Reduction In 30-day Mortality Research Articles

Non-catecholamine vasopressors in the treatment of adult patients with septic shock—evidence from meta-analysis and trial sequential analysis of randomized clinical trials

BackgroundNorepinephrine (NE) has currently been the first-choice vasopressor in treating septic shock despite generally insufficient for patients with refractory septic shock. The aim of this update meta-analysis was to assess the safety and efficacy of a combination of non-catecholamine vasopressors (vasopressin/pituitrin/terlipressin/selepressin/angiotensin II) and NE versus NE in managing adult septic shock patients.MethodsWe conducted this study of literatures published from the inception to April 30, 2020, using PubMed, Embase, and the Cochrane Library databases without language restriction. Randomized controlled trials comparing NE with non-catecholamine vasopressors among adult septic shock patients were included in this meta-analysis. Pooled effects of relative risk (RR) or standard mean difference (SMD) and corresponding 95% confidence interval (CI) were calculated using a random-effects model.ResultsTwenty-three studies covering 4380 participants were finally enrolled. The combined analysis of non-catecholamine vasopressors resulted in a nonsignificant reduction in 90-day/ICU/hospital mortality except for a decreased in 28-day mortality (n = 4217; RR, 0.92; 95% CI 0.86–0.99; P = 0.02). This favorable result was subsequently verified by the subgroup analyses of low risk of bias studies (RR = 0.91, 95% CI = 0.84 to 0.98; P = 0.02) and catecholamine-resistant refractory shock patients group (RR, 0.84; 95% CI = 0.70–1.00; P = 0.048). The pooled analysis of non-catecholamine vasopressors showed a 14% higher success rate of shock reversal at 6 h, a 29% decreased risk of continuous renal replacement therapy, but a 51% increased risk of hyponatremia and a 2.43 times higher risk of digital ischemia. Besides, the pooled data showed that non-catecholamine vasopressors decreased heart rate (HR) (SMD, − 0.43; 95% CI − 0.66 – − 0.19; P < 0.001), serum creatinine (− 0.15; 95% CI − 0.29 – − 0.01; P = 0.04), and the length of mechanical ventilation (MV) (− 0.19; 95% CI − 0.31 – − 0.07; P < 0.01, but there was no significant difference in other parameters.ConclusionsCurrent pooled results suggest that the addition of NE to non-catecholamine vasopressors was associated with a marginally significant reduction in 28-day mortality. Moreover, they were able to shorten the length of MV, improved renal function, decreased HR, and increased the 6-h shock reversal success rate at the expense of increased the risk of hyponatremia and digital ischemia.

Dexamethasone in hospitalised patients with COVID-19: addressing uncertainties

Dexamethasone in hospitalised patients with COVID-19: addressing uncertainties

Metformin is Associated with Decreased 30-Day Mortality Among Nursing Home Residents Infected with SARS-CoV2

ObjectivesThe COVID-19 pandemic presents an urgent need to investigate whether existing drugs can enhance or even worsen prognosis; metformin, a known mammalian target of rapamycin (m-TOR) inhibitor, has been identified as a potential agent. We sought to evaluate mortality benefit among older persons infected with SARS-CoV-2 who were taking metformin as compared to those who were not. DesignRetrospective cohort study. Setting and Participants775 nursing home residents infected with SARS-CoV-2 who resided in one of the 134 Community Living Centers (CLCs) of the Veterans Health Administration (VHA) during March 1, 2020, to May 13, 2020, were included. MethodsUsing a window of 14 days prior to SARS-CoV-2 testing, bar-coded medication administration records were examined for dispensing of medications for diabetes. The COVID-19–infected residents were divided into 4 groups: (1) residents administered metformin alone or in combination with other medications, (2) residents who used long-acting or daily insulin, (3) residents administered other diabetes medications, and (4) residents not administered diabetes medication, including individuals without diabetes and patients with untreated diabetes. Proportional hazard models adjusted for demographics, hemoglobin A1c, body mass index, and renal function. ResultsRelative to those not receiving diabetes medications, residents taking metformin were at significantly reduced hazard of death [adjusted hazard ratio (HR) 0.48, 95% confidence interval (CI) 0.28, 0.84] over the subsequent 30 days from COVID-19 diagnosis. There was no association with insulin (adjusted HR 0.99, 95% CI 0.60, 1.64) or other diabetes medications (adjusted HR 0.71, 95% CI 0.38, 1.32). Conclusions and ImplicationsOur data suggest a reduction in 30-day mortality following SARS-CoV-2 infection in residents who were on metformin-containing diabetes regimens. These findings suggest a relative survival benefit in nursing home residents on metformin, potentially through its mTOR inhibition effects. A prospective study should investigate the therapeutic benefits of metformin among persons with COVID-19.

Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury

In-hospital administration of tranexamic acid after injury improves outcomes in patients at risk for hemorrhage. Data demonstrating the benefit and safety of the pragmatic use of tranexamic acid in the prehospital phase of care are lacking for these patients. To assess the effectiveness and safety of tranexamic acid administered before hospitalization compared with placebo in injured patients at risk for hemorrhage. This pragmatic, phase 3, multicenter, double-blind, placebo-controlled, superiority randomized clinical trial included injured patients with prehospital hypotension (systolic blood pressure ≤90 mm Hg) or tachycardia (heart rate ≥110/min) before arrival at 1 of 4 US level 1 trauma centers, within an estimated 2 hours of injury, from May 1, 2015, through October 31, 2019. Patients received 1 g of tranexamic acid before hospitalization (447 patients) or placebo (456 patients) infused for 10 minutes in 100 mL of saline. The randomization scheme used prehospital and in-hospital phase assignments, and patients administered tranexamic acid were allocated to abbreviated, standard, and repeat bolus dosing regimens on trauma center arrival. The primary outcome was 30-day all-cause mortality. In all, 927 patients (mean [SD] age, 42 [18] years; 686 [74.0%] male) were eligible for prehospital enrollment (460 randomized to tranexamic acid intervention; 467 to placebo intervention). After exclusions, the intention-to-treat study cohort comprised 903 patients: 447 in the tranexamic acid arm and 456 in the placebo arm. Mortality at 30 days was 8.1% in patients receiving tranexamic acid compared with 9.9% in patients receiving placebo (difference, -1.8%; 95% CI, -5.6% to 1.9%; P = .17). Results of Cox proportional hazards regression analysis, accounting for site, verified that randomization to tranexamic acid was not associated with a significant reduction in 30-day mortality (hazard ratio, 0.81; 95% CI, 0.59-1.11, P = .18). Prespecified dosing regimens and post-hoc subgroup analyses found that prehospital tranexamic acid were associated with significantly lower 30-day mortality. When comparing tranexamic acid effect stratified by time to treatment and qualifying shock severity in a post hoc comparison, 30-day mortality was lower when tranexamic acid was administered within 1 hour of injury (4.6% vs 7.6%; difference, -3.0%; 95% CI, -5.7% to -0.3%; P < .002). Patients with severe shock (systolic blood pressure ≤70 mm Hg) who received tranexamic acid demonstrated lower 30-day mortality compared with placebo (18.5% vs 35.5%; difference, -17%; 95% CI, -25.8% to -8.1%; P < .003). In injured patients at risk for hemorrhage, tranexamic acid administered before hospitalization did not result in significantly lower 30-day mortality. The prehospital administration of tranexamic acid after injury did not result in a higher incidence of thrombotic complications or adverse events. Tranexamic acid given to injured patients at risk for hemorrhage in the prehospital setting is safe and associated with survival benefit in specific subgroups of patients. ClinicalTrials.gov Identifier: NCT02086500.

The initial validation of a novel outcome measure in severe burns- the Persistent Organ Dysfunction +Death: Results from a multicenter evaluation

IntroductionA need exists to improve the efficiency of clinical trials in burn care. The objective of this study was to validate “Persistent Organ Dysfunction” plus death as endpoint in burn patients and to demonstrate its statistical efficiency. MethodsThis secondary outcome analysis of a dataset from a prospective international multicenter RCT (RE-ENERGIZE) included patients with burned total body surface area >20% and a 6-month follow-up. Persistent organ dysfunction was defined as persistence of organ dysfunction with life-supportiing technologies and ICU care. ResultsIn the 539 included patients, the prevalence of 0p p+ pdeath was 40% at day 14 and of 27% at day 28. At both timepoints, survivors with POD (vs. survivors without POD) had a higher mortality rate, longer ICU- and hospital-stays, and a reduced quality of life. POD + death as an endpoint could result in reduced sample size requirements for clinical trials. Detecting a 25% relative risk reduction in 28-day mortality would require a sample size of 4492 patients, whereas 1236 patients would be required were 28-day POD + death used. ConclusionsPOD + death represents a promising composite outcome measure that may reduce the sample size requirements of clinical trials in severe burns patients. Further validation in larger clinical trials is warranted. Study typeProspective cohort study, level of evidence: II

A Comparison of Colistin versus Colistin Plus Meropenem for the Treatment of Carbapenem-Resistant Acinetobacter baumannii in Critically Ill Patients: A Propensity Score-Matched Analysis.

Carbapenem-resistant Acinetobacter baumannii (CRAB), an important nosocomial pathogen, occurs particularly in the intensive care unit (ICU). Thus, the aim of this study was to compare the efficacy and safety of documented treatment with colistin monotherapy versus colistin plus meropenem in critically ill patients with CRAB infections at Chiang Mai University Hospital (CMUH). We conducted a retrospective cohort study of critically ill patients with CRAB infections in an ICU from 2015 to 2017, who received colistin monotherapy versus colistin plus meropenem. After propensity score matching, an adjusted odds ratio (aOR) of a 30-day mortality rate in patients who received colistin plus meropenem was 0.43 compared to those who received colistin monotherapy (95% CI, 0.23–0.82, p = 0.01). aORs of clinical response and microbiological response were also higher in patients who received colistin plus meropenem (1.81, 95% CI 1.01–3.26, p = 0.048 and 2.08, 95% CI 1.11–3.91, p = 0.023, respectively). There was no significant difference in nephrotoxicity (aOR, 0.76, 95% CI, 0.43–1.36, p = 0.363) between colistin monotherapy and colistin plus meropenem. In conclusion, the addition of meropenem to colistin caused a reduction in 30-day mortality, higher clinical and microbiological responses, and did not increase nephrotoxicity compared to colistin monotherapy. Furthermore, 30-day mortality was significantly related with age, receiving vasopressor, having malignancy, and the APACHE II score.

Timing of Ablation and Prognosis of Patients With Electrical Storm and Scar-Related Left Ventricular Dysfunction

Although radiofrequency catheter ablation (RFCA) is indicated in electrical storm (ES) refractory to antiarrhythmic drugs, its most appropriate timing has not been determined. Our objective is to analyse the impact of the timing of RFCA on 30-day mortality in patients with ES and previous scar-related systolic dysfunction. In this multi-centre study, we analysed 104 patients (age: 72 ± 10, left ventricular ejection fraction: 30 ± 6%) attended consecutively due to an ES caused by monomorphic ventricular tachycardia. Sixty-four subjects were treated with RFCA (mean time from admission = 83 ± 67 hours) and 40 were not. Upon admission 25 (24%) individuals had severe heart failure. Mortality rate at 30 days was 24 (23%) patients. RFCA was associated with a reduction of 30-day mortality (hazard ratio = 0.2; p = 0.008). After showing a positive correlation between the time of the RFCA (hours) and survival at 30 days (C-statistic = 0.77; p <0.001), we found that only subjects ablated >48 hours after admission had lower mortality at 30 days than those treated conservatively: 38% (no RFCA) versus 30% (RFCA ≤48 hours) versus 7% (RFCA >48 hours) (adjusted hazard ratio for RFCA >48 hours vs others = 0.2; p = 0.007). Among the patients ablated, those who were non-inducible had lower 30-day mortality: 8% versus 29% (p = 0.03). Extracorporeal membrane oxygenation was associated with a higher rate of non-inducibility in RFCA >48 hours (100% vs 76%; p = 0.03), but not in RFCA ≤48 hours (60% vs 60%; p = 1). In conclusion, among high-risk patients with ES, RFCA performed >48 hours after admission is associated with a reduction in 30-day mortality. In such subjects, the probability of successful RFCA increases when performed under extracorporeal membrane oxygenation support.

Tranexamic acid in hip hemiarthroplasty

BackgroundIntraoperative use of tranexamic acid (TXA) has been proven to reduce the administration of allogenic blood transfusion in total joint arthroplasty (TJA) patients. Data on TXA efficacy in reducing blood loss in trauma patients undergoing hip hemiarthroplasty are sparse, and its use is not yet well-established. The purpose of this study was to assess the efficacy and safety of intraoperative TXA use in patients undergoing hip hemiarthroplasty as treatment for intracapsular femoral neck fracture. MethodsThis is a historical cohort of patients who underwent hip hemiarthroplasty in a tertiary medical center between 2011 and 2019, with minimum follow-up of one year. The cohort was divided into one group of patients who received intraoperative TXA treatment and another group that did not. Blood loss, peri‑ and postoperative complications, readmissions, and short- and long-term mortality were compared between groups. ResultsOf the 1722 consecutive patients (601 males and 1121 females) who underwent hip hemiarthroplasty who were included in this study, 504 were in the "TXA" group and 1218 were in the "non-TXA" group. TXA use significantly reduced 30-day mortality (4.6% vs 7.3%, respectively, p < 0.046) and perioperative blood loss, as indicated by changes in hemoglobin levels before and after surgery (Δ-1.38 gr/dL vs Δ-1.76 gr/dL, p < 0.001), and by administration of allogenic blood transfusions (17.5% vs 44.4%, p < 0.001). ConclusionsSimilar to the known effect of TXA in TJA patients, the use of TXA treatment in patients undergoing hip hemiarthroplasty led to a significant reduction in 30-day mortality, in postoperative blood loss and in the proportion of patients requiring allogenic blood transfusions.

Impella in cardiogenic shock following acute myocardial infarction: a systematic review and meta-analysis.

Cardiogenic shock (CS) conveys ahigh mortality risk. Acardiac assist device may serve as bridge to patient recovery. We aimed to provide apooled estimate on mortality and complications from studies evaluating the use of the left ventricular assist device Impella in CS following acute myocardial infarction. In addition, we evaluated whether mortality risk differed with device placement before or after percutaneous coronary intervention (PCI). We searched Medline, Embase and Web of Science from 2005 until July 2019 for observational studies or clinical trials on this specific patient group. Studies were required to report on 30-day all-cause mortality and device-related complications. We calculated pooled proportions with 95% confidence intervals (CI) using random effects models and the inverse variance method. Overall, 671 patients from 11studies (2randomized and 9observational) were included. Pooled proportions showed a30-day mortality of 54.6% (95% CI 47.3-61.8; P = 0.22; I2 = 65.8%). Among complications, major bleeding was found in 19.9% (95% CI 14.2-27.3; P < 0.05; I2 = 69.1%), hemolysis in 10.5% (95% CI 7.2-15.0; P < 0.05; I2 = 52.1%), limb ischemia in 5.0% (95% CI 2.6-9.5; P < 0.05; I2 = 48.3%) and stroke in 3.8% of patients (95% CI 2.4-5.9; P < 0.05; I2 = 0%). Sensitivity analysis demonstrated astatistically significant risk reduction in 30-day mortality when Impella was implanted prior to PCI as compared to after PCI, risk ratio (RR): 0.71, CI 0.58-0.86, P = 0.001, I2 = 0%. Pooled estimates of Impella use in myocardial infarction with CS revealed a high 30-day mortality; however, as compared to post-PCI, Impella initiation prior to PCI was associated with a survival benefit.

Evaluation of the early fluconazole treatment of candidemia protocol with automated short message service alerts: a before-and-after study.

Background/AimsWe introduced the Early Fluconazole Treatment in Candidemia (EFTC) protocol in August 2015 to improve the outcomes of patients with candidemia. This study evaluated the effectiveness of the EFTC protocol.MethodsWe conducted a retrospective before-and-after study among patients in the intensive care units and Hemato-Oncology and General Surgery wards of our hospital between January 2013 and December 2018. The EFTC protocol entailed sending an automatic notification by short message service, feedback to the responsible healthcare worker, and regular standardized education of medical staff. On receiving a notification, physicians prescribed empirical fluconazole immediately. The effectiveness of the EFTC protocol was evaluated by multivariate analysis of risk factors for 30-day mortality.ResultsOf 103 patients with candidemia, 50 were admitted before (pre-EFTC group) and 53 were admitted after (post-EFTC group) the introduction of the EFTC protocol. Patients’ mean age ± SD was 67.1 ± 18.6 years, and 55 (53.4%) were male. The mean ± SD time from Candida isolation to antifungal drug administration in the pre-EFTC and post-EFTC groups was 89.1 ± 73.6 and −9.8 ± 63.9 minutes, respectively (p = 0.01). The 30-day mortality in the pre-EFTC and post-EFTC groups was 54.5% (95% confidence interval [CI], 42.3 to 66.7), and 37.6% (95% CI, 26.1 to 49.1), respectively (p = 0.05). In the multivariate analysis, implementation of the EFTC protocol was independently associated with a reduction in 30-day mortality (odds ratio, 0.27; 95% CI, 0.12 to 0.63; p = 0.01).ConclusionsThe early f luconazole treatment, monitoring, and education were effective in reducing mortality in patients with candidemia.

β-adrenergic blockade is associated with a reduced risk of 90-day mortality after surgery for hip fractures.

BackgroundThere is a significant postoperative mortality risk in patients subjected to surgery for hip fractures. Adrenergic hyperactivity induced by trauma and subsequent surgery is thought to be an important contributor. By downregulating the effect of circulating catecholamines the increased risk of postoperative mortality may be reduced. The aim of the current study is to assess the association between regular β-blocker therapy and postoperative mortality.MethodsThis cohort study used the prospectively collected Swedish National Quality Registry for hip fractures to identify all patients over 40 years of age subjected to surgery for hip fractures between 2013 and 2017 in Örebro County, Sweden. Patients with ongoing β-blocker therapy at the time of surgery were allocated to the β-blocker-positive cohort. The primary outcome of interest was 90-day postoperative mortality. Risk factors for 90-day mortality were evaluated using Poisson regression analysis.ResultsA total of 2443 patients were included in this cohort of whom 900 (36.8%) had ongoing β-blocker therapy before surgery. The β-blocker positive group was significantly older, less fit for surgery based on their American Society of Anesthesiologists classification and had a higher prevalence of comorbidities. A significant risk reduction in 90-day mortality was detected in patients receiving β-blockers (adjusted incidence rate ratio=0.82, 95% CI 0.68 to 0.98, p=0.03).Conclusionsβ-blocker therapy is associated with a significant reduction in 90-day postoperative mortality after hip fracture surgery. Further investigation into this finding is warranted.Level of evidenceTherapeutic study, level III; prognostic study, level II.

Demographics, Procedural Characteristics, and Clinical Outcomes When Cardiogenic Shock Precedes TAVR in the United States

ObjectivesThis paper details trends and outcomes in U.S. patients undergoing transcatheter aortic valve replacement (TAVR) who present pre-procedurally with cardiogenic shock. BackgroundDemographic, procedural characteristics, and clinical outcomes in U.S. patients undergoing TAVR after presenting with cardiogenic shock are unknown. MethodsThe STS/ACC TVT (Society of Thoracic Surgeons and the American College of Cardiology Transcatheter Valve Therapy) registry linked with Centers for Medicare & Medicaid Services claims data was used to identify patients between 2014 and 2017 who presented with cardiogenic shock before TAVR in comparison to a high-risk cohort that did not present with cardiogenic shock. The primary outcome of interest was 30-day mortality. Secondary outcomes included 30-day procedural complications. ResultsPresentations with cardiogenic shock currently represent 4.1% of the U.S. TAVR population. A total of 2,220 patients with acute cardiogenic shock undergoing TAVR (median STS 9.8) were compared with 12,851 high-risk patients (median STS 10.2). Cardiogenic shock was associated with higher 30-day mortality (19.1% vs. 4.9%) and higher rates of complications. The absence of 30-day major complications was not associated with a marked reduction in 30-day mortality, and overall procedural success rates were high. The risk of death from acute cardiogenic shock before TAVR was strongly related to the degree of shock pre-procedure. ConclusionsTAVR appears to be a viable treatment option for patients presenting with aortic stenosis and acute cardiogenic shock. Although procedural success is high, this population remains at an elevated risk of death, which appears to be mostly driven by the degree of pre-procedural shock.

National Trends and Impact of Regionalization of Radical Cystectomy on Survival Outcomes in Patients with Muscle Invasive Bladder Cancer.

To evaluate national trends and the effect of surgical volume on perioperative mortality and overall survival (OS)in patients undergoing radical cystectomy (RC) for muscle invasive bladder cancer (MIBC). We investigated the National Cancer Database to identify patients with localized MIBC (cT2a-T4, M0) who underwent RC from 2004 to 2014. Demographics, 30- and 90-day mortality rates, as well as OS were analyzed. Hospitals were stratified into low-, medium-, and high-volume centers according to median number of RCs performed per year. Multivariate logistic regression models were fitted to identify independent predictors of perioperative mortality. Kaplan-Meier survival curves were generated to evaluate OS. Cox proportional hazard modeling was performed to identify independent predictors of OS. A total of 24,763 patients with localized MIBC who underwent RC from 2004 to 2014 were included in the study. Overall, most (70.85%) RCs occurred at low-volume hospitals, whereas only 15.83% were performed at high-volume hospitals. Thirty-day mortality rates were 2.87%, 2.19%, and 1.83% (P< .01); and 90-day mortality rates were 8.25%, 6.9%, and 5.9% (P< .01) at low-, medium-, and high-volume hospitals, respectively. Multivariate analyses identified RC volume as an independent predictor of 30- and 90-day mortality. RC in high-volume hospitals was associated with a 35% risk reduction in 30-day mortality (odds ratio 0.65, 95% confidence interval [CI] 0.49-0.85; P< .01), and a 26% risk reduction in 90-day mortality (0.74, 95% CI, 0.63-0.87; P< .01). Treatment at high-volume centers offers improved outcomes and OS benefit. However, in the United States, only 16% of RCs are performed in high-volume hospitals.

Efficacy and safety of antibiotic agents in children with COVID-19: a rapid review.

BackgroundThe aim of this review was to evaluate the efficacy and safety of antibiotic agents in children with COVID-19, as well as to introduce the present situation of antibiotics use and bacterial coinfections in COVID-19 patients.MethodsWe searched Cochrane library, Medline, Embase, Web of Science, CBM, Wanfang Data and CNKI from their inception to March 31, 2020. In addition, we searched related studies on COVID-19 published before March 31, 2020 through Google Scholar. We evaluated the risk of bias of included studies, and synthesized the results using a qualitative synthesis.ResultsSix studies met our inclusion criteria. Five studies on SARS showed an overall risk of death of 7.2% to 20.0%. One study of SARS patients who used macrolides, quinolones or beta lactamases showed that the mean duration of hospital stay was 14.2, 13.8 and 16.2 days, respectively, and their average duration of fever was 14.3, 14.0 and 16.2 days, respectively. One cohort study on MERS indicated that macrolide therapy was not associated with a significant reduction in 90-day mortality (adjusted OR 0.84, 95% CI: 0.47–1.51, P=0.56) and improvement in MERS-CoV RNA clearance (adjusted HR 0.88, 95% CI: 0.47–1.64, P=0.68). According to the findings of 33 studies, the proportion of antibiotics use ranged from 19.4% to 100.0% in children and 13.2% to 100.0% in adults, despite the lack of etiological evidence. The most commonly used antibiotics in adults were quinolones, cephalosporins and macrolides and in children meropenem and linezolid.ConclusionsThe benefits of antibiotic agents for adults with SARS or MERS were questionable in the absence of bacterial coinfections. There is no evidence to support the use of antibiotic agents for children with COVID-19 in the absence of bacterial coinfection.

Association of Baseline Inflammation With Effectiveness of Nutritional Support Among Patients With Disease-Related Malnutrition

Inflammation is a key driver of malnutrition during illness and is often accompanied by metabolic effects, including insulin resistance and reduction of appetite. However, it still remains unclear if inflammation influences the response to nutritional support among patients with disease-related malnutrition. To examine whether patients' baseline inflammatory status is associated with the effect of nutritional support on 30-day mortality. This is a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized clinical trial conducted in 8 Swiss hospitals from April 2014 to February 2018. A total of 1950 participants who had C-reactive protein measurements at the time of admission were included in this secondary analysis. Data analysis was conducted between June and July 2019. Hospitalized patients at risk for malnutrition were randomly assigned to receive protocol-guided individualized nutritional support to reach protein and energy goals (intervention group) or standard hospital food (control group). The primary end point was 30-day mortality. Based on C-reactive protein levels at admission, patients were stratified into groups with low, moderate, or high inflammation (<10 mg/L, 10-100 mg/L, and >100 mg/L, respectively). A total of 1950 patients (median [interquartile range] age, 75 [65-83] years; 1025 [52.6%] men) were included; 533 (27.3%) had low levels of inflammation, 894 (45.9%) had moderate levels of inflammation, and 523 (26.8%) had high levels of inflammation. Compared with the control group, patients receiving nutritional support showed a significant reduction in 30-day mortality, regardless of C-reactive protein level (adjusted odds ratio, 0.61; 95% CI, 0.43-0.86; P = .005). In the subgroup of patients with high inflammation, there was no beneficial effect of nutritional support (adjusted odds ratio, 1.32; 95% CI, 0.70-2.50; P = .39), providing evidence that inflammation has a significant modifying association (P for interaction = .005). Based on this secondary analysis of a multicenter randomized trial, a patient's admission inflammatory status was associated with their response to nutritional support. If validated in future clinical trials, nutritional support may need to be individualized based on a patient's initial presentation and markers of inflammation. These results may also help to explain some of the heterogeneity in treatment effects of nutrition seen in previous critical care trials. ClinicalTrials.gov Identifier: NCT02517476.

Integrated Fragility Hip Fracture Program: A Model for High Quality Care.

Hip fractures are a significant cause of morbidity and mortality among elderly patients. Coordinated multidisciplinary care is required to optimize medical outcomes. To determine the effect of the implementation of standardized, evidence-based protocols on clinical outcomes and mortality in patients with fragility hip fractures. A multidisciplinary group was convened to define best practices in fragility hip fracture care and implement a fragility hip fracture clinical protocol at Yale-New Haven Hospital. Clinical outcomes in 2015, prior to program initiation, were compared with 2018, after the program was well established. Measured outcomes included 30-day mortality, blood transfusion utilization, adverse effects of drugs, venous thromboembolic complications, sepsis, myocardial infarction, mechanical surgical fixation complications during the index admission, length of stay, 30-day readmission, unexpected return to the operating room (OR) and time to the OR. The implementation of the Integrated Fragility Hip Fracture Program was associated with significant reductions in 30-day mortality from 8.0% in 2015 to 2.8% in 2018 (P = .001). Significant reductions were also seen in use of blood transfusions (46.6% to 28.1%; P < .001), adverse effects of drugs (4.0% to 0%; P < .001), length of stay (5.12 to 4.47 days; P = .004), unexpected return to the OR (5.1% to 0%; P < .001), and time to the OR <24 hours (41.8% to 55.0%, P = .001). An Integrated Fragility Hip Fracture Program using multidisciplinary care, physician and nursing engagement, evidence-based protocols, data tracking with feedback, and accountability can reduce mortality and improve clinical outcomes in patients with hip fractures.

The Impact Of Pharmaceutical Interventions On The Use Of Carbapenems In A Chinese Hospital: A Pre-Post Study.

BackgroundThe challenge of drug resistance to carbapenems is of international concern with leading to increased hospital lengths of stay, costs, and mortality rates. How to get rid of the vicious cycle of drug resistance, new drugs, and re-resistance, and even the emergence of all-drug-resistant bacteria that humans cannot cope with, are the major challenges we face. To date, data about pharmaceutical interventions on the use of carbapenems are currently limited.Patients and methodsA retrospective cohort study was conducted to compare pre- and post-intervention in Tongde Hospital of Zhejiang Province. Pharmaceutical interventions were performed in the post-intervention group, including real time monitoring of medication orders, educative group activities, and making interventions to physicians. Intervention acceptance and outcomes, including the length of hospital stay, readmission rates, 30-day mortality, and utilization of carbapenems, which was evaluated by the daily defined doses (DDDs), the days of therapy (DOTs), and the cost of carbapenems, were reviewed.ResultsDuring the study, 593 interventions were provided by clinical pharmacists with an average acceptance rate of 82.79%. Compared with the pre-intervention group, prescriptions of carbapenems for pathogen-directed therapy were improved significantly in the post-intervention group (59.27% vs 21.74%, p=0.022). The DDDs decreased from 281.96 to 174.28 and DOTs decreased from 9.19 to 5.18 after pharmaceutical intervention, and the pharmaceutical interventions had significantly lower mean total cost of carbapenems ($13,828.8 vs $8137.1, p=0.004) and length of hospital stay (9.3±1.5 vs 15.9±2.2, p=0.014). There was a significant reduction in 30-day mortality in the post-intervention group (9.46% vs 17.86%, p=0.013) while there were no differences found in the 30-day readmission (20.19% vs 20.66%, p=0.99).ConclusionImplementation of pharmaceutical interventions in our hospital successfully improved the appropriateness of carbapenem prescribing overall, and reduced the DDDs, DOTs, length of hospital day, and cost of carbapenems.

Outcomes After Rectal Cancer Surgery: A Population-Based Study Using Quality Indicators.

Quality indicators are increasingly being used to measure the safety of cancer treatments. We examined factors associated with poorer outcomes after major resection for rectal cancer over time. We linked population-based cancer registry and cancer-related procedure data for rectal cancer cases over a 15-year period. Multivariable logistic regression models were used to examine factors associated with 30- and 90-day postoperative mortality, and overall survival (OS) was estimated using the Kaplan-Meier survival function. The study included 9,222 patients who had major resection for invasive rectal cancer. Thirty-day and 90-day mortality were 2.1% and 3.8%, respectively. Risk of 30-day mortality was elevated in older patients (p < .001); patients with ≥2 comorbidities (p < .001); and those admitted as an emergency (p < .001). An approximate 45% reduction in 30-day mortality (p = .01) was observed over time. Two-year OS was 81.5%, again with significant improvements observed over time (p < .001). No significant association was observed between hospital volume and mortality or 2-year survival. A reduction in rates of postoperative mortality and improved 2-year OS were observed over time. Quality indicators are a valuable tool to monitor clinical outcomes over time and as a means of improving clinical care for all patients.

1073 Integration of Cirrhosis Best Practices Into Electronic Medical Record Associated With Reduction in 30-Day Mortality

INTRODUCTION: Hospital admissions for patients with cirrhosis continue to increase. In New York City, 25-30% of hospitalized cirrhotics are readmitted within 30 days. Re-hospitalization is associated with increased mortality, poor quality of life, and financial burden to patients, hospitals, and payers. Preventable readmissions are partially accounted for by a well documented quality gap between evidence based guidelines for cirrhosis management and real world adherence to these recommendations. METHODS: We performed a prospective cohort study that compared outcomes among cirrhotic patients admitted to four internal medicine teams over a 6-month period. An electronic medical record (EMR) note template that outlined best practice measures for cirrhotics was developed. Inpatient providers on two teams were instructed to include it in daily progress notes and discharge summaries. The recommended practices included diagnostic paracentesis and diuretics for ascites, rifaximin and lactulose for hepatic encephalopathy, beta blockers for esophageal varices, and antibiotic prophylaxis for spontaneous bacterial peritonitis. The remaining two teams continued standard of care of cirrhotic patients. The primary outcome was 30-day readmissions. Secondary outcomes included in-hospital mortality, 30-day mortality, length of stay, and adherence to best practice guidelines. RESULTS: Over a 6-month period, 108 cirrhotic patients were admitted, 83 in the interventional group and 25 in the control group. MELD-Na scores on admission did not differ between the groups (20.1 v 21.1, P = 0.57). Thirty-day readmissions were not significantly different between the interventional and control groups (19.3% v 24%, P = 0.61). However, 30-day mortality was significantly lower in the interventional group (7.2% v 24%, P = 0.02). There was no difference between the two groups in in-hospital mortality (3.6% v 0%, P = 0.34) or length of stay (10.2 days v 12.6 days, P = 0.34). Adherence to best practice metrics was similar between the groups, except for rates of diagnostic paracentesis, which were higher in the interventional group (98% v 80%, P = 0.01). CONCLUSION: Implementation of an EMR note template with cirrhosis best practices was associated with lower 30-day mortality and higher rates of diagnostic paracentesis among admitted patients with cirrhosis. These findings suggest that integration of best practice measures into the EMR may improve outcomes in hospitalized cirrhotic patients. Larger studies are required to validate these findings.

Association of Early, High Plasma-to–Red Blood Cell Transfusion Ratio With Mortality in Adults With Severe Bleeding After Trauma

Optimal transfusion management is crucial when treating patients with trauma. However, the association of an early, high transfusion ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) with survival remains uncertain. To study the association of an early, high FFP-to-PRBC ratio with all-cause 30-day mortality in patients with severe bleeding after trauma. This cohort study analyzes the data included in a multicenter national French trauma registry, Traumabase, from January 2012 to July 2017. Traumabase is a prospective, active, multicenter adult trauma registry that includes all consecutive patients with trauma treated at 15 trauma centers in France. Overall, 897 patients with severe bleeding after trauma were identified using the following criteria: (1) received 4 or more units of PRBC during the first 6 hours or (2) died from hemorrhagic shock before receiving 4 units of PRBC. Eligible patients were divided into a high-ratio group, defined as an FFP-to-PRBC ratio more than 1:1.5, and a low-ratio group, defined as an FFP-to-PRBC ratio of 1:1.5 or less. The ratio was calculated using the cumulative units of FFP and PRBC received during the first 6 hours of management. A Cox regression model was used to analyze 30-day survival with the transfusion ratio as a time-dependent variable to account for survivorship bias. Of the 12 217 patients included in the registry, 897 (7.3%) were analyzed (median [interquartile range] age, 38 (29-54) years; 639 [71.2%] men). The median (interquartile range) injury severity score was 34 (22-48), and the overall 30-day mortality rate was 33.6% (301 patients). A total of 506 patients (56.4%) underwent transfusion with a high ratio and 391 (43.6%) with a low ratio. A high transfusion ratio was associated with a significant reduction in 30-day mortality (hazard ratio, 0.74; 95% CI, 0.58-0.94; P = .01). When only analyzing patients who had complete data, a high transfusion ratio continued to be associated with a reduction in 30-day mortality (hazard ratio, 0.57; 95% CI, 0.33-0.97; P = .04). In this analysis of the Traumabase registry, an early FFP-to-PRBC ratio of more than 1:1.5 was associated with increased 30-day survival among patients with severe bleeding after trauma. This result supports the use of early, high FFP-to-PRBC transfusion ratios in patients with severe trauma.