Six-month Mortality Research Articles

Comparative analysis of CRASH and IMPACT in predicting the outcome of 340 patients with traumatic brain injury.

Both the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) and the Corticosteroid randomization after significant head injury (CRASH) models are globally acknowledged prognostic algorithms for assessing traumatic brain injury (TBI) outcomes. The aim of this study is to externalize the validation process and juxtapose the prognostic accuracy of the CRASH and IMPACT models in moderate-to-severe TBI patients in the Chinese population. We conducted a retrospective study encompassing a cohort of 340 adult TBI patients (aged > 18 years), presenting with Glasgow Coma Scale (GCS) scores ranging from 3 to 12. The data were accrued over 2 years (2020-2022). The primary endpoints were 14-day mortality rates and 6-month Glasgow Outcome Scale (GOS) scores. Analytical metrics, including the area under the receiver operating characteristic curve for discrimination and the Brier score for predictive precision were employed to quantitatively evaluate the model performance. Mortality rates at the 14-day and 6-month intervals, as well as the 6-month unfavorable GOS outcomes, were established to be 22.06, 40.29, and 65.59%, respectively. The IMPACT models had area under the curves (AUCs) of 0.873, 0.912, and 0.927 for the 6-month unfavorable GOS outcomes, with respective Brier scores of 0.14, 0.12, and 0.11. On the other hand, the AUCs associated with the six-month mortality were 0.883, 0.909, and 0.912, and the corresponding Brier scores were 0.15, 0.14, and 0.13, respectively. The CRASH models exhibited AUCs of 0.862 and 0.878 for the 6-month adverse outcomes, with uniform Brier scores of 0.18. The 14-day mortality rates had AUCs of 0.867 and 0.87, and corresponding Brier scores of 0.21 and 0.22, respectively. Both the CRASH and IMPACT algorithms offer reliable prognostic estimations for patients suffering from craniocerebral injuries. However, compared to the CRASH model, the IMPACT model has superior predictive accuracy, albeit at the cost of increased computational intricacy.

Understanding the Utility of Less Than Six-Month Prognosis Using Administrative Data Among U.S. Nursing Home Residents With Cancer.

There is a dearth of studies evaluating the utility of reporting prognostication among nursing home (NH) residents with cancer. To study factors associated with documented less than six-month prognosis, and its relationship with end-of-life (EOL) care quality measures among residents with cancer. The Surveillance, Epidemiology, and End Results linked with Medicare, and the Minimum Data Set databases was used to identify 20,397 NH residents in the United States with breast, colorectal, lung, pancreatic, or prostate cancer who died between July 2016 and December 2018. Of these, 2205 residents (10.8%) were documented with less than six-month prognosis upon NH admission. Main outcomes were more than one hospitalization, more than one emergency department visit, and any intensive care unit admission within the last 30 days of life as aggressive EOL care markers, as well as admission to hospice, receipt of advance care planning and palliative care, and survival. Specificity and sensitivity of prognosis were assessed using six-month mortality as the outcome. Propensity score matching adjusted for selection biases, and logistic regression examined association. Specificity and sensitivity of documented less than six-month prognosis for mortality were 94.2% and 13.7%, respectively. Residents with documented less than six-month prognosis had greater odds of being admitted to hospice than those without (adjusted odds ratio: 3.27, 95% confidence interval: 2.86-3.62), and lower odds to receive aggressive EOL care. In this cohort study, documented less than six-month prognosis was associated with less aggressive EOL care. Despite its high specificity, however, low sensitivity limits its utility to operationalize care on a larger population of residents with terminal illness.

Atorvastatin for reduction of 28-day mortality in severe and critical COVID-19 patients: a randomized controlled trial

BackgroundCOVID-19 is an abnormal host response to the SARS-CoV-2 infection, which is associated with endothelial dysfunction and multi-organ failure. Atorvastatin has been proposed to reduce COVID-19 severity and mortality in chronic and de-novo users.MethodsThis randomized double-blind trial included 220 COVID-19 patients admitted to Mansoura University's isolation hospital in Egypt. One hundred and ten cases were given 40 mg of atorvastatin once daily for 28 days (group A), while 110 received a placebo (group B). All patients received treatment as per hospital protocol. The primary outcome is all-cause mortality at 28 days. We also tracked 6-month mortality, time to clinical improvement, the risk of invasive mechanical ventilation, acute kidney injury, potential adverse events, and hospital and intensive care length of stay.ResultsThe 28-day all-cause mortality was 52/104 (50%) in group A vs. 54/103 (52.4%) in group B, odds ratio (OR) = 0.907 (0.526, 1.565), P = 0.727; adjusted OR = 0.773 (0.407, 1.47), P = 0.433. Six-month mortality occurred in 53/102 (52%) and 59/79 (60.8%) in group A vs. B, respectively, P = 0.208. Among hospital survivors in group A vs. group B, the median time to clinical improvement was 10 days (7–14) vs. 10 (7–15), P = 0.715; the duration of hospital stay was 10 days (7–14) vs. 10 (8–17), P = 0.378. Discontinuation was higher in group B (four vs. one), but statistically insignificant, P = 0.369.ConclusionsIn adults with severe or critical COVID-19, atorvastatin did not reduce the risk of 28-day or 6-month mortality and did not shorten the length of hospital stay or time to clinical improvement.Trial registration Clinical Trial Registry (NCT04952350) on July 1st, 2021. https://clinicaltrials.gov/ct2/show/NCT04952350

Ambulatory Status at Discharge Predicts Six-Month Mortality in Patients with COVID-19: A Retrospective Cohort Study.

This retrospective cohort study aimed to evaluate the association between ambulatory status at discharge and six-month post-discharge mortality among adults with coronavirus disease (COVID-19). We analyzed data from 398 patients aged over 18 admitted to a tertiary hospital in South Korea between December 2019 and June 2022. Patients were classified into two groups based on their ambulatory status at discharge: ambulatory (able to walk independently, n = 286) and non-ambulatory (unable to walk independently, requiring wheelchair or bed-bound, n = 112). Our analysis revealed that six-month survival rates were significantly higher in the ambulatory group (94.2%) compared to the non-ambulatory group (84.4%). Multivariate analysis identified ambulatory status at discharge (p = 0.047) and pre-existing malignancy (p = 0.007) as significant prognostic factors for post-discharge survival. This study highlights that the ability to walk independently at discharge is a crucial predictor of six-month survival in COVID-19 patients. These findings emphasize the need for interventions to improve the physical performance of non-ambulatory patients, potentially enhancing their survival prospects. This underscores the importance of targeted rehabilitation and physical therapy for the comprehensive care of COVID-19 survivors.

Morbidity and mortality of common femoral endarterectomy

ObjectiveCommon femoral endarterectomy (CFE) comprises the current standard-of-care for symptomatic common femoral artery occlusive disease. Although it provides effective inflow revascularization via a single incision, it remains an invasive procedure in an often-frail patient population. The purpose of this retrospective clinical study was to assess the morbidity and mortality of CFE in a contemporary cohort. MethodsConsecutive CFEs performed at a large, urban hospital were reviewed. Six-month mortality, local complications (hematoma, lymphatic leak, pseudoaneurysm, wound infection, and/or dehiscence), and systemic complications were analyzed using univariate and multivariate analyses. ResultsA total of 129 isolated CFEs were performed over 7 years for claudication (36%), rest pain (16%), tissue loss (29%), or acute on chronic limb ischemia (21%). Mean age was 75 ± 9 years, and 68% of patients were male. Comorbidities were prevalent, including coronary artery disease (54%), diabetes (41%), chronic pulmonary disease (25%), and congestive heart failure (22%). The majority of CFEs were performed under general anesthesia (98%) with patch angioplasty using bovine pericardium (73% vs 27% Dacron). Twenty-two patients (17%) sustained local complications following the procedure; their occurrence was significantly associated with obesity (P = .002) but no technical or operative factors. Nineteen patients (15%) sustained serious systemic complications; their occurrence was significantly associated with chronic limb-threatening ischemia (P < .001), and a high American Society of Anesthesiologists (ASA) class (P = .002). By 6 months, 17 patients (13%) had died. Being on dialysis, presenting with chronic limb-threatening ischemia, and being in a high ASA class at the time of operation were all associated with 6-month mortality; a high ASA class at the time of operation was independently predictive of mortality (odds ratio, 3.08; 95% confidence interval, 1.03-9.24; P = .044). ConclusionsAlthough commonly performed, CFE is not a benign vascular procedure. Disease presentation, anesthetic risk, and expected longevity play an important role in clinical outcomes. Evolving endovascular approaches to the common femoral artery could serve to reduce morbidity and mortality in the future.

The Impact of the COVID-19 Pandemic on Orthopaedic Trauma Surgery in a District General Hospital in the United Kingdom.

Introduction The 2020 COVID-19 pandemic led to a national lockdown and a major reorganization of healthcare services in the United Kingdom. The center where the study was done was one of the worst affected hospitals in the United Kingdom at the outset of the pandemic. Our study evaluates the impact of the pandemic and national lockdown on the outcomes for patients undergoing orthopedic trauma surgery. Methods We prospectively identified all patients undergoing orthopedic trauma surgery in the unit from 1st March 2020 to 31st May 2020. We recorded demographics, diagnoses, COVID-19 infection status, length of stay, and mortality. This was compared with a comparative group in the same period in 2018 and 2019. Results There was a significant reduction in the number of orthopedic trauma surgery cases (318) performed in 2020 compared to 2019 (423 cases, p<0.001) and 2018 (444 cases, p<0.001). The mean time from injury to presentation was 3.6 days, with 40 patients (12.6%) presenting more than one week after injury. The 30-day mortality was 8.2%, and the six-month mortality was 15.1%, with both significantly higher than in 2018 (p<0.001) and 2019 (p<0.001). COVID-19 testing was positive in 39% of patients, with 30-day mortality in this group at 37%, rising to a 53% six-month mortality. No patients under the age of 50 years old died. The majority of admissions (51%) were due to falls at home. The second most common mechanism was Do-It-Yourself (DIY) injuries. Road traffic accidents accounted for 2%. Conclusion There were significantly fewer cases of orthopedic trauma surgery during the first wave of the COVID-19 pandemic compared to the same period in previous years. The type of trauma also showed low numbers of high-energy and sporting injuries as a result of the national lockdown. Patients undergoing orthopedic trauma surgery who tested positive for COVID-19 had significantly higher 30-day mortality than those without COVID-19, and this increased mortality persisted to six months post-operatively. However, patients under 50 years old appear to be at low risk of death.

Healthcare exposures and associated risk of endocarditis after open-heart cardiac valve surgery

BackgroundInfective endocarditis (IE) following cardiac valve surgery is associated with high morbidity and mortality. Data on the impact of iatrogenic healthcare exposures on this risk are sparse. This study aimed to investigate risk factors including healthcare exposures for post open-heart cardiac valve surgery endocarditis (PVE).MethodsIn this population-linkage cohort study, 23,720 patients who had their first cardiac valve surgery between 2001 and 2017 were identified from an Australian state-wide hospital-admission database and followed-up to 31 December 2018. Risk factors for PVE were identified from multivariable Cox regression analysis and verified using a case-crossover design sensitivity analysis.ResultsIn 23,720 study participants (median age 73, 63% male), the cumulative incidence of PVE 15 years after cardiac valve surgery was 7.8% (95% CI 7.3–8.3%). Thirty-seven percent of PVE was healthcare-associated, which included red cell transfusions (16% of healthcare exposures) and coronary angiograms (7%). The risk of PVE was elevated for 90 days after red cell transfusion (HR = 3.4, 95% CI 2.1–5.4), coronary angiogram (HR = 4.0, 95% CI 2.3–7.0), and healthcare exposures in general (HR = 4.0, 95% CI 3.3–4.8) (all p < 0.001). Sensitivity analysis confirmed red cell transfusion (odds ratio [OR] = 3.9, 95% CI 1.8–8.1) and coronary angiogram (OR = 2.6, 95% CI 1.5–4.6) (both p < 0.001) were associated with PVE. Six-month mortality after PVE was 24% and was higher for healthcare-associated PVE than for non-healthcare-associated PVE (HR = 1.3, 95% CI 1.1–1.5, p = 0.002).ConclusionsThe risk of PVE is significantly higher for 90 days after healthcare exposures and associated with high mortality.

Clinical presentation, management, and outcome of suspected central nervous system infections in Indonesia: a prospective cohort study

BackgroundLittle is known about the etiology, clinical presentation, management, and outcome of central nervous system (CNS) infections in Indonesia, a country with a high burden of infectious diseases and a rising prevalence of HIV.MethodsWe included adult patients with suspected CNS infections at two referral hospitals in a prospective cohort between April 2019 and December 2021. Clinical, laboratory, and radiological assessments were standardized. We recorded initial and final diagnoses, treatments, and outcomes during 6 months of follow-up.ResultsOf 1051 patients screened, 793 were diagnosed with a CNS infection. Patients (median age 33 years, 62% male, 38% HIV-infected) presented a median of 14 days (IQR 7–30) after symptom onset, often with altered consciousness (63%), motor deficits (73%), and seizures (21%). Among HIV-uninfected patients, CNS tuberculosis (TB) was most common (60%), while viral (8%) and bacterial (4%) disease were uncommon. Among HIV-infected patients, cerebral toxoplasmosis (41%) was most common, followed by CNS TB (19%), neurosyphilis (15%), and cryptococcal meningitis (10%). A microbiologically confirmed diagnosis was achieved in 25% of cases, and initial diagnoses were revised in 46% of cases. In-hospital mortality was 30%, and at six months, 45% of patients had died, and 12% suffered from severe disability. Six-month mortality was associated with older age, HIV, and severe clinical, radiological and CSF markers at presentation.ConclusionCNS infections in Indonesia are characterized by late presentation, severe disease, frequent HIV coinfection, low microbiological confirmation and high mortality. These findings highlight the need for earlier disease recognition, faster and more accurate diagnosis, and optimized treatment, coupled with wider efforts to improve the uptake of HIV services.

Long-term outcomes after COVID-19 infection in transplant recipients.

Long-term outcomes after COVID-19 infection unique to solid organ transplant recipients (SOTR) are not published. We describe outcomes including readmission, allograft rejection, allograft dysfunction, allograft failure, and death. We conducted a retrospective cohort study of mostly unvaccinated SOTR with COVID-19 from March 2020 to November 2021. Disease severity was assigned by NIH criteria. Data included demographics, clinical features, treatment, and outcomes and are presented as mean±standard deviation or median (range). One hundred and thirty-eight SOTR were diagnosed with COVID-19 at a median of 5 (IQR 3-8) years post-transplant with a mean age of 57±12years at diagnosis. Forty-one recovered at home; 97 were admitted. 12/32 (37.5%) SOTR with critical disease expired during initial admission. Among those who recovered, 48/126 (38.0%) had asymptomatic or mild infection, 31/126 (24.6%) had moderate, 27/126 (21.4%) severe, and 20/126 (15.9%) critical infection. 38/85 (44.7%) of SOTR who survived initial admission had 74 readmissions within 180days (Figure 1). The 6-month mortality rate among those who survived infection was 4/126 (3.2%). The mean time from initial infection to death was 32±66days in inpatient deaths and 95±39days in those who were discharged or never admitted. Six-month graft dysfunction occurred in 18/125 (14.4%) and graft failure in 9/126 (7.2%); five failures were deaths with function. Readmissions after COVID-19 infection were frequent after the index admission. Rejection was relatively infrequent; graft dysfunction at 6months post-infection was more common than rejection. Six-month mortality following COVID-19 recovery in SOTR was significant; close follow-up of patients is warranted.

Effect of multidisciplinary refined time management combined with organized stroke management on the efficacy of intravenous thrombolysis in patients with acute ischemic stroke

This study aims to investigate the effects of multidisciplinary refined time management combined with organized stroke management in intravenous thrombolysis on patients with acute ischemic stroke. 226 acute ischemic stroke patients treated with intravenous thrombolysiswere selected for retrospective analysis. A Control group participants underwent organized stroke management, whereas study group participants underwent multidisciplinary refined time management based on the control group. The study group responded to intravenous thrombolysis for 24 hours at an overall rate of 92.92%, significantly higher than 79.65% in the control group (p &lt; 0.05). The time from onset to emergency, time for National Institute of Health Stroke Scale (NIHSS) scoring by emergency doctors, consultation time for neurologists, judgement time for head computed tomography (CT), interpretation time for examination results, communication time with family members to sign the consent form, and time from admission to medication in the study group were significantly shorter than that in control group (p &lt; 0.05). The incidence of hemorrhagic transformation, six-month mortality and six-month rehospitalization rate in the study group were significantly lower than those in the control group (p &lt; 0.05). Before thrombolysis, cerebrovascular reserve function and neurological function indexes in both groups were improved, and there was significant difference before and after thrombolysis in this group (p &gt; 0.05); After thrombolysis, mean blood flow velocity (MFV) and breath-holding index (BHI) in the study group were significantly higher than those in the control group (p &lt; 0.05); pulsatility index (PI) was lower than that in the control group, showing a significant difference (p &lt; 0.05); Serum nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) were significantly higher than those in the control group (p &lt; 0.05). Multidisciplinary refined time management combined with organized stroke management can improve the effect of intravenous thrombolysis in acute ischemic stroke.

Association between Hemodynamic Profile at Hospital Admission and Mortality in Acute Heart Failure Patients Included in the Best Practice in Cardiology Program in Brazil.

Heart failure (HF) contributes to a high burden of hospitalization, and its form of presentation is associated with disease prognosis. To describe the association of hemodynamic profile of acute HF patients at hospital admission, based on congestion (wet/dry) and perfusion (cold/warm), with mortality, hospital length of stay and risk of readmission. Cohort study, with patients participating in the "Best Practice in Cardiology" program, admitted for acute HF in Brazilian public hospitals between March 2016 and December 2019, with a six-month follow-up. Characteristics of the population and hemodynamic profile at admission were analyzed, in addition to survival analysis using Cox proportional hazard model for associations between hemodynamic profile at admission and mortality, and logistic regression for the risk of rehospitalization, using a statistical significance level of 5%. A total of 1,978 patients were assessed, with mean age of 60.2 (±14.8) years and mean left ventricular ejection fraction of 39.8% (±17.3%). A high six-month mortality rate (22%) was observed, with an association of cold hemodynamic profiles with in-hospital mortality (HR=1.72, 95%CI 1.27-2.31; p < 0.001) and six-month mortality (HR= 1.61, 95%CI 1.29-2.02). Six-month rehospitalization rate was 22%, and higher among patients with wet profiles (OR 2.30; 95%CI 1.45-3.65; p < 0.001). Acute HF is associated with high mortality and rehospitalization rates. Patient hemodynamic profile at admission is a good prognostic marker of this condition.

Is having a moderate or low history, electrocardiogram, age, risk factors, troponin risk score a handicap for long-term mortality?

History, electrocardiogram, age, risk factors, troponin risk score and troponin level follow-up are used to safely discharge low-risk patients with suspected non-ST elevation acute coronary syndrome from the emergency department for a 1-month period. We aimed to comprehensively investigate the 6-month mortality of patients with the history, electrocardiogram, age, risk factors, troponin risk score. A total of 949 non-ST elevation acute coronary syndrome patients admitted to the emergency department from 01.01.2019 to 01.10.2019 were included in this retrospective study. History, electrocardiogram, age, risk factors, troponin scores of all patients were calculated by two emergency clinicians and a cardiologist. We compared the 6-month mortality of the groups. The mean age of the patients was 67.9 (56.4-79) years; 57.3% were male and 42.7% were female. Six-month mortality was significantly lower in the high-risk history, electrocardiogram, age, risk factors, troponin score group than in the low- and moderate-risk groups: 11/80 (12.1%), 58/206 (22%), and 150/444 (25.3%), respectively (p=0.019). Patients with high history, electrocardiogram, age, risk factors, troponin risk scores are generally treated with coronary angioplasty as soon as possible. We found that the mortality rate of this group of patients was lower in the long term compared with others. Efforts are also needed to reduce the mortality of moderate and low-risk patients. Further studies are needed on the factors affecting the 6-month mortality of moderate and low-risk acute coronary syndrome patients.

Post-discharge all-cause mortality in COVID-19 recovered patients hospitalized in 2020: the impact of chronic kidney disease.

In Brazil, the COVID-19 burden was substantial, and risk factors associated with higher in-hospital mortality rates have been extensively studied. However, information on short-term all-cause mortality and the factors associated with death in patients who survived the hospitalization period of acute SARS-CoV-2 infection is limited. We analyzed the six-month post-hospitalization mortality rate and possible risk factors of COVID-19 patients in a single center in Brazil. This is a retrospective cohort study focused on a six-month follow-up. The exclusion criteria were death during hospitalization, transference to another hospital, and age under 18. We collected data from the charts of all hospitalized patients from March 2020 to December 2020 with a positive RT-PCR test for SARS-CoV-2, resulting in a sample size of 106 patients. The main outcome was death after hospitalization, whereas comorbidities and demographics were evaluated as risk factors. The crude post-hospitalization death rate was 16%. The first 30 days of follow-up had the highest mortality rate. In a Cox regression model for post-hospitalization mortality, previous chronic kidney disease (HR, 4.06, 95%CI 1.46 - 11.30) and longer hospital stay (HR 1.01, 95%CI 1.00 - 1.02) were the only factors statistically associated with death. In conclusion, a high six-month all-cause mortality was observed. Within the six-month follow-up, a higher risk of death was observed for patients who had prior CKD and longer hospital stay. These findings highlight the importance of more intensive medical surveillance during this period.

The significance of early-onset malignant arrhythmias in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention and their relationship with biomarkers

Background/Aim. Patients who were treated with primary percutaneous coronary intervention (pPCI) and survived ventricular tachycardia (VT) and ventricular fibrillation (VF) in the first 48 hrs after ST-elevation myocardial infarction (STEMI) had, in most investigations, a similar long-term prognosis of the outcome, compared to those patients who did not have VT and VF during the first 48 hrs after STEMI. The aim of the study was to determine the association of myocardial infarction markers: creatine kinase-MB fraction (CK-MB), heart failure marker ? B-type natriuretic peptide (BNP), and systemic inflammation factor ? C-reactive protein (CRP) with early VT and VF onset, in relation to patient mortality during the first six months after STEMI. Methods. The retrospective study included 971 patients with STEMI treated with pPCI for ten years. VF and sustained VT (sVT) were detected outside of the hospital and during the first 48 hrs of hospitalization. Results. During the first 4 8 hrs from admission, 1 08 ( 11.1%) patients had life-threatening arrhythmias, of which 75 (69.4%) had VF, and 33 (30.6%) had sVT and were treated with direct current ? DC shock and intravenous amiodarone. Intrahospital mortality was significantly higher in patients with VF/sVT in the first 48 hrs compared to patients without VF/sVT (14.8% vs. 5.7%, p = 0.001). BNP level had higher accuracy in the prediction of six-month death than the maximum blood level of CRP in patients without VF/sVT after 48 hrs. However, in patients with early-onset malignant arrhythmias, BNP showed a lower level of accuracy in predicting the six-month mortality, a s did the CRP values, which had almost the same level of accuracy. Admission glycemia had a much lower predictive value in both groups of patients compared to BNP and C RP [ 0.705 ( 0.628? 0.781), p &lt; 0.001 and 0.662 (0.521?0.803), p = 0.046, respectively]. In either of the groups, maximum CK-MB levels were not significant in predicting the six-month all-cause mortality. Conclusion. Our study indicates that STEMI patients with early onset of VF and sVT, treated with pPCI, with a high BNP level, have a statistically significantly higher mortality rate compared to patients with a lower BNP level.

Peri-operative score for elderly patients with resectable hepatocellular carcinoma.

Liver resection is the mainstay for a curative treatment for patients with resectable hepatocellular carcinoma (HCC), also in elderly population. Despite this, the evaluation of patient condition, liver function and extent of disease remains a demanding process with the aim to reduce postoperative morbidity and mortality. To identify new perioperative risk factors that could be associated with higher 90- and 180-d mortality in elderly patients eligible for liver resection for HCC considering traditional perioperative risk scores and to develop a risk score. A multicentric, retrospective study was performed by reviewing the medical records of patients aged 70 years or older who electively underwent liver resection for HCC; several independent variables correlated with death from all causes at 90 and 180 d were studied. The coefficients of Cox regression proportional-hazards model for six-month mortality were rounded to the nearest integer to assign risk factors' weights and derive the scoring algorithm. Multivariate analysis found variables (American Society of Anesthesiology score, high rate of comorbidities, Mayo end stage liver disease score and size of biggest lesion) that had independent correlations with increased 90- and 180-d mortality. A clinical risk score was developed with survival profiles. This score can aid in stratifying this population in order to assess who can benefit from surgical treatment in terms of postoperative mortality.

Low ADAMTS13 Activity in Patients with Liver Disease- Thrombotic Thrombocytopenic Purpura or Not?

Introduction: Patients with liver injury have hemostatic defects including reduced ADAMTS13 (A disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13). Severe deficiency of ADAMTS13 (ADMS13) activity (&amp;lt; 10%) is pathognomonic for thrombotic thrombocytopenic purpura (TTP), a rare thrombotic microangiopathy (TMA). Differentiating TTP from severe liver injury is complex for multiple reasons including 1) low baseline ADMS13 2) concomitant coagulopathies complicating differentiation from disseminated intravascular coagulation (DIC) 3) ADMS13 activity (ADMS13:AC) assay interference (hyperbilirubinemia (&amp;gt;30mg/dL) can cause artifactual reduction of ADMS13:AC). Here we sought to characterize the clinical presentation, management, and outcomes of patients with liver injury presenting with thrombocytopenia (TCP), microangiopathic hemolytic anemia (MAHA) and low ADMS13:AC at our institution. Methods: In this retrospective study, after IRB approval, electronic medical records (EMR) of institutional patients who had ADMS13:AC and inhibitor profile performed in our special coagulation laboratory between 2018 and July 17, 2023, were reviewed. Eligible patients had ADMS13:AC ≤20% were ≥ 18 years and had evidence of liver injury at time of ADMS13. Liver injury was defined as ALT or AST elevations greater than two times the upper level of normal within one month prior to ADMS13:AC testing, history of end stage liver disease or cirrhosis, or liver transplant with evidence of graft dysfunction. Details regarding clinical presentation, management and outcomes were extracted from the EMR. PLASMIC and ISTH DIC scores were retrospectively calculated. Results: 70 patients had at least one ADMS13:AC &amp;lt; 20% during the study period. 28/70 patients met liver injury inclusion criteria and 20/28 had TCP and MAHA. Of those 20 patients, median age at initial ADMS13:AC was 56.5 years (29-85). Most patients (n=14) had ADMS13:AC of 10-20%. ADMS13:AC was &amp;lt; 5% and 5-10% in 3 patients each. Eleven patients had a positive inhibitor with a median Bethesda titer of 1.85 BU (0.5-3.9). Etiology of liver included: ischemic hepatopathy (n=8), liver graft failure (n=4), liver metastasis (n=3), cirrhosis (n=2), alcoholic hepatitis (n=1), unknown (n=2). Median hemoglobin and platelet (plt) count at time of ADMS13 was 7 g/dL (6.4-13.2) and 30 x10 9/L (3-98), respectively. 7/20 patients had a PLASMIC score of ≥5; PLASMIC score was ≥5, in 2/6 patients with ADMS13:AC &amp;lt;10%. 16/18 patients had an ISTH DIC score ≥5. 18/20 patients had a creatinine &amp;gt; 2 mg/dL or were receiving renal replacement therapy the time of ADMS13: AC. 7/20 patients had total or direct bilirubin of &amp;gt;30mg/dL. Eight/20 patients were treated with plasma exchange (PEX) for a median duration of 7 days (2-13). 66.7% of pts with ADMS13:AC &amp;lt;10% received PEX. Glucocorticoids and Rituximab were used with the intent to treat TTP in 7 and 3 patients, respectively. Caplacizumab was used in 2 patients. 3/8 (37.5%) patients receiving PEX demonstrated normalization of MAHA. One of these patients demonstrated improvement but not normalization of plts (Table 1B, case 5). All patients had recurrence of hematologic abnormalities after PEX was stopped. One patient was treated with plasma infusion with stabilization in plt count. There were 13 and 15 deaths within 1 and 6 months of first ADMTS13:AC, respectively. One death was potentially attributable to management of TTP (Table 1B, case 1). There was no difference in time to death or mortality with the use of PEX. Repeat ADMS13:AC remote from PEX, TCP and MAHA was available for 1/5 surviving patients. This patient (Table1, case 2) had normalization of ADMS:AC after undergoing liver transplant. Conclusion: The differential diagnosis of TCP and MAHA in patients with liver injury includes hepatic dysfunction, DIC and TMA. In the current cohort, 89% of evaluable patients met criteria for overt DIC per ISTH criteria. Due to a low ADMTS13:AC, 40% of patients underwent a trial of PEX with 37.5% demonstrating improvement in MAHA that was not sustained upon discontinuation of PEX due to persistent liver dysfunction. Six-month mortality was 75% and use of PEX did not affect mortality. Given the high mortality, further studies evaluating which patients with TMA and liver injury are more likely to benefit from therapies typically used to treat TTP are necessary.

Socio-economic factors determine maternal and neonatal outcomes in women with peripartum cardiomyopathy: A study of the ESC EORP PPCM registry

BackgroundPeripartum cardiomyopathy (PPCM) is a global disease with substantial morbidity and mortality. The aim of this study was to analyze to what extent socioeconomic factors were associated with maternal and neonatal outcomes. MethodsIn 2011, >100 national and affiliated member cardiac societies of the European Society of Cardiology (ESC) were contacted to contribute to a global PPCM registry, under the auspices of the ESC EORP Programme. We investigated the characteristics and outcomes of women with PPCM and their babies according to individual and country-level sociodemographic factors (Gini index coefficient [GINI index], health expenditure [HE] and human developmental index [HDI]). Results739 women from 49 countries (Europe [33%], Africa [29%], Asia-Pacific [15%], Middle East [22%]) were enrolled. Low HDI was associated with greater left ventricular (LV) dilatation at time of diagnosis. However, baseline LV ejection fraction did not differ according to sociodemographic factors. Countries with low HE prescribed guideline-directed heart failure therapy less frequently. Six-month mortality was higher in countries with low HE; and LV non-recovery in those with low HDI, low HE and lower levels of education. Maternal outcome (death, re-hospitalization, or persistent LV dysfunction) was independently associated with income. Neonatal death was significantly more common in countries with low HE and low HDI, but was not influenced by maternal income or education attainment. ConclusionsMaternal and neonatal outcomes depend on country-specific socioeconomic characteristics. Attempts should therefore be made to allocate adequate resources to health and education, to improve maternal and fetal outcomes in PPCM.

Inpatient peritoneal dialysis catheters placed across the United States during a 3-year period: Lessons learned from 15,000 patients

BackgroundPeritoneal dialysis is a popular option for patients with end-stage renal disease. A recent presidential executive order has incentivized in-home end-stage renal disease treatments, leading to an increase in peritoneal dialysis use. Guidelines exist for creating and maintaining peritoneal dialysis access without addressing the optimal technique. This study evaluates nationwide peritoneal dialysis catheter placement practices and their long-term outcomes. MethodsRetrospective cohort analysis of Nationwide Readmission Database from 2017 to 2019. Patients with end-stage renal disease undergoing inpatient peritoneal dialysis catheter placement were included. Six-month readmissions, mortality, and peritoneal dialysis catheter-specific outcome measures were assessed among survivors of admission, including catheter leakage, mechanical breakdown, displacement, revision or replacement, removal, exit site infections, intra-abdominal abscess, and sepsis. Binary logistic regression analyses were performed. ResultsIn the study, 14,863 patients with inpatient peritoneal dialysis catheter insertions were identified, of which 7,096 were analyzed (4,150 [59%] laparoscopic, 1,781 [25%] fluoroscopic, 1,165 [16%] open), 847 (12%) had major complications, 931 (13%) were readmitted, and 102 (1.4%) died within 6 months. Univariate analyses demonstrated that laparoscopy had higher mechanical complications, exit-site infections, catheter revision, and removal within 6 months, and fluoroscopy had higher sepsis and mortality. Multivariate analyses showed fluoroscopy was associated with intraabdominal abscess (adjusted odds ratio, 2.36; P = .025), laparoscopy with exit-site infections (adjusted odds ratio, 0.49; P = .005), and open surgery with catheter displacement (adjust odds ratio, 2.95; P = .021). ConclusionThis is the first large-scale study on inpatient peritoneal dialysis catheter placement outcomes in the United States. Fluoroscopic and open surgical placements are routinely performed, but laparoscopy remains the mainstay with fewer exit-site infections. Overall, peritoneal dialysis is a safe option, with 1 in 9 patients having an infectious or mechanical complication within 6 months. Furthermore, large-scale prospective studies are warranted to identify the optimal placement technique.

Immediate, early and late ventricular fibrillation complicating acute myocardial infarction: insights from a real life registry

Abstract Background Conflicting data exist on the prognosis of ventricular fibrillation (VF) based on its timing in relation to coronary occlusion in acute myocardial infarction (AMI). Purpose To describe the patient profile and prognostic impact of VF during AMI according to its time of occurrence. Methods Data from three nationwide French cohorts carried out 5 years apart from 2005 to 2015 were analysed (FAST-MI program). All consecutive patients with AMI (STEMI and Non-STEMI) over a 1-month period were enrolled and followed 5 years. The present analysis focused on patients who presented with VF according to its time of occurrence defined as: immediate (out-of-hospital cardiac arrest), early (&amp;lt;48h at admission) and late (≥48h after admission). Results Out of 13 125 patients admitted for AMI (66±14 years, 71% men, 52% ST-elevation myocardial infarction-STEMI), 406 (3.1%) presented with VF including 205 immediate (50.5%), 147 early (36.2%) and 54 late (13.3%) VF episodes. Immediate and early VF were most frequent during STEMI (respectively 2.3% and 1.8% vs. 0.8% and 0.4% in non-STEMI, p&amp;lt;0.001), while late VF incidence was as frequent in ST-elevation and non-STEMI (0.5% vs 0.4%, p value). The proportion of immediate, early and late VF in AMI were similar in 2005, 2010 and 2015. Patients with immediate (61.6±13.2 yo) or early (62.4±14.2 yo) VF were younger than those with no VF (66.1±14.1 yo, p&amp;lt;0.001) while patients with late VF patients were the oldest (70.5±13.6 yo). LVEF was lower in patients with early (48±10%) or late (48±13%), compared with patients without VF (52±11%) or those with immediate VF (51±12%) (p&amp;lt;0.001). In-hospital mortality was particularly high in patients who developed immediate (24.9%) and late (37.0%) VF, intermediate in early VF patients (10.9%) and lowest in non-VF patients (3.0%) (p&amp;lt;0.001). Among patients alived at hospital discharge, and compared with patients with no VF (4.2%), the six-month mortality was considerably increased in the late VF subgroup (17.6%, adjusted HR: 6.04 [2.69-13.58], P&amp;lt;0.001), moderately increased in immediate VF (5.2%, HR:2.15 [1.06-4.34, P=0.03) ) and did not differ in early VF (1.5%, HR: 0.52 [0.13-2.11 P=0.36). At five years, mortality was also significantly higher in patients with late VF (38.2%, adjusted HR 1.72 [1.01-2.91]), with no significant difference between immediate, early, and non VF patients (14.2%, 11.5% and 19.3% respectively). Conclusions Patients with immediate, early and late VF during AMI do present with significantly different profiles. Still, only late VF (≥48h after admission) was associated with poorer outcome after the index hospitalisation, especially within the initial 6 months. By contrast with current guidelines based on relatively old data from the 2000s in secondary prevention in ischemic or non-ischemic settings, the extent to which patients with late VF would benefit from rapid cardioverter defibrillator implantation is questionable.3 months survival after VF in AMI5 year survival after VF in AMI

Risk of myocardial infarction following capecitabine treatment in patients with gastrointestinal cancer - a nationwide registry-based study

Abstract Background Myocardial infarction is a cardiac adverse event associated with fluoropyrimidines such as 5-fluorouracil and its orally available prodrug capecitabine. There are limited data on the incidence, risk, and prognosis of capecitabine associated myocardial infarction. Purpose The aim of this study was to examine the risk of myocardial infarction in patients with gastrointestinal (GI) cancer treated with capecitabine compared with age- and sex-matched population control subjects without cancer (1:2 ratio). Methods Patients with GI cancer treated with capecitabine between 2004-2016 were identified within the Danish National Patient Registry. Those with a history of ischemic heart disease were excluded. Absolute and relative risks of myocardial infarction at 6 months and 1 year were derived from multivariable Cox regression with average treatment effect modeling. Estimates were standardized to the distributions of age, sex, selected comorbidities, and pharmacotherapies of all included subjects. Results A total of 71,460 patients were included in the final analysis of whom 23,820 had GI cancer treated with capecitabine, and 47,640 were population control subjects without cancer. Differences in the prevalences of selected comorbid conditions, including diabetes, hypertension, and other risk factors for coronary artery disease and antianginal medications were not significant (P&amp;gt;0.05 for all). The 6-month absolute risk (AR) of myocardial infarction was significantly higher for capecitabine-treated patients at 0.6% [95% confidence interval (CI): 0.5%-0.7%] versus 0.3% [95% CI: 0.2%-0.3%] in population control subjects, corresponding to a relative risk (RR) of 2.00 [95% CI 1.53-2.48; P &amp;lt;0.001]. The corresponding 1-year ARs were 0.7% [95% CI: 0.6%-0.9%] versus 0.6% [95% CI: 0.5%-0.6%]; RR 1.28 [95% CI 1.03-1.52; P= 0.03]. Six-month and one-year all-cause mortality ARs for patients treated with capecitabine versus controls were 15.2% vs. 0.7% and 29.7% vs. 1.6% respectively. Conclusions The risk of myocardial infarction of capecitabine-treated patients both 6- and 12-month risks were significantly higher compared with population controls. Despite the absolute risk were low, the clinical significance of the differences appears limited in the context of the significant competing risk of death in this population.Risk of Myocardial InfarctionMortality