Lower Risk Of In-hospital Death Research Articles

Markedly elevated high-sensitivity troponin and in-hospital mortality after cardiac surgery

BackgroundHigh-sensitivity troponin (hsTnI) is correlated with cardiac mortality; however, studies on the relationship of markedly elevated hsTnI with in-hospital mortality after cardiac surgery are sparse. Therefore, we aimed to define this relationship in order to help guide in-hospital, acute management of post-surgical patients. MethodsWe retrospectively analyzed all cardiac surgeries completed at our institution between January 2020 and June 2022 in which a peak hsTnI was noted to be >35× upper limit of normal (ULN = 34 ng/L). The primary outcome was in-hospital death. Subgroup analysis was performed to assess differences between coronary artery bypass grafting (CABG) and other cardiac surgeries. ResultsA total of 1382 cases met inclusion criteria. The patients' mean age was 64.8 years and 68.2 % were male. Median peak hsTnI after surgery was 4202 ng/L (interquartile ratio: 2427–7654). Univariate analysis of troponin level with mortality found that for every 1000 ng/L increase in hsTnI, odds of in-hospital death increased by 3.8 % (odds ratio [OR]: 1.038; 95 % confidence interval [CI] 1.027–1.050; p < 0.0001). In a multivariate model, troponin (OR 1.02; 95 % CI 1.01–1.04; p = 0.004) maintained a significant association with in-hospital death. CABG had a lower risk of in-hospital death for any given hsTnI level up to 60,000 ng/L compared to other cardiac surgeries. ConclusionIncreasing hsTnI level is associated with increasing probability of in-hospital mortality and, therefore, serves as an additional, objective measure of risk to help guide in-hospital clinical management.

Outcomes of Catheter-Based Therapy for Cancer-Associated Intermediate or High-Risk Pulmonary Embolism

Background: Pulmonary embolism (PE) is a well-known complication of cancer and is associated with significant morbidity and mortality. The standard of care for the treatment of PE is anticoagulation and systemic thrombolysis for high-risk PE. However, both carry risk of bleeding, and patients with cancer are particularly at higher risk of both bleeding and thrombotic complications. The development of catheter-based therapies (CBT) has provided an alternative reperfusion therapy for patients with high-risk and select intermediate risk PE patients. However, despite the increased prevalence of PE, patients with cancer are often excluded from clinical trials of invasive medical devices, including CBT for PE. Therefore, we investigated outcomes of patients with cancer hospitalized for intermediate or high-risk PE treated with or without CBT. Methods: This was a retrospective cohort analysis of the National Readmission Database (NRD) of adult patients with a primary diagnosis of intermediate or high-risk PE from 2017 and 2018 with a history of cancer, which was identified using ICD-10 codes. High-risk PE was defined as PE with hemodynamic instability (either cardiac arrest, cardiogenic shock, or vasopressor use). Intermediate-risk PE was defined as PE with signs of right ventricular strain (type 2 myocardial infarction or cor pulmonale) without hemodynamic instability. Primary outcome was in-hospital mortality. Secondary outcomes were in-hospital major bleeding (composite of gastrointestinal, intracranial, and post-procedural bleeding), and 90-day any-cause, VTE-related, and bleeding-related readmissions. Propensity scores (PS) for estimating probability of CBT were calculated using non-parsimonious multivariable logistic regression that included all baseline patient characteristics examined. Inverse-probability treatment weighting (IPTW) was utilized to adjust for potential confounders. Patients treated with CBT were compared to those without and standardized mean difference (SMD) was calculated for variables before and after IPTW. Imbalances between groups were significant if SMD for any given covariable was ≥ 0.10. Hazard ratios (HR) were estimated for 90-day readmission outcomes using Cox proportional hazards regression, and odds ratio (OR) were calculated for estimating in-hospital outcomes using logistic regression. Results: 3,333 patients were identified of which 388 (11.6%) were treated with CBT. Prior to IPTW, patients treated with CBT were younger (mean age 66.3 vs 67.6 years) and less likely to have metastatic cancer (43.3% vs 50.3%), Khorana high or intermediate risk cancer type (40.5% vs 49.4%) or high-risk PE (34.5% vs 46.3%), Table 1. After IPTW, baseline characteristics were well balanced between groups. After IPTW, CBT was associated with lower risk of in-hospital death (23.3% vs 28.3%, OR 0.77, 95% CI 0.69 - 0.86) but higher risk of in-hospital bleeding (16.4% vs 13.7%, OR 2.34, 95% CI 2.11 - 2.60) which was driven by post-procedure bleeding (12.5% vs 9.2%, OR 1.40, 95% CI 1.20 - 1.64). CBT was also associated with lower 90-day any-cause (HR 0.88, 95% CI 0.79 - 0.98) and VTE-related (HR 0.54, 95% CI 0.35 - 0.83) but not bleeding-related (HR 0.69, 95% CI 0.34 - 1.40) readmissions, Figure 1. Conclusions: Patients with cancer admitted with intermediate or high-risk PE have high rates of in-hospital death and bleeding. Treatment with CBT was associated with lower in-hospital death and 90-day any-cause and VTE-related readmissions at the cost of increased in-hospital bleeding driven by post-procedural bleeding. Prospective studies and trials of CBT in PE should include patients with cancer and further investigation is warranted to confirm our findings.

Catheter-based therapy for intermediate or high-risk pulmonary embolism is associated with lower in-hospital mortality in patients with cancer: Insights from the National Inpatient Sample.

Pulmonary embolism (PE)is a common complication among patients with cancer and is a significant contributor to morbidity and mortality. Catheter-based therapies (CBT),including catheter-directed thrombolysis (CDT)and mechanical thrombectomy, have been developed and are used in patients with intermediate or high-risk PE. However, there is a paucity of data on outcomes in patients with cancer as most clinical studies exclude this group of patients. To characterize outcomes of patients with cancer admitted with intermediate or high-risk PE treated with CBT compared with no CBT. Patients with an admission diagnosis of intermediate or high-risk PE and a history of cancer from October 2015 to December 2018 were identified using the National Inpatient Sample. Outcomes of interest were in-hospital death or cardiac arrest (CA)and major bleeding. Inverse probability treatment weighting (IPTW)was utilized to compare outcomes between patients treated with and without CBT. Variables that remained unbalanced after IPTW were adjusted using multivariable logistic regression. A total of 2084 unweighted admissions (10,420 weighted) for intermediate or high-risk PE and cancer were included, of which 136 (6.5%) were treated with CBT. After IPTW, CBT was associated with lower death or CA (aOR 0.54, 95% CI 0.46-0.64) but higher major bleeding (aOR1.41, 95% CI 1.21-1.65). After stratifying by PE risk type, patients treated with CBT had lower risk of death or CA in both intermediate (aOR0.52, 95% CI 0.36-0.75) and high-risk PE (aOR0.48, 95% CI 0.33-0.53). However, patients with CBT were associated with increased risk of major bleeding in intermediate-risk PE (aOR2.12, 95% CI 1.67-2.69) but not in those with high-risk PE (aOR0.84, 95% CI 0.66-1.07). Among patients with cancer hospitalized with intermediate or high-risk PE, treatment with CBT was associated with lower risk of in-hospital death or CA but higher risk of bleeding. Prospective studies and inclusion of patients with cancer in randomized trials are warranted to confirm our findings.

Outcomes of Patients With Myeloproliferative Neoplasms AdmittedWith Myocardial Infarction: Insights From National Inpatient Sample.

Myeloproliferative neoplasms (MPNs) are hematopoietic stem cell neoplasms with a high risk of thrombosis, including acute myocardial infarction (AMI). However, outcomes after AMI have not been thoroughly characterized. The purpose of this study was to characterize outcomes after AMI in patients with MPNs compared with patients without MPNs. Patients with a primary admission of AMI from January 2006 to December 2018 were identified using the National Inpatient Sample. Outcomes of interest included in-hospital death or cardiac arrest (CA) and major bleeding. Propensity score weighting was used to compare outcomes between MPN and non-MPN groups. A total of 1,644,304 unweighted admissions for AMI were included; of these admissions, 5,374 (0.3%) were patients with MPNs. After propensity score weighting, patients with MPNs had a lower risk of in-hospital death or CA (OR: 0.83; 95% CI: 0.82-0.84) but a higher risk of major bleeding (OR: 1.29; 95% CI: 1.28-1.30) compared with non-MPN patients. There was a decreasing temporal rate of in-hospital death or CA and bleeding in patients without MPNs (Ptrend< 0.001 for both). However, there was an increasing temporal rate of in-hospital death or CA (Ptrend< 0.001) and a stable rate of major bleeding (Ptrend=0.48) in patients with MPNs. Among patients hospitalized with AMI, patients with MPNs have a lower risk of in-hospital death or CA compared with patients without MPNs, although they have a higher risk of bleeding. More investigation is needed in order to improve post-AMI bleeding outcomes in patients with MPN.

Disparities in the Outcomes of Acute Pulmonary Embolism in Hospitalized Patients with Hematologic Malignancy and Solid Tumor.

This study aimed to compare the clinical burden and healthcare utilization outcomes of hematologic versus solid malignancies in patients hospitalized with acute pulmonary embolism (PE). This population-based, retrospective study extracted and analyzed the discharge data from the 2016-2018 US National Inpatient Sample (NIS) of hospitalized patients with a primary diagnosis of acute PE and a subsequent diagnosis of hematologic malignancies or solid tumors. Prolonged length-of-stay (LOS) was defined as ≥75th percentile LOS of the study cohort. Unfavorable discharge was defined as discharged to nursing home or long-term facility. Univariate and multivariate regression analyses were conducted to determine associations between cancer type, presence of unstable PE, and in-hospital outcomes in acute PE patients. Patients with acute PE with solid tumors had higher rates of in-hospital deaths and unfavorable discharge than those with hematologic malignancies (6.4% versus 3.2%, P < 0.001; 14.0% versus 11.2%, P = 0.01, respectively). Acute PE patients with hematologic malignancies had a lower risk of in-hospital death (aOR: 0.43, 95% CI: 0.31-0.60), unfavorable discharge (aOR: 0.76, 95% CI: 0.63-0.92), and prolonged LOS (aOR: 0.83, 95% CI: 0.71-0.98) than those with solid tumors. Stratified analysis showed that male patients aged <60 years with hematologic malignancies had a lower risk of prolonged LOS (aOR: 0.70, 95% CI: 0.52-0.94; aOR: 0.85, 95% CI: 0.68-1.05) and unfavorable discharge (aOR: 0.40, 95% CI: 0.22-0.71; aOR: 0.65, 95% CI: 0.50-0.85) than those with solid tumors. In the comparison of the outcomes of acute PE with hematologic malignancies and solid tumors, patients with hematologic malignancy had a lower risk of in-hospital deaths, prolonged LOS, and unfavorable discharge than those with solid tumors.

Effect of nintedanib on acute exacerbations of fibrosing interstitial lung diseases: a national database study in Japan.

Acute exacerbation is a life-threatening event in patients with fibrosing interstitial lung diseases (ILDs). Although nintedanib reduces acute exacerbation incidence, its effectiveness during acute exacerbation is unclear. Using data from the Diagnosis Procedure Combination database (September 2015-March 2020) in Japan, we identified patients with fibrosing ILDs who received intravenous injection of high-dose corticosteroid within 3 days post-admission and analysed their first hospitalisation. We performed overlap propensity score weighting to compare in-hospital outcomes between patients who received nintedanib within 14 days post-admission and those who did not. The primary and secondary outcomes were in-hospital mortality and length of hospitalisation in the patients discharged alive, respectively. Among the 6235 identified patients, 353 patients received nintedanib within 14 days post-admission. In-hospital mortality occurred in 13.7% and 6.0% patients in the control (n=5882) and nintedanib-treated (n=353) patients, respectively. The mean length of hospitalisation was 39.9 and 30.4 days in the control and nintedanib-treated patients, respectively. After overlap propensity score weighting, nintedanib treatment was significantly associated with lower in-hospital mortality in the adjusted cohort (OR 0.43, 95% CI 0.27-0.70; p=0.001). The mean length of hospitalisation in nintedanib-treated patients (30.7 days) was significantly shorter than that in the control group (37.5 days; p<0.001). Nintedanib initiation during acute exacerbation was significantly associated with a lower risk of in-hospital death and shorter length of hospitalisation in patients with fibrosing ILDs. Our results elucidate the potential role of nintedanib in the treatment of acute exacerbation in patients with fibrosing ILDs. Further prospective studies are warranted.

Impact of Arterial Hypertension and Use of Antihypertensive Pharmacotherapy on Mortality in Patients Hospitalized due to COVID-19: The CRACoV-HHS Study.

Background:Cardiovascular diseases including arterial hypertension are common comorbidities among patients hospitalized due to COVID-19. We assessed the influence of preexisting hypertension and its pharmacological treatment on in-hospital mortality in patients hospitalized with COVID-19.Methods:We studied all consecutive patients who were admitted to the University Hospital in Krakow, Poland, due to COVID-19 between March 2020 and May 2021. Data of 5191 patients (mean age 61.9±16.7 years, 45.2% female) were analyzed.Results:The median hospitalization time was 14 days, and the mortality rate was 18.4%. About a quarter of patients had an established cardiovascular disease including coronary artery disease (16.6%) or stroke (7.6%). Patients with hypertension (58.3%) were older and had more comorbidities than patients without hypertension. In multivariable logistic regression analysis, age above median (64 years), male gender, history of heart failure or chronic kidney disease, and higher C-reactive protein level, but not preexisting hypertension, were independent risk factors for in-hospital death in the whole study group. Patients with hypertension already treated (n=1723) with any first-line antihypertensive drug (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers, or thiazide/thiazide-like diuretics) had a significantly lower risk of in-hospital death (odds ratio, 0.25 [95% CI, 0.2–0.3]; P<0.001) compared to nontreated hypertensives (n=1305).Conclusions:Although the diagnosis of preexisting hypertension per se had no significant impact on in-hospital mortality among patients with COVID-19, treatment with any first-line blood pressure–lowering drug had a profound beneficial effect on survival in patients with hypertension. These data support the need for antihypertensive pharmacological treatment during the COVID-19 pandemic.

Presence of Antibodies to Severe Acute Respiratory Syndrome Coronavirus-2 on Admission Is Associated With Decreased Mortality in COVID-19 Critical Illness.

OBJECTIVES:To determine whether the early serologic response in COVID-19 critical illness is associated with hospital mortality. To evaluate if time-to-seroconversion differs by receipt of dexamethasone therapy.DESIGN:Patients were prospectively enrolled within 24 hours of ICU admission from two University of Washington Hospitals. Plasma was collected on enrollment and on days 3, 7, 10, and 14.SETTING:ICUs between March 2020 and April 2021.PATIENTS:Consecutive adults with COVID-19 admitted to an ICU.MEASUREMENTS AND MAIN RESULTS:We measured longitudinal total antispike protein antibody levels (anti-S abs) and total antinucleocapsid antibody levels (anti-N ab) using a U.S. Food and Drug Administration-authorized Roche instrument. We evaluated whether detectable anti-S abs on ICU admission were associated with host factors, initial disease severity, and hospital mortality. We evaluated whether dexamethasone therapy was associated with time-to-seroconversion. Among 93 unvaccinated participants, 47 (51%) had detectable anti-S abs on ICU admission. There was no difference in Acute Physiology and Chronic Health Evaluation II score or time between first positive severe acute respiratory syndrome coronavirus-2 PCR and ICU admission in those with detectable versus undetectable anti-S abs. Adjusting for age, body mass index, and sex, patients with detectable anti-S abs had a lower risk of inhospital death (hazard ratio, 0.40; 95% CI, 0.17–0.94; p = 0.04). Among 21 patients with undetectable anti-S abs on ICU admission and serial measurements available, time-to-seroconversion was not significantly affected by receipt of dexamethasone therapy.CONCLUSIONS:In COVID-19 critical illness, a significant proportion of patients do not have detectable antibodies at ICU admission, and this is independent of severity of illness. Detectable anti-S abs were associated with lower risk of inhospital death. Despite concern that corticosteroids may impair an appropriate antiviral serologic response, early antibody kinetics were not significantly affected by administration of dexamethasone; however, CIs were wide and require further study.

Trends and Outcomes of Myocardial Infarction in Patients With Previous Coronary Artery Bypass Surgery

Data on myocardial infarction (MI) treatment in patients with previous coronary artery bypass grafting (CABG) is limited. We queried the Nationwide Readmissions Database to identify hospitalizations of patients with MI from 2016 to 2019. Among hospitalized patients presenting with MI, 10.3% had previous CABG. Patients with MI who had previous CABG were less likely to be revascularized than those without previous CABG for both ST-segment elevation MI (STEMI) (46.4% vs 68.4%) and non-ST-segment elevation MI (NSTEMI) (30.8% vs 36.7%). CABG was associated with a lower risk of death in NSTEMI patients (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.82 to 0.86), but a higher risk in STEMI patients (OR 1.06, 95% CI 1.01 to 1.13). Revascularization was associated with a lower risk of in-hospital death in patients with previous CABG presenting with STEMI (OR 0.30, 95% CI 0.26 to 0.35) and NSTEMI (OR 0.21, 95% CI 0.19 to 0.23).

Milder disease trajectory among COVID-19 patients hospitalised with the SARS-CoV-2 Omicron variant compared with the Delta variant in Norway.

Using individual-level national registry data, we conducted a cohort study to estimate differences in the length of hospital stay, and risk of admission to an intensive care unit and in-hospital death among patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variant, compared with patients infected with Delta variant in Norway. We included 409 (38%) patients infected with Omicron and 666 (62%) infected with Delta who were hospitalised with coronavirus disease 2019 (COVID-19) as the main cause of hospitalisation between 6 December 2021 and 6 February 2022. Omicron patients had a 48% lower risk of intensive care admission (adjusted hazard ratios (aHR): 0.52, 95% confidence interval (CI): 0.34-0.80) and a 56% lower risk of in-hospital death (aHR: 0.44, 95%CI: 0.24-0.79) compared with Delta patients. Omicron patients had a shorter length of stay (with or without ICU stay) compared with Delta patients in the age groups from 18 to 79 years and those who had at least completed their primary vaccination. This supports growing evidence of reduced disease severity among hospitalised Omicron patients compared with Delta patients.

IMPACT OF ARTERIAL HYPERTENSION AND ANTIHYPERTENSIVE PHARMACOTHERAPY ON IN-HOSPITAL MORTALITY IN COVID-19 PATIENTS: THE CRACOV-HHS STUDY

Objective: Cardiovascular diseases including hypertension are common comorbidities in patients hospitalized due to COVID-19. We assessed the impact of hypertension on in-hospital mortality in patients hospitalized due to COVID-19. Design and method: We retrospectively analyzed the medical records of all consecutive patients who were admitted to the University Hospital in Krakow, Poland, due to confirmed SARS-CoV2 infection from March 2020 to May 2021. Results: Overall, data of 5191 patients (mean age 61.9 ± 16.7 years) were available for analysis. Patients with preexisting hypertension (58.3% of the study population) were older and had more comorbidities than patients without hypertension (p &lt; 0.05). In-hospital mortality was significantly higher in patients with hypertension compared to those without hypertension also after adjustment for age (22.2% vs 12.9%; P = 0.02). Age above median (64 years, odds ratio [OR] 3.93; 95% confidence interval [CI] 3.23–4.83), male gender (OR 1.19; CI 1.01–1.40), a history of heart failure (OR 2.01; CI 1.58–2.56) or chronic kidney disease (OR 2.35; CI 1.86–2.96) and increased C-reactive protein levels (OR 1.09; CI 1.08–1.10), but not preexisting hypertension (OR 0.90; CI 0.74–1.09) were significantly associated with a higher risk of in-hospital death after multivariate logistic regression analysis. However, hypertension (OR 1.45; CI 1.06–1.97) was an independent predictor of in-hospital death in patients without established cardiovascular disease and antihypertensive treatment. Treatment with any first-line antihypertensive drug class in patients with hypertension at the time of hospitalization was associated with a lower risk of in-hospital death (beta-blockers OR 0.52; CI 0.41–0.65; angiotensin converting enzyme inhibitors OR 0.52; CI 0.38–0.68; angiotensin receptor blockers OR 0.24; CI 0.12–0.41; calcium channel blockers OR 0.61; CI 0.44–0.84; thiazide diuretics OR 0.40; CI 0.24–0.64). Conclusions: Besides the high prevalence, hypertension was not an independent risk factor of in-hospital death in the overall group of hospitalized COVID-19 patients. Treatment with all first-line antihypertensive medications was associated with significant reduction of in-hospital death in patients with hypertension.

Effectiveness of influenza vaccination on in-hospital death and recurrent hospitalization in older adults with cardiovascular diseases

ObjectivesThere is limited evidence on the effectiveness of influenza vaccination on hospitalization outcomes by cardiovascular disease (CVD) subtypes or comorbidities. MethodsThis study involved 713,488 records of hospitalization of adults ≥60 years with CVD from the Beijing Urban Employee Basic Medical Insurance database. Logistic regression with generalized estimating equations was conducted to estimate the effectiveness of influenza vaccination on in-hospital death and recurrent hospitalization, adjusting for unmeasured confounders. ResultsThe coverage of influenza vaccination was only 13.3% among older adults hospitalized for CVD. Influenza vaccination was associated with 15% (odds ratios 0.85 [0.74, 0.99]) lower risk of in-hospital death among patients with CVD, with stronger associations in patients with stroke. Influenza vaccination was associated with 6% (0.94 [0.88, 0.99]) and 28% (0.72 [0.56, 0.93]) lower risks of recurrent hospitalization for ischemic heart disease (IHD) and respiratory disease in patients with IHD, but there were no clear associations in patients with stroke. For in-hospital death, the protective association of influenza vaccination was stronger in patients with fewer comorbidities and was similar to that of joint vaccinations of influenza and pneumococcal vaccinations. ConclusionThe protective association of influenza vaccination on CVD hospitalization outcomes serves as the evidence base to increase the uptake of influenza vaccination among older adults in China.

Prognostic Factors Related to In-hospital Death in Children with Biliary Atresia: Analysis of a Nationwide Inpatient Database.

Patients with biliary atresia (BA) are prone to hepatic decompensation, which might eventually lead to death. This study aimed to identify the possible risk factors affecting in-hospital death in BA patients in China. We collected data from the Hospital Quality Monitoring System, a national inpatient database. All patients aged up to 2 years old with a diagnosis of BA were included. The subjects were divided to three groups, including Kasai portoenterostomy (KP), liver transplantation (LT), and no surgery. Logistic regression with Firth's method was performed to identify potential influencing variables associated with in-hospital death. During the year 2013 to 2017, there were 14,038 pediatric admissions with a diagnosis of BA. The proportion of in-hospital death in pediatric BA admissions was 1.08%. Compared with patients under six months, there was a higher risk of in-hospital death for children aged six months to 1 year and 1-2 years old. Clinical signs, including cirrhosis, variceal bleeding, and hepatic encephalopathy, were significantly associated with the risk of in-hospital death. In no surgery group, compared to those in Beijing and Shanghai, BA patients admitted in other districts had a lower risk of in-hospital death (OR=0.39, 95% CI: 0.21, 0.70). However, in the LT group, patients admitted in other districts had a higher risk of in-hospital death (OR=9.13, 95% CI: 3.99, 20.87). In-hospital survival remains unsatisfactory for pediatric BA patients with severe complications. Furthermore, more resources and training for BA treatment, especially LT, are essential for districts with poor medical care in the future.

Sex-specific difference of in-hospital mortality from COVID-19 in South Korea.

We sought to assess the impact of sex on in-hospital mortality of patients with COVID-19 infection in South Korea. The study recruited 5,628 prospective consecutive patients who were hospitalized in South Korea with COVID-19 infection, and enrolled in the Korea Centers for Disease Control and Prevention (KCDC) dataset between January 20, 2020, and April 30, 2020. The primary endpoint was in-hospital death from COVID-19. The cohort comprised of 3,308 women (59%) and 2,320 men (41%). In-hospital death was significantly lower in women than men (3.5% vs. 5.5%, hazard ratio (HR): 0.61; 95% confidence interval (CI): 0.47 to 0.79, p <0.001). Results were consistent after multivariable regression (HR: 0.59; 95% CI: 0.41 to 0.85, p = 0.023) and propensity score matching (HR: 0.51; 95% CI: 0.30 to 0.86, p = 0.012). In South Korea, women had a significantly lower risk of in-hospital death amongst those patients hospitalized with COVID-19 infection.

S1430 Early Enteral Nutrition Reduces In-Hospital Mortality of Critically Ill COVID-19 Patients

Introduction: Early enteral nutrition (EEN) is a therapeutic strategy that is used in critical illness to reduce morbidity and mortality. There is no data on the role of nutrition therapy for intubated critically ill COVID-19 patients. The aim of our study was to assess if early enteral nutrition reduced morbidity and mortality during the first wave of the COVID-19 pandemic. Methods: A retrospective chart review of COVID-19 patients >18 years who were mechanically ventilated for >48 hours at Montefiore Medical Center from March 2020 to November 2020 (n = 669) was performed. Using a landmark analysis approach, patients were divided into (1) an EEN group, defined as having enteral feeding initiated before 48 hours of mechanical ventilation; (2) delayed or no enteral nutrition ( >48 hours of mechanical ventilation). Patients who died or were extubated prior to the landmark time were excluded. Cumulative incidence curves stratified by EEN status were estimated for the primary endpoint of in-hospital death, accounting for the competing risk of discharge. Secondary analysis examined time to extubation. Cox PH models were estimated to examine the association between EEN and the hazard of death while adjusting for an a priori set of COVID-related predictors. Two-sided p-values ≤ 0.05 were considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc., Cary NC, USA). Results: There were 515 patients in the EEN group and 154 patients in the delayed enteral nutrition group. EEN was associated with a lower hazard of in-hospital death (adjusted HR = 0.79, 95% CI: 0.63-1.0; P = 0.05). Older age, male gender, and CKD were significantly associated with a higher hazard of death. The cumulative incidence of mortality was lower in the EEN group, with an estimated incidence of 40% and 53% at 10 and 20 days compared to 47% and 60% with delayed EN. Time to extubation and hospital discharge were not associated with EEN. Conclusion: EEN helps treat critically ill patients to maintain gut integrity, modulate stress and the systemic immune response and attenuate disease severity. The lower risk of in-hospital death in the EEN group supports this therapeutic modality in critically ill intubated COVID-19 patients. Further analysis to assess barriers for EEN including prone positioning, fluid restriction, and use of vasopressors is an area of future research.Figure 1.: De Novo Patients and Patients With Prior Diagnoses of EG and/or EoD Have Significant Reductions in Symptoms Compared With Patients Given Placebo.Table 1.: Cause-specific Cox PH model for the time to death from landmark time of 48 hours post intubation.

Optimal Timing of Remdesivir Initiation in Hospitalized Patients With Coronavirus Disease 2019 (COVID-19) Administered With Dexamethasone.

BackgroundEvidence is lacking about any additional benefits of introducing remdesivir on top of dexamethasone, and the optimal timing of initiation.MethodsIn a territory-wide cohort of 10,445 COVID-19 patients from Hong Kong who were hospitalized between 21st January 2020 and 31st January 2021, 1544 patients had received dexamethasone during hospitalization. Exposure group consisted of patients who had initiated remdesivir prior to dexamethasone (n=93), or co-initiated the two drugs simultaneously (n=373); whereas non-exposure group included patients who were given remdesivir after dexamethasone (n=149), or those without remdesivir use (n=929). Multiple imputation and inverse probability of treatment weighting for propensity score were applied and hazard ratios (HR) of event outcomes were estimated using Cox regression models.ResultsTime to clinical improvement (HR=1.23, 95%CI 1.02-1.49, p=0.032) and positive IgG antibody (HR=1.22, 95%CI 1.02-1.46, p=0.029) were significantly shorter in the exposure group than that of non-exposure. The exposure group had a shorter hospital length of stay by 2.65 days among survivors, lower WHO clinical progression scale scores from five days of follow-up onwards, lower risks of in-hospital death (HR=0.59, 95%CI 0.36-0.98, p=0.042) and composite outcomes; and without experiencing an increased risk of ARDS. Differences in the cumulative direct medical costs between groups were no longer significant from 17 days of follow-up onwards.ConclusionsInitiation of remdesivir prior to or simultaneously with dexamethasone was associated with significantly shorter time to clinical improvement and positive IgG antibody, lower risk of in-hospital death, in addition to shorter length of hospital stay in patients with moderate COVID-19.

Clinical Improvement, Outcomes, Antiviral Activity, and Costs Associated With Early Treatment With Remdesivir for Patients With Coronavirus Disease 2019 (COVID-19).

BackgroundEvidence remains inconclusive on any significant benefits of remdesivir in mild-to-moderate COVID-19 patients. This study explored the disease progression, various clinical outcomes, changes in viral load, and costs associated with early remdesivir treatment among COVID-19 patients.MethodsA territory-wide retrospective cohort of 10,419 patients with COVID-19 hospitalized from 21st January 2020 to 31st January 2021 in Hong Kong were identified. Early remdesivir users were matched with controls using propensity-score matching in a ratio of up to 1:4. Study outcomes were time to clinical improvement on the WHO clinical progression scale of at least 1 score; hospital discharge; recovery; viral clearance; low viral load; positive IgG antibody; in-hospital death; and composite outcomes of in-hospital death, requiring invasive ventilation or intensive care.ResultsAfter multiple imputation and propensity-score matching, the median follow-up was 14 days for both remdesivir (n=352) and control (n=1,347) groups. Time to clinical improvement was significantly shorter in the remdesivir group than that of control (hazard ratio (HR)=1.14, 95%CI 1.01-1.29, p=0.038), as well as for achieving low viral load (HR=1.51, 95%CI 1.24-1.83, p<0.001) and positive IgG antibody (HR=1.50, 95%CI 1.31-1.70, p<0.001). Early remdesivir treatment was associated with a lower risk of in-hospital death (HR=0.58, 95%CI 0.34-0.99, p=0.045), in addition to a significantly shorter length of hospital stay (difference -2.56 days, 95%CI -4.86 to -0.26, p=0.029), without increasing the risks of composite outcomes for clinical deterioration.ConclusionsEarly remdesivir treatment could be extended to hospitalized patients presenting with moderate COVID-19 and not requiring oxygen therapy on admission.

Association between previous anticoagulant use and mortality among hospitalized patients with COVID-19.

Although COVID-19 disease primarily affects the respiratory system, it has been seen in many studies that it causes thromboembolic (TE) events in many tissues and organs. So that, to prevent TE can reduce mortality and morbidity. In this context, this study aimed to investigate the relationship between the previous use of warfarin or other new direct oral anticoagulants (OAC) and mortality in patients hospitalized with a diagnosis of COVID-19 before hospitalization. A total of 5575 patients who were diagnosed with COVID-19 were hospitalized and started treatment between March 21 and November 30, 2020 were included in the study. The primary outcome was in-hospital all-cause mortality. A retrospective cohort study design was planned. Patients were followed up until death or censoring on November 30, 2020. The candidate predictors for primary outcome should be clinically and biologically plausible, and their relationships with all-cause death should be demonstrated in previous studies. We considered all candidate predictors included in the model in accordance with these principles. The main candidate predictor was previous OAC use. The primary analysis method was to compare the time to deaths of patients using and not using previous OAC by a multivariable Cox proportional hazard model (CPHM). In the CPHM, previous OAC use was found to be associated with a significantly lower mortality risk (adjusted hazard ratio 0.62, 95% CI 0.42–0.92, p = 0.030). In hospitalized COVID-19 patients, in patients who previously used anticoagulantswas associated with lower risk of in-hospital death than in those who did not.

Association Between Dexamethasone and Delirium in Critically Ill Patients: A Retrospective Cohort Study of a Large Clinical Database

BackgroundDelirium is a common complication in intensive care unit (ICU) patients, and it can significantly increase the length of hospital stay and cost. Dexamethasone is widely used in various inflammatory diseases and must be used with caution in critically ill patients. Previous studies have shown that the effect of corticosteroid use on the development of delirium in critically ill patients is still controversial, and there is inconclusive conclusion about the effect of dexamethasone on delirium in such patients. Therefore, this study aimed to confirm the effect of dexamethasone use and the dose on the incidence of delirium and patient prognosis in critically ill patients through a large cohort study. MethodsA retrospective cohort study was conducted using data extracted from the Medical Information Mart for Intensive Care III database, which is a large and freely available database of all 46,476 patients who visited Beth Israel Deaconess Medical Center in Boston, Massachusetts, USA and were admitted to the ICU between 2001 and 2012. The primary outcome was the development of delirium, using multivariate logistic regression analysis to reveal the relationship between dexamethasone and delirium. Secondary endpoints were in-hospital mortality, ICU mortality, total length of stay, and length of ICU stay, and the relationship between dexamethasone and prognosis was assessed with Cox proportional hazards models. Propensity score matching with 1:1 grouping was used to eliminate the effect of confounders on both cohorts. The locally weighted scatter plot smoothing technique was used to investigate the dose correlation between dexamethasone and outcomes, subgroup analysis was used to account for heterogeneity, and different correction models and propensity matching analysis were used to eliminate potential confounders. ResultsFinally, 38,509 patients were included, and 2204 (5.7%) used dexamethasone. No significant statistical difference was observed in basic demographic information after propensity score matching between the two study groups. A significantly higher incidence of delirium (5.0% versus 3.4%, P < 0.001), increased in-hospital mortality (14.9% versus 10.3%, P < 0.001), ICU mortality (9.0% versus 7.5%, P = 0.008), and longer length of stay and ICU stay were observed in patients taking dexamethasone compared with those not taking dexamethasone. Multivariate logistic and Cox regression analyses confirmed that dexamethasone was significantly associated with delirium (adjusted odds ratio = 1.48, 95% confidence interval [CI] = 1.09-2.00, P = 0.012), in-hospital mortality (adjusted hazard ratio = 1.19, 95% CI = 1.02-1.40, P = 0.032), and ICU mortality (adjusted hazard ratio = 1.62, 95% CI = 1.22-2.15, P = 0.001). Compared with critically ill patients using high-dose dexamethasone, the risk of delirium was lower in the dose less than the 10 mg group, and patients using 10-14 mg may be associated with a lower risk of in-hospital death and the least ICU mortality, length of hospital stay, and ICU stay. ConclusionsThis study demonstrated that the use of dexamethasone in critically ill patients exacerbated the occurrence of delirium while increasing the risk of in-hospital death, ICU death, and length of hospital stay, with a lower risk of delirium and a shorter total length of hospital stay with low-dose dexamethasone than with larger doses.

Assessment of fluid resuscitation on time to hemodynamic stability in obese patients with septic shock.

Assess time to hemodynamic stability (HDS) in obese patients with septic shock who received <30 vs. ≥30ml/kg of initial fluid resuscitation based on actual body weight (ABW). Multicenter, retrospective, cohort analysis of 322 patients. Overall 216 (67%) patients received <30ml/kg of initial fluid resuscitation. Initial fluid received was lower in the <30ml/kg vs. ≥30ml/kg group (16 vs. 37ml/kg). The ≥30ml/kg group had shorter time to HDS (multivariable p=0.038) and lower riskof in-hospital death (multivariable p=0.038). An exploratory subgroup analysis (n=227) was performed, classifying patients by dosing strategy [ABW, adjusted body weight (AdjBW), ideal body weight (IBW)] based on fluid received at 3h divided by 30ml/kg. ABW dosed patients had a shorter time to HDS (multivariable p=0.013) and lower risk of in-hospital death (multivariable p=0.008) vs. IBW. Similar outcomes were observed between ABW vs. AdjBW. Obese patients given ≥30ml/kg based on ABW had a shorter time to HDS and a lower risk of in-hospital death. Exploratory results suggest improved outcomes resuscitating by ABW vs. IBW; ABW showed no strong benefit over AdjBW. Further prospective studies are needed to confirm the optimal fluid dosing in obese patients.