Risk Factors For 30-day Mortality Research Articles

Risk Factors for 30-Day Mortality in Patients with Bacteremic Pneumonia Caused by Escherichia coli and Klebsiella pneumoniae: A Retrospective Study.

Escherichia coli and Klebsiella pneumoniae are prevalent Gram-negative microorganisms responsible for pneumonia, as well as the primary Enterobacteriaceae pathogens causing bacteremic pneumonia. The objective of this research is to analyze the risk factors associated with bacteremic pneumonia caused by these pathogens and develop a predictive model. This retrospective investigation encompassed a cohort of 252 patients diagnosed with Escherichia coli or Klebsiella pneumoniae-induced bacteremic pneumonia between 2018 and 2022. The primary endpoint was 30-day mortality, which was analyzed using multifactorial logistic regression, nomogram construction, and Bootstrap validation. Among the 252 patients diagnosed with Escherichia coli and Klebsiella pneumoniae, 65 succumbed to the disease while 187 survived. The overall 30-day mortality was found to be 25.8%. A multifactorial logistic regression analysis revealed that diastolic blood pressure, cerebrovascular diseases/transient ischemic attacks (TIA), immunosuppression, blood urea nitrogen, Pitt score, and CURB-65 score were statistically significant factors. The Nomogram model demonstrated an AUC of 0.954, which closely aligns with the Bootstrap-derived mean AUC of 0.953 (95% CI: 0.952-0.954). In patients with bacteremic pneumonia caused by Escherichia coli and Klebsiella pneumoniae, Low diastolic blood pressure (≤61 mmHg), pre-existing cerebrovascular disease/ transient ischemic attacks (TIA), immunosuppression status, elevated blood urea nitrogen levels (≥8.39 mmol/L), high Pitt score (≥3), and a high CURB-65 score (≥2) are all independent risk factors for Escherichia coli and Klebsiella pneumoniae bacteremic pneumonia, among which the first three warrant particular attention.

2456. Methicillin-Resistant Staphylococcus aureus Bacteremia 30-Day Mortality During 2020 Compared to 2016-2019: Assessing the Impact of COVID-19

Abstract Background Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is associated with substantial mortality, but the effect of the COVID-19 pandemic on MRSA mortality has not been fully explored. Methods For 2016-2020, MRSA bacteremia cases among adults aged ≥ 18 years were identified through CDC Emerging Infections Program’s active laboratory- and population-based surveillance in 5 states (16 counties). Death within 30 days of initial MRSA blood culture was determined from medical record documentation or linked state vital statistics data. Cases were classified (epi class) as hospital-onset (HO), healthcare-associated community onset (HACO), or community associated (CA) (Figure 1). Thirty-day mortality was calculated by year and epi class and, for 2020, stratified by whether a SARS-CoV-2 test was positive in the 30 days preceding MRSA culture (recent COVID-19). Using multivariate logistic regression to adjust for potential confounders, the effect of recent COVID-19 on 30-day mortality was assessed. Results MRSA bacteremia 30-day mortality was 22% (2,113/9,689) during 5 surveillance years. Mortality in 2020 was higher than in 2016-2019 overall (25% vs. 21%, p< .01), for HO cases (43% vs 32%, p< .01), and for CA cases (19% vs. 13%, p< .01). When limited to cases without recent COVID-19, mortality in 2020 was still higher than in 2016-2019 for CA (18%, p< .01) but not HO (35%, p=.39). During 2020, cases with recent COVID-19 comprised 37% of HO deaths and a smaller proportion of HACO (13%) and CA (7%) deaths. Cases with recent COVID-19 had higher 30-day mortality than those without across all epi classes (Figure 2; p≤ .01 for all), with mortality highest among HO cases with recent COVID-19 (77%). After adjusting for other factors, recent COVID-19 remained a significant risk factor for 30-day mortality (adjusted odds ratio: 5.3, 95% CI: 3.6-8.0; Table).Table.Multivariate Analysis of Factors Associated with Methicillin-Resistant Staphylococcus aureus Bacteremia 30-Day Mortality, 5 Emerging Infections Program Sites, 2020 Conclusion COVID-19 emerged as a significant independent risk factor for MRSA bacteremia-associated death in 2020, and the very high mortality for HO cases with recent COVID-19 resulted in a higher mortality for HO cases overall. Conversely, the contribution of COVID-19 to the increased mortality for CA cases in 2020 appeared small, and reasons for the increase in mortality for CA cases without recent COVID-19 need additional investigation. Disclosures Ghinwa Dumyati, MD, Pfizer: Grant/Research Support

184. Implications of Enterococcus faecalis penicillin susceptibility in patients with bacteremia

Abstract Background Enterococcus faecalis isolates with an elevated penicillin minimum inhibitory concentration (MIC) ≥ 4 mg/L have decreased in vitro ampicillin plus ceftriaxone bactericidal and synergistic activity, despite ampicillin susceptibility. This phenotype’s implication on patient outcomes and prevalence in the US is unknown due to limited penicillin susceptibility reporting. Methods This was a retrospective cohort study of adult patients with E. faecalis bacteremia between August 20, 2018 and May 13, 2021 from the Mount Sinai Health System in New York City. Patients were excluded if they were discharged or deceased within 48 hours of index blood culture, did not receive active definitive therapy, or the blood culture was determined to be contamination. The primary outcome was differences in 30-day and 90-day mortality based on the penicillin MIC and the secondary outcome was microbiological relapse. Multivariable logistic regression was used to identify risk factors for 90-day mortality. Corresponding blood isolates were tested for penicillin susceptibility by broth microdilution in accordance with CLSI. Results A total of 124 patients were included, with 27% having an elevated penicillin MIC ≥ 4 mg/L. Differences in baseline characteristics (Table 1) as well as source of infection and treatments received (Table 2) were similar between groups. Endocarditis infected 18.5% of patients and was less common in cases with an elevated penicillin MIC. Thirty-day and 90-day mortality, and microbiological relapse were higher in cases with an elevated penicillin MIC (14.4% vs. 20.6%, p=0.58; 20% vs. 26.5%, p=0.59; and 4.4% vs. 8.8%, p=0.39, respectively). Pitt bacteremia score and prior ceftriaxone usage had a higher odds of 90-day mortality (OR 1.2 [95% CI 1.03-1.4], p=0.02; OR 2.8 [95% CI 1.02-7.9], p=0.04, respectively), whereas definitive treatment with an aminopenicillin compared to piperacillin/tazobactam was protective of 90-day mortality (OR 0.21 [95% CI 0.05-0.93], p=0.04). Conclusion E. faecalis with an elevated penicillin MIC ≥ 4 mg/L is present in over a quarter of patients across New York City. Larger studies are warranted to determine the impact on patient outcomes. E. faecalis bacteremia treatment with piperacillin/tazobactam may be associated higher mortality. Disclosures Jaclyn A. Cusumano, PharmD, BCIDP, Shionogi: Advisor/Consultant

390. Corticosteroid Treatment in Severe Patients with SARS-CoV-2 and Chronic HBV Co-infection: A Retrospective Multicenter Study

Abstract Background The impact of corticosteroids on patients with severe coronavirus disease 2019 (COVID-19)/chronic hepatitis B virus (HBV) co-infection is currently unknown. We aimed to investigate the association of corticosteroids with these patients. Methods This retrospective multicenter study screened 5447 confirmed COVID-19 patients hospitalized between Jan 1, 2021, to December 1, 2022, in three centers in India, where the prevalence of chronic HBV infection is moderate to high. Severe patients who had chronic HBV and acute SARS-CoV-2 infection were potentially eligible. The diagnosis of chronic HBV infection was based on positive testing for hepatitis B surface antigen (HBsAg) or HBV DNA during hospitalization and a medical history of chronic HBV infection. Severe patients (meeting one of the following criteria: respiratory rate > 30 breaths/min; severe respiratory distress; or SpO2 ≤ 93% on room air; or oxygen index < 300 mmHg) with COVID-19/HBV co-infection were identified. The bias of confounding variables on corticosteroid effects was minimized using a multivariable logistic regression model and inverse probability of treatment weighting (IPTW) based on the propensity score. Results The prevalence of HBV co-infection in COVID-19 patients was 4.1%. There were 105 patients with severe COVID-19/HBV co-infections (median age 62 years, 57.1% male). Fifty-five patients received corticosteroid treatment and 50 patients did not. In the multivariable analysis, corticosteroid therapy (OR, 6.32, 95% CI 1.17-34.24, P = 0.033) was identified as an independent risk factor for 28-day mortality. With IPTW analysis, corticosteroid treatment was associated with delayed SARS-CoV-2 viral RNA clearance (OR, 2.95, 95% CI 1.63-5.32, P < 0.001), increased risk of 28-day and in-hospital mortality (OR, 4.90, 95% CI 1.68-14.28, P = 0.004; OR, 5.64, 95% CI 1.95-16.30, P = 0.001, respectively), and acute liver injury (OR, 4.50, 95% CI 2.57-7.85, P < 0.001). Methylprednisolone dose per day and cumulative dose in non-survivors were significantly higher than in survivors. Conclusion In patients with severe COVID-19/HBV co-infection, corticosteroid treatment may be associated with an increased risk of 28-day and in-hospital mortality. Disclosures All Authors: No reported disclosures

Predictors of hospital mortality and multidrug-resistant pathogens in hospitalized pneumonia patients residing in the community

Background and objectiveThe 2019 ATS/ADSA guidelines for adult community-acquired pneumonia (CAP) eliminated healthcare-associated pneumonia (HCAP) and considered it to be a form of CAP. This concept, however, was based on studies with relatively small sample sizes. MethodsWe investigated the risk factors of 30-day mortality, and methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa infections in patients with pneumonia coming from the community using the Diagnosis Procedure Combination database, a nationwide discharge database of acute care hospitals. Furthermore, we compared these factors between CAP and HCAP. ResultsA total of 272,337 patients aged ≥20 years with pneumonia were grouped into 145,082 CAP patients and 127,255 HCAP patients. The 30-day mortality rate (8.9 % vs.3.3 %), MRSA infection (2.4 % vs. 1.4 %), and Pseudomonas aeruginosa infection (1.6 % vs. 1.0 %) were significantly higher in HCAP than in CAP patients. Multivariable logistic regression analysis showed that 12 of 13 identified predictors of mortality (i.e., high age, male, underweight, non-ambulatory status, bedsore, dehydration, respiratory failure, consciousness disturbance, hypotension, admitted in critical care, comorbidity of heart failure, and chronic obstructive pulmonary disease) were identical in CAP and HCAP patients. Similarly, five of six distinct risk factors for MRSA infection, and three of three for Pseudomonas aeruginosa infection were identical between the patients. ConclusionThe risk factors for mortality and MRSA or Pseudomonas aeruginosa infection were almost identical in patients with CAP and HCAP. The assessment of individual risk factors for mortality and MRSA or Pseudomonas aeruginosa infection in CAP and abandoning categorization as HCAP can improve and simplify empiric therapy.

Acinetobacter spp. bloodstream infection in hematological patients: a 10-year single-center study

PurposeThis study investigated the clinical and antimicrobial characteristics of Acinetobacter spp. bloodstream infection (BSI) in hematological patients. Risk factors for 30-day mortality and carbapenem-resistant Acinetobacter spp. (CRA) BSI acquisition were also identified.MethodsWe reviewed forty hematological patients with Acinetobacter spp. BSI in a large Chinese blood disease hospital between 2013 and 2022. The remaining CRA isolates were subjected to whole-genome sequencing.ResultsThe 30-day mortality rate was high at 35%. Hematological patients with Acinetobacter spp. BSI often presented with severe conditions and co-infections at multiple sites. All strains were colistin-susceptible and 40.0% were CR. Multivariate analysis identified several risk factors associated with CRA BSI acquisition, including previous exposure to carbapenems within 30 days and CRA colonization. Very severe aplastic anaemia, tetracycline-resistant Acinetobacter spp. BSI, and unresolved neutropenia after infection were closely associated with 30-day mortality. Non-survivors often presented with higher median PCT and CRP levels and severe complications, such as intracranial infection, cardiac dysfunction, respiratory failure, and severe sepsis or septic shock. Our study also identified inappropriate empirical antibiotic therapy as an independent predictor of 30-day mortality (OR: 11.234, 95% CI: 1.261–20.086, P = 0.030). This study was the first to report A. oleivorans as a human pathogen, and to identify its unique oxacillinase, OXA-325.ConclusionAn environment-originated non-pathogenic species can become pathogenic when the body’s immunity is compromised. Our results also highlighted the importance of improving neutropenia after infection, treating severe organ dysfunction, and administering appropriate empirical antibiotic therapy to reduce mortality in this patient population.

Association Between Plasma Levels of Monocyte Chemoattractant Protein-1 (MCP-1) and 28-Day Mortality in Elderly Patients with Sepsis: A Retrospective Single-Center Study.

BACKGROUND Previous studies have identified an association between plasma levels of the inflammatory cytokine, monocyte chemoattractant protein-1 (MCP-1), and outcomes for patients with sepsis. This retrospective single-center study assessed the association between plasma levels of MCP-1 and 28-day mortality in 136 patients ≥65 years diagnosed with sepsis between October 2020 and October 2021. MATERIAL AND METHODS The objective was to compare and analyze the parameters in the survival group (n=35) and the 28-day mortality group (n=101), including Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation II (APACHE II), plasma MCP-1, and laboratory test results. Plasma MCP-1 was quantified by cytokine test kit (LKTM014B, R&D). Statistical analysis was carried out in SPSS 26.0 and MedCalc 92.1.0 software. RESULTS The 28-day mortality group exhibited higher levels of SOFA, APACHEII, and plasma MCP-1 (all P<0.001), as well as lower levels of albumin, compared to the survival group (P<0.05). The logistic regression analysis findings indicated that SOFA, APACHEII, plasma MCP-1, and SBP are all independent risk factors for 28-day mortality. The area under the curve for SOFA, APACHEII, MCP-1, MCP-1+ SOFA, and MCP-1+APACHEII were 0.845, 0.744, 0.712, 0.879, and 0.822, respectively. MCP-1+SOFA exhibited higher sensitivity than SOFA alone. Furthermore, the assessment values of plasma MCP-1 combined with SOFA were superior to those of APACHE II or plasma MCP-1 (Z₁=2.661, Z₂=3.272, both P<0.01). CONCLUSIONS The findings from this study from a single center support those of previous studies that increased plasma levels of MCP-1 are significantly associated with 28-day mortality in patients with sepsis.

Clinical features and 28-day mortality predictors of vaccinated patients admitted to a COVID-19 ICU hub in Italy

BackgroundCOVID-19 vaccination has been proved to be effective in preventing hospitalization and illness progression, even though data on mortality of vaccinated patients in the intensive care unit (ICU) are conflicting. The aim of this study was to investigate the characteristics of vaccinated patients admitted to ICU according to their immunization cycle and to outline the risk factors for 28-day mortality. This observational study included adult patients admitted to ICU for acute respiratory failure (ARF) due to SARS-CoV-2 and who had received at least one dose of vaccine.ResultsFully vaccination was defined as a complete primary cycle from < 120 days or a booster dose from > 14 days. All the other patients were named partially vaccinated. One-hundred sixty patients (91 fully and 69 partially vaccinated) resulted eligible, showing a 28-day mortality rate of 51.9%. Compared to partially vaccinated, fully vaccinated were younger (69 [60–77.5] vs. 74 [66–79] years, p 0.029), more frequently immunocompromised (39.56% vs. 14.39%, p 0.003), and affected by at least one comorbidity (90.11% vs 78.26%, p 0.045), mainly chronic kidney disease (CKD) (36.26% vs 20.29%, p 0.035). At multivariable analysis, independent predictors of 28-day mortality were as follows: older age [OR 1.05 (CI 95% 1.01–1.08), p 0.005], history of chronic obstructive pulmonary disease (COPD) [OR 3.05 (CI 95% 1.28–7.30), p 0.012], immunosuppression [OR 3.70 (CI 95% 1.63–8.40), p 0.002], and admission respiratory and hemodynamic status [PaO2/FiO2 and septic shock: OR 0.99 (CI 95% 0.98–0.99), p 0.009 and 2.74 (CI 95% 1.16–6.48), p 0.022, respectively].ConclusionsDespite a full vaccination cycle, severe COVID-19 may occur in patients with relevant comorbidities, especially immunosuppression and CKD. Regardless the immunization status, predisposing conditions (i.e., older age, COPD, and immunosuppression) and a severe clinical presentation were predictors of 28-day mortality.

Prognostic scores in predicting 90-day mortality in the cardiac intensive care units

Abstract Introduction During the last years the Coronary Care Units (CCU) have evolved into Cardiac Intensive Care Units (CICU) for patients with acute cardiovascular diseases. The prognostic scores were developed in general Intensive Care Units with the aim of evaluating the severity of the disease and predicting the short-term outcome of the critically ill patients. Although a number of prognostic scores have also been used in the CICU, none of them has been proposed, so far, for prediction of the 90-day mortality which is considered a more reliable outcome metric. Purpose To evaluate the predictive ability for 90-day mortality of five prognostic scores in patients admitted to the CICU due to various cardiovascular etiologies. Methods This is a single-center, prospective cohort study in a CICU admitting patients with acute cardiovascular diseases. APACHE II, SOFA, FRAILTY and MCARS scoring systems as well as CHARLSON comorbidity index (CCI) were calculated on CICU admission. Results A total of 527 patients [mean (SD) age 70 (15) years, 69% males] were included (NSTEMI 23%, STEMI 22%, Heart Failure 10%). Crude 90-day mortality was 16%. The univariate analyses showed that all five scores (FRAILTY, MCARS, SOFA, APACHE II, and CCI) were significantly higher in non-survivors as compared to survivors. The area under the receiver operating characteristic curve (AUC) for FRAILTY, MCARS, SOFA, APACHE II, and CHARLSON’s scores was 0.83, 0.91, 0.92, 0.90, and 0.74, respectively. A multivariate logistic regression including all five prognostic scores revealed FRAILTY, MCARS and SOFA scores as independent predictors of 90-day mortality (OR, CI: 0.57, 0.42-0.77; 0.70, 0.53-0.90; 0.83, 0.70-0.99, respectively). Conclusion MCARS, SOFA, and FRAILTY scores at CICU admission were independent risk factors for 90-day mortality. Therefore, they could be recommended as tools for accurate risk stratification in patients admitted to the CICU.

Targeted versus Empiric Embolization for Delayed Postpancreatectomy Hemorrhage: A Retrospective Study of 312 Patients

PurposeTo assess the safety and clinical effectiveness of empiric embolization (EE) compared with targeted embolization (TE) in the treatment of delayed postpancreatectomy hemorrhage (PPH). Materials and MethodsThe data of patients with delayed PPH between January 2012 and August 2022 were analyzed retrospectively. In total, 312 consecutive patients (59.6 years ± 10.8; 239 men) were included. The group was stratified into 3 cohorts according to angiographic results and treatment strategies: TE group, EE group, and no embolization (NE) group. The χ2 or Fisher exact test was implemented for comparing the clinical success and 30-day mortality. The variables related to clinical failure and 30-day mortality were identified by univariable and multivariable analyses. ResultsClinical success of transcatheter arterial embolization was achieved in 70.0% (170/243) of patients who underwent embolization. There was no statistical difference in clinical success and 30-day mortality between the EE and TE groups. Multivariate analyses demonstrated that malignant disease (odds ratio [OR] = 5.76), Grade C pancreatic fistula (OR = 7.59), intra-abdominal infection (OR = 2.54), and concurrent extraluminal and intraluminal hemorrhage (OR = 2.52) were risk factors for clinical failure. Moreover, 33 patients (13.6%) died within 30 days after embolization. Advanced age (OR = 2.59) and intra-abdominal infection (OR = 5.55) were identified as risk factors for 30-day mortality. ConclusionsEE is safe and as effective as TE in preventing rebleeding and mortality in patients with angiographically negative delayed PPH.

Association between ventilatory ratio and mortality in patients with acute respiratory distress syndrome and COVID 19: A multicenter, retrospective cohort study

BackgroundMortality rates in patients with COVID-19 undergoing mechanical ventilation in the intensive care unit are high. The causes of this mortality have been rigorously investigated. The aim of the present study is to establish mortality risk factors related to lung mechanics measured at days 1 and 5 in patients with covid-19 ARDS managed with invasive mechanical ventilation in the intensive care unit.MethodsA retrospective observational multicenter study including consecutive patients with a confirmed diagnosis of COVID-19-induced ARDS, admitted to three institutions and seven intensive care units in the city of Bogota between May 20, 2020 and May 30, 2022 who required mechanical ventilation for at least five days. Data were collected from the medical records of patients who met the inclusion criteria on day 1 and day 5 of mechanical ventilation. The primary outcome assessed was mortality at day 30.ResultsA total of 533 consecutive patients admitted with ARDS with COVID-19 were included. Ventilatory ratio, plateau pressure and driving pressure measured on day 5 were significantly higher in non-survivors (p < 0.05). Overall, 30-day follow-up mortality was 48.8%. The increases between day 1 and day 5 in the ventilatory ratio (OR 1.42, 95%CI 1.03–2.01, p = 0.04), driving pressure (OR 1.56, 95%CI 1.10–2.22, p = 0.01); and finally plateau pressure (OR 1.9, 95%CI 1.34–2.69, p = 0.001) were associated with an increased risk of death. There was no association between deterioration of PaO2/FIO2 index and mortality (OR 1.34, 95%CI 0.96–1.56, p = 0.053).ConclusionsVentilatory ratio, plateau pressure, driving pressure, and age were identified as independent risk factors for 30-day mortality in patients with ARDS due to COVID-19 on day 5 of invasive mechanical ventilation.

Impact of Previous Open Abdominal Surgery on Open Abdominal Aortic Repair: A Study from the NSQIP Database

While endovascular aneurysm repair has become a first-line strategy in many centers, open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) is still the best option for certain patients. A significant number of patients who are offered OSR for AAA have been previously submitted to other open abdominal surgeries (PAS). It is unclear, however, how this may impact their outcomes. The purpose of this study was to determine if there is an association between PAS and outcomes of OSR of AAA. This is a retrospective cohort study based on clinical data from the American College of Surgeons National Surgical Quality Improvement Program database, including all patients undergoing elective OSR for AAA between 2011 and 2017. Excluded were patients with missing data on prior abdominal surgery, supramesenteric clamping, or urgent repairs. Patients with prior abdominal surgery (PAS) and patients without prior abdominal surgeries (nonPAS) were compared. The primary outcome was 30-day postoperative mortality. Secondary outcomes were operating time, ischemic colitis, postoperative complications, and lengths of hospital stay. Of the 2034 patients included, 27% had previous open abdominal surgery and 73% did not. Overall, the median age was 71(interquartile range 65-76), 72% of patients were male, 44% were smokers, and the average body mass index was 27kg/m2. Univariate analysis showed no difference in postoperative 30-day mortality (4.0% PAS vs. 4.1% nonPAS, P=0.91) or overall postoperative complication rates (33% PAS vs. 29% nonPAS, P=0.07). Previous open abdominal surgery was significantly associated with longer operating times (P=0.032) and an almost doubled rate of ischemic colitis (4.7% PAS vs. 2.6% nonPAS, P=0.02). Postoperative intensive care unit and hospitalization were also significantly longer in patients with prior abdominal surgery (P=0.005 and P=0.014, respectively). Finally, there were significantly less patients discharged home, as opposed to institutionalized care (75.7% PAS down from 82.4% nonPAS, P=0.001). Despite these initial univariate analysis results, on multivariate analysis, PAS actually did not prove to be a statistically significant independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. This study suggests that patients who have undergone PAS may have some disadvantages in OSR of AAA. However, these negative trends do not go so far as to statistically significantly identify PAS as an independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. As such, we suggest that a history of previous open abdominal surgery, in and of its own, should not exclude patients from consideration for open aortic abdominal aneurysm repair.

The ongoing challenge of ventilator-associated pneumonia: epidemiology, prevention, and risk factors for mortality in a secondary care hospital intensive care unit

Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality among intensive care unit infections. Despite various preventive measures, the incidence of VAP remains high. This study aimed to explore the epidemiology and risk factors for VAP associated mortality in a secondary care hospital, comparing outcomes before and after implementing a VAP prevention bundle. This retrospective study was conducted from July 1, 2021, to June 30, 2023, at a secondary care hospital. Patients over 18 years old who underwent mechanical ventilation for more than 48 hours were included. The study compared the incidence, microbiological etiology, and outcomes of VAP before and after implementing the VAP prevention bundle and analyzed risk factors for mortality from VAP. A total of 83 patients diagnosed with VAP were included. Despite concerted efforts to implement the VAP prevention bundle, there was no significant decrease in the VAP rate per 1000 ventilator days, early-onset VAP, secondary bloodstream infections, acute respiratory distress syndrome, and 30-day mortality. The microbiological etiology of VAP remained consistent between the two periods. A decrease in lymphocyte count and albumin level were identified as independent risk factors for 30-day mortality. Concerted efforts to implement a VAP prevention bundle did not significantly reduce the incidence or improve outcomes of VAP in this secondary care hospital setting. The microbiological etiology remained unchanged. Monitoring lymphocyte count and albumin level may help identify patients at high mortality risk. Further research is needed to develop more effective VAP prevention and management strategies.

The Influence of Hepatic Steatosis and Fibrosis on Postoperative Outcomes After Major Liver Resection of Perihilar Cholangiocarcinoma

BackgroundSurgical resection for perihilar cholangiocarcinoma (pCCA) is associated with high operative risks. Impaired liver regeneration in patients with pre-existing liver disease may contribute to posthepatectomy liver failure (PHLF) and postoperative mortality. This study aimed to determine the incidence of hepatic steatosis and fibrosis and their association with PHLF and 90-day postoperative mortality in pCCA patients.MethodsPatients who underwent a major liver resection for pCCA were included in the study between 2000 and 2021 from three tertiary referral hospitals. Histopathologic assessment of hepatic steatosis and fibrosis was performed. The primary outcomes were PHLF and 90-day mortality.ResultsOf the 401 included patients, steatosis was absent in 334 patients (83.3%), mild in 58 patients (14.5%) and moderate to severe in 9 patients (2.2%). There was no fibrosis in 92 patients (23.1%), periportal fibrosis in 150 patients (37.6%), septal fibrosis in 123 patients (30.8%), and biliary cirrhosis in 34 patients (8.5%). Steatosis (≥ 5%) was not associated with PHLF (odds ratio [OR] 1.36; 95% confidence interval [CI] 0.69–2.68) or 90-day mortality (OR 1.22; 95% CI 0.62–2.39). Neither was fibrosis (i.e., periportal, septal, or biliary cirrhosis) associated with PHLF (OR 0.76; 95% CI 0.41–1.41) or 90-day mortality (OR 0.60; 95% CI 0.33–1.06). The independent risk factors for PHLF were preoperative cholangitis (OR 2.38; 95% CI 1. 36–4.17) and future liver remnant smaller than 40% (OR 2.40; 95% CI 1.31–4.38). The independent risk factors for 90-day mortality were age of 65 years or older (OR 2.40; 95% CI 1.36–4.23) and preoperative cholangitis (OR 2.25; 95% CI 1.30–3.87).ConclusionIn this study, no association could be demonstrated between hepatic steatosis or fibrosis and postoperative outcomes after resection of pCCA.

Estimated plasma volume status can help identify patients with sepsis at risk of death within 30 days in the emergency department

For patients with sepsis in the Emergency Department (ED), early risk stratification is important to improve prognosis. The study aimed to evaluate the predictive role of estimated plasma volume (ePVS) on admission to the ED. All sepsis patients who were admitted to our ED in 2021, were included in this prospective study. Multivariate models adjusted for patients' clinical characteristics were used to assess the contribution of ePVS to the independent prediction of death at 30 days. A total of 455 septic patients were enrolled and 16.9% of patients died. Patients who survived to 30 days had a mean ePVS of 5.19, while those who died at 30 days had a value of 5.74 (p=0.004). ePVS was an independent risk factor for 30-day mortality with an adjusted OR of 1.211 (95% CI 1.004–1.460, p=0.045). The AUROC of ePVS was 0.619 (95% CI 0.545–0.689). Decision tree analysis showed a predictive role for ePVS in less severe patients. In septic patients, ePVS is an independent predictor of 30-day mortality and may improve risk prediction in less severe patients.

Sex-specific disparities in patients undergoing isolated CABG

Study objectiveExamine sex-specific characteristics in patients undergoing coronary artery bypass grafting (CABG) at our institution. DesignRetrospective chart review was performed utilizing our institutional Society of Thoracic Surgeons (STS) database. SettingAn academic, quaternary care center from 2010 to 2021. Participants3163 females and 9573 males underwent isolated CABG. InterventionsThe institutional STS database was queried for preoperative, intraoperative, and postoperative variables. Main outcome measuresUnivariate comparisons between female and male groups were performed using chi-squared tests or fisher exact tests. Multivariate logistic regression was used to assess risk factors for 30-day mortality. ResultsFemales had more preoperative comorbidities than males, including hypertension, diabetes, peripheral arterial disease, cerebrovascular disease, renal failure, and prior myocardial infarction. Females more frequently underwent urgent (61 % vs. 58 %) or emergent CABG (5.8 % vs. 4.3 %) compared to males (p < 0.0001). Females experienced longer total intensive care unit (ICU) hours (48.3 h vs. 43.5 h) (p < 0.0001), were more frequently discharged to an extended care facility (13 % vs. 6.4 %) (p < 0.0001) and prescribed less aspirin and beta blocker therapy at discharge than males. In-hospital mortality was higher in females (1.9 % vs. 1.2 %, p = 0.002), as was 30-day mortality (2.7 % vs. 1.6 %, p = 0.0001). Female sex was an independent risk factor for 30-day mortality (odds ratio = 1.46, 95 % CI: 1.06, 2.03, p = 0.02). ConclusionOver the past decade, females undergoing CABG had more preoperative comorbidities, urgent and emergent operations, longer postoperative ICU stay and a higher risk of mortality than their male counterparts. Further studies must investigate these disparities to improve outcomes for females undergoing CABG.

Use of Spinal Anesthesia during Thoracic Endovascular Aortic Repair

The purpose of this study was to assess outcomes after spinal anesthesia (SA) versus general anesthesia (GA) in patients undergoing thoracic endograft placement and to evaluate the adjunctive use of cerebrospinal fluid drainage (CSFD) placement. A single-center retrospective review of patients that underwent thoracic endograft placement from 2001 to 2019 was performed. Patients were stratified based on the type of anesthesia they received: GA, SA or epidural, GA with CSFD, and SA with CSFD. Primary outcomes included 30-day mortality and length of stay (LOS). Baseline characteristics were analyzed with Student's t-test and Pearson's chi-squared test. Multivariate logistic regression analysis was performed to identify risk factors for 30-day mortality and longer LOS. A total of 333 patients underwent thoracic endograft placement; 104 patients received SA, 180 patients received GA, 30 patients received GA and CSFD, and 19 patients received SA and CSFD. Of the total patients, 16.2% underwent thoracic endograft placement for type B aortic dissection, 3.3% for type A aortic dissection, and 12.3% for penetrating ulcer. The mean age of the study population was 68.7years old. Patients undergoing SA were older with a mean age of 73.4years versus 64.7years for patients undergoing GA (P<0.001). Spinal anesthesia (SA) was preferred in patients at high risk for GA (>75years old: 52.9% vs. 33.3%, P<0.001; renal comorbidities: 20.6% vs. 10.6%, P=0.03, and current smokers: 26.7% vs. 9.6%, P<0.001). Length of stay (LOS) was decreased in the SA group (4.29days vs. 9.70days, P<0.001). There was a lower incidence of spinal cord ischemia in the SA group (1.0% vs. 2.2%, P=0.44), as well as significantly decreased 30-day mortality (0% vs. 5.6%, P=0.01), reintervention (19.2% vs. 26.8%, P=0.02), and return to the operating room (6.8% vs. 12.7%, P=0.02). Of the 19 patients that had SA+CSFD, there were no signs and symptoms of spinal cord ischemia and decreased incidence of perioperative complications (0% vs. 33.3%, P=0.01). There was no difference in the risk for intraoperative complications, neurologic complications, or 30-day mortality between GA+CSFD patients versus SA+CSFD patients. Age >75 (P=0.002), intraoperative complications (P<0.001), and perioperative complications (P=0.02) were associated with increased mortality after thoracic endograft placement per multivariate logistic regression analysis. Spinal anesthesia (SA) in select high-risk patients was associated with reduced 30-day mortality, neurologic complications, and LOS compared to GA. The concurrent use of spinal drainage and SA had satisfactory results compared to spinal drainage and GA.

Risk Factors for Postoperative Morbidity, Suture Insufficiency, Re-Surgery and Mortality in Patients with Gastroduodenal Perforation.

(1) Background: The aim of the present study was to identify risk factors associated with postoperative morbidity, suture/anastomotic insufficiency, re-surgery, and mortality in patients undergoing surgery for gastroduodenal perforation. (2) Methods: A retrospective analysis of 273 adult patients who received surgical treatment for gastroduodenal perforation from January 2006 to June 2021 at the University Hospital Erlangen was performed. The patient demographics and preoperative, intraoperative, and postoperative parameters were collected and compared among the different outcome groups (in-hospital morbidity, suture/anastomotic insufficiency, re-surgery, and 90-day mortality). (3) Results: In-hospital morbidity, suture/anastomotic insufficiency, need for re-surgery, and 90-day mortality occurred in 71%, 10%, 26%, and 25% of patients, respectively. The independent risk factors for morbidity were a significantly reduced general condition, a lower preoperative hemoglobin level, and a higher preoperative creatinine level. The independent risk factors for suture/anastomotic insufficiency could be identified as an intake of preoperative steroids and a perforation localization in the proximal stomach or duodenum. The four parameters were independent risk factors for the need for re-surgery: a significantly reduced general condition, a perforation localization in the proximal stomach, a higher preoperative creatinine level, and a higher preoperative CRP level. An age over 66 years and a higher preoperative CRP level were independent risk factors for 90-day mortality. (4) Conclusions: Our study could identify relevant risk factors for the postoperative outcome of patients undergoing surgical treatment for gastroduodenal perforation. Patients exhibiting the identified risk factors should receive heightened attention in the postoperative period and may potentially benefit from personalized and tailored therapy.

Screening Tool Risk Score Assessment in the Emergency Department for Geriatric (S-TRIAGE) in 28-day mortality

BackgroundThe number of older adults with a high risk of frailty and severe illness continues to increase. Moreover, physiological change and multiple comorbidities are challenging to triage in geriatrics. Therefore, we aimed to evaluate variables to predict 28-day mortality and develop a screening tool to predict mortality and lifesaving intervention among geriatric patients in the emergency department (ED).MethodsThis study was a retrospective, single-center, observational study at the ED of Ramathibodi Hospital, Bangkok. Patients aged ≥ 65 years who visited the ED between January 2018 and December 2019 were enrolled. In the development cohort, univariable logistic regression was used to identify predictors of 28-day mortality in older patients. A predictive model for mortality and the need for lifesaving intervention was developed by multivariable logistic regression. In addition, the score was validated with internal validation and compared between development and validation set by chi-square.ResultsWe enrolled 1393 patients. In the development cohort, among these 1002 patients, 103 (10.3%) of whom died within 28 days. Malignancy, shock index (SI), systolic blood pressure (SBP) < 100 mmHg, and altered mentation were independent risk factors of 28-day mortality. We developed new screening tools named the S-TRIAGE score, which has the respiratory rate (< 11, > 22 breaths/min), the ratio of pulse oximetric saturation to the fraction of inspired oxygen (< 420, 420–450), SI (> 1, 0.6–0.99), SBP < 100 mmHg, body temperature (< 36, > 37.5 °C), and mental change. The area under a receiver operating characteristic (ROC) curve of the S-TRIAGE score in the validation cohort was 0.826 [95% confidence interval (95%CI) 0.773–0.879] in predicting mortality and lifesaving intervention, and the clinical score classified patients into five groups.ConclusionThis study showed malignancy, hypotension, increased SI, and mental status change were predictive factors for 28-day mortality in older adults in the ED. The screening tool risk score for geriatrics used in this study is potentially a good predictor of mortality and lifesaving intervention in high-risk older patients in the ED.

IL-10 predicts the prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure combined with spontaneous bacterial peritonitis.

Spontaneous bacterial peritonitis (SBP) is common in patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF). The prognostic value of interleukin-related serum markers for patients with ACLF is coming to the fore. However, there is an unmet need to predict the survival of such patients. We aimed to analyze the independent predictors of 28- and 90-day mortality in HBV-ACLF patients with SBP. This was a retrospective study that included 368 patients with HBV-ACLF. In the SBP group, logistic regression analysis was used to understand the independent predictors of mortality at 28-day and 90-day. The accuracy of prediction was analyzed using the area under the receiver operating characteristic curve (AUROC). Finally, decision curve analysis (DCA) was used to determine the clinical utility value. Interleukin 10 (IL-10) levels were statistically significantly different between the HBV-ACLF group with SBP and without. Aspartate aminotransferase (AST), serum sodium, IL-10 and vasoactive drug treatment were independent risk factors for 28-day mortality. International normalized ratio (INR), AST and IL-10 were independent risk factors for 90-day mortality. IL-10 combined with the Chinese Severe Hepatitis B Study Group-ACLF II score (COSH-ACLF IIs) had excellent performance in predicting 28- and 90-day mortality (AUCs: 0.848 and 0.823, respectively). DCA analysis suggests promising clinical utility. IL-10 is an independent predictor of mortality at 28- and 90-day in HBV-ACLF patients with SBP and predictive performance is improved when combined with COSH-ACLF IIs.