Impact of Preexisting Depression and Anxiety on Hospital Readmission and Long-Term Survival After Cardiac Arrest.

BACKGROUND: While sudden cardiac arrest (CA) survivors are at risk for developing psychiatric disorders, little is known about the impact of preexisting mental health conditions on long-term survival or postacute healthcare utilization. We examined the prevalence of preexisting psychiatric conditions in CA patients who survived hospital discharge, characterized incidence and reason for inpatient psychiatry consultation during these patients' acute hospitalizations, and determined the association of pre-CA depression and anxiety with hospital readmission rates and long-term survival. We hypothesized that prior depression or anxiety would be associated with higher hospital readmission rates and lower long-term survival. METHODS: We conducted a retrospective cohort study including patients resuscitated from in- and out-of-hospital CA who survived both admission and discharge from a single hospital between January 1, 2010, and December 31, 2017. We identified patients from our prospective registry, then performed a structured chart review to abstract past psychiatric history, prescription medications for psychiatric conditions, and identify inpatient psychiatric consultations. We used administrative data to identify readmissions within 1 year and vital status through December 31, 2020. We used multivariable Cox regressions controlling for patient demographics, medical comorbidities, discharge Cerebral Performance Category and disposition, depression, and anxiety history to predict long-term survival and hospital readmission. RESULTS: We included 684 subjects. Past depression or anxiety was noted in 24% (n = 162) and 19% (n = 129) of subjects. A minority of subjects (n = 139, 20%) received a psychiatry consultation during the index hospitalization. Overall, 262 (39%) subjects had at least 1 readmission within 1 year. Past depression was associated with an increased hazard of hospital readmission (hazard ratio 1.50, 95% CI 1.11-2.04), while past anxiety was not associated with readmission. Neither depression nor anxiety were independently associated with long-term survival. CONCLUSIONS: Depression is an independent risk factor for hospital readmission in CA survivors.

Bradyrhizobium diazoefficiens USDA 110 displays plasticity in the attachment phenotype when grown in different soybean root exudate compounds.

Introduction: Bradyrhizobium diazoefficiens, a symbiotic nitrogen fixer for soybean, forms nodules after developing a symbiotic association with the root. For this association, bacteria need to move toward and attach to the root. These steps are mediated by the surface and phenotypic cell properties of bacteria and secreted root exudate compounds. Immense work has been carried out on nodule formation and nitrogen fixation, but little is known about the phenotype of these microorganisms under the influence of different root exudate chemical compounds (RECCs) or how this phenotype impacts the root attachment ability. Methods: To address this knowledge gap, we studied the impact of 12 different RECCs, one commonly used carbon source, and soil-extracted solubilized organic matter (SESOM) on attachment and attachment-related properties of B. diazoefficiens USDA110. We measured motility-related properties (swimming, swarming, chemotaxis, and flagellar expression), attachment-related properties (surface hydrophobicity, biofilm formation, and attachment to cellulose and soybean roots), and surface polysaccharide properties (colony morphology, exopolysaccharide quantification, lectin binding profile, and lipopolysaccharide profiling). Results and discussion: We found that USDA 110 displays a high degree of surface phenotypic plasticity when grown on the various individual RECCs. Some of the RECCs played specific roles in modulating the motility and root attachment processes. Serine increased cell surface hydrophobicity and root and cellulose attachment, with no EPS formed. Gluconate and lactate increased EPS production and biofilm formation, while decreasing hydrophobicity and root attachment, and raffinose and gentisate promoted motility and chemotaxis. The results also indicated that the biofilm formation trait on hydrophilic surfaces (polystyrene) cannot be related to the attachment ability of Bradyrhizobium to the soybean root. Among the tested phenotypic properties, bacterial cell surface hydrophobicity was the one with a significant impact on root attachment ability. We conclude that USDA 110 displays surface plasticity properties and attachment phenotype determined by individual RECCs from the soybean. Conclusions made based on its behavior in standard carbon sources, such as arabinose or mannitol, do not hold for its behavior in soil.

Large Bore Portal Vein Thrombectomy: An Inari FlowTriever Case Series.

PURPOSE: Portal vein thrombus (PVT) can worsen portal hypertension and hepatic decompensation in patients with cirrhosis and impact liver transplant outcomes. This retrospective case series describes large bore mechanical thrombectomy of PVT with the Inari FlowTriever device during, or remotely after, transjugular intrahepatic portosystemic shunt (TIPS) placement. MATERIALS AND METHODS: Ten patients with PVT were treated with large bore thrombectomy. All patients had underlying cirrhosis, complicated by portal hypertension with acute/subacute PVT. Thrombectomy was performed either with TIPS placement, or via a previously placed thrombosed shunt. Median time from TIPS placement to thrombectomy was 3 years. RESULTS: Thrombectomy was technically successful in all patients with a majority achieving complete resolution of PVT in a single session. During mean follow-up of 13.3 months, all patients achieved complete resolution of PVT without recurrence. CONCLUSION: Large bore mechanical thrombectomy together with TIPS is a feasible and effective treatment of acute/subacute PVT in cirrhotic patients with portal hypertension, often with complete resolution in a single session.

Development of atrial fibrillation following trauma increases short term risk of cardiovascular events.

CONTEXT: New onset atrial fibrillation (AF) is associated with poor outcomes in several different patient populations. OBJECTIVES: To assess the effect of developing AF on cardiovascular events such as myocardial infarction (MI) and cerebrovascular accident (CVA) during the acute index hospitalization for trauma patients. METHODS: The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida were used to identify adult trauma patients (18 years of age or older) who were admitted between 2007 and 2010. After excluding patients with a history of AF and prior history of cardiovascular events, patients were evaluated for MI, CVA, and death during the index hospitalization. A secondary analysis was performed using matched propensity scoring based on age, race, and preexisting comorbidities. RESULTS: During the study period, 1,224,828 trauma patients were admitted. A total of 195,715 patients were excluded for a prior history of AF, MI, or CVA. Of the remaining patients, 15,424 (1.5%) met inclusion criteria and had new onset AF after trauma. There was an associated increase in incidence of MI (2.9 vs. 0.7%; p<0.001), CVA (2.6 vs. 0.4%; p<0.001), and inpatient mortality (8.5 vs. 2.1%; p<0.001) during the index hospitalization in patients who developed new onset AF compared with those who did not. Cox proportional hazards regression demonstrated an increased risk of MI (odds ratio [OR], 2.35 [2.13-2.60]), CVA (OR, 3.90 [3.49-4.35]), and inpatient mortality (OR, 2.83 [2.66-3.00]) for patients with new onset AF after controlling for all other potential risk factors. CONCLUSIONS: New onset AF in trauma patients was associated with increased incidence of myocardial infarction (MI), cerebral vascular accident (CVA), and mortality during index hospitalization in this study.

Red blood cell distribution width and outcome in trauma patients.

Context: Red blood cell distribution width (RDW) has been used to predict mortality during infection and inflammatory diseases. It also been purported to be predictive of mortality following traumatic injury. Objective: To identify the role of RDW in predicting mortality in trauma patients. We also sought to identify the role of RDW in predicting the development of sepsis in trauma patients. Methods: A retrospective observational study was performed of the medical records for all adult trauma patients admitted to Loyola University Medical Center from 2007 to 2014. Patients admitted for fewer than four days were excluded. Admission, peak, and change from admission to peak (Δ) RDW were recorded to determine the relationship with in-hospital mortality. Patient age, development of sepsis during the hospitalization, admission to the intensive care unit (ICU), and discharge disposition were also examined. Results: A total of 9,845 patients were admitted to the trauma service between 2007 and 2014, and a total of 2,512 (25.5%) patients fit the inclusion criteria and had both admission and peak values available. One-hundred twenty (4.6%) died while in the hospital. RDW values for all patients were (mean [standard deviation, SD]): admission 14.09 (1.88), peak 15.09 (2.34), and Δ RDW 1.00 (1.44). Admission, peak, and Δ RDW were not significant predictors of mortality (all p>0.50; hazard ratio [HR], 1.01-1.03). However, trauma patients who eventually developed sepsis had significantly higher RDW values (admission RDW: 14.27 (2.02) sepsis vs. 13.98 (1.73) no sepsis, p<0.001; peak RDW: 15.95 (2.55) vs. 14.51 (1.97), p<0.001; Δ RDW: 1.68 (1.77) vs. 0.53 (0.91), p<0.001). Conclusion: Admission, peak, and Δ RDW were not associated with in-hospital mortality in adult trauma patients with a length of stay (LOS) ≥four days. However, the development of sepsis in trauma patients is closely linked to increased RDW values and in-hospital mortality.

Unsupervised learning of early post-arrest brain injury phenotypes.

INTRODUCTION: Trials may be neutral when they do not appropriately target the experimental intervention. We speculated multimodality assessment of early hypoxic-ischemic brain injury would identify phenotypes likely to benefit from therapeutic interventions. METHODS: We performed a retrospective study including comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA) by one of 126 emergency medical services or in-hospital arrest at one of 26 hospitals from 2011 to 2019. All patients were ultimately transported to a single tertiary center for care including standardized initial neurological examination, brain imaging and electroencephalography; targeted temperature management (TTM); hemodynamic optimization targeting mean arterial pressure (MAP) >80 mmHg; and, coronary angiography for clinical suspicion for acute coronary syndrome. We used unsupervised learning to identify brain injury phenotypes defined by admission neurodiagnostics. We tested for interactions between phenotype and TTM, hemodynamic management and cardiac catheterization in models predicting recovery. RESULTS: We included 1086 patients with mean (SD) age 58 (17) years of whom 955 (88%) were resuscitated from OHCA. Survival to hospital discharge was 27%, and 248 (23%) were discharged with Cerebral Performance Category (CPC) 1-3. We identified 5 clusters defining distinct brain injury phenotypes, each comprising 14% to 30% of the cohort with discharge CPC 1-3 in 59% to <1%. We found significant interactions between cluster and TTM strategy (P = 0.01), MAP (P < 0.001) and coronary angiography (P = 0.04) in models predicting outcomes. CONCLUSIONS: We identified patterns of early hypoxic-ischemic injury based on multiple diagnostic modalities that predict responsiveness to several therapeutic interventions recently tested in neutral clinical trials.

Does the Halo Effect for Level 1 Trauma Centers Apply to High-Acuity Nonsurgical Admissions?

CONTEXT: The halo effect describes the improved surgical outcomes at trauma centers for nontrauma conditions. OBJECTIVE: To determine whether level 1 trauma centers have improved inpatient mortality for common but high-acuity nonsurgical diagnoses (eg, acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia [PNA]) compared with non--level 1 trauma centers. METHODS: The authors conducted a population-based, retrospective cohort study analyzing data from the Healthcare Cost and Utilization Project State Inpatient Database and the American Hospital Association Annual Survey Database. Patients who were admitted with AMI, CHF, and PNA between 2006-2011 in Florida and California were included. Level 1 trauma centers were matched to non-level 1 trauma centers using propensity scoring. The primary outcome was risk-adjusted inpatient mortality for each diagnosis (AMI, CHF, or PNA). RESULTS: Of the 190,474 patients who were hospitalized for AMI, CHF, or PNA, 94,037 patients (49%) underwent treatment at level 1 trauma centers. The inpatient mortality rates at level 1 trauma centers vs non-level 1 trauma centers for patients with AMI was 8.10% vs 8.40%, respectively (P=.73); for patients with CHF, 2.26% vs 2.71% (P=.90); and for patients with PNA, 2.30% vs 2.70% (P=.25). CONCLUSION: Level 1 trauma center designation was not associated with improved mortality for high-acuity, nonsurgical medical conditions in this study.

Impact and treatment success of new-onset atrial fibrillation with rapid ventricular rate development in the surgical intensive care unit.

BACKGROUND: Atrial fibrillation (AF) with rapid ventricular rate (RVR; heart rate >100) in noncardiac postoperative surgical patients is associated with poor outcomes. The objective of this study was to evaluate the practice patterns of AF management in a surgical intensive care unit to determine practices associated with rate and rhythm control and additional outcomes. MATERIALS AND METHODS: Adult patients (≥18 y) admitted to the surgical intensive care unit (SICU) from June 2014 to June 2015 were retrospectively screened for the development of new-onset AF with RVR. Demographics, hospital course, evaluation and treatment of AF with RVR, and outcome were evaluated and analyzed. RESULTS: Thousand seventy patients were admitted to the SICU during the study period; 33 met inclusion criteria (3.1%). Twenty-six patients (79%) had rate and rhythm control within 48 h of AF with RVR onset. ß-Blockers were the most commonly used initial medication (67%) but were successful at rate and rhythm control in only 27% of patients (6/22). Amiodarone had the highest rate of success if used initially (5/6, 83%) and secondarily (11/13, 85%). Failure to control rate and rhythm was associated with a greater likelihood of comorbidities (100% versus 57%; P = 0.06). CONCLUSIONS: New-onset AF with RVR in the noncardiac postoperative patient is associated with a high mortality (21%). Amiodarone is the most effective treatment for rate and rhythm control. Failure to establish rate and rhythm control was associated with cardiac comorbidities. These results will help to form future algorithms for the treatment of AF with RVR in the SICU.