In-hospital Mortality Odds Ratio Research Articles

Association between patient and system delays and in-hospital mortality in primary PCI for STEMI: Findings from a large, nationwide inpatients sample

PurposeSystem delay is associated with mortality in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). However, the influence of patient delay has been relatively overlooked. We aimed to evaluate the influence of patient and system delays on STEMI patients undergoing primary PCI in China. MethodsSTEMI patients registered at the Nationwide Chinese Cardiovascular Association Database-Chest Pain Center from January 2017 to September 2021 were screened. The exposures were total ischemic time (TIT), system delay and patient delay. The primary outcome was in-hospital mortality. ResultsAmong 458,260 patients from 2,529 centers, median TIT, system delay and patient delay were 4.1, 1.5 and 2.1 hours, respectively. The adjusted odds ratio of in-hospital mortality increased by 2.2% (odds ratio [OR], 1.022, 95% confidence interval [CI], 1.017-1.027), 2.3% (1.023, 1.006-1.040) and 2.2% (1.022, 1.017-1.027) for every one-hour increase in TIT, system delay and patient delay, respectively. ConclusionsPatient delay demonstrated a comparable impact to system delay on in-hospital mortality among STEMI patients undergoing primary PCI. Widespread primary PCI-capable center, improved awareness about myocardial infarction and regional transfer system are essential to shorten patient delay.

Outcomes of Covid-19 among patients with ischemic heart disease: A propensity matched analysis

BackgroundPrior research has linked cardiovascular diseases with higher COVID-19 mortality and worse hospital outcomes, particularly in severe heart failure. Large population-based data regarding the impact of pre-existing ischemic heart disease (IHD) on COVID-19 outcomes is not well established. ObjectiveTo study the impact of COVID-19 infection on IHD hospital mortality and other outcomes. MethodsThe study included a patient cohort from the 2020 and 2021 National Inpatient Sample (NIS) database. Propensity score matching was used to match the study cohort (COVID-19 with IHD) to controls (COVID-19 without IHD) using a 1:1 matching ratio. The outcomes analyzed were in-hospital mortality, rates of acute kidney injury (AKI), acute myocardial injury (AMI), cardiogenic shock, cardiac arrest, mechanical ventilation, tracheal intubation, pulmonary embolism (PE), ventricular tachycardia (VT), ventricular fibrillation (VF), length of stay (LOS), and total hospitalization charges. ResultsA total of 2,532,652 patients met the inclusion criteria (1,199,008 females [47.3 %), predominantly Caucasian 1,456,203 (57.5 %); mean [SD] age 63, (5.4), including 29,315 (1.1 %) patients with a history of IHD. Following propensity matching, 4,772 COVID-19 patients with and without IHD were matched. IHD patients had higher rates of AMI (adjusted odds ratio (aOR) 3.75, 95 % CI 3.27–4.31, p < 0.001), cardiogenic shock (aOR 2.89, 95 % CI 1.60–5.19, p < 0.001), VT (aOR 3.26, 95 % CI 2.48–4.29, p < 0.001), and VF (aOR 2.23, 95 % CI 1.25–3.99, p < 0.001). The odds ratios of in-hospital mortality, AKI, PE, mechanical ventilation, tracheal intubation, and resource use were not significantly different. ConclusionA history of IHD does not impact COVID-19 mortality but increases the risk of in-hospital cardiac complications.

Inpatient mortality and outcomes of COVID-19 among patients with non-ischemic cardiomyopathy: A propensity matched analysis

BackgroundPatients with chronic medical conditions, particularly cardiovascular diseases, are at a greater risk of adverse outcomes due to COVID-19. The effect of COVID-19 on patients with non-ischemic cardiomyopathy (NICM) is not known well. ObjectivesTo study the impact of COVID-19 infection on NICM hospital mortality and other outcomes. MethodsThis study included a cohort of patients from the 2020 and 2021 National Inpatient Sample databases. Patients hospitalized for COVID-19 with and without NICM were matched using a 1:1 propensity score-matching ratio. Outcomes analyzed were in-hospital mortality, rates of acute kidney injury (AKI), acute myocardial infarction (AMI), cardiogenic shock, cardiac arrest, mechanical ventilation, tracheal intubation, pulmonary embolism (PE), ventricular tachycardia (VT), ventricular fibrillation (VF), length of stay (LOS), and total hospitalization charges. ResultsA total of 2,532,652 patients met the inclusion criteria (1,199,008 females [47.3 %], predominantly white 1,456,203 (57.5 %); mean [SD] age 63 [5.4] years), including 64,155 (2.5 %) patients with a history of NICM. Following propensity matching, 10,258 COVID-19 patients with and without NICM were matched. Patients with NICM had higher rates of AMI (11.1 vs. 7.1 %, p < 0.001), cardiogenic shock (2 vs. 0.6 %, p < 0.001), cardiac arrest (4.4 vs. 3.2 %, p < 0.01), mechanical ventilation (13.7 vs 12 %, p < 0.01), VT (8.5 vs. 2.2 %, p < 0.001), and VF (1.0 vs 0.25 %, p < 0.001). The odds ratios for in-hospital mortality, AKI, and PE did not differ significantly. ConclusionA History of NICM does not affect COVID-19 mortality but increases the risk of cardiovascular complications.

The prevalence, risk factors, and outcomes of acute pulmonary embolism complicating sepsis and septic shock: a national inpatient sample analysis

The study aimed to evaluate the prevalence, risk factors, and clinical outcomes of pulmonary embolism in patients diagnosed with sepsis with and without shock. The National Inpatient Sample was used to identify adults with sepsis with and without shock between 2017 and 2019. The prevalence of acute pulmonary embolism and the association of acute pulmonary embolism with in-hospital mortality, hospital length of stay for survivors, and overall costs of hospitalization were evaluated. Multivariable logistic and linear regression analyses, adjusted for various parameters, were used to explore these associations. Of the estimated 5,019,369 sepsis hospitalizations, 1.2% of patients with sepsis without shock and 2.3% of patients with septic shock developed pulmonary embolism. The odds ratio for in-hospital mortality was 1.94 (95% confidence interval (CI) 1.85–2.03, p < 0.001). The coefficient for hospital length of stay was 3.24 (95% CI 3.03–3.45, p < 0.001). The coefficient for total costs was 46,513 (95% CI 43,079–49,947, p < 0.001). The prevalence of pulmonary embolism in patients diagnosed with sepsis with and without shock was 1.2 and 2.3%, respectively. Acute pulmonary embolism was associated with higher in-hospital mortality, longer hospital length of stay for survivors, and higher overall costs of hospitalization.

Artificial intelligence–based skeletal muscle estimates and outcomes of EUS-guided treatment of pancreatic fluid collections

Background and AimsSkeletal muscle status may impact clinical outcomes of a variety of pancreatic diseases. Skeletal muscle quality and quantity have not been fully examined in relation to the outcomes of endoscopic ultrasound (EUS)-guided treatment of pancreatic fluid collections (PFCs). MethodsUsing a multi-institutional cohort of 372 patients receiving EUS-guided treatment of PFCs in 2010-2020, we examined the association of skeletal muscle status with adverse outcomes including clinical treatment failure and in-hospital mortality. Utilizing an in-house deep learning-based platform for pre-procedural computed tomography images, we calculated skeletal muscle density (SMD) and skeletal muscle index (SMI, height-adjusted muscle area) as surrogates for muscular quality and quantity, respectively. Multivariable logistic regression analysis was conducted to calculate odds ratios (ORs) for adverse outcomes. ResultsLower-level SMD was associated with higher risks of clinical failure and in-hospital mortality (Ptrend < 0.001). The adjusted OR for clinical failure comparing the extreme quartiles was 3.64 (95% confidence interval, 1.52-8.72). Compared with patients in the top two quartiles, patients in the lowest quartile had an adjusted OR for in-hospital mortality of 12.4 (95% confidence interval, 3.43-44.8). We observed no effect modification by the PFC types on the SMD-outcome relationship (Pinteraction > 0.16). SMD was not associated with the risk of procedure-related adverse events or PFC recurrence. SMI was not associated with adverse outcomes (Ptrend > 0.39). ConclusionsIn patients with endoscopically managed PFCs, SMD, but not SMI, was associated with the risks of clinical failure and in-hospital mortality, supporting the prognostic role of skeletal muscle quality.

Complications and Mortality After Surgery in Patients with Chronic Kidney Disease: A Retrospective Cohort Study Based on a Multicenter Clinical Database.

To evaluate the postoperative complications and mortality among patients with chronic kidney disease. Biochemical measurements, diagnosis codes for CKD and comorbid conditions for surgical patients aged ≥20 years were obtained from electronic medical records of three large hospitals in Taiwan in 2009-2017. We conducted this retrospective cohort study by using propensity score-matching methods to balance the baseline characteristics between CKD and non-CKD groups. The multiple logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of risks of primary outcome (included postoperative mortality) and secondary outcome (included postoperative infectious complications and non-infectious complications) associated with CKD. Among 31950 eligible surgical patients, the adjusted OR of in-hospital mortality in patients with CKD was 5.49 (95% CI 3.42-8.81) compared with that in non-CKD controls. The adjusted ORs of postoperative septicemia, pneumonia and cellulitis in patients with CKD were 5.90 (95% CI 2.12-16.5), 5.39 (95% CI 1.37-21.16), and 4.42 (95% CI 1.57-12.4), respectively, when compared with the non-CKD patients. CKD was also associated with postoperative stroke (OR 2.21, 95% CI 1.47-3.31). Patients with CKD are at increased risk of postoperative stroke, infectious complications, and mortality. Our study implicated that it is crucial to improve the levels of hemoglobin and K+ in patients with CKD before surgery. Preventive strategies should be developed to improve clinical outcomes in these populations.

The effect of incremental increases in the number of packed red blood cell units transfused on perioperative outcomes in open abdominal aortic aneurysm repair.

Despite abundant evidence in the surgical and critical care literature demonstrating inferior outcomes in transfused patients, liberal use of blood transfusion, particularly after the initial unit, remains common in vascular surgery. We therefore sought to investigate the incremental risk of each additional unit of blood transfused intraoperatively for patients undergoing elective open repair of abdominal aortic aneurysm (AAA) with regards to postoperative mortality and complications. Patients in the Vascular Quality Initiative registry undergoing elective open infrarenal AAA repair from 2003 to 2020 were included. Exclusion criteria were age greater than 90, prior aortic surgery, concomitant iliac aneurysm, and concomitant additional major procedure. Multivariable logistic regression was used to calculate adjusted odds ratios for in-hospital mortality with incremental increases in packed red blood cells (pRBCs) given intraoperatively. Univariate analysis was performed for secondary outcomes including postoperative cardiac, respiratory, renal, and wound complications. Of 4608 patients who underwent elective open AAA repair, 796 patients (16.9%) underwent perioperative transfusion. The overall in-hospital mortality rate was 2.5%. Adjusting for relevant factors, there was an increase in the odds of in-hospital mortality of 24% for each additional unit transfused. Incremental increases in the number of units transfused were associated with significantly higher risk of postoperative myocardial infarction, congestive heart failure, pulmonary complications, renal failure, and wound complications. There appears to be an important increase in the odds of mortality for each additional unit transfused during infrarenal open AAA repair even when controlling for confounders.

Basic host response parameters to classify mortality risk in COVID-19 and community-acquired pneumonia

Improved phenotyping in pneumonia is necessary to strengthen risk assessment. Via a feasible and multidimensional approach with basic parameters, we aimed to evaluate the effect of host response at admission on severity stratification in COVID-19 and community-acquired pneumonia (CAP). Three COVID-19 and one CAP multicenter cohorts including hospitalized patients were recruited. Three easily available variables reflecting different pathophysiologic mechanisms—immune, inflammation, and respiratory—were selected (absolute lymphocyte count [ALC], C-reactive protein [CRP] and, SpO2/FiO2). In-hospital mortality and intensive care unit (ICU) admission were analyzed as outcomes. A multivariable, penalized maximum likelihood logistic regression was performed with ALC (< 724 lymphocytes/mm3), CRP (> 60 mg/L), and, SpO2/FiO2 (< 450). A total of 1452, 1222 and 462 patients were included in the three COVID-19 and 1292 in the CAP cohort for the analysis. Mortality ranged between 4 and 32% (0 to 3 abnormal biomarkers) and 0–9% in SARS-CoV-2 pneumonia and CAP, respectively. In the first COVID-19 cohort, adjusted for age and sex, we observed an increased odds ratio for in-hospital mortality in COVID-19 with elevated biomarkers altered (OR 1.8, 3, and 6.3 with 1, 2, and 3 abnormal biomarkers, respectively). The model had an AUROC of 0.83. Comparable findings were found for ICU admission, with an AUROC of 0.76. These results were confirmed in the other COVID-19 cohorts Similar OR trends were reported in the CAP cohort; however, results were not statistically significant. Assessing the host response via accessible biomarkers is a simple and rapidly applicable approach for pneumonia.

Case volume and specialization in critically ill emergency patients: a nationwide cohort study in Japanese ICUs.

Previous studies have explored the association between the number of cases and patient outcomes for critical illnesses such as sepsis and trauma, as well as various surgeries, with the expectation that a higher number of cases would have a more favorable effect on patient outcomes. The aim of this study was to elucidate the association among intensive care unit (ICU) case volume, specialization, and patient outcomes in critically ill emergency patients and to determine how ICU case volumes and specializations impact the outcomes of these patients in Japanese ICUs. Utilizing data from the Japanese Intensive Care PAtient Database (JIPAD) from April 2015 to March 2021, this retrospective cohort study was conducted in 80 ICUs across Japan and included 72,214 emergency patients aged ≥ 16years. The primary outcome measure was in-hospital mortality, and the secondary outcomes encompassed ICU mortality, 28-day mortality, ventilator-free days, and the lengths of ICU and hospital stays. Bayesian hierarchical generalized linear mixed models were used to adjust for patient- and ICU-level variables. This study revealed a significant association between a higher ICU case volume and decreased in-hospital mortality. In particular, ICUs with a higher percentage (> 75%) of emergency patients showed more pronounced effects, with the odds ratios for in-hospital mortality in the higher case volume quartiles (Q2, Q3, and Q4) being 0.92 (95% credible interval [CI]: 0.88-0.96), 0.70 (95% CI: 0.67-0.73), and 0.78 (95% CI: 0.73-0.83), respectively, compared with the lowest quartile (Q1). Similar trends were observed for various secondary outcomes. Higher ICU case volumes were significantly associated with lower in-hospital mortality rates in Japanese ICUs predominantly treating critically ill emergency patients. These findings emphasize the importance of ICU specialization and highlight the potential benefits of centralized care for critically ill emergency patients. These findings are potential insights for improving health care policy in Japan and may be valuable in emergency care settings in other countries with similar healthcare systems, after careful consideration of contextual differences.

Contemporary Management of Blunt Splenic Trauma in Adults: An Analysis of the Trauma Quality Improvement Program Registry

PurposeThe aim of this study was to evaluate the effectiveness of management strategies for blunt splenic injuries in adult patients. MethodsPatients 18 years and older with blunt splenic injuries registered via the Trauma Quality Improvement Program (2013-2019) were identified. Management strategies initiated within 24 hours of hospital presentation were classified as watchful waiting, embolization, surgery, or combination therapy. Patients were stratified by injury grade. Linear models estimated each strategy’s effect on hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality. ResultsOf 81,033 included patients, 86.3%, 10.9%, 2.5%, and 0.3% of patients received watchful waiting, surgery, embolization, and combination therapy, respectively. Among patients with low-grade injuries and compared with surgery, embolization was associated with shorter hospital LOS (9.4 days, Q < .001, Cohen’s d = .30) and ICU LOS (5.0 days, Q < .001, Cohen’s d = .44). Among patients with high-grade injuries and compared with surgery, embolization was associated with shorter hospital LOS (8.7 days, Q < .001, Cohen’s d = .12) and ICU LOS (4.5 days, Q < .001, Cohen’s d = .23). Among patients with low- and high-grade injuries, the odds ratios for in-hospital mortality associated with surgery compared with embolization were 4.02 (Q < .001) and 4.38 (Q < .001), respectively. ConclusionsAmong patients presenting with blunt splenic injuries and compared with surgery, embolization was associated with shorter hospital LOS, shorter ICU LOS, and lower risk for mortality.

Effect of early serum phosphate disorder on in-hospital and 28-day mortality in sepsis patients: a retrospective study based on MIMIC-IV database

BackgroundThis study aims to assess the influence of early serum phosphate fluctuation on the short-term prognosis of sepsis patients.MethodsThis retrospective study used the Medical Information Mart for Intensive Care IV database to analyze serum phosphate levels in sepsis patients within 3 days of ICU admission. According to the absolute value of delta serum phosphate (the maximum value minus the minimum value of serum phosphorus measured within three days), the patients were divided into four groups, 0–1.3, 1.4–2.0, 2.1–3.1, and ≥ 3.2 mg/dl. Meanwhile, the direction of delta serum phosphate was compared. With the serum phosphate change group of 0–1.3 mg/dl as the reference group, the relationship between delta serum phosphate and in-hospital mortality and 28-day mortality was analyzed by multivariate Logistics regression analysis.ResultsThe study involved 1375 sepsis patients. Serum phosphate changes (0–1.3, 1.4–2.0, 2.1–3.1, and ≥ 3.2 mg/dl) correlated with in-hospital and 28-day mortality variations (p = 0.005, p = 0.008). Much higher serum phosphate fluctuation elevated in-hospital and 28-day mortality. Compared to the 0–1.3 mg/dl change group, adjusted odds ratios (OR) in other groups for in-hospital mortality were 1.25 (0.86–1.81), 1.28 (0.88–1.86), and 1.63 (1.10–2.43), and for 28-day mortality were 1.21 (0.86–1.72), 1.10 (0.77–1.57), and 1.49 (1.03–2.19). Under the trend of increasing serum phosphate, the ORs of in-hospital mortality and 28-day mortality in ≥ 3.2 mg/dl group were 2.52 and 2.01, respectively.ConclusionIn conclude, the delta serum phosphate ≥ 3.2 mg/dl was associated with in-hospital mortality and 28-day mortality in patients with sepsis.

Non-COVID-19 hospitalization and mortality during the COVID-19 pandemic in Iran: a longitudinal assessment of 41 million people in 2019-2022.

During a COVID-19 pandemic, it is imperative to investigate the outcomes of all non-COVID-19 diseases. This study determines hospital admissions and mortality rates related to non-COVID-19 diseases during the COVID-19 pandemic among 41 million Iranians. This nationwide retrospective study used data from the Iran Health Insurance Organization. From September 23, 2019, to Feb 19, 2022, there were four study periods: pre-pandemic (Sept 23-Feb 19, 2020), first peak (Mar 20-Apr 19, 2020), first year (Feb 20, 2020-Feb 18, 2021), and the second year (Feb 19, 2021-Feb 19, 2022) following the pandemic. Cause-specific hospital admission and in-hospital mortality are the main outcomes analyzed based on age and sex. Negative binomial regression was used to estimate the monthly adjusted Incidence Rate Ratio (IRR) to compare hospital admission rates in aggregated data. A logistic regression was used to estimate the monthly adjusted in-hospital mortality Odds Ratio (OR) for different pandemic periods. During the study there were 6,522,114 non-COVID-19 hospital admissions and 139,679 deaths. Prior to the COVID-19 outbreak, the standardized hospital admission rate per million person-month was 7115.19, which decreased to 2856.35 during the first peak (IRR 0.40, [0.25-0.64]). In-hospital mortality also increased from 20.20 to 31.99 (OR 2.05, [1.97-2.13]). All age and sex groups had decreased admission rates, except for females at productive ages. Two years after the COVID-19 outbreak, the non-COVID-19 hospital admission rate (IRR 1.25, [1.13-1.40]) and mortality rate (OR 1.05, [1.04-1.07]) increased compared to the rates before the pandemic. The respiratory disease admission rate decreased in the first (IRR 0.23, [0.17-0.31]) and second years (IRR 0.35, [0.26-0.47] compared to the rate before the pandemic. There was a significant reduction in hospitalizations for pneumonia (IRR 0.30, [0.21-0.42]), influenza (IRR 0.04, [0.03-0.06]) and COPD (IRR 0.39, [0.23-0.65]) during the second year. There was a significant and continuous rise in the hematological admission rate during the study, reaching 186.99 per million person-month in the second year, reflecting an IRR of 2.84 [2.42-3.33]compared to the pre-pandemic period. The mortality rates of mental disorders (OR 2.15, [1.65-2.78]) and musculoskeletal (OR 1.48, [1.20-1.82), nervous system (OR 1.42, [1.26-1.60]), metabolic (OR 1.99, [1.80-2.19]) and circulatory diseases (OR 1.35, [1.31-1.39]) increased in the second year compare to pre-pandemic. Myocardial infarction (OR 1.33, [1.19-1.49]), heart failure (OR 1.59, [1.35-1.87]) and stroke (OR 1.35, [1.24-1.47]) showed an increase in mortality rates without changes in hospitalization. In the era of COVID-19, the changes seem to have had a long-term effect on non-COVID-19 diseases. Countries should prepare for similar crises in the future to ensure medical services are not suspended.

IDENTIFYING FACTORS THAT WORSEN IN-HOSPITAL OUTCOMES IN PATIENTS WITH VENTRICULAR TACHYCARDIA (VT) AND INFLAMMATORY BOWEL DISEASE (IBD)

Abstract BACKGROUND IBD is a proinflammatory state that can have numerous complications involving all systems of the body. There is a known association with cardiovascular disease. However, there are limited studies that have examined the impact of cardiac arrhythmias such as VT on patients with IBD (Crohn’s Disease and Ulcerative Colitis). The aim of this study was to evaluate the economic burden and various hospital outcomes associated with patients with IBD with and without VT. METHODS Patients aged 18 years with IBD and VT versus IBD alone were identified from the US Nationwide Inpatient Sample (NIS), from the years 2010-2019. ICD 9 and 10 codes were utilized and multivariate regression analysis utilizing propensity matching (Kernel method) was used to estimate the odds ratios of in-hospital mortality, the average length of hospital stay (LOS), and hospital charges (TOTHC), after adjusting for age, gender, race, primary insurance payer status, hospital type and size (number of beds), hospital region, hospital teaching status, and other demographic characteristics. Weighted analysis utilizing Stata 17 MP was performed. RESULTS For patients with Crohn’s disease and depression, mean age at readmission was 51.6 years and there was a high readmission rate and mortality at 30 days (readmission rate 5.2%, p&amp;lt;0.01 and mortality rate 2.8%, p&amp;lt;0.01) which increased significantly at 90 days (readmission rate 8.4%, p&amp;lt;0.01). Hospital LOS and TOCHG remained relatively the same compared to the index admission for both 30 day and 90 day readmissions (Table 1). A very similar trend was seen for UC and depression as well: mean age at readmission was 51.4 years and there was a high readmission rate and mortality at 30 days (readmission rate 5.0%, p&amp;lt;0.01 and mortality rate 2.6%, p&amp;lt;0.01) which increased significantly at 90 days (readmission rate 8.4%, p&amp;lt;0.01 and mortality rate 2.9%, p&amp;lt;0.01). The top 10 causes of readmission at 30 days and 90 days for both UC and Crohn’s are summarized in Table 1. CONCLUSION Our study revealed that patients with IBD and VT had increased mortality, LOS, and TOTHC were increased compared to patients with IBD only. Further studies are required to further evaluate this patient population.

175. Clindamycin versus linezolid for Group A Streptococcal bloodstream infections?: A comparative effectiveness study of adjunctive antitoxin therapy at 137 US Hospitals

Abstract Background Adjunctive clindamycin has survival benefit in invasive Group A streptococcus (GAS) infections. Like clindamycin, linezolid also leads to decreased toxin and virulence factor production. However, rising clindamycin resistance among GAS isolates and inadequate clinical data on linezolid both offer pause on which to choose. We examined the impact of adjunctive clindamycin vs. linezolid on survival among patients with GAS bloodstream infections (BSI) in the presence and absence of clindamycin resistant (clinda-R) isolates Methods Clinical characteristics, antimicrobial susceptibility testing (AST), and antibiotic therapy were examined for unique adult inpatient encounters with GAS BSIs in the PINC-AI Database. Patients treated with a β-lactam for ≥3 days ±3 days of culture who received clindamycin ±3 days of culture were overlap weighted on a propensity-score to those who received linezolid using basine patient and hospital factors. The primary outcome was odds ratio (OR) of in-hospital mortality associated with clindamycin (vs linezolid). The secondary outcome was length of stay (LOS) among survivors. Subgroups analyses were conducted excluding clindamycin receipients with clinda-R isolates (subgroup 1) and also missing clindamycin AST(including D-test; subgroup 2).Figure 1.Study Flow chart Selection of patients with Group A streptococcal blood stream infections. The database was queried for inpatients (aged ≥18 years) with blood culture displaying growth of Group A streptococcus, filtered on the basis of receiving β-lactam antibiotics within 3 days either side of culture sampling for a minimum duration of 3 days and received either adjunctive clindamycin or linezolid treatment within 3 days either side of culture sampling.Table 1:Baseline characteristics of all patients with Group A Streptococcal blood stream infections treated with β-lactam antibiotics and adjunctive clindamycin or linezolid (N=660)Abbreviations: IVIG: intravenous immunoglobulin, ICU: intensive care unit, IQR: interquartile range, SOFA: Sequential Organ Failure Assessment * This score was calculated by use of ICD-10-clinical modification codes and adapted from the methods used by Quan and colleagues ^ Calculated by use of an electronic health record-based adaption of the original Sequential Organ Failure Assessment ^^ Deteremined by clindamycin antimicrobial susceptibility and D-test results. Defined as resistant or intermediate clindamycin susceptibility results and/or a positive D-test result. † Defined as presence of ICD-10 codes coding for any of the following conditions: Human immunodeficiency virus, cancer, solid organ or hematopoietic stem cell transplantation, receipt of systemic corticosteroids, chemotherapy or other immunosuppressive therapy and immunodeficiency. ‡ Receipt of norepinephrine, epinephrine, phenylephrine, and dopamine administered within a 24-h period either side of culture sampling. Results Of 3019 β-lactam–treated inpatients with GAS BSI, 500 (17%) received clindamycin and 160 (5%) received linezolid. The prevalence of clinda-R isolates was 19%;1 isolate was linezolid resistant and excluded (Figure 1). Overlap weighting resulted in well balanced groups (Figure 2). In the overlap weighted cohort, mortality risk was similar between recipients of clindamycin (10%, [50/500]) vs linezolid (9%, [14/160]; OR 1.38 [95% CI: 0.76-2.49]). Among survivors median[interquartile range] LOS was similar between the two groups (8[9] vs. 9[8] days, p=0.45). Removing those with clinda-R isolates (N=84) and also missing AST (N=166) yielded similar results (Figure 3).Figure 2.Standardized mean differences for covariates included the propensity score calculation Standardized mean differences for covariates included in the propensity score generation averaged across exposure categories in the unweighted cohort (blue triangles) and overlap weighted cohort weight (red circles). After overlap weighting, the mean standard difference at each variable assessed was zero . Abbreviations: ICU: intensive care unit, IVIG: intravenous immunoglobulin, NSTI: necrotizing soft tissue infectionFigure 3.Odds Ratio of in-hospital mortality in patients with invasive group A streptococcal blood stream infection treated with adjunctive clindamycin versus adjunctive linezolid The ORs (95% CIs) of in-hospital mortality (including discharge to hospice) in the primary analysis and subgroup analysis with patients withclindamycin resistant isolates (subgroup 1) and those with clindamycin resistant isolates and missing clindamycin susceptibility results (subgroup 2) removed from clindamycin group. Abbreviations: CI: confidence interval Conclusion Among β-lactam-treated patients with GAS BSI, linezolid and clindamycin displayed comparable effectiveness as adjunctive antitoxin agents. Similar intrinsic effectiveness (i.e., in patients with only susceptible isolates) supports linezolid as an alternative even in low clinda-R settings. Disclosures Ahmed Babiker, MBBS, Roche: Advisor/Consultant Morgan Walker, MD, Cytovale: Advisor/Consultant

Regional differences in infective endocarditis epidemiology and outcomes in Spain. A population-based study

Abstract Introduction Population-based studies of infective endocarditis (IE) provide nationwide representative information of the disease, with a lower risk of selection and referral bias. Purpose Our aim was to describe the contemporary epidemiological profile of IE in Spain, and to evaluate regional variations in the incidence, characteristics and outcomes of IE in the different Spanish regions (autonomous communities, AC). Methods Retrospective population-based study to analyse the incidence, epidemiological and clinical characteristics and outcomes of all patients discharged with a diagnosis of IE from hospitals included in the Spanish National Health System, from January 2016 to December 2019. Differences in the IE profile among the 17 Spanish AC were also evaluated. Results A total of 9008 episodes were identified during the study period. Mean age was 69.5 (14.6) years, and 66.1% of the patients were male. 52.6% of episodes were treated at referral centers. Direct standardized incidence of IE in the study period was 5.77 (95% CI: 5.12-6.41) cases per 100000 person-years. 26.8% of episodes were prosthetic valve carriers, 36.8% had some kind of valve heart disease, and 10.6% had a cardiac implantable electronic device. The most frequently isolated microorganisms were staphylococci (33.3%; 19.0% Staphylococcus aureus and 14.3% coagulase-negative staphylococci), followed by gram-negative (21.0%) and streptococci (20.8%). Culture-negative IE accounted for 20.7% of episodes. 38.6% of patients developed heart failure during hospitalization, and 27.5% had acute renal failure. Cardiac surgery was performed in 19.3% of episodes in the total cohort, and in 33.4% of episodes treated in high-volume referral centres. In-hospital mortality was 25.1%. The standardized incidence of IE in Spain in the period 2016-2019 was 5.77 (95% CI: 5.12-6.41) cases per 100000 person-years. Standardized incidence rates (cases per 1000000 person-years) and risk-adjusted in-hospital mortality rates of infective endocarditis among AC are shown at Figure 1, were significant differences were found. In a multilevel logistic regression analysis, cardiogenic shock (OR 5.95, CI 4.98-7.9) and septic shock (OR 4.54, CI 3.78-5.44) were associated with the highest odds ratio for in-hospital mortality, whereas Streptococci viridans was associated with the lowest (OR 0.44, CI 0.37-0.52). Irrespectively of the AC, patients treated at high-volume centres (&amp;gt; 22 episodes per year) had a slightly lower risk-adjusted mortality (22.7±4.1 vs 23±3.6) p&amp;lt;0.001) (Figure 2, blue dots represent low-volume hospitals, red dots represent high-volume hospitals). Conclusions We found relevant and statistically significant differences in standardized incidence rates of IE, and risk-adjusted in-hospital mortality rates among regions. Regardless of the AC, patients treated in high-volume centres (&amp;gt;22 episodes per year) had a slightly lower risk-adjusted mortality.Figure 1Figure 2

The impact of hospital volume on the prognosis of patients with cardiogenic shock requiring mechanical circulatory support

Abstract Background Short-term mechanical circulatory support (MCS) is indicated in refractory cardiogenic shock (CS). Each hospital's volume of MCS relates to the many factors including population served, clinician experience and availability of MCS. To establish regional integrated Hub-and-spoke care CS systems for improving the prognosis of patients with CS, detailed data on relationship between the volume of MCS and prognosis are required but are lacking. We evaluated the relationship between outcomes, including in-hospital mortality and case volume, and explored whether there is an upper limit to this relationship. Methods We used the Japanese nationwide database to identify patients receiving short-term MCS for CS between April 2012 and March 2020. Of 65,837 patients receiving short-term MCS, three sub-cohorts were created based on the MCS type used; the intra-aortic balloon pump (IABP) alone (n=48,643), the extracorporeal membrane oxygenation (ECMO) (n=16,871), and the Impella cohorts (n=696). Results The median volume of annual cases in each hospital was 13.5 (7.4–22.1) in the IABP alone cohort, 6.4 (3.4-11.0) in the ECMO cohort, and 7.5 (4.0–10.7) in the Impella cohort. In the IABP alone and ECMO cohorts, the group with the higher case volume had less acute myocardial infarctions and received right heart catheterization more frequently. The highest quintile for the volume of cases in the IABP alone and ECMO cohorts had the lowest in-hospital mortality (IABP alone cohort, 25.1% in quintile 1 vs. 15.2% in quintile 5; ECMO cohort, 73.7% in quintile 1 in 67.4% in quintile 5), while it had the highest cost. Adjusted odds ratios for in-hospital mortality increased as case volume increased (IABP alone cohort, 0.63 [0.58–0.68] in quintile 5; ECMO cohort, 0.73 [0.65–0.82] in quintile 5, with the lowest quintile as reference) but did not increase significantly in the Impella cohort (0.90 [0.58–1.39] in tertile 3, with the lowest tertile as reference) (Figure 1). In continuous models, in-hospital mortality decreased to 28 cases/year in the IABP alone cohort and 12 cases/year in the ECMO cohort, and the mortality became almost flat above that (Figure 2). Hospitals with 28 or more cases/year in the IABP cohort were 3.6 % including 15.5 % of patients, and hospitals with 12 or more cases/year in the ECMO cohort were 4.7% including 20.9% of patients. Conclusions Higher volumes of IABP and ECMO are associated with a lower mortality. There is an upper limit to the decline, above which in-hospital mortality remains constant or increases slightly. Centralizing patients with refractory cardiogenic shock in a particular hospital might improve patient outcomes in each region.

Abstract 18918: Outcomes of Patients With Transcatheter Aortic Valve Replacement (TAVR) and Cardiac Resynchronization Therapy (CRT): A Retrospective Analysis

Introduction: Many patients with TAVR have a pre-existing reduced LVEF &lt;35% and left bundle branch block (LBBB) requiring CRT-D for potential improvement in LV function and secondary prevention of sudden death. Few studies have examined patient outcomes in this specific subpopulation. The aim of our study was to see if this patient population had worse outcomes compared to patients with TAVR without CRT-D. Hypothesis: We hypothesized that patients undergoing CRT would have better outcomes. Methods: Patients aged &gt;18 years with TAVR and CRT versus TAVR alone were identified from the United States National Inpatient Sample (2015-2020). ICD 9 and 10 codes were utilized and multivariate regression analysis was used to estimate the odds ratios of in-hospital mortality, average length of stay (LOS), and hospital charges (TOTHC), after adjusting for age, gender, race, insurance, and hospital demographics (type, size, region, and teaching status). Propensity matching was performed using the Kernel method. Weighted analysis utilizing Stata 17 MP was performed. Results: This study identified approximately 324,563 patients with TAVR, of which 2,613 patients had CRT. The analysis revealed mortality (OR: 2.59, p&lt;0.025, CI: 1.13-5.94), length of stay (LOS) (+5.69 days, p&lt;0.0001, CI: 4.44-6.95), and TOTHC ($165,520, p&lt;0.0001, CI: 134,551-196,489) were increased for patients with TAVR and CRT compared to patients with only TAVR. Secondary analysis is described in Table 1. Conclusions: Our study revealed that patients with TAVR and CRT had worse outcomes including increased mortality, LOS, and TOTHC. Despite CRT, this patient subpopulation had worse outcomes compared to those with only a TAVR. We suspect that these patients either have a poor functional status at baseline or CRT may not have as much benefit for patients with TAVR. Further studies are required to further evaluate this patient population.

Outcomes of Hospital-Acquired Hypernatremia.

Hospital-acquired hypernatremia is highly prevalent, overlooked, and associated with unfavorable consequences. There are limited studies examining the outcomes and discharge dispositions of various levels of hospital-acquired hypernatremia in patients with or without CKD. We conducted an observational retrospective cohort study, and we analyzed the data of 1,728,141 patients extracted from the Cerner Health Facts database (January 1, 2000, to June 30, 2018). In this report, we investigated the association between hospital-acquired hypernatremia (serum sodium [Na] levels >145 mEq/L) and in-hospital mortality or discharge dispositions with kidney function status at admission using adjusted multinomial regression models. Of all hospitalized patients, 6% developed hypernatremia after hospital admission. The incidence of in-hospital mortality was 12% and 1% in patients with hypernatremia and normonatremia, respectively. The risk of all outcomes was significantly greater for serum Na >145 mEq/L compared with the reference interval (serum Na, 135-145 mEq/L). In patients with hypernatremia, odds ratios (95% confidence interval) for in-hospital mortality, discharge to hospice, and discharge to nursing facilities were 14.04 (13.71 to 14.38), 4.35 (4.14 to 4.57), and 3.88 (3.82 to 3.94), respectively ( P < 0.001, for all). Patients with eGFR (Chronic Kidney Disease Epidemiology Collaboration) 60-89 ml/min per 1.73 m 2 and normonatremia had the lowest odds ratio for in-hospital mortality (1.60 [1.52 to 1.70]). Hospital-acquired hypernatremia is associated with in-hospital mortality and discharge to hospice or to nursing facilities in all stages of CKD.

Pneumothorax, pneumomediastinum, and subcutaneous emphysema in hospitalized COVID-19 patients: incidence, clinical characteristics, and outcomes

ABSTRACT Background Limited data is available on the incidence and outcomes of pneumothorax (PTX), pneumomediastinum (PNM), and subcutaneous emphysema (SCE) in COVID-19 patients. This study aimed to investigate the characteristics of these complications in hospitalized COVID-19 patients. Research design and methods A retrospective study was conducted, involving adult COVID-19 patients admitted to Mayo Clinic Florida from 03/2020–06/2022. Patients were divided into two groups based on the presence or absence of PTX/PNM/SCE Results 1926 hospitalized patients with COVID-19 were included, of which 518 were admitted to the ICU. The incidence of PTX/PNM/SCE was 6.3%. Patients with these complications were more likely to be male, Asian, and unvaccinated. Conversely, they were less likely to have chronic obstructive pulmonary disease. Patients who developed PTX/PNM/SCE after 72 hours of admission were more likely to receive high-dose corticosteroids and for an extended duration. The affected group had an adjusted odds ratio for in-hospital mortality of 13.32 (95%CI, 8.19–21.59) and ICU admission of 9.14 (95%CI, 5.3–12.78) compared to the unaffected group. Conclusion Although the occurrence of PTX/PNM/SCE in hospitalized COVID-19 patients was rare, it was associated with worse outcomes. Corticosteroids may contribute to the pathogenesis of these complications; however, further studies are needed to investigate this relationship in more detail.

Obesity paradox or hypoxia preconditioning: How obstructive sleep apnea modifies the Obesity-MI relationship

ObjectivesThe objective of this study was to evaluate the interaction between obesity and obstructive sleep apnea on acute MI in hospital mortality. MethodsThis retrospective cohort study utilized Veterans Health Administration data from years 1999–2020. Participants were categorized according to their body mass index (BMI) to non-obese (BMI <30) and obese (BMI ≥30) groups. Clinical obstructive sleep apnea (SA) diagnosis was confirmed using ICD9/10 codes and the study subgroups included non-obese with no obstructive sleep apnea (nOB-nSA), non-Obese with obstructive sleep apnea (nOB-SA), obese with no obstructive sleep apnea (OB-nSA), and obese with obstructive sleep apnea (OB-SA). The primary outcome was odds ratio of in-hospital mortality during the hospitalization with acute MI as the principal diagnosis adjusted for age, gender, race, ethnicity, and Charlson comorbidity index (CCI) with the nOB-nSA group as the comparison group. ResultsAmong 72,036 veterans with acute-MI hospitalization, individuals with obesity and obstructive sleep apnea (OB-SA) had the lowest in-hospital mortality rate (1.0%) compared to those without obesity and obstructive sleep apnea (nOB-nSA, 2.8%), with obesity but without obstructive sleep apnea (OB-nSA, 2.4%), and with obesity and obstructive sleep apnea (nOB-SA, 1.4%). The adjusted odds ratio for mortality, compared to nOB-nSA, was 9% higher but not significant in OB-nSA (aOR, 1.09, 95%CI: 0.95, 1.25), 46% lower in OB-nSA (aOR, 0.54, 95%CI: 0.45, 0.66), and 52% lower in OB-SA (aOR, 0.48: 95%CI: 0.41, 0.57). ConclusionOur data suggest that the association between obesity and improved survival in acute MI is largely driven by the presence of sleep apnea.