Risk Of 30-day In-hospital Mortality Research Articles

Variation in risk-adjusted cardiac intensive care unit (CICU) length of stay and the association with in-hospital mortality: An analysis from the Critical Care Cardiology Trials Network (CCCTN) registry

BackgroundPrevious studies have suggested that there is wide variability in cardiac intensive care unit (CICU) length of stay (LOS); however, these studies are limited by the absence of detailed risk assessment at the time of admission. Thus, we evaluated inter-hospital differences in CICU LOS, and the association between LOS and in-hospital mortality. MethodsUsing data from the Critical Care Cardiology Trials Network (CCCTN) registry, we included 22,862 admissions between 2017 and 2022 from 35 primarily tertiary and quaternary CICUs that captured consecutive admissions in annual two-month snapshots. The primary analysis compared inter-hospital differences in CICU LOS, as well as the association between CICU LOS and all-cause in-hospital mortality using a Fine and Gray competing risk model. ResultsThe overall median CICU LOS was 2.2 (1.1-4.8) days, and the median hospital LOS was 5.9 (2.8-12.3) days. Admissions in the longest tertile of LOS tended to be younger with higher rates of pre-existing comorbidities, and had higher Sequential Organ Failure Assessment (SOFA) scores, as well as higher rates of mechanical ventilation, intravenous vasopressor use, mechanical circulatory support, and renal replacement therapy. Unadjusted all-cause in-hospital mortality was 9.3%, 6.7%, and 13.4% in the lowest, intermediate, and highest CICU LOS tertiles. In a competing risk analysis, individual patient CICU LOS was correlated (r2=0.31) with a higher risk of 30-day in-hospital mortality. The relationship remained significant in admissions with heart failure, ST-elevation myocardial infarction and non-ST segment elevation myocardial infarction. ConclusionsIn a large registry of academic CICUs, we observed significant variation in CICU LOS and report that LOS is independently associated with all-cause in-hospital mortality. These findings could potentially be used to improve CICU resource utilization planning and refine risk prognostication in critically ill cardiovascular patients.

CLINICAL VALUE OF SYNDECAN-1 LEVELS IN TRAUMA BRAIN INJURY: A META-ANALYSIS.

Background: Traumatic brain injury (TBI) is a head trauma usually associated with death and endothelial glycocalyx damage. Syndecan-1 (SDC-1)-a biomarker of glycocalyx degradation-has rarely been reported in meta-analyses to determine the clinical prognostic value in TBI patients. Methods: We looked into PubMed, EMBASE, Cochrane Library, and Web of Science databases from January 1, 1990, to May 1, 2023, to identify eligible studies. A meta-analysis was conducted using RevMan 5.4 and Stata 16.0 with the search terms "SDC-1" and "traumatic brain injury." Results: The present study included five studies with a total of 640 enrolled patients included. Syndecan-1 concentrations were higher in the isotrauma TBI group than in the non-TBI group (standardized mean difference [SMD] = 0.52; 95% CI: 0.03-1.00; P = 0.04). Subgroup analysis revealed statistical significance when comparing the SDC-1 level of multitrauma TBI (TBI + other injuries) group with the isotrauma TBI group (SMD = 0.74; 95% CI: 0.42-1.05; P < 0.001), and the SDC-1 level of the TBI coagulopathy (+) group (TBI with early coagulopathy) with the TBI coagulopathy (-) group (SMD = 1.75; 95% CI: 0.41-3.10; P = 0.01). Isotrauma TBI patients with higher SDC-1 level were at a higher risk of 30-day in-hospital mortality (odds ratio = 3.32; 95% CI: 1.67-6.60; P = 0.0006). Conclusion: This meta-analysis suggests that SDC-1 could be a biomarker of endotheliopathy and coagulopathy in TBI, as it was increased in isotrauma TBI patients and was higher in multitrauma TBI patients. There is a need for additional research into the use of SDC-1 as a prognostic biomarker in TBI, especially in isotrauma TBI patients.

Factors associated with 30-day in-hospital mortality in critically ill adult patients receiving extracorporeal membrane oxygenation: A retrospective cohort study

ObjectiveTo identify factors associated with the 30-day in-hospital mortality rate among adult patients requiring extracorporeal membrane oxygenation (ECMO) in intensive care units. Research MethodologyRetrospective cohort study including 148 patients who underwent ECMO for at least 48 h between March 2010 and August 2021. The patients were divided into survivors and non-survivors based on their 30-day in-hospital survival. We obtained the sociodemographic information and pre- and post-ECMO data from electronic medical records. Kaplan–Meier survival curves and Multivariate Cox proportional hazards regression were used to analyse the data. SettingA tertiary-care university hospital in South Korea. Main Outcome MeasuresThe 30-day in-hospital mortality rate was the principal outcome measure. ResultsThe 30-day in-hospital mortality rate was 49.3% (n = 73). Kaplan–Meier analysis demonstrated that the duration of ECMO support in the 50th percentile of surviving patients was 13 days. Multivariable Cox regression analysis showed that new-onset renal failure, lower mean arterial pressure, and ECMO weaning failure were associated with an increased 30-day in-hospital mortality risk among patients who received ECMO. Subgroup analysis also revealed a significant association between weaning failure and 30-day in-hospital mortality after adjusting for covariates in patients undergoing veno-arterial ECMO. ConclusionClose monitoring of post-ECMO renal function and mean arterial pressure is required to minimize the risk of 30-day in-hospital mortality, especially in adults within the first two weeks of ECMO initiation. Moreover, the success of ECMO weaning should be optimized by collaboration within the ECMO team. Implications for Clinical PracticeCritical care nurses should pay close attention to patients’ response to weaning trials as well as alternations in renal function and mean arterial pressure during ECMO support. Furthermore, developing nursing care guidelines for adult patients receiving ECMO and standardized training programs for nurses in intensive care, are required in Korea.

Preoperative renal insufficiency predicts postoperative adverse outcomes in a mixed surgical population: a retrospective matched cohort study using the NSQIP database.

The incidence of chronic kidney disease is increasing, but most cases are not diagnosed until the accidental finding of abnormal laboratory data or the presentation of severe symptoms. Patients with chronic kidney disease are reported to have an increased risk of postoperative mortality and morbidities, but previous studies mainly targeted populations undergoing cardiovascular surgery. The authors aimed to evaluate the risk of postoperative mortality and complications in a surgical population with preoperative renal insufficiency (RI). This retrospective cohort study used data from the National Surgical Quality Improvement Program database between 2013 and 2018 to evaluate the risk of postoperative morbidity and mortality in the surgical population. Patients with estimated glomerular filtration rate less than 60ml/min/1.73m2 were defined as the RI group. Propensity score matching methods and multivariate logistic regression were used to calculate the risk of postoperative morbidity and mortality. After propensity score matching, 502281 patients were included in the RI and non-RI groups. The RI group had a higher risk of 30-day in-hospital mortality (odds ratio: 1.54, 95% CI: 1.49-1.58) than the non-RI group. The RI group was associated with a higher risk of postoperative complications, including myocardial infarction, stroke, pneumonia, septic shock, and postoperative bleeding. The RI group was also associated with an increased risk of prolonged ventilator use for over 48h, readmission, and reoperation. Patients with preoperative RI have an increased risk of postoperative 30-day mortality and complications. RI group patients with current dialysis, estimated glomerular filtration rate less than or equal to 30ml/min/1.73m2 or concomitant anemia had an elevated risk of postoperative mortality.

Melatonin use and the risk of 30-day mortality among USveterans with sepsis: A retrospective study.

Prior research suggests melatonin has beneficial effects that could improve survival among sepsis patients. This exploratory analysis sought to compare 30-day survival among melatonin treated and untreated patients with sepsis. A retrospective cohort study was conducted among patients with a primary inpatient admission diagnosis for sepsis utilizing the International Classification of Diseases, versions 9 and 10, Clinical Modification(ICD-9-CM and ICD-10-CM) diagnosis codes between 2000 and 2021. Propensity score weighting was utilized, accounting for demographic, clinical, and laboratory factors. Weighted Cox models were estimated for 30-day in-hospital and 30-day overall survival. A total of 9386 patients were included in the study with 593 exposed to melatonin within the first day of hospitalization. Propensity score weighted Cox models reveal melatonin was associated with a 37.9% decreased risk of 30-day in-hospital mortality (HR = 0.621; 95% CI = [0.415-0.931]) and a 33.5% decreased risk of 30-day overall mortality (HR = 0.665; 95% CI = [0.493-0.897]). Factors associated with higher risk of both in-hospital and overall mortality include male sex, white race, age, higher Charlson comorbidity burden, sodium and potassium levels, intensive care unit stay, invasive ventilation, and vasopressor use. Higher serum albumin levels are associated with lower mortality risks. Among patients diagnosed with sepsis, exposure to melatonin was associated with a lower in-hospital and 30-day mortality. Additional research is warranted to fully understand the role of melatonin in sepsis.

Effect of influenza vaccination on the outcomes of hospitalization for kidney disease in a geriatric population: A propensity-score matched study.

Background and aimsThe effects of influenza vaccination (IV) on the outcomes of patients with kidney disease (KD) are not completely understood. We aimed to evaluate and compare the outcomes during admission of KD between elderly patients who did or did not receive an IV within the previous 12 months.MethodsWe used health insurance research data in Taiwan and conducted a population-based cohort study that included 22,590 older people aged ≥ 65 years who were hospitalized for KD in 2008–2013. We performed propensity score matching (case-control ratio 1:1) to select 4386 eligible IV recipients and 4386 nonrecipient controls for comparison. The adjusted odds ratios (ORs) with 95% confidence intervals (CIs) of IV associated with complications and mortality during KD admission were calculated using multivariable logistic regression analyses.ResultsDuring hospitalization for KD, IV was significantly associated with lower risks of 30-day in-hospital mortality (OR 0.56, 95% CI 0.39–0.82), septicemia (OR 0.77, 95% CI 0.68–0.87), and intensive care (OR 0.85, 95% CI 0.75–0.96). Additionally, IV recipients had a shorter length of hospital stay and lower medical expenditure than nonrecipients. Subgroup analyses further showed that the association of IV with reduced adverse events was confined to patients aged ≥ 75 years.ConclusionsPrevious IV was associated with reduced risks of complications and mortality and in elderly patients hospitalized for KD. We raised the possibility and suggested the need to promote IV for this susceptible population of patients with KD.

Development and Validation of a 30-Day In-hospital Mortality Model Among Seriously Ill Transferred Patients: a Retrospective Cohort Study.

BackgroundPredicting the risk of in-hospital mortality on admission is challenging but essential for risk stratification of patient outcomes and designing an appropriate plan-of-care, especially among transferred patients.ObjectiveDevelop a model that uses administrative and clinical data within 24 h of transfer to predict 30-day in-hospital mortality at an Academic Health Center (AHC).DesignRetrospective cohort study. We used 30 putative variables in a multiple logistic regression model in the full data set (n = 10,389) to identify 20 candidate variables obtained from the electronic medical record (EMR) within 24 h of admission that were associated with 30-day in-hospital mortality (p < 0.05). These 20 variables were tested using multiple logistic regression and area under the curve (AUC)–receiver operating characteristics (ROC) analysis to identify an optimal risk threshold score in a randomly split derivation sample (n = 5194) which was then examined in the validation sample (n = 5195).ParticipantsTen thousand three hundred eighty-nine patients greater than 18 years transferred to the Indiana University (IU)–Adult Academic Health Center (AHC) between 1/1/2016 and 12/31/2017.Main MeasuresSensitivity, specificity, positive predictive value, C-statistic, and risk threshold score of the model.Key ResultsThe final model was strongly discriminative (C-statistic = 0.90) and had a good fit (Hosmer-Lemeshow goodness-of-fit test [X2 (8) =6.26, p = 0.62]). The positive predictive value for 30-day in-hospital death was 68%; AUC-ROC was 0.90 (95% confidence interval 0.89–0.92, p < 0.0001). We identified a risk threshold score of −2.19 that had a maximum sensitivity (79.87%) and specificity (85.24%) in the derivation and validation sample (sensitivity: 75.00%, specificity: 85.71%). In the validation sample, 34.40% (354/1029) of the patients above this threshold died compared to only 2.83% (118/4166) deaths below this threshold.ConclusionThis model can use EMR and administrative data within 24 h of transfer to predict the risk of 30-day in-hospital mortality with reasonable accuracy among seriously ill transferred patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06593-z.

In Hospital Outcomes of Patients With Right Bundle Branch Block and Anterior Wall ST-Segment Elevation Myocardial Infarction (From a Nationwide Study Using the National Inpatient Sample)

Previous studies have reported worse outcomes for patients with right bundle branch block (RBBB) complicating acute ST-segment elevation myocardial infarction (STEMI). There is a paucity of data examining outcomes with RBBB and STEMI in contemporary large-scale studies. This study aims to explore the outcomes of patients with anterior wall STEMI (AW-STEMI) and RBBB. Using ICD-9 codes, we queried the National Inpatient Sample of 1999 to 2014 to identify AW-STEMI admissions and stratified them for the presence of RBBB. Primary outcome was in-hospital mortality within 30 days. Secondary outcomes included acute heart failure, complete heart block, and permanent pacemaker implantation. Cox-proportional logistic regression models were used to determine the hazard ratios of the primary outcome and secondary outcomes and interventions. Among 1,075,875 weighted anterior wall STEMI (AW-STEMI) admissions, 19,153 (1.8%) had RBBB. Compared with patients without RBBB, mortality was significantly higher for patients with RBBB (9.2% vs 15.3%; p <0.0001). RBBB in the setting of AW-STEMI was associated with a 66% increased risk of 30-day in-hospital mortality (hazard ratios [HR], 1.66; 95% confidence interval [CI], 1.52 to1.81; p <0.0001) and a higher likelihood of acute heart failure (HR, 1.37; 95% CI, 1.29 to 1.45; p <0.0001), complete heart block (HR, 2.90; 95% CI, 2.64 to 3.18; p <0.0001) and utilization of a permanent pacemaker (HR, 2.51; 95% CI, 1.89 to 3.35; p <0.0001). In conclusion, the presence of RBBB in the setting of an AW-STEMI is a significant independent predictor of a poor prognosis, including a higher rate of acute heart failure, complete heart block, need for a permanent pacemaker, and a higher 30-day in-hospital mortality.

Preexisting Dementia Is Associated with Increased Risks of Mortality and Morbidity Following Major Surgery: A Nationwide Propensity Score Matching Study.

Patients with dementia are predisposed to multiple physiological abnormalities. It is uncertain if dementia associates with higher rates of perioperative mortality and morbidity. We used reimbursement claims data of Taiwan’s National Health Insurance and conducted propensity score matching analyses to evaluate the risk of mortality and major complications in patients with or without dementia undergoing major surgery between 2004 and 2013. We applied multivariable logistic regressions to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for the outcome of interest. After matching to demographic and clinical covariates, 7863 matched pairs were selected for analysis. Dementia was significantly associated with greater risks of 30-day in-hospital mortality (aOR: 1.71, 95% CI: 1.09–2.70), pneumonia (aOR: 1.48, 95% CI: 1.16–1.88), urinary tract infection (aOR: 1.59, 95% CI: 1.30–1.96), and sepsis (OR: 1.77, 95% CI: 1.34–2.34) compared to non-dementia controls. The mortality risk in dementia patients was attenuated but persisted over time, 180 days (aOR: 1.49, 95% CI: 1.23–1.81) and 365 days (aOR: 1.52, 95% CI: 1.30–1.78) after surgery. Additionally, patients with dementia were more likely to receive blood transfusion (aOR: 1.32, 95% CI: 1.11–1.58) and to need intensive care (aOR: 1.40, 95% CI: 1.12–1.76) compared to non-dementia controls. Senile dementia and Alzheimer’s disease were independently associated with higher rates of perioperative mortality and complications, but vascular dementia was not affected. We found that preexisting dementia was associated with mortality and morbidity after major surgery.

Presentation characteristics, use of treatments and outcomes in patients with ischaemic vs. non-ischaemic cardiogenic shock

Abstract Aim Evidence on non-ischaemic cardiogenic shock (CS) is scarce. The aim of this study was to investigate differences in presentation characteristics, use of treatments and outcomes in patients with ischaemic vs. non-ischaemic CS. Methods Patients with CS admitted to a tertiary care hospital between October 2009 and October 2017 were identified and stratified as ischaemic CS/non-ischaemic CS based on the presence/absence of acute myocardial infarction. Missing data was handled by chained equation multiple imputation. Logistic and Cox regression models were fitted to investigate the association of non-ischaemic CS with presentation characteristics (adjusted for all baseline variables), and use of treatments as well as30-day in-hospital mortality (adjusted for relevant confounders including age, sex, prior cardiac arrest, haemodynamics, pH and lactate). Results A total of 978 patients were enrolled in this study; median age was 70 (interquartile range 58, 79) years and 70% were male. 505 patients (43%) had non-ischaemic CS. Patients with non-ischaemic CS were more likely younger and female; were less likely to be active smokers or to have diabetes, but more likely to have chronic renal disease and history of myocardial infarction; and were more likely to present with unfavourable haemodynamics and with mechanical ventilation. Regarding use of treatments, patients with non-ischaemic CS were more likely to be treated with catecholamines [odds ratio (OR) 1.58, 95% confidence interval (CI) 1.11–2.27, p0.01], but less likely to be treated with extracorporeal membrane oxygenation (OR 0.66, 95% CI 0.48–0.92, p=0.02) or percutaneous left ventricular assist devices (OR 0.51, 0.35–0.74, p&amp;lt;0.01). Unadjusted survival probabilities in patients with non-ischaemic vs. ischaemic CS were 36% (95% CI 32–42%) vs. 39% (95% CI 35–45%). After adjustment for multiple relevant confounders, non-ischaemic CS was associated with a significant increase in the risk of 30-day in-hospital mortality (hazard ratio 1.30, 95% CI 1.09–1.55, p&amp;lt;0.01, Figure 1). Conclusion In this large study, non-ischaemic CS accounted for almost 50% of all CS cases. Non-ischaemic CS was not only associated with relevant differences in presentation characteristics and use of treatments, but also with a worse prognosis. These findings highlight the need for effective treatment strategies for patients with non-ischaemic CS. Figure 1 Funding Acknowledgement Type of funding source: None

Patient Characteristics, Treatment and Outcome in Non-Ischemic vs. Ischemic Cardiogenic Shock.

Aim: Evidence on non-ischemic cardiogenic shock (CS) is scarce. The aim of this study was to investigate differences in patient characteristics, use of treatments and outcomes in patients with non-ischemic vs. ischemic CS. Methods: Patients with CS admitted between October 2009 and October 2017 were identified and stratified as non-ischemic/ischemic CS based on the absence/presence of acute myocardial infarction. Logistic/Cox regression models were fitted to investigate the association between non-ischemic CS and patient characteristics, use of treatments and 30-day in-hospital mortality. Results: A total of 978 patients were enrolled in this study; median age was 70 (interquartile range 58, 79) years and 70% were male. Of these, 505 patients (52%) had non-ischemic CS. Patients with non-ischemic CS were more likely to be younger and female; were less likely to be active smokers, to have diabetes or decreased renal function, but more likely to have a history of myocardial infarction; and they were more likely to present with unfavorable hemodynamics and with mechanical ventilation. Regarding treatments, patients with non-ischemic CS were more likely to be treated with catecholamines, but less likely to be treated with extracorporeal membrane oxygenation or percutaneous left-ventricular assist devices. After adjustment for multiple relevant confounders, non-ischemic CS was associated with a significant increase in the risk of 30-day in-hospital mortality (hazard ratio 1.14, 95% confidence interval 1.04–1.24, p < 0.01). Conclusion: In this large study, non-ischemic CS accounted for more than 50% of all CS cases. Non-ischemic CS was not only associated with relevant differences in patient characteristics and use of treatments, but also with a worse prognosis. These findings highlight the need for effective treatment strategies for patients with non-ischemic CS.

Prognostic Value of QRS Duration among Patients with Cardiogenic Shock Complicating Acute Heart Failure: Data from the Korean Acute Heart Failure (KorAHF) Registry.

Background and ObjectivesProlonged QRS duration is associated with poor outcomes in patients with chronic heart failure (HF). However, the prognostic value of QRS duration in patients with cardiogenic shock complicating acute HF remains unknown. We evaluated the hypothesis that prolonged QRS duration may be associated with short-term mortality among acute HF patients with cardiogenic shock (CS).MethodsFrom March 2011 through December 2013, a total of 5,625 acute HF patients were consecutively enrolled in ten tertiary university hospitals. Among them, we analyzed patients who presented with CS. Patients were divided into three groups by QRS duration cutoff values of 130 and 150 ms. The primary endpoint was 30-day in-hospital mortality.ResultsTwo hundred eleven patients presented with CS at admission and those with available electrocardiograms were included in this analysis. There were 35 patients with QRS durations of 150 ms or above, 30 patients with QRS durations between 130 ms and 150 ms, and 146 patients with QRS durations below 130 ms. The 30-day all cause in-hospital mortality rates were 43.7%, 33.1%, and 24.9%, respectively. After multivariate adjustment, severe prolonged QRS duration was a significant prognostic factor for 30-day in-hospital mortality (hazard ratio, 1.909; 95% confidence interval, 1.024–3.558; p=0.042).ConclusionsProlonged QRS duration was associated with a higher risk of 30-day in-hospital mortality among patients with acute HF who presented with CS.Trial RegistrationClinicalTrials.gov Identifier: NCT01389843

Risk prediction of in-hospital mortality in patients with venoarterial extracorporeal membrane oxygenation for cardiopulmonary support: The ECMO-ACCEPTS score

PurposeVenoarterial extracorporeal membrane oxygenation (VA-ECMO) is an increasingly used treatment option for patients in need of mechanical cardiopulmonary support, while available outcome data is limited. The aim of this study was to identify predictors for 30-day in-hospital mortality. Material and methodsWe analyzed baseline characteristics and outcomes of 8351 VA-ECMO procedures performed in Germany from 2007 to 2015. Using a multivariable model, we identified the ten most important variables to allow for prediction of 30-day in-hospital mortality. Based on these variables, we created a mortality prediction score (ECMO-ACCEPTS score) to enhance decision making in patients considered for or treated with VA-ECMO support. ResultsOf 8351 patients (71.7% male) 3567 had prior CPR. Mean age was 62 years in the present cohort. The overall 30-day in-hospital mortality was 61%. The ECMO-ACCEPTS score, derived among randomly selected 4175 patients, included ten independent predictors for in-hospital mortality. Internal validation in the remaining 4176 patients confirmed strong differentiation between low and high risk of 30-day in-hospital mortality (r = 0.97 for correlation of predicted with observed mortality, p < .001). ConclusionsThe ECMO-ACCEPTS score might help clinicians to improve risk prediction among VA-ECMO patients for refractory cardiogenic shock.

In-hospital 30-day mortality for older patients with pancreatic cancer undergoing pancreaticoduodenectomy

ObjectiveSurgical resection remains the only potentially curative therapy for pancreatic ductal adenocarcinoma (PDAC). There is paucity of literature about morbidity and mortality in older patients with PDAC undergoing pancreaticoduodenectomy. This retrospective analysis evaluates the in-hospital 30-day mortality of this population utilizing the Nationwide Inpatient Sample (NIS) database. Subjects and MethodsAll US patients hospitalized for pancreaticoduodenectomy (Whipple procedure) were included. Data was obtained from the NIS provided by the Agency for Healthcare Research and Quality. Pancreaticoduodenectomy diagnoses were identified using Clinical Classifications Software codes based on ICD-9 between 2007 and 2010. Univariable and multivariable analyses were performed using the logistic model, weighted chi-square test, and generalized linear model. ResultsA total of 6149 patient discharges for pancreaticoduodenectomy were identified. Mean age was 64.9 years (SD ± 12.3); 21% of patients were ≥ 76 years of age. Majority were White (N = 5257, 77.9%) with a male:female ratio of 1. Patients aged 76 and older (OR: 1.76; 1.36–2.28; p < .001), Hispanics (OR: 1.40; 0.92–2.13; p = .12), and high comorbidity score (OR: 5.70; 3.44–9.46; p < .001) were found to be associated with a higher risk of 30-day in-hospital mortality. In the multivariable analysis, advanced age (>76) remained a significant predictor of longer in-hospital length of stay (OR: 1.09; 1.04–1.14; p < .001) and 30-day in-hospital mortality (OR 1.46; 1.07–2.00; p = .016). The 30-day in-hospital mortality rate for all patients across all years was 3.24%, for patients >76 years 4.11% and for patients <76 years 2.77%. Patients who underwent surgery at teaching hospitals (OR: 0.61; 0.42–0.88; p = .008) had a lower risk of 30-day in-hospital mortality compared to non-teaching hospitals. ConclusionIn-hospital 30 day mortality was higher in selected older patients with PDAC undergoing pancreaticoduodenectomy. Mortality was lower at high volume and teaching centers. Further stringent selection criteria are needed to decrease mortality in the older population.

Kidney Stone History and Adverse Outcomes After Percutaneous Coronary Intervention

ObjectiveTo determine whether kidney stone history is associated with adverse outcomes after percutaneous coronary intervention (PCI). Kidney stone formers have an increased risk of developing coronary artery disease; however, whether these patients have worse cardiac outcomes is unknown. Materials and MethodsWe identified adult patients who underwent first-time PCI in Vanderbilt University Medical Center (VUMC) Synthetic Derivative from 2008 to 2016 (n = 11,289) and in a nationwide database of Taiwan (NHIRD) from 2005 to 2012 (n = 155,762). Odds ratios (ORs) of 30-day in-hospital mortality and hazard ratios (HRs) of 1-year and 3-year adverse outcomes associated with kidney stone history were estimated using a propensity score approach. ResultsOverall, 294 and 12,286 stone formers undergoing PCI were identified in the VUMC and NHIRD, respectively. After matching, stone formers at VUMC were at higher risks of 30-day in-hospital mortality (OR 2.79, 95% CI 1.15-6.69) and 1-year (HR 1.59, 95% CI 1.13-2.24) and 3-year (HR 1.36, 95% CI 1.02-1.81) myocardial infarction. In the NHIRD, kidney stone history was associated with 1-year (HR 1.12, 95% CI 1.03-1.21) and 3-year (HR 1.14, 95% CI 1.06-1.22) myocardial infarction. In a sensitivity analysis, stone formers undergoing kidney stone surgery were marginally associated with 30-day in-hospital mortality (OR 1.21, 95% CI 0.99-1.48) and were associated with 3-year myocardial infarction (HR 1.13, 95% CI 1.02-1.25). ConclusionKidney stone history is associated with poorer cardiac outcomes after PCI. Improving secondary cardiac prevention strategies after PCI may be necessary for patients with a history of kidney stone disease.

A novel heart rate variability based risk prediction model for septic patients presenting to the emergency department.

A quick, objective, non-invasive means of identifying high-risk septic patients in the emergency department (ED) can improve hospital outcomes through early, appropriate management. Heart rate variability (HRV) analysis has been correlated with mortality in critically ill patients. We aimed to develop a Singapore ED sepsis (SEDS) predictive model to assess the risk of 30-day in-hospital mortality in septic patients presenting to the ED. We used demographics, vital signs, and HRV parameters in model building and compared it with the modified early warning score (MEWS), national early warning score (NEWS), and quick sequential organ failure assessment (qSOFA) score.Adult patients clinically suspected to have sepsis in the ED and who met the systemic inflammatory response syndrome (SIRS) criteria were included. Routine triage electrocardiogram segments were used to obtain HRV variables. The primary endpoint was 30-day in-hospital mortality. Multivariate logistic regression was used to derive the SEDS model. MEWS, NEWS, and qSOFA (initial and worst measurements) scores were computed. Receiver operating characteristic (ROC) analysis was used to evaluate their predictive performances.Of the 214 patients included in this study, 40 (18.7%) met the primary endpoint. The SEDS model comprises of 5 components (age, respiratory rate, systolic blood pressure, mean RR interval, and detrended fluctuation analysis α2) and performed with an area under the ROC curve (AUC) of 0.78 (95% confidence interval [CI]: 0.72–0.86), compared with 0.65 (95% CI: 0.56–0.74), 0.70 (95% CI: 0.61–0.79), 0.70 (95% CI: 0.62–0.79), 0.56 (95% CI: 0.46–0.66) by qSOFA (initial), qSOFA (worst), NEWS, and MEWS, respectively.HRV analysis is a useful component in mortality risk prediction for septic patients presenting to the ED.

Prediction of multiple organ dysfunction syndrome complicating acute myocardial infarction on the basis of comorbidities on admission.

Acute myocardial infarction (AMI) can be complicated by multiple organ dysfunction syndrome (MODS), but the exact influence of MODS on AMI remains unclear. This was a retrospective study of 6674 Chinese patients with AMI. The impact of MODS was assessed using the Cox proportional hazard model. Using the occurrence of MODS as the outcome, a prediction model was developed using the factors identified by logistic regression analysis and analyzed using receiving operator characteristic curves. Of 6674 patients with AMI, 83 (1.2%) progressed to MODS. MODS independently predicted the risk of 30-day in-hospital mortality [hazard ratio, 2.3; 95% confidence interval (95% CI), 1.7-3.2; P<0.001]. Advanced age [odds ratio (OR), 2.76; 95% CI, 1.26-6.03; P=0.011 for age 65-74 years; OR, 4.85; 95% CI, 2.96-7.93; P<0.001 for age ≥75 years), pneumonia (OR, 4.27; 95% CI, 2.68-6.81; P<0.001), and chronic renal failure (OR, 2.09; 95% CI, 1.09-4.01; P=0.027) were associated independently with MODS. The area under the receiving operator characteristic curve for the predictive model was 0.802, indicating a good predictive value. MODS can predict the worst severity of AMI. Using common clinical variables, it is possible to identify patients with AMI who are at high risk of MODS. Additional studies are necessary to confirm this model.

Indication Bias Explains Some of the Observed Increased Mortality Associated With Use of Prehospital Intravenous Fluids in a Pediatric Trauma Population.

Traditionally, in both pediatric and adult trauma patients, management of hemorrhage and shock has included early rapid intravenous fluid (IVF) replacement at the scene or during transport to a definitive care facility. Because prehospital resuscitation can be considered as a lifesaving intervention, severely injured patients are more likely to receive IVF. Observational studies not adequately adjusting for this confounding by indication (indication bias) while evaluating the impact of prehospital IVF on mortality in clinically heterogeneous patient populations are likely to find an increased mortality associated with the use of prehospital IVF, an association that may be spurious even after traditional multivariable risk adjustment. Propensity scores can be used to mitigate the impact of this selection bias on the estimated effect. The authors hypothesized that the effect of IVF on mortality will differ based on whether propensity scores (based on a set of prehospital indications for IVF) are adjusted for in a multivariable outcome model. This was a retrospective cohort study of severely injured pediatric (<18 years) patients consecutively evaluated and treated between January 1, 2008, and June 30, 2011, at Oklahoma's only Level I pediatric trauma center. Patients were divided into those receiving 250mL or more (GE250 group) and those receiving less (LT250 group) of prehospital IVF based on area under curve (AUC) analysis (AUC=0.7, 95% confidence interval [CI]=0.6 to 0.80, sensitivity=0.81 and specificity=0.56). Propensity scores were used to minimize confounding by indication of the mortality estimate and were calculated based on measurable prehospital factors. Using Cox's regression to minimize survival bias, the independent effect of prehospital IVF on the risk of 30-day in-hospital mortality was evaluated with and without adjusting for the propensity to receive 250mL of prehospital IVF. A total of 482 patients met study criteria. Of these, 46.3% (223 of 449) were in the GE250 group. After adjusting for Injury Severity Score, presence of a severe head injury, shock, and a penetrating injury, all of which were significant predictors of mortality, receiving 250mL or more of prehospital IVF was significantly associated with an almost threefold increase in the risk of 30-day in-hospital mortality (hazard ratio [HR]= 2.96, 95% CI=1.1 to 8.2). However, further adjusting for the propensity to be in the GE250 group, in addition to the aforementioned variables, attenuated the effect estimate and resulted in a nonsignificant (p=0.3408), more precise association between prehospital IVF and mortality (HR= 1.9, 95% CI=0.6 to 6.6). Propensity-adjusted survival analysis suggests that the observed increased risk in mortality associated with use of prehospital IVF replacement may be a spurious association resulting from inadequate control of confounding by indication inherent in observational studies. In the absence of patient subgroup-specific results from well-controlled studies, IVF resuscitation should not be a reason to delay patient transport to a definitive care facility. Randomized trials evaluating the effect of prehospital fluids are warranted in the pediatric trauma population, as such studies have shown clinical significance in the adult trauma population.

The effects of a tailored intensive care unit delirium prevention protocol: A randomized controlled trial

BackgroundA decreased incidence of delirium following the application of non-pharmacologic intervention protocols to several patient populations has been previously reported. However, few studies have been conducted to examine the effects of their application to intensive care unit (ICU) patients. ObjectivesTo examine the effects of applying a tailored delirium preventive protocol, developed by the authors, to ICU patients by analyzing its effects on delirium incidence, in-hospital mortality, ICU readmission, and length of ICU stay in a Korean hospital. DesignA single-blind randomized controlled trial. SettingsA 1049-bed general hospital with a 105-bed ICU. ParticipantsSixty and 63 ICU patients were randomly assigned to the intervention and control groups, respectively. MethodsThe researchers applied the delirium prevention protocol to the intervention group every day for the first 7 days of ICU hospitalization. Delirium incidence, mortality, and re-admission to the ICU during the same hospitalization period were analyzed by logistic regression analysis; the 7- and 30-day in-hospital mortality by Kaplan–Meier survival and Cox proportional hazard regression analysis; and length of ICU stay was assessed by linear regression analysis. ResultsApplication of the protocol had no significant effect on delirium incidence, in-hospital mortality, re-admission to the ICU, or length of ICU stay. Whereas the risk of 30-day in-hospital mortality was not significantly lower in the intervention than in the control group (OR: 0.33; 95% CI: 0.10–1.09), we found a significantly decreased 7-day in-hospital mortality in the intervention group after protocol application (HR: 0.09; 95% CI: 0.01–0.72). ConclusionsApplication of a tailored delirium prevention protocol to acute stage patients during the first 7 days of ICU hospitalization appeared to reduce the 7-day in-hospital risk of mortality only for this patient population.

Facility characteristics and inhospital pediatric mortality after severe traumatic brain injury.

More than 500,000 children sustain a traumatic brain injury (TBI) each year. Previous studies have described significant variation in inhospital mortality after pediatric TBI. The aim of this study was to identify facility-level characteristics independently associated with 30-day inhospital mortality after pediatric severe TBI. We hypothesized that, even after accounting for patient-level characteristics associated with mortality, the characteristics of facilities where patients received care would be associated with inhospital mortality. Using data from the National Trauma Data Bank from 2009-2012, we identified a cohort of 6707 pediatric patients hospitalized with severe TBI in 391 facilities and investigated their risk of 30-day inhospital mortality. Pre-specified facility-level characteristics (trauma certification level, teaching status, census region, facility size, nonprofit status, and responsibility for pediatric trauma care) were added to a Poisson regression model that accounted for patient-level characteristics associated with mortality. In multivariable analyses, patients treated in facilities located in the Midwest (risk ratio [RR]=1.42; 95% confidence interval [CI] 1.12-1.81) and South (RR=1.39; 95% CI: 1.12-1.72) regions had higher likelihoods of 30-day inhospital mortality compared with patients treated in the Northeast. Other facility-level characteristics were not found to be significant. To our knowledge, this is one of the largest investigations to identify regional variation in inhospital mortality after pediatric severe TBI in a national sample after accounting for individual and other facility-level characteristics. Further investigations to help explain this variation are needed to inform evidence-based decision-making for pediatric severe TBI care across different settings.