Significant Risk Factor For Mortality Research Articles

The value of trauma patients’ centralization: an analysis of a regional Italian Trauma System performance with TMPM-ICD-9

In recent years, many studies showed that the Trauma Mortality Probability Model (TMPM-ICD-9) had better calibration compared to other ICD-9-based models and to the ones based to the Abbreviated Injury Scale (AIS). The study aims to assess the validity of TMPM-ICD-9 in predicting injury severity in an Italian region and, through this model, to assess the performances of the Trauma Systems SIAT Romagna. Administrative data of trauma patients admitted in the Trauma System of SIAT Romagna, in Northern Italy, from 2014 to 2018 were obtained. The XISS, an indirect indicator of Injury Severity Score (ISS) and the TMPM-POD (Probability of Death) were calculated from ICD-9-CM codes. Only patients with XISS > 15 were included. Student t-test, Mann-Whitney test and Chi-square test were used for univariate analyses, while logistic regression for multivariate analyses. 3907 trauma patients with XISS > 15 were included. The Hub hospital (HUB) received 47.1% of these patients. Patients treated in HUB had higher TMPM-POD than in SPOKE + PST (mean TMPM-POD ± SD: HUB 0.093 ± 0.091, SPOKE + PST 0.082 ± 0.90, p < 0.027), but only age and sex were significant risk factors for centralization at multivariate analyses. Higher age (73.1 ± 21.2 vs 66.9 ± 21.2, p < 0.001), higher XISS (16(9) vs 16(4), p < 0.001) and higher TMPM-POD (0.15 ± 0.14 vs 0.08 ± 0.08, p < 0.001) resulted significant risk factors for mortality at multivariate analysis. Lower age, higher XISS and lower Trauma Centers (TC) level were significant risk factors for splenectomy at multivariate analysis. The splenectomy rate was 1.3% in HUB and of 2.2% in SPOKE + PST (Risk Ratio = 0.4, p = 0.002). Present analysis proved the validity of TMPM-ICD-9 in predicting mortality of trauma patients in an Italian region. Furthermore, the usefulness of data extracted from an administrative database to assess the performance of a TS and the importance of an adequate centralization process have emerged. Even with a higher TMPM-POD and with the same mortality rate, HUB showed a higher spleen salvage rate compared to SPOKE + PST. However, thanks to this model, an improvable centralization process in SIAT Romagna was found in the study period. Probably, an enhanced centralization would have improved the spleen salvage rate, which is an important quality indicator in the evaluation of the performance of the TS.

Risk Factors of Mortality in Patients with Bloodstream Infections Due to Carbapenem Resistant Klebsiella pneumoniae

Objective: Carbapenem-resistant Klebsiella pneumoniae (CRKp) is among the leading causes of hospital-acquired infections worldwide and causes serious and life-threatening infections. Treatment options are very limited for blood stream infections (BSIs) and prognosis is poor due to increasing multi-drug resistance. The aim of this study was to assess risk factors for the mortality due to CRKp-BSI. Methods: A retrospective study was conducted in a university hospital from September 2013 to October 2017. Patients (aged &gt;16 years) with CRKp-BSI were included in this study. Data, including demographics, Charlson comorbidity index (CCI), acute physiology and chronic health evaluation II (APACHE II) score on hospitalisation date, minimum inhibitory concentration (MIC) of CRKp, antibiotic treatment and outcome (30-day mortality) data were collected from the electronic medical records and microbiology databases. Results: A total of 82 patients with CRKP-BSIs were analysed. The median age was 54.5 years, and 48 (58.5%) of them were male. The median APACHE II score on hospitalisation was 14 (IQR 6-28) and CCI was 4.0 (IQR 0-12). Forty-six (56.1%) patients had ICU-acquired bacteremia and 36 (43.9%) had central-line associated bacteremia and 25 (30.5%) had primary bacteremia. Fifty (61.0%) patients had combination therapy, colistin/tigecycline (28%) was the most used antibiotic combination. The mortality of all patients was 56.1% (46/82) and 65.2% (30/46) in ICU patients. In univariate analysis, risk factors for the mortality of CRKp-BSI were high CCI, not having clinical response on the fifth day of treatment, high APACHE II score on hospitalisation and infection date and multiple organ dysfunction syndrome. In multivariate analysis, the most significant risk factor for mortality was APACHE II score on infection day (OR: 1.190; 95% CI: 1.088-1.301). Treatment regimens and combination therapy vs. monotherapy were not found to be significantly associated with survival. In addition, MIC values of CRKp were not associated with mortality. Conclusions: Patients with CRKp-BSI had high mortality (56.1%). APACHE II score on infection day was significantly associated with mortality. The outcome was similar between patients receiving combination (54.3%) or monotherapy (45.7%).

Mortality prediction models for severe burn patients: Which one is the best?

For prediction of mortality and clinical course, various scoring systems had been developed. We choose four well known burn specific scoring systems and a general scoring system that using in Intensive Care Units. The primary outcome of this study was evaluate the predictive performances of this models and define the optimal one for our patient population. Variables analyzed were age, gender, burn type, total burned surface area (TBSA), total partial thickness burn area, total full thickness burn area, inhalation injuries, mechanical ventilation supports, blood products usage, total scores of Abbreviated Burn Severity Index (ABSI), revised Baux, Belgian Outcome in Burn Injury, Fatality by Longevity, Acute Physiology and Chronic Health Eval-uation II (APACHE II) score, Measured Extent of burn and Sex (FLAMES) and APACHE II, and their relations with mortality. In our study, a statistically significant relationship was found with mortality between age, TBSA, full thickness burn percent-age, inhalation injury, burn type, and it was similar to literature. Female gender was found to be a significant risk factor for mortality. We compared several burn mortality scoring systems and their predictional mortality rates. ABSI scores of patients for estimated mortality rates were similar to our mortality rate. Consequently, it was thought that ABSI was included all mortality-re-lated parameters.

Risk factors of the poor long-term prognosis of osteoporotic vertebral fractures: A multicenter cohort study.

The presence of existing osteoporotic vertebral fracture (OVF) increases the mortality risk. However, the influence of the characteristics of OVF is unclear. This study aimed to investigate the influence of new OVF on patients' long-term prognosis using our past cohort study. This is an extension study of our cohort study carried out between 2005 and 2007. In the present extension study, of 420 patients, 197 whose contact information was available at the 6-month follow-up were included in the telephone survey in 2018. Five patients refused to participate in the survey, and 82 could not be contacted. Eventually, 110 patients were enrolled. Of the Demographic data, radiological findings, medical history, and clinical outcome were investigated at injury onset and at the 6-month follow-up. A proportional hazard model was used to investigate the risk factors for mortality. Among 110 patients, 33 died. Male sex and low body mass index (BMI <18.5 kg/m2) were significant risk factors for mortality [hazard ratio (HR) = 6.40, 1.01-40.50; 5.24, 1.44-19.04, respectively]. The history of stroke and liver disease increased the risk of mortality (HR = 13.37, 1.93-92.7; 6.62, 1.15-38.14, respectively). As regards radiological findings, local kyphosis progression per 1° or ≥7° were significant risk factors of mortality (HR = 1.20, 1.06-1.36; 5.38, 1.81-16.03, respectively). A telephone survey at 12 years after the occurrence of OVF analyzed risk factors for mortality and showed that a progression of local kyphosis in fractures between injury onset and 6 months after injury was a risk factor of poor prognosis.

1487. Pneumonia due to Co-Infection in the ICU: Detection and Clinical Significance

BackgroundPneumonia is a significant cause of morbidity and mortality, with increasing interest in the detection and clinical significance of co-infection. However, the impact of methodology to obtain lower respiratory samples along with the utility of various microbiological diagnostic testing remains unclear.MethodsA single-center retrospective analysis was performed on bronchoalveolar lavage (BAL) samples obtained from mechanically ventilated adults treated in critical care units from August 2012 to December 2017. BAL methodology (bronchoscopic vs blinded), microbiological diagnostic testing, and outcomes measures were obtained. Associations between categorical variables were assessed using Chi-Square or Fisher’s exact tests. Kruskal Wallace tests analyzed differences in distributions of measures between categories based on number of organism types detected. SAS software version 9.4 (SAS Institute Inc., Cary, NC).ResultsAnalysis of the 803 samples that met inclusion criteria found a significant linear association between mortality and number of organism types detected by BAL, with 30 day mortality rates of 43.0%, 47.8%, and 58.3% among those with zero, one, and two or more organisms respectively (p = 0.003). Comparing BALs with at least one organism isolated, the detection of viruses specifically was associated with increased mortality, with the presence and absence of viral organisms corresponding to 56.3% and 46.5% mortality at thirty days (p = 0.03). No association was found between mortality and isolation of acid-fast bacilli, bacteria, or fungi. Co-infection was detected more frequently among bronchoscopic BALs than blinded BALs (26.3% vs 8.6%, p < 0.0001), with more viruses detected bronchoscopic BALs (41.9% vs 13.1%, p < 0.0001), and more bacteria in blinded BALs (41.8% vs 33.0%, p = 0.01).30 Day Mortality vs Isolation of Specific Organism Types from BAL Number of Organism Types Isolated from BAL Compared to BAL Methodology BAL Methodology vs Isolation of Specific Organism Types ConclusionCo-infection in mechanically ventilated adult patients with pneumonia appears to be a significant risk factor for mortality, with the detection of viral organisms potentially playing an independent role. Within this population, bronchoscopic BALs may have a valuable diagnostic and prognostic methodology.Disclosures All Authors: No reported disclosures

844. Nosocomial Pseudomonas aeruginosa Blood-Stream Infections; Susceptibility Pattern and Mortality at a Tertiary Care Centre in Edmonton, Alberta, Canada

Background Pseudomonas aeruginosa is one of the leading gram negative nosocomial pathogens, causing severe infections including blood-stream infections (BSI) with high mortality rates. (1). Multi-drug resistant P. aeruginosa (MDRPA) infection rates are reported to be increasing (2) and have been associated with increased mortality (3). This study aims to review the susceptibility pattern and trend of P. aeruginosa BSIs and mortality and identify patients at increased risk of BSI with a resistant P. aeruginosa isolate. This data has important treatment implications.MethodsCases of nosocomial P. aeruginosa bacteremia were prospectively identified at the University of Alberta, Edmonton, Alberta, Canada by the infection prevention and control surveillance program between January 1, 2007 and December 31, 2018. Patient charts were retrospectively reviewed to collect microbiological, clinical, and epidemiological information.Results148 cases of P. aeruginosa BSI were identified over a 12-year period between January 2007 and December 2018. There were 19 cases of MDRPA BSI and 9 cases of XDRPA BSI. The incidence of P. aeruginosa BSI was 0.47 per 10,000 patient days and remained relatively stable over the study period. 66.9% of cases occurred in men. The mean age was 60 years. The average length of stay prior to bacteremia was 42 days. The overall 30-day mortality following P. aeruginosa BSI was 36.4%. Risk factors for increased 30-day mortality included: pulmonary source of infection (OR 4.26, p < 0.001), bacteremia with extremely drug resistant Pseudomonas aeruginosa (XDRPA) (p < 0.0001), and diabetes (OR 2.24, p < 0.05). BSI with MDRPA was not an independent risk factor for increased mortality. Significant risk factors for bacteremia with an MDRPA or XDRPA were length of stay > 28 days (OR 4.22, p < 0.001) and hemodialysis (OR 8.92, p < 0.000001).Annual hospital acquired P. aeruginosa blood-stream infections from 2007-2018 Antibiogram of P. aeruginosa blood-stream isolates from 2007-2018 ConclusionThe incidence of P. aeruginosa BSI as well as the rate of MDRPA and XDRPA BSI have remained stable at our centre between 2007 and 2018. We found that BSI with XDRPA but not MDRPA alone was a significant risk factor for mortality. Risk factors for BSI with a resistant P. aeruginosa strain may be considered to guide empiric therapy.Disclosures All Authors: No reported disclosures

Differences in Cause-Specific Mortality Between Frail Men and Women in the United States

While frailty is associated with risk of numerous adverse health outcomes including mortality, little is known about the most common specific causes of death among frail older adults or how these causes might differ by gender. This information may be important to understanding the frailty syndrome and to informing screening and treatment. We used linked data from the Health and Retirement Study (2004 – 2012) and the National Death Index (NDI). We analyzed data from HRS participants age 65 and older who completed a general health interview and physiological measures (n=10,490). Frailty was operationalized using the phenotype criteria – low weight, low energy expenditure, exhaustion, slow gait, and weakness. Causes of death were determined using International Classification of Diseases (v10) codes from death certificates. We used Cox proportional hazards to compare incidence of cause-specific mortality by frailty status and gender. The attributable risk of mortality due to frailty in the sample was 16.6% among women and 17.3% among men. Overall, frail older adults had greater risk of death from heart disease (hazard ratio (HR): 2.97; 95% CI: 2.18, 4.04), cancer (HR: 2.81; 95% CI: 2.01, 3.93), and dementia 2.86 (95% CI: 1.46, 5.58) but not cerebrovascular disease or accidents. Frail women were more approximately 29% more likely to die from heart disease than frail men. Findings suggest that frailty is a significant risk factor for mortality from several different causes, especially among women. Findings may help inform screening and treatment decisions for older adults at risk for frailty.

Gender Differences in Prescribing Antihypertensive Drugs in a Public Hospital in Alkharj

Introduction: Hypertension is considered one of the most significant risk factors for mortality and morbidity worldwide. There are major clinical implications for gender-specific pharmacokinetics and pharmacodynamics. It is important to know the potential gender differences in hypertension treatment and to know the prescribing trends in male and female hypertensive patients in order to optimize the treatment of hypertension.&#x0D; Aim: This is a retrospective study that aims to describe the difference in prescribing antihypertensive drugs between male and female patients.&#x0D; Methodology: This is a retrospective study that includes the revision of patient electronic records of outpatients with hypertension in 2018 in Alkharj.&#x0D; Results: The total number of prescribed antihypertensive drugs was 1838 drugs. The calcium channel blocker was the most commonly prescribed antihypertensive class (27.86%). The study showed that there are different patterns of antihypertensive drug use among hypertensive men and women and showed that female patients are more frequently treated with diuretics and less frequently with angiotensin-converting enzyme inhibitors and angiotensin receptors blockers than male patients.&#x0D; Conclusion: Stratified guidelines and policies based on gender will be appropriate if more studies show a difference in the efficacy and safety of antihypertensive drugs between male and female patients. It is important to conduct more studies about these differences.

Pediatric Index of Mortality 3 score as a predictor for the outcomes of critically ill patients

Background The ability to predict mortality in critically ill patients is important for assessing patient prognosis, evaluating therapy, and assessing intensive care unit quality. The Pediatric Index of Mortality (PIM) 3 is a scoring system to predict outcomes in order to assist clinical decision-making. Objective To assess the ability of PIM 3 to predict outcomes of critically ill PICU patients.Methods This prospective cohort study included 150 children aged 1 month to 18 years who were admitted to the pediatric intensive care unit (PICU), Sanglah Hospital, Denpasar, Bali. Subjects were grouped into two based on ROC curve PIM score ≥48 and &lt;48. The PIM 3 score was consisted of 10 variables, with a re-diagnosis classification of the PIM 2 score. Bivariate analysis was conducted to both groups to find the distribution of mortality in both groups, followed by homogenity test on variables gender, age, nutritional status, lenght of stay and mechanical ventilation. Variables which made the cut on bivariate test were included in multivariate analysis.Results The optimal PIM 3 score limit in predicting mortality was ≥48, with area under the curve (AUC) 76% (95%CI 0.69 to 0.85). Multivariate analysis revealed a 2.48 times increased risk to mortality in patients with PIM 3 score ≥48 (95%CI 1.6 to 3.7). In addition, PICU length of stay ≤7 days was a significant risk factor for mortality. Conclusion The PIM 3 has a good ability to predict the outcome of critically ill PICU patients. Critically ill patients with PIM 3 score ≥48 have a higher risk of mortality compared to those with PIM 3 &lt; 48.

Type of underlying fracture after the surgical treatment of geriatric trauma patients has no effect on mortality during intensive care treatment.

Due to demographic change, the number of geriatric patients is still rising. Although hip fractures are the subject of current research, little is known about the remaining geriatric trauma entities. The aim of this study was to collect data of the age-related traumatological intensive care unit (ICU) population, its underlying diagnosis, and the influence on mortality and length of stay in the ICU. Geriatric trauma patients (aged ≥65 years) treated postoperatively in our surgical ICU were included in this retrospective observational study covering the period 2013-2017. In addition to the underlying fracture entities, patient characteristics, such as age, sex, Charlson Comorbidity Index, length of stay and mortality, were collected to identify possible independent predictive factors for mortality in the ICU using multivariate analysis. During the observation period, 805 (60.5%) patients met the inclusion criteria. 47.6% of the patients suffered from a proximal femoral fracture. The total mortality rate during the stay in the ICU was 7.5%. Significant predictive factors for mortality in the ICU were Charlson Comorbidity Index (P < 0.001) and length of stay (P < 0.001). The different fracture types themselves were not a significant risk factor for mortality (P = 0.862). Patients with proximal femoral fractures account for approximately half of the patients in intensive care. The mortality rate of these patients is no higher than that in geriatric trauma patients with other fractures. The progression is essentially influenced by the patient's comorbidities. Nowadays, the focus shifts from trauma care to the therapy of concomitant diseases. Nevertheless, this cohort, when adequately treated, shows a comparatively low mortality rate. Geriatr Gerontol Int 2020; 20: 1120-1125.

Good long-term survival of Icelandic women following acute myocardial infarction

Abstract Background Mortality from coronary artery disease has decreased considerably in recent decades in Western societies, but less in women compared with men. Possible explanations for this difference include delayed medical attention, atypical presenting symptoms and also a higher incidence of myocardial infarction with non-obstructive coronary arteries in women. In addition, recent studies suggest that women with acute myocardial infarction (AMI) are less likely to receive treatment according to guidelines, which results in worse prognosis for women. Iceland is listed as one of the most gender-equal countries in the world and we hypothesised that this may reduce the gender gap in treatment and survival following AMI. Purpose The aim of this nationwide study was to compare clinical characteristics and treatment of men and women with AMI, identify independent risk factors for long-term mortality and estimate the impact of gender on relative survival. Methods This was a retrospective cohort study on all patients in Iceland with STEMI (2008–2018) and NSTEMI (2013–2018) who had obstructive coronary artery disease on coronary angiography. Information about patients and angiography results and treatment were obtained from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and electronic health records. Data for all-cause mortality was extracted through linkage with Statistics Iceland and survival was estimated with Kaplan-Meier method and Cox regression analysis used to identify significant risk factors for long-term mortality. Excess mortality from the AMI episode was estimated by comparing the survival with age- and gender-matched population in Iceland in 30-day intervals. Results A total of 1345 STEMI patients (24% women) and 1249 NSTEMI patients (24% women) were evaluated. Women with both STEMI (mean age: 71±11. vs. 67±12) and NSTEMI (mean age: 69±13 vs. 62±12) were older and less likely to have a cardiovascular history. There was no gender difference in the extent of coronary artery disease or treatment. Whilst long-term survival for women following STEMI (A) was lower, female gender was not found to be an independent risk factor for mortality after adjusting for age and comorbidities (HR 0.98, 95%-CI: 0.75–1.29). The survival after NSTEMI was similar between genders (B) and female gender was a protective prognostic factor (HR 0.67, 95% CI: 0.46–0.97). There was an excess 30-day mortality following STEMI (C) and NSTEMI (D) for both women and men compared to the matched Icelandic population, but thereafter the mortality rate was similar. Conclusion Our findings indicates that women and men in Iceland receive comparable treatment for AMI, including invasive treatment. Prognosis following NSTEMI is better in women. Higher early mortality after STEMI may be caused by delays in presentation and diagnosis as well as older age of women because female gender was not a significant risk factor for mortality. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): University hospital of Iceland, 4 weeks research leave

Impact of Fluid Balance on Mortality Is Mediated by Fluid Accumulation Index in Sepsis: A Cohort Study.

Fluid balance (FB) is associated with poor sepsis outcomes; however, it cannot accurately reflect the dynamic fluid accumulation status. Here, we explored a new index, the FB to fluid intake ratio (FB/FI), for evaluating dynamic fluid accumulation in sepsis. FB/FI values within 48 hours were recorded. Their association with in-hospital mortality was investigated using logistic regression and mediation analyses of data from 7,839 patients. In extended logistic models, a linear association was found between FB and mortality (odds ratio [OR]: 1.05-1.08, p < 0.001). However, this association became non-significant after the adjustment of FB/FI (OR: 1.00, 95% confidence interval [CI]: 0.98-1.02). For FB/FI and mortality, a cut-off value of 0.25 was defined. In the spline function logistic model, FB/FI > 0.25 was significantly associated with increased mortality (OR: 4.46, 95% CI: 2.92-6.80), whereas FB/FI ≤ 0.25 was not. For the FB/FI > 0.25 subgroup, mediation analysis was used to clarify the relationship between FB, FB/FI, and mortality. We observed that the direct effect of FB was non-significant (adjusted coefficient: -0.001, 95% CI: -0.005 to 0.002) while the indirect effect was significant (adjusted coefficient: 0.009, 95% CI: 0.006-0.011). In the FB/FI ≤ 0.25 subgroup, both the FB volume (0.9 ± 0.7 vs. -2.0 ± 1.9, p < 0.001) and the FB/FI ratio (0.14 ± 0.07 vs. -0.77 ± 1.60, p < 0.001) were significantly higher in patients with FB > 0 than those with FB ≤ 0. However, both the crude and adjusted comparisons of hospital mortality were non-significant. Similar associations were observed in septic shock patients. FB/FI > 0.25 is a significant risk factor for mortality in sepsis, while FB/FI ≤ 0.25 is not. The association between FB and mortality is completely mediated by this new fluid accumulation index. More comprehensive indices are required for evaluating dynamic fluid status in sepsis.

Risk Factors for Severe Coronavirus Disease (COVID-19)

Background: During the recent coronavirus disease (COVID-19) pandemic there have been several studies implicating an association between obesity, COVID-19 severity, and mortality. This retrospective study aims to investigate the association between obesity, other risk factors, and COVID-19 mortality of patients admitted over a 6-week period to the respiratory units at the authors’ hospitals. Methods: This is a retrospective study of 71 patients who were admitted into a respiratory unit over a 6-week period where the data were analysed for correlation between various risk factors, COVID-19 severity, and mortality. The statistical analysis was performed using excel statistics and SPSS (IBM, Armonk, New York, USA) statistical software. The significance was considered at p&lt;0.05. The multivariate analysis, Z-test, Cox regression, Pearson correlation, and Kaplan–Meier analysis were used. Results: The mean age of the patients was 65.8 years (range: 35.0–93.0 years) standard deviation (13.21) and the male to female ratio was 2.73 (52:19, respectively). The most frequent comorbidities were obesity (42/71; 59%), hypertension (36/71; 50%), diabetes (22/71; 31%), heart disease (13/71; 18%), respiratory disease (9/71; 13%), and cancer (8/71; 11%). The mean body weight was 83.7 kg (60.4–147.7 kg) and the mean BMI was 32.2 (22.0–53.0 kg/m2). Smoking was reported in 8 (11%) of the patients. There were 20 (83%) mortalities among patients &gt;70 years old (p&lt;0.0001), 20 (83%) deaths among male patients (p&lt;0.0001), 14 (58%) deaths among patients with a BMI &gt;25 kg/m2 (p=0.001), 17 (70%) deaths reported for patients with hypertension (p=0.008), 6 (25%) mortalities for patients with cardiovascular disease (p=0.001), 14 (30%) deaths among patients who were mechanically ventilated (p=0.00028), and 5 (20%) mortalities among patients with cancer (p=0.003). Conclusions: Obesity, cancer, mechanical ventilation, male sex, intensive care unit admission, cardiovascular disease, and hypertension are significant risk factors for mortality in patients with COVID-19.

Clinical Course and Outcome of 395 Covid 19 Patients Admitted to One Hospital in Jeddah- Saudi Arabia

Background: Since the first case of SARS-CoV 2 has been reported from Wuhan China back in December 2019, the virus has spread all over the world and has so far infected more than 35 million humans and led to more than one million deaths woldwide. We describe in this paper the clinical characteristics and outcome of PCR confirmed Covid 19 patients that were admitted to a tertiary care hospital in Saudi Arabia. Methods: Retrospective review of patients that had positive PCR on nasopharyngeal swab for SARS Cov2 and that were admitted and discharged from a tertiary care hospital in the city of Jeddah, Saudi Arabia between March and July 2020. Epidemiological, demographic, and clinical data were collected. The clinical course of patients was reviewed. Risk factors for involvement of lower respiratory tract (Pneumonia), for need for ICU and for death were analyzed. Results: The records of total of 395 patients were reviewed. 15% of Covid 19 patients in our population were completely asymptomatic, one quarter of which had abnormalities on chest imaging. Among the patients with one or more Covid 19 symptoms, 75% had lower respiratory tract involvement and one quarter had normal chest imaging. One third of all patients developed leukopenia and around 2 thirds had lymphocytopenia. Thrombocytopenia was not common (occurred in 15%), 29% of our patients had CRP>10 and 25.1% had elevated ALT (not exceeding 5 times upper normal). Nine percent of our patients needed ICU admission, 3.8% needed mechanical ventilation. 9 patients (2.3%) in our population died. Advancing age, increasing BMI, and smoking history were significantly associated with increased mortality. Developing abnormalities on chest imaging (Pneumonia) was significantly associated with increasing BMI, advancing age, not receiving BCG vaccination at birth, history of smoking and presence of co-morbidities (p value less 0.05 with all these variables). Blood group and presence of co-morbidities was significantly associated with need for ICU care but not with mortality. In our population neither ethnicity, nor gender, had significant association with hospital course or outcome, and no one younger than 45 years and no one with BMI less than 24 died. Conclusion: Advancing age, increasing BMI and history of smoking were found to be significant risk factors for mortality in our population. History of Bacille calmette Guerin (BCG) vaccination was significantly associated with less involvement of lower respiratory tract but had no significant association with final outcome. Asymptomatic Covid 19 is more of a silent active infection rather than a silent inactive carrier state.

Value of preoperative echocardiography for the diagnosis of coronary artery patterns in neonates with transposition of the great arteries

Abnormal coronary pattern may complicate coronary transfer during arterial switch operation. To evaluate the accuracy of echocardiography in assessing the anatomy of coronary arteries in neonates with transposition of the great arteries, and determine impact on outcomes. We conducted a retrospective analysis of data in neonates with transposition of the great arteries. Preoperative echocardiographic coronary artery pattern and surgical intraoperative reports were compared. Mismatch between transthoracic echocardiography and surgical intraoperative reports and the impact on perioperative outcome were assessed. Coronary patterns were classified into four groups: type 1 (normal); type 2 (risk of coronary with intramural course); type 3 (coronary loop); and type 2+3. Overall, 108 neonates who underwent an arterial switch operation were included: 68 were classified as type 1; seven as type 2; 32 as type 3; and one as type 2+3. Overall, 10 adverse events occurred. Five patients died, three from coronary causes. Survival was 96% at 1 month. Transthoracic echocardiography and surgical intraoperative reports differed in 17.6% of cases. Mortality was 15.8% in case of inappropriate diagnosis and 2.2% for appropriate diagnosis (P=0.01). Mortality in type 2 was 66.7% in case of discordance versus 0% when concordant. Multivariable analysis found that inappropriate preoperative transthoracic echocardiography diagnosis of coronary pattern was the only significant risk factor for mortality (P=0.04). Echocardiography can assess coronary artery anatomy in neonates with transposition of the great arteries. Intramural coronary course is often misdiagnosed. Preoperative misdiagnosis of coronary artery anomaly may impact perioperative mortality. However, this assessment will have to be confirmed by further larger studies.

Chemotherapy and Hepatic Steatosis: Impact on Postoperative Morbidity and Survival after Liver Resection for Colorectal Liver Metastases

Background: Hepatic steatosis and chemotherapy in the treatment of colorectal liver metastases (CLM) are often linked to increased mortality and morbidity after liver resection. This study evaluates the influence of macrovesicular hepatic steatosis and chemotherapeutic regimes on graded morbidity and mortality after liver resection for CLM. Methods: A total of 323 cases of liver resection for CLM were retrospectively analysed using univariable and multivariable linear, ordinal and Cox regression analyses. The resected liver tissue was re-evaluated by a single observer to determine the grade and type of hepatic steatosis. Results: Macrovesicular steatosis did not influence postoperative morbidity and survival, as evidenced by risk-adjusted multivariable Cox regression analysis (p = 0.521). Conversion chemotherapy containing oxaliplatin was an independent and significant risk factor for mortality in risk-adjusted multivariable Cox regression analysis (p = 0.005). Identified independently, significant risk factors for postoperative morbidity were neoadjuvant treatment of metastases of the primary tumour with irinotecan (p = 0.003), the duration of surgery in minutes (p = 0.001) and the number of intraoperatively transfused packed red blood cells (p ≤ 0.001). Surprisingly, macrovesicular hepatic steatosis was not a risk factor for postoperative morbidity and was even associated with lower rates of complications (p = 0.006). Conclusion: The results emphasize the multifactorial influence of preoperative liver damage and chemotherapy on the severity of postoperative morbidity, as well as the significant impact of conversion chemotherapy containing oxaliplatin on survival.

Mortality and Conversion Rate to Below Knee or Above Knee Amputation Following Transmetatarsal Amputation

Category:Midfoot/Forefoot; Diabetes; OtherIntroduction/Purpose:Non-traumatic lower extremity amputations (LEA), especially those performed in dysvascular and diabetic patients, are known to have poor long-term prognosis. Perioperative mortality has been reported at between 4 and 10%, and the 1 and 5 year mortality rates range between 22-33% and 39-69%, respectively. While poor outcomes in these patients have been described, there is no consensus as to the predictors of mortality. The purpose of the study is to determine the percentage of patients who had a complication following transmetatarsal amputation (TMA) and identify associated risk factors for complications and mortality.Methods:We queried our institution’s administrative database to identify 247 TMA procedures performed in 229 patients between January, 2002 and December, 2016. Electronic health records were reviewed to document complications defined as reoperation, amputation and mortality. Mortality was also verified using the National Death Index. Additionally, we recorded risk factors including diabetes, A1c level, end stage renal disease (ESRD), cardiovascular disease (CVD), peripheral vascular disease (PVD), history of revascularization, contralateral amputation, and neuropathy. The majority of the study patients were males (157, 69%) and the average age was 57 years (range 24-91). The median BMI was 28 (range 16-58) and 29% of the study patients were obese with a BMI ≥ 30. Fishers Exact tests were used to compare categorical variables. Kruskal-Wallis and Independent T-tests were used to compare numeric data. All data were analyzed using SAS/STAT software version 9.4 (Carey, NC) and a 0.05 level of significance was defined apriori.Results:The conversion rate to below (BKA) or above knee amputation (AKA) was 26% (64 of 247). Males (p=.0274), diabetics (p=.0139), patients in ESRD (p=.019), and patients with a history of CVD (p=.0247) or perioperative revascularization (p=.022) were more likely to undergo further amputation following an index TMA. BMI was significantly higher in patients requiring BKA/AKA (p=.0305). There were no significant differences in age (p=.2723) or A1c levels (p=.4219). The overall mortality rate was 35% (84 of 229). Diabetes (p=.0272), ESRD (p=.0031), history of CVD (p<.0001) or PVD (p=.0179) were all significantly associated with mortality. Patients who died were significantly older (p=.0006) and had significantly higher A1c levels (p=.0373). BMI was not significantly associated with mortality. Twenty-two patients who had 23 further amputations subsequently died.Conclusion:In our series of patients undergoing TMA, 26% underwent further amputation and 35% of patients died. Conversion rate to BKA or AKA occurred at a high rate regardless of preoperative revascularization or the use of tendo-achilles or gastrocnemius lengthening procedures. Male sex, diabetes, ESRD, history of CVD or revascularization are significant risk factors for further amputation. ESRD, diabetes, history of CVD or PVD, older age and higher A1c levels are significant risk factors for mortality. These data provide useful insight into risk factors to be emphasized when counseling patients and their families to establish realistic postoperative expectations.

Hospitalised COVID-19 patients of the Mount Sinai Health System: a retrospective observational study using the electronic medical records

ObjectiveTo assess association of clinical features on COVID-19 patient outcomes.DesignRetrospective observational study using electronic medical record data.SettingFive member hospitals from the Mount Sinai Health System in New York City (NYC).Participants28 ...

Trends in the effects of pre-transplant diabetes on mortality and cardiovascular events after kidney transplantation.

Aims/IntroductionIt is not clear whether survival in kidney transplant recipients with pre‐transplant diabetes has improved over the past decades. We compared the rates of mortality and major adverse cardiovascular events (MACE) after renal transplantation in patients with and without pre‐transplant diabetes. Furthermore, we investigated whether transplant era and recipient age affected the association between diabetes status and adverse events.Materials and MethodsThis retrospective cohort study included 691 patients who underwent renal transplantation between 1994 and 2016 at a single tertiary center. We compared the incidences of post‐transplant mortality and four‐point MACE in patients with and without pre‐transplant diabetes using Kaplan–Meier analysis and the Cox proportional hazard model, and assessed the interactions between diabetes status and transplant era and recipient age.ResultsOf 691 kidney recipients, 143 (20.7%) had pre‐transplant diabetes. The mean follow‐up duration was 94.5 months. Kaplan–Meier analysis showed that patients with pre‐transplant diabetes had higher incidences of post‐transplant mortality and four‐point MACE compared with those without pre‐transplant diabetes (log–rank test, P < 0.001 for both). After adjusting for potential confounding factors, pre‐transplant diabetes was associated with an increased risk of post‐transplant mortality and four‐point MACE (hazard ratio 1.90, 95% confidence interval 1.05–3.44, P = 0.034; and hazard ratio 1.75; 95% confidence interval 1.02–3.00, P = 0.043, respectively). The associations between pre‐transplant diabetes status and all‐cause mortality and four‐point MACE were not affected by transplant era or recipient age.ConclusionsPre‐transplant diabetes remains a significant risk factor for mortality and four‐point MACE in kidney transplant recipients.

Primary Versus Staged Repair in Neonates With Pulmonary Atresia and Ventricular Septal Defect

The 2 surgical strategies for neonates with ductal-dependent pulmonary atresia and ventricular septal defect are primary biventricular repair (BVR) or initial palliation with a modified Blalock-Taussig shunt (BTS) followed by second stage repair. In this study, we report the combined outcomes from 2 hospitals using different strategies. Between 2004 and 2017, 66 neonates underwent surgery with palliative shunts (BTS group: n= 30, 45.5%) or primary biventricular repair (pBVR group: n= 36, 54.5%). The 2 groups were similar in age, body weight, and Nakata index scores. The overall mean follow-up duration was 7.51 ± 4.35 years, and early and late results were compared between the groups. The 10-year overall survival was 84.8% (94.4% for pBVR vs 75.7% for BTS, P= .032). The BTS group had 2 early and 6 interstage mortalities, and the pBVR group had no early and 2 late mortalities. In the BTS group, the Nakata index score significantly increased during the interstage period (P < .001). In univariable analysis, genetic or extracardiac anomalies were a risk factor for mortality (hazard ratio, 5.56; P= .038). After achieving BVR, the pBVR group underwent significantly more frequent right ventricle outflow tract reinterventions (P < .001) at a much earlier period (P= .017) compared with the BTS group. In neonates with ductal-dependent pulmonaryatresia and ventricular septal defect, the primary BVR approach provides an excellent survival rate, but the burden of right ventricle outflow tract reintervention is heavy. The staged approach with BTSpromotes pulmonary artery growth, but hospital and interstage mortality are significant. Genetic and extracardiac anomalies are significant risk factors for mortality.