Charlson and Elixhauser Comorbidity Indices for Prediction of Mortality and Hospital Readmission in Patients With Acute Pulmonary Embolism.

Several risk stratification systems aid clinicians in classifying pulmonary embolism (PE) severity and prognosis. We compared 2 clinical PE scoring systems, the PESI and sPESI scores, with 2 comorbidity indices, the Charlson Comorbidity Index (CCI) and the val Walraven Elixhauser Comorbidity Index (ECI), to determine the utility of each in predicting mortality and hospital readmission. Information was collected from 436 patients presenting with PE via retrospective chart review. The PESI, sPESI, CCI, and ECI scores were calculated for each patient. Multivariate analysis was used to determine each system's ability to predict in-hospital mortality, 90-day mortality, overall mortality, and all-cause hospital readmission. The impact of various demographic and clinical characteristics of each patient on these outcomes was also assessed. The PESI score was found to be an independent predictor of in-hospital mortality and 90-day mortality. The PESI score and the CCI were able to independently predict overall mortality. None of the 4 risk scores independently predicted hospital readmission. Other factors including hypoalbuminemia, serum BNP, coagulopathy, anemia, and diabetes were associated with increased mortality and readmission at various endpoints. The PESI score was the best tool for predicting mortality at any endpoint. The CCI may have utility in predicting long-term outcomes. Further work is needed to better determine the roles of the CCI and ECI in predicting patient outcomes in PE. The potential prognostic implications of low serum albumin and anemia at the time of PE also warrant further investigation.

Glycemic Control and Plasma Levels of Pro-Inflammatory and Pro-Thrombotic Biomarkers in Diabetic Patients Presenting with Acute Pulmonary Embolism.

Type I and type II diabetes are closely associated with a pro-inflammatory state and to a pro-thrombotic state. The role of glycemic control in pulmonary embolism (PE) is poorly understood and requires additional investigation. The aim of this study is to investigate the relationship between glycemic control and thrombo-inflammatory biomarkers in a PE patient cohort compared to normal samples. Demographic and clinical information for 86 diabetic patients and 106 non-diabetic patients presenting with acute PE was collected via retrospective chart review. Plasma levels of pro-inflammatory (C-reactive protein [CRP], tumor necrosis factor-alpha [TNF-α], interleukin-6 [IL-6]) and pro-thrombotic (d-dimer, plasminogen activator inhibitor-1 [PAI-1], tissue plasminogen activator [tPA], thrombin activatable fibrinolysis inhibitor [TAFI], von-Willebrand factor [vWF], endogenous glycosaminoglycans [GAGs]) biomarkers were drawn within 24 hours of diagnosis of acute PE. Data was also obtained for a population of healthy adult controls. All the pro-inflammatory and pro-thrombotic biomarkers were elevated in diabetic PE patients in comparison to healthy controls. None of the biomarkers were elevated in diabetic PE patients when compared to non-diabetic PE patients. There was no difference in the levels of the pro-inflammatory biomarkers according to glycemic control. The plasma level of TAFI was elevated in diabetic patients with poor glycemic control. Diabetic patients were more likely to have a more severe PE. These studies demonstrate that thrombo-inflammatory biomarkers are elevated in diabetic PE patients with associated comorbidities in comparison to normal individuals. However, there is no difference between the PE cohort alone in comparison to PE with diabetes. The role of TAFI within the continuum of diabetic vascular disease warrants additional investigation.

Racial Disparities in the Risk for Thromboembolic Events in COVID-19 Patients during the Height of the SARS-CoV-2 Pandemic and Impact on Outcomes.

BACKGROUND: The primary objective of this study is to assess the risk of thromboembolic events (TEs) in hospitalized patients with coronavirus disease 2019 (COVID-19) and study the impact of TEs on hospital course and mortality risk during the initial height of the severe acute respiratory syndrome coronavirus-2 pandemic. METHODS: A retrospective review of all adult inpatients (≥ 18 years old) with COVID-19 infection at a single academic institution from March 15, 2020 to July 1, 2020 was performed. Collected data included patient demographics, comorbidities, hospital admission type, TEs, laboratory values, use of anticoagulants/antiplatelet agents, hospital length of stay, and in-hospital mortality. A logistic regression was used to estimate associations between risk factors and TEs. RESULTS: A total of 826 inpatients with COVID-19 were identified. Of these, 56% were male, average age was 60.9 years, and race/ethnicity was reported as Hispanic in 51%, non-Hispanic Black in 25%, and non-Hispanic White in 18%. A total of 98 TEs were documented in 87 patients (10.5%). Hypertension, coronary artery disease, and chronic limb threatening ischemia were associated with an increased incidence of thromboembolism (P < 0.05). Hispanic patients had higher incidence of thromboembolism compared to White non-Hispanic patients (odds ratio {[OR] confidence interval [CI]}: 2.237 [1.053, 4.754], P = 0.036). As D-dimer increased, the odds of TE increased by 5.2% (OR [CI]: 1.052 [1.027, 1.077], P < 0.001). Patients with TEs had longer hospital stay (median 13 vs. 6 days, P < 0.001), higher likelihood of intensive care unit admission (63% vs. 33%, P < 0.001), and higher in-hospital mortality (28% vs. 16%, P = 0.006). Arterial TEs were associated with higher in-hospital mortality than venous TEs (37% vs. 15%, P = 0.027). CONCLUSIONS: During the initial height of the severe acute respiratory syndrome coronavirus-2 pandemic, TEs were relatively frequent in hospitalized patients with COVID-19. Racial disparities were seen with an increased proportion of minority patients admitted with respect to percentages seen in the general population. There was also a significantly increased incidence of TEs in Hispanic patients. TEs were associated with significantly longer hospital stay and higher in-hospital mortality. Patients with arterial TEs fared worse with significantly higher mortality than those with venous events. Inconsistencies in anticoagulation management early in the pandemic may have contributed to poor outcomes and more contemporary management outcomes need to be investigated.

Octogenarians undergoing pancreaticoduodenectomy: Assessing outcomes, disposition, and timing of chemotherapy.

BACKGROUND: Inclusion of pancreaticoduodenectomy has demonstrated higher rates of curative treatment in pancreatic cancer, yet prior research has suggested increased postoperative complications in octogenarians (patients older than 80 years). This study aimed to understand the impact of age on patients undergoing a pancreaticoduodenectomy, focusing on postoperative outcomes and return to intended oncologic treatment. MATERIALS AND METHODS: We conducted a single-institution retrospective cohort study for patients undergoing pancreaticoduodenectomy from 2007 to 2018. Collected data included demographics, preoperative comorbidities, and postoperative data (length of stay, 30-day mortality, 1-year mortality, infection, discharge location). Data were separated into 2 cohorts: octogenarians (≥ 80 years) and nonoctogenarians (< 80). χ2 and independent-sample t tests were used for analysis. RESULTS: A total of 649 patients underwent pancreaticoduodenectomy from 2007 to 2018; 63 (9.7%) were octogenarians. No differences were found in infectious complications (P = .607), 30-day mortality (P = .363), or 1-year mortality (P = .895). Octogenarians had a longer length of stay (P = .003) and were more likely to be discharged to skilled nursing facilities (P < .001). There was no significant difference in neoadjuvant chemotherapy administration, although octogenarians were less likely to receive adjuvant chemotherapy (P = .048) and declined adjuvant therapy at a higher rate (P = .003). CONCLUSION: Performing a pancreaticoduodenectomy in octogenarians can be safe and effective in a properly selected cohort. Although postoperative morbidity and mortality are similar to younger patients, elderly patients are more likely to be discharged to nursing facilities and less likely to receive adjuvant chemotherapy. This study suggests that age alone should not be a discriminating factor when discussing surgical therapy for pancreatic cancer treatment in octogenarians.

Clinical Predictors and Outcomes of Oral Food Challenges Illustrate Differences Among Individual Tree Nuts.

BACKGROUND: Although allergy to tree nuts is often considered a single entity, there is heterogeneity in patient reactivity and immune response to different tree nuts. OBJECTIVE: We sought to characterize tree nut oral food challenges (OFCs) in a pediatric population performed at a single center over a 12-year period and determine differences in OFC outcome to different tree nuts. METHODS: A retrospective chart review was conducted in patients (0-20 years) who completed an unblinded OFC to any tree nut from 2007 to 2019 at Lurie Chlildren's Hospital of Chicago. Differences among almond, cashew, hazelnut, and walnut challenges were compared, and probability curves were used to estimate positive predictive values (PPVs) of specific IgE at OFC. RESULTS: A total of 531 tree nut OFCs were included. The mean age at OFC was 7.77 years (standard deviation, 4.33). Overall, 74.0% of children passed clinically indicated OFCs. Of the 4 most commonly challenged tree nuts, almost all patients passed OFC to almond (97.3%) and hazelnut (87.9%). Pass rates were lower for cashew (65.3%) and walnut (57.0%), P < .0001. The odds of failure were 0.83 times lower for patients who were avoiding without a previous reaction compared with those who had previously reacted (P = .0025). CONCLUSIONS: The majority of patients pass low-risk almond and hazelnut OFCs. PPVs at the 50th percentile for walnut (2.84 kU/L) and cashew (3.35 kU/L) were lower than those previous studies have suggested.