Mortality Risk Score Research Articles

Comparison of 5 acute pulmonary embolism mortality risk scores in patients with COVID-19.

ObjectivePulmonary embolism (PE) is a common complication of SARS-CoV-2 infection. We aimed to explore the short-term outcomes among patients with acute PE and COVID-19 and to further determine and compare the performance of the different prognostic scores (PESI, sPESI, BOVA, FAST and ESC scores) for risk-stratification in this scenario.MethodsRetrospective single-centre study of 85 patients with SARS-CoV-2 infection and PE admitted to the Emergency Department (ED). The diagnostic accuracy of each above-mentioned prognostic score was calculated post hoc, and their discriminative power was evaluated through an AUC curve.ResultsAmong the 85 patients, all-cause death occurred within 7 days for 6 patients (7.1%) and within 30 days for 14 patients (16.5%). Despite being older and having a higher percentage of altered mental status on presentation, non-survivors patients did not differ from survivors regarding comorbidities, traditional risk factors for venous thromboembolism and signs and symptoms at the ED presentation.Each risk stratification tool had modest discriminative power for 7-day mortality (AUC range, 0.601–0.730) with slightly lower discrimination for 30-day mortality (AUC range, 0.543–0.638). The pair-wise comparison of ROC curves showed that PESI had better predictive value for short-term mortality than ESC score (z test = 3.92, p = 0.001) and sPESI (z test = 2.43, p = 0.015); there is no significant difference between PESI and BOVA score (z test = 1.05, p = 0.295) and FAST score (z test = 0.986, p = 0.324).ConclusionThe most common risk-stratification tools for PE had modest discriminative power to predict short-term mortality in patients with acute PE and COVID-19.

A simple risk score for mortality including the PCR Ct value upon admission in patients hospitalized due to COVID-19.

PurposeTo develop a simple score for the outcomes from COVID-19 that integrates information obtained at the time of admission including the Ct value (cycle threshold) for SARS-CoV-2.MethodsPatients with COVID-19 hospitalized from February 1st to May 31st 2021 in RoMed hospitals, Germany, were included. Clinical and laboratory parameters upon admission were recorded and patients followed until discharge or death. Logistic regression analysis was used to determine predictors of outcomes. Regression coefficients were used to develop a risk score for death.ResultsOf 289 patients (46% female, median age 66 years), 29% underwent high-flow nasal oxygen (HFNO) therapy, 28% were admitted to the Intensive Care Unit (ICU, 51% put on invasive ventilation, IV), and 15% died. Age > 70 years, oxygen saturation ≤ 90%, oxygen supply upon admission, eGFR ≤ 60 ml/min and Ct value ≤ 26 were significant (p < 0.05 each) predictors for death, to which 2, 2, 1, 1 and 2 score points, respectively, could be attributed. Sum scores of ≥ 4 or ≥ 5 points were associated with a sensitivity of 95.0% or 82.5%, and a specificity of 72.5% or 81.7% regarding death. The high predictive value of the score was confirmed using data obtained between December 15th 2020 and January 31st 2021 (n = 215).ConclusionIn COVID-19 patients, a simple scoring system based on data available shortly after hospital admission including the Ct value had a high predictive value for death. The score may also be useful to estimate the likelihood for required interventions at an early stage.Supplementary InformationThe online version contains supplementary material available at 10.1007/s15010-022-01783-1.

Development and validation of gender specific risk models in prediction of mortality for hospitalized heart failure patients in a multiethnic asian population

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Heart failure carries substantial morbidity and mortality. Female has different characteristics compared to male which may affect prognosis and are not represented well in many trials. Multiple risk scores for in-hospital mortality have been created and validated such as ADHERE (Acute Decompensated Heart Failure National Registry) and GWTG (Get With The Guidelines). However, these risk scores were in Western population and not gender specific. Purpose To develop and validate a gender specific risk model in predicting mortality amongst Asian patients admitted for acute decompensated heart failure (ADHF). Methods We analyzed data from our national centre’s ADHF registry. Epidemiological, clinical, laboratory and imaging variables were ascertained. Univariate and multivariate analysis using forward stepwise logistic regression were performed to identify predictors for all-cause in hospital mortality with emphasis on disparities between male and female. The accuracy of risk score was assessed using the concordance statistics while calibration was done using the Hosmer-Lemeshow method. The validity of the risk score was determined using separate gender validation cohorts. Results A total of 10148 patients admitted for ADHF were analyzed. 8262 patients admitted for ADHF from January 2009 to December 2018 (6008 males and 2254 females) were in the derivation cohort where as 1886 patients (1304 males and 582 females) were selected randomly from January 2019 to July 2021 for our validation cohort. Female had better survival (p value =0.04). There were 8 predictive variables for female cohort and 10 predictive variables for male cohort. Similar variables were low systolic blood pressure, loop diuretic use, dialysis, mechanical ventilation and CPR (cardiopulmonary resuscitation). Interestingly, there were significant differences. For female, other variables that had impact on mortality were hypertension (AOR, 0.23; 95% CI,0.09–0.58), high urea (AOR, 3.32; 95% CI, 1.36–8.09) and hyponatremia (AOR, 2.87, 95% CI, 1.21–6.78). However for male, the variables were renal insufficiency (AOR, 1.749; 95% CI, 1.13–2.72), history of stroke (AOR, 2.386, 95% CI, 1.22–4.65), LVEF less than 40% (AOR, 2.81; 95% CI, 1.40–5.63), absence of ARB/ACEi (AOR, 2.31; 95% CI, 1.48–3.60) and absence of beta blockers (AOR, 2.65; 95% CI, 1.73–4.05). The AUC for the female derivation cohort was 0.97 (95% CI, 0.95–0.99) and 0.94 (95% CI, 0.92–0.96) for male derivation cohort. AUC in the female validation cohort was 0.91 (95% CI, 0.83-0.98) and male was 0.90 (95% CI, 0.84–0.97). The risk scores showed good calibration (female; x²=8.88, p = 0.18 and male; x²=13.11, p = 0.07). Conclusion A gender specific risk score for ADHF was developed and validated successfully in our Asian population. This will change our practice in providing valuable prognostic information in both female and male thereby guiding the need for more intensive treatment. Abstract Figure. ROC Curves (Female and Male) Abstract Figure. Key Variables (Female and Male)

Dolutegravir/rilpivirine 2-drug regimen comparable to commonly prescribed 3-drug regimens up to 18-months in a real-world setting

Background This study compared the effectiveness and durability of DTG/RPV with commonly prescribed 3-drug regimens (3-DR) in people living with HIV (PLWH) in a real-world setting. Methods Antiretroviral therapy (ART)-experienced, virologically suppressed PLWH who initiated DTG/RPV or a 3-DR in 2018 were identified in the OPERA® database and followed through 6/30/2019. Virologic failure (two consecutive viral loads (VL) ≥ 200 copies/mL or single VL ≥ 200 copies/mL with regimen modification/discontinuation) and maintained virologic suppression (last VL test &lt; 50 or &lt; 200 copies/mL) were described. Kaplan–Meier methods were used to estimate time to virologic failure and treatment discontinuation. Risk of virologic failure was adjusted for age, sex, race/ethnicity, risk of infection, region, baseline CD4 cell count, history of substance abuse or syphilis, and mortality risk score at baseline in a Cox model. Results PLWH initiating DTG/RPV were older and more likely to be Hispanic or have comorbidities than 3-DR initiators. DTG/RPV users experienced fewer discontinuations (15%) and were more likely to be suppressed at study end (98%) than 3-DR users (28% and 96%, respectively). Virologic failure was uncommon; rates per 100 person-years did not differ between the DTG/RPV (1.45, 95% CI: 0.69, 3.03) and 3-DR (2.63, 95% CI: 2.21, 3.14) groups. The risk of virologic failure did not differ significantly between the groups in adjusted Cox models (adjusted hazard ratio 1.32, 95% CI: 0.61, 2.89). Conclusions The findings of this real-world OPERA® study suggest that DTG/RPV can be a viable alternative to standard 3-DRs for ART-experienced, virologically suppressed PLWH.

Prognostic Value of the Pattern of Non-Adherence to Anti-Platelet Regimen in Stented Patients (PARIS) Bleeding Risk Score for Long-Term Mortality After Percutaneous Coronary Intervention.

The Patterns of non-Adherence to Anti-Platelet Regimen in Stented Patients (PARIS) bleeding risk score has been proposed to predict the risk of bleeding events after percutaneous coronary intervention (PCI). However, the prognostic value of the PARIS bleeding risk score for long term all-cause mortality, cardiac mortality and hospitalization due to heart failure has not yet been evaluated. Therefore, the aim of the present study was to evaluate the prognostic value of the PARIS bleeding risk score for all-cause and cardiac mortalities and hospitalization due to heart failure after PCI. Consecutive 1061 patients who had undergone PCI were divided into 3 groups based on the PARIS bleeding risk score; low (n = 112), intermediate (n = 419) and high-risk groups (n = 530). We prospectively followed up the 3 groups for all-cause and cardiac mortalities and hospitalization due to heart failure. Kaplan-Meier analysis revealed that all of the outcomes were highest in the high-risk group among the 3 groups (P < 0.001, P < 0.001 and P < 0.001 respectively). Multivariable Cox proportional hazard analysis, adjusted for confounding factors, revealed that all-cause mortality of the intermediate or high-risk groups was higher than those of the low-risk group (adjusted hazard ratio 6.06 and 12.50, P = 0.013 and P < 0.001, respectively). The PARIS bleeding risk score is a significant indicator of prognosis for all-cause mortality in patients after PCI.

Concurrent Validity and Prognostic Utility of the Needs Assessment Tool: Progressive Disease Heart Failure

ContextPeople with advanced heart failure have supportive and palliative needs requiring systematic assessment. ObjectivesWe aimed to assess the validity of the Needs Assessment Tool: Progressive Disease – Heart Failure (NAT:PD-HF). MethodsSecondary analysis of routinely collected patient data from a specialist palliative care-heart disease service improvement project. NAT:PD-HF, the Integrated Palliative care Outcome Scale (IPOS), and patient and/or carer-report data were collected. Concurrent validity between NAT:PD-HF items and comparison measures (Kendall's tau; kappa); construct validity via known-group comparisons; predictive utility of NAT:PD-HF for survival (multivariable Cox hazard regression model). ResultsData from 88 patients (50% men; mean age 85; median survival 205 days; 64% left ventricular systolic dysfunction) were analyzed. Prevalence- and bias-adjusted kappa values indicated moderate agreement for physical symptom needs (k: 0.33 for patients, 0.42 for carers). Substantial agreement was observed for patient and/or carer psychological symptoms, and information needs (k ≥ 0.6). NAT:PD-HF distinguished between patients with different survival, comorbidities, functional scores, and palliative Phase of Illness with moderate to high effect sizes. NAT did not predict survival when adjusted for mortality risk score and functional status (2+ needs HR: 1.52, 95% CI: 1.01-1.74). ConclusionThe NAT:PD-HF is a valid tool for clinician assessment of physical, psychosocial, and information patient and/or carer needs.

Shape of the association between preoperative hemoglobin level and postoperative outcomes in patients undergoing primary arthroplasty.

Background:The shape of the association between preoperative hemoglobin level and outcomes after primary arthroplasty has not been adequately described. This study aimed to characterize the association between preoperative hemoglobin level and important outcomes after primary hip and knee arthroplasty and how this association is influenced by other key confounders.Methods:Using de-identified, population-based health administrative data for Ontario housed at ICES, we identified all primary hip and knee arthroplasty procedures performed in Ontario between April 2007 and March 2017. Preoperative hemoglobin level, age, sex, Charlson Comorbidity Index score, American Society of Anesthesiologists score, preadmission living status, Hospital-patient One-year Mortality Risk (HOMR) score, and serum sodium and creatinine levels were extracted. All relevant postoperative outcomes that could be measured accurately were identified. We performed multivariable logistic regression and restricted cubic splines analyses.Results:A total of 188 176 patients clustered within 532 surgeons were studied. The adjusted likelihood of transfusion increased notably and progressively when the preoperative hemoglobin level was below 135 g/L; duration of surgery, patient age and HOMR score amplified this association. Risk of postoperative admission to critical care showed a linear association with preoperative hemoglobin level. Risks of unplanned 30-day emergency department visit, 30-day readmission and 1-year all-cause mortality showed curvilinear associations with baseline hemoglobin level, with risks being notably greater as the level deviated from 137 g/L to 141 g/L.Conclusion:Preoperative hemoglobin levels, both high and low, were independently significantly associated with primary arthroplasty outcomes, and levels at which outcome risks started to increase exceeded threshold values commonly used to define “normal.” Preoperative hemoglobin level should be considered in future bundled payment models that aim to account for case-mix when grading postarthroplasty outcomes.

An individualized algorithm to predict mortality in COVID-19 pneumonia: a machine learning based study.

IntroductionIdentifying SARS-CoV-2 patients at higher risk of mortality is crucial in the management of a pandemic. Artificial intelligence techniques allow one to analyze large amounts of data to find hidden patterns. We aimed to develop and validate a mortality score at admission for COVID-19 based on high-level machine learning.Material and methodsWe conducted a retrospective cohort study on hospitalized adult COVID-19 patients between March and December 2020. The primary outcome was in-hospital mortality. A machine learning approach based on vital parameters, laboratory values and demographic features was applied to develop different models. Then, a feature importance analysis was performed to reduce the number of variables included in the model, to develop a risk score with good overall performance, that was finally evaluated in terms of discrimination and calibration capabilities. All results underwent cross-validation.Results1,135 consecutive patients (median age 70 years, 64% male) were enrolled, 48 patients were excluded, and the cohort was randomly divided into training (760) and test (327) groups. During hospitalization, 251 (22%) patients died. After feature selection, the best performing classifier was random forest (AUC 0.88 ±0.03). Based on the relative importance of each variable, a pragmatic score was developed, showing good performances (AUC 0.85 ±0.025), and three levels were defined that correlated well with in-hospital mortality.ConclusionsMachine learning techniques were applied in order to develop an accurate in-hospital mortality risk score for COVID-19 based on ten variables. The application of the proposed score has utility in clinical settings to guide the management and prognostication of COVID-19 patients.

Epigenetic biomarkers of ageing are predictive of mortality risk in a longitudinal clinical cohort of individuals diagnosed with oropharyngeal cancer

BackgroundEpigenetic clocks are biomarkers of ageing derived from DNA methylation levels at a subset of CpG sites. The difference between age predicted by these clocks and chronological age, termed “epigenetic age acceleration”, has been shown to predict age-related disease and mortality. We aimed to assess the prognostic value of epigenetic age acceleration and a DNA methylation-based mortality risk score with all-cause mortality in a prospective clinical cohort of individuals with head and neck cancer: Head and Neck 5000. We investigated two markers of intrinsic epigenetic age acceleration (IEAAHorvath and IEAAHannum), one marker of extrinsic epigenetic age acceleration (EEAA), one optimised to predict physiological dysregulation (AgeAccelPheno), one optimised to predict lifespan (AgeAccelGrim) and a DNA methylation-based predictor of mortality (ZhangScore). Cox regression models were first used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for associations of epigenetic age acceleration with all-cause mortality in people with oropharyngeal cancer (n = 408; 105 deaths). The added prognostic value of epigenetic markers compared to a clinical model including age, sex, TNM stage and HPV status was then evaluated.ResultsIEAAHannum and AgeAccelGrim were associated with mortality risk after adjustment for clinical and lifestyle factors (HRs per standard deviation [SD] increase in age acceleration = 1.30 [95% CI 1.07, 1.57; p = 0.007] and 1.40 [95% CI 1.06, 1.83; p = 0.016], respectively). There was weak evidence that the addition of AgeAccelGrim to the clinical model improved 3-year mortality prediction (area under the receiver operating characteristic curve: 0.80 vs. 0.77; p value for difference = 0.069).ConclusionIn the setting of a large, clinical cohort of individuals with head and neck cancer, our study demonstrates the potential of epigenetic markers of ageing to enhance survival prediction in people with oropharyngeal cancer, beyond established prognostic factors. Our findings have potential uses in both clinical and non-clinical contexts: to aid treatment planning and improve patient stratification.

Effect and Blood Flow Parameters of Biomaterials-Based Endovascular Interventional Embolization and Craniotomy Clipping in the Treatment of Cerebral Aneurysms.

Objective: The effects of interventional embolization and craniotomy clipping on the treatment of intracranial aneurysms were investigated in this study, as well as their influence on the hemodynamics of postoperative patients. Methods: 102 patients with intracranial aneurysms were selected as the research objects, and they were rolled into an experimental (group A) and a control group (group B) according to the random number table method, with 51 cases in each group. The group A was treated with intravascular interventional embolization, and the group B received craniotomy clipping. Besides, a biodegradable magnesium titanium alloy biological stent was independently developed in this study, which was applied to endovascular interventional embolization in the group A. The hemodynamic model was established by using three-dimensional (3D) computer hemodynamic numerical simulation technology. Besides, the effects of all the patients before and after treatment were evaluated, in terms of blood pressure (BP), average wall shear stress (WSS) (AWSS), AWSS gradient (AWSSG), oscillatory shear index (OSI), aneurysm formation index (AFI), gradient oscillation number (GON), and intraoperative complication rate. Results: After 3 days of treatment, the BP, AWSS, and AWSSG of patients from the two groups were higher than those before treatment. The index values of the group A were greater markedly than the values of the group B (P < 0.05); the BP of the group A and the group B at the 0th day, 1st day, 3rd day, 5th day, and 7th day after treatment was 21±5.1 Versus 20.1±4.7, 22±4.8 Versus 21.1± 5.17, 26±6.2 Versus 22.31±5.21, 27±5.77 Versus 24.02±5.11, and 30±6.09 Versus 24.99±5.03, respectively; AWSSG values were 120±10.11 Versus 120.1±10.98, 130.1±10.36 Versus 123.3±11.06, 162.5±9.92 Versus 131.31±10.97, 171±8.13 Versus 155.02±8.36, and 200.1±7.22 Versus 180.01±8.98 in turn. GON and OSI were both decreased, and the values of various indexes in the group A were sharply lower than those of the group B (P < 0.05); the values of GON at the 0th day, 1st day, 3rd day, 5th day, and 7th day after treatment in the group A and the group B were 0.077±0.01 Versus 0.08±0.011, 0.07±0.012 Versus 0.073 ± 0.01, 0.051 ± 0.02 Versus 0.071 ± 0.011, 0.045 ± 0.01 Versus 0.069 ± 0.011, and 0.042 ± 0.012 Versus 0.063±0.013, respectively; OSI values were 4.8±0.51 Versus 4.9±0.52, 3.6±0.52 Versus 3.62±0.51, 2.82±0.51 Versus 3.1 ± 0.57, 1.9 ± 0.512 Versus 2.91 ± 0.51, and 0.5 ± 0.51 Versus 1.8 ± 0.501 in turn. By comparing the intraoperative complications and postoperative mortality risk score (MRS) of patients in the two groups, it was found that the incidence of intraoperative complications and postoperative MRS scores in the group A were lower steeply than those of the group B, suggesting that endovascular interventional embolization had a better effect on the treatment of intracranial aneurysms. Conclusion: Endovascular interventional embolization based on biodegradable magnesium alloy coated scaffold could better improve the distribution of shear stress on the vascular wall, stabilize vascular blood flow, and achieve better therapeutic effect for patients.

NUTRITIONAL SUPPORT IN GERIATRIC PATIENTS IN INTENSIVE CARE: THE RELATIONSHIPS BETWEEN PREALBUMIN, ALBUMIN AND TOTAL PROTEIN LEVELS AND THE ROUTE OF NUTRITION ADMINISTRATION

Background: Adequate nutrition for geriatric elderly patients hospitalized in the intensive care unit (ICU) is of great importance. Objective: This study included critically-ill patients hospitalized in the ICU and aimed to determine the relationships between nutritional status, patient severity and the time-bound changes in various parameters known to be associated with malnutrition. Methods: The study was conducted by retrospectively examining the files of 112 patients (63 women and 49 men) who received inpatient treatment in the ICU of Bartın State Hospital for at least 21 days. Results: Apache II score (p=0.001), mortality risk score (p=0.003), intermittent nutrition (p = 0.046), low energy intake on day 7 (p=0.008), total protein level on day 30 (p=0.016), prealbumin level on day 21 (p=0.021), the change in prealbumin level from the 1st to the 21st day (p&lt;0.001), and CRP level on day 30 (p=0.025) were significantly different between the groups. Multivariate analysis performed with these variables revealed that the change in prealbumin level from the 1st to the 21st day was the only parameter to be independently associated with length of stay (p=0.003). Conclusions: In geriatric elderly patients admitted to the ICU, it was observed that albumin and total protein values did not change significantly during feeding, whereas prealbumin levels increased significantly on the 21st day compared to the 1st day. Keywords: Nutritionists; Hospitals; Malnutrition; Albumins; Prealbumin.

Is Primary Care Physician Involvement Associated with Earlier Advance Care Planning?: A Study of Patients in an Academic Primary Care Setting.

Background: Advance care planning (ACP) is important to improving end-of-life care. Few studies have examined the impact of primary care physician (PCP) involvement in ACP. Objectives: To determine whether complete ACP, defined as health care proxy (HCP), provider orders for life-sustaining treatment (POLST), and documented goals-of-care (GOC) conversations, would occur earlier when the PCP was involved in POLST and/or GOC conversations. Design: Charts of deceased patients from 2015 to 2017 in a U.S. academic primary care practice were reviewed. Demographic factors, mortality risk scores, palliative care involvement, and visits within the last year of life to PCPs and specialists were collected. Poisson models with robust variance estimators were used to estimate the likelihood of PCP involvement being associated with earlier complete ACP after adjusting for confounders and accounting for clustering by PCP. Due to high rates of HCP documentation at the institution, 10 patients without HCP were excluded from the review. Results: Of 403 decreased patients, 71 (18%) met criteria for complete ACP and 214 (53%) had HCP only; the remaining 118 patients had partial (2/3 components) ACP. Of the 71 patients with complete ACP, 40.1% had ACP earlier than three months of death (early) and 59.2% had ACP within three months of death (late). PCP involvement was associated with early ACP compared with late ACP and HCP only for both PCP completion of the POLST (risk ratio [RR]: 4.7; 95% confidence interval [CI]: 1.3-17.1) and for PCP documentation of GOC conversation (RR: 4.6; 95% CI: 1.2-17.1) after adjustment for clustering by PCP and other relevant variables. Conclusion: This retrospective cohort study suggests that PCP involvement in ACP correlates with earlier completion. This finding highlights the importance of educating and encouraging PCPs on completing ACP with their patients.

Comfort Measures Only in Myocardial Infarction: Prevalence of This Status, Change Over Time, and Predictors From a Nationwide Study.

Patients hospitalized with acute myocardial infarction (AMI) have a high mortality rate. Despite increasing recognition of the role for comfort focused care, little is known about the prevalence of comfort measures only (CMO) care among patients with AMI. The objective of this study was to investigate patient- and hospital-level patterns and predictors of CMO care among patients admitted with AMI. This retrospective cohort study used the National Cardiovascular Data Registry Chest Pain-MI Registry, which contains data on patients admitted with AMI. Data were analyzed in 6-month increments from January 2015 to June 2018. Among 483 696 patients with AMI across 827 hospitals, 13 955 (2.9%) had CMO status at discharge (2.6% non-ST-segment-elevation myocardial infarction and 3.4% ST-segment-elevation myocardial infarction). There was a modest decline in CMO rates over time (3.0% to 2.8%). Independent patient characteristics associated with CMO status included male gender, White race, nonprivate insurance, frailty, and higher estimated bleeding and mortality risks. There was substantial variation in CMO rates across hospitals, with the proportion of CMO patients ranging from 0% to 17.1% and a median odds ratio of 1.59 (95% CI, 1.56-1.62). Among the 13 955 patients who were CMO by discharge, 8134 (58.3%) underwent diagnostic catheterization. This is despite significantly elevated risks predicted using precatheterization models, specifically the ACTION Registry GWTG in-hospital major bleeding and mortality risk scores. Patients who were initially managed invasively but later made CMO experienced high rates of procedural complications, including cardiogenic shock (38.3%), dialysis (10.1%), and bleeding (33.3%). Most patients with AMI who were CMO by discharge had aggressive initial management and became CMO following in-hospital complications of their care. Early identification of high-risk patients and appropriate transition of such patients to CMO, if aligned with their values, remain important areas for future quality programs in AMI.

Usefulness of the SYNTAX Score II to Predict In-Hospital and Long-Term Mortality in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention.

ObjectivesThe prognostic significance of SYNTAX Score II (SS-II) is well-known in patients with chronic coronary syndromes. However, its predictive ability for mortality in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (p-PCI) remains unclear. Therefore, we aimed to investigate the prognostic accuracy of SS-II in STEMI patients who underwent p-PCI.MethodsA total of 743 STEMI patients treated with p-PCI were retrospectively analyzed. Study population was divided into three groups according to SS-II and defined as SS-IILOW ≤22.5 (n=245), 22.5 <SS-II MID ≤31 (n=243) and SS-II HIGH >31 (n=255). In-hospital and long-term mortality at long-term follow-up were defined as clinical endpoints of the study.ResultsThe incidence of in-hospital (15% vs. 0.4% vs. 0.8%, p<0.001) and all-cause mortality (32.2% vs. 6.6% vs. 2.9%, p<0.001) were significantly higher in SS-IIHIGH group compared with the other two groups. In addition, Kaplan–Meier analysis showed statistically significantly increased incidence of death in SS-II > 31 group (P [log-rank] <0.001). SS-II >31 was defined as an independent predictor of all-cause mortality (hazard ratio 5.22 95% confidence interval 2.11–12.87 p<0.001). Area under the curve values derived from ROC analysis to evaluate the predictive accuracy of SS-II, anatomical and clinical SS, modified ACEF score, and Global Registry of Acute Coronary Events risk scores for all-cause mortality were 0.82, 0.71, 0.81, 0.82, and 0.82, respectively (p<0.001).ConclusionSS-II has an increased predictive ability for in-hospital and long-term mortality in STEMI patients undergoing p-PCI.

The MIDA quantitative mortality risk score: Prognostic model in floppy mitral valves

The Mitral-Regurgitation-International-Database (MIDA) score is a validated tool for Degenerative-Mitral-Regurgitation (DMR) management. However, whether this score complemented with DMR quantitation is applicable and incremental over the entire span of Floppy Mitral Valves (FMV), and DMR severity remains unsubstantiated. The MIDA-Quantitative (MIDA-Q) unprecedented registries include 8187 consecutive patients (age 64 ± 17 years, 45% women, follow-up 5.5 ± 3.4 years) with isolated FMV diagnosed at tertiary (European/North-American/Middle East) centers in which DMR quantitative grading was consistently and prospectively performed. The MIDA-Q Score ranged from 0 to 15 depending on accumulating risk factors. Long-term survival overall, under medical management and post-mitral surgery was analyzed. By quantitative grading, MR was no/trivial in 1938 (24%), mild in 1423 (17%), moderate in 2027 (25%) and severe in 2799 (34%), with ERO 0.24 ± 24 cm 2 , RVol 37 ± 35 mL and with posterior leaflet prolapse in 49%. MIDA-Q Scores stratified in 8 categories were 0 (score 0, n = 851), 1 (score 1–2, n = 1301), 2 (score 3–4, n = 2043), 3 (score 5–6, n = 1581), 4 (score 7–8, n = 1273), 5 (score 9–10, n = 718), 6 (score 11–12, n = 331) and 7 (score 13–15, n = 89). In the whole MIDA-Q population ( n = 8187 patients), 5-year survival under medical management with Scores categories 0-1, 2–4, and 5–7 was 96 ± 1%, 73 ± 1%, and 61 ± 3% respectively ( P < 0.0001). After mitral surgery, 1-year mortality with Scores categories 0–1, 2–4, and 5–7 was 0%, 1%, and 6% respectively and 5-year post-operative survival was 99 ± 1%, 94 ± 1%, and 82 ± 2% (all P < 0.0001). In nested models including age, sex and EuroScoreII, the MIDA Score was incrementally, and the MIDA-Q Score further incrementally prognostic for long-term survival ( P < 0.001) ( Fig. 1 ). This very large international cohort demonstrates the strong, independent and incremental predictive power of the MIDA-Q Score for survival after diagnosis of FMV.

Transcatheter Aortic Valve Replacement in Nonagenarians: A Systematic Review and Meta-Analysis.

Nonagenarians represent only a small proportion of patients included in large transcatheter aortic valve replacement (TAVR) trials, but will become a relevant future population in need of treatment due to demographic change. Thus, this study sought to evaluate outcomes of TAVR for the treatment of severe aortic stenosis (AS) in nonagenarian patients. We screened Medline/Pubmed for studies that stated specific outcomes for nonagenarians undergoing TAVR. A weighted meta-analysis was conducted, calculating pooled estimate rates using a binary random-effects model for dichotomous variables, and comparing non-dichotomous outcomes with a continuous random-effects model. Data from 23 studies including 16,094 nonagenarians were merged; 53.4% were women. Despite reasonable rates of comorbidities, Society of Thoracic Surgeons mortality risk score was 10.2 ± 5.4. Pooled estimate rate of procedural success was 94.1% (95% confidence interval [CI], 91.7-96.6), with major vascular complications occurring in 6.3% (95% CI, 2.7-9.8) and at least moderate postprocedural paravalvular leak in 7.5% (95% CI, 4.4-10.6). The rate of periprocedural stroke or transient ischemic attack was 2.6% (95% CI, 2.0-3.2). At 30 days, the pooled estimate of mortality was 6.1% (95% CI, 4.7-7.4) and a permanent pacemaker was implanted in 12.6% (95% CI, 7.6-17.6). After 1 year, the mortality rate was 20.5% (95% CI, 15.9-25.1). TAVR in nonagenarians is an effective and safe procedure, with encouraging outcomes given the general life expectancy of these patients. Currently, only selected nonagenarians are undergoing TAVR, but their number will grow as life expectancy continues to increase in the developed world. Specific research to identify ideal candidates and techniques in this cohort is needed.

Valve-in-Valve Transcatheter Aortic Valve Replacement in a High-Risk Patient with a Biocor Bioprosthesis and a Flail Prosthetic Valve Leaflet

An 80-year-old woman with a history of surgical aortic valve replacement with a 21 mm St. Jude Medical Biocor porcine aortic valve 14 years prior presented with New York Heart Association (NYHA) class III symptoms, severe aortic insufficiency from a degenerated prosthesis, and a large echocardiographic mobile mass representing a highly mobile prosthetic leaflet. The patient worsened to NYHA class IV symptoms despite medical management. The Society of Thoracic Surgery mortality risk score was extremely high. However, a valve-in-valve transcatheter aortic valve replacement (TAVR) was found to be a reasonable option. We used a 20 mm SAPIEN 3 Ultra valve (Edwards Lifesciences Inc., Irvine, CA, USA) with a SENTINEL embolic protection device (Boston Scientific, Marlborough, MA, USA). During valve deployment, the echocardiographic mobile mass was visually pinned between the new TAVR valve and the surgical bioprosthetic valve. No large embolic debris was noted within the embolic protection device, and the patient remained without any new focal neurologic deficits in the perioperative period and at the 30-day follow-up. The severe aortic insufficiency resolved, and the patient clinically improved to NYHA class II symptoms.

Simple scoring system to predict in hospital mortality after surgery for infective endocarditis at the Ibn Rochd university hospital in Casablanca, Morocco

Aspecific scoring systems are used to predict the risk of death postsurgery in patients with infective endocarditis (IE). The purpose of the present study was both to analyze the risk factors for in-hospital death, which complicates surgery for IE, and to create a mortality risk score based on the results of this analysis. Outcomes of 361 consecutive patients (mean age, 59.1 ± 15.4 years) who had undergone surgery at the IBN ROCHD University Hospital in Casablanca, Morocco, and a risk factor analysis (multivariable logistic regression) for in-hospital death was performed. The discriminatory power of a new predictive scoring system was assessed with the receiver operating characteristic curve analysis. Score validation procedures were carried out. Fifty-six (15.5%) patients died postsurgery. BMI > 27 kg/m 2 (odds ratio [OR], 1.79; P = 0.049), estimated glomerular filtration rate < 50 mL/min (OR, 3.52; P < 0.0001), New York Heart Association class IV (OR, 2.11; P = 0.024), systolic pulmonary artery pressure >55 mm Hg (OR, 1.78; P = 0.032), and critical state (OR, 2.37; P = 0.017) were independent predictors of in-hospital death. A scoring system was devised to predict in-hospital death postsurgery for IE (area under the receiver operating characteristic curve, 0.780; 95% CI, 0.734–0.822). The score performed better than 5 of 6 scoring systems for in-hospital death after cardiac surgery that were considered. A simple scoring system based on risk factors for in-hospital death was specifically created to predict mortality risk postsurgery in patients with IE.

Development of a repeated-measures predictive model and clinical risk score for mortality in ventilated COVID-19 patients.

PurposeThe COVID-19 pandemic has caused intensive care units (ICUs) to reach capacities requiring triage. A tool to predict mortality risk in ventilated patients with COVID-19 could inform decision-making and resource allocation, and allow population-level comparisons across institutions.MethodsThis retrospective cohort study included all mechanically ventilated adults with COVID-19 admitted to three tertiary care ICUs in Toronto, Ontario, between 1 March 2020 and 15 December 2020. Generalized estimating equations were used to identify variables predictive of mortality. The primary outcome was the probability of death at three-day intervals from the time of ICU admission (day 0), with risk re-calculation every three days to day 15; the final risk calculation estimated the probability of death at day 15 and beyond. A numerical algorithm was developed from the final model coefficients.ResultsOne hundred twenty-seven patients were eligible for inclusion. Median ICU length of stay was 26.9 (interquartile range, 15.4–52.0) days. Overall mortality was 42%. From day 0 to 15, the variables age, temperature, lactate level, ventilation tidal volume, and vasopressor use significantly predicted mortality. Our final clinical risk score had an area under the receiver-operating characteristics curve of 0.9 (95% confidence interval [CI], 0.8 to 0.9). For every ten-point increase in risk score, the relative increase in the odds of death was approximately 4, with an odds ratio of 4.1 (95% CI, 2.9 to 5.9).ConclusionOur dynamic prediction tool for mortality in ventilated patients with COVID-19 has excellent diagnostic properties. Notwithstanding, external validation is required before widespread implementation.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12630-021-02163-3.

Trained Clinician's Documentation of Serious Illness Conversations and Use of Billing CPT 99497.

Background: Advance care planning (ACP) involves patients and family members in discussions with clinicians about their values, goals, and preferences regarding future medical care. Objectives: To (1) assess whether an ACP conversation using the Serious Illness Conversation (SIC) was initiated and documented; (2) assess which components of SIC were documented; (3) determine how frequently clinicians trained to use the SIC guide used ACP billing codes during the study time period, (4) determine whether there was a significant difference in mortality risk score according to documentation of each component of the SIC. Methods; Thirteen clinicians at three family medicine offices were trained in the Serious Illness Care Program and asked to document SICs in the electronic medical record (EMR). A retrospective chart review of SIC components was conducted in the EMRs of patients who presumably had ACP conversations initiated by the trained clinicians. Patients were identified using the billing codes for ACP conversations and through referrals from another study that requires clinicians to have ACP conversations with their patients. Pearson chi-square test for categorical variables and t-tests for continuous variables were conducted. Results: A total of 157 patients were included in this study; 131 patients referred from another ACP study and an additional 26 patients using the billing codes of ACP conversations. Through retrospective chart review, the mean age of patients was 72 years and 54 were male. Sixty-two (40%) charts had one or more SIC components documented. "Explore key topics" was documented most frequently for 58 (38%) patients by the 13 participating clinicians. Mean mortality risk score was 10.7 and higher scores were significantly correlated with more SIC components documented (rp = 0.217, P = 0.007). Conclusion: Little use of the SIC guide among trained physicians was found in the EMR. It was expected that provision of an EMR template for documenting the SIC would have facilitated documentation of SICs.