Incidence, Risk Factors and Outcome of Postoperative Acute Kidney Injury in China

BACKGROUND AND HYPOTHESIS

Postoperative acute kidney injury (AKI) is a common condition after surgery, however, the available data about nationwide epidemiology of postoperative AKI in China from the large and high-quality studies is limited. This study was aimed to determine the incidence, risk factors, and outcomes of postoperative AKI among patients undergoing surgery in China.

METHODS

This was a large, multicenter, retrospective study performed in 16 tertiary medical centers in China. Adult (at least 18 years old) patients who undergoing surgical procedures from January 1, 2013 to December 31, 2019 were included. Postoperative AKI was defined by the Kidney Disease: Improving Global Outcomes creatinine criteria. The associations of AKI and in-hospital outcomes were investigated using logistic regression models adjusted for potential confounders.

RESULTS

Among 520 707 patients included in our study, 25 830 (5.0%) patients developed postoperative AKI. The incidence of postoperative AKI varied by surgery type, which was highest in cardiac (34.6%) surgery, followed by urologic (8.7%), and general (4.2%) surgeries. 89.2% postoperative AKI cases were detected in the first 2 postoperative days. However, only 584 (2.3%) patients with postoperative AKI were diagnosed with AKI on discharge. Risk factors for postoperative AKI included advanced age, male sex, lower baseline kidney function, pre-surgery hospital stay ≤ 3 days or > 7 days, hypertension, diabetes mellitus, and use of PPIs or diuretics. The risk of in-hospital death increased with the stage of AKI. In addition, patients with postoperative AKI had longer length of hospital stay (12 vs 19 days), were more likely to require intensive unit care (13.1% vs 45.0%) and renal replacement therapy (0.4% vs 7.7%).

CONCLUSIONS

Postoperative AKI was common across surgery type in China, particularly for patients undergoing cardiac surgery. Implementation and evaluation of an alarm system is important for the battle against postoperative AKI.

Comparison of the Life-Sustaining Treatment, Cardiopulmonary Resuscitation, and Palliative Care Implementation Rates between Homebound Patients with Malignant and Nonmalignant Disease Who Died in an Acute Hospital Setting: A Single-Center Retrospective Study

OBJECTIVE

This study investigated and compared the implementation of life-support treatment (LST), cardiopulmonary resuscitation (CPR) implementation rates, and the influence of acute illnesses on the introduction of palliative care (PC) to homebound patients with malignant and nonmalignant disease, who subsequently died in an acute hospital setting.

METHODS

Among the homebound patients admitted to the ward in our hospital from 2011 to 2018, we investigated and compared the attributes, underlying diseases, causes of death, and rates of implementation of LST, CPR, and PC between patients with malignant and nonmalignant disease who died in the ward, using data obtained from hospitalization records. Furthermore, acute illnesses related to the introduction of PC were examined.

RESULTS

Of the 551 homebound patients admitted to the ward of an acute hospital, 119 died in the ward. Of the deceased patients, 60 had malignant disease and 59 had nonmalignant disease. Patients with nonmalignant disease had higher rates of LST implementation and CPR and a lower rate of PC. Patients with infectious disease, who required antimicrobial drugs, had significantly lower PC introduction rates.

CONCLUSION

Understanding the influence of the timing of PC introduction in acute care for homebound patients with advanced chronic illness are issues to be considered.

Elevated ApoB/apoA-1 is Associated with in-Hospital Mortality in Elderly Patients with Acute Myocardial Infarction

Background

Apolipoprotein B/apolipoprotein A-1 (apoB/apoA-1) has been shown to be strongly associated with the risk of future cardiovascular disease, but the association between apoB/apoA-1 and the risk of in-hospital death in elderly patients with acute myocardial infarction(AMI) is inconclusive.

Aim

To investigate the association between apoB/apoA-1 and the risk of in-hospital death in elderly patients with AMI.

Methods

From December 2015 to December 2021, a total of 1495 elderly AMI patients (aged ≥ 60 years) with complete clinical history data were enrolled in the Second Hospital of Dalian Medical University. Outcome was defined as all-cause mortality during hospitalization. Multivariate logistic regression and restricted spline cubic (RCS) models were used to evaluate the association between apoB/apoA-1 and in-hospital mortality risk, respectively. Receiver operating characteristic(ROC) curves were used to evaluate the predictive value of apoB/apoA-1 for in-hospital mortality events. Discordance analysis was performed when apoB/apoA-1 and LDL-C/HDL-C were not in concordance.

Results

(1) A total of 128 patients (8.6%) died during hospitalization. Patients in the death group had higher apoB/apoA-1 than those in the non-death group, but lower apoA-1 levels than those in the non-death group, and the difference was statistically significant (P < 0.05); (2) Multivariate logistic regression analysis showed that apoB/apoA-1 was associated with the risk of in-hospital death in elderly AMI patients [Model 3 OR = 3.524 (1.622-7.659), P = 0.001]; (3) ROC curve analysis showed that apoB/apoA-1 (AUC = 0.572, P = 0.011) had some predictive value for the risk of in-hospital death in elderly AMI patients; (4) RCS models showed a linear dose-response relationship between apoB/apoA-1 and in-hospital death after adjusting for confounders (P for non-linearity = 0.762).

Conclusion

ApoB/apoA-1 is associated with the risk of in-hospital death in elderly patients with AMI, and is superior to other blood lipid parameters and blood lipid ratio.

Predictors of In-Hospital Death in Patients With Acute Myocardial Infarction

OBJECTIVE

Factors such as age, vital signs, renal function, Killip class, cardiac arrest, elevated cardiac biomarker levels, and ST deviation predict survival in patients with acute myocardial infarction (AMI). However, the existing risk assessment tools lack comprehensive consideration of catheter-related factors, and short-term prognostic predictors are unknown. This study aimed to clarify in-hospital prognostic predictors in hospitalized patients with AMI.

METHODS

Five hundred and thirty-six patients who underwent percutaneous coronary intervention (PCI) for AMI were divided into non-survivor (n = 36) and survivor (n = 500) groups. Coronary risk factors, laboratory findings, angiographic findings, and clinical courses were compared between the two groups. Multiple logistic regression was used to analyze in-hospital death in pre- and post-PCI phases.

RESULTS

In the pre-PCI phase, multiple logistic regression analysis revealed several predictors of in-hospital death, including systolic blood pressure [odds ratio (OR) = 0.985, p = 0.023)], Killip class ≥2 (OR = 14.051, p <0.001), and chronic kidney disease (OR = 4.859, p = 0.040). In the post-PCI phase, multiple logistic regression analysis revealed additional predictors of in-hospital death, including Killip class ≥2 (OR = 5.982, p = 0.039), presence of lesions in the left main trunk (OR = 51.381, p = 0.044), utilization of intra-aortic balloon pumps and percutaneous cardiopulmonary support (OR = 6.141, p = 0.016), and presence of multi-vessel disease (OR = 6.323, p = 0.022).

CONCLUSION

Predictors of in-hospital death in AMI extend beyond conventional risk factors to include culprit lesions, mechanical support, and multi-vessel disease that manifest post-PCI.

Is patients' rurality associated with in-hospital sepsis death in US hospitals?

Background

The focus of this study was to explore the association of patients' rurality and other patient and hospital-related factors with in-hospital sepsis mortality to identify possible health disparities across United States hospitals.

Methods

The National Inpatient Sample was used to identify nationwide sepsis patients (n = 1,977,537, weighted n = 9,887,682) from 2016 to 2019. We used multivariate survey logistic regression models to identify predictors for how patients' rurality is associated with in-hospital death.

Findings

During the study periods, in-hospital death rates among sepsis inpatients continuously decreased (11.3% in 2016 to 9.9% in 2019) for all rurality levels. Rao-Schott Chi-Square tests demonstrated that certain patient and hospital factors had varied in-hospital death rates. Multivariate survey logistic regressions suggested that rural areas, minorities, females, older adults, low-income, and uninsured patients have higher odds of in-hospital mortality. Further, specific census divisions like New England, Middle Atlantic, and East North Central had greater in-hospital sepsis death odds.

Conclusion

Rurality was associated with increased in-hospital sepsis death across multiple patient populations and locations. Further, rurality in New England, Middle Atlantic, and East North Central locations is exceptionally high odds. In addition, minority races in rural areas also have an increased odds of in-hospital death. Therefore, rural healthcare requires a more significant influx of resources and should also include assessing patient-related factors.

Association of Country Income Level With the Characteristics and Outcomes of Critically Ill Patients Hospitalized With Acute Kidney Injury and COVID-19

Introduction

Acute kidney injury (AKI) has been identified as one of the most common and significant problems in hospitalized patients with COVID-19. However, studies examining the relationship between COVID-19 and AKI in low- and low-middle income countries (LLMIC) are lacking. Given that AKI is known to carry a higher mortality rate in these countries, it is important to understand differences in this population.

Methods

This prospective, observational study examines the AKI incidence and characteristics of 32,210 patients with COVID-19 from 49 countries across all income levels who were admitted to an intensive care unit during their hospital stay.

Results

Among patients with COVID-19 admitted to the intensive care unit, AKI incidence was highest in patients in LLMIC, followed by patients in upper-middle income countries (UMIC) and high-income countries (HIC) (53%, 38%, and 30%, respectively), whereas dialysis rates were lowest among patients with AKI from LLMIC and highest among those from HIC (27% vs. 45%). Patients with AKI in LLMIC had the largest proportion of community-acquired AKI (CA-AKI) and highest rate of in-hospital death (79% vs. 54% in HIC and 66% in UMIC). The association between AKI, being from LLMIC and in-hospital death persisted even after adjusting for disease severity.

Conclusions

AKI is a particularly devastating complication of COVID-19 among patients from poorer nations where the gaps in accessibility and quality of healthcare delivery have a major impact on patient outcomes.

Risk factors for in-hospital death in 2,179 patients with acute aortic dissection

Background

This study aims to investigate the risk factors for in-hospital death in patients with acute aortic dissection (AAD) and to provide a straightforward prediction model to assist clinicians in determining the outcome of AAD patients.

Methods

Retrospective analysis was carried out on 2,179 patients admitted for AAD from March 5, 1999 to April 20, 2018 in Wuhan Union Hospital, China. The risk factors were investigated with univariate and multivariable logistic regression analysis.

Results

The patients were divided into two groups: Group A, 953patients (43.7%) with type A AAD; Group B, 1,226 patients (56.3%) with type B AAD. The overall in-hospital mortality rate was 20.3% (194/953) and 4% (50/1,226) in Group A and B respectively. The multivariable analysis included the variables that were statistically significant predictors of in-hospital death (P < 0.05). In Group A, hypotension (OR = 2.01, P = 0.001) and liver dysfunction (OR = 12.95, P < 0.001) were independent risk factors. Tachycardia (OR = 6.08, P < 0.001) and liver dysfunction (OR = 6.36, P < 0.05) were independent risk factors for Group B mortality. The risk factors of Group A were assigned a score equal to their coefficients, and the score of -0.5 was the best point of the risk prediction model. Based on this analysis, we derived a predictive model to help clinicians determine the prognosis of type A AAD patients.

Conclusions

This study investigate the independent factors associated with in-hospital death in patients with type A or B aortic dissection, respectively. In addition, we develop the prediction of the prognosis for type A patients and assist clinicians in choosing treatment strategies.

Understanding the Relationships Between Health Care Providers' Moral Distress and Patients' Quality of Death

Introduction: Moral distress is a commonly recognized phenomenon among health care providers; however, the experience of moral distress by staff caring for patients who die during an acute care hospital stay has not been previously examined. It also remains unclear how the quality of a death may impact moral distress among these providers. Objectives: We sought to understand levels of moral distress experienced by intern physicians and nurses who provided care during a patient's final 48 hours of life, and how the perceived quality of death impacted moral distress. Materials and Methods: We utilized a mixed-method prospective cohort design, surveying nurses and interns following inpatient hospital deaths at an academic safety-net hospital in the United States. Participants completed surveys and answered open-ended questions to evaluate moral distress and the quality of the patient's death. Results: A total of 126 surveys were sent to nurses and interns caring for 35 patients who died, with 46 surveys completed. Overall moderate-to-high levels of moral distress were identified among participants, and we found that higher levels of moral distress correlated with lower perceived quality of death. We identified five themes in our qualitative analysis highlighting the challenges nurses and interns face in end-of-life care, including the following: poor communication, unexpected deaths, patient suffering, resource limitations, and failure to prioritize a patient's wishes or best interests. Conclusions: Nurses and interns experience moderate-to-high levels of moral distress when caring for dying patients. Lower quality of end-of-life care is associated with higher levels of moral distress.

Assessment of In-Hospital Mortality and Its Risk Factors in Patients with Myocardial Infarction Considering the Logistical Aspects of the Treatment Process-A Single-Center, Retrospective, Observational Study

Technological progress, such as the launching of a new generation of drug-coated stents as well as new antiplatelet drugs, has resulted in the treatment of myocardial infarction (MI) becoming much more effective. The aim of this study was to assess in-hospital mortality and to conduct an assessment of risk factors relevant to the in-hospital death of patients with MI. This study was based on an observational hospital registry of patients with MI (ACS GRU registry). For the purpose of the statistical analysis of the risk factors of death, a univariate logistic regression model was applied. In-hospital general mortality amounted to 7.27%. A higher death risk was confirmed in the following cases: (1) serious adverse events (SAEs) that occurred during the procedure; (2) patients transferred from another department of a hospital (OR = 2.647, p = 0.0056); (3) primary percutaneous coronary angioplasty performed on weekdays between 10 p.m. and 8 a.m. (OR = 2.540, p = 0.0146). The influence of workload and operator experience on the risk of death in a patient with MI has not been confirmed. The results of this study indicate the increasing importance of new risk factors for in-hospital death in patients with MI, such as selected logistical aspects of the MI treatment process and individual SAEs.

Disparities in mortality among acute myeloid leukemia-related hospitalizations

Racial and socioeconomic disparities have become apparent in acute myeloid leukemia (AML) outcomes. We conducted a retrospective cohort study of hospitalizations for adults with a diagnosis of AML from 2009 to 2018 in the Nationwide Inpatient Sample (NIS). We categorized patients' ages in groups of <60 years and ≥60 years and stratified them by reported race/ethnicity. Exposures of interest were patient sociodemographics, hospital characteristics, and Elixhauser-comorbidity Index. Outcome of interest was in-hospital death. Statistical analyses included survey logistic regression to generate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to quantify the independent associations between patient characteristics and mortality. Of 622,417 AML-related hospitalizations, 57.6% were in patients ≥60 years. The overall rate of in-hospital death was 9.4%. Compared to patients <60, older patients experienced a higher rate of in-hospital death. In both age groups and in all ethnicities, mortality decreased over time. Differences in mortality were observed based on gender, payer, hospital location, and teaching status. For hospitalizations in patients ≥60, NH-Black race was associated with inferior in-hospital death outcomes (OR 1.17; CI 1.08-1.28). Urban teaching hospitals were associated with a 38% increase (OR 1.38; CI 1.06-1.80) in inpatient mortality in patients <60 and a 15% decrease (OR 0.85; CI 0.77-0.95) in inpatient mortality in patients ≥60. Our results highlight the increased need to recognize the role of race/ethnicity and socioeconomic factors and their contribution to disparate outcomes in AML.

Predictors of poor clinical outcomes including in-hospital death and low ability to perform activities of daily living at discharge in hospitalized patients with chronic obstructive pulmonary disease exacerbation

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity worldwide. Many patients with COPD experience exacerbations that require hospitalization, which is associated with an increased risk of in-hospital death and impaired ability to perform activities of daily living (ADL). Declining ability to perform ADL is a critical issue for these patients.

OBJECTIVES

To identify predictors of poor clinical outcomes, including in-hospital death and low ability to perform ADL at discharge, in patients who are hospitalized with exacerbation of COPD.

DESIGN

This retrospective study involved a cohort of patients with exacerbation of COPD who were admitted to Iwata City Hospital in Japan between July 2015 and October 2019.

METHODS

We collected clinical data, measured the cross-sectional area of the erector spinae muscles (ESM_CSA) on computed tomography (CT) scans at admission, and investigated the associations of poor clinical outcomes (in-hospital death and severe dependence when performing ADL, defined as a Barthel Index (BI) of ⩽40 at discharge) with clinical parameters.

RESULTS

Overall, 207 patients were hospitalized for exacerbation of COPD during the study period. The incidence of poor clinical outcomes was 21.3%, and the in-hospital mortality rate was 6.3%. Multivariate logistic regression analyses showed that older age, long-term oxygen therapy, an elevated D-dimer concentration, and a reduced ESM_CSA on chest CT at admission were significantly associated with poor clinical outcomes (in-hospital death and a BI of ⩽40).

CONCLUSION

Hospitalization for exacerbation of COPD was associated with high rates of in-hospital mortality and a BI of ⩽40 at discharge, which may be predicted by assessment of ESM_CSA.

Chronic Anti-Coagulation Therapy Reduced Mortality In Patients With High Cardiovascular Risk Early In COVID-19 Pandemic

Background: Coronavirus disease 2019 (COVID-19) is associated with provoked thrombo-inflammatory responses. Early in the COVID-19 pandemic this was thought to contribute to hypercoagulability and multi-organ system complications in infected patients. Limited studies have evaluated the impact of therapeutic anti-coagulation therapy (AC) in alleviate these risks in COVID-19 positive patients. Our study aimed to investigate whether long-term therapeutic AC can decrease the risk of multi-organ system complications (MOSC) including stroke, limb ischemia, gastrointestinal (GI) bleeding, in-hospital and intensive care unit death in COVID-19 positive patients during the early phase of the pandemic in the United States. Methods: A retrospective analysis was conducted of all COVID-19 positive United States Veterans between March 2020 and October 2020. Patients receiving continuous therapeutic AC for a least 30 days prior to or after their initial COVID-19 positive test were assigned to the AC group. Patients who did not receive AC were included in a control group. We analyzed the primary study outcome of MOSC between the AC and control groups using binary logistic regression analysis (Odd-Ratio; OR). Results: We identified 48,066 COVID-19 patients, of them 879 (1.8%) were receiving continuous therapeutic AC. The AC cohort had significantly worse comorbidities than the control group. On the adjusted binary logistic regression model, therapeutic AC significantly decreased in-hospital mortality rate (OR; 0.67, p = 0.04), despite a higher incidence of GI bleeding (OR; 4.00, p = 0.02). However, therapeutic AC did not significantly reduce other adverse events. Conclusion: AC therapy reduced in-hospital death early in the COVID-19 pandemic among patients who were hospitalized with the infection. However, it did not decrease the risk of MOSC. Additional trials are needed to determine the effectiveness of AC in preventing complications associated with ongoing emerging strains of the COVID-19 virus.

Chronic Anti-Coagulation Therapy Reduced Mortality In Patients With High Cardiovascular Risk Early In COVID-19 Pandemic

Background: Coronavirus disease 2019 (COVID-19) is associated with provoked thrombo-inflammatory responses. Early in the COVID-19 pandemic this was thought to contribute to hypercoagulability and multi-organ system complications in infected patients. Limited studies have evaluated the impact of therapeutic anti-coagulation therapy (AC) in alleviate these risks in COVID-19 positive patients. Our study aimed to investigate whether long-term therapeutic AC can decrease the risk of multi-organ system complications (MOSC) including stroke, limb ischemia, gastrointestinal (GI) bleeding, in-hospital and intensive care unit death in COVID-19 positive patients during the early phase of the pandemic in the United States. Methods: A retrospective analysis was conducted of all COVID-19 positive United States Veterans between March 2020 and October 2020. Patients receiving continuous therapeutic AC for a least 30 days prior to or after their initial COVID-19 positive test were assigned to the AC group. Patients who did not receive AC were included in a control group. We analyzed the primary study outcome of MOSC between the AC and control groups using binary logistic regression analysis (Odd-Ratio; OR). Results: We identified 48,066 COVID-19 patients, of them 879 (1.8%) were receiving continuous therapeutic AC. The AC cohort had significantly worse comorbidities than the control group. On the adjusted binary logistic regression model, therapeutic AC significantly decreased in-hospital mortality rate (OR; 0.67, p = 0.04), despite a higher incidence of GI bleeding (OR; 4.00, p = 0.02). However, therapeutic AC did not significantly reduce other adverse events. Conclusion: AC therapy reduced in-hospital death early in the COVID-19 pandemic among patients who were hospitalized with the infection. However, it did not decrease the risk of MOSC. Additional trials are needed to determine the effectiveness of AC in preventing complications associated with ongoing emerging strains of the COVID-19 virus.

Effectiveness of influenza vaccination on in-hospital death in older adults with respiratory diseases

Influenza vaccination is associated with lower risk of hospitalization outcomes among older adults with respiratory diseases, but there is limited evidence by disease subtypes and patients' characteristics. This study included patients aged ≥60 years hospitalized for respiratory diseases from the Beijing Urban Employee Basic Medical Insurance database during 6 influenza seasons. Vaccination status was assessed by linking with the Beijing Elderly Influenza Vaccination database. Multi-variable logistic regression was performed to calculate effect estimates. After adjusting for measured and unmeasured confounders, influenza vaccination was associated with a lower risk of in-hospital death among older adults hospitalized for respiratory diseases (odds ratio [95% confidence interval], 0.70 [0.62-0.80]). The protective association was observed among patients with chronic obstructive pulmonary disease (0.67 [0.47-0.98]) as well as those with pneumonia or influenza (0.77 [0.64-0.93]). The protective association was stronger in younger patients (0.59 [0.43-0.81] for <75 and 0.72 [0.63-0.83] for ≥75) and those with fewer comorbidities (0.49 [0.16-1.62] for 0, 0.65 [0.50-0.86] for 1-2, and 0.72 [0.63-0.83] for ≥3 comorbidities). Influenza vaccination was associated with lower risk of in-hospital death among older patients hospitalized for respiratory diseases, with stronger associations in patients with younger age and fewer comorbidities.

Development of nomogram to predict in-hospital death for patients with intracerebral hemorrhage: A retrospective cohort study

Aim

This study aimed to investigate the association between systemic immune-inflammation (SII) and the risk of in-hospital death for patients with intracerebral hemorrhage (ICH) in the intensive care units (ICU) and to further develop a prediction model related to SII in predicting the risk of in-hospital death for patients with ICH.

Methods

In this retrospective cohort study, we included 1,176 patients with ICH from the Medical Information Mart for Intensive Care III (MIMIC-III) database. All patients were randomly assigned to the training group for the construction of the nomogram and the testing group for the validation of the nomogram based on a ratio of 8:2. Predictors were screened by the least absolute shrinkage and selection operator (LASSO) regression analysis. A multivariate Cox regression analysis was used to investigate the association between SII and in-hospital death for patients with ICH in the ICU and develop a model for predicting the in-hospital death risk for ICU patients with ICH. The receiver operator characteristic curve was used to assess the predicting performance of the constructed nomogram.

Results

In the training group, 232 patients with ICH died while 708 survived. LASSO regression showed some predictors, including white blood cell count, glucose, blood urea nitrogen, SII, the Glasgow Coma Scale, age, heart rate, mean artery pressure, red blood cell, bicarbonate, red blood cell distribution width, liver cirrhosis, respiratory failure, renal failure, malignant cancer, vasopressor, and mechanical ventilation. A prediction model integrating these predictors was established. The area under the curve (AUC) of the nomogram was 0.810 in the training group and 0.822 in the testing group, indicating that this nomogram might have a good performance.

Conclusion

Systemic immune-inflammation was associated with an increased in-hospital death risk for patients with ICH in the ICU. A nomogram for in-hospital death risk for patients with ICH in the ICU was developed and validated.

Establishment and external validation of an online dynamic nomogram for predicting in-hospital death risk in sepsis-associated acute kidney disease

OBJECTIVES

Approximately one-third of patients with sepsis-associated acute kidney injury (AKI) progress to acute kidney disease (AKD) with higher short-term mortality. We aimed to identify the clinical characteristics that influence in-hospital death in sepsis-associated AKD and develop a nomogram to facilitate early warning.

METHODS

Logical regression was applied to screen variables based on clinical data from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. A nomogram was established to predict in-hospital death risk in patients with sepsis-associated AKD. The eICU Collaborative Research Database (eICU-CRD) was used for external validation. The receiver operating characteristic and calibration curves were used to determine the model's performance.

RESULTS

A total of 1,779 patients with sepsis-associated AKD were included from the MIMIC-IV and 344 from the eICU-CRD. Age, Glasgow coma scale score, systolic blood pressure, peripheral oxygen saturation, platelet count, white blood cell count, and bicarbonate levels were significantly correlated with death. The nomogram demonstrated high discrimination in the training (C-index, 0.829; 95% confidence interval [CI] [0.807-0.852]) and testing sets (C-index: 0.760; 95% CI [0.706-0.814]). At the optimal cut-off value of 0.270, the model's sensitivity in the training and validation datasets was 72.8% (95% CI [68.3-76.9%]) and 64.5% (95% CI [54.9-73.4%]), while the specificity was 79.2% (95% CI [76.9-81.4%]) and 74.8% (95% CI [68.7-80.2%]), respectively.

CONCLUSION

We identified seven predictors of in-hospital death in patients with sepsis-associated AKD. In addition, we developed an online dynamic nomogram to accurately and conveniently predict short-term outcomes, which performed well in the external dataset.

Age-specific associations between underlying health conditions and hospitalisation, death and in-hospital death among confirmed COVID-19 cases: a multi-country study based on surveillance data, June to December 2020

Background

Underlying conditions are risk factors for severe COVID-19 outcomes but evidence is limited about how risks differ with age.

Aim

We sought to estimate age-specific associations between underlying conditions and hospitalisation, death and in-hospital death among COVID-19 cases.

Methods

We analysed case-based COVID-19 data submitted to The European Surveillance System between 2 June and 13 December 2020 by nine European countries. Eleven underlying conditions among cases with only one condition and the number of underlying conditions among multimorbid cases were used as exposures. Adjusted odds ratios (aOR) were estimated using 39 different age-adjusted and age-interaction multivariable logistic regression models, with marginal means from the latter used to estimate probabilities of severe outcome for each condition–age group combination.

Results

Cancer, cardiac disorder, diabetes, immunodeficiency, kidney, liver and lung disease, neurological disorders and obesity were associated with elevated risk (aOR: 1.5–5.6) of hospitalisation and death, after controlling for age, sex, reporting period and country. As age increased, age-specific aOR were lower and predicted probabilities higher. However, for some conditions, predicted probabilities were at least as high in younger individuals with the condition as in older cases without it. In multimorbid patients, the aOR for severe disease increased with number of conditions for all outcomes and in all age groups.

Conclusion

While supporting age-based vaccine roll-out, our findings could inform a more nuanced, age- and condition-specific approach to vaccine prioritisation. This is relevant as countries consider vaccination of younger people, boosters and dosing intervals in response to vaccine escape variants.

High-density lipoprotein cholesterol to apolipoprotein A-1 ratio is an important indicator predicting in-hospital death in patients with acute coronary syndrome

BACKGROUND

Dyslipidemia plays a pivotal role in the pathogenesis of acute coronary syndrome (ACS). This study aims to investigate the value of two indices associated with lipid metabolism, low-density lipoprotein cholesterol to apolipoprotein B ratio (LBR) and high-density lipoprotein cholesterol to apolipoprotein A-1 ratio (HAR), to predict in-hospital death in patients with ACS.

METHODS

This single-center, retrospective, observational study included 3,366 consecutive ACS patients in Zhongda Hospital, Southeast University from July 2013 to January 2018. The clinical and laboratory data were extracted, and the in-hospital death and hospitalization days were also recorded.

RESULTS

All patients were equally divided into four groups according to quartiles of HAR: Q1 (HAR < 1.0283), Q2 (1.0283 ≤ HAR < 1.0860), Q3 (1.0860 ≤ HAR < 1.1798), and Q4 (HAR ≥ 1.1798). Overall, HAR was positively associated with the counts of neutrophils and monocytes, whereas negatively correlated to lymphocyte counts. HAR was negatively correlated to left ventricular ejection fraction (LVEF). Compared to other three groups, in-hospital mortality (vs. Q1, Q2, and Q3, p < 0.001) and hospitalization length (vs. Q1, Q2, and Q3, p < 0.001) were significantly higher in the Q4 group. When grouped by LBR, however, there was no significant difference in LVEF, in-hospital mortality, and hospitalization length among groups. After adjusting potential impact from age, systolic blood pressure, creatine, lactate dehydrogenase, albumin, glucose, and uric acid, multivariate analysis indicated that HAR was an independent factor predicting in-hospital death among ACS patients.

CONCLUSIONS

HAR had good predictive value for patients' in-hospital death after the occurrence of acute coronary events, but LBR was not related to in-hospital adverse events.

Real World Estimate of Vaccination Protection in Individuals Hospitalized for COVID-19

Whether vaccination confers a protective effect against progression after hospital admission for COVID-19 remains to be elucidated. Observational study including all the patients admitted to San Paolo Hospital in Milan for COVID-19 in 2021. Previous vaccination was categorized as: none, one dose, full vaccination (two or three doses >14 days before symptoms onset). Data were collected at hospital admission, including demographic and clinical variables, age-unadjusted Charlson Comorbidity index (CCI). The highest intensity of ventilation during hospitalization was registered. The endpoints were in-hospital death (primary) and mechanical ventilation/death (secondary). Survival analysis was conducted by means of Kaplan-Meier curves and Cox regression models. Effect measure modification by age was formally tested. We included 956 patients: 151 (16%) fully vaccinated (18 also third dose), 62 (7%) one dose vaccinated, 743 (78%) unvaccinated. People fully vaccinated were older and suffering from more comorbidities than unvaccinated. By 28 days, the risk of death was of 35.9% (95%CI: 30.1−41.7) in unvaccinated, 41.5% (24.5−58.5) in one dose and 28.4% (18.2−38.5) in fully vaccinated (p = 0.63). After controlling for age, ethnicity, CCI and month of admission, fully vaccinated participants showed a risk reduction of 50% for both in-hospital death, AHR 0.50 (95%CI: 0.30−0.84) and for mechanical ventilation or death, AHR 0.49 (95%CI: 0.35−0.69) compared to unvaccinated, regardless of age (interaction p > 0.56). Fully vaccinated individuals in whom vaccine failed to keep them out of hospital, appeared to be protected against critical disease or death when compared to non-vaccinated. These data support universal COVID-19 vaccination.

Specific characteristics of STEMI in COVID-19 patients and their practical implications

ST-elevation myocardial infarction (STEMI) is one of the cardiac emergencies whose management has been most challenged by the COVID-19 pandemic. Patients presenting with the "lethal combo" of STEMI and concomitant SARS-CoV-2 infection have faced dramatic issues related to the need for self-isolation, systemic inflammation with multi-organ disease and difficulties to obtain timely diagnosis and treatment. The interplay between these and other factors has partly neutralized the major advances in STEMI care achieved in the last decades, significantly impairing prognosis in these patients. In the present review article, we will provide an overview on mechanisms of myocardial injury, specific clinical and angiographic characteristics and contemporary management in different settings of STEMI patients with COVID-19, alongside the inherent implications in terms of in-hospital mortality and short-term clinical outcomes.

Risk factor analysis for in-hospital death of geriatric hip fracture patients

OBJECTIVES

To investigate the risk factors of perioperative in-hospital death in elderly patients with hip fracture and the applicability of risk assessment tools.

METHODS

Thirteen in-hospital death cases from 1878 geriatric hip fracture treated in Jishuitan Hospital, China from May 2015 to December 2017 were collected, each dead patient was compared with 4 normal discharged patients with a postoperative survival of more than 90 days at the same admission time (within 2 weeks), gender, age (±5 years), and fracture type. Binary logistic regression was used to analyze the risk factors of in-hospital death; Hosmer-lemeshow goodness of fit test was used to evaluate the goodness of fit of E-PASS (estimation of physical ability and surgical stress) and NHFS (Nottingham hip fracture score).

RESULTS

Mortality in hospital was 0.7%; the number of comorbidities and the time from fracture to operation were the risk factors of in-hospital death. Nottingham hip fracture score system is more accurate to elderly hip fractures in China.

CONCLUSION

Early operation is the key factor to reduce mortality in elderly patients with hip fracture, and the comorbidities in the basic state of the elderly are the independent risk factors of death; NHFS is recommended to estimate death risk in geriatric hip fractures.

Influence of ambulatory blood pressure-related indicators within 24 h on in-hospital death in sepsis patients

Background: Sepsis is a serious public health problem worldwide. Blood pressure is one of the indicators that is closely monitored in intensive-care units, and it reflects complex interactions between the internal cardiovascular control mechanism and the external environment. We aimed to determine the impact of indicators related to the ambulatory blood pressure on the prognosis of sepsis patients. Methods: This retrospective study was based on the Medical Information Mart for Intensive Care IV database. Relevant information about sepsis patients was extracted according to specific inclusion and exclusion criteria. Examined parameters included the average blood pressure, blood pressure variability (BPV), and circadian rhythm, and the study outcome was in-hospital death. We investigated the effects of these indicators on the risk of in-hospital death among sepsis patients using Cox proportional-hazards models, restricted cubic splines analysis, and subgroup analysis. Results: This study enrolled 10,316 sepsis patients, among whom 2,117 died during hospitalization. All parameters except the nighttime variation coefficient of the diastolic blood pressure (DBP) were associated with in-hospital death of sepsis patients. All parameters except for fluctuations in DBP exhibited nonlinear correlations with the outcome. The subgroup analysis revealed that some of the examined parameters were associated with in-hospital death only in certain subgroups. Conclusion: Indicators related to the ambulatory blood pressure within 24 h are related to the prognosis of sepsis patients. When treating sepsis, in addition to blood pressure, attention should also be paid to BPV and the circadian rhythm in order to improve the prognosis and the survival rate.

Development and Validation of a Predictive Scoring System for In-hospital Death in Patients With Intra-Abdominal Infection: A Single-Center 10-Year Retrospective Study

Objective: To develop and validate a scoring system to predict the risk of in-hospital death in patients with intra-abdominal infection (IAI).

Materials and Methods: Patients with IAI (n = 417) treated at our hospital between June 2010 and May 2020 were retrospectively reviewed. Risk factors for in-hospital death were identified by logistic regression analysis. The regression coefficients of each risk factor were re-assigned using the mathematical transformation principle to establish a convenient predictive scoring system. The scoring system was internally validated by bootstrapping sample method.

Results: Fifty-three (53/417, 12.7%) patients died during hospitalization. On logistic regression analysis, high APACHE II score (P = 0.012), pneumonia (P = 0.002), abdominal surgery (P = 0.001), hypoproteinemia (P = 0.025), and chronic renal insufficiency (P = 0.001) were independent risk factors for in-hospital death. On receiver operating characteristic curve analysis, the composite index combining these five risk factors showed a 62.3% sensitivity and 80.2% specificity for predicting in-hospital death (area under the curve: 0.778; 95% confidence interval: 0.711–0.845, P < 0.001). The predictive ability of the composite index was better than that of each independent risk factor. A scoring system (0–14 points) was established by re-assigning each risk factor based on the logistic regression coefficient: APACHE II score (10–15 score, 1 point; >15 score, 4 points); pneumonia (2 points), abdominal surgery (2 points), hypoproteinemia (2 points), and chronic renal insufficiency (4 points). Internal validation by 1,000 bootstrapping sample showed relatively high discriminative ability of the scoring system (C-index = 0.756, 95% confidence interval: 0.753–0.758).

Conclusions: The predictive scoring system based on APACHE II score, pneumonia, abdominal surgery, hypoproteinemia, and chronic renal insufficiency can help predict the risk of in-hospital death in patients with IAI.

A New Scoring System for Predicting In-hospital Death in Patients Having Liver Cirrhosis With Esophageal Varices

Introduction: Liver cirrhosis is caused by the development of various acute and chronic liver diseases. Esophageal varices is a common and serious complication of liver cirrhosis during decompensation. Despite the development of various treatments, the prognosis for liver cirrhosis with esophageal varices (LCEV) remains poor. We aimed to establish and validate a nomogram for predicting in-hospital death in LCEV patients.

Methods: Data on LCEV patients were extracted from the Medical Information Mart for Intensive Care III and IV (MIMIC-III and MIMIC-IV) database. The patients from MIMIC-III were randomly divided into training and validation cohorts. Training cohort was used for establishing the model, validation and MIMIC-IV cohorts were used for validation. The independent prognostic factors for LCEV patients were determined using the least absolute shrinkage and selection operator (LASSO) method and forward stepwise logistic regression. We then constructed a nomogram to predict the in-hospital death of LCEV patients. Multiple indicators were used to validate the nomogram, including the area under the receiver operating characteristic curve (AUC), calibration curve, Hosmer-Lemeshow test, integrated discrimination improvement (IDI), net reclassification index (NRI), and decision curve analysis (DCA).

Results: Nine independent prognostic factors were identified by using LASSO and stepwise regressions: age, Elixhauser score, anion gap, sodium, albumin, bilirubin, international normalized ratio, vasopressor use, and bleeding. The nomogram was then constructed and validated. The AUC value of the nomogram was 0.867 (95% CI = 0.832–0.904) in the training cohort, 0.846 (95% CI = 0.790–0.896) in the validation cohort and 0.840 (95% CI = 0.807–0.872) in the MIMIC-IV cohort. High AUC values indicated the good discriminative ability of the nomogram, while the calibration curves and the Hosmer-Lemeshow test results demonstrated that the nomogram was well-calibrated. Improvements in NRI and IDI values suggested that our nomogram was superior to MELD-Na, CAGIB, and OASIS scoring system. DCA curves indicated that the nomogram had good value in clinical applications.

Conclusion: We have established the first prognostic nomogram for predicting the in-hospital death of LCEV patients. The nomogram is easy to use, performs well, and can be used to guide clinical practice, but further external prospective validation is still required.

Rhabdomyolysis is Associated with In-Hospital Mortality in Patients with COVID-19

PURPOSE

Rhabdomyolysis (RM) has been associated with many viral infectious diseases, and associated with poor outcomes. We aim to evaluate the clinical features and outcomes of RM in patients with coronavirus disease 2019 (COVID-19).

METHOD

This was a single-center, retrospective, cohort study of 1,014 consecutive hospitalized patients with confirmed COVID-19 at the Huoshenshan Hospital in Wuhan, China, between February 17 and April 12, 2020.

RESULTS

The overall incidence of RM was 2.2%. Compared with patients without RM, those with RM tended to have a higher risk of deterioration. Patients with RM also constituted a greater percentage of patients admitted to the intensive care unit (90.9% vs. 5.3%, P < 0.001) and a greater percentage of patients undergoing mechanical ventilation (86.4% vs. 2.7% P < 0.001). Moreover, patients with RM had laboratory test abnormalities, including the presence of markers of inflammation, activation of coagulation, and kidney injury. Patients with RM also had a higher risk of in-hospital death (P < 0.001). Cox's proportional hazard regression model analysis confirmed that RM indicators, including peak creatine kinase levels > 1,000 IU/L (HR = 6.46, 95% CI: 3.02-13.86) and peak serum myoglobin concentrations > 1,000 ng/mL (HR = 9.85, 95% CI: 5.04-19.28), were independent risk factors for in-hospital death. Additionally, patients with COVID-19 that developed RM tended to have delayed viral clearance.

CONCLUSION

RM might be an important contributing factor to adverse outcomes in COVID-19 patients. The early detection and effective intervention of RM may help reduce mortality among COVID-19 patients.

Combination of D-dimer and simplified pulmonary embolism severity index to improve prediction of hospital death in patients with acute pulmonary embolism

Objective

To investigate whether the combination of D-dimer and simplified pulmonary embolism severity index (sPESI) could improve prediction of in-hospital death from pulmonary embolism (PE).

Methods

Patients with PE (n = 272) were divided into a surviving group (n = 249) and an in-hospital death group (n = 23).

Results

Compared with surviving patients, patients who died in hospital had significantly higher rates of hypotension and tachycardia, reduced SaO₂ levels, elevated D-dimer and troponin T levels, higher sPESI scores, and were more likely to be classified as high risk. Elevated D-dimer levels and high sPESI scores were significantly associated with in-hospital death. Using thresholds for D-dimer and sPESI of 3.175 ng/mL and 1.5, respectively, the specificity for prediction of in-hospital death was 0.357 and 0.414, respectively, and the area under the receiver operating characteristic curve (AUC) was 0.665 and 0.668, respectively. When D-dimer and sPESI were considered together, the specificity for prediction of in-hospital death increased to 0.838 and the AUC increased to 0.74.

Conclusions

D-dimer and sPESI were associated with in-hospital death from PE. Considering D-dimer levels together with sPESI can significantly improve the specificity of predicting in-hospital death for patients with PE.

Accuracy and Prognosis Value of the Sequential Organ Failure Assessment Score Combined With C-Reactive Protein in Patients With Complicated Infective Endocarditis

This study aimed to evaluate the accuracy and prognostic value of the sequential organ failure assessment (SOFA) score combined with C-reactive protein (CRP) in patients with complicated infective endocarditis (IE). A total of 246 consecutive patients with complicated IE were included in the multicentric prospective observational study. These patients were divided into four groups depending on the SOFA score and CRP optimal cutoff values (≥5 points and ≥17.6 mg/L, respectively), which were determined using the receiver operating characteristic analysis: low SOFA and low CRP (n = 83), low SOFA and high CRP (n = 87), high SOFA and low CRP (n = 25), and high SOFA and high CRP (n = 51). The primary endpoint was in-hospital death, and the secondary endpoint was long-time mortality, defined as subsequent readmission and 3-years mortality in the follow-up period. High SOFA score and high CRP were associated with approximately 29.410% (15/51) of higher incidence of in-hospital death with an area under the curve of 0.872. Multivariate analyses showed that age [odds ratio (OR) = 2.242, 1.142–4.401], neurological failure (Glasgow Coma Scale ≤ 12) (OR = 2.513, 1.041–4.224), Staphylococcus aureus (OR = 2.151, 1.252–4.513), SOFA ≥ 5 (OR = 9.320, 3.621–16.847), and surgical treatment (OR = 0.121, 0.031–0.342) were clinical predictors for in-hospital death. On following up for 12–36 months, SOFA ≥ 5 (p = 0.000) showed higher mortality. A high SOFA score combined with increased CRP levels is associated with in-hospital mortality. Also, SOFA score, but not CRP, predicts long-term mortality in complicated IE.

Nurses' Attitude Toward Caring for Dying Patients in a Nigerian Teaching Hospital

Introduction

Death and the dying experience are common phenomena in all clinical settings. Death and the dying presents physical and emotional strain on the dying patient, his relations and professional caregivers.

Objective

The study therefore assessed the sociodemographic determinants of nurses’ attitudes towards death and caring for dying patient.

Method

A cross–sectional design was used to study 213 randomly selected nurses, working in one of the tier one teaching hospital in Nigeria. Attitude towards death and the dying was collected with Frommelt Attitude Care of the Dying and Death Attitude Profit–Revised questionnaire. The data collected was analysed with SPSS version 20 and inferential analyses were considered statistically significant at p < 0.05.

Results

The study revealed that most of the nurses had negative attitudes toward the concept of death (76.5%) and caring for dying patient (68%). Furthermore, a chi-square test revealed significant associations between the nurses’ years of working experience (χ² = 24.57, p <.00) and current unit of practice (χ² = 21.464; p = .002) and their attitude towards caring for the dying patient. Also, nurses’ age (χ² = 13.77, p = .032), professional qualifications (χ² = 13.774, p = .008), and current ward of practice (χ² = 16.505, p = .011) were significantly associated with their attitudes to death. Furthermore, the study observed a significant association between nurses’ attitudes to death and caring for the dying patient (χ² = 11.26, p < 0.01).

Conclusion

This study concluded that nurses had negative attitudes towards death and dying and therefore prescribes, as part of continuing professional development strategy, the need for requisite positive value – laden, ethnoreligious specific education regarding end of life care.

The prognostic value of IL-8 for the death of severe or critical patients with COVID-19

Inflammation has been believed to contribute to coronavirus disease 2019 (COVID-19). Risk factors for death of COVID-19 pneumonia have not yet been well established.In this retrospective cohort study, we included the deceased patients in COVID-19 specialized ICU with laboratory-confirmed COVID-19 from Guanggu hospital area of Tongji Hospital from February 8th to March 30th. Demographic, clinical, laboratory, and outcome data were extracted from electronic medical records using a standard data collection form. We used Spearman rank correlation and Cox regression analysis to explore the risk factors associated with in-hospital death, especially the association between inflammatory cytokines and death.A total of 205 severe/critical COVID-19 pneumonia patients were admitted in the COVID-19 specialized ICU and 75 deceased patients were included in the final analysis. The median age of the deceasing patients was 70 years (IQR 65-79). The common symptoms were fever (78.9%), cough (70.4%), and expectoration (39.4%). The BNP and CRP levels were far beyond the normal reference range. In the Spearman rank correlation analysis, IL-8 was found to be significantly associated with the time from onset to death (rs= -0.30, P = .034) and that from admission to death (rs= -0.32, P = .019). Cox regression showed after adjusting age and sex, IL-8 levels were still significantly associated with the time from onset to death (P = .003) and that from admission to death (P  = .01).IL-8 levels were associated with in-hospital death in severe/critical COVID-19 patients, which could help clinicians to identify patients with high risk of death at an early stage.

Associations Between Health Literacy and End-of-Life Care Intensity Among Medicare Beneficiaries

BACKGROUND

Despite well-documented disparities in end-of-life (EOL) care, little is known about whether patients with low health literacy (LHL) received aggressive EOL care.

OBJECTIVE

This study examined the association between health literacy (HL) and EOL care intensity among Medicare beneficiaries.

METHOD

We conducted a retrospective analysis of Medicare fee-for-service decedents who died in July-December, 2011. ZIP-code-level HL scores were estimated from the 2010-2011 Health Literacy Data Map, where a score of 225 or lower was defined as LHL. Aggressive EOL care measures included repeated hospitalizations within the last 30 days of life, no hospice enrollment within the last 6 months of life, in-hospital death, and any of above. Using hierarchical generalized linear models, we examined the association between HL and aggressive EOL care.

RESULTS

Of 649,556 decedents, the proportion of decedents who received any aggressive EOL care among those in LHL areas was 82.7%, compared to 72.7% in HHL areas. In multivariable analyses, decedents residing in LHL areas, compared to those in HHL areas, had 31% higher odds of aggressive EOL care (adjusted odds ratio [AOR] 1.31; 95% confidence interval [CI]:1.21-1.42), including higher odds of no hospice use (AOR 1.35; 95% CI: 1.27-1.44), repeated hospitalization (AOR 1.07; 95% CI: 1.01-1.14) and in-hospital death (AOR 1.21; 95% CI: 1.13-1.29).

CONCLUSION

Medicare beneficiaries who resided in LHL areas were likely to receive aggressive EOL care. Tailored efforts to improve HL and facilitate patient-provider communications in LHL areas could reduce EOL care intensity.

Development of a Predictive Model for Mortality in Hospitalized Patients With COVID-19

Introduction:

Early identification of patients with novel corona virus disease 2019 (COVID-19) who may be at high mortality risk is of great importance.

Methods:

In this retrospective study, we included all patients with COVID-19 at Huanggang Central Hospital from January 23 to March 5, 2020. Data on clinical characteristics and outcomes were compared between survivors and nonsurvivors. Univariable and multivariable logistic regression were used to explore risk factors associated with in-hospital death. A nomogram was established based on the risk factors selected by multivariable analysis.

Results:

A total of 150 patients were enrolled, including 31 nonsurvivors and 119 survivors. The multivariable logistic analysis indicated that increasing the odds of in-hospital death associated with higher Sequential Organ Failure Assessment score (odds ratio [OR], 3.077; 95% confidence interval [CI]: 1.848-5.122; P < 0.001), diabetes (OR, 10.474; 95% CI: 1.554-70.617; P = 0.016), and lactate dehydrogenase greater than 245 U/L (OR, 13.169; 95% CI: 2.934-59.105; P = 0.001) on admission. A nomogram was established based on the results of the multivariable analysis. The AUC of the nomogram was 0.970 (95% CI: 0.947-0.992), showing good accuracy in predicting the risk of in-hospital death.

Conclusions:

This finding would facilitate the early identification of patients with COVID-19 who have a high-risk for fatal outcome.

A risk score to predict in-hospital mortality in patients with acute coronary syndrome at early medical contact: results from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) Project

Background

A number of models have been built to evaluate risk in patients with acute coronary syndrome (ACS). However, accurate prediction of mortality at early medical contact is difficult. This study sought to develop and validate a risk score to predict in-hospital mortality among patients with ACS using variables available at early medical contact.

Methods

A total of 62,546 unselected ACS patients from 150 tertiary hospitals who were admitted between 2014 and 2017 and enrolled in the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project, were randomly assigned (at a ratio of 7:3) to a training dataset (n=43,774) and a validation dataset (n=18,772). Based on the identified predictors which were available prior to any blood test, a new point-based risk score for in-hospital death, CCC-ACS score, was derived and validated. The CCC-ACS score was then compared with Global Registry of Acute Coronary Events (GRACE) risk score.

Results

The in-hospital mortality rate was 1.9% in both the training and validation datasets. The CCC-ACS score, a new point-based risk score, was developed to predict in-hospital mortality using 7 variables that were available before any blood test including age, systolic blood pressure, cardiac arrest, insulin-treated diabetes mellitus, history of heart failure, severe clinical conditions (acute heart failure or cardiogenic shock), and electrocardiographic ST-segment deviation. This new risk score had an area under the curve (AUC) of 0.84 (P=0.10 for Hosmer-Lemeshow goodness-of-fit test) in the training dataset and 0.85 (P=0.13 for Hosmer-Lemeshow goodness-of-fit test) in the validation dataset. The CCC-ACS score was comparable to the Global Registry of Acute Coronary Events (GRACE) score in the prediction of in-hospital death in the validation dataset.

Conclusions

The newly developed CCC-ACS score, which utilizes factors that are acquirable at early medical contact, may be able to stratify the risk of in-hospital death in patients with ACS.

Clinical trial registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616.

Association Between D-Dimer Level and In-Hospital Death of Pulmonary Embolism Patients

To investigate whether D-dimer level could predict pulmonary embolism (PE) severity and in-hospital death, a total of 272 patients with PE were divided into a survival group (n = 249) and a death group (n = 23). Comparisons of patient characteristics between the 2 groups were performed using Mann-Whitney U test. Significant variables in univariate analysis were entered into multivariate logistic regression analysis. Receiver operating characteristic (ROC) curve analysis was performed to determine the predictive value of D-dimer level alone or together with the simplified Pulmonary Embolism Severity Index (sPESI) for in-hospital death. Results showed that patients in the death group were significantly more likely to have hypotension (P = 0.008), tachycardia (P = 0.000), elevated D-dimer level (P = 0.003), and a higher sPESI (P = 0.002) than those in the survival group. Multivariable logistic regression analysis showed that D-dimer level was an independent predictor of in-hospital death (OR = 1.07; 95% CI, 1.003-1.143; P = 0.041). ROC curve analysis showed that when D-dimer level was 3.175 ng/ml, predicted death sensitivity and specificity were 0.913 and 0.357, respectively; and when combined with sPESI, specificity (0.838) and area under the curve (0.740) were increased. Thus, D-dimer level is associated with in-hospital death due to PE; and the combination with sPESI can improve the prediction level.

Clinical predictors of COVID-19 disease progression and death: Analysis of 214 hospitalised patients from Wuhan, China

INTRODUCTION

COVID-19 has spread rapidly worldwide and has been declared a pandemic.

OBJECTIVES

To delineate clinical features of COVID-19 patients with different severities and prognoses and clarify the risk factors for disease progression and death at an early stage.

METHODS

Medical history, laboratory findings, treatment and outcome data from 214 hospitalised patients with COVID-19 pneumonia admitted to Eastern Campus of Renmin Hospital, Wuhan University in China were collected from 30 January 2020 to 20 February 2020, and risk factors associated with clinical deterioration and death were analysed. The final date of follow-up was 21 March 2020.

RESULTS

Age, comorbidities, higher neutrophil cell counts, lower lymphocyte counts and subsets, impairment of liver, renal, heart, coagulation systems, systematic inflammation and clinical scores at admission were significantly associated with disease severity. Ten (16.1%) moderate and 45 (47.9%) severe patients experienced deterioration after admission, and median time from illness onset to clinical deterioration was 14.7 (IQR 11.3-18.5) and 14.5 days (IQR 11.8-20.0), respectively. Multivariate analysis showed increased Hazards Ratio of disease progression associated with older age, lymphocyte count <1.1 × 10⁹/L, blood urea nitrogen (BUN)> 9.5 mmol/L, lactate dehydrogenase >250 U/L and procalcitonin >0.1 ng/mL at admission. These factors were also associated with the risk of death except for BUN. Prediction models in terms of nomogram for clinical deterioration and death were established to illustrate the probability.

CONCLUSIONS

These findings provide insights for early detection and management of patients at risk of disease progression or even death, especially older patients and those with comorbidities.

Impact of a Japanese Incentivization Program to Increase End-of-Life Care Outside of Hospitals

OBJECTIVES

To analyze the association of an incentivization program to promote death outside of hospitals with changes in place of death.

DESIGN

A longitudinal observational study using national databases.

SETTING AND PARTICIPANTS

Participants comprised Japanese decedents (≥65 years) who had used long-term care insurance services and died between April 2007 and March 2014.

METHODS

Using a database of Japanese long-term care insurance service claims, subjects were divided into community-dwelling and residential aged care (RAC) facility groups. Based on national death records, change in place of death after the Japanese government initiated incentivization program was observed using logistic regression.

RESULTS

Hospital deaths decreased by 8.7% over time, mainly due to an increase in RAC facility deaths. The incentivization program was more associated with decreased in-hospital deaths for older adults in RAC facilities than community-dwelling older adults.

CONCLUSIONS AND IMPLICATIONS

In Japan, the proportion of in-hospital deaths of frail older adults decreased since the health services system introduced the incentivization program for end-of-life care outside of hospitals. The shift of place of death from hospitals to different locations was more prominent among residents of RAC facilities, where informal care from laymen was required less, than among community residents.

Epidemiological Trends in the Timing of In-Hospital Death in Acute Myocardial Infarction-Cardiogenic Shock in the United States

BACKGROUND

There are limited data on the epidemiology and timing of in-hospital death (IHD) in patients with acute myocardial infarction-cardiogenic shock (AMI-CS).

METHODS

Adult admissions with AMI-CS with IHDs were identified using the National Inpatient Sample (2000-2016) and were classified as early (≤2 days), mid-term (3-7 days), and late (>7 days). Inter-hospital transfers and those with do-not-resuscitate statuses were excluded. The outcomes of interest included the epidemiology, temporal trends and predictors for IHD timing.

RESULTS

IHD was noted in 113,349 AMI-CS admissions (median time to IHD 3 (interquartile range 1-7) days), with early, mid-term and late IHD in 44%, 32% and 24%, respectively. Compared to the mid-term and late groups, the early IHD group had higher rates of ST-segment-elevation AMI-CS (74%, 63%, 60%) and cardiac arrest (37%, 33%, 29%), but lower rates of acute organ failure (68%, 79%, 89%), use of coronary angiography (45%, 56%, 67%), percutaneous coronary intervention (33%, 36%, 42%), and mechanical circulatory support (31%, 39%, 50%) (all p < 0.001). There was a temporal increase in the early (adjusted odds ratio (aOR) for 2016 vs. 2000 2.50 (95% confidence interval (CI) 2.22-2.78)) and a decrease in mid-term (aOR 0.75 (95% CI 0.71-0.79)) and late (aOR 0.34 (95% CI 0.31-0.37)) IHD. ST-segment-elevation AMI-CS and cardiac arrest were associated with the increased risk of early IHD, whereas advanced comorbidity and acute organ failure were associated with late IHD.

CONCLUSIONS

Early IHD after AMI-CS has increased between 2000 and 2016. The populations with early vs. late IHD were systematically different.

Kidney disease is associated with in-hospital death of patients with COVID-19

In December 2019, a coronavirus 2019 (COVID-19) disease outbreak occurred in Wuhan, Hubei Province, China, and rapidly spread to other areas worldwide. Although diffuse alveolar damage and acute respiratory failure were the main features, the involvement of other organs needs to be explored. Since information on kidney disease in patients with COVID-19 is limited, we determined the prevalence of acute kidney injury (AKI) in patients with COVID-19. Further, we evaluated the association between markers of abnormal kidney function and death in patients with COVID-19. This was a prospective cohort study of 701 patients with COVID-19 admitted in a tertiary teaching hospital that also encompassed three affiliates following this major outbreak in Wuhan in 2020 of whom 113 (16.1%) died in hospital. Median age of the patients was 63 years (interquartile range, 50-71), including 367 men and 334 women. On admission, 43.9% of patients had proteinuria and 26.7% had hematuria. The prevalence of elevated serum creatinine, elevated blood urea nitrogen and estimated glomerular filtration under 60 ml/min/1.73m2 were 14.4, 13.1 and 13.1%, respectively. During the study period, AKI occurred in 5.1% patients. Kaplan-Meier analysis demonstrated that patients with kidney disease had a significantly higher risk for in-hospital death. Cox proportional hazard regression confirmed that elevated baseline serum creatinine (hazard ratio: 2.10, 95% confidence interval: 1.36-3.26), elevated baseline blood urea nitrogen (3.97, 2.57-6.14), AKI stage 1 (1.90, 0.76-4.76), stage 2 (3.51, 1.49-8.26), stage 3 (4.38, 2.31-8.31), proteinuria 1+ (1.80, 0.81-4.00), 2+∼3+ (4.84, 2.00-11.70), and hematuria 1+ (2.99, 1.39-6.42), 2+∼3+ (5.56,2.58- 12.01) were independent risk factors for in-hospital death after adjusting for age, sex, disease severity, comorbidity and leukocyte count. Thus, our findings show the prevalence of kidney disease on admission and the development of AKI during hospitalization in patients with COVID-19 is high and is associated with in-hospital mortality. Hence, clinicians should increase their awareness of kidney disease in patients with severe COVID-19.

Improvement of clinical outcome in patients with ST-elevation myocardial infarction between 1999 and 2016 in China: The Prospective, Multicentre Registry MOODY study

BACKGROUND

Reports showed no change of 7-day mortality after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) between 2001 and 2011 in China. National rolling one-year interventional standardized training programme began in September 2009. However, the improvement in clinical outcome following STEMI PCI after 2011 remains unclear.

METHODS AND RESULTS

This multicentre MOODY registry study aimed to analyse the clinical improvement after STEMI PCI. Of a total of 9265 acute MI patients registered from 24 centres, 3142 STEMIs having a first medical contact time ≤12 hours and undergoing primary PCI were assigned to the Pre Group (n = 1014, between March 1999 and October 2010) or the Post Group (n = 2128, between 2010 November and 2016 October). The primary endpoint was in-hospital cardiac death. Study endpoints were also compared between trained and untrained operators and between experienced (≥50 primary PCIs/year) and inexperienced personnel. In-hospital death after PCI was 3.0% in the Pre Group, significantly higher than 1.6% in the Post Group (P = .035). The improvements in clinical outcome after PCI between the 2016 and Pre Groups were stably sustained through one-year follow-up. The significant reduction for in-hospital death was noted when primary PCI was performed by trained (1.4% vs 5.4%, P < .001) or experienced (2.7% vs 4.8%, P = .001) operators, compared to untrained or inexperienced operators, respectively. Inclusion of the untrained operator into the conventional risk model strongly enhanced the prediction for endpoints. Age, Killip Class 3, diabetes, trans-radial approach and system delay were five predictors of in-hospital death after primary PCI.

CONCLUSION

PCI for STEMI by a trained and experienced operator was associated with significant reduction of in-hospital death. Our results strongly warrant the need for promoting the current system response and patient education.

Trends of Hospital Palliative Care Utilization and Its Associated Factors Among Patients With Systemic Lupus Erythematosus in the United States From 2005 to 2014

OBJECTIVE

To investigate trends and associated factors of utilization of hospital palliative care among patients with systemic lupus erythematosus (SLE) and analyze its impact on length of hospital stay, hospital charges, and in-hospital mortality.

METHODS

Using the 2005-2014 National Inpatient Sample in the United States, the compound annual growth rate was used to investigate the temporal trend of utilization of hospital palliative care. Multivariate multilevel logistic regression analyses were performed to analyze the association with patient-related factors, hospital factors, length of stay, in-hospital mortality, and hospital charges.

RESULTS

The overall proportion of utilization of hospital palliative care for the patient with SLE was 0.6% over 10 years. It increased approximately 12-fold from 0.1% (2005) to 1.17% (2014). Hospital palliative care services were offered more frequently to older patients, patients with high severity illnesses, and in urban teaching hospitals or large size hospitals. Patients younger than 40 years, the lowest household income group, or Medicare beneficiaries less likely received palliative care during hospitalization. Hospital palliative care services were associated with increased length of stay (β = 1.407, P < .0001) and in-hospital mortality (odds ratio, 48.18; 95% confidence interval, 41.59-55.82), and reduced hospital charge (β = -0.075, P = .009).

CONCLUSION

Hospital palliative care service for patients with SLE gradually increased during the past decade in US hospitals. However, this showed disparities in access and was associated with longer hospital length of stay and higher in-hospital mortality. Nevertheless, hospital palliative care services yielded a cost-saving effect.

Hospitalizations of nursing home residents at the end of life: A systematic review

BACKGROUND

End-of-life hospitalizations in nursing home residents are common, although they are often burdensome and potentially avoidable.

AIM

We aimed to summarize the existing evidence on end-of-life hospitalizations in nursing home residents.

DESIGN

Systematic review (PROSPERO registration number CRD42017072276).

DATA SOURCES

A systematic literature search was carried out in PubMed, CINAHL, and Scopus (date of search 9 April 2019). Studies were included if they reported proportions of in-hospital deaths or hospitalizations of nursing home residents in the last month of life. Two authors independently selected studies, extracted data, and assessed the quality of studies. Median with interquartile range was used to summarize proportions.

RESULTS

A total of 35 studies were identified, more than half of which were from the United States (n = 18). While 29 studies reported in-hospital deaths, 12 studies examined hospitalizations during the last month of life. The proportion of in-hospital deaths varied markedly between 5.9% and 77.1%, with an overall median of 22.6% (interquartile range: 16.3%-29.5%). The proportion of residents being hospitalized during the last month of life ranged from 25.5% to 69.7%, and the median was 33.2% (interquartile range: 30.8%-38.4%). Most studies investigating the influence of age found that younger age was associated with a higher likelihood of end-of-life hospitalization. Four studies assessed trends over time, showing heterogeneous findings.

CONCLUSION

There is a wide variation in end-of-life hospitalizations, even between studies from the same country. Overall, such hospitalizations are common among nursing home residents, which indicates that interventions tailored to each specific health care system are needed to improve end-of-life care.

Health Inequalities Among Elderly Type 2 Diabetes Mellitus Patients in Japan

The influence of socioeconomic status (SES) on health inequalities has received much attention worldwide. This study examined the effect of SES on the following older type 2 diabetes mellitus patient health outcomes: oral hypoglycemic agent (OHA) medication adherence (proportion of days covered, PDC), risk of hospitalization for diabetic macrovascular complications, and in-hospital death. A retrospective cohort design using 2013–2016 claims data was used. Subjects were 58,349 diabetes patients aged >74 years in 2013. Age, sex, residential area, and comorbidities were controlled for. Logistic regression was conducted to assess the effects of income on PDC; survival analysis was used to assess the effects on hospitalization and in-hospital death. Regressions were conducted separately by sex. Compared with the lowest income group, adjusted PDC odds ratios for medium- and high-income males, respectively, were 1.35 (95% CI: 1.27–1.43) and 1.41 (95% CI: 1.30–1.54); females: 1.17 (95% CI: 1.11–1.23) and 1.24 (95% CI: 1.13–1.35). Adjusted hazard ratios (AHRs) for male hospitalization were 0.88 (95% CI: 0.80–0.96) and 0.88 (95% CI: 0.79–0.99); females: 1.00 (95% CI: 0.93–1.07) and 0.95 (95% CI: 0.83–1.08). AHRs for male in-hospital death were 0.83 (95% CI: 0.75–0.91) and 0.62 (95% CI: 0.54–0.70); females: 0.94 (95% CI: 0.87–1.02) and 0.77 (95% CI: 0.65–0.92). Results revealed sex-specific health inequalities among older Japanese diabetes patients. Subjects with worse SES had significantly poorer OHA medication adherence (both sexes), higher hospitalization risk for diabetes complications (males), and higher in-hospital death risk (both sexes).

Blood albumin as a prognostic factor among unselected medically treated inpatients

Aim: The aim of this study is to determine the prognostic value of blood albumin (BA) in an unselected population of inpatients. Materials & methods: We performed prospective analysis of the medical documentation of 7279 patients hospitalized between July 2014 and September 2017. Results: Individuals with BA ≥3.35 mg/dl had significantly lower risk of in-hospital death (odds ratio [OR]: 0.22; 95% CI: 0.19-0.27; p < 0.001) and 14-day readmission (OR: 0.64; 95% CI: 0.55-0.77; p < 0.0001). BA concentration was the strongest favorable factor predicting inpatient survival in a Cox hazard regression model (OR: 0.43; 95% CI: 0.36-0.50; p < 0.001), did not correlate with body mass index and actual-to-ideal bodyweight ratio and was strongly affected by numerous non-nutrient factors. Conclusion: BA concentration showed similar or better predictive and diagnostic power in relation to all-cause in-hospital mortality and 14-day readmission among inpatients than selected multifactorial scores.

Predicting in-hospital death in patients with type B acute aortic dissection

The outcome of patients with acute type B aortic dissection (BAAD) is largely dictated by whether or not the case is "complicated." The purpose of this study was to investigate the risk factors leading to in-hospital death among patients with BAAD and then to develop a predictive model to estimate individual risk of in-hospital death.A total of 188 patients with BAAD were enrolled. Risk factors for in-hospital death were investigated with univariate and multivariable logistic regression analysis. Significant risk factors were used to develop a predictive model.The in-hospital mortality rate was 9% (17 of 188 patients). Univariate analysis revealed 7 risk factors to be statistically significant predictors of in-hospital death (P < .1). In multivariable analysis, the following variables at admission were independently associated with increased in-hospital mortality: hypotension (odds ratio [OR], 4.85; 95% confidence interval [CI], 1.12-18.90; P = .04), ischemic complications (OR, 8.24; 95% CI, 1.25-33.85; P < .001), renal dysfunction (OR, 12.32; 95% CI, 10.63-76.66; P < .001), and neutrophil percentage ≥80% (OR, 5.76; 95% CI, 2.58-12.56; P = .03). Based on these multivariable results, a reliable and simple prediction model was developed, a total score of 4 offered the best point value.Independent risk factors associated with in-hospital death can be predicted in BAAD patients. The prediction model could be used to identify the prognosis for BAAD patients and assist physicians in their choice of management.

Association of thrombocytopenia with in-hospital outcome in patients with acute ST-segment elevated myocardial infarction

This study investigated the association of thrombocytopenia (TP) with in-hospital medication and outcome of patients with acute ST-segment elevated myocardial infarction (STEMI). A total of 16,678 consecutive patients with STEMI from multiple centers that participated in the China Acute Myocardial Infarction registry was included. In-hospital adverse event rates were compared between patients with TP and those with a normal platelet count. Multivariate logistic regression was applied to adjust for confounders. Propensity score matching (PSM) was applied to control for baseline differences. There were 359 patients with baseline TP, accounting for 2.2% of the total cohort. The risk of in-hospital death (11.1% vs 6.0%, P < 0.001); major adverse cardiovascular events (MACE) (11.7% vs 6.4%, P < 0.001); and newly occurred or aggravated heart failure, cardiogenic shock, malignant arrhythmia, acute pulmonary embolism, and bleeding (3.6% vs 1.8%, P = 0.024) were significantly higher in the TP group than in the normal platelet group. After multivariate adjustment, TP was independently associated only with malignant arrhythmia (odds ratio: 1.49; 95% confidence interval: 1.09-2.05, P = 0.014). A total of 289 patients in each group were matched by PSM. The risk of all endpoints was not significantly different between the two matched groups before and after multivariate adjustment. In-hospital outcomes were worse in patients with STEMI and TP than in those with a normal platelet count. However, baseline TP was not independently associated with in-hospital death, MACE, or bleeding risk after multivariate adjustment and controlling for baseline differences.

Experience with long-term administration of tolvaptan to patients with acute decompensated heart failure

Tolvaptan (TLV) is an oral selective vasopressin type 2 receptor antagonist. Long-term use of TLV is not recommended in patients with heart failure (HF) if fluid retention disappears and/or body weight is within the target range. However, some patients require long-term use of TLV. The current study investigated the efficacy and safety of long-term use of TLV. Subjects were 258 consecutive patients with HF who received TLV during hospitalization from January 2011 to March 2015. The rate of continuing administration of TLV was evaluated. Moreover, the one-year mortality rate and rate of re-hospitalization either with or without TLV were investigated. Results at discharge and one year later were compared for patients who continued to receive TLV one year after discharge. Oral concomitant medications, blood pressures, heart rate, blood tests, chest X-ray and transthoracic echocardiography were investigated. In-hospital and one-year mortality rates were 15.9% and 27.8%, respectively. Moreover, the mortality rate and/or rate of re-hospitalization within one year was 54.4%. The rate of re-hospitalization for HF was significantly higher in patients who continued to receive TLV after discharge compared to patients who ceased receiving TLV after discharge (p < 0.001). However, the subjects who continued to receive TLV for up to one year after discharge tended to have a longer duration until re-hospitalization for HF and significantly decreased brain natriuretic peptide levels (577.6 ± 528.5 pg/mL to 397.3 ± 365.8 pg/mL, p = 0.015). Long-term use of TLV might delay re-hospitalization for HF in patients with severe HF. Large-scale clinical studies are necessary to verify these results.

Onset seasons and clinical outcomes in patients with Stanford type A acute aortic dissection: an observational retrospective study

OBJECTIVES

To evaluate the association of onset season with clinical outcome in type A acute aortic dissection (AAD).

DESIGN

A single-centre, observational retrospective study.

SETTING

The study was conducted in Fuwai Hospital, the National Centre for Cardiovascular Disease, Beijing, China.

PARTICIPANTS

From 2008 to 2010, a set of consecutive patients with type A AAD, confirmed by CT scanning, were enrolled and divided into four groups according to onset season: winter (December, January and February), spring (March, April and May), summer (June, July and August) and autumn (September, October and November). The primary end points were in-hospital death and all-cause mortality during follow-up.

RESULTS

Of the 492 cases in this study, 129 occurred in winter (26.2%), 147 in spring (29.9%), 92 in summer (18.7%), and 124 in autumn (25.2%). After a median follow-up of 20.4 months (IQR 9.7-38.9), the in-hospital mortality in cases occurring in autumn was higher than in the other three seasons (23.4% vs 8.4%, p<0.01). Long-term mortality was comparable among the four seasonal groups (p=0.63). After adjustment for age, gender and other risk factors, onset in autumn was still an independent factor associated with increased risk of in-hospital mortality (HR 2.05; 95% CI 1.15 to 3.64, p=0.02) in addition to surgical treatment. Further analysis showed that the seasonal effect on in-hospital mortality (autumn vs other seasons: 57.4% vs 27.3%, p<0.01) was only significant in patients who did not receive surgical treatment. No seasonal effect on long-term clinical outcomes was found in this cohort.

CONCLUSIONS

Onset in autumn may be a factor that increases the risk of in-hospital death from type A AAD, especially in patients who receive conservative treatment. Immediate surgery improves the short-term and long-term outcomes regardless of onset season.

Basic laboratory parameters as predictors of in-hospital death in patients with acute decompensated heart failure: data from a large single-centre cohort

BACKGROUND

Heart failure (HF) is a growing cause of hospitalisation worldwide, and despite significant progress in its treat-ment it is still associated with high mortality.

AIM

The aim of this study was to find factors predicting in-hospital death in acute decompensated HF by analysis of basic laboratory data and echocardiography, routinely collected on admission to the hospital.

METHODS

To this single-centre retrospective study we involved 638 consecutive patients hospitalised in the years 2007-2008 due to acute decompensated HF. To the initial univariate analysis we included the results of echocardiography and 36 basic laboratory tests performed at hospital admission. Parameters significantly associated with in-hospital death in univariate analysis were taken to multivariate regression analysis.

RESULTS

In-hospital death occurred in 119 cases (median age 75 years; 40.3% females). The multivariate analysis revealed sig-nificant association between in-hospital death and: higher leukocyte count (death [D]: 13.5 vs. survival [S]: 8.8 G/L, p < 0.01), higher neutrophil count (D: 10.5 vs. S: 5.9 G/L, p < 0.01), lower lymphocyte count (D: 1.3 vs. S: 1.7 G/L, p < 0.05), higher C-reactive protein concentration (D: 20.8 vs. S: 6.7 mg/dL, p < 0.01), higher serum glucose concentration (D: 167.0 vs. S: 116.0 mg/dL, p < 0.00001), higher serum creatinine concentration (D: 1.5 vs. S: 1.2 mg/dL, p < 0.0001), higher blood urea nitrogen concentration (D: 29.0 vs. S: 22.0 mg/dL, p < 0.00001), and higher aspartate aminotransferase (D: 72.0 vs. S: 27.0 U/L, p < 0.0001). Surprisingly, there was no significant association with echocardiographic parameters.

CONCLUSIONS

Analysis of basic laboratory data collected on admission to the hospital may help to identify patients with acute decompensated HF, who are at high risk of in-hospital death.

Electrocardiographic Abnormalities Predict Adverse Clinical Outcomes in Patients with Subarachnoid Hemorrhage

BACKGROUND

We conducted a retrospective cohort study of a large sample to assess whether electrocardiographic (ECG) abnormalities are independently associated with the occurrence of neurogenic pulmonary edema (NPE), delayed cerebral ischemia (DCI), and in-hospital death after nontraumatic subarachnoid hemorrhage (SAH).

METHODS

In this retrospective observational study, patients who were admitted within 72 hours of SAH symptom onset between 2013 and 2015 were enrolled. Twelve-lead ECG findings obtained within 72 hours after SAH and the presence of NPE, DCI, and in-hospital death were collected based on the results reported in the medical records.

RESULTS

We included 834 patients. NPE occurred in 192 patients (23%). The median delay from SAH onset to NPE was 3 days (interquartile range [IQR]: 5 days). DCI occurred in 223 patients (27%; median delay to DCI, 4 days; IQR: 5 days). In total, 141 patients (17%) died in the hospital (median time to death, 12 days; IQR: 18 days). The frequency of ECG abnormalities for all enrolled patients was 65%. Corrected QT prolongation had an adjusted risk ratio (RR) of 1.5 (1.1-2.2) for NPE and 1.8 (1.3-2.4) for DCI. ST depression had an adjusted RR of 3.0 (1.2-7.5) for in-hospital death. NSSTTCs (nonspecific ST- or T-wave changes) had an adjusted RR of 2.7 (1.8-4.2) for NPE, 2.8 (1.9-4.3) for DCI, and 2.2 (1.3-3.5) for in-hospital death. All RRs were adjusted for age and Hunt-Hess scores.

CONCLUSIONS

ECG abnormalities assessed within 72 hours after SAH using a standard 12-lead ECG are independently associated with an increased risk of adverse clinical outcomes in patients with nontraumatic SAH.

Mortality from adverse drug reactions in adult medical inpatients at four hospitals in South Africa: a cross-sectional survey

AIMS

Fatal adverse drug reactions (ADRs) are important causes of death, but data from resource-limited settings are scarce. We determined the proportion of deaths in South African medical inpatients attributable to ADRs, and their preventability, stratified by human immunodeficiency virus (HIV) status.

METHODS

We reviewed the folders of all patients who died over a 30 day period in the medical wards of four hospitals. We identified ADR-related deaths (deaths where an ADR was 'possible', 'probable' or 'certain' using WHO-UMC criteria and where the ADR contributed to death). We determined preventability according to previously published criteria.

RESULTS

ADRs contributed to the death of 2.9% of medical admissions and 56 of 357 deaths (16%) were ADR-related. Tenofovir, rifampicin and co-trimoxazole were the most commonly implicated drugs. 43% of ADRs were considered preventable. The following factors were independently associated with ADR-related death: HIV-infected patients on antiretroviral therapy (adjusted odds ratio (aOR) 4.4, 95% confidence interval (CI) 1.6, 12), exposure to more than seven drugs (aOR 2.5, 95% CI 1.3, 4.8) and increasing comorbidity score (aOR 1.3, 95% CI 1.1, 1.7).

CONCLUSIONS

In our setting, where HIV and tuberculosis are highly prevalent, fatal in-hospital ADRs were more common than reported in high income settings. Most deaths were attributed to drugs used in managing HIV and tuberculosis. A large proportion of the ADRs were preventable, highlighting the need to strengthen systems for health care worker training and support.

A retrospective observational study of obstetric care in rural Andhra Pradesh by Dangoria Charitable Trust (1979 to 2009)

BACKGROUND & OBJECTIVES

In India several models of health care delivery have been explored to increase access to skilled obstetric care in rural areas, where there is a lack of specialists and appropriate facilities. We present here an innovative and affordable approach to the delivery of antenatal and obstetric care provided by the Dangoria Charitable Trust (DCT) since 1979, twinning a not-for-profit hospital in rural Andhra Pradesh with a for-profit one in the capital Hyderabad.

METHODS

A retrospective observational study of a random sample of the deliveries performed from 1979 to 2009 by the Dangoria Charitable Trust, based on the maternity hospital birth register, was conducted. The profile of mothers, such as their age, parity and previous miscarriages, as well as type of delivery, gender and birth weight of the newborn, and frequency of stillbirths and in hospital deaths as they evolved over time were presented using simple descriptive methods. The risk of stillbirth and in hospital death over time was explored by logistic regression after allowance for selected factors.

RESULTS

From 1979 to 2009 the cumulative number of deliveries at the Narsapur maternity hospital was 9333, from a few dozens per year in the early 1980s to over 1000 in 2009. The number of primiparae significantly increased over time, while the percentage of low birth weight babies (less than 2.5 kg) did not change appreciably. Caesarean section increased significantly over time, from 8.6 per cent in the first decade to 20.3 per cent in the last. The risk of death (stillbirths and in hospital death) consistently decreased over time, reaching 15 per thousand in the last decade. The results of a logistic regression adjusted for potential confounders showed that low birth weight babies had 4 times the risk of dying as compared to those weighing 2.5 kg or above.

CONCLUSIONS

Over the 30 year period the percentage of babies discharged alive from DCT improved considerably. Caesarean sections increased significantly from the first decade to the third decade. The model adopted by the DCT to improve maternal and child health in rural areas could be replicated in other rural parts of the country.