Editor's Choice - Prognostic Factors and Models to Predict Mortality Outcomes in Patients with Peripheral Arterial Disease: A Systematic Review.

OBJECTIVE: Predicting adverse outcomes in patients with peripheral arterial disease (PAD) is a complex task owing to the heterogeneity in patient and disease characteristics. This systematic review aimed to identify prognostic factors and prognostic models to predict mortality outcomes in patients with PAD Fontaine stage I - III or Rutherford category 0 - 4. DATA SOURCES: PubMed, Embase, and Cochrane Database of Systematic Reviews were searched to identify studies examining individual prognostic factors or studies aiming to develop or validate a prognostic model for mortality outcomes in patients with PAD. REVIEW METHODS: Information on study design, patient population, prognostic factors, and prognostic model characteristics was extracted, and risk of bias was evaluated. RESULTS: Sixty nine studies investigated prognostic factors for mortality outcomes in PAD. Over 80 single prognostic factors were identified, with age as a predictor of death in most of the studies. Other common factors included sex, diabetes, and smoking status. Six studies had low risk of bias in all domains, and the remainder had an unclear or high risk of bias in at least one domain. Eight studies developed or validated a prognostic model. All models included age in their primary model, but not sex. All studies had similar discrimination levels of > 70%. Five of the studies on prognostic models had an overall high risk of bias, whereas two studies had an overall unclear risk of bias. CONCLUSION: This systematic review shows that a large number of prognostic studies have been published, with heterogeneity in patient populations, outcomes, and risk of bias. Factors such as sex, age, diabetes, hypertension, and smoking are significant in predicting mortality risk among patients with PAD Fontaine stage I - III or Rutherford category 0 - 4.

Long-term mortality risk in obstructive sleep apnea: the critical role of oxygen desaturation index.

BACKGROUND: Mortality predictors in obstructive sleep apnea (OSA) patients yet to be comprehensively understood, especially within large cohorts undergoing long-term follow-up. We aimed to determine the independent predictors of mortality in OSA patients. METHODS: In our retrospective cohort study, 3,541 patients were included and survival data was obtained from electronic medical records. Demographic characteristics, anthropometric measurements, comorbidities, laboratory tests, and polysomnography parameters were analyzed for the survived and deceased patient groups. Univariate and multivariate Cox regression analyses were performed to determine independent predictors of all-cause mortality in patients followed for at least 5 years. RESULTS: Among all patients, 2,551 (72%) patients were male, with a mean age of 49.7 years. 231 (6.5%) patients had died. Deceased patients were significantly older and had higher waist-to-hip ratio and Epworth Sleepiness Scale (p < 0.001, p < 0.001, p = 0.003). OSA (nonpositional and not-rapid eye movement-related), periodic limb movements in sleep and Comorbidities of Sleep Apnea Score ≥ 1 were found to be associated with increased mortality (p < 0.001). Systemic immune-inflammation index was also significantly higher in the deceased group (p < 0.001). Higher oxygen desaturation index (ODI) and apnea-hypopnea index (AHI) were associated with increased mortality (p < 0.001). Due to the high correlation between ODI and AHI, two separate multivariate Cox regression models were created. While AHI lost its significance in the multivariate analysis, ODI remained significantly higher in the deceased patient group (HR = 1.007, 1.001-1.013, p = 0.01). CONCLUSION: ODI, as the only polysomnography parameter, emerged as an independent predictor of mortality in OSA patients.

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.

Developing a mortality risk prediction model using data of 3663 hospitalized COVID-19 patients: a retrospective cohort study in an Egyptian University Hospital.

PURPOSE: Since the declaration of COVID-19 as a pandemic, a wide between-country variation was observed regarding in-hospital mortality and its predictors. Given the scarcity of local research and the need to prioritize the provision of care, this study was conducted aiming to measure the incidence of in-hospital COVID-19 mortality and to develop a simple and clinically applicable model for its prediction. METHODS: COVID-19-confirmed patients admitted to the designated isolation areas of Ain-Shams University Hospitals (April 2020-February 2021) were included in this retrospective cohort study (n = 3663). Data were retrieved from patients' records. Kaplan-Meier survival and Cox proportional hazard regression were used. Binary logistic regression was used for creating mortality prediction models. RESULTS: Patients were 53.6% males, 4.6% current smokers, and their median age was 58 (IQR 41-68) years. Admission to intensive care units was 41.1% and mortality was 26.5% (972/3663, 95% CI 25.1-28.0%). Independent mortality predictors-with rapid mortality onset-were age ≥ 75 years, patients' admission in critical condition, and being symptomatic. Current smoking and presence of comorbidities particularly, obesity, malignancy, and chronic haematological disorders predicted mortality too. Some biomarkers were also recognized. Two prediction models exhibited the best performance: a basic model including age, presence/absence of comorbidities, and the severity level of the condition on admission (Area Under Receiver Operating Characteristic Curve (AUC) = 0.832, 95% CI 0.816-0.847) and another model with added International Normalized Ratio (INR) value (AUC = 0.842, 95% CI 0.812-0.873). CONCLUSION: Patients with the identified mortality risk factors are to be prioritized for preventive and rapid treatment measures. With the provided prediction models, clinicians can calculate mortality probability for their patients. Presenting multiple and very generic models can enable clinicians to choose the one containing the parameters available in their specific clinical setting, and also to test the applicability of such models in a non-COVID-19 respiratory infection.

Common hematological values predict unfavorable outcomes in hospitalized COVID-19 patients.

COVID-19 can range from asymptomatic to life-threatening. Early identification of patients who will develop severe disease is crucial. A number of scores and indexes have been developed to predict severity. However, most rely on measurements not readily available. We evaluated hematological and biochemical markers taken on admission and determined how predictive they were of development of critical illness or death. We observed that higher values of readily available tests, including neutrophil:lymphocyte ratio; derived neutrophil index; and troponin I were associated with a higher risk of death or critical care admission (P < 0.001). We show that common hematological tests can be helpful in determining early in the course of illness which patients are likely to develop severe forms, as well as allocating resources to those patients early, while avoiding overuse of limited resources in patients with reduced risk of progression to severe disease.

Frailty assessment, hip fracture and long-term clinical outcomes in older adults.

BACKGROUND: The primary aim of the study was determining the validation of the modified 19-item Frailty Index (mFI-19), based on the standard procedure for creating a frailty index scoring in the accumulation deficit theory of Rockwood and comparing it with the gold standard comprehensive geriatric assessment (CGA) in old age patients with hip fracture. As a secondary aim, we compared prognostic accuracies of mFI-19 and CGA in predicting long-term mortality after surgery. MATERIALS AND METHODS: A total of 364 older patients with hip fractures, each a candidate for surgery, were consecutively enrolled. All were subjected to CGA and mFI-19 at baseline and time to death (years from hip surgery) were collected prospectively. RESULTS: Mean patient age was 86.5 (SD: 5.65) years. The most common clinical phenotype (77%) was frail. Both CGA and mFI-19 performed similarly in predicting long-term mortality (Harrell's C-index: 0.66 and 0.68, respectively). CONCLUSIONS: The mFI-19 was validated, compared to the gold standard CGA, based on a systematic process for creating a frailty index in relation to the accumulation deficit. This is one of few prospective studies addressing long-term mortality in older adults with hip fractures, invoking a methodologically robust frailty screening assessment.

Upgrade from implantable cardioverter-defibrillator vs. de novo implantation of cardiac resynchronization therapy: long-term outcomes.

AIMS: To assess and compare long-term mortality and predictors thereof in de novo cardiac resynchronization therapy defibrillators (CRT-D) vs. upgrade from an implantable cardioverter-defibrillator (ICD) to CRT-D. METHODS AND RESULTS: Study population consisted of 595 consecutive patients with CRT-D implanted between 2002 and 2015 in a tertiary care, university hospital, in a densely inhabited, urban region of Poland [480 subjects (84.3%) with CRT-D de novo implantation; 115 patients (15.7%) upgraded from ICD to CRT-D]. In a median observation of 1692 days (range 457-3067), all-cause mortality for de novo CRT-D vs. CRT-D upgrade was 35.5% vs. 43.5%, respectively (P = 0.045). On multivariable regression analysis including all CRT recipients, the previously implanted ICD was an independent predictor for death [hazard ratio (HR) 1.58, 95% confidence interval (CI) 1.10-2.29, P = 0.02]. For those, who were upgraded from ICD to CRT-D, the independent predictors for all-cause death were as follows: creatinine level (HR 1.01, 95% CI 1.00-1.02, P = 0.01), left ventricular end-systolic diameter (HR 1.07, 95% CI 1.02-1.11, P = 0.002), New York Heart Association (NYHA) IV class at baseline (HR 2.36, 95% CI 1.00-5.53, P = 0.049) and cardiac device-related infective endocarditis during follow-up (HR 2.42, 95% CI 1.02-5.75, P = 0.046). A new CRT scale (Creatinine ≥150 µmol/L; Remodelling, left ventricular end-systolic ≥59 mm; Threshold for NYHA, NYHA = IV) showed high prediction for mortality in CRT-D upgrades (AUC 0.70, 95% CI 0.59-0.80, P = 0.0007). CONCLUSION: All-cause mortality in patients upgraded from ICD is significantly higher compared with de novo CRT-D implantations and reaches almost 45% within 4.5 years. A new CRT scale (Creatinine; Remodelling; Threshold for NYHA) has been proposed to help survival prediction following CRT upgrade.

Long-term mortality predictors of ICU fungaemia.

Bloodstream fungal infections have a high mortality rate. There is little data about the long-term mortality rate of fungaemia.This study aimed to explore the mortality of fungaemia and the influencing factors associated with death. In total, 204 intensive care unit (ICU) patients with fungaemia from Multi-parameter Intelligent Monitoring in Intensive Care-III (MIMIC-III) Database were studied. Age, gender, major underlying diseases, data about vital signs and blood test results were analysed to identify the predictors of the mortality and prognosis of fungaemia in ICU patients. Cox regression models were constructed, together with Kaplan-Meier survival curves. The 30-day, 1-year, 2-year, 3-year and 4-year mortality rates were 41.2%, 62.3%, 68.1%, 72.5% and 75%, respectively. Age (P ＜ 0.001, OR = 1.530; P ＜ 0.001, OR = 1.485)，serum bilirubin (P = 0.016, OR = 2.125；P = 0.001, OR = 1.748) and international normalised ratio (INR) (P = 0.001, OR = 2.642; P ＜ 0.001 OR = 2.065) were predictors of both the 30-day and 4-year mortality rates. Renal failure (P = 0.009, OR = 1.643) performed good in prediction of the 4-year mortality. The mortality of fungaemia is high. Age，the serum bilirubin and INR are good predictors of the 30-day and 4-year mortality rates of fungaemia. Renal failure has good performance in predicting the long-term mortality.

Survival rates and prognostic factors in right- and left-sided colon cancer stage I-IV: an unselected retrospective single-center trial.

PURPOSE: Colorectal cancer revealed over the last decades a remarkable shift with an increasing proportion of a right- compared to a left-sided tumor location. In the current study, we aimed to disclose clinicopathological differences between right- and left-sided colon cancer (rCC and lCC) with respect to mortality and outcome predictors. METHODS: In total, 417 patients with colon cancer stage I-IV were analyzed in the present retrospective single-center study. Survival rates were assessed using the Kaplan-Meier method and uni/multivariate analyses were performed with a Cox proportional hazards regression model. RESULTS: Our study showed no significant difference of the overall survival between rCC and lCC stage I-IV (p = 0.354). Multivariate analysis revealed in the rCC cohort the worst outcome for ASA (American Society of Anesthesiologists) score IV patients (hazard ratio [HR]: 16.0; CI 95%: 2.1-123.5), CEA (carcinoembryonic antigen) blood level > 100 µg/l (HR: 3.3; CI 95%: 1.2-9.0), increased lymph node ratio of 0.6-1.0 (HR: 5.3; CI 95%: 1.7-16.1), and grade 4 tumors (G4) (HR: 120.6; CI 95%: 6.7-2179.6) whereas in the lCC population, ASA score IV (HR: 8.9; CI 95%: 0.9-91.9), CEA blood level 20.1-100 µg/l (HR: 5.4; CI 95%: 2.4-12.4), conversion to laparotomy (HR: 14.1; CI 95%: 4.0-49.0), and severe surgical complications (Clavien-Dindo III-IV) (HR: 2.9; CI 95%: 1.5-5.5) were identified as predictors of a diminished overall survival. CONCLUSION: Laterality disclosed no significant effect on the overall prognosis of colon cancer patients. However, group differences and distinct survival predictors could be identified in rCC and lCC patients.

Renal and brain failure predict mortality of patients with acute-on-chronic liver failure admitted to the intensive care unit.

INTRODUCTION AND OBJECTIVES: Acute on Chronic Liver Failure (ACLF) is characterized by organ failure and high 28-day mortality. Identifying clinical predictors associated with early mortality could have implications for the treatment of patients with ACLF. PATIENTS AND METHODS: Patients diagnosed with chronic liver failure that developed ACLF based on the EASL-CLIF Consortium definition admitted to the Intensive care unit of a tertiary hospital between 2012-2018 were included. Bivariate and multivariate Cox regression analyses were performed to identify factors associated with mortality. RESULTS: 148 patients (55% female) were diagnosed with ACLF of which 55% (n = 82) had ACLF grade 3, 28% (n = 41) grade 2 and 17% (n = 25) grade 1. The median age was 54 years (41-63). Hepatitis C virus (HCV) was the most frequent etiology in 29.8% (n = 44) of the patients with bacterial infection being the most predominant precipitant factor in 58.1% (n = 86). Ninety-day global cumulative survival was only 18%. When divided by grade, mortality reached to 10% in ACLF 3. Moreover, in the multivariate Cox regression analysis, renal failure (HR 3.26, 95% CI (2.13-4.99), brain failure (HR 1.37, 95% CI 1.09-2.04) and male sex (HR 1.62, 95% CI 1.10-2.40) were independent predictors of 28- and 90-day mortality. CONCLUSIONS: ACLF is a frequent syndrome among chronic liver disease patients. Brain and renal failure are significantly associated with higher mortality and are independent predictors of 28 and 90-day mortality.

Arterial Blood Gas as a Predictor of Mortality in COVID Pneumonia Patients Initiated on Noninvasive Mechanical Ventilation: A Retrospective Analysis.

Background: The alveolar-arterial oxygen (A-a) gradient measures the difference between the oxygen concentration in alveoli and the arterial system, which has considerable clinical utility. Materials and methods: It was a retrospective, observational cohort study involving the analysis of patients diagnosed with acute COVID pneumonia and required noninvasive mechanical ventilation (NIV) over a period of 3 months. The primary objective was to investigate the utility of the A-a gradient (pre-NIV) as a predictor of 28-day mortality in COVID pneumonia. The secondary objective included the utility of other arterial blood gas (ABG) parameters (pre-NIV) as a predictor of 28-day mortality. The outcome was also compared between survivors and nonsurvivors. The outcome variables were analyzed by receiver-operating characteristic (ROC) curve, Youden index, and regression analysis. Results: The optimal criterion for A-a gradient to predict 28-day mortality was calculated as ≤430.43 at a Youden index of 0.5029, with the highest area under the curve (AUC) of 0.755 (p <0.0001). On regression analysis, the odds ratio for the A-a gradient was 0.99. A significant difference was observed in ABG predictors, including PaO2, PaCO2, A-a gradient, AO2, and arterial-alveolar (a-A) (%) among nonsurvivors vs survivors (p-value <0.001). The vasopressor requirement, need for renal replacement therapy, total parenteral requirement, and blood transfusion were higher among nonsurvivors; however, a significant difference was achieved with the vasopressor need (p <0.001). Conclusion: This study demonstrated that the A-a gradient is a significant predictor of mortality in patients initiated on NIV for worsening respiratory distress in COVID pneumonia. All other ABG parameters also showed a significant AUC for predicting 28-day mortality, although with variable sensitivity and specificity. Key messages: COVID-19 pneumonia shows an initial presentation with type 1 respiratory failure with increased A-a gradient, while a subsequent impending type 2 respiratory failure requires invasive ventilation. A significant difference was observed in ABG predictors, including PaO2, PaCO2, A-a gradient, AO2, and a-A (%) among nonsurvivors vs survivors. (p-value <0.001). The vasopressor requirement, need for renal replacement therapy, total parenteral requirement, and blood transfusion need were higher among nonsurvivors than survivors; however, a significant difference was achieved with the vasopressor need (p <0.001). How to cite this article: Gupta B, Jain G, Chandrakar S, Gupta N, Agarwal A. Arterial Blood Gas as a Predictor of Mortality in COVID Pneumonia Patients Initiated on Noninvasive Mechanical Ventilation: A Retrospective Analysis. Indian J Crit Care Med 2021;25(8):866-871.

Predictive value of perfusion index for mortality in mechanically ventilated patients.

AIM: This study aimed to examine the prognostic significance of the perfusion index (PI) in mechanically ventilated patients. METHODS: Study included sixty patients who had the risk factors for the development of acute respiratory distress syndrome and received mechanical ventilator (MV) support in intensive care unit (ICU) unit between January 2017/January 2018. The demographic characteristics, vital signs, blood gas parameters, lactate levels, prognostic scores, and use of inotropic drugs were recorded. Arterial blood gas and PI measurements at the frontal region were performed at the time of and 12th and 24th hours of admission to the ICU. The patients were followed up for 60 days, and the outcome was recorded. RESULTS: Twelve patients (20%) died during the first 7 days, and 27 patients (45%) died within 60 days of the admission. Multivariate analyses to determine potential predictors of 7 and 30-day mortality showed that only 24th-hour lactate level was independent predictor of 60-day mortality, and the PI at 24th was the sole independent predictor of 7-day mortality. CONCLUSION: The PI did not predict 60-day mortality in MV patients who had risk factors for the development of Acute Respiratory Distress Syndrome (ARDS). However, the PI at 24th may be a significant predictor of 7-day mortality.

A Retrospective Observational Study to Determine the Early Predictors of In-hospital Mortality at Admission with COVID-19.

INTRODUCTION: Coronavirus disease-2019 (COVID-19) systemic illness caused by a novel coronavirus severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been spreading across the world. The objective of this study is to identify the clinical and laboratory variables as predictors of in-hospital death at the time of admission in a tertiary care hospital in India. MATERIALS AND METHODS: Demographic profile, clinical, and laboratory variables of 425 patients admitted from April to June 2020 with symptoms and laboratory-confirmed diagnosis through real-time polymerase chain reaction (RT-PCR) were studied. Descriptive statistics, an association of these variables, logistic regression, and CART models were developed to identify early predictors of in-hospital death. RESULTS: Twenty-two patients (5.17%) had expired in course of their hospital stay. The median age [interquartile range (IQR)] of the patients admitted was 49 years (21-77 years). Gender distribution was male - 73.38% (mortality rate 5.83%) and female-26.62% (mortality rate 3.34%). The study shows higher association for age (>47 years) [odds ratio (OR) 4.52], male gender (OR 1.78), shortness of breath (OR 2.02), oxygen saturation <93% (OR 9.32), respiratory rate >24 (OR 5.31), comorbidities like diabetes (OR 2.70), hypertension (OR 2.12), and coronary artery disease (OR 3.18) toward overall mortality. The significant associations in laboratory variables include lymphopenia (<12%) (OR 8.74), C-reactive protein (CRP) (OR 1.99), ferritin (OR 3.18), and lactate dehydrogenase (LDH) (OR 3.37). Using this statistically significant 16 clinical and laboratory variables, the logistic regression model had an area under receiver operating characteristic (ROC) curve of 0.86 (train) and 0.75 (test). CONCLUSION: Age above 47 years, associated with comorbidities like hypertension and diabetes, with oxygen saturation below 93%, tachycardia, and deranged laboratory variables like lymphopenia and raised CRP, LDH, and ferritin are important predictors of in-hospital mortality. HOW TO CITE THIS ARTICLE: Jain AC, Kansal S, Sardana R, Bali RK, Kar S, Chawla R. A Retrospective Observational Study to Determine the Early Predictors of In-hospital Mortality at Admission with COVID-19. Indian J Crit Care Med 2020;24(12):1174-1179.

Predictors of one-year outcomes in chronic heart failure: the portrait of a middle income country.

BACKGROUND: Heart failure (HF) is a major public health problem with increasing prevalence worldwide. It is associated with high mortality and poor quality of life due to recurrent and costly hospital admissions. Several studies have been conducted to describe HF risk predictors in different races, countries and health systems. Nonetheless, understanding population-specific determinants of HF outcomes remains a great challenge. We aim to evaluate predictors of 1-year survival of individuals with systolic heart failure from the GENIUS-HF cohort. METHODS: We enrolled 700 consecutive patients with systolic heart failure from the SPA outpatient clinic of the Heart Institute, a tertiary health-center in Sao Paulo, Brazil. Inclusion criteria were age between 18 and 80 years old with heart failure diagnosis of different etiologies and left ventricular ejection fraction ≤50% in the previous 2 years of enrollment on the cohort. We recorded baseline demographic and clinical characteristics and followed-up patients at 6 months intervals by telephone interview. Study data were collected and data quality assurance by the Research Electronic Data Capture tools. Time to death was studied using Cox proportional hazards models adjusted for demographic, clinical and socioeconomic variables and medication use. RESULTS: We screened 2314 consecutive patients for eligibility and enrolled 700 participants. The overall mortality was 6.8% (47 patients); the composite outcome of death and hospitalization was 17.7% (123 patients) and 1% (7 patients) have been submitted to heart transplantation after one year of enrollment. After multivariate adjustment, baseline values of blood urea nitrogen (HR 1.017; CI 95% 1.008-1.027; p < 0.001), brain natriuretic peptide (HR 1.695; CI 95% 1.347-2.134; p < 0.001) and systolic blood pressure (HR 0.982;CI 95% 0.969-0.995; p = 0.008) were independently associated with death within 1 year. Kaplan Meier curves showed that ischemic patients have worse survival free of death and hospitalization compared to other etiologies. CONCLUSIONS: High levels of BUN and BNP and low systolic blood pressure were independent predictors of one-year overall mortality in our sample. TRIAL REGISTRATION: Current Controlled Trials NTC02043431, retrospectively registered at in January 23, 2014.

Evolving trends in infective endocarditis in a developing country: a consequence of medical progress?

BACKGROUND: Staphylococcus has replaced streptococcus as the most common cause of infective endocarditis (IE) in developed health care systems. The trend in developing countries is less clear. AIM: To examine the epidemiological trends of infective endocarditis in a developing nation. METHODS: Single-centre, retrospective study of patients admitted with IE to a tertiary hospital in Malaysia over a 12-year period. RESULTS: The analysis included 182 patients (n = 153 Duke's definite IE, n = 29 possible IE). The mean age was 51 years. Rheumatic heart disease was present in 42%, while 7.6% were immunocompromised. IE affected native valves in 171 (94%) cases. Health-care associated IE (HCAIE) was recorded in 68 (37.4%). IE admission rates increased from 25/100,000 admissions (2012) to 59/100,000 admissions (2017). At least one major complication on admission was detected in 59 (32.4%) patients. Left-sided IE was more common than right-sided IE [n = 159 (87.4%) vs. n = 18 (9.9%)]. Pathogens identified by blood culture were staphylococcus group [n = 58 (40.8%)], streptococcus group [n = 51 (35.9%)] and Enterococcus species [n = 13 (9.2%)]. staphylococcus infection was highest in the HCAIE group. In-hospital death occurred in 65 (35.7%) patients. In-hospital surgery was performed for 36 (19.8%) patients. At least one complication was documented in 163 (85.7%). CONCLUSION: Staphylococcus is the new etiologic champion, reflecting the transition of the healthcare system. Streptococcus is still an important culprit organism. The incidence rate of IE appears to be increasing. The rate of patients with underlying rheumatic heart disease is still high.

Predictors of mortality in outborns with neonatal sepsis: A prospective observational study.

BACKGROUND: Neonatal sepsis-related mortalities are the outcome of a complex interaction of maternal-foetal colonisation, transplacental immunity and physical and cellular defence mechanisms of neonates. OBJECTIVE: The objective of this study was to evaluate the risk factors of mortality in outborn neonatal sepsis. MATERIALS AND METHODS: A 1-year prospective observational study was undertaken at a tertiary care centre. All referred neonates with maternal and neonatal risk factors of sepsis were enrolled. Blood culture, sepsis screen and other relevant investigations were performed. RESULTS: The mortality rate of neonatal sepsis among outborns was 38.24%. The common presentations of these neonates were respiratory distress, lethargy and hypothermia. On univariate analysis, significant risk factors for mortality included male sex (P = 0.05), weight on admission <1500 g (P < 0.001), hypothermia (P = 0.003), respiratory distress (P = 0.04), cyanosis (P = 0.001), convulsions (P = 0.02), prolonged capillary refill time (P < 0.001), thrombocytopenia (P < 0.001), abnormal radiological finding (P = 0.01), cerebrospinal fluid cellularity (P = 0.002) and positive C-reactive protein (P < 0.001). Maternal factors such as hypertension in pregnancy (P = 0.001) and antepartum haemorrhage (P = 0.03) were associated with statistically significant mortality. Gestational age (odds ratio [OR]: 0.49, confidence interval [CI]: 0.26-0.90, P = 0.02), weight on admission (OR: 1.57, CI: 1.08-2.27, P = 0.01), age at admission (OR: 0.89, CI: 0.78-0.99, P = 0.04), distance travelled with neonate (OR: 1.01, CI: 1.00-1.01, P = 0.003), duration of hospital stay (OR: 0.69, CI: 0.63-0.74, P < 0.001), hypothermia (OR: 1.87, CI: 1.01-3.42, P = 0.04), convulsion (OR: 2.88, CI: 1.33-6.20, P = 0.007), cyanosis (OR: 2.39, CI: 1.07-5.35, P = 0.03) and prolonged capillary refill time (OR: 3.34, CI: 1.78-6.24, P < 0.001) were the independent predictors of mortality in neonatal sepsis. CONCLUSION: Gestational age; birth weight; long distance travelled with neonate and presentation with hypothermia, cyanosis, convulsions and prolonged capillary refill time were the independent risk factors for mortality in neonatal sepsis among outborns.

Study on Clinical Profile and Predictors of Mortality in Cerbera odollam Poisoning.

CONTEXT: Cerbera odollam is a tree native to South Asia. It belongs to the poisonous Apocynaceae family. Deliberate self-harm with fruit of this plant is a major clinical problem in the developing world. Ingestion of C. odollam kernels is the cause of deaths in more than half of Kerala's plant poisoning deaths. The data on clinical features and complications of C. odollam poisoning are sparse, apart from a few case reports and limited studies. AIMS: The present study was done to find the mode of presentation, complications, need for cardiac pacing, inhospital mortality, and the predictors of mortality in patients with C. odollam poisoning. SETTINGS AND DESIGN: This was a retrospective study conducted in the department of general medicine in a tertiary care center in Alappuzha district, Kerala. The study period was for 1 year from January 1, 2016, to December 31, 2016. SUBJECTS AND METHODS: All the patients admitted with a history of ingestion of odollam during the study period were included in the study. Data were collected from case records. The study was approved by the institutional ethics committee and research committee (IEC/TDMCA/EC3.dated29/11/201). STATISTICAL ANALYSIS USED: The data were analyzed using SPSS 16 for Windows (SPSS Inc., Chicago, IL, USA). RESULTS: In this study, 102 patients were identified with C. odollam poisoning, and the mortality rate was 16.7%. Electrocardiogram (ECG) changes were common in our patients, and we observed different types of heart block in the same ECG itself. Ingestion of more than two kernels of odollam, late presentation to hospital, vomiting, bradycardia, hypotension, hyperkalemia, and more severe ECG changes were associated with significantly higher mortality in this study. CONCLUSIONS: C. odollam poisoning is a common method of deliberate self-harm in Kerala. It carries a high mortality rate, and the predictors of mortality include vomiting, bradycardia, hypotension, hyperkalemia, and the presence of severe ECG changes.

Analysis of Shahid Rajaee hospital administrative data on injuries resulting from car accidents in Shiraz, Iran: 2011-2014 data.

PURPOSE: The administrative data from trauma centers could serve as potential sources of invaluable information while studying epidemiologic features of car accidents. In this cross-sectional analysis of Shahid Rajaee hospital administrative data, we aimed to evaluate patients injured in car accidents in terms of age, gender, injury severity, injured body regions and hospitalization outcome in the recent four years (2011-2014). METHODS: The hospital registry was accessed at Shiraz Trauma Research Center (Shiraz, Iran) and the admission's unit data were merged with the information gathered upon discharge. A total number of 27,222 car accident patients aged over 15 years with International Classification of Diseases 10th revision (ICD-10) external causes of injury codes (V40.9-V49.9) were analyzed. Injury severity score and injured body regions were determined based on converting ICD-10 injury codes to Abbreviated Injury Scale (AIS-98) severity codes using a domestically developed electronic algorithm. A binary logistic regression model was applied to the data to examine the contribution of all independent variables to in-hospital mortality. RESULTS: Men accounted for 68.9% of the injuries and the male to female ratio was 2.2:1. The age of the studied population was (34 ± 15) years, with more than 77.2% of the population located in the 15-45 years old age group. Head and neck was the most commonly injured body region (39.0%) followed by extremities (27.2%). Injury severity score (ISS) was calculated for 13,152 (48.3%) patients, of whom, 80.9% had severity scores less than 9. There were 332 patients (1.2%) admitted to the intensive care units and 422 in-hospital fatalities (1.5%) were recorded during the study period. Age above 65 years [OR = 7.4, 95% CI (5.0-10.9)], ISS above 16 [OR = 9.1, 95% CI (5.5-14.9)], sustaining a thoracic injury [OR = 7.4, 95% CI (4.6-11.9)] and head injury [OR = 4.9, 95% CI (3.1-7.6)] were the most important independent predictors of death following car accidents. CONCLUSION: Hospital administrative databases of this hospital could be used as reliable sources of information in providing epidemiologic reports of car accidents in terms of severity and outcomes. Improving the quality of recordings at hospital databases is an important initial step towards more comprehensive injury surveillance in Fars, Iran.

[Acute aortic regurgitation due to infective endocarditis]. / Insuficiencia aórtica aguda por endocarditis infecciosa.

Acute aortic regurgitation (AAR) due to infective endocarditis (IE) is a serious disease and usually requires surgical treatment. Our study aims to compare the clinical, echocardiographic, and microbiological characteristics as well as in-hospital outcome of patients with AAR according to the severity of heart failure (HF) and to evaluate predictors of in-hospital mortality in a tertiary centre. In a prospective analysis, we compared patients with NYHA functional class I-II HF (G1) vs. functional class III-IV HF (G2). From 06/92 to 07/16, 439 patients with IE were hospitalized; 86 presented AAR: (G1, 39: 45.4% y G2, 47: 54.7%). The G1 had higher prosthetic IE (43.6% vs. 17%, p 0.01). All G2 patients had dyspnoea vs. 30.8% of the G1 (p < 0.0001). There were no differences in clinical, echocardiographic and microbiological characteristics. Surgical treatment was indicated mainly due to infection extension or valvular dysfunction in G1 and HF in G2. In-hospital mortality was 15.4% vs. 27.7% (G1 and G2 respectively p NS). In multivariate analysis, health care-associated acquisition (p 0.001), negative blood cultures (p 0.004), and functional class III-IV HF (p 0.039) were in-hospital mortality predictors. One-fifth of the patients with EI had AAR. Half of them had severe HF which needed emergency surgery and the remaining needed surgery for extension of the infection and / or valvular dysfunction. Both groups remain to have high surgical and in-hospital mortality. Health care-associated acquisition, negative blood cultures and advanced HF were predictors of in-hospital mortality.

Predictors of a severe course and mortality in patients with COVID-19-associated pneumonia.

INTRODUCTION: Severe and critical forms of SARS-CoV-2 pneumonia are associated with high morbidity and mortality. Numerous research studies have been conducted around the world to investigate various variables (demographic, clinical, laboratory, etc.) in an attempt to understand the relationships between them and the course and outcome of patients with COVID-19 infection and pneumonia.