Effect of disability, homelessness, and neighborhood marginalization on risk-adjustment for hospital performance measurement.

Background It is not known how disability, homelessness, or neighborhood marginalization influence risk-adjusted hospital performance measurement in a universal health care system. Methods We evaluated the effect of including these equity-related factors in risk-adjustment models for in-hospital mortality, and 7- and 30-day readmission in 28 hospitals in Ontario, Canada. We compared risk-adjustment with commonly-used clinical factors to models that also included homelessness, disability, and neighborhood indices of marginalization. We evaluated models in historical data using internal-external cross-validation. We calculated risk-standardized outcome rates for each hospital in a recent reporting period using mixed-effects logistic regression. Results The cohort included 544,805 admissions. Adjustment for disability, homelessness, and neighborhood marginalization had little impact on discrimination or calibration of risk-adjustment models. However, it influenced comparative hospital performance on risk-standardized 30-day readmission rates, resulting in 5 hospitals being reclassified between below-average, average, and above-average groups. No hospitals were reclassified for mortality and 7-day readmission. Conclusion In a system with universally insured hospital services, adjustment for disability, homelessness, and neighborhood marginalization influenced estimates of hospital performance for 30-day readmission but not 7-day readmission or in-hospital mortality. These findings can inform researchers and policymakers as they thoughtfully consider when to adjust for these factors in hospital performance measurement.

Clinical Features and Outcomes of Hospitalized Adult Patients With Breakthrough COVID-19 Infections: A Propensity-Score-Matched Observational Study.

In this study, we aimed to evaluate the impact of vaccination on intensive care unit (ICU) admission and in-hospital mortality among breakthrough coronavirus disease 2019 (COVID-19) infections. A total of 3,351 adult patients hospitalized with COVID-19 in the Memorial Healthcare System (Hollywood, Florida) between June 1 and September 20, 2021, were included; 284 (8.5%) were fully vaccinated. A propensity-score-matched analysis was conducted to compare fully vaccinated patients with unvaccinated controls. Propensity scores were calculated on the basis of variables associated with vaccination status. A 1:1 matching ratio was applied using logistic regression models, ensuring balanced characteristics between the two groups. The matched samples were then subjected to multivariate analysis. Among breakthrough infections, vaccinated patients demonstrated lower incidences of ICU admission (10.3% vs. 16.4%; P = 0.042) and death (12.2% vs. 18.7%; P = 0.041) than the matched controls. Risk-adjusted multivariate analysis demonstrated a significant inverse association between vaccination and ICU admission (odds ratio = 0.52, 95% confidence interval: 0.31, 0.89; P = 0.019) as well as in-hospital mortality (odds ratio = 0.57, 95% confidence interval: 0.34, 0.94; P = 0.027). Vaccinated individuals experiencing breakthrough infections had significantly lower risks of ICU admission and in-hospital mortality. These findings highlight the benefits of COVID-19 vaccines in reducing severe outcomes among patients with breakthrough infections.

An observational study of therapeutic procedures and in-hospital outcomes among patients admitted for acute myocardial infarction in Spain, 2016-2022: the role of diabetes mellitus.

BACKGROUND: We used the Spanish national hospital discharge data from 2016 to 2022 to analyze procedures and hospital outcomes among patients aged ≥ 18 years admitted for ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) according to diabetes mellitus (DM) status (non-diabetic, type 1-DM or type 2-DM). METHODS: We built logistic regression models for STEMI/NSTEMI stratified by DM status to identify variables associated with in-hospital mortality (IHM). We analyzed the effect of DM on IHM. RESULTS: Spanish hospitals reported 201,950 STEMIs (72.7% non-diabetic, 0.5% type 1-DM, and 26.8% type 2-DM; 26.3% female) and 167,285 NSTEMIs (61.6% non-diabetic, 0.6% type 1-DM, and 37.8% type 2-DM; 30.9% female). In STEMI, the frequency of percutaneous coronary intervention (PCI) increased among non-diabetic people (60.4% vs. 68.6%; p < 0.001) and people with type 2-DM (53.6% vs. 66.1%; p < 0.001). In NSTEMI, the frequency of PCI increased among non-diabetic people (43.7% vs. 45.7%; p < 0.001) and people with type 2-DM (39.1% vs. 42.8%; p < 0.001). In NSTEMI, the frequency of coronary artery by-pass grafting (CABG) increased among non-diabetic people (2.8% vs. 3.5%; p < 0.001) and people with type 2-DM (3.7% vs. 5.0%; p < 0.001). In the entire population, lower IHM was associated with undergoing PCI (odds ratio [OR] [95% confidence interval] = 0.34 [0.32-0.35] in STEMI; 0.24 [0.23-0.26] in NSTEMI) or CABG (0.33 [0.27-0.40] in STEMI; 0.45 [0.38-0.53] in NSTEMI). IHM decreased over time in STEMI (OR = 0.86 [0.80-0.93]). Type 2-DM was associated with higher IHM in STEMI (OR = 1.06 [1.01-1.11]). CONCLUSIONS: PCI and CABG were associated with lower IHM in people admitted for STEMI/NSTEMI. Type 2-DM was associated with IHM in STEMI.

Chronic obstructive pulmonary disease affects outcome in surgical patients with perioperative organ injury: a retrospective cohort study in Germany.

BACKGROUND: The impact of chronic obstructive pulmonary disease (COPD) on outcome in perioperative organ injury (POI) has not yet been investigated sufficiently. METHODS: This retrospective cohort study analysed data of surgical patients with POI, namely delirium, stroke, acute myocardial infarction, acute respiratory distress syndrome, acute liver injury (ALI), or acute kidney injury (AKI), in Germany between 2015 and 2019. We compared in-hospital mortality, hospital length of stay (HLOS) and perioperative ventilation time (VT) in patients with and without COPD. RESULTS: We analysed the data of 1,642,377 surgical cases with POI of which 10.8% suffered from COPD. In-hospital mortality was higher (20.6% vs. 15.8%, p < 0.001) and HLOS (21 days (IQR, 12-34) vs. 16 days (IQR, 10-28), p < 0.001) and VT (199 h (IQR, 43-547) vs. 125 h (IQR, 32-379), p < 0.001) were longer in COPD patients. Within the POI examined, AKI was the most common POI (57.8%), whereas ALI was associated with the highest mortality (54.2%). Regression analysis revealed that COPD was associated with a slightly higher risk of in-hospital mortality (OR, 1.19; 95% CI:1.18-1.21) in patients with any POI. CONCLUSIONS: COPD in patients with POI is associated with higher mortality, longer HLOS and longer VT. Especially patients suffering from ALI are susceptible to the detrimental effects of COPD on adverse outcome.

Inpatient outcomes of NSTEMI among patients with immune thrombocytopenia: a propensity matched national study.

Patients with immune thrombocytopenia (ITP) admitted for non-ST elevation myocardial infarction (NSTEMI) present a unique therapeutic challenge due to the increased risk of bleeding with antiplatelet and anticoagulation therapies. There is limited evidence studying hospital mortality and complications in this population. The study included a patient cohort from the 2018-2021 National Inpatient Sample database. Propensity score matched NSTEMI patients with and without ITP using a 1:1 matching ratio. Outcomes analyzed were in-hospital mortality, rates of diagnostic angiogram, percutaneous coronary intervention (PCI), acute kidney injury (AKI), congestive heart failure (CHF), cardiogenic shock, cardiac arrest, mechanical ventilation, tracheal intubation, ventricular tachycardia (VT), ventricular fibrillation (VF), major bleeding, need for blood and platelet transfusion, length of stay (LOS), and total hospitalization charges. A total of 1,699,020 patients met inclusion criteria (660,490 females [39%], predominantly Caucasian 1,198,415 (70.5%); mean [SD] age 67, [3.1], including 2,615 (0.1%) patients with ITP. Following the propensity matching, 1,020 NSTEMI patients with and without ITP were matched. ITP patients had higher rates of inpatient mortality (aOR 1.98, 95% CI 1.11-3.50, p 0.02), cardiogenic shock, AKI, mechanical ventilation, tracheal intubation, red blood cells and platelet transfusions, longer LOS, and higher total hospitalization charges. The rates of diagnostic angiogram, PCI, CHF, VT, VF, and major bleeding were not different between the two groups. Patients with ITP demonstrated higher odds of in-hospital mortality for NSTEMI and need for platelet transfusion with no difference in rates of diagnostic angiogram or PCI.

Intubation and In-Hospital Mortality After Trauma With Glasgow Coma Scale Score Eight or Less-A Cohort Study.

INTRODUCTION: Most trauma societies recommend intubating trauma patients with Glasgow Coma Scale (GCS) scores ≤8 without robust supporting evidence. We examined the association between intubation and 30-d in-hospital mortality in trauma patients arriving with a GCS score ≤8 in an Indian trauma registry. METHODS: Outcomes of patients with a GCS score ≤8 who were intubated within 1 h of arrival (intubation group) were compared with those who were intubated later or not at all (nonintubation group) using various analytical approaches. The association was assessed in various subgroup and sensitivity analyses to identify any variability of the effect. RESULTS: Of 3476 patients who arrived with a GCS score ≤8, 1671 (48.1%) were intubated within 1 h. Overall, 1957 (56.3%) patients died, 947 (56.7%) in the intubation group and 1010 (56.0%) in the nonintubation group, with no significant difference in mortality (odds ratio = 1.2 [confidence interval, 0.8-1.8], P value = 0.467) in multivariable regression and propensity score-matched analysis. This result persisted across subgroup and sensitivity analyses. Patients intubated within an hour of arrival had longer durations of ventilation, intensive care unit stay, and hospital stay (P < 0.001). CONCLUSIONS: Intubation within an hour of arrival with a GCS score ≤8 after major trauma was not associated with differences in-hospital mortality. The indications and benefits of early intubation in these severely injured patients should be revisited to promote optimal resource utilization in LMICs.

Short-Term Complications and Mortality Following Open Abdominal Aortic Aneurysm Repair by a Single High-Volume Surgeon.

INTRODUCTION: Although endovascular repair is now considered the first-line surgical treatment for abdominal aortic aneurysms (AAAs), some surgeons maintain a high volume of open aortic repairs (OARs) with very good outcomes. This study examines postoperative 30-d and 12-mo mortality and in-hospital complications from a single surgeon who performed 316 elective OARs for unruptured AAAs over a 10-y period. METHODS: A retrospective cohort study was performed for all patients who underwent elective OAR for unruptured AAAs between April 1st, 2007, and March 31st, 2017, at a single community center in Quebec, Canada. The primary outcome was the incidence of all-cause 30-d and 12-mo mortality in patients undergoing OAR. Binomial logistic and linear regressions were performed to examine whether operative time correlated with postoperative outcomes. RESULTS: There were 316 patients included: most of whom were male (74.4%), with a mean age of 70 y, and a mean AAA diameter of 59.8 mm. Most patients had a low-to-intermediate predicted risk of postoperative major cardiovascular complications, myocardial infarction, or in-hospital mortality. At the time of OAR, 95.6% of patients were asymptomatic, 70.9% had a tube graft repair, and very few required suprarenal aortic clamping (1.6%). The mean operative time was 101 min, and the median length of hospital stay was six days. One patient died in hospital or within 30 d of surgery (0.3%), and 7 patients had died 12 mo after surgery (2.2%). All-cause mortality was 27.5% (87 patients) over a median follow-up of 5.5 y. Twenty-five percent of patients suffered any in-hospital complication postoperatively, and 18 (5.7%) patients suffered a major cardiac complication. The operative time was significantly associated with increased risk of any in-hospital complication (OR 1.02, 95% CI [1.01, 1.03], P = 0.001), reintervention (OR 1.04, 95% CI [1.02, 1.06], P = 0.001), and length of stay in hospital (ß = 0.063, 95% CI [0.01, 0.11], P = 0.044) or intensive care unit (ß = 0.043, 95% CI [0.01, 0.08], P = 0.021). There was no association between operative time and mortality at any time point. CONCLUSIONS: Favorable postoperative outcomes can be achieved with OAR as the first-line surgical management of unruptured asymptomatic AAAs when performed by an experienced high-volume surgeon in appropriately selected patients with favorable perioperative risk factors.

iCover as Bridging Stent Graft in Fenestrated Endovascular Aortic Aneurysm Repair.

BACKGROUND: Complex endovascular repair with fenestrated or branched stent grafts is a common approach for treating various types of aortic aneurysms. Bridging stent grafts (BSs) are crucial in connecting aortic endoprosthesis to target vessels, yet current options have demonstrated significant complications. OBJECTIVE: This retrospective single-center study evaluates the initial outcomes and durability of the iCover stent graft (iCover-SG) when used as a BS in fenestrated endovascular aneurysm repair (FEVAR). METHODS: Retrospective analysis screened procedures for complex aortic aneurysms between August 2021 and January 2024. Patients who underwent FEVAR with iCover-SG as BS were included. Primary and secondary endpoints focused on freedom from iCover-SG-related target vessel instability, technical success, and postoperative outcomes. RESULTS: Within the cohort of 28 patients, 94 iCover-SGs were used as BS, supplying 87 target vessels. The freedom from iCover-SG-related target vessel instability throughout the study reached 94% (82/87). Technical success rates were notably high, with primary success achieved in 94% of cases and secondary success in 99%. Over the follow-up duration, there were instances necessitating reintervention related to iCover-SG, including 4 cases of endoleak, 2 cases of T1cEL, and 2 cases of T3cEL. In-hospital mortality was 7% (n=4), with 2 cases attributed to intraoperative complications. Importantly, no deaths were directly attributed to iCover-SG-related issues. CONCLUSION: The iCover-SG demonstrates promising initial outcomes as a BS in FEVAR, with high technical success rates and satisfactory rates of target vessel instability. Continued monitoring and further studies are warranted to assess long-term durability and outcomes. CLINICAL IMPACT: This study shows that the iCover stent graft achieves satisfactory technical success and target vessel stability in the short- and mid-term when used as a bridging stent graft in FEVAR procedures. Its successful integration into clinical practice broadens the range of available options, providing clinicians with more versatile tools for managing complex endovascular aortic aneurysms. This expanded selection of bridging stent grafts allows for more personalised treatment strategies, improving procedural precision and patient outcomes. The iCover stent graft's reliable performance highlights its potential as a valuable addition to current endovascular techniques, ultimately enhancing patient care in challenging cases.

Association between toxicity-index of diquat and in-hospital mortality in patients with acute diquat poisoning: a retrospective cohort study.

BACKGROUND: This study investigates the impact of diquat toxicity levels on in-hospital mortality rates among patients with acute diquat poisoning. It aims to clarify the relationship between diquat toxicity scores and the likelihood of death during hospitalization. METHODS: A retrospective cohort study was conducted on 98 individuals with acute diquat poisoning. Data on post-ingestion time, initial diquat plasma concentration, and clinical outcomes were systematically collected for all participants. The toxicity-index of diquat was calculated based on post-ingestion time and initial diquat plasma concentration. Logistic regression analysis was utilized to assess the association between the toxicity-index of diquat and in-hospital mortality rates, adjusting for potential confounding variables such as age, comorbidities, and treatment interventions. RESULTS: The study found that the overall prevalence of in-hospital mortality was 34.7%, with 58.2% in males. The multivariable-adjusted regression coefficient for in-hospital mortality associated with the toxicity-index was 1.09, with a 95% confidence interval (CI) of 1.01-1.17. Subsequent exploratory subgroup analysis indicated that there were no significant interactions (all p values for interaction were >0.05). CONCLUSIONS: The study found that higher diquat toxicity-index values correlate with increased in-hospital mortality in acute diquat poisoning cases, indicating that the toxicity-index could be a useful biomarker for assessing mortality risk.

The toxicity-index of diquat plays a pivotal role in the identification, management, and prognostic prediction of acute diquat poisoning; however, its specific predictive value warrants further investigation.The toxicity-index of diquat serves as a more precise biomarker for differentiating between low-risk and high-risk categories.In comparison to low-risk patients with acute diquat poisoning, the toxicity-index of diquat in high-risk patients were significantly elevated.

Malignant tumor increases the risk of all causes in-hospital mortality in critically ill patients with ischemic stroke: analysis of the MIMIC-IV database.

BACKGROUND: Ischemic stroke (IS) and malignant tumor (MT) have high morbidity and mortality rates worldwide, and several associations exist between them. This study aimed to determine the effect of MT on hospital mortality in patients with IS. METHODS: Based on their MT status, participants with IS in the Medical Information Mart for Intensive Care IV (MIMIC-IV) were divided into two groups. The primary outcome was in-hospital all causes mortality. Kaplan-Meier survival analysis was performed to evaluate the intergroup in-hospital mortality, and three Cox regression models were used to determine the association between MT and in-hospital mortality. RESULTS: A total of 1605 participants (749 males and 856 females) were included in the study. The mean age was 72.030 ± 15.463 years. Of these, 257 (16%) patients died in the hospital. Kaplan-Meier analysis showed that the MT group had a significantly lower possibility of in-hospital survival than the non-MT group. In the unadjusted model, in-hospital mortality among MT patients had a higher odds ratio (OR) of 1.905 (95% CI, 1.320-2.748; P < 0.001) than the non-MT group. After adjusting for basic information, vital signs, and laboratory data, MT was also associated with increased in-hospital mortality (OR = 1.844, 95% CI: 1.255-2.708; P = 0.002). CONCLUSIONS: Among the patients with IS, the risk of all causes in-hospital mortality was higher for MT than for patients non-MT. This finding can assist clinicians in more accurately assessing prognosis and making informed treatment decisions.

Sex Differences in Cardiovascular Disease-Related Hospitalization and Mortality in Japan　- Analysis of Health Records From a Nationwide Claim-Based Database, the Japanese Registry of All Cardiac and Vascular Disease (JROAD).

BACKGROUND: The prevalence of cardiovascular disease (CVD) is rising in Japan with its aging population, but there is a lack of epidemiological data on sex differences in CVD, including acute coronary syndrome (ACS), acute heart failure (AHF), and acute aortic disease. METHODS AND RESULTS: This retrospective study analyzed data from 1,349,017 patients (January 2012-December 2020) using the Japanese Registry Of All Cardiac and Vascular Diseases database. ACS patients were youngest on average (70.5±12.9 years) and had the lowest female proportion (28.9%). AHF patients had the oldest mean age (79.7±12.0 years) and the highest proportion of females (48.0%). Acute aortic disease had the highest in-hospital mortality (26.1%), followed by AHF (11.5%) and ACS (8.9%). Sex-based mortality differences were notable in acute aortic disease, with higher male mortality in Stanford Type A acute aortic dissection (AAD) with surgery (males: 14.2% vs. females: 10.4%, P<0.001) and similar rates in Type B AAD (males: 6.2% vs. females: 7.9%, P=0.52). Aging was a universal risk factor for in-hospital mortality. Female sex was a risk factor for ACS and acute aortic disease but not for AHF or Types A and B AAD. CONCLUSIONS: Sex-based disparities in the CVD-related hospitalization and mortality within the Japanese national population have been highlighted for the first time, indicating the importance of sex-specific strategies in the management and understanding of these conditions.

Characteristics and In-Hospital Outcomes of Patients With Myocardial Infarction With Non-Obstructive Coronary Arteries　- Insights From the Real-World JAMIR Database.

BACKGROUND: Few studies have investigated the clinical characteristics and in-hospital outcomes of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) using real-world databases in the coronary intervention era. METHODS AND RESULTS: We conducted a retrospective analysis of 22,236 patients (mean [±SD] age 68±13 years, 23.4% female) enrolled in the Japan Acute Myocardial Infarction Registry (JAMIR) between 2011 and 2016. Based on urgent coronary angiography findings, 286 (1.3%) patients were diagnosed as MINOCA, and the remaining 21,950 (98.7%) as MI with obstructive coronary artery disease (MI-CAD). MINOCA patients were characterized by younger age, fewer coronary risk factors, lower rate of ST-elevation myocardial infarction, lower Killip classification, and lower peak creatinine phosphokinase levels than MI-CAD patients. In-hospital all-cause mortality did not differ between the MINOCA and MI-CAD groups (5.2% vs. 5.7%, respectively; P=0.82). Comparing cause-specific mortality, non-cardiac mortality was higher in the MINOCA than MI-CAD group (4.2% vs. 1.6%; P<0.01). Importantly, non-cardiac death was more prevalent among elderly (≥65 years) than younger (<65 years) patients in the MI-CAD group, whereas this trend was not observed in the MINOCA group. CONCLUSIONS: Analysis of the real-world JAMIR database revealed a relatively high prevalence of non-cardiac death among MINOCA patients, underscoring the need for comprehensive management to improve disease prognosis, particularly in younger patients.

In-Hospital Mortality in Patients With Cardiogenic Shock Requiring Veno-Arterial Extracorporeal Membrane Oxygenation With Concomitant Use of Impella vs. Intra-Aortic Balloon Pump　- A Retrospective Cohort Study Using a Japanese Claims-Based Database.

BACKGROUND: Patients with refractory cardiogenic shock (CS) necessitating peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) often require an intra-aortic balloon pump (IABP) or Impella for unloading; however, comparative effectiveness data are currently lacking. METHODS AND RESULTS: Using Diagnosis Procedure Combination data from approximately 1,200 Japanese acute care hospitals (April 2018-March 2022), we identified 940 patients aged ≥18 years with CS necessitating peripheral VA-ECMO along with IABP (ECMO-IABP; n=801) or Impella (ECPella; n=139) within 48 h of admission. Propensity score matching (126 pairs) indicated comparable in-hospital mortality between the ECPella and ECMO-IABP groups (50.8% vs. 50.0%, respectively; P=1.000). However, the ECPella cohort was on mechanical ventilator support for longer (median [interquartile range] 11.5 [5.0-20.8] vs. 9.0 [4.0-16.8] days; P=0.008) and had a longer hospital stay (median [interquartile range] 32.5 [12.0-59.0] vs. 23.0 [6.3-43.0] days; P=0.017) than the ECMO-IABP cohort. In addition, medical costs were higher for the ECPella than ECMO-IABP group (median [interquartile range] 9.09 [7.20-12.20] vs. 5.23 [3.41-7.00] million Japanese yen; P<0.001). CONCLUSIONS: Our nationwide study could not demonstrate compelling evidence to support the superior efficacy of Impella over IABP in reducing in-hospital mortality among patients with CS necessitating VA-ECMO. Further investigations are imperative to determine the clinical situations in which the potential effect of Impella can be maximized.

Association between liver fibrosis and the in-hospital mortality in patients with sepsis-induced coagulopathy.

BACKGROUND: The impact of liver fibrosis on the clinical outcomes of patients with sepsis-induced coagulopathy (SIC) is not well understood. This study aimed to evaluate the association between liver fibrosis scores and in-hospital mortality in SIC patients. METHODS: In this retrospective observational cohort study, data were collected from patients diagnosed with sepsis and admitted to the ICU at the First Affiliated Hospital of Wenzhou Medical University between January 2017 and December 2023. Liver fibrosis was evaluated using three scores: Fibrosis-4 (Fib-4), Aspartate Aminotransferase-to-Platelet Ratio Index (APRI), and Nonalcoholic Fatty Liver Disease Fibrosis Score (NFS). Patients were divided into tertiles according to their liver fibrosis scores, and the primary outcome was in-hospital mortality. Multivariable logistic regression and restricted cubic spline regression analyses were used to assess associations, complemented by sensitivity analyses through subgroup evaluations. RESULTS: The cohort included 948 patients diagnosed with SIC with an in-hospital mortality of 26.16%. Multivariate logistic regression analysis revealed a significant association between higher liver fibrosis scores and increased in-hospital mortality. Specifically, patients in the highest tertile of Fib-4, APRI, and NFS scores had significantly higher odds of mortality (FIB-4: OR 3.62, 95% CI 1.03-12.69; APRI: OR 2.16, 95% CI 0.88-5.30; NFS: OR 6.80, 95% CI 2.11-21.93) compared to those in the lowest tertile. The restricted cubic spline regression model showed a linear increase in the risk of in-hospital mortality with increasing liver fibrosis score. Sensitivity analysis confirmed the consistency and stability of the results across the different subgroups. CONCLUSION: Our study suggests that elevated liver fibrosis scores, particularly Fib-4 and NFS, are associated with higher in-hospital mortality in SIC patients. Further research, especially larger prospective studies, are needed to validate these findings.

Dexamethasone versus methylprednisolone for multiple organ dysfunction in COVID-19 critically ill patients: a multicenter propensity score matching study.

BACKGROUND: Dexamethasone usually recommended for patients with severe coronavirus disease 2019 (COVID-19) to reduce short-term mortality. However, it is uncertain if another corticosteroid, such as methylprednisolone, may be utilized to obtain better clinical outcome. This study assessed dexamethasone's clinical and safety outcomes compared to methylprednisolone. METHODS: A multicenter, retrospective cohort study was conducted between March 01, 2020, and July 31, 2021. It included adult COVID-19 patients who were initiated on either dexamethasone or methylprednisolone therapy within 24 h of intensive care unit (ICU) admission. The primary outcome was the progression of multiple organ dysfunction score (MODS) on day three of ICU admission. Propensity score (PS) matching was used (1:3 ratio) based on the patient's age and MODS within 24 h of ICU admission. RESULTS: After Propensity Score (PS) matching, 264 patients were included; 198 received dexamethasone, while 66 patients received methylprednisolone within 24 h of ICU admission. In regression analysis, patients who received methylprednisolone had a higher MODS on day three of ICU admission than those who received dexamethasone (beta coefficient: 0.17 (95% CI 0.02, 0.32), P = 0.03). Moreover, hospital-acquired infection was higher in the methylprednisolone group (OR 2.17, 95% CI 1.01, 4.66; p = 0.04). On the other hand, the 30-day and the in-hospital mortality were not statistically significant different between the two groups. CONCLUSION: Dexamethasone showed a lower MODS on day three of ICU admission compared to methylprednisolone, with no statistically significant difference in mortality.

Identification of novel sub-phenotypes of severe ARDS requiring ECMO using latent class analysis.

BACKGROUND: Sub-phenotyping of acute respiratory distress syndrome (ARDS) could be useful for evaluating the severity of ARDS or predicting its responsiveness to given therapeutic strategies, but no studies have yet investigated the heterogeneity of patients with severe ARDS requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO). METHODS: We conducted this retrospective multicenter observational study in adult patients with severe ARDS treated by V-V ECMO. We performed latent class analysis (LCA) for identifying sub-phenotypes of severe ARDS based on the radiological and clinical findings at the start of ECMO support. Multivariate Cox regression analysis was conducted to investigate the differences in mortality and association between the PEEP setting of ≥ 10 cmH2O and mortality by the sub-phenotypes. RESULTS: We identified three sub-phenotypes from analysis of the data of a total of 544 patients with severe ARDS treated by V-V ECMO, as follows: Dry type (n = 185; 34%); Wet type (n = 169; 31%); and Fibrotic type (n = 190; 35%). The 90-days in-hospital mortality risk was higher in the patients with the Fibrotic type than in those with the Dry type (adjusted hazard ratio [95% confidence interval] 1.75 [1.10-2.79], p = 0.019) or the Wet type (1.50 [1.02-2.23], p = 0.042). The PEEP setting of ≥ 10 cmH2O during the first 3 days of ECMO decreased the 90-days in-hospital mortality risk only in patients with the Wet type, and not in those with the Dry or Fibrotic type. A significant interaction effect was observed between the Wet type and the PEEP setting of ≥ 10 cmH2O in relation to the 90-day in-hospital mortality (pinteraction = 0.036). CONCLUSIONS: The three sub-phenotypes showed different mortality rates and different relationships between higher PEEP settings in the early phase of V-V ECMO and patient outcomes. Our data suggest that we may need to change our management approach to patients with severe ARDS during V-V ECMO according to their clinical sub-phenotype.

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.

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.

Association of alactic base excess with in-hospital mortality in patients with acute myocardial infarction: a retrospective cohort study.

BACKGROUND: Alactic base excess (ABE) is a novel biomarker to evaluate the renal capability of handling acid-base disturbances, which has been found to be associated with adverse prognosis of sepsis and shock patients. This study aimed to evaluate the association between ABE and the risk of in-hospital mortality in patients with acute myocardial infarction (AMI). METHODS: This retrospective cohort study collected AMI patients' clinical data from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The outcome was in-hospital mortality after intensive care unit (ICU) admission. Univariate and multivariate Cox proportional hazards models were performed to assess the association of ABE with in-hospital mortality in AMI patients, with hazard ratios (HRs) and 95% confidence intervals (CI). To further explore the association, subgroup analyses were performed based on age, AKI, eGFR, sepsis, and AMI subtypes. RESULTS: Of the total 2779 AMI patients, 502 died in hospital. Negative ABE (HR = 1.26, 95%CI: 1.02-1.56) (neutral ABE as reference) was associated with a higher risk of in-hospital mortality in AMI patients, but not in positive ABE (P = 0.378). Subgroup analyses showed that negative ABE was significantly associated with a higher risk of in-hospital mortality in AMI patients aged>65 years (HR = 1.46, 95%CI: 1.13-1.89), with eGFR<60 (HR = 1.35, 95%CI: 1.05-1.74), with AKI (HR = 1.32, 95%CI: 1.06-1.64), with ST-segment elevation acute myocardial infarction (STEMI) subtype (HR = 1.79, 95%CI: 1.18-2.72), and without sepsis (HR = 1.29, 95%CI: 1.01-1.64). CONCLUSION: Negative ABE was significantly associated with in-hospital mortality in patients with AMI.

Shock index creatinine: a new predictor of mortality in acute coronary syndrome patients.

BACKGROUND: The Shock Index Creatinine (SIC) scoring is a recently developed tool for risk stratification patients. These updated scoring was already used in ST-Elevation Myocardial Infarction (STEMI) patients. However its utility in predicting outcomes for patients with Acute Coronary Syndrome (ACS) remains unclear. This study aims to evaluate and update the current SIC score to predict in-hospital mortality among patients with ACS. PATIENTS AND METHODS: A retrospective cohort, Single-centered study enrolled 1349 ACS patients aged ≥ 18 years old diagnosed with ACS was conducted between January 2018 to January 2022 who met for inclusion and exclusion criteria. Study subjects were analyzed for in-hospital mortality and evaluated using binary linear regression analysis. The area under the curve (AUC) of SIC score was obtain to predict the sensitivity and specificity. RESULTS: Multivariate analysis showed that SIC score was significantly associated with in-hospital mortality. High SIC score (SIC ≥ 25) had significantly higher in-hospital mortality (p < 0.001) with odds ratio for (95% CIs) were 2.655 (1.6-4.31). Receiver operating characteristics (ROC) curve analysis determine the predictive power of SIC score for in-hospital mortality. SIC had an acceptable predictive value for in-hospital mortality (AUC = 0.789, 95% CI: 0.748-0.831, p < 0.001). The SIC score for sensitivity and specificity were, respectively, 71.5% and 74.4%, with optimal cutoff of SIC ≥ 25. CONCLUSION: SIC had acceptable predictive value for in-hospital mortality in patients with all ACS spectrums. SIC was a useful parameter for predicting in-hospital mortality, particularly with a score ≥ 25. This is the first study to evaluate SIC in all spectrums of ACS.