Low Risk Of Short-term Mortality Research Articles

Nonspecific stress biomarkers for mortality prediction in older emergency department patients presenting with falls: a prospective multicenter observational study.

Older patients presenting to the emergency department (ED) after falling are increasingly prevalent. Falls are associated with functional decline and death. Biomarkers predicting short-term mortality might facilitate decisions regarding resource allocation and disposition. D-dimer levels are used to rule out thromboembolic disease, while copeptin and adrenomedullin (MR-proADM) may be used as measures of the patient`s stress level. These nonspecific biomarkers were selected as potential predictors for mortality. Prospective, international, multicenter, cross-sectional observation was performed in two tertiary and two regional hospitals in Germany and Switzerland. Patients aged 65years or older presenting to the ED after a fall were enrolled. Demographic data, Activities of Daily Living (ADL), and D-dimers were collected upon presentation. Copeptin and MR-proADM levels were determined from frozen samples. Primary outcome was 30-day mortality; and secondary outcomes were mortality at 90, 180, and 365days. Five hundred and seventy-two patients were included. Median age was 83 [IQR 78, 89] years, 236 (67.7%) were female. Mortality overall was 3.1% (30d), 5.4% (90d), 7.5% (180d), and 13.8% (365d), respectively. Non-survivors were older, had a lower ADL index and higher levels of all three biomarkers. Elevated levels of MR-proADM and D-dimer were associated with higher risk of mortality. MR-proADM and D-dimer showed high sensitivity and low negative likelihood ratio regarding short-term mortality, whereas copeptin did not. D-dimer and MR-proADM levels might be useful as prognostic markers in older patients presenting to the ED after a fall, by identifying patients at low risk of short-term mortality. ClinicalTrials.gov Identifier: NCT02244983.

Impact of early administration of beta-blocker and RAS inhibitor during VA-ECMO treatment for cardiogenic shock; the post-hoc study of the EARLY-UNLOAD trial

Abstract Funding Acknowledgements None. Background/introduction No data about timing and impact of beta-blocker (BB) or renin-angiotensin-aldosterone system inhibitor (RASi) administration for cardiogenic shock (CS) treated with venoatrial extracorporeal membrane oxygenation (VA-ECMO). Purpose To analyze an impact of early administration of BB or RASi during VA-ECMO treatment. Methods This study is a post-hoc analysis of the EARLY-UNLOAD trial (NCT04775472), the trial evaluated an impact of an early prophylactic unloading strategy using left atrial cannulation (LAC) performed within 12 hours from the initiation of VA-ECMO treatment for CS. Among total population (N=116), patients whose lactate was normalized during VA-ECMO and survived more than 2 days were included in this analysis (N=103). Patients were classified whether each medication (BB, RASi or one of BB or RASi) was administered during VA-ECMO or not. The primary endpoint was all-cause mortality. Survival analysis for a primary outcome and landmark analysis for all-cause mortality during different periods (<10 days, 10 to 30 days) were performed. Results BB, RASi, and BB or RASi were administered in 71.8%, 72.8%, and 83.5% of patients, respectively, during VA-ECMO treatment. In early treatment groups, Both BB and RASi were initiated on day 1 (as median). Duration of VA-ECMO treatment was longer in a group who treated with BB during VA-ECMO (8.5 days, vs 5.0 days as median, P = 0.003), and for RASi, it was comparable (8.0 days vs 7.0 days, P = 0.609). Incidence of 30-day all-cause mortality at were statistically comparable between groups (figure 1). The results of survival analysis are described in the figure 2. In Kaplan-Meier analysis, BB, RASi, and BB or RASi during VA-ECMO treatment was not associated with lower probability of 30-day all-cause mortality. Landmark analysis, however, showed lower probability of 10-day mortality in the group treated with BB (P by log-rank test = 0.045), RASi (P = 0.008) and BB or RASi (P=0.005) during VA-ECMO. Multivariate Cox proportional modellings also provided lower risk of 10-day all-cause mortality in groups with BB treatment (Hazard ratio [HR] = 0.26, 95% confidence interval [CI]=0.10-0.69, P = 0.007), RASi treatment (HR = 0.22, 95% CI = 0.08-0.56, P = 0.001) or BB or RASi (HR = 0.15, 95% CI = 0.05-0.41, P < 0.001) during VA-ECMO. RASi (HR = 0.47, 95% CI = 0.22-0.97, P = 0.041) or BB or RASi (HR = 0.37, 95% CI = 0.15-0.93, P = 0.038) treatment during VA-ECMO was also associated with lower risk of 30-day all-cause mortality. Conclusions In this post-hoc analysis of the EARLY-UNLOAD trial, administration of BB or RASi during VA-ECMO treatment for CS was associated with lower risk of short-term mortality.

Septic Shock Short-Term Outcomes in Patients With Psychiatric Disorders: Analysis From the National Inpatient Sample Database.

Major psychiatric disorders are associated with lower life expectancy primarily due to comorbid illnesses and suboptimal access to health care. Large-scale contemporary data in the United States on in-hospital mortality of patients with major psychiatric disorder and sepsis are lacking. To describe the short-term outcomes of hospitalized patients with major psychiatric disorders and septic shock. We performed a retrospective cohort study using the National Inpatient Sample database from 2016 to 2019 to identify septic shock hospitalizations in patients with versus without major psychiatric disorder (defined as schizophrenia and affective disorders). Baseline variables and in-hospital mortality trends were compared between the 2 groups. Out of 1,653,255 hospitalizations with septic shock identified between 2016 and 2019, 16.2% had a diagnosis of major psychiatric disorder as defined above. After adjusting for various patient-level and hospital-level demographics and coexisting clinical conditions in a multivariable logistic regression, the odds of in-hospital mortality in patients with any major psychiatric disorder were 0.71 times that of those without a diagnosis of psychiatric illness (95% confidence interval [CI], 0.69-0.73; P < 0.001). Similarly, when the disorders were divided into 2 categories for subanalysis, those with schizophrenia had 38% lower odds of dying compared to those without schizophrenia (adjusted odds ratio, 0.62; 95% CI, 0.58-0.66; P < 0.001). Those with affective disorders had 25% lower odds of in-hospital mortality than those without a diagnosis of an affective disorder (adjusted odds ratio, 0.75; 95% CI, 0.73-0.77; P < 0.001). The adjusted mean length of stay for those diagnosed with major psychiatric disorder was 0.38 days longer than those without significant psychiatric illness (95% CI, 0.28-0.49; P < 0.001). On the other hand, the mean hospitalization charges were $10,516 less for patients with a major psychiatric disorder compared to those without (95% CI, -$11,830 to -$9,201; P < 0.001). Hospitalized patients with major psychiatric disorder and septic shock had lower risk of short-term mortality. Further studies are needed to examine the reasons behind this lower in-hospital mortality risk.

Hemoptysis as the presenting manifestation of bronchiectasis-associated hospitalization in Korea.

Patients with bronchiectasis commonly experience disease exacerbations, which cause significant morbidity and mortality. However, data regarding the clinical features of bronchiectasis patients hospitalized with hemoptysis are scarce. We retrospectively collected the data of patients with bronchiectasis-associated hospitalization at a tertiary referral center in Korea, and classified them into the hemoptysis and infective exacerbation (IE) groups. The presence of hemoptysis was defined as a volume of expectorated blood larger than 10 mL per 24 hours. The clinical, radiological, and laboratory parameters were compared between the two groups. Patients were classified into the hemoptysis [267 (54.5%)] and IE [223 (45.5%)] groups. Among the 44 patients of the hemoptysis group, 37 (84.1%) presented with hemoptysis than with IE at the recurrent episode. The hemoptysis group had a significantly lower 30-day mortality than that of the IE group. Previous pulmonary tuberculosis (TB), mycetoma, and bronchial artery hypertrophy were independently associated with the hemoptysis group. In contrast, male sex, poor performance status, colonization of Pseudomonas aeruginosa, ≥3 involved lobes, cystic bronchiectasis, and emphysema were inversely associated with the hemoptysis group. The absence of hemoptysis was one of the independent predictors of 30-day mortality in patients with bronchiectasis-associated hospitalization. In Korea, bronchiectasis patients hospitalized with hemoptysis exhibit a distinct phenotype, and are more likely to have previous pulmonary TB, mycetoma, and bronchial artery hypertrophy. Hemoptysis is associated with a lower risk of short-term mortality compared to IE in bronchiectasis-associated hospitalization.

SHORT- AND LONG-TERM MORTALITY RISK OF TOTAL HIP ARTHROPLASTY IN OBESE PATIENTS: DOES IT CONSTITUTE THA CONTRAINDICATION?

Osteoarthritis (OA) of the hip is the most common indication for total hip replacement (THR). Obesity is a risk factor for the development of OA and has recently resulted in patients requiring THRs at much younger ages to relieve pain at the joint capsule and restore mobility. However, the impact of obesity on THR mortality is not well understood.An updated systematic review was performed to identify whether an obese BMI should influence patient selection for surgery. Specifically, the impact of obesity on short-term mortality, long-term mortality, and peri- and post-operative complications was assessed with a particular focus on BMI classes.A comprehensive literature search of Ovid Medline and EMBASE in November 2022 identified relevant papers in accordance with PRISMA methodology. After removing duplicates, 2988 articles underwent strict inclusion and exclusion criteria, resulting in 12 papers for analysis.There was no statistically significant difference in mortality risk between obese and non-obese populations. Obesity was associated with a lower risk of short-term mortality than in the normal weight control group, however there was an increased mortality risk in obese patients long-term likely due to comorbidities. Obese patients were significantly younger than normal BMI and underweight patients. However, the paper found increased mortality risk in underweight and morbidly obese patients.Obese patients did not have an increased risk of mortality when compared to non-obese patients following THR. Obesity may have a protective effect on mortality up to a BMI of 40kg/m2, although this may be influenced by the obesity paradox which states only the healthiest obese individuals are selected for surgery, which could attribute to a lower mortality risk. The greatest risk of mortality and complication was associated with underweight patients. As a result, a BMI greater than 30kg/m2 may not necessitate a hip replacement contraindication. It is important surgeons apply careful consideration and comprehensive risk assessment on patients who require a THR, especially at the BMI extremes.

Survivorship after reverse total shoulder arthroplasty and predictors of 1-year and overall mortality.

Patient survivorship and risk factors of mortality after reverse total shoulder arthroplasty (RTSA) are seldom and inadequately studied. The purpose of this study was to evaluate the mortality rates and predictors of 1-year and overall mortality after RTSA. We retrospectively reviewed 1518 consecutive adult patients who underwent RTSA at our institution. The Social Security Death Index and institutional electronic medical records were queried to verify patient living status. Patients were censored at date of death if deceased, the date that living status was verified if alive, or latest follow-up if living status could not be verified. Mortality rates and risk factors of 1-year and overall mortality after RTSA were identified on univariate and multivariate analysis. Mean follow-up was 5.1±3.8 years. Thirty-day (0.1%), 90-day (0.7%), and 1-year (1.8%) mortality rates were low but increased to 11% at 5 years. Increased odds of 1-year mortality were independently associated with heart disease (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.07-6.50, P=.035) and use of a cemented stem (OR 2.64, 95% CI 1.04-6.69, P=.041). Independent risk factors of overall mortality included older age at surgery (hazard ratio [HR] 1.05, 95% CI 1.03-1.07, P<.001), minority ethnicity (protective risk factor, HR 0.37, 95% CI 0.15-0.91, P=.031), heart disease (HR 1.42, 95% CI 1.00-2.02, P=.048), diabetes mellitus (HR 1.47, 95% CI 1.04-2.08, P=.028), tobacco use (HR 1.79, 95% CI 1.08-2.98, P=.025), post renal transplant (HR 12.69, 95% CI 3.92-41.05, P<.001), chronic liver failure (HR 4.40, 95% CI 1.38-14.09, P=.013), and receiving a cemented stem (HR 1.60, 95% CI 1.13-2.26, P=.008). RTSA carries a low risk of short-term mortality postoperatively. When counseling patients preoperatively, surgeons should consider the predictors of mortality after RTSA reported herein to ensure appropriate patient selection and counseling.

1199: ASSOCIATION OF SUBSTANCE USE DISORDERS WITH SHORT-TERM MORTALITY IN SEPSIS

Introduction: Substance use disorders (SUD) are associated with increased risk of sepsis compared to the general population and may be expected to adversely affect sepsis outcomes. Recent studies have suggested lower risk of death among septic patients with opioid use disorder-related hospitalizations. However, the prognostic impact of the full spectrum of SUD, irrespective of its relationship to admission diagnoses, among septic patients has not been well-characterized. Methods: We used a statewide dataset to identify hospitalizations aged ≥18 years with sepsis in Texas during 2014-2017. Sepsis was defined by “explicit” ICD-9 and ICD-10 codes for severe sepsis (995.92, R65.20) and septic shock (785.52, R65.21). SUD was defined by the ICD code-based Clinical Classification Software category 661. A hierarchical, mixed-effects model was fit to estimate the association of SUD with short-term mortality (defined as in-hospital death or discharge to hospice) among sepsis hospitalizations. Sensitivity analyses of sepsis hospitalization aged ≥65 years, those with septic shock, and those with ICU admission were performed using similar modeling approach. Results: Among 283,025 sepsis hospitalizations, 22,789 (8.1%) had SUD. Compared to sepsis hospitalizations without SUD, those with SUD were younger (aged ≥65 years 32.7% vs 58.8%), less commonly racial/ethnic minority (46.4% vs 48.1%), and with lower burden chronic illness (mean [SD] Charlson Comorbidity Index (2.6 [2.5] vs 2.7 [2.4]) [p< 0.001 for all comparisons]. Short-term mortality among sepsis hospitalizations with and without SUD was 24.0% vs 31.9%. On adjusted analysis, SUD remained associated with lower risk of short-term mortality (adjusted odds ratio [aOR] 0.66 [95% CI 0.64-0.69]). The lower risk of short-term mortality in SUD patients remained on sensitivity analyses of sepsis hospitalizations aged ≥65 years (aOR 0.61 [95% CI 0.57-0.64]), those with septic shock (aOR 0.68 [95% CI 0.65-0.71]), and ICU admission (aOR 0.66 [95% CI 0.62-0.70]). Conclusions: SUD were associated, unexpectedly, with markedly lower risk of short-term mortality among sepsis hospitalizations, including older patients and across escalating illness severity. Further studies are needed to explore the mechanisms of the apparent “protective” association of SUD in sepsis.

A Meta-Analysis on the Impact of High BMI in Patients Undergoing Transcatheter Aortic Valve Replacement.

A paradoxical association of obesity with lower risk of transcatheter aortic valve replacement (TAVR) outcomes has been reported. We aimed to systematically review the literature and compare TAVR-related morbidity and mortality among individuals with overweight or obesity and their peers with normal body mass index (BMI). PubMed and Embase databases were systematically searched for studies reporting TAVR outcomes in different BMI groups. Separate meta-analyses were conducted for studies reporting hazard ratios (HR) and odds ratios/relative risks. Short- and mid-/long-term outcomes were examined. 26 studies with a total of 74,163 patients were included in our study. Overweight was associated with lower risk of short-term mortality (HR: 0.77; 95% CI: 0.60-0.98) and mid-/long-term mortality (HR: 0.79; 95% CI: 0.70-0.89). Obesity was associated with lower risk for mid-/long-term mortality (HR: 0.79; 95% CI: 0.73-0.86), but no difference was observed in short-term mortality, although a trend was noted (HR: 0.87l 95% CI: 0.74-1.01). Individuals with obesity demonstrated an association with higher odds of major vascular complications (OR: 1.33; 95% CI: 1.05-1.68). Both overweight (OR: 1.16; 95% CI: 1.03-1.30) and obesity (OR: 1.26; 95% CI: 1.06-1.50) were associated with higher likelihood for receiving permanent pacemakers after TAVR. Individuals with overweight and obesity were associated with lower mortality risk compared to those with normal BMI but with higher likelihood of major vascular complications and permanent pacemaker implantation after TAVR.

Meta-Analysis Comparing Venoarterial Extracorporeal Membrane Oxygenation With or Without Impella in Patients With Cardiogenic Shock

Cardiogenic shock is associated with high short-term mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a mechanical circulatory support strategy for patients with refractory cardiogenic shock. A drawback of this hemodynamic support strategy is increased left ventricular (LV) afterload, which is mitigated by concomitant use of Impella (extracorporeal membrane oxygenation with Impella [ECPELLA]). However, data regarding the benefits of this approach are limited. We conducted a systematic search of Medline, EMBASE, and Cochrane databases to identify studies including patients with cardiogenic shock reporting clinical outcomes with Impella plus VA-ECMO compared with VA-ECMO alone. Primary outcome was short-term all-cause mortality (in-hospital or 30-day mortality). Secondary outcomes included major bleeding, hemolysis, continuous renal replacement therapy, weaning from mechanical circulatory support, limb ischemia, and transition to destination therapy with LV assist device (LVAD) or cardiac transplant. Of 2,790 citations, 7 observational studies were included. Of 1,054 patients with cardiogenic shock, 391 were supported with ECPELLA (37%). Compared with patients on only VA-ECMO support, patients with ECPELLA had a lower risk of short-term mortality (risk ratio [RR] 0.89 [0.80 to 0.99], I2=0%, p=0.04) and were significantly more likely to receive a heart transplant/LVAD (RR 2.03 [1.44 to 2.87], I2=0%, p <0.01). However, patients with ECPELLA had a higher risk of hemolysis (RR 2.03 [1.60 to 2.57], I2=0%, p <0.001), renal failure requiring continuous renal replacement therapy (RR 1.46 [1.23 to 174], I2=11%, p <0.0001), and limb ischemia (RR 1.67 [1.15 to 2.43], I2=0%, p=0.01). In conclusion, among patients with cardiogenic shock requiring VA-ECMO support, concurrent LV unloading with Impella had a lower likelihood of short-term mortality and a higher likelihood of progression to durable LVAD or heart transplant. However, patients supported with ECPELLA had higher rates of hemolysis, limb ischemia, and renal failure requiring continuous renal replacement therapy. Future prospective randomized are needed to define the optimal treatment strategy in this high-risk cohort.

Efficacy of different anticoagulant doses for patients with COVID-19: a systematic review and network meta-analysis.

PurposeAs no reported randomized control trials (RCTs) directly compare the three administration doses of anticoagulants (prophylactic dose, treatment dose, and no treatment), the most recommended dose to be administered to patients with coronavirus disease 2019 (COVID-19) remains unclear. The purpose of this study was to examine the effects of anticoagulant doses administered to patients with COVID-19, using a network meta-analysis (NMA) including high-quality studies.MethodsAll eligible trials from the Cochrane Central Register of Controlled Trials, MEDLINE, and Clinicaltrials.gov were included. We included RCTs and observational studies adjusted for covariates for patients aged ≥ 18 years and hospitalized due to objectively confirmed COVID-19. The main study outcome was mortality.ResultsIn patients with moderate COVID-19, the prophylactic (relative risk (RR) 0.64 [95% confidence interval (CI) 0.52–0.80]) and treatment dose (RR 0.57 [95% CI 0.45–0.72] were associated with a lower risk of short-term mortality than that with no anticoagulant treatment. However, the prophylactic and treatment dose groups were not significantly different. The hierarchy for efficacy in reducing short-term mortality was treatment dose (P score 92.4) > prophylactic dose (57.6) > no treatment (0.0). In patients with severe COVID-19, due to the absence of trials with the no-treatment group, NMA could not be conducted. However, pairwise comparison did not show a significant difference between the prophylactic and treatment dose groups.ConclusionsTreatment and prophylactic doses of anticoagulants showed similar effects on mortality; however, the treatment dose is preferred over the prophylactic dose for patients with both moderate and severe COVID-19.Trial registration number and registration datesPROSPERO (registration number: CRD42021245308, 05/21/2021).Supplementary InformationThe online version contains supplementary material available at 10.1007/s15010-022-01809-8.

Impact of history of mental disorders on short-term mortality among hospitalized patients with sepsis: A population-based cohort study.

BackgroundMental disorders are associated with markedly reduced life expectancy, in part due to an increased risk of death due to infection, likely reflecting sepsis-associated mortality. Patients with mental disorders are at an increased risk of sepsis, but data on the prognostic impact of mental disorders in sepsis are sparse, showing conflicting findings.MethodsWe used statewide data to identify hospitalizations aged ≥18 years with sepsis in Texas during 2014–2017. Mental disorders, including mood, anxiety, psychosis, and personality disorders were identified using Clinical Classification Software codes. Multilevel, multivariable logistic regression with propensity adjustment (primary model), with propensity score matching, and multivariable logistic regression as alternative models, were used to estimate the association between mental disorders and short-term mortality (defined as in-hospital mortality or discharge to hospice). Additional models were fitted for sensitivity analyses and to estimate the prognostic associations of individual categories of mental disorders.ResultsAmong 283,025 hospitalizations with sepsis, 56,904 (20.1%) had mental disorders. Hospitalizations with vs without mental disorders were younger (age 18–44 years 12.2% vs 10.6%), more commonly white (61.0% vs 49.8%), with lower burden of comorbidities (mean [SD] Deyo comorbidity index 2.53 [2.27] vs 2.73 [2.47]), and with lower need for organ support (mechanical ventilation 32.8% vs 36.0%); p<0.0001 for all comparisons. Crude short-term mortality among sepsis hospitalizations with and without mental disorders was 25.0% vs 32.8%, respectively. On adjusted analyses, mental disorders remained associated with lower odds of short-term mortality (adjusted odds ratio 0.792 [95% CI 0.772–0.812]). This finding was consistent on the alternative modeling approaches, sensitivity analyses, and examination of individual categories of mental disorders.ConclusionsMental disorders were associated, unexpectedly, with markedly lower risk of short-term mortality in sepsis. Further studies to examine the mechanisms underlying these findings may inform future efforts to improve sepsis outcomes.

Prognostic significance of intra-aortic balloon pumping support in patients with acute myocardial infarction and veno-arterial extracorporeal membrane oxygenation therapy

BackgroundThe prognostic significance of combining intra-aortic balloon pumping (IABP) with extracorporeal membrane oxygenation (ECMO) for acute myocardial infarction (AMI) patients is still unclear. We investigated whether combining IABP with veno-arterial (VA)-ECMO is associated with a lower risk of short-term mortality. MethodsAmong 12,093 AMI cases enrolled in the Osaka Acute Coronary Insufficiency Study (OACIS), we identified 519 who were administered VA-ECMO during hospitalization. Among these, 459 received IABP support (IABP group) and 60 cases did not (no-IABP group). The primary endpoint was 30-day all-cause death; the secondary endpoint was major bleeding. Logistic regression analysis using original data was conducted. We also established weighted logistic regression models with inverse probability of treatment weighting (IPTW). ResultsLogistic regression analysis revealed that IABP use was significantly associated with a reduced risk of 30-day death in the original data [odds ratio (OR) 0.504, 95% confidence interval (CI) 0.282–0.901, p = 0.021]. After IPTW-adjustment for clinically relevant covariates with the use of IABP, patients receiving VA-ECMO with IABP had a lower risk of 30-day death (OR 0.816, 95% CI 0.746–0.892, p < 0.001) compared to those without IABP. The incidence of major bleeding was comparable between the groups (IABP 29.0% vs. non-IABP 21.7%, p=0.302). However, the risk of major bleeding was higher in the IABP group after IPTW-adjustment (OR 1.092, 95% CI 1.008-1.184, p=0.032). ConclusionsIABP support for AMI patients with VA-ECMO was significantly associated with reduced risk of short-term mortality, suggesting that the addition of IABP support might contribute to improved survival in AMI patients requiring VA-ECMO.

373 Emergency Physicians Can Safely Treat and Release Selected Influenza, Pneumonia and Pyelonephritis Patients With Sepsis

Some patients (pts) with “sepsis”, as classically defined, are nonetheless “treated and released” (Tx/Rel) from the emergency department (ED). [“Sepsis” means at least 2 “SIRS” criteria with an infectious diagnosis (dx)]. Careful ED physicians (EDPs) probably use “physician gestalt” to identify septic pts for this strategy. Prior peer-reviewed outcomes studies of septic pts have included only those hospitalized. Thus, no peer-reviewed literature exists to support an ED “Tx/Rel” strategy for any septic pts. We tested the hypothesis that the 95% CI for 7-day (d) mortality of septic pts Tx/Rel from the ED with a dx of pneumonia (PNEU), influenza (INF) pyelonephritis (PYELO), Urinary Tract Infection (UTI) or undifferentiated sepsis (SEP) includes 0%. We tracked the short term outcomes (STO) of 7-d & 30-d mortality, & 7-d & 30-d returns for ED care. Search of the Social Security Death Index verified a lack of short-term (<30 d) mortality among pts who did not return to our ED for any subsequent care. SIRS scores, not qSOFA scores, plus one of these 5 infectious dx, were used to identify the study group with sepsis, because qSOFA score is a prognostic tool, validated in an Intensive Care Unit (ICU) setting, & because a valid prognostic study requires all pts to have a correct dx upon study entry. Thus, qSOFA is a tool unsuitable for identifying septic pts in the ED, because: 1) Use of qSOFA for diagnostic purposes would require “circular reasoning” & 2) An ED environment differs from ICUs where qSOFA was validated. *Between 1/1/2017 and 12/31/2018, 2677 patients were Tx/Rel from a busy tertiary hospital ED (2018 pt volume 59,788) with a dx of PNEU, INFL, PYELO, UTI or SEP. Of these, 1067 patients were “SIRS-positive” at ED arrival. *The 7-d and 30-d mortality of these 1067 pts was zero (95% CI 0-0.28%). Thus, these pts were safely Tx/Rel. 4/1067 returned to the ED within 30d for an unrelated reason. 17/1067 returned with a chief complaint (CC) apparently related to the 1st visit, but without evidence of decline of clinical status; 13/17 within 7d. All 17 were again Tx/Rel. 23/1067 pts returned to the ED within 30d due to evidence of decline or failure to improve as expected, of whom 1 returned beyond 7d. All 23 had a change in the therapeutic plan implemented, such as administration of oxygen and/or change of antibiotic. 13/23 were admitted to hospital at time of the 2nd ED visit, none to an ICU, & 12/13 within 7d. 10/23 were again Tx/Rel. Characteristics (Age, Sex, Dx, SIRS & qSOFA scores of those 23 with objective evidence of need to return to the ED will be presented at the Forum. Only 9/1067 SIRS+ pts had initial qSOFA scores of 2 or 3. ED physicians can safely Tx/Rel selected septic patients, apparently via “physician gestalt,” with very low risk of short-term mortality. Occasionally, septic pts Tx/Rel from an ED will deteriorate or fail to improve after discharge, demonstrating a need for clear “ED return precautions.”

Artificial liver treatment improves survival in patients with hepatitis B virus-related acute-on-chronic liver failure: A case-control matched analysis.

The artificial liver support system (ALSS) is recognized as a bridge to liver transplantation in hepatitisB virus-related acute-on-chronic liver failure (HBV-ACLF) patients. However, patient survival remains unknown. We aim to assess the effects of ALSS on survival in HBV-ACLF patients. The clinical data of HBV-ACLF patients receiving standard medical treatment (SMT) plus ALSS (ALSS group, n = 507) or only SMT (SMT group, n = 417) were collected for survival assessment. The main end-points were cumulative survival rates at days21, 28, and 90. Four different rigorous analyses were carried out to reduce bias and confounding. In the entire cohort, the cumulative survival rates at days21, 28, and 90 were significantly higher in patients who underwent ALSS treatment (73.3% vs. 59.6%, 69.2% vs. 56.6%, 56.5% vs. 49.1%, respectively, P < 0.01) than in those who underwent SMT only. In the 276-pair case-control matched cohort, a significantly higher survival rate was also observed in the ALSS group than in the SMT group on days21, 28, and 90 (72.5% vs. 60.3%, 68.3% vs. 57.4%, 55.9% vs. 48.5%, respectively, P < 0.05), especially in patients with ACLF-1 and -2. By a multivariable-adjusted analysis, ALSS treatment was associated with a significantly lower risk of mortality, especially for ACLF-2 at days21, 28, and 90. These findings were also confirmed through propensity score matching and inverse probability treatment weighting analysis. ALSS treatment can improve short-term survival and is associated with a significantly lower risk of short-term mortality in patients with HBV-ACLF, especially ACLF-2.

Long-term outcomes in patients with decompensated alcohol-related liver disease, steatohepatitis and Maddrey's discriminant function

Patients with alcoholic hepatitis and a modified Maddrey's discriminant function (mDF) <32 have a low risk of short-term mortality. However, few data exist concerning long-term outcomes. The aims of this study were to evaluate 5-year survival rates and to identify predictive factors for long-term prognosis in this patient population. We studied patients from 2 centers who were admitted for hepatic decompensation (ascites, hepatic encephalopathy, or jaundice) and who had histological findings of steatohepatitis and an mDF <32. Clinical and biological parameters were recorded at the time of liver biopsy and alcohol consumption was recorded during follow-up. We performed Cox proportional hazard survival analysis to identify factors associated with 5-year survival. One hundred and twenty-one patients were included (male: 64%, mean age: 51.5 ± 10.3 years, presence of cirrhosis: 84%). The median model for end-stage liver disease and mDF scores were 14 (IQR 11.7-16.1) and 19 (IQR 11.1-24), respectively. During follow-up, 30% of the patients remained abstinent. Survival rates at 1, 6, 12, 24, and 60 months were 96.7 ± 1.6%, 90.1 ± 2.7%, 80.8 ± 3.6%, 69.9 ± 4.3%, and 50.7 ± 4.9%, respectively. The majority of deaths (80%) were liver related. In multivariable analysis, encephalopathy at baseline and alcohol abstinence were predictive of 5-year survival. The 5-year survival rates of patients without and with encephalopathy at baseline were 60.5 ± 5.8% and 29.7 ± 8.0%, respectively, and the 5-year survival rates of abstinent and non-abstinent patients were 74.0 ± 8.0% and 40.9 ± 5.8%, respectively. The mortality rate of patients with alcoholic hepatitis and an mDF <32 is around 50% at 5 years. Hepatic encephalopathy at baseline and lack of alcohol abstinence impair long-term prognosis. New treatment strategies, including measures to ensure abstinence, are required. Patients with alcoholic hepatitis that is of intermediate severity have a low risk of short-term mortality but not much is known regarding long-term outcomes for these patients. This study clearly indicates that patients with intermediate disease characteristics have poor long-term outcomes. The presence of hepatic encephalopathy at the time of diagnosis and the absence of alcohol abstinence during follow-up are factors that predict poor long-term mortality.

Artificial Liver Treatment Improves Survival in Patients with Acute-on-Chronic Liver Failure

Background: The artificial liver support system (ALSS) is recognized as a bridge to liver transplantation (LT) in hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) patients; however, its impact on patient survival remains unknown. This study aimed to assess the effects of ALSS on survival in patients with HBV-ACLF. Methods: The clinical data of HBV-ACLF patients receiving standard medical treatment (SMT) plus ALSS (ALSS group, n = 507) or only SMT (SMT group, n = 417) were collected for survival assessment. The main endpoints were cumulative survival rates at days 21, 28 and 90. A case-control matched analysis was used to reduce bias between the ALSS and SMT groups. A propensity score matching (PSM) and inverse probability treatment weighting (IPTW) analysis were performed to confirm the survival effect of ALSS. Findings: In the entire cohort, the cumulative survival rates at days 21, 28 and 90 were significantly higher in patients who underwent ALSS treatment (73.3% vs. 59.6%, 69.2% vs. 56.6%, 56.5% vs. 49.1%, respectively, P <0.01) than in those who underwent SMT only. In the 276-pair case-control matched cohort, a significantly higher survival rate was also observed in the ALSS group than in the SMT group on days 21, 28 and 90 (72.5% vs. 60.3%, 68.3% vs. 57.4%, 55.9% vs. 48.5%, respectively, P <0.05), especially in patients with ACLF-1 and -2. By a multivariable-adjusted analysis, ALSS treatment was associated with a significantly lower risk of mortality, especially for ACLF-2 at days 21, 28 and 90 (HR: 0.587, 0.596 and 0.640, respectively). These findings were also confirmed through PSM and IPTW analysis (HR: 0.482/0.538 and 0.538/0.552 at day 21/28, respectively, P <0.01). Interpretation: Compared with SMT, ALSS treatment improved the short-term survival and was associated with a significantly lower risk of short-term mortality in patients with HBV-ACLF, especially ACLF-2. Funding Statement: The authors declared: None. Declaration of Interests: The authors stated: No conflict. Ethics Approval Statement: The study protocol was approved by the Clinical Research Ethics Committee of the First Affiliated Hospital, Zhejiang University School of Medicine (No. 2011-13). All patients were well informed, and written consent was obtained from the study subjects or the legal surrogates of patients before enrolment.

Venous thromboembolism in young adults: Findings from the RIETE registry

Little is known on the clinical characteristics, risk factors and outcomes during anticoagulation in young patients with acute venous thromboembolism (VTE). We used data from the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry to assess the clinical characteristics, risk factors and outcomes during anticoagulation in VTE patients aged 10-24 years. Data were separately analyzed according to initial presentation and gender. Of 76,719 patients with VTE, 1571 (2.0%) were aged 10-24 years. Of these, 989 (63%) were women and 669 (43%) presented with pulmonary embolism (PE). Most women were using estrogens (680, 69%) or were pregnant (101, 10%), while 59% of men had unprovoked VTE. Women were more likely to present with PE (48% vs. 34%). The majority (87%) of PE patients had Sat O2 levels ≥90% at baseline. The vast majority (97%) of PE patients were at low risk according to the PESI score, many (90%) at very low risk. During the course of anticoagulation (median, 192 days), 40 patients had VTE recurrences, 17 had major bleeding and 10 died (3 died of PE). Women had as many VTE recurrences as major bleeds (15 vs. 14 events), while men had many more VTE recurrences than major bleeding (25 vs. 3 events). VTE is associated with low risk of short-term mortality in young adults. Noticeable gender differences exist in the risk factor profile and the risk of VTE recurrences and major bleeding in the course of anticoagulation.

Prognostic value of new-onset right bundle-branch block in acute myocardial infarction patients: a systematic review and meta-analysis.

BackgroundPatients with acute myocardial infarction (AMI) and bundle-branch block have poor prognoses. The new European Society of Cardiology guideline suggests a primary percutaneous coronary intervention strategy when persistent ischemic symptoms occur in patients with persistent ischemic symptoms and right bundle-branch block (RBBB), but the level of evidence is not high. In fact, the presence of RBBB may lead to the misdiagnosis of transmural ischemia and mask the early diagnosis of ST-elevation myocardial infarction. Moreover, new-onset RBBB is occasionally caused by AMI. Our study aims to investigate the prognostic value of new-onset RBBB in AMI.Methods and ResultsWe conducted a meta-analysis of studies to evaluate the prognostic value of RBBB in AMI patients. Of 914 primary records, five studies and 874 MI patients were included for meta-analysis. Compared with previous RBBB, AMI patients with new-onset RBBB had a higher risk of long-term mortality (RR, 1.66, 95% CI [1.31–2.09], I2 = 0.0%, p = 0.000, n = 2), ventricular arrhythmia (RR, 4.86, 95% CI [2.10–11.27], I2 = 0.0%, p = 0.000, n = 3), and cardiogenic shock (RR, 2.76, 95% CI [1.66–4.59], I2 = 0.0%, p = 0.000, n = 3), but a lower risk of heart failure (RR, 0.66, 95% CI [0.52–0.85], I2 = 2.50%, p = 0.001, n = 4). Compared with AMI patients with new-onset permanent RBBB, patients with new-onset transient RBBB had a lower risk of short-term mortality (RR, 0.20, 95% CI [0.11–0.37], I2 = 44.1%, p = 0.000, n = 4).ConclusionNew-onset RBBB is likely to increase long-term mortality, ventricular arrhythmia, and cardiogenic shock, but not heart failure in AMI patients. AMI patients with new-onset transient RBBB have a lower risk of short-term mortality than those with new-onset permanent RBBB. Revascularization therapies should be considered when persistent ischemic symptoms occur in patients with RBBB, especially new-onset RBBB.

Derivation and validation of a novel prediction model to identify low-risk patients with acute pulmonary embolism

Accurate identification of low-risk patients with acute pulmonary embolism (PE) who may be eligible for outpatient treatment or early discharge can have substantial cost-saving benefit. The purpose of this study was to derive and validate a prediction model to effectively identify patients with PE at low risk of short-term mortality, right ventricular dysfunction, and other nonfatal outcomes. This study analyzed data from 400 consecutive patients with acute PE. We derived and internally validated our prediction rule based on clinically significant variables that are routinely available at initial examination and that were categorized and weighted using coefficients in the multivariate logistic regression. The model was externally validated in an independent cohort of 82 patients. The final model (HOPPE score) consisted of 5 categorized patient variables (1, 2, or 3 points, respectively): systolic blood pressure (>120, 100 to 119, 80, 65 to 79, 101 beats/min), arterial partial pressure of oxygen (>80, 60 to 79, 4). The 30-day mortality rates were 0% in low risk (0 to 6 points), 7.5% to 8.5% in intermediate risk (7 to 10), and 18.2% to 18.8% in high-risk patients (≥11) across the derivation and validation cohorts. In comparison with the previously validated PESI score, the HOPPE score had a higher discriminatory power (area under the curve 0.74 vs 0.85, p = 0.033) and significantly improved both the discrimination (integrated discrimination improvement, p = 0.002) and reclassification (net reclassification improvement, p = 0.003) of the model for short-term mortality. In conclusion, the HOPPE score accurately identifies acute patients with PE at low risk of short-term mortality, right ventricular dysfunction, and other nonfatal outcomes. Prospective validation of the prediction model is necessary before implementation in clinical practice.

Derivation and Validation of a Novel Prediction Model to Identify Low-Risk Patients With Acute Pulmonary Embolism

Accurate identification of low-risk patients with acute pulmonary embolism (PE) who may be eligible for outpatient treatment or early discharge can have substantial cost-saving benefit. The purpose of this study was to derive and validate a prediction model to effectively identify patients with PE at low risk of short-term mortality, right ventricular dysfunction, and other nonfatal outcomes. This study analyzed data from 400 consecutive patients with acute PE. We derived and internally validated our prediction rule based on clinically significant variables that are routinely available at initial examination and that were categorized and weighted using coefficients in the multivariate logistic regression. The model was externally validated in an independent cohort of 82 patients. The final model (HOPPE score) consisted of 5 categorized patient variables (1, 2, or 3 points, respectively): systolic blood pressure (>120, 100 to 119, <99 mm Hg), diastolic blood pressure (>80, 65 to 79, <64 mm Hg), heart rate (<80, 81 to 100, >101 beats/min), arterial partial pressure of oxygen (>80, 60 to 79, <59 mm Hg), and modified electrocardiographic score (<2, 2 to 4, >4). The 30-day mortality rates were 0% in low risk (0 to 6 points), 7.5% to 8.5% in intermediate risk (7 to 10), and 18.2% to 18.8% in high-risk patients (≥11) across the derivation and validation cohorts. In comparison with the previously validated PESI score, the HOPPE score had a higher discriminatory power (area under the curve 0.74 vs 0.85, p= 0.033) and significantly improved both the discrimination (integrated discrimination improvement, p= 0.002) and reclassification (net reclassification improvement, p= 0.003) of the model for short-term mortality. In conclusion, the HOPPE score accurately identifies acute patients with PE at low risk of short-term mortality, right ventricular dysfunction, and other nonfatal outcomes. Prospective validation of the prediction model is necessary before implementation in clinical practice.