Indigenous Australians critically ill with sepsis: Characteristics, outcomes, and areas for improvement.

BACKGROUND: Aboriginal and Torres Strait Islander Australians have amongst the highest incidence of sepsis globally. OBJECTIVE: The objective of this study was to describe the characteristics, short- and long-term outcomes of non-Indigenous, Aboriginal Australian and Torres Strait Islander Australians admitted with sepsis to an intensive care unit (ICU) to inform healthcare outcome improvement. METHODS: A retrospective cohort study of 500 consecutive sepsis admissions to the Cairns Hospital ICU compared clinical characteristics, short-term (before ICU discharge) and long-term (2000 days posthospital discharge) outcomes. Cohort stratification was done by voluntary disclosure of Indigenous status. RESULTS: Of the 442 individual admissions, 145 (33%) identified as Indigenous Australian. Indigenous and non-Indigenous Australians had similar admission Acute Physiology and Chronic Health Evaluation-3 scores (median [interquartile range]: 70 [52-87] vs. 69 [53-87], P = 0.87), but Indigenous patients were younger (53 [43-60] vs. 62 [52-73] years, P < 0.001) and were more likely to have chronic comorbidities such as type 2 diabetes (58% vs. 23%, P < 0.001), cardiovascular disease (40% vs 28%, P = 0.01), and renal disease (39% vs. 10%, P < 0.001). They also had more hazardous healthcare behaviours such as smoking (61% vs. 45%, P = 0.002) and excess alcohol consumption (40% vs. 18%, P < 0.001). Despite this, the case-fatality rate of Indigenous and non-Indigenous Australians before ICU discharge (13% vs. 12%, P = 0.75) and 2000 days post hospital discharge (25 % vs. 28 %, P = 0.40) was similar. Crucially, however, Indigenous Australians died younger both in the ICU (median [interquartile range] 54 (50-60) vs. 70 [61-76], P < 0.0001) and 2000 days post hospital discharge (58 [53-63] vs. 70 [63-77] years, P < 0.0001). CONCLUSIONS: Although Indigenous Australians critically ill with sepsis have similar short and long-term mortality rates, they present to hospital, die in-hospital, and die post-discharge significantly younger. Unique cohort characteristics may explain these outcomes, and assist clinicians, researchers and policy-makers in targeting interventions to these characteristics to best reduce the burden of sepsis in this cohort and improve their healthcare outcomes.

PATHWAYS ASSOCIATED WITH POSITIVE SEPSIS SURVIVAL OUTCOMES IN AFRICAN AMERICAN/BLACK AND NON-HISPANIC WHITE PATIENTS WITH URINARY TRACT INFECTION.

ABSTRACT: Urinary tract infections (UTIs) are a common cause of sepsis worldwide. Annually, more than 60,000 US deaths can be attributed to sepsis secondary to UTIs, and African American/Black adults have higher incidence and case-fatality rates than non-Hispanic White adults. Molecular-level factors that may help partially explain differences in sepsis survival outcomes between African American/Black and Non-Hispanic White adults are not clear. In this study, patient samples (N = 166) from the Protocolized Care for Early Septic Shock cohort were analyzed using discovery-based plasma proteomics. Patients had sepsis secondary to UTIs and were stratified according to self-identified racial background and sepsis survival outcomes. Proteomics results suggest patient heterogeneity across mechanisms driving survival from sepsis secondary to UTIs. Differentially expressed proteins (n = 122, false discovery rate-adjusted P < 0.05) in Non-Hispanic White sepsis survivors were primarily in immune system pathways, while differentially expressed proteins (n = 47, false discovery rate-adjusted P < 0.05) in African American/Black patients were mostly in metabolic pathways. However, in all patients, regardless of racial background, there were 16 differentially expressed proteins in sepsis survivors involved in translation initiation and shutdown pathways. These pathways are potential targets for prognostic intervention. Overall, this study provides information about molecular factors that may help explain disparities in sepsis survival outcomes among African American/Black and Non-Hispanic White patients with primary UTIs.

Identifying and Mitigating Disparities in Central Line-Associated Bloodstream Infections in Minoritized Racial, Ethnic, and Language Groups.

Importance: Although inequitable care due to racism and bias is well documented in health care, the impact on health care-associated infections is less understood. Objective: To determine whether disparities in first central catheter-associated bloodstream infection (CLABSI) rates existed for pediatric patients of minoritized racial, ethnic, and language groups and to evaluate the outcomes associated with quality improvement initiatives for addressing these disparities. Design, Setting, and Participants: This cohort study retrospectively examined outcomes of 8269 hospitalized patients with central catheters from October 1, 2012, to September 30, 2019, at a freestanding quaternary care children's hospital. Subsequent quality improvement interventions and follow-up were studied, excluding catheter days occurring after the outcome and episodes with catheters of indeterminate age through September 2022. Exposures: Patient self-reported (or parent/guardian-reported) race, ethnicity, and language for care as collected for hospital demographic purposes. Main Outcomes and Measures: Central catheter-associated bloodstream infection events identified by infection prevention surveillance according to National Healthcare Safety Network criteria were reported as events per 1000 central catheter days. Cox proportional hazards regression was used to analyze patient and central catheter characteristics, and interrupted time series was used to analyze quality improvement outcomes. Results: Unadjusted infection rates were higher for Black patients (2.8 per 1000 central catheter days) and patients who spoke a language other than English (LOE; 2.1 per 1000 central catheter days) compared with the overall population (1.5 per 1000 central catheter days). Proportional hazard regression included 225 674 catheter days with 316 infections and represented 8269 patients. A total of 282 patients (3.4%) experienced a CLABSI (mean [IQR] age, 1.34 [0.07-8.83] years; female, 122 [43.3%]; male, 160 [56.7%]; English-speaking, 236 [83.7%]; LOE, 46 [16.3%]; American Indian or Alaska Native, 3 [1.1%]; Asian, 14 [5.0%]; Black, 26 [9.2%]; Hispanic, 61 [21.6%]; Native Hawaiian or Other Pacific Islander, 4 [1.4%]; White, 139 [49.3%]; ≥2 races, 14 [5.0%]; unknown race and ethnicity or refused to answer, 15 [5.3%]). In the adjusted model, a higher hazard ratio (HR) was observed for Black patients (adjusted HR, 1.8; 95% CI, 1.2-2.6; P = .002) and patients who spoke an LOE (adjusted HR, 1.6; 95% CI, 1.1-2.3; P = .01). Following quality improvement interventions, infection rates in both subgroups showed statistically significant level changes (Black patients: -1.77; 95% CI, -3.39 to -0.15; patients speaking an LOE: -1.25; 95% CI, -2.23 to -0.27). Conclusions and Relevance: The study's findings show disparities in CLABSI rates for Black patients and patients who speak an LOE that persisted after adjusting for known risk factors, suggesting that systemic racism and bias may play a role in inequitable hospital care for hospital-acquired infections. Stratifying outcomes to assess for disparities prior to quality improvement efforts may inform targeted interventions to improve equity.

Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study.

BACKGROUND: Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention. METHODS: Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis. DISCUSSION: This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.

Race Does Not Impact Sepsis Outcomes When Considering Socioeconomic Factors in Multilevel Modeling.

OBJECTIVES: To determine whether race is a major determinant of sepsis outcomes when controlling for socioeconomic factors. DESIGN: Retrospective cohort study. SETTING: Barnes-Jewish Hospital a 1,350 bed academic medical center. PATIENTS: Eleven-thousand four-hundred thirty-two patients hospitalized between January 2010 and April 2017 with sepsis and septic shock. INTERVENTIONS: Multilevel random effects modeling was employed whereby patients were nested within ZIP codes. Individual patient characteristics and socioeconomic variables aggregated at the ZIP code level (education, employment status, income, poverty level, access to healthcare) were included in the model. MEASUREMENTS AND MAIN RESULTS: In hospital mortality, length of stay, need for vasopressors, and mechanical ventilation were the main endpoints. Black patients had more comorbidities than White patients except for cirrhosis and malignancy. In unadjusted comparisons, White individuals were more likely to require mechanical ventilation and had higher mortality rates and longer hospital stays for both low- and high-income groups. When nesting within ZIP codes and accounting for socioeconomic variables, race did not have a significant effect on mortality. Non-White races had lower odds ratio for mechanical ventilation. CONCLUSIONS: Our study demonstrates that race is not an independent risk factor for sepsis mortality, as well as sepsis-related length of stay. We should expand our inquiry into determinants of sepsis outcomes by including socioeconomic variables.

Assessment of Racial Disparities in the Risks of Septic and Aseptic Revision Total Knee Replacements.

Importance: Black patients are at higher risk of revision total knee replacement (TKR) than White patients, but whether racial disparities exist for both septic and aseptic revision TKR and the reason for any disparities are unknown. Objective: To assess the risk of septic and aseptic revision TKR in Black and White patients and to examine interactions among race and socioeconomic and hospital-related variables that are associated with revision TKR risk. Design, Setting, and Participants: This cohort study included residents of New York, California, and Florida who underwent TKR. Patient-level data were obtained from the New York Statewide Planning and Research Cooperative System, California's Office of Statewide Health Planning and Development Patient Discharge Database, and Florida's Healthcare Utilization Project State Inpatient Database from January 1, 2004, to December 31, 2014. Community characteristics were calculated from the US Census and linked to discharges by patient zip code. American Hospital Association Annual Survey data were linked to discharges using hospital identifiers. The analyses were performed from March 1 to October 30, 2020, with subsequent analyses in April 2021. Main Outcomes and Measures: Cox proportional hazards regression modeling was used to measure the association of race with septic and aseptic revision TKR. Results: A total of 722 492 patients underwent primary TKR, of whom 445 616 (61.68%) were female and 61 092 (8.46%) were Black. Black patients were at higher risk of septic (hazard ratio [HR], 1.11; 95% CI, 1.03-1.20) and aseptic (HR, 1.39; 95% CI, 1.33-1.46) revision TKR compared with White patients. Other risk factors for septic revision TKR were diabetes (HR, 1.24; 95% CI, 1.17-1.30), obesity (HR, 1.13; 95% CI, 1.17-1.30), kidney disease (HR, 1.42; 95% CI, 1.29-1.57), chronic obstructive pulmonary disease (HR, 1.22; 95% CI, 1.15-1.30), inflammatory arthritis (HR, 1.53; 95% CI, 1.39-1.69), surgical site complications during the index TKR (HR, 2.19; 95% CI, 1.87-2.56), Medicaid insurance (HR, 1.17; 95% CI, 1.04-1.31), and low annual TKR volume at the hospital where the index TKR was performed (HR, 1.54; 95% CI, 1.41-1.68). Risk factors for aseptic revision TKR were male sex (HR, 1.03; 95% CI, 1.00-1.06), workers' compensation insurance (HR, 1.61; 95% CI, 1.51-1.72), and low hospital TKR volume (HR, 1.14; 95% CI, 1.07-1.22). Patients with obesity had a lower risk of aseptic TKR revision (HR, 0.81; 95% CI, 0.77-0.84). In an analysis within each category of hospital TKR volume, the HR for aseptic revision among Black vs White patients was 1.20 (95% CI, 1.04-1.37) at very-low-volume hospitals (≤89 TKRs annually) compared with 1.68 (95% CI, 1.48-1.90) at very-high-volume hospitals (≥645 TKRs annually). Conclusions and Relevance: In this cohort study, Black patients were at significantly higher risk of aseptic revision TKR and, to a lesser extent, septic revision TKR compared with White patients. Racial disparities in aseptic revision risk were greatest at hospitals with very high TKR volumes.

Birth hospital and racial and ethnic differences in severe maternal morbidity in the state of California.

BACKGROUND: Birth hospital has recently emerged as a potential key contributor to disparities in severe maternal morbidity, but investigations on its contribution to racial and ethnic differences remain limited. OBJECTIVE: We leveraged statewide data from California to examine whether birth hospital explained racial and ethnic differences in severe maternal morbidity. STUDY DESIGN: This cohort study used data on all births at ≥20 weeks gestation in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least 1 of the 21 diagnoses and procedures (eg, eclampsia, blood transfusion, hysterectomy). Mixed-effects logistic regression models (ie, women nested within hospitals) were used to compare racial and ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, comorbidities, and hospital characteristics. We also estimated the risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percentage reduction in severe maternal morbidity if each group of racially and ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic white women. RESULTS: Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian and Pacific Islander; 1.1% white; 1.6% American Indian and Alaska Native, and Mixed-race referred to as Other). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, the odds of severe maternal morbidity were greater among nonwhite women than white women in a given hospital (Black: odds ratio, 1.25; 95% confidence interval, 1.19-1.31); US-born Hispanic: odds ratio, 1.25; 95% confidence interval, 1.20-1.29; foreign-born Hispanic: odds ratio, 1.17; 95% confidence interval, 1.11-1.24; Asian and Pacific Islander: odds ratio, 1.26; 95% confidence interval, 1.21-1.32; Other: odds ratio, 1.31; 95% confidence interval, 1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of white women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared with 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and white women and accounted for 16.1% to 24.2% of the differences for all other racial and ethnic groups. CONCLUSION: In California, excess odds of severe maternal morbidity among racially and ethnically minoritized women were not fully explained by birth hospital. Structural causes of racial and ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.

Hospital outcomes for children with severe sepsis in the USA by race or ethnicity and insurance status: a population-based, retrospective cohort study.

BACKGROUND: Disparities in outcomes of adult sepsis are well described by insurance status and race and ethnicity. There is a paucity of data looking at disparities in sepsis outcomes in children. We aimed to determine whether hospital outcomes in childhood severe sepsis were influenced by race or ethnicity and insurance status, a proxy for socioeconomic position. METHODS: This population-based, retrospective cohort study used data from the 2016 database release from the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). The 2016 KID included 3 117 413 discharges, accounting for 80% of national paediatric discharges from 4200 US hospitals across 47 states. Using multilevel logistic regression, clustered by hospital, we tested the association between race or ethnicity and insurance status and hospital mortality, adjusting for individual-level and hospital-level characteristics, in children with severe sepsis. The secondary outcome of length of hospital stay was examined through multilevel time to event (hospital discharge) regression, with death as a competing risk. FINDINGS: 12 297 children (aged 0-21 years) with severe sepsis with or without shock were admitted to 1253 hospitals in the 2016 KID dataset. 1265 (10·3%) of 12 297 patients did not have race or ethnicity data recorded, 15 (0·1%) were missing data on insurance, and 1324 (10·8%) were transferred out of hospital, resulting in a final cohort of 9816 children. Black children had higher odds of death than did White children (adjusted odds ratio [OR] 1·19, 95 % CI 1·02-1·38; p=0·028), driven by higher Black mortality in the south (1·30, 1·04-1·62; p=0·019) and west (1·58, 1·05-2·38; p=0·027) of the USA. We found evidence of longer hospital stays for Hispanic children (adjusted hazard ratio 0·94, 95% CI 0·88-1·00; p=0·049) and Black children (0·88, 0·82-0·94; p=0·0002), particularly Black neonates (0·53, 95% CI 0·36-0·77; p=0·0011). We observed no difference in survival between publicly and privately insured children; however, other insurance status (self-pay, no charge, and other) was associated with increased mortality (adjusted OR 1·30, 95% CI 1·04-1·61; p=0·021). INTERPRETATION: In this large, representative analysis of paediatric severe sepsis in the USA, we found evidence of outcome disparities by race or ethnicity and insurance status. Our findings suggest that there might be differential sepsis recognition, approaches to treatment, access to health-care services, and provider bias that contribute to poorer sepsis outcomes for racial and ethnic minority patients and those of lower socioeconomic position. Studies are warranted to investigate the mechanisms of poorer sepsis outcomes in Black and Hispanic children. FUNDING: None.

Psychiatric Disorders Are Associated with Increased Risk of Sepsis Following a Cancer Diagnosis.

Psychiatric disorders and infections are both common comorbidities among patients with cancer. However, little is known about the role of precancer psychiatric disorders on the subsequent risk of sepsis as a complication of infections among patients with cancer. We conducted a cohort study of 362,500 patients with newly diagnosed cancer during 2006-2014 in Sweden. We used flexible parametric models to calculate the HRs of sepsis after cancer diagnosis in relation to precancer psychiatric disorders and the analyses were performed in two models. In model 1, analyses were adjusted for sex, age at cancer diagnosis, calendar period, region of residence, and type of cancer. In model 2, further adjustments were made for marital status, educational level, cancer stage, infection history, and Charlson Comorbidity Index score. During a median follow-up of 2.6 years, we identified 872 cases of sepsis among patients with cancer with precancer psychiatric disorders (incidence rate, IR, 14.8 per 1,000 person-years) and 12,133 cases among patients with cancer without such disorders (IR, 11.6 per 1000 person-years), leading to a statistically significant association between precancer psychiatric disorders and sepsis in both the simplified (HR, 1.31; 95% CI, 1.22-1.40) and full (HR, 1.26; 95% CI, 1.18-1.35) models. The positive association was consistently noted among patients with different demographic factors or cancer characteristics, for most cancer types, and during the entire follow-up after cancer diagnosis. Collectively, preexisting psychiatric disorders were associated with an increased risk of sepsis after cancer diagnosis, suggesting a need of heightened clinical awareness in this patient group. SIGNIFICANCE: These results call for extended prevention and surveillance of sepsis among patients with cancer with psychiatric comorbidities.

Increased Risk of Severe Sepsis in Hispanic Children Hospitalized With Acute Myeloid Leukemia.

The purpose of this study, a secondary analysis of a publicly available database, was to identify racial and ethnic disparities in the risk of severe sepsis facing children undergoing the intensive therapy necessary to treat acute myeloid leukemia (AML). The sample consisted of 1,913 hospitalizations of children, younger than 21 years, in the United States during the year 2016 with documentation of both AML and at least one infectious complication. Binary logistic regression models were used to examine the association between race/ethnicity and severe sepsis in children with AML and infection. We found that, after controlling for potential confounding variables, the odds of developing severe sepsis were significantly increased for Hispanic children compared with White children. There were no significant differences in the likelihood of the development of sepsis in Black, Asian, or other race children. The increased risk of severe sepsis for Hispanic children may contribute to the disparate rates of overall survival in this group. This inequitable rate of severe sepsis was evident despite the generally accepted practice of retaining children in the hospital throughout recovery of blood counts following AML therapy. Nurses are in a position to identify and eliminate modifiable risk factors contributing to this disparity.

Treatment in Disproportionately Minority Hospitals Is Associated With Increased Risk of Mortality in Sepsis: A National Analysis.

OBJECTIVES: Treatment in a disproportionately minority-serving hospital has been associated with worse outcomes in a variety of illnesses. We examined the association of treatment in disproportionately minority hospitals on outcomes in patients with sepsis across the United States. DESIGN: Retrospective cohort analysis. Disproportionately minority hospitals were defined as hospitals having twice the relative minority patient population than the surrounding geographical mean. Minority hospitals for Black and Hispanic patient populations were identified based on U.S. Census demographic information. A multivariate model employing a validated algorithm for mortality in sepsis using administrative data was used. SETTING: The National Inpatient Sample from 2008 to 2014. PATIENTS: Patients over 18 years of age with sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 4,221,221 patients with sepsis were identified. Of these, 612,217 patients (14.5%) were treated at hospitals disproportionately serving the black community (Black hospitals), whereas 181,141 (4.3%) were treated at hospitals disproportionately serving the Hispanic community (Hispanic hospitals). After multivariate analysis, treatment in a Black hospital was associated with a 4% higher risk of mortality compared to treatment in a nonminority hospital (odds ratio, 1.04; 95% CI, 1.03-1.05; p < 0.01). Treatment in a Hispanic hospital was associated with a 9% higher risk of mortality (odds ratio, 1.09; 95% CI, 1.07-1.11; p < 0.01). Median hospital length of stay was almost 1 day longer at each of the disproportionately minority hospitals (nonminority hospitals: 5.9 d; interquartile range, 3.1-11.0 d vs Hispanic: 6.9 d; interquartile range, 3.6-12.9 d and Black: 6.7 d, interquartile range, 3.4-13.2 d; both p < 0.01). CONCLUSIONS: Patients with sepsis regardless of race who were treated in disproportionately high minority hospitals suffered significantly higher rates of in-hospital mortality.

Agreement of claims-based methods for identifying sepsis with clinical criteria in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort.

BACKGROUND: Claims-based algorithms are commonly used to identify sepsis in health services research because the laboratory features required to define clinical criteria may not be available in administrative data. METHODS: We evaluated claims-based sepsis algorithms among adults in the US aged ≥65 years with Medicare health insurance enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Suspected infections from baseline (2003-2007) through December 31, 2012 were analyzed. Two claims-based algorithms were evaluated: (1) infection plus organ dysfunction diagnoses or sepsis diagnoses (Medicare-Implicit/Explicit) and (2) Centers for Medicare and Medicaid Services Severe Sepsis/Septic Shock Measure diagnoses (Medicare-CMS). Three classifications based on clinical criteria were used as standards for comparison: (1) the sepsis-related organ failure assessment (SOFA) score (REGARDS-SOFA), (2) "quick" SOFA (REGARDS-qSOFA), and (3) Centers for Disease Control and Prevention electronic health record criteria (REGARDS-EHR). RESULTS: There were 2217 suspected infections among 9522 participants included in the current study. The total number of suspected infections classified as sepsis was 468 for Medicare-Implicit/Explicit, 249 for Medicare-CMS, 541 for REGARDS-SOFA, 185 for REGARDS-qSOFA, and 331 for REGARDS-EHR. The overall agreement between Medicare-Implicit/Explicit and REGARDS-SOFA, REGARDS-qSOFA, and REGARDS-EHR was 77, 79, and 81%, respectively, sensitivity was 46, 53, and 57%, and specificity was 87, 82, and 85%. Comparing Medicare-CMS and REGARDS-SOFA, REGARDS-qSOFA, and REGARDS-EHR, agreement was 77, 87, and 85%, respectively, sensitivity was 27, 41, and 36%, and specificity was 94, 92, and 93%. Events meeting the REGARDS-SOFA classification had a lower 90-day mortality rate (140.7 per 100 person-years) compared with the Medicare-CMS (296.1 per 100 person-years), REGARDS-qSOFA (238.6 per 100 person-years), Medicare-Implicit/Explicit (219.4 per 100 person-years), and REGARDS-EHR classifications (201.8 per 100 person-years). CONCLUSION: Claims-based sepsis algorithms have high agreement and specificity but low sensitivity when compared with clinical criteria. Both claims-based algorithms identified a patient population with similar 90-day mortality rates as compared with classifications based on qSOFA and EHR criteria but higher mortality relative to SOFA criteria.

A five-year longitudinal observational study in morbidity and mortality of negative appendectomy in Sulaimani teaching Hospital/Kurdistan Region/Iraq.

The most common surgical emergency is suspected acute appendicitis, the lifetime risk of acute appendicitis is estimated to be 8.6% for men and 6.7% for women, with a male to female ratio of 1.4:1; correct diagnosis can be made in 70-80% of patients after the operations about 32% of appendectomies revealed normal appendices and meanwhile appendectomy has a considerable morbidity and mortality. The aim is to explore potential morbidity and mortality associated with negative appendectomy. Prospective case series study, including 5847 patients, who were suspected to have acute appendicitis over a period of five years from 1st December 2013 to 30th November 2018, in emergency department of Sulaimani Teaching Hospital. All the collected data were collected, organized then analyzed by Statistical Package for the Social Sciences version 21. Morbidity in the patients with negative appendectomies occurred in patients in the form of 90 (01.91%) wound infection, 48 (01.02%) intestinal obstruction and last 15 (00.32%) patients developed septicemia. While mortality in negative appendectomy patients was 21, (00.45%). Negative appendectomies have high rates of morbidity and mortality, knowing real rates may help in considering various policies and may be helpful to elude avoidable complications and potential mortality.

Risk Factors for Maternal Readmission with Sepsis.

OBJECTIVE: Our primary objective was to identify risk factors for maternal readmission with sepsis. Our secondary objectives were to (1) assess diagnoses and infecting organisms at readmission and (2) compare early (<6 weeks) and late (6 weeks to 9 months postpartum) maternal readmission with sepsis. STUDY DESIGN: We identified our cohort using linked hospital discharge data and birth certificates for California deliveries from 2008 to 2011. Consistent with the 2016 sepsis classification, we defined sepsis as septicemia plus acute organ dysfunction. We compared women with early or late readmission with sepsis to women without readmission with sepsis. RESULTS: Among 1,880,264 women, 494 (0.03%) were readmitted with sepsis, 61% after 6 weeks. Risk factors for readmission with sepsis included preterm birth, hemorrhage, obesity, government-provided insurance, and primary cesarean. For both early and late sepsis readmissions, the most common diagnoses were urinary tract infection and pyelonephritis, and the most frequently identified infecting organism was gram-negative bacteria. Women with early compared with late readmission with sepsis shared similar obstetric characteristics. CONCLUSION: Maternal risk factors for both early and late readmission with sepsis included demographic characteristics, cesarean, hemorrhage, and preterm birth. Risks for sepsis after delivery persist beyond the traditional postpartum period of 6 weeks.

Mediating Effects of Frailty Indicators on the Risk of Sepsis After Cancer.

BACKGROUND: Cancer survivors are at increased risk of sepsis, possibly attributed to weakened physiologic conditions. The aims of this study were to examine the mediation effect of indicators of frailty on the association between cancer survivorship and sepsis incidence and whether these differences varied by race. METHODS: We performed a prospective analysis using data from the REasons for Geographic and Racial Differences in Stroke cohort from years 2003 to 2012. We categorized frailty as the presence of ≥2 frailty components (weakness, exhaustion, and low physical activity). We categorized participants as "cancer survivors" or "no cancer history" derived from self-reported responses of being diagnosed with any cancer. We examined the mediation effect of frailty on the association between cancer survivorship and sepsis incidence using Cox regression. We repeated analysis stratified by race. RESULTS: Among 28 062 eligible participants, 2773 (9.88%) were cancer survivors and 25 289 (90.03%) were no cancer history participants. Among a total 1315 sepsis cases, cancer survivors were more likely to develop sepsis (12.66% vs 3.81%, P < .01) when compared to participants with no cancer history (hazard ratios: 2.62, 95% confidence interval: 2.31-2.98, P < .01). The mediation effects of frailty on the log-hazard scale were very small: weakness (0.57%), exhaustion (0.31%), low physical activity (0.20%), frailty (0.75%), and total number of frailty indicators (0.69%). Similar results were observed when stratified by race. CONCLUSION: Cancer survivors had more than a 2-fold increased risk of sepsis, and indicators of frailty contributed to less than 1% of this disparity.

Association of CFH polymorphism with susceptibility to sepsis caused by Pseudomonas aeruginosa in Chinese Han populations: A multi-center study.

Complement factor H (CFH) serves as a major down-regulator in the complement system, often utilized by bacterial pathogens to evade complement attack. Yet, little is currently known about the genetic correlation of CFH polymorphisms with sepsis due to various microbial infections. A case-control method (488 septic patients and 527 healthy individuals) was carried out in this study to investigate the genetic relationship between CFH polymorphisms (rs3753394 C/T, rs1065489 G/T and rs1061170 C/T) and susceptibility to sepsis caused by bacterial infections in Chinese Han populations. Our findings indicated that the frequency of rs3753394 CT/TT genotype in the septic patients with P. aeruginosa was significantly higher than that in the control individuals (P = 0.033, OR = 2.668, 95%CI = 1.072-6.334). The rs3753394 T allele frequency in the P. aeruginosa-infected patients was significantly increased, compared to that in the healthy controls (P = 0.014, OR = 1.68, 95%CI = 1.118-2.538). Moreover, these significant differences of rs3753394 genotype and allele frequencies remained after multiple testing corrections [P (corr.) = 0.033 for genotype; P (corr.) = 0.033 for allele]. The current study highlighted the significance of CFH polymorphism rs3753394 as a potential biomarker for targeting P. aeruginosa infection in critically ill patients.

Racial Differences in Sepsis Recognition in the Emergency Department.

OBJECTIVES: We assessed racial differences in sepsis recognition in a pediatric emergency department (ED) with an established electronic sepsis alert system. METHODS: Quality-improvement data from June 1, 2016 to May 31, 2017 was used in this retrospective cohort study. All ED visits were included for non-Hispanic black (NHB) and non-Hispanic white (NHW) patients. The sepsis pathway was activated through the alert, 2 stages and a huddle, or outside of the alert using clinician judgment alone. We evaluated racial differences in the frequency of alerts and sepsis pathway activation within and outside of the alert. Multivariable regression adjusted for high-risk condition, sex, age, and insurance. RESULTS: There were 97 338 ED visits: 56 863 (58.4%) and 23 008 (23.6%) from NHBs and NHWs, respectively. NHWs were more likely than NHBs to have a positive second alert (adjusted odds ratio [aOR] 2.4; 95% confidence interval [CI] 2.1-2.8). NHWs were more likely than NHBs to have the sepsis pathway activated (aOR 1.4; 95% CI 1.02-2.1). Of those treated within the alert, there was no difference in pathway activation (aOR 0.93; 95% CI 0.62-1.4). Of those recognized by clinicians when the alert did not fire, NHWs were more likely than NHBs to be treated (aOR 3.4; 95% CI 1.8-6.4). CONCLUSIONS: NHWs were more likely than NHBs to be treated for sepsis, although this difference was specifically identified in the subset of patients treated for sepsis outside of the alert. This suggests that an electronic alert reduces racial differences compared with clinician judgment alone.