1; Model 4 was adjusted for Model 1 plus evidence-based practices through causal mediation analysis. After excluding 3,544 patients with missing Killip classification or ambulance use, data for 56,923 patients in 384 acute care hospitals were analyzed. Drug prescription in accordance with the evidence was significantly greater in the Presentation group than in the Control group. Moreover, conference presentation was significantly associated with lower in-hospital mortality in all models (Odds ratios (OR) = 0.68, 95% Confidence intervals (CIs): 0.65 to 0.72 in the Crude model; OR = 0.73, 95% CIs: 0.68 to 0.79 in Model 1; OR = 0.76, 95% CIs: 0.70 to 0.82 in Model 2; OR = 0.84, 95% CIs: 0.76 to 0.92 in Model 3; OR = 1.00, 95% CIs: 0.92 to 1.09 in Model 4). The promotion of scholarly activities such as conference presentations might improve patient outcomes through increased evidence-based practice.

In-hospital and delayed mortality in patients with upper gastrointestinal bleeding on antithrombotic treatment: effects of withdrawal and resuming

ABSTRACT Background Antithrombotic drugs pose a dual challenge to acute upper gastrointestinal bleeding, with associated risks of bleeding complications and thromboembolic events upon withdrawal. We aimed to determine the impact of antithrombotic medications on in-hospital and delayed outcomes and whether suspension and resumption influenced delayed mortality. Methods This study was a prospective registry analysis of patients between 2013–2021. Anticoagulants and antiplatelets were classified as antithrombotic. The examined outcomes included in-hospital mortality and delayed 6-month cardiovascular, bleeding, and mortality events. Results A total of 1345 patients were included. 21.7% were taking anticoagulants and 19.1% were taking antiplatelets. Patients on antithrombotic therapy have a longer delay in endoscopic performance (11 ± 11 h vs. 9.6 ± 8 h; p = 0.027) and less need for therapy (38.5% vs. 48.1%;p = 0.002), with gastric erosion being more usual (14.2% vs. 9.1%; p = 0.006). In-hospital mortality was higher in patients not taking antithrombotic (12% vs. 8%;p = 0.022) and suspension < 72 h was associated with increased mortality (14.9% vs. 2.3%;p = 0.001). Delayed mortality was higher in patients taking antithrombotic (9.4% vs. 6%; p=0.034) and in those who suspended them for more than 7days (17% vs. 8.7%; p=0.033), with no differences when it lasted<72h. Patients on antithrombotic therapy exhibited more delayed cardiovascular (13.7% vs. 3.4%; p<0.0001) and hemorrhagic events (22.9% vs. 12.9%; p<0.0001), with no differences observed in patients who withheld antithrombotic medication. Multivariate analysis identified ASA, disseminated malignancy, and NSAIDs as independent risk factors for in-hospital mortality, whereas antithrombotic therapy and hemoglobin levels were protective factors. Conclusion Patients with upper gastrointestinal bleeding treated with antithrombotic drugs had lower in-hospital mortality despite increased comorbidities and older age. Conversely, delayed 6-month mortality was higher. Shorter antithrombotic suspension durations increased in-hospital mortality, whereas suspension for > 7 days increased delayed mortality.

Dexmedetomidine Is Associated with Reduced In-Hospital Mortality Risk of Subarachnoid Hemorrhage Patients undergoing surgery

BackgroundSubarachnoid hemorrhage (SAH) is a severe neurological event with high mortality. The choice of sedatives in SAH management may influence patient outcomes. This study aimed to investigate the association between sedatives and in-hospital mortality among SAH patients. MethodsThis study analyzed data from the MIMIC-IV database, and in-hospital mortality was the primary outcome. Key variables collected included sedatives, demographics, comorbidities, vital signs, laboratory tests, and severity scores. Univariate and multivariate logistic regression analyses were used to assess associations between sedative use and in-hospital mortality, with adjustments for confounding factors. Further stratified analyses explored the effects of dexmedetomidine across different patient subgroups, and mediation analysis evaluated creatinine's role in the relationship between dexmedetomidine and mortality. ResultsA total of 527 patients were included in this study, with 301 males. Compared to propofol and midazolam, the use of dexmedetomidine was significantly related to the reduction of in-hospital mortality in SAH patients (OR = 0.369, 95% CI: 0.237-0.574, p < 0.001). After adjusting for variables such as demographics, comorbidities, and laboratory tests, dexmedetomidine remained associated with lower in-hospital mortality. Additionally, our findings indicated that dexmedetomidine use was associated with a reduced risk of in-hospital mortality regardless of the presence of cerebrovascular disease. Importantly, we discovered that creatinine acted as a mediator in the protective effect of dexmedetomidine on in-hospital mortality. ConclusionDexmedetomidine is associated with significantly lower in-hospital mortality in SAH patients. These findings underscore the importance of sedative choice for SAH patients, suggesting that dexmedetomidine could enhance patient outcomes.

Impact of chest pain on mortality in patients with acute pulmonary embolism

Evidence for the prognostic impact of chest pain in acute pulmonary embolism (APE) is limited. This study aimed to assess the prognostic value of chest pain in a Chinese cohort of patients with APE. Consecutive hospitalized patients diagnosed with APE between January 2016 and December 2019 were retrospectively enrolled and followed prospectively for 2 years at West China Hospital of Sichuan University. The primary outcome was in-hospital all- cause mortality, while the secondary outcomes included 3-month, 6-month, and 2-year all-cause mortality, APE recurrence, mechanical ventilation, and length of hospital stay (LOS). A total of 737 APE patients met the study criteria, with 254 patients (34.5%) presented with chest pain at admission. Patients with chest pain had significantly lower in-hospital (3.1% vs. 11.2%), 3-month (3.7% vs. 7.5%), 6-month (5.3% vs. 10.0%), and 2-year (9.8% vs. 15.4%) all-cause mortality compared to patients without chest pain (all P < 0.05). A lower rate of mechanical ventilation was observed in APE patients with chest pain, and no significant differences were identified in terms of APE recurrence and LOS between APE patients with and without chest pain. Chest pain was an independent predictor of in-hospital mortality in three separate multivariable models (range of odds ratios 0.390–0.423, all P < 0.05). APE patients with chest pain had a lower short-term and long-term all-cause mortality compared to those without chest pain. Chest pain may be considered a strong, favorable prognostic marker in acute pulmonary embolism.

Transcatheter vs Surgical Aortic Valve Replacement in Bicuspid Aortic Valves.

Recent approval of transcatheter aortic valve replacement (TAVR) in patients at lower risk profiles has resulted in a real-world expansion in patients with bicuspid aortic valves (BAV), otherwise excluded from trials comparing TAVR with surgical aortic valve replacement (SAVR). This study compared perioperative and longitudinal outcomes between BAV patients undergoing TAVR vs SAVR. Using the United States Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all beneficiaries with BAV undergoing isolated SAVR or TAVR (2018-2022). Comorbidities and frailty were accounted for using validated metrics with doubly robust risk adjustment using inverse probability weighting, multilevel regression models, and competing-risk time to event analysis. Subgroup analysis evaluated patients <75 years with low surgical risk (<4%). The study included 11,289 BAV patients (8123 SAVR and 3166 TAVR). Accounting for age, comorbidities, and frailty, TAVR was associated with lower procedural mortality (odds ratio, 0.40; P < .001) but higher pacemaker (12.4% vs 2.3%; odds ratio, 5.4; P < .001), longitudinal stroke (2.4% vs 1.5%; hazard ratio [HR], 1.35; P < .001), and all-cause mortality (8.8% vs 5.7%; HR, 1.49; P < .001) compared with SAVR. The young low-risk subgroup (5393 SAVR and 1731 TAVR) highlighted similar findings, with TAVR associated with higher longitudinal stroke (2.1% vs 1.7%; HR, 1.22; P= .017) and composite stroke, valve reintervention, or death (8.1% vs 5.9%; HR, 1.37; P < .001) compared with SAVR. Among Medicare beneficiaries with BAV, TAVR was associated with lower index in-hospital mortality but also lower 5-year risk-adjusted freedom from longitudinal stroke compared with SAVR, even in the youngest low-risk patients.