Predictors of In-Hospital Mortality in Type A Acute Aortic Syndrome: Data From the RENADA-RO Registry.

BACKGROUND: This study aimed to analyse the baseline characteristics of patients admitted with acute type A aortic syndrome (ATAAS) and to identify the potential predictors of in-hospital mortality in surgically managed patients. METHODS: Data regarding demographics, clinical presentation, laboratory work-up, and management of 501 patients with ATAAS enrolled in the National Registry of Aortic Dissections-Romania registry from January 2011 to December 2022 were evaluated. The primary endpoint was in-hospital all-cause mortality. Multivariate logistic regression was conducted to identify independent predictors of mortality in patients with acute Type A aortic dissection (ATAAD) who underwent surgery. RESULTS: The mean age was 60±11 years and 65% were male. Computed tomography was the first-line diagnostic tool (79%), followed by transoesophageal echocardiography (21%). Cardiac surgery was performed in 88% of the patients. The overall mortality in the entire cohort was 37.9%, while surgically managed ATAAD patients had an in-hospital mortality rate of 29%. In multivariate logistic regression, creatinine value (OR 6.76), ST depression on ECG (OR 6.3), preoperative malperfusion (OR 5.77), cardiogenic shock (OR 5.77), abdominal pain (OR 4.27), age ≥70 years (OR 3.76), and syncope (OR 3.43) were independently associated with in-hospital mortality in surgically managed ATAAD patients. CONCLUSIONS: Risk stratification based on the variables collected at admission may help to identify ATAAS patients with high risk of death following cardiac surgery.

Characteristics and outcome of hospitalized patients with heart failure stratified for chronic kidney disease.

AIMS: Heart failure (HF) and chronic kidney disease (CKD) place significant challenges on the healthcare system, and their co-existence is associated with shared adverse outcomes. The multinational CaReMe project was initiated to provide contemporary, real-world epidemiological data on cardiovascular and reno-metabolic diseases. Utilizing data from the German CaReMe cohort, we characterize a multicentric HF population and describe in-hospital outcomes stratified for co-morbid CKD. METHODS AND RESULTS: This retrospective, observational study analysed administrative data from inpatient cases hospitalized in 87 German Helios hospitals between 1 January 2016 and 31 August 2022. The first hospitalization of patients aged ≥18 years with a primary discharge diagnosis of HF, based on ICD-10 codes, were considered the index cases, and subsequent hospitalizations were considered as readmissions. Baseline characteristics and outcomes were stratified for co-morbid CKD using ICD-10-encoding from the index cases. Cox regression was utilized for readmission endpoints and in-hospital mortality. In total, 174 829 index cases (mean age 79 ± 15 years, 49.9% female) were included; of these, 55.0% had coexisting CKD. Patients with CKD were older, suffered from worse HF-related symptoms, had a higher co-morbidity burden, and in-hospital mortality was increased at index and during follow-up. Prevalent CKD was associated with higher rehospitalization rates and was an independent predictor for in-hospital death. CONCLUSIONS: Within this HF inpatient cohort from a multicentric German database, CKD was diagnosed in more than half of the patients and was associated with increased in-hospital mortality at baseline and during follow-up. Rehospitalizations were observed earlier and more frequently in patients with HF and co-morbid CKD.

Diabetes mellitus in stroke unit: prevalence and outcomes-the Verona acute coronary syndrome and stroke in diabetes outcome (VASD-OUTCOME) study.

BACKGROUND: Cerebrovascular accidents (CVA) represent a major complication in diabetes (DM). Real-life evidence as to whether modern management of CVA and DM have softened this relationship is limited. Therefore, we estimated prevalence and impact of DM on in-hospital survival and complications in a contemporary cohort of subjects with CVA. METHODS: We retrospectively evaluated the records of 937 patients admitted for CVA at the Stroke Unit of Verona University Hospital during a 3-year period. Pre-existing or de novo DM was ascertained by prior diagnosis, glucose-lowering therapy at admission/discharge or admittance plasma glucose ≥ 200 mg/dL. Multiple regressions were applied to test DM as predictor of in-hospital mortality, complications (composite of infections, cardio- and cerebrovascular complications, major bleeding and pulmonary complications), duration and costs of hospitalization. RESULTS: Diabetes prevalence was 21%, of which 22% de novo diagnoses. Compared to non-DM, diabetic individuals were older and carried an increased burden of cardiovascular risk factors. Compared to known DM, de novo DM individuals were younger, had higher admittance plasma glucose and poorer cardiovascular comorbidities. Overall, DM versus non-DM individuals did not show significantly increased risk of death (14.0 vs. 9.3%; crude-OR 1.59 95% CI 0.99-2.56). Controlling for confounders did not improve significance. DM resulted independent predictor for in-hospital complications (36.2% vs. 26.9%; adj-OR 1.49, 1.04-2.13), but not for duration and costs of hospitalization. CONCLUSION: DM frequently occurs in patients admitted for stroke and carries an excess burden of adverse in-hospital complications, urgently calling for strategies to anticipate DM diagnosis and tailored treatment in high-risk individuals.

Association between blood urea nitrogen to serum albumin ratio and in-hospital mortality in critical patients with diabetic ketoacidosis: a retrospective analysis of the eICU database.

Background: This study aimed to investigate the association between blood urea nitrogen to serum albumin ratio (BAR) and the risk of in-hospital mortality in patients with diabetic ketoacidosis. Methods: A total of 3,962 diabetic ketoacidosis patients from the eICU Collaborative Research Database were included in this analysis. The primary outcome was in-hospital death. Results: Over a median length of hospital stay of 3.1 days, 86 in-hospital deaths were identified. One unit increase in LnBAR was positively associated with the risk of in-hospital death (hazard ratio [HR], 1.82 [95% CI, 1.42-2.34]). Furthermore, a nonlinear, consistently increasing correlation between elevated BAR and in-hospital mortality was observed (P for trend =0.005 after multiple-adjusted). When BAR was categorized into quartiles, the higher risk of in-hospital death (multiple-adjusted HR, 1.99 [95% CI, (1.1-3.6)]) was found in participants in quartiles 3 to 4 (BAR≥6.28) compared with those in quartiles 1 to 2 (BAR<6.28). In the subgroup analysis, the LnBAR-hospital death association was significantly stronger in participants without kidney insufficiency (yes versus no, P-interaction=0.023). Conclusion: There was a significant and positive association between BAR and the risk of in-hospital death in patients with diabetic ketoacidosis. Notably, the strength of this association was intensified among those without kidney insufficiency.

Normalized lactate load as an independent prognostic indicator in patients with cardiogenic shock.

BACKGROUND: Early prognosis evaluation is crucial for decision-making in cardiogenic shock (CS) patients. Dynamic lactate assessment, for example, normalized lactate load, has been a better prognosis predictor than single lactate value in septic shock. Our objective was to investigate the correlation between normalized lactate load and in-hospital mortality in patients with CS. METHODS: Data were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The calculation of lactate load involved the determination of the cumulative area under the lactate curve, while normalized lactate load was computed by dividing the lactate load by the corresponding period. Receiver Operating Characteristic (ROC) curves were constructed, and the evaluation of areas under the curves (AUC) for various parameters was performed using the DeLong test. RESULTS: Our study involved a cohort of 1932 CS patients, with 687 individuals (36.1%) experiencing mortality during their hospitalization. The AUC for normalized lactate load demonstrated significant superiority compared to the first lactate (0.675 vs. 0.646, P < 0.001), maximum lactate (0.675 vs. 0.651, P < 0.001), and mean lactate (0.675 vs. 0.669, P = 0.003). Notably, the AUC for normalized lactate load showed comparability to that of the Sequential Organ Failure Assessment (SOFA) score (0.675 vs. 0.695, P = 0.175). CONCLUSION: The normalized lactate load was an independently associated with the in-hospital mortality among CS patients.

Machine learning models predict triage levels, massive transfusion protocol activation, and mortality in trauma utilizing patients hemodynamics on admission.

BACKGROUND: The effective management of trauma patients necessitates efficient triaging, timely activation of Massive Blood Transfusion Protocols (MTP), and accurate prediction of in-hospital outcomes. Machine learning (ML) algorithms have emerged as up-and-coming tools in the domains of optimizing triage decisions, improving intervention strategies, and predicting clinical outcomes, consistently outperforming traditional methodologies. This study aimed to develop, assess, and compare several ML models for the triaging processes, activation of MTP, and mortality prediction. METHODS: In a 10-year retrospective study, the predictive capabilities of seven ML models for trauma patients were systematically assessed using on-admission patients' hemodynamic data. All patient's data were randomly divided into training (80 %) and test (20 %) sets. Employing Python for data preprocessing, feature scaling, and model development, we evaluated K-Nearest Neighbors (KNN), Logistic Regression (LR), Decision Tree (DT), Support Vector Machines (SVM) with RBF kernels, Random Forest (RF), Extreme Gradient Boosting (XGBoost), and Artificial Neural Network (ANN). We employed various imputation techniques and addressed data imbalance through down-sampling, up-sampling, and synthetic minority for the over-sampling technique (SMOTE). Hyperparameter tuning, coupled with 5-fold cross-validation, was performed. The evaluation included essential metrics like sensitivity, specificity, F1 score, accuracy, Area Under the Receiver Operating Curve (AUC ROC), and Area Under the Precision recall Curve (AUC PR), ensuring robust predictive capability. RESULT: This study included 17,390 adult trauma patients; of them, 19.5 % (3385) were triaged at a critical level, 3.8 % (664) required MTP, and 7.7 % (1335) died in the hospital. The model's performance improved using imputation and balancing techniques. The overall models demonstrated notable performance metrics for predicting triage, MTP activation, and mortality with F1 scores of 0.75, 0.42, and 0.79, sensitivities of 0.73, 0.82, and 0.9, and AUC ROC values of 0.89, 0.95 and 0.99 respectively. CONCLUSION: Machine learning, especially RF models, effectively predicted trauma triage, MTP activation, and mortality. Featured critical hemodynamic variables include shock indices, systolic blood pressure, and mean arterial pressure. Therefore, models can do better than individual parameters for the early management and disposition of patients in the ED. Future research should focus on creating sensitive and interpretable models to enhance trauma care.

Association of hydration status and in-hospital mortality in critically ill patients with ischemic stroke: Data from the MIMIC-IV database.

BACKGROUND: Hydration plays a critical role in the pathophysiological progression of ischemic stroke. However, the impact of extreme hydration on the mortality of critically ill patients with ischemic stroke remains unclear. Therefore, our objective was to evaluate the association between hydration, as indicated by the blood urea nitrogen to creatinine ratio (UCR), and in-hospital mortality in critically ill patients with ischemic stroke. METHODS: Data from the Medical Information Mart for Intensive Care (MIMIC-IV) database were utilized. Patients with ischemic stroke admitted to the Intensive Care Unit (ICU) for the first time were identified. The exposure variable was the hydration state represented by the UCR. The study outcome measure was in-hospital mortality. The primary analytical approach involved multivariate Cox regression analysis. Kaplan-Meier curves were constructed, and subgroup analyses with interaction were performed. RESULTS: A total of 1539 patients, with a mean age of 69.9 years, were included in the study. Kaplan-Meier curves illustrated that patients in higher UCR tertiles exhibited increased in-hospital mortality. Accordingly, the risk of in-hospital mortality significantly rose by 29 % with every 10 units increase in UCR. Subgroup analysis indicated a robust association between UCR and in-hospital mortality in each subgroup, with no statistically significant interactions observed. CONCLUSION: Hydration status is significantly associated with in-hospital all-cause mortality in critically ill patients with ischemic stroke. This finding underscores the importance of closely monitoring critically ill patients for adequate hydration and implementing appropriate rehydration strategies.

Unlocking the potential of HB/RDW ratio as a simple marker for predicting mortality in acute ischemic stroke patients after thrombolysis.

BACKGROUND: Systemic inflammation impairs outcomes in acute ischemic stroke (AIS). There is limited knowledge regarding the prognostic value of inflammatory biomarkers derived from complete blood count in predicting in-hospital mortality (IHM) in AIS patients treated with recombinant tissue plasminogen activator (rt-PA). Our study aims to compare the predictive performance of various inflammatory biomarkers for predicting IHM in AIS patients. METHODS: This retrospective study included AIS patients treated with rt-PA between January 2015 and July 2022. We identified the following inflammatory biomarkers: white blood cell counts (WBCs), absolute neutrophil count, absolute lymphocyte count, neutrophil to lymphocyte count ratio, platelet to neutrophil ratio, platelet to lymphocyte ratio, red cell distribution width (RDW), RDW to platelet ratio (RPR), and hemoglobin to RDW (HB/RDW) at admission before rt-PA administration. We assessed the predictive value of these biomarkers for IHM by plotting receiver operating characteristic (ROC) curves. The associations between inflammatory biomarkers and IHM were analyzed using multivariable logistic regression (MVLR) analyses. RESULTS: Of 345 AIS patients, IHM occurred in 65 patients (18.84%). HB/RDW and RDW showed better predictive performance compared to other inflammatory biomarkers. In ROC curve analysis, HB/RDW and RDW had an area under ROC of 0.668. HB/RDW outperformed RDW in terms of the positive likelihood ratio (2.733 vs 1.575), accuracy (0.757 vs 0.585), specificity (0.814 vs 0.560), and positive predictive values (0.388 vs 0.267). In MVLR analysis, RDW, RPR, and HB/RDW remained significantly associated with IHM (per 1-unit increases: odds ratios (ORs) = 1.450, 95% CI: [1.178-1.784]; per 1-unit increases: ORs = 1.329, 95% CI [1.103-1.602]; and per 0.1-unit decreases: ORs = 1.412, 95% CI [1.089-1.831], respectively). CONCLUSIONS: The association between HB/RDW and IHM in AIS patients treated with rt-PA was significant. HB/RDW exhibited superior predictive performance compared to other inflammatory biomarkers in predicting IHM.

Prior emergency medical services utilization is a risk factor for in-hospital death among patients with substance misuse: a retrospective cohort study.

BACKGROUND: Substance misuse poses a significant public health challenge, characterized by premature morbidity and mortality, and heightened healthcare utilization. While studies have demonstrated that previous hospitalizations and emergency department visits are associated with increased mortality in patients with substance misuse, it is unknown whether prior utilization of emergency medical service (EMS) is similarly associated with poor outcomes among this population. The objective of this study is to determine the association between EMS utilization in the 30 days before a hospitalization or emergency department visit and in-hospital outcomes among patients with substance misuse. METHODS: We conducted a retrospective analysis of adult emergency department visits and hospitalizations (referred to as a hospital encounter) between 2017 and 2021 within the Substance Misuse Data Commons, which maintains electronic health records from substance misuse patients seen at two University of Wisconsin hospitals, linked with state agency, claims, and socioeconomic datasets. Using regression models, we examined the association between EMS use and the outcomes of in-hospital death, hospital length of stay, intensive care unit (ICU) admission, and critical illness events, defined by invasive mechanical ventilation or vasoactive drug administration. Models were adjusted for age, comorbidities, initial severity of illness, substance misuse type, and socioeconomic status. RESULTS: Among 19,402 encounters, individuals with substance misuse who had at least one EMS incident within 30 days of a hospital encounter experienced a higher likelihood of in-hospital mortality (OR 1.52, 95% CI [1.05 - 2.14]) compared to those without prior EMS use, after adjusting for confounders. Using EMS in the 30 days prior to an encounter was associated with a small increase in hospital length of stay but was not associated with ICU admission or critical illness events. CONCLUSIONS: Individuals with substance misuse who have used EMS in the month preceding a hospital encounter are at an increased risk of in-hospital mortality. Enhanced monitoring of EMS users in this population could improve overall patient outcomes.

Long-Term Outcome of Lower Extremity Bypass Surgery in Patients with Chronic Kidney Disease and Critical Limb Ischemia in Germany.

The aim of this study is to present short- and long-term outcomes after lower extremity bypass (LEB) surgery in patients with chronic limb-threatening ischemia (CLTI) and chronic kidney disease (CKD), differentiated by peripheral artery disease (PAD) Fontaine stage III and IV. METHODS: Retrospective analysis of anonymized data from a nationwide German health insurance company (AOK). Data from 22,633 patients (14,523 men) who underwent LEB from 2010 to 2015, were analyzed, presenting 18,271 with CKD stage 1/2, 2,483 patients with CKD stage 3 and 1,879 with CKD stage 4/5. RESULTS: Perioperative mortality (60-day mortality) was 7.2% for CKD stage 1/2, 12.4% for CKD stage 3, and 18.0% for CKD stage 4/5. Patients with PAD stage IV had a significantly higher perioperative mortality (43.2%) than patients with PAD stage III (22.7%). The perioperative major amputation rate depended significantly on PAD stage IV (Odds Ratio (OR): 2.57 CI: 2.16 - 3.05, p < .001), the LEB level below the knee and crural/pedal (OR: 2.49 CI: 2.14 - 2.90, p < .001), CKD stage 4/5 (OR: 1.28, CI: 1.06 - 1.54, p = .009), and the presence of diabetes mellitus type 2 (OR: 1.19, CI: 1.05 - 1.36, p = .007). Kaplan-Meier estimated long-term survival of up to 9 years after surgery was 31.7% for patients with CKD stage 1 and 2, 14.3% for CKD stage 3, and only 10.1% for CKD stage 4 and 5 (p < .001). PAD Fontaine stage IV vs. III (Hazard Ratio (HR): 1.64, CI: 1.56 - 1.71, p < .001), but not bypass level had an independent adverse influence on long-term survival. CONCLUSION: CKD and PAD stage were equally significant independent predictors of patient survival and MACE with higher PAD and CKD stages associated with less favorable long-term outcomes.

Association between advanced lung cancer inflammation index and in-hospital mortality in ICU patients with community-acquired pneumonia: A retrospective analysis of the MIMIC-IV database.

Objective: The objective of the present study was to explore the correlation between the advanced lung cancer inflammation index (ALI) and in-hospital mortality among patients diagnosed with community-acquired pneumonia (CAP). Methods: Data from the Medical Information Mart for Intensive Care-IV database were adopted to analyze the in-hospital mortality of ICU patients with CAP. Upon admission to the ICU, fundamental data including vital signs, critical illness scores, comorbidities, and laboratory results, were collected. The in-hospital mortality of all CAP patients was documented. Multivariate logistic regression (MLR) models and restricted cubic spline (RCS) analysis together with subgroup analyses were conducted. Results: This study includes 311 CAP individuals, involving 218 survivors as well as 93 nonsurvivors. The participants had an average age of 63.57 years, and the females accounted for approximately 45.33%. The in-hospital mortality was documented to be 29.90%. MLR analysis found that ALI was identified as an independent predictor for in-hospital mortality among patients with CAP solely in the Q1 group with ALI ≤ 39.38 (HR: 2.227, 95% CI: 1.026-4.831, P = 0.043). RCS analysis showed a nonlinear relationship between the ALI and in-hospital mortality, with a turning point at 81, and on the left side of the inflection point, a negative correlation was observed between ALI and in-hospital mortality (HR: 0.984, 95% CI: 0.975-0.994, P = 0.002). The subgroup with high blood pressure showed significant interaction with the ALI. Conclusion: The present study demonstrated a nonlinear correlation of the ALI with in-hospital mortality among individuals with CAP. Additional confirmation of these findings requires conducting larger prospective investigations.

Evaluation of the Efficacy of Remdesivir for the Treatment of Coronavirus Disease 2019.

Background: Coronavirus disease 2019 (COVID-19), caused by a novel coronavirus, SARS-CoV-2, has accounted for more than 1 000 000 deaths in the United States alone. In May 2020, the Food and Drug Administration issued an Emergency Use Authorization to allow the investigational use of intravenous remdesivir for the treatment of suspected or confirmed COVID-19 in hospitalized children and adults. Several other agents, such as hydroxychloroquine, dexamethasone, and tocilizumab have been investigated as potential treatment options; however, dexamethasone is currently the only agent that has been proven to reduce mortality in patients who require supplemental oxygen. The purpose of this study was to determine if initiation of remdesivir treatment in patients who presented with early symptoms of COVID-19 (defined as symptom onset < 7 days) had a significant impact on in-patient all-cause mortality compared to initiation of remdesivir treatment in patients who presented with symptom onset of at least 7 days. Methods: This ethics-committee-approved, retrospective, multicenter, double-arm study was conducted across 10 facilities in the HCA Healthcare West Florida Division. Adult inpatients age 18 and older with confirmed COVID-19 and administered intravenous remdesivir from May 1, 2020, to July 31, 2020, were included. Exclusion criteria included patients less than 18 years of age, the concomitant use of hydroxychloroquine or tocilizumab for any indication, or an estimated glomerular filtration rate less than 30 milliliters per minute. The primary outcome of this study was in-patient all-cause mortality. Secondary outcomes included total length of stay, time to discharge, oxygen requirements, and number of ventilator days. Results: A total of 217 patients from facilities in the HCA Healthcare West Florida Division were evaluated for inclusion. The primary outcome of all-cause mortality occurred in 34.9% of patients with symptom onset of fewer than 7 days versus 31.0% of patients with symptom onset of at least 7 days (P = .57). There were no statistical differences found among the secondary outcomes. Conclusion: Time since symptom onset did not result in a statistically significant difference in all-cause mortality in patients who received intravenous remdesivir for the treatment of COVID-19.

Survival, mortality and epidemic risk status of COVID-19: a population-based Study in Golestan province, Iran.

BACKGROUND: Appreciating the various dimensions of the coronavirus disease 2019 (COVID-19) pandemic can improve health systems and prepare them to deal better with future pandemics and public health events. This study was conducted to investigate the association between the survival of hospitalized patients with COVID-19 and the epidemic risk stratification of the disease in Golestan province, Iran. METHODS: In this study, all patients with COVID-19 who were hospitalized in the hospitals of Golestan province of Iran from February 20, 2020, to December 19, 2022, and were registered in the Medical Care Monitoring Center (MCMC) system (85,885 individuals) were examined.The community's epidemic risk status (ERS) was determined based on the daily incidence statistics of COVID-19. The survival distribution and compare Survival in different subgroups was investigated using Kaplan-Meier and log-rank test and association between the survival and ERS by multiple Cox regression modeling. RESULTS: Out of 68,983 individuals whose data were correctly recorded, the mean age was 49 (SD = 23.98) years, and 52.8% were women. In total, 11.1% eventually died. The length of hospital stay was varying significantly with age, gender, ERS, underlying diseases, and COVID-19 severity (P < 0.001 for all). The adjusted hazard ratio of death for the ERS at medium, high, and very high-risk status compared to the low-risk status increased by 19%, 26%, and 56%, respectively (P < 0.001 for all). CONCLUSIONS: Enhancing preparedness, facilitating rapid rises in hospital capacities, and developing backup healthcare capacities can prevent excessive hospital referrals during health crises and further deaths.

Transcatheter Versus Surgical Mitral Valve Interventions in Patients With Prior Coronary Artery Bypass Grafting.

BACKGROUND: A significant proportion of patients requiring mitral valve (MV) intervention have undergone prior coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased risk. AIMS: To evaluate the utilization and outcomes of transcatheter versus surgical MV interventions in patients with prior CABG. METHODS: We queried the Nationwide Readmission Database (2016-2021) to identify adults with prior CABG hospitalized for transcatheter or surgical MV intervention. In-hospital outcomes were compared using multivariable regression and propensity-matching analyses. Readmissions were compared using Cox proportional hazards regression model. RESULTS: Of 305,625 weighted hospitalizations for MV intervention, 23,506 (7.7%) occurred in patients with prior CABG. From 2016-2021, the use of transcatheter MV interventions increased among patients with prior CABG (72 to 191 for repair and 6 to 45 for replacement per 100,000 hospitalizations, both ptrend<0.001). Compared with surgical MV repair and replacement, transcatheter MV repair and replacement were associated with similar in-hospital mortality (adjusted odds ratio [aOR] 0.44, 95% confidence interval [CI] 0.20-1.03 for repair; aOR 0.61, 95% CI 0.38-1.02 for replacement) and 180-day heart failure readmissions (adjusted hazard ratio [aHR] 1.56, 95% CI 0.85-2.87 for repair; aHR 1.15, 95% CI 0.63-2.09 for replacement) and lower stroke, acute kidney injury, permanent pacemaker placement, length of stay, and nonhome discharges, respectively. Vascular complications were higher with transcatheter versus surgical MV replacement. CONCLUSIONS: Transcatheter MV interventions are increasingly used as the preferred modality of MV intervention in patients with prior CABG and are associated with similar in-hospital mortality and 180-day heart failure readmissions compared with surgical MV interventions.

Presentation, management, and early outcomes of young acute coronary syndrome patients- analysis of 23,560 South Asian patients from 2012 to 2021.

BACKGROUND: There is dearth of literature addressing early outcomes of acute coronary syndrome (ACS) among young patients, particularly South Asians descent who are predisposed to premature coronary artery disease (CAD). Therefore, we compared presentation, management, and early outcomes of young vs. old ACS patients and explored predictors of in-hospital mortality. METHODS: We extracted data of 23,560 ACS patients who presented at Tabba Heart Institute, Karachi, Pakistan, from July 2012-June 2020, from the Chest pain-MI-Registry™. We categorized data into young ≤ 45 and old ACS patients > 45 years. Chi-sq/Fischer exact tests were used to assess the difference between presentation, disease management, and in-hospital mortality between both groups. Logistic regression was used to determine odds ratio along with 95% confidence interval of factors associated with early mortality. RESULTS: The younger patients were 12.2% and women 23.5%. The prevalence of dyslipidemia (34.5% vs. 22.4%), diabetes (52.1% vs. 27.4%), and hypertension (68.3% vs. 42.9%) was higher in older patients. Family history of premature CAD (18.1% vs. 32.7%), smoking (40.0% vs. 22.9%), and smokeless tobacco use (6.5% vs. 8.4%) were lower in older patients compared to younger ones. Younger patients were more likely to present with STEMI (33.2% vs. 45%). The median symptom-to-door time was 125 min longer (p-value < 0.01) in the young patients compared to the older age group. In-hospital mortality (4.3% vs. 1.7%), cardiac arrest (1.9% vs. 0.7%), cardiogenic shock (1.9% vs. 0.9%), and heart failure (1% vs. 0.6%) were more common in older patients. After adjusting for other factors, younger age (AOR 0.6, 95% CI 1.5-3.7) had significantly lesser odds of in-hospital mortality. Other factors associated with early mortality included women, family history of premature CAD, STEMI, Killip class III and IV, coronary angiography, revascularization, CABG, and use of aspirin and beta blockers within the first 24 h. CONCLUSION: We found every tenth ACS patient was younger than 45 years of age despite a lesser number of comorbidities such as hypertension and diabetes. Overall, the in-hospital prognosis of young patients was more favorable than that of older patients. The study emphasizes the need for tailored primary prevention programs for ACS, considering the varying risks among different age groups.

Assessing the predictive value of the controlling nutritional status score on all-cause mortality during hospitalization in patients with acute decompensated heart failure: a retrospective cohort study from Jiangxi, China.

Objective: Nutritional status is closely associated with the prognosis of heart failure. This study aims to assess the relationship between the Controlling Nutritional Status (CONUT) score and in-hospital mortality among patients with acute decompensated heart failure (ADHF) in Jiangxi, China. Methods: A retrospective cohort study was conducted. Multivariable Cox regression models and restricted cubic spline regression were employed to evaluate the relationship between the CONUT score and in-hospital mortality in ADHF patients from Jiangxi, China. The predictive value of the CONUT score for in-hospital mortality in ADHF patients was analyzed using receiver operating characteristic curves. Subgroup analyses were performed to identify risk dependencies of the CONUT score in specific populations. Results: The study included 1,230 ADHF patients, among whom 44 (3.58%) mortality events were recorded. After adjusting for confounding factors, a positive correlation was found between the CONUT score and the risk of in-hospital mortality in ADHF patients. Restricted cubic spline regression analysis indicated a non-linear relationship between the CONUT score and the risk of in-hospital mortality in ADHF patients, estimating a rapid increase in mortality risk when the CONUT score exceeded 5. Receiver operating characteristic analysis demonstrated a good predictive value of the CONUT score for all-cause mortality events in ADHF patients [area under the curve = 0.7625, optimal threshold = 5.5]. Additionally, a relatively higher risk associated with the CONUT score was observed in male patients and those with concomitant cerebral infarction. Conclusion: This study reveals a positive correlation between the CONUT score and the risk of in-hospital mortality in ADHF patients. Based on the findings of this study, we recommend maintaining a CONUT score below 5 for patients with ADHF in Jiangxi, China, as it may significantly contribute to reducing the risk of in-hospital all-cause mortality.

Acute kidney injury and cardiogenic shock severity for mortality risk stratification in patients supported with VA ECMO.

AIMS: To assess the stage of acute kidney injury (AKI), as an index of organ perfusion, combined with shock severity, measured by the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage classification, to stratify the risk of mortality in patients diagnosed with cardiogenic shock (CS) and supported with venoarterial extracorporeal membrane oxygenation (VA ECMO). METHODS ANS RESULTS: From January 2018 to December 2020, consecutive adult patients diagnosed with CS and received VA ECMO were retrospectively evaluated. The highest AKI stage within 48 h after ECMO initiation was assessed using the Kidney Disease: Improving Global Outcomes criteria. We included 216 patients with a mean age of 58.8 years and 31.0% were females. 88.4% of patients received ECMO for postcardiotomy, while 11.6% for medical CS. The total in-hospital mortality was 53.2%. AKI occurred in 182 (84.3%) patients receiving ECMO for CS. AKI stage 0, 1, 2, and 3 were present in 15.7%, 17.6%, 18.1%, and 48.6% of patients with in-hospital mortality of 26.5%, 26.3%, 61.5%, and 68.6%, respectively (P < 0.001). The AKI stage (P < 0.001), SCAI shock stage before ECMO (P = 0.008), and NYHA ≥ Class III on admission (P = 0.044) were independent predictors of in-hospital mortality. The area under the receiver operating characteristic curve of 0.754 (95% confidence interval: 0.690 to 0.811) for AKI stage combined with SCAI shock stage was better than those for AKI stage (0.676), SCAI shock stage (0.657), serum lactate level (0.682), SOFA score (0.644), SVAE score (0.582), and VIS score (0.530) prior to ECMO. CONCLUSIONS: In this single-center CS population who received VA ECMO for circulatory support, predominantly postcardiotomy cases, AKI occurred in 84.3% of the patients. AKI stage, as an index of organ perfusion combined with shock severity measured by the SCAI shock classification, demonstrates a good correlation with in-hospital mortality.

Predictive modeling of perioperative patient deterioration: combining unanticipated ICU admissions and mortality for improved risk prediction.

OBJECTIVE: This paper presents a comprehensive analysis of perioperative patient deterioration by developing predictive models that evaluate unanticipated ICU admissions and in-hospital mortality both as distinct and combined outcomes. MATERIALS AND METHODS: With less than 1% of cases resulting in at least one of these outcomes, we investigated 98 features to identify their role in predicting patient deterioration, using univariate analyses. Additionally, multivariate analyses were performed by employing logistic regression (LR) with LASSO regularization. We also assessed classification models, including non-linear classifiers like Support Vector Machines, Random Forest, and XGBoost. RESULTS: During evaluation, careful attention was paid to the data imbalance therefore multiple evaluation metrics were used, which are less sensitive to imbalance. These metrics included the area under the receiver operating characteristics, precision-recall and kappa curves, and the precision, sensitivity, kappa, and F1-score. Combining unanticipated ICU admissions and mortality into a single outcome improved predictive performance overall. However, this led to reduced accuracy in predicting individual forms of deterioration, with LR showing the best performance for the combined prediction. DISCUSSION: The study underscores the significance of specific perioperative features in predicting patient deterioration, especially revealed by univariate analysis. Importantly, interpretable models like logistic regression outperformed complex classifiers, suggesting their practicality. Especially, when combined in an ensemble model for predicting multiple forms of deterioration. These findings were mostly limited by the large imbalance in data as post-operative deterioration is a rare occurrence. Future research should therefore focus on capturing more deterioration events and possibly extending validation to multi-center studies. CONCLUSIONS: This work demonstrates the potential for accurate prediction of perioperative patient deterioration, highlighting the importance of several perioperative features and the practicality of interpretable models like logistic regression, and ensemble models for the prediction of several outcome types. In future clinical practice these data-driven prediction models might form the basis for post-operative risk stratification by providing an evidence-based assessment of risk.

Impact of the COVID-19 Pandemic on Elective and Emergency Surgeries, and Postoperative Mortality in a Brazilian Metropolitan Area: A Time-Series Cohort Study.

Purpose: The COVID-19 pandemic posed a worldwide challenge, leading to radical changes in surgical services. The primary objective of the study was to assess the impact of COVID-19 on elective and emergency surgeries in a Brazilian metropolitan area. The secondary objective was to compare the postoperative hospital mortality before and during the pandemic. Patients and Methods: Time-series cohort study including data of all patients admitted for elective or emergency surgery at the hospitals in the Public Health System of Federal District, Brazil, between March 2018 and February 2022, using data extracted from the Hospital Information System of Brazilian Ministry of Health (SIH/DATASUS) on September 30, 2022. A causal impact analysis was used to evaluate the impact of COVID-19 on elective and emergency surgeries and hospital mortality. Results: There were 174,473 surgeries during the study period. There was a reduction in overall (absolute effect per week: -227.5; 95% CI: -307.0 to -149.0), elective (absolute effect per week: -170.9; 95% CI: -232.8 to -112.0), and emergency (absolute effect per week: -57.7; 95% CI: -87.5 to -27.7) surgeries during the COVID-19 period. Comparing the surgeries performed before and after the COVID-19 onset, there was an increase in emergency surgeries (53.0% vs 68.8%, P < 0.001) and no significant hospital length of stay (P = 0.112). The effect of the COVID-19 pandemic on postoperative hospital mortality was not statistically significant (absolute effect per week: 2.1, 95% CI: -0.01 to 4.2). Conclusion: Our study showed a reduction in elective and emergency surgeries during the COVID-19 pandemic, possibly due to disruptions in surgical services. These findings highlight that it is crucial to implement effective strategies to prevent the accumulation of surgical waiting lists in times of crisis and improve outcomes for surgical patients.

Impact of index admission cholecystectomy vs interval cholecystectomy on readmission rate in acute cholangitis: National Readmission Database survey.

BACKGROUND: Elective cholecystectomy (CCY) is recommended for patients with gallstone-related acute cholangitis (AC) following endoscopic decompression to prevent recurrent biliary events. However, the optimal timing and implications of CCY remain unclear. AIM: To examine the impact of same-admission CCY compared to interval CCY on patients with gallstone-related AC using the National Readmission Database (NRD). METHODS: We queried the NRD to identify all gallstone-related AC hospitalizations in adult patients with and without the same admission CCY between 2016 and 2020. Our primary outcome was all-cause 30-d readmission rates, and secondary outcomes included in-hospital mortality, length of stay (LOS), and hospitalization cost. RESULTS: Among the 124964 gallstone-related AC hospitalizations, only 14.67% underwent the same admission CCY. The all-cause 30-d readmissions in the same admission CCY group were almost half that of the non-CCY group (5.56% vs 11.50%). Patients in the same admission CCY group had a longer mean LOS and higher hospitalization costs attributable to surgery. Although the most common reason for readmission was sepsis in both groups, the second most common reason was AC in the interval CCY group. CONCLUSION: Our study suggests that patients with gallstone-related AC who do not undergo the same admission CCY have twice the risk of readmission compared to those who undergo CCY during the same admission. These readmissions can potentially be prevented by performing same-admission CCY in appropriate patients, which may reduce subsequent hospitalization costs secondary to readmissions.