Post-discharge Mortality Research Articles

Epidemiological and clinical management aspects related to urinary tract infections diagnosed in the emergency department in elderly patients in Spain: Results of the EDEN-36 study

To estimate the incidence of urinary tract infections (UTI) in elderly patients in Spanish emergency departments (ED), the need for hospitalization, diagnostic confirmation in hospitalized patients, adverse events and the predictive capacity of several biomarkers. In this a posteriori substudy of a generic study of reasons for ED visits in elderly patients, we included patients aged ≥65 years seen in 52 Spanish EDs for 1 week, selecting those diagnosed with UTI. As adverse events, in-hospital and 30-day mortality and combined adverse event (death or hospitalization) at 30 days post-discharge were collected. Relative risks (RR) were calculated. The predictive capacity of 10 variables and 6 biomarkers was investigated. A total of 25,375 patients were included, 1058 with UTI (annual incidence: 24.7 per 1000 inhabitants aged ≥65 years and year, 95%CI: 24.5-24.9). A total of 36.5% were hospitalized, and in 80% the diagnosis of UTI was confirmed at discharge. Overall 30-day mortality was 5.4% and in-hospital mortality was 3.4%. Functional dependence was associated with both events (RR:2.91;1.18-7.17 and RR:12.61;1.47-108.11, respectively), as was having a CRP greater than 100 mg/L (RR:2.24;1.17-4.30 and RR:3.21;1.37-7.51, respectively). The combined post-high event occurred in 10.6%, and was associated with functional dependence (RR:2.05;1.04-4.06). CRP and hemoglobin had significant value in predicting 30-day post-discharge mortality or hospitalization. UTI is a frequent diagnosis in elderly patients consulting in the ED. Functional dependence is the best factor associated with adverse events. The biomarkers analyzed do not have a good predictive capacity.

Impact of hospital readmissions following hospitalisation with delirium on 12-month mortality: a quaternary Australian hospital experience.

Inpatient delirium and unplanned hospital readmissions are associated with increased mortality. This study aimed to determine the effect of 28-day unplanned hospital readmissions on 12-month mortality post-discharge in patients with delirium during index hospitalisation. Retrospective longitudinal cohort study of adults aged 65 or above with delirium during hospitalisation at a Victorian quaternary hospital was performed. Delirium was identified by the inclusion of ICD-10 (International Classification of Diseases, 10th revision) codes in the hospital medical discharge summary. Descriptive statistics was obtained for baseline characteristics. Cox proportional hazards model was developed to identify independent predictors of 12-month post-discharge mortality. One thousand six hundred thirty-four patients with delirium during in-patient admission were included. The overall 12-month mortality rate was 35% (572 patients). Of the 1,425 patients who survived their index admission, 11.2% had an unplanned 28-day readmission. In Cox regression analysis, unplanned readmission (hazard ratio (HR) 2.3, 95% confidence internal (CI) 1.7-2.9), older age (HR 1.38, CI 1.11-1.72), Charlson Comorbidity Index (HR 1.21, CI 1.17-1.27), and discharge to nursing home (HR 1.58, CI 1.23-2.02) were independent predictors of 12-month mortality. Readmitted patients with 12-month mortality were older, with higher rates of dementia, polypharmacy, and nursing home residence compared to readmitted patients who did not reach this endpoint. Unplanned hospital readmission within 28days of discharge is an independent predictor of 12-month mortality post in-hospital delirium admission. Admissions complicated by delirium and readmission episodes should instigate discussions regarding prognostication and goals of care. Greater research is required to minimise hospital readmission rates following discharge in this cohort.

Rural-Urban Disparities in Mortality of Patients with Acute Myocardial Infarction and Heart Failure: A Systematic Review and Meta-Analysis.

Patients with cardiac disease living in rural areas may face significant challenges in accessing care and studies suggest that living in rural areas may be associated with worse outcomes. However, it is unclear whether rural-urban disparities have an impact on mortality in patients presenting with acute myocardial infarction (AMI) and heart failure (HF). This meta-analysis aimed to assess differences in mortality between rural and urban patients presenting with AMI and HF. A systematic search of the literature was performed using PubMed, Embase, MEDLINE and CENTRAL for all studies published until January 16, 2024. A grey literature search was also performed using a manual web search. The following inclusion criteria were applied: (i) studies must compare rural patients to urban patients presenting to hospital with AMI or HF; and (ii) studies must report on mortality. The primary outcome was all-cause mortality. Comprehensive data were extracted including study design, patient characteristics (sex, age and comorbidities), sample size, follow-up period and outcomes. Odds ratios (ORs) were pooled with random-effects model. A subgroup analysis was performed to investigate causes for heterogeneity in which studies were separated based on in-hospital mortality, post-discharge mortality, and region of origin including North America, Europe, Asia and Australia. In total, 37 studies were included (29 retrospective studies, 4 cross-sectional studies and 4 prospective cohort studies) in our meta-analysis; 24 studies for AMI, 11 studies for HF and 2 studies for both AMI and HF. This included a total of 21,107,886 patients with AMI (2,230,264 of which were in rural regions) and 18,434,270 patients with HF (2,655,469 of which were in rural regions). Rural patients with AMI had similar age (mean age 69.8 +/- 5.7; vs 67.5 +/- 5.1) and were more likely to be female (43.2% vs 38.5%) compared to urban patients. Rural patients with HF had similar age (mean age 77.1 +/- 4.4 vs 76.5 +/- 4.2) and were more likely to be female (56.4% vs 49.5%) compared to urban patients. The range of follow-up for the AMI cohort was 0 days to 24 months and the range of follow-up for the HF cohort was 0 days to 24 months. Compared with urban patients, rural patients with AMI had higher mortality rate at follow-up (15.5% vs 13.4%; OR 1.18, 95% CI, 1.13-1.24; I2 = 97%). Compared with urban patients, rural patients with HF had higher mortality rate at follow-up (12.3% vs 11.6%; OR 1.11, 95% CI, 1.11-1.12; I2 = 98%). To our knowledge, this is the first systematic review and meta-analysis assessing mortality differences between rural and urban patients presenting with AMI and HF. We found that patients living in rural areas had an increased risk of mortality when compared to patients in urban areas. Clinical and policy efforts are required to reduce these disparities.

Impact of skilled nursing facility quality on Medicare beneficiaries with dementia: Evidence from vacancies.

People living with dementia are less likely to be admitted to high-rated nursing homes than people without dementia, despite their increased care needs. We investigated the effect of admission to nursing homes with higher staffing ratings on adverse outcomes for individuals with and without dementia post-hospitalization. Among Traditional Medicare beneficiaries discharged to nursing homes between 2011 and 2017, we examined the relationship between facility staffing star-ratings and short-term readmission and mortality using an instrumental variables approach to account for selection bias. The instrumental variables were the number of nearby vacant beds in high-rated facilities. Admission to a higher-rated nursing home lowered post-discharge mortality risk at 90 days and reduced 30- and 90-day readmission. Point estimates were larger for people with dementia. Findings underscore the need for enhancing direct care staffing in nursing homes and addressing access disparities, particularly for individuals with dementia who benefit significantly from high-quality care. We assessed how admission to nursing homes with higher staffing ratings impacted outcomes for individuals with and without dementia by exploiting variation in local bed vacancies as a source of quasi-random assignment. For both persons with and without dementia, adjusted short-term mortality and readmission rates were lower among those discharged to nursing homes with higher staffing ratings. Effects were larger for persons with dementia, indicating welfare loss from inequitable access to higher-rated nursing homes. Increasing staffing in nursing homes and reducing disparities for persons with dementia is essential for enhancing both equity and value.

A practical risk score for prediction of 6-month mortality in patients with acute heart failure: CHAM2P2

Abstract Background Admission with acute heart failure carries a poor prognosis. Multiple predictive risk scores exist in heart failure presentation, however the utility of these scores in acute heart failure setting among older adults is limited. Aim The purpose of this study was to develop a practical risk score to predict 6-month mortality in patients presenting with acute heart failure. Methods Between January-August 2020, 474 consecutive patients (mean age 80 ± 11 years) admitted with acute heart failure to a large tertiary hospital in the South-West of England were identified. Data was retrospectively collected on admission bloods, comorbidities, imaging, echocardiography and post discharge mortality. Prediction modelling with multivariate Cox regression was then used to identify clinically relevant predictors of six-month mortality. Continuous variables were dichotomised around the mean/median for simplification. Variables were assigned points proportional to hazard ratios on Cox regression. Results Mortality at six months was 34% (161/474). Cox regression identified five significant (p<0.05) predictors of mortality: C: Clinical Frailty Score>5, H: hospital stay >10 days, A: age >80yrs, M: malignancy (current or previous) history and P: NT pro-BNP>4500pg/ml. In our final model, malignancy and NT pro-BNP were assigned two points with the remainder being assigned one. In total, 304 patients had data available to generate CHAM2P2 scores. Mortality increased sequentially from 16.0% in patients with CHAM2P2 0-2, 44.4% in patients with CHAM2P2 scores of 3-5 and 94.1% in patients with CHAM2P2 scores of 6 or 7 (log rank <0.01). AUC demonstrated good discriminatory value of the CHAM2P2 score in predicting six-month mortality (AUC 0.74). Conclusion The CHAM2P2 score is a readily available and simple tool to predict 6-month mortality in patients admitted with acute heart failure.

Medicare Transitional Care Management Service Association with Readmissions and Mortality

Abstract In 2013 CMS introduced codes to reimburse outpatient providers for post-discharge Transitional Care Management (TCM). Understanding the implications of TCM reimbursement on outcomes is crucial for evaluating CMS’s investment and guiding future policy. We analyzed the association between physician organization (PO) TCM code use and post-discharge readmissions and mortality using 100% fee-for-service Medicare claims. Employing a difference-in-differences approach we compared 1131 “high-TCM” POs (top quartile of TCM code use from 2015-2017) to 1133 “low-TCM” POs (bottom quartile) from before (2012) and after (2015-2017) TCM code implementation, controlling for PO and beneficiary attributes and readmission risk. TCM code use was associated with decreased 30- and 90-day readmissions [-0.31 (95%CI -0.52, -0.09) and -0.42 (95%CI -0.71, -0.14) percentage points, respectively], but no significant difference in mortality. Year-by-year, 2017 saw greatest readmission reduction, with a slight mortality reduction in that year only. Readmission reductions were greatest in POs not affiliated with health systems, Accountable Care Organizations (ACOs), or academic medical centers, and least in those with fewer primary care physicians. Narrow, indirect interventions like fee-for-service TCM billing code reimbursement may have limited potential to improve post-discharge outcomes overall. However, small independent practices may derive somewhat greater benefit from this support for post-discharge care.

Comparing the ability of GRACE 2.0 scores for predicting mortality in patients with and without diabetes

Abstract Background The GRACE 2.0 (G2) was an improvement on GRACE. Neither contains DM in the model. In the GRACE, DM independently predicted in-hospital but not the 6-month post-discharge mortality. Similar analysis for GRACE 2.0 score is unavailable. Purpose Assess the ability of the GRACE 2.0 score in predicting mortality in patients with and without diabetes. Methods Retrospective cohort analysis of data on non-STEMI and UA patients admitted in two hospitals between 2010 and 2019 entered into the Myocardial Infarction National Audit Project database. All baseline characteristics of the population and G2 scores were recorded. Death at 1 year was recorded from hospital and general practice records. Follow up was censored at the last recorded contact of the patient with a medical professional. The discriminative power of the G2 score in patients with and without diabetes in predicting mortality was determined by comparing the area under the receiver operating characteristic curve (c-statistics). Accuracy of calibration was evaluated by plotting the mean predicted vs observed mortality in each decile of predicted risk. Results Of 2841 patients entered, complete data was available for 2768 patients (age 69±14yrs, 62.3% male, 877(31.7%) with diabetes). G2 risk was higher in DM (8.3, IQR 3.9 to 19.0 v 5.5, IQR 2.6 to 13.0; p<0.0001). 337 patients died, 156 with DM. Higher deaths occurred in DM group (17.8% vs 16.3; adjusted OR 1.81, 95% CI 1.41-2.33, p<0.0001) (fig 1D). G2 discriminated between events well in whole cohort (AUC 0.81, p<0.001) with no difference between DM and non-DM patients (AUC DM: 0.78, 95% CI 0.75 to 0.81; non-DM 0.81, 0.79 to 0.83; δAUC 0.0301, p=0.242) (fig1E). Calibration of predictions by G2 was excellent across all deciles of risk for the whole cohort (fig 1A). However, G2 underestimated mortality in DM versus non-DM (fig1B,C), especially in the higher deciles of risk (fig 1 F,G). Conclusion(s) Discrimination of the GRACE 2.0 model was excellent for mortality at 1-year with no difference between patient with and without diabetes in our cohort of NSTEMI and UA patients. However, calibration plots suggest GRACE 2.0 underestimates mortality in diabetic compare to non-diabetic patients. This may suggest that risk stratification with GRACE 2.0 in diabetic patients may have to be considered with caution.Figure 1.

Post-Discharge Outcomes of Elderly Patients Hospitalized for Inflammatory Bowel Disease Flare Complicated by Clostridioides difficile Infection.

Elderly hospitalized patients with inflammatory bowel disease (IBD) flare and concurrent Clostridioides difficile infection (CDI) are considered at high risk of IBD-related complications. We aimed to evaluate the short, intermediate, and long-term post-discharge complications among these patients. A retrospective multicenter cohort study assessing outcomes of elderly individuals (≥60 years) hospitalized for an IBD flare who were tested for CDI (either positive or negative) and discharged. The primary outcome was the 3-months post-discharge IBD-related complication rates defined as: steroid dependency, re-admissions (emergency department or hospitalization), IBD-related surgery, or mortality. We assessed post-discharge IBD-related complications within 6-months and mortality at 12-months among secondary outcomes. Risk factors for complication were assessed by multivariable logistic regression. In a cohort of 654 patients hospitalized for IBD (age 68.9 [interquartile range {IQR}]:63.9-75.2) years, 60.9% ulcerative colitis), 23.4% were CDI-positive. Post-discharge complication rates at 3 and 6-months, and 12-months mortality, did not differ significantly between CDI-positive and CDI-negative patients (32% vs. 33.1%, p=0.8; 40.5% vs. 42.5%, p=0.66; and 4.6% vs. 8%, p=0.153, respectively). The Charlson comorbidity index was the only significant risk factor for complications within 3-months (aOR 1.1), whereas mesalamine (5-aminosalicylic acid [5-ASA]) use was protective (aOR 0.6). An ulcerative colitis diagnosis was the sole risk factor for complication at 6-months (aOR 1.5). CDI did not significantly impact outcomes or interact with IBD type. In elderly IBD patients hospitalized for IBD flare and subsequently discharged, a concurrent CDI infection was not associated with post-discharge IBD-related complications or mortality up to 1-year.

Home-Time, Mortality, and Readmissions Among Patients Hospitalized With Heart Failure: A Baseline Prior to IMPLEMENT-HF.

Home-time is an emerging, patient-centered outcome that represents the amount of time a patient spends alive and outside of health care facility settings, comprising of hospitals, skilled nursing facilities, and acute rehabilitation centers. Studies evaluating home-time in the context of heart failure are limited, and the impact of quality improvement interventions on home-time has not been studied. Medicare beneficiaries aged 65 years or older who were hospitalized for heart failure in the Get With the Guidelines-Heart Failure registry between 2019 and 2021 were included. Postdischarge home-time, mortality, and readmission rates at 30 days and 1 year were calculated with the goal of establishing baseline metrics before the initiation of IMPLEMENT-HF, a multicenter quality improvement program aimed at improving heart failure management. Overall, 66 019 patients were included across 437 sites. Median 30-day and 1-year home-time were 30 (18-30) and 333 (139-362) days, respectively. Only 22.1% of patients experienced 100% home-time in the year after discharge. Older patients spent significantly less time at home, with a median 1-year home-time of 302 (86-359) compared with 345 (211-365) days in patients over 85 and those between 65 and 74 years old, respectively (P<0.001). Black patients also experienced the least amount of home-time with only 328 (151-360) days at 1-year follow-up. Rates of heart failure readmission and all-cause mortality 1-year post-discharge were high at 29.8% and 37.0%, respectively. In this contemporary multicenter cohort, patients hospitalized with heart failure spent a median of 91.2% of their time in the year after discharge alive and at home, largely driven by high mortality rates. These findings serve as a preimplementation baseline for IMPLEMENT-HF, which will evaluate the impact of targeted heart failure initiatives on home-time and other clinical outcomes.

Incidence, In-Hospital and Long-Term Mortality, and Sequelae of Epidermal Necrolysis in Adults

The incidence of epidermal necrolysis (EN), including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), varies across studies. While in-hospital mortality rates range from 15% to 20%, contributors to long-term mortality have been rarely evaluated and remain unknown. To assess the incidence of and compare factors associated with in-hospital mortality and postdischarge mortality and sequelae among patients with EN. This cohort study used French Health System data from January 1, 2013, to December 31, 2022, and included all adult patients (aged ≥18 years) with EN identified using International Statistical Classification of Diseases, Tenth Revision codes combined with a validated algorithm. Epidermal necrolysis. Incidence, in-hospital mortality, postdischarge mortality, and sequelae were assessed as main outcomes. Factors associated with mortality were assessed using a multivariable Cox proportional hazards model. A total of 1221 adult patients with EN (median [IQR] age, 66 [49-79] years; 688 females [56.3%]) were included. Incidence was 2.6 (95% CI, 2.5-2.7) cases per million person-years. The in-hospital mortality rate was 19% (95% CI, 17%-21%) and postdischarge mortality rate, 15% (95% CI, 13%-17%) for an overall mortality of 34% (95% CI, 31%-36%). In multivariable analysis, factors associated with in-hospital mortality were age (adjusted hazard ratio [AHR], 1.03 per year of age; 95% CI, 1.02-1.04 per year of age), history of cancer (AHR, 2.04; 95% CI, 1.53-2.72), dementia (AHR, 1.85; 95% CI, 1.12-3.07), liver disease (AHR, 1.81; 95% CI, 1.24-2.64), and EN severity (TEN vs SJS: AHR, 2.14; 95% CI, 1.49-3.07). Cancer, liver disease, and dementia remained associated with postdischarge mortality (AHR, 3.26 [95% CI, 2.35-4.53], 1.86 [95% CI, 1.11-3.13], and 1.95 [95% CI, 1.11-3.43], respectively). Conversely, EN initial severity was not associated with mortality after hospital discharge (TEN vs SJS: AHR, 0.95; 95% CI, 0.60-1.47), but acute complications remained associated (AHR, 2.14 [95% CI, 1.26-3.63] and 2.44 [95% CI, 1.42-4.18] for acute kidney injury and sepsis, respectively). The main sequelae were ophthalmologic and mood disorders. The findings of this cohort study suggest that although EN is a rare condition, it is associated with high rates of in-hospital and postdischarge mortality among patients who are older and have comorbid conditions. However, in contrast with in-hospital mortality, postdischarge mortality is not associated with EN initial severity but with acute in-hospital complications (eg, acute kidney injury and sepsis). Future studies are needed to construct models to estimate long-term outcomes and sequelae in patients with EN.

Caregivers' and nurses' perceptions of the Smart Discharges Program for children with sepsis in Uganda: A qualitative study.

Sepsis arises when the body's response to an infection injures its own tissues and organs. Among children hospitalized with suspected sepsis in low-income country settings, mortality rates following discharge are high, similar to mortality rates in hospital. The Smart Discharges Program uses a mobile health (mHealth) platform to identify children at high risk of post-discharge mortality to receive enhanced post-discharge care. This study sought to explore the perceptions and experiences of the caregivers and nurses of children enrolled into the Smart Discharges Program and the program's effect on post-discharge care. We conducted an exploratory qualitative study, which included in-person focus group discussions (FGDs) with 30 caregivers of pediatric patients enrolled in the Smart Discharges Program and individual, semi-structured interviews with eight Smart Discharges Program nurses. The study was carried out at four hospitals in Uganda in 2019. Following thematic analysis, three key themes pertaining to the Smart Discharges program were identified: (1) Facilitators and barriers to follow-up care after discharge; (2) Changed caregiver behavior following discharge; and (3) Increased involvement of male caregivers. Facilitators included telephone/text message reminders, positive nurse-patient relationship, and the complementary aspects of the program. Barriers included resource constraints and negative experiences during post-discharge care seeking. With regards to behavior, when provided with relevant and well-timed information, caregivers reported increased knowledge about post-discharge care and improvements in their ability to care for their child. Enrolment in the Smart Discharges Program also increased male caregiver involvement, increased provision of resources and improved communication within the family and with the healthcare system. The Smart Discharges approach is an impactful strategy to improve pediatric post-discharge care, and similar approaches should be considered to improve the hospital to home transition in similar low-income country settings.

Inpatient and postdischarge mortality among children with anaemia and malaria parasitaemia in Kenya: a cohort study

BackgroundAnaemia and malaria are leading causes of paediatric hospitalisation and inpatient mortality in sub-Saharan Africa. However, there is limited empirical data on survival following hospital discharge. We aimed to estimate...

A Machine Learning Derived Risk Score Improves Prediction of Outcomes Post-LVAD Implantation: An Analysis of the INTERMACS database.

BackgroundSignificant variability in post-left ventricular assist device (LVAD) implantation outcomes emphasize the importance of accurately assessing patients' risk prior to surgery. This study assesses the MARKER-HF mortality risk model, a machine learning-based tool utilizing 8 clinical variables, to predict post-LVAD implantation mortality and its prognostic enhancement over the INTERMACS profile. MethodsAnalyzing 25,365 INTERMACS database patients (mean age 56.8 years, 78% male), 5,663 (22.3%) and 19,702 (77.7%) received HeartMate 3 and other types of LVAD. They were categorized into low, moderate, high, and very high-risk groups based on MARKER-HF score. The outcomes of interest were in-hospital and 1-year post-discharge mortality. ResultsIn patients receiving HM3 devices, 6.2% died during index hospitalization. In-hospital mortality progressively increased from 4.4% in low to 15.2% in very high -risk groups with MARKER-HF score. MARKER-HF provided additional risk discrimination within each INTERMACS profile. Combining MARKER-HF score and INTERMACS profile identified patients with the lowest (3.5%) and highest in-hospital mortality (19.8%) rates. Post-discharge mortality rate at one year was 5.8% in this population. In a Cox-proportional hazard regression analysis adjusting for both MARKER-HF and INTERMACS profile, only MARKER-HF score (hazard ratio: 1.27, 95% CI: 1.11-1.46, P<0.001) was associated with post-discharge mortality. Similar findings were observed for patients receiving other types of LVAD. ConclusionsThe MARKER-HF score is a valuable tool for assessing mortality risk in HF patients undergoing HM3 and other LVAD implantation. It offers prognostic information beyond that of the INTERMACS profile alone and it's use should help in the shared decision-making process for LVAD implantation.

Association between sarcopenia index, intraoperative events and post-discharge mortality in patients undergoing percutaneous coronary intervention: a retrospective cohort study in a teaching hospital in Western China.

To examine the association between the sarcopenia index (SI) and the risk of intraprocedural events and post-discharge death during percutaneous coronary intervention (PCI). A retrospective cohort study. The study was conducted at a teaching hospital in Western China. The participants were patients aged 45 years and older who underwent PCI at the hospital and had an estimated glomerular filtration rate (eGFR) of ≥15 mL/min/1.73 m2. Patients who died during hospitalisation, as well as those with unknown death dates, those lost to follow-up and those with missing information for the SI calculation, were excluded. The SI was calculated as serum creatinine/cystatin C (Cr/CysC) × 100. The high-SI group was defined as the highest quartile, while the remaining participants were included in the low-SI group. Intraprocedural events included intraprocedural coronary slow flow (CSF)/coronary artery no-reflow (CNR) and malignant ventricular arrhythmia (MVA). In the event of death, the date of death was recorded. The study included 497 patients who underwent PCI in our hospital, of whom 369 (74.25%) were males. A total of 57 (11.47%) patients developed CSF, 100 (20.12%) developed CNR and 4 (0.8%) developed MVA. Forty-four (8.85%) patients died post-discharge. The proportion of patients in the low-SI group who developed CSF was higher than those who did not (16.94% vs 9.65%, p=0.027). In addition, the average SI was lower in patients who developed CSF than in those who did not (81.99 vs 87.11, p=0.043). After adjusting for possible confounding factors, logistic regression analysis showed that the risk of CSF in the low-SI group was higher than that in the high-SI group (OR = 2.01, 95% CI: 1.04 to 3.89). In addition, it was found that the lower the SI, the higher the risk of CSF (OR = 0.983, 95% CI: 0.967 to 0.999). Patients with lower SI had a greater risk of developing CSF, and the lower the SI, the higher the risk of CSF. However, these data suggest that SI is not associated with CNR and the risk of post-discharge death in patients after PCI.

Usefulness of the SARC-F questionnaire and the measurement of the hand grip strength in predicting short-term mortality in older patients hospitalized for acute heart failure.

Sarcopenia is a potentially reversible syndrome that increases the risk of cardiogenic cachexia and adverse outcomes in older patients with heart failure (HF). Despite its clinical significance, sarcopenia remains underdiagnosed due to the complexities of comprehensive assessment in patients with acute HF. This study aimed to evaluate whether the SARC-F questionnaire, its inviduals components,and the handgrip strength test (HGS) can predict short-term prognostic risk in very old patients recently discharged after acute HF. We consecutively enrolled patients aged 75years or older hospitalized with acute HF in the Geriatrics Unit of a tertiary care hospital. All patients underwent physical examination, complete blood tests, point-of-care ultrasound, and a comprehensive geriatric assessment, including physical performance through SARC-F and HGS. The thirty-day post-discharge mortality rate was assessed by phone interview. Out of 184 patients hospitalized with acute HF who were enrolled in the study (mean [SD], 86.8 [5.9] years, 60.3% female), 47 died within 30days after discharge. By multivariate logistic analysis, HGS (β = -0.73 ± 0.03, p = 0.008) and SARC-F [adjusted OR = 1.18 (CI 95% 1.03-1.33), p = 0.003] resulted independently associated with mortality. Furthermore, two SARC-F sub-items, namely, limitation in rising from a chair and history of falls [aOR: 3.26 (CI95% 1.27-8.34), p = 0.008; aOR: 3.30 (CI 95% 1.28-8.49), p = 0.01; respectively] emerged as determinants of 30-days mortality. SARC-F and HGS test independently predict 30-day post-discharge mortality in oldest-old patients hospitalized for acute HF.

Simultaneous Periprosthetic Joint Infection and Infective Endocarditis: Prevalence, Risk Factors, and Clinical Presentation

BackgroundInfective endocarditis (IE) and periprosthetic joint infections (PJI) occur due to hematogenous bacterial spread, theoretically increasing the risk for concurrent infections. There is a scarcity of literature investigating this specific association. We aimed to assess the prevalence, comorbidities, and clinical presentation of patients who have simultaneous PJI and IE. MethodsWe retrospectively identified 655 patients (321 men, 334 women; 382 total hip arthroplasty, 273 total knee arthroplasty) who developed a PJI from July 1, 2015, to December 31, 2020, at one institution. There were two groups created: patients diagnosed with PJI with IE (PJI + IE) and PJI patients who did not have IE (PJI). We analyzed clinical outcomes and comorbidities. ResultsThere were nine patients who had PJI with IE (1.4% of PJI patients). The C-reactive protein (170.9 versus 78, P = 0.026), Elixhauser comorbidity score (P = 0.002), length of hospital stay (LOS) (10.9 versus 5.7 days, P = 0.043), and the two-year post-discharge mortality rate (55.6 versus 9.0%, P = 0.0007) were significantly greater in the PJI+IE group. Comorbidities such as iron deficiency anemia (P = 0.03), coagulopathy (P = 0.02), complicated diabetes mellitus (P = 0.02), electrolyte disorders (P = 0.01), neurological disease (P = 0.004), paralysis (P = 0.04), renal failure (P = 0.0001), and valvular disease (P = 0.0008) occurred more frequently in the PJI + IE group. Modified Duke’s criteria were met for possible or definite IE in 8 of the 9 patients (88.9%). ConclusionConcurrent PJIs and IE, although rare, are a potentially devastating disease state with increased LOS and two-year mortality rates. This emphasizes the need for appropriate IE workups in patients who have a PJI. The modified Duke’s criteria is effective in establishing a diagnosis for IE in this scenario.

Safety and efficacy of early beta-blocker initiation in acute heart failure and cardiogenic shock: systematic review and meta-analysis

BackgroundThe beta-blocker (BB) initiation in acute heart failure (AHF) patients is still controversial. Some show the benefit of BB employment in decreasing the mortality outcome. This study aims to assess the safety and efficacy of in-hospital and long-term outcomes of BB initiation in AHF hospitalized patients. We searched multiple databases examining the outcome of AHF patients who had administered BB as the therapy initiation. Primary outcomes were all-cause mortality, composite endpoint after BB initiation when hospitalized, and post-discharge all-cause mortality. The secondary outcomes were adverse events after in-hospital BB initiation, including hypotension and symptomatic bradycardia after BB initiation when hospitalization and rehospitalization.ResultsEight cohort studies with 16,639 patients suffering from AHF and cardiogenic shock, with 9923 participants allocated to the early BB group and 6,713 patients in the control group. The follow-up durations ranged from 2 to 24 months. Early BB administration significantly reduced in-hospital composite endpoints (RR: 0.42; 95% CI (0.30–0.58); p < 0.001), in-hospital all-cause mortality (RR: 0.43; 95% CI (0.31–0.61); p < 0.001), discharge mortality (RR: 0.51; 95% CI (0.41–0.63); p < 0.001), and rehospitalization (RR: 0.57; 95% CI (0.44–0.74); p < 0.001). There were no discernible differences in in-hospital BB-related adverse events between the two groups (p = 0.13). Subgroup analyses conducted on AHF patients presenting with cardiogenic shock revealed no significant differences in in-hospital composite endpoint and in-hospital mortality, and similar results were shown in the naive BB population.ConclusionsThe BB initiation in AHF patients shows advantages in efficacy and safety outcome.

Hospital and post-discharge mortality in COVID-19 patients with a preexisting cancer diagnosis in Iran

BackgroundDespite the severe impact of COVID-19 on cancer patients, data on COVID-19 outcomes in cancer patients from low- and middle-income countries is limited. We conducted a large study about the mortality rate of COVID-19 in cancer patients in Iran.MethodsWe analyzed data from 1,079 cancer (average age: 58.2 years) and 5,514 non-cancer patients (average age: 57.2 years) who were admitted for COVID-19 in two referral hospitals between March 2019 and August 2021. Patients were followed up until death or 31st August 2021. Multiple logistic regression models estimated the odds ratio (OR) and 95% confidence intervals (CI) of factors associated with ICU admission and intubation. The Cox regression model estimated hazard ratios (HRs) and 95% CI of factors associated with hospital and post-discharge 60-day mortalities.ResultsThe cancer patients had higher ICU admission (OR = 1.65, 95% CI: 1.42–1.91; P-value 0.03) and intubation (OR = 3.13, 95% CI = 2.63–3.73, P-value < 0.001) than non-cancer patients. Moreover, hospital mortality was significantly higher in cancer patients than in non-cancer patients (HR = 2.12, 95% CI: 1.89–2.41, P-value < 0.001). HR for the post-discharge mortality was higher in these patients (HR = 2.79, 95% CI: 2.49–3.11, < 0.001). The hospital, comorbidities, low oxygen saturation, being on active treatment, and non-solid tumor were significantly associated with ICU admission (P-value < 0.05) in cancer patients, while only low oxygen saturation was associated with intubation. In addition, we found that old age, females, low oxygen saturation level, active treatment, and having a metastatic tumor were associated with death due to COVID-19 (P-value < 0.05). Only lung cancer patients had a significantly higher risk of death compared to other cancer types (HR = 1.50, 95% CI: 1.06–2.10, P-value = 0.02).ConclusionCancer patients are at a higher risk of ICU admission, intubation, and death due to COVID-19 than non-cancer patients. Therefore, cancer patients who are infected with COVID-19 require intensive care in the hospital and active monitoring after their discharge from the hospital.

J-shaped relationship between serum creatinine and mortality in Korean patients with acute heart failure.

Cachexia and sarcopenia are common among heart failure (HF) patients and are linked to poor outcomes. As serum creatinine levels are influenced by both renal function and muscle mass, our study aimed to investigate the relationship between serum creatinine levels and mortality in acute HF patients. We enrolled 5198 consecutive acute HF patients from the Korea Acute Heart Failure (KorAHF) registry, excluding those on renal replacement therapy. Patients were categorized into five groups based on their discharge serum creatinine levels: low (< 0.6mg/dL), reference (0.6-0.89mg/dL), upper normal (0.9-1.19mg/dL), high (1.2-1.49mg/dL), and very high (≥ 1.5mg/dL). The primary endpoint was post-discharge all-cause mortality. The mean creatinine level was 1.20 ± 0.88mg/dL. Notably, 335 (6.4%) patients had serum creatinine levels < 0.6mg/dL. These patients were younger (mean age, 67years) and more likely to have a low BMI (< 18.5kg/m2) compared to the reference group (15.3% vs. 6.4%). Over a median follow-up of 975days, 1743 (34.8%) patients died. We observed a J-shaped relationship between serum creatinine levels and mortality, with both low and high levels associated with increased mortality. After adjusting for covariates, including age, sex, body mass index, diabetes, hypertension, smoking, malignancy, atrial fibrillation on electrocardiography, levels of C-reactive protein, sodium, hemoglobin, albumin, brain natriuretic peptide, de novo heart failure, use of beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists, patients with serum creatinine levels < 0.6mg/dL had a 33% higher risk of all-cause mortality (HR, 1.33; 95% CI, 1.06 to 1.66) compared to those with levels of 0.6-0.89mg/dL. However, BUN, which is not affected by muscle metabolism, exhibited a linear relationship with mortality. Among acute HF patients, there exists a J-shaped relationship between discharge serum creatinine levels and mortality, highlighting the increased mortality risk in individuals with very low serum creatinine levels.

The influence of postoperative morbidity on long-term quality of life outcomes following pelvic exenteration

IntroductionPelvic exenteration provides significant survival benefits for selected patients diagnosed with locally advanced rectal cancer. However, in-hospital postoperative morbidity such as abdominal abscess, sepsis, and anastomotic leak remain highly prevalent, which can have short/long-term impacts on patient quality of life (QoL). The aim of this study was to determine the influence of postoperative morbidity on QoL outcomes in patients following pelvic exenteration. MethodsThis prospective cohort study included patients who underwent pelvic exenteration at a tertiary teaching hospital in Sydney, between 2008 and 2023. QoL measures were collected at baseline, 6, 12, 18, 24, 36, 48, and 60 months using the short-form 36 (SF-36v2) survey. The predictors included variables relating to postoperative morbidity, including hospital and ICU length of stay (LOS), post-discharge mortality and the number of postoperative complications. Mixed-effects analyses were used to determine the influence of these postoperative outcomes on physical and mental QoL trajectories. ResultsThis study included 674 patients, with a median age of 61 years. Shorter hospital and ICU LOS, and fewer or no postoperative complications were associated with higher physical QoL scores across all time points. Conversely, postoperative morbidity did not exhibit a significant impact on mental QoL scores. Furthermore, there was a longitudinal improvement in mental QoL outcomes compared to baseline, independent of postoperative morbidity. ConclusionPostoperative morbidity significantly impacted physical QoL outcomes after pelvic exenteration, whereas mental QoL outcomes were not influenced. Interventions aimed at mitigating postoperative morbidity may hold the potential to enhance long-term QoL outcomes following pelvic exenteration.