Weekend admissions with ascites are associated with delayed paracentesis: A nationwide analysis of the ‘weekend effect’

Introduction and objectivesWeekend admissions has previously been associated with worse outcomes in conditions requiring specialists. Our study aimed to determine in-hospital outcomes in patients with ascites admitted over the weekends versus weekdays. Time to paracentesis from admission was studied as current guidelines recommend paracentesis within 24 h for all patients admitted with worsening ascites or signs and symptoms of sepsis/hepatic encephalopathy (HE).PatientsWe analyzed 70 million discharges from the 2005–2014 National Inpatient Sample to include all adult patients admitted non-electively for ascites, spontaneous bacterial peritonitis (SBP), and HE with ascites with cirrhosis as a secondary diagnosis. The outcomes were in-hospital mortality, complication rates, and resource utilization. Odds ratios (OR) and means were adjusted for confounders using multivariate regression analysis models.ResultsOut of the total 195,083 ascites/SBP/HE-related hospitalizations, 47,383 (24.2%) occurred on weekends. Weekend group had a higher number of patients on Medicare and had higher comorbidity burden. There was no difference in mortality rate, total complication rates, length of stay or total hospitalization charges between the patients admitted on the weekend or weekdays. However, patients admitted over the weekends were less likely to undergo paracentesis (OR 0.89) and paracentesis within 24 h of admission (OR 0.71). The mean time to paracentesis was 2.96 days for weekend admissions vs. 2.73 days for weekday admissions.ConclusionsWe observed a statistically significant “weekend effect” in the duration to undergo paracentesis in patients with ascites/SBP/HE-related hospitalizations. However, it did not affect the patient's length of stay, hospitalization charges, and in-hospital mortality.     

Diabetes, comorbidities and increased long-term mortality in older patients admitted for geriatric inpatient care

AimsTo study the specific impact of diabetes on long-term mortality in very old subjects with multiple comorbidities and functional disabilities.MethodsThe prevalence of vascular disorders, global comorbidity load (cumulative illness rating scale [CIRS]) and functional disabilities (activities of daily living [ADL] and Lawton's instrumental ADL [IADL] scores) were determined according to diabetes status in a cohort of 444 patients (mean age 85.3 ± 6.7 years; 74.0% women) admitted to our geriatric service. Also, the specific impact of diabetes on 4-year mortality was analyzed using Cox proportional-hazards models.ResultsDiabetic patients had higher BMI scores (27.1 ± 4.9 vs. 23.4 ± 4.7 kg/m² in controls; P < 0.001), and higher prevalences of hypertension (81.9% vs. 65.1%, respectively; P = 0.003) and ischaemic heart disease (33.7% vs. 22.2%, respectively; P = 0.033), but not of stroke and renal insufficiency. They also had more comorbidities (CIRS score excluding diabetes: 15.1 ± 4.5 vs. 13.8 ± 4.8, respectively; P = 0.016) and functional disabilities. Diabetes was associated with mortality (HR: 1.42, 95% CI: 1.02–1.99; P = 0.041) after adjusting for age, gender and BMI, and this persisted after adjusting for individual vascular comorbidities, but disappeared after adjusting for CIRS, ADL or IADL scores.ConclusionDiabetes was associated with 4-year mortality after adjusting for the inverse relationship between mortality and BMI. This association was better accounted for by the global comorbidity load and functional disabilities than by the individual vascular comorbidities. These findings suggest that the active management of all – rather than selected – comorbidities is the key to improving the prognosis for older diabetic patients.     

The effect of weekend versus weekday admission on outcomes of esophageal variceal hemorrhage

BACKGROUND

Hospital staffing is often lower on weekends than weekdays, and may contribute to higher mortality in patients admitted on weekends. Because esophageal variceal hemorrhage (EVH) requires complex management and urgent endoscopic intervention, limitations in physician expertise and the availability of endoscopy on weekends may be associated with increased EVH mortality.

OBJECTIVE

To assess the differences in mortality, hospital length of stay (LOS), and costs between patients admitted on weekends versus patients who were admitted on weekdays.

METHODS

The United States Nationwide Inpatient Sample database was used to identify patients hospitalized for EVH between 1998 and 2005. Differences in mortality, LOS, and costs between patients admitted on weekends and weekdays were evaluated using regression models with adjustment for patient and clinical factors, including the timing of endoscopy.

RESULTS

Between 1998 and 2005, 36,734 EVH admissions to 2207 hospitals met the inclusion criteria. Compared with patients admitted on weekdays, individuals admitted on the weekend were slightly less likely to undergo endoscopy on the day of admission (45% versus 43%, respectively; P=0.01) and by the second day (81% versus 75%; P<0.0001). However, mortality (11.3% versus 10.8%; P=0.20) and the requirement for endoscopic therapy (70% versus 69%; P=0.08) or portosystemic shunt insertion (4.4% versus 4.7%; P=0.32) did not differ between weekend and weekday admissions. After adjusting for confounding factors, including the timing of endoscopy, the risk of mortality was similar between weekend and weekday admissions (OR 1.05; 95% CI 0.97 to 1.14). Although LOS was similar between groups, adjusted hospital charges were 4.0% greater (95% CI 2.3 to 5.8%) for patients hospitalized on the weekend.

CONCLUSIONS

In patients with EVH, admission on the weekend is associated with a small delay in receiving endoscopic intervention, but no difference in mortality or the requirement for portosystemic shunt insertion. The weekend effect observed for some medical and surgical conditions does not apply to patients with EVH.     

High sodium intake adversely affects oxidative-inflammatory response, cardiac remodelling and mortality after myocardial infarction

ObjectiveEnhanced sodium intake increases volume overload, oxidative stress and production of proinflammatory cytokines. In animal models, increased sodium intake favours ventricular dysfunction after myocardial infarction (MI). The aim of this study was to investigate, in human subjects presenting with ST-segment elevation MI (STEMI), the impact of sodium intake prior the coronary event.MethodsConsecutive patients (n = 372) admitted within the first 24 h of STEMI were classified by a food intake questionnaire as having a chronic daily intake of sodium higher (HS) or lower (LS) than 1.2 g in the last 90 days before MI. Plasma levels of 8-isoprostane, interleucin-2 (IL-2), tumour necrosis factor type α (TNF-α), C-reactive protein (CRP) and brain natriuretic peptide (BNP) were measured at admission and at the fifth day. Magnetic resonance imaging was performed immediately after discharge. Total mortality and recurrence of acute coronary events were investigated over 4 years of follow-up.ResultsThe decrease of 8-isoprostane was more prominent and the increase of IL-2, TNF-α and CRP less intense during the first 5 days in LS than in HS patients (p < 0.05). Sodium intake correlated with change in plasma BNP between admission and fifth day (r = 0.46; p < 0.0001). End-diastolic volumes of left atrium and left ventricle were greater in HS than in LS patients (p < 0.05). In the first 30 days after MI and up to 4 years afterwards, total mortality was higher in HS than in LS patients (p < 0.05).ConclusionExcessive sodium intake increases oxidative stress, inflammatory response, myocardial stretching and dilatation, and short and long-term mortality after STEMI.     

Type 2 diabetes mellitus and chronic hepatitis C: Which is worse? Results of a long-term retrospective cohort study

BackgroundThe long-term outcome in patients with chronic hepatitis C and type 2 diabetes mellitus treated with interferon and ribavirin is unclear. We compared incidence of liver-related events and mortality rates between hepatitis C virus-positive patients with or without diabetes mellitus, and the incidence of diabetes-related events between diabetic patients with and without hepatitis C.MethodsRetrospective study of 309 patients with chronic hepatitis C. Incidence of liver-related events, diabetes-related events and mortality rates were assessed over a mean follow-up of 11.02 ± 4.9 years.Results50 (16%) chronic hepatitis C patients had diabetes mellitus. Diabetics showed a higher number of diabetes- and liver-related events than non-diabetics (10% vs 1.5%, p = 0.006; 18% vs 5.7%, p = 0.007, respectively) with a mortality of 14% vs 1.5% (p = 0.0003). Baseline cirrhosis (p = 0.002) and non-sustained virological response (p = 0.01) were independent risk factors for liver events; diabetes mellitus (p = 0.01) and hypertension (p = 0.0017) were independent factors for diabetes-related events.ConclusionsIn patients with chronic hepatitis C, comorbidity with diabetes mellitus was associated with a higher mortality rate and incidence of liver/diabetes-related events. Independent risk factors for liver-related events were the non-response to antiviral therapy and cirrhosis at baseline.     

Circulating high-mobility group box 1 and cardiovascular mortality in unstable angina and non-ST-segment elevation myocardial infarction

ObjectiveHigh-mobility group box 1 (HMGB1) is a damage-associated molecular pattern molecule, which suggests a potential role of this protein in the pathophysiology of acute coronary syndrome (ACS). Circulating HMGB1 has been shown to be independently associated with cardiac mortality in ST-segment elevation myocardial infarction. However, its prognostic value remains unclear in unstable angina and non-ST-segment elevation myocardial infarction (UA/NSTEMI).MethodsHMGB1, high-sensitivity C-reactive protein (hsCRP), cardiac troponin I and B-type natriuretic peptide concentrations were measured on admission in 258 consecutive patients (mean age of 67 years) hospitalized for UA/NSTEMI within 24 h (mean, 7.4 h) of the onset of chest symptoms.ResultsA total of 38 (14.7%) cardiovascular deaths, including 10 in-hospital deaths, occurred during a median follow-up period of 49 months after admission. In a stepwise Cox regression analysis including 19 well-known clinical predictors of ACS, HMGB1 [relative risk (RR) 3.24 per 10-fold increment; P = 0.0003], cardiac troponin I (RR 1.83 per 10-fold increment, P = 0.0007), Killip class > 1 (RR 4.67, P = 0.0001) and age (RR 1.05 per 1-year increment, P = 0.03), but not hsCRP, were independently associated with cardiovascular mortality. In-hospital and cardiovascular mortality rates were higher in patients with increased HMGB1 (≥2.4 ng/mL of median value) than those without increased HMGB1 (6.3% vs. 1.5%, P = 0.04; and 23% vs. 6.9%, P = 0.0003).ConclusionCirculating concentration of HMGB1 on admission may be a potential and independent predictor of cardiovascular mortality in patients hospitalized for UA/NSTEMI within 24 h of onset.     

Taxa de filtração glomerular: que fórmula deverá ser usada em doentes com enfarte agudo do miocárdio?

IntroductionThere is disagreement regarding the best method for assessing renal dysfunction in patients with myocardial infarction (MI). This study aims to compare two commonly used formulas for measuring glomerular filtration rate (GFR) (Cockcroft-Gault [CG] and modification of diet in renal disease [MDRD]) in terms of predicting extent of coronary artery disease (CAD) and short- and long-term cardiovascular risk.MethodsWe studied 452 patients admitted to a cardiac intensive care unit (ICU) with MI (age 69.01 ± 13.64 years; 61.7% male, 38.5% diabetic) and followed for two years. CG and MDRD GFR estimates were compared in terms of prediction of CAD extent, in-hospital mortality risk and cardiovascular risk during follow-up.ResultsGFR <60 ml/min/1.73 m² using the MDRD formula was associated with a tendency for more extensive CAD (2.70 affected segments vs. 2.20, p = 0.052) and higher two-year mortality risk (p < 0.001, OR 3.84, 95% CI 2.04-7.22) and risk for reinfarction (p < 0.001, OR 4.09, 95% CI 2.00-8.39), decompensated heart failure (DHF) (p < 0.001, OR 3.95, 95% CI 2.04-7.66) and combined cardiovascular endpoints (p = 0.001, OR 2.47, 95% CI 1.47-4.17). Using the CG formula, GFR < 60 ml/min/1.73 m² only predicted higher risk for DHF (p = 0.016, OR 4.5, 95% CI 1.11-16.57), despite a tendency for more overall combined cardiovascular endpoints (p = 0.09, OR 2.84). Both formulas predicted in-hospital mortality.Discussion/ConclusionsThis study confirmed the value of GFR in predicting various cardiovascular endpoints in patients with MI. Compared to the CG formula, the MDRD formula was significantly more accurate in predicting the severity of CAD and two-year CV risk in patients admitted to the ICU with MI.     

The influence of nursing homes in the functioning of internal medicine services

BackgroundSome hospitals attend to great number of patients who come from nursing homes whose median age, seriousness of illness and comorbidity differ of these patients from those of non-institutionalized patients. This can partly modify and thereby affect some of the parameters used to measure “assistance quality”.Materials and methodsThe data related to the demographic, clinical factors, severity criteria and mortality, were studied in patients hospitalized in two Internal Medicine Services during 2005–6 on the basis of whether they arrived from a nursing home or not. The data were obtained from the electronic databases of the two centers.ResultsDuring the study period, 13,712 patients were hospitalized (7110 in Fundación Hospital Alcorcón (FHA) and 6602 in Hospital Universitario Fuenlabrada (HUF)). A total of 789 (15.3%) patients of FHA arrived from a nursing home in comparison to 132 (2.6%) of those in HUF. Patients arriving from nursing homes were older (84.1 vs 69.8; p < 0.05), had a more serious illness (Group Related Diagnostic weight 2.1 vs 1.9; p < 0.05), more comorbidity (Charlson Index > 0; 75.5% vs 67.3%; p < 0.05) and increased mortality (16.8% vs 6.8%; p < 0.05) than the non-institutionalized patients, while length of hospital stay were shorter in the institutionalized patients (7.8 vs 8.3; p < 0.05). Intrahospital mortality was significantly associated with living in a nursing home (Odds Ratio 1.4 Confidence Interval 95% 1.1–1.8), regardless of age, gender, condition, comorbidity (Charlson Index), and the involved hospital.DiscussionThe number of nursing homes attended by a hospital determined the activity of an Internal Medicine Service. This study indicates that the patients from nursing homes were older, with increased severity and comorbidity of their illness, greater mortality and rehospitalization although, with similar length of stay.     

Hypoglycemia-associated mortality is not drug-associated but linked to comorbidities

ObjectiveAlthough tight glucose control is used widely in hospitalized patients, there is concern that medication-induced hypoglycemia may worsen patient outcomes. We sought to determine if the mortality risk associated with hypoglycemia in hospitalized noncritically ill patients is linked to glucose-lowering medications (drug-associated hypoglycemia) or merely an association mediated by comorbidities (spontaneous hypoglycemia).MethodsA retrospective cohort of patients admitted to the general wards of an academic center during 2007 was studied. The in-hospital mortality risk of a hypoglycemic group (at least 1 blood glucose ≤ 70 mg/dL) was compared with that of a normoglycemic group using survival analysis. Stratification by subgroups of patients with spontaneous and drug-associated hypoglycemia was performed.ResultsAmong 31,970 patients, 3349 (10.5%) had at least 1 episode of hypoglycemia. Patients with hypoglycemia were older, had more comorbidities, and received more antidiabetic agents. Hypoglycemia was associated with increased in-hospital mortality (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.33-2.09; P < .001). However, this greater risk was limited to patients with spontaneous hypoglycemia (HR, 2.62; 95% CI, 1.97-3.47; P < .001) and not to patients with drug-associated hypoglycemia (HR, 1.06; 95% CI, 0.74-1.52; P = .749). After adjustment for patient comorbidities, the association between spontaneous hypoglycemia and mortality was eliminated (HR, 1.11; 95% CI, 0.76-1.64; P = .582).ConclusionDrug-associated hypoglycemia was not associated with increased mortality risk in patients admitted to the general wards. The association between spontaneous hypoglycemia and mortality was eliminated after adjustment for comorbidities, suggesting that hypoglycemia may be a marker of disease burden rather than a direct cause of death.     

Predictors of survival within 2years of inpatient rehabilitation among older adults

BackgroundRestoring functional independence in elderly people with disabilities is one of the main purposes of a geriatric rehabilitation unit. However, the rehabilitation period may also represent a useful circumstance to identify predictors of long-term health outcomes. The aim of this study was to evaluate a broad spectrum of characteristics in geriatric patients admitted to a rehabilitation unit in order to identify possible predictors of long-term survival.MethodsThis cross-sectional and prospective study was carried out in an Evaluation and Rehabilitation unit in Northern Italy. 243 persons aged 65 or older were enrolled over a period of 12 months (2007–8) and followed for 2 years. Possible predictors of survival were identified among a large spectrum of demographic, clinical (Charlson Index, lab data), nutritional (Mini-Nutritional Short-Form, bio-impedance analysis), and respiratory (spirometry) features. Logistic regression models were used to evaluate the association between patients' characteristics and survival.Results189 (86.3%) participants were alive after 2 years of follow-up. Younger age, better functional status at discharge, a lower Charlson Index score, higher hemoglobin and albumin values at discharge, lower basal fasting glucose, creatinine, TNF-α levels, and extra-cellular water, as well as higher cholesterol, vital capacity (VC), and inspiratory capacity were significantly associated with survival. In the multivariate model, higher VC (OR = 6.2; 95%CI = 1.6–24.6) and albumin (OR = 3.7; 95%CI = 1.2–11.8) were associated with survival, whereas the Charlson Index and male gender showed an inverse correlation (OR = 0.77; 95%CI = 0.60–0.99 and OR = 0.23; 95%CI = 0.10–0.95, respectively).ConclusionVC was identified as one of the best predictors of survival along with higher albumin and lower Charlson Index score within 2 years of inpatient rehabilitation among older adults.     

Implementation of a pre-hospital network favoring primary angioplasty in STEMI to reduce mortality: the Algarve Project

ObjectiveTo analyze the impact of reperfusion by either primary percutaneous coronary intervention (PPCI) or fibrinolysis, and mortality rates of a pre-hospital fast-track network for treating patients with ST-elevation myocardial infarction (STEMI).Methods and ResultsA pre-hospital network for STEMI patients, designated the Green Lane for Acute Myocardial Infarction (GL-AMI), has been implemented in the southern region of Portugal – the Algarve Project. We performed an observational study based on a prospective registry of 1338 patients admitted to Faro Hospital between 2004 and 2009, classified in two groups according to the method of admission: emergency department group (EDG) and GL-AMI group (GLG). More patients from GLG were reperfused (p < 0.0001). PPCI was the preferred method of reperfusion, 73.1% in GLG and 45.3% in EDG. Time delays were significantly shorter in GLG, except for pre-hospital delay: pre-hospital delay (p = 0.11); door-to-needle (p < 0.0001); door-to-balloon (p < 0.0001); and delay between symptoms and reperfusion (p < 0.0001). In-hospital mortality (4.3% vs 9.2%, p = 0.0007) and 6-month mortality (6.3% vs 13.8%, p < 0.0001) were significantly lower in GLG.ConclusionsThe Algarve Project significantly reduced the time delay between onset of symptoms and reperfusion, significantly increased the rate of reperfusion, and significantly reduced in-hospital and six-month mortality.     

Multicentre, randomised, controlled study of the impact of continuous sub-cutaneous glucose monitoring (GlucoDay) on glycaemic control in type 1 and type 2 diabetes patients

AimThis randomised study was designed to investigate the impact of continuous glucose monitoring (CGM) for 48 h on glycaemic control with a 3-month follow-up in patients with type 1 (T1D) or type 2 (T2D) diabetes.MethodsA total of 48 patients with poor glycaemic control (HbA_1c: 8–10.5%) underwent CGM for 48 h using the GlucoDay^® system (A. Menarini Diagnostics), after which they were randomly assigned to treatment adjustments based on either their CGM profile (CGM group) or their usual self-monitoring of blood glucose (SMBG group). HbA_1c measurement and 48-h CGM were repeated 3 months later.ResultsAltogether, 34 patients with either T1D (n = 9) or T2D (n = 25) completed the study; seven patients chose to leave the study, and seven patients in the CGM group were excluded because their baseline CGM graphs were not interpretable. HbA_1c levels decreased significantly in the CGM group (n = 14, –0.63 ± 0.27%; P = 0.023), but not in the controls (n = 20, –0.28 ± 0.21%; P = 0.30). In T2D patients, the improvement associated with CGM vs SMBG was due to HbA_1c decreases (mean: –0.63 ± 0.34%; P = 0.05 vs –0.31 ± 0.29%; P = 0.18, respectively). However, HbA_1c did not change significantly with CGM in T1D patients. Comparisons of CGM data at baseline and after 3 months showed no significant changes in glucose control, glucose variability or hypoglycaemia. No major adverse events related to the GlucoDay^® system were reported.ConclusionThis is the first randomised study showing that CGM improves glycaemic control in patients with T2D.     

High serum matrix metalloproteinase-9 level predict increased risk of in-hospital cardiac events in patients with type 2 diabetes and ST segment elevation myocardial infarction

IntroductionThe purpose of this study was to compare serum matrix metalloproteinase (MMP)-9 levels in a population of type 2 diabetic versus non-diabetic patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and to examine the relationship between serum MMP-9 levels and the incidence of in-hospital cardiac events, including death and cardiogenic shock.MethodsWe recruited 120 patients with STEMI, of whom 48 were type 2 diabetic and 72 non-diabetic. Serum MMP-9 levels were measured on admission, using a commercially available ELISA. The primary study endpoint was cardiac death in-hospital and cardiogenic shock.ResultsMean serum MMP-9 levels were significantly higher in type 2 diabetic patients compared to non-diabetic patients (240 ± 52 ng/mL versus 185 ± 47 ng/mL; P < 0.0001). In multivariable analysis, type 2 diabetes was an independent factor for mortality [OR: 1.75 (1.40–2.30); P = 0.005] and cardiogenic shock [OR: 1.55 (1.20–1.70); P = 0.03] when the variable MMP-9 level was not introduced into the model, but it was less significantly associated with mortality [OR: 1.60 (1.40–2.10); P = 0.01] and no longer associated with cardiogenic shock when MMP-9 was in the model.ConclusionAfter STEMI, type 2 diabetes is independently associated with high serum MMP-9 levels. This elevated MMP-9 is strongly associated with the increased incidence of in-hospital mortality and cardiogenic shock observed in type 2 diabetes. Our findings clearly indicate that serum MMP-9 provides a highly valuable prognostic information on in-hospital outcome after STEMI, in particular in type 2 diabetic patients.     

Ketamine does not inhibit interleukin-6 synthesis in hepatic resections requiring a temporary porto-arterial occlusion (Pringle manoeuvre): a controlled, prospective, randomized, double-blinded study

IntroductionPrevious studies have shown that interleukin-6 (IL-6) levels correlated with mortality in critically ill patients.GoalTo determine the effect of ketamine on IL-6 levels in liver resections patients with a temporary porto-arterial occlusion (Pringle manoeuvre).Materials and methodsControlled, prospective, randomized, double-blinded study. One group (n = 21) received ketamine whereas the other group (n = 17) received placebo. IL-6 levels were obtained at baseline, 4, 12, 24 h, 3 and 5 days.ResultsThere were no significant differences in IL-6 levels between the groups (basal P = 089, 4 h P = 0.83, 12 h P = 0.39, 24 h, P = 0.55, 3 days P = 0.80 and 5 days P = 0.45). Both groups had elevated IL-6 levels that became almost undetectable by day 5. There was no major morbidity and no mortality in either group.ConclusionsKetamine does not seem to have an effect on plasma levels of IL-6. This could be interpreted as a potential finding associated with outcome as we did not encounter any deaths or major complications. Further studies will likely be needed to determine the range of IL-6 levels associated with survival and mortality, and whether it could be a predictor of survival.     

Trastornos por consumo de alcohol y neumonía neumocócica adquirida en la comunidad: mortalidad atribuible,prolongación de estancias y sobrecostes hospitalarios

IntroductionThe aim of this study was to investigate the impact of alcohol use disorders (AUD) on community-acquired pneumococcal pneumonia (CAPP) admissions, in terms of in-hospital mortality, prolonged stay and increased hospital spending.MethodsRetrospective observational study of a sample of CAPP patients from the minimum basic datasets of 87 Spanish hospitals during 2008-2010. Mortality, length of hospital stay and additional spending attributable to AUD were calculated after multivariate covariance analysis for variables such as age and sex, type of hospital, addictions and comorbidities.ResultsAmong 16,202 non-elective admissions for CAPP in patients aged 18-74 years, 2,685 had AUD. Patients admitted with CAPP and AUD were predominantly men with a higher prevalence of tobacco or drug use disorders and higher Charlson comorbidity index. Patients with CAPP and AUD had notably higher in-hospital mortality (50.8%; CI 95%: 44.3-54.3%), prolonged length of stay (2.3 days; CI 95%: 2.0-2.7 days) and increased costs (1,869.2 €; CI 95%: 1,498.6-2,239.8 €).ConclusionsAccording to the results of this study, AUD in CAPP patients was associated with increased in-hospital mortality, length of hospital stay and hospital spending.     

Factors associated with in-hospital mortality in patients with acute aortic syndrome involving the ascending aorta

BackgroundAortic intramural hematoma (IMH), a variant form of classic dissection (AD), is an increasingly recognized and potentially fatal entity of acute aortic syndrome (AAS). We sought to assess the real impact of increased recognition of IMH on mortality of AAS involving the ascending aorta.MethodsWe evaluated 186 consecutive patients with AAS involving the ascending aorta (57.0 ± 13.5 years, 95 females) admitted between January 1993 and March 2003.ResultsFinal diagnosis was AD in 135 patients and IMH in 51 (27%). Patients with AD were younger (54.0 ± 13 vs. 65.6 ± 10.7 years, p < 0.05) and surgery was more frequently performed (82% vs. 31%, p < 0.001). Overall in-hospital mortality was 16% (30/186); both total mortality (19% vs. 8%, p = 0.059) and mortality without surgery (71% vs. 9%, p < 0.001) was higher in AD. Logistic regression identified the following presenting variables as predictors of mortality: AD (OR 53.0; 95% CI, 6.6–425.4; p < 0.001), confusion/coma (OR 20.1; 95% CI, 3.8–107.8; p < 0.001), tamponade (OR 5.3; 95% CI, 1.2–24.3; p = 0.031), heart failure (OR 8.1; 95% CI, 1.1–61.0; p = 0.043), and medical treatment only (OR 17.6; 95% CI, 4.6–67.6, p < 0.001). Tamponade was more prevalent in IMH (25% vs. 11%, p = 0.038), and was a predictor of higher mortality in both groups.ConclusionIMH comprises of significant proportion of AAS involving the ascending aorta and is an independent variable associated with lower mortality despite lower frequency of surgery. Treatment option including optimal timing of surgery can be individualized based on underlying disease entity of AAS and some clinical features at the initial presentation.     

An acute hospital admission greatly increases one year mortality – Getting sick and ending up in hospital is bad for you: A multicentre retrospective cohort study

BackgroundFor most of the population a serious acute illness that require an emergency admission to hospital is a rare “once in a life time” event. This paper reports the one year mortality of patients admitted to hospital as acute emergencies compared to the general population.MethodThis is a post-hoc retrospective multicentre cohort study of acutely admitted patients from October 2008 to December 2013 aged 40 or higher. It compares the observed one-year mortality of both acute medical and surgical patients with the overall mortality in the general population at comparable age bands.ResultsWe included 18,375 patients and 4037 (22.0%) died within one year. For all age groups the one year mortality of those admitted to hospital for acute illness was markedly greater than for the general population. Although the odds ratio of death was highest in younger patients (e.g. odds ratio > 20 for 40 year olds), the absolute risk of death was greatest in the elderly (e.g. 20% mortality rate for men admitted to hospital over 65 years of age, compared to 1.7% for the general population).DiscussionAdmission to hospital for an acute illness is associated with a greatly increased risk of death within a year and for many elderly patients may be a seminal event.     

Initial management of septic patients with hyperglycemia in the noncritical care inpatient setting

BackgroundPrevious research on the management of hyperglycemia in patients with sepsis has focused primarily on those with established organ failure in the critical care setting. The impact of hyperglycemia and glycemic control in patients with infection before developing severe sepsis or shock remains undefined.MethodsThis observational, prospective, cohort study investigated the relationship between initial 72-hour time-weighted mean glucose concentrations and in-hospital mortality, intensive care unit transfer, and hospital length of stay in a cohort of patients with an acute infection who were admitted from the emergency department to a non-intensive care unit hospital ward. We used multivariate regression models adjusted for age, diabetes, and disease severity.ResultsA total of 1849 patients were included, of whom 29% had diabetes. In the 1310 nondiabetic patients, we observed hyperglycemia using time-weighted glucose concentrations: 121 to 150 mg/dL (n = 204, 16%), 151 to 180 mg/dL (n = 32, 2.4%), and greater than 180 mg/dL (n = 21, 1.6%). Insulin treatment was infrequent in nondiabetic patients, with 9%, 13%, and 29% of nondiabetic patients in these ranges receiving insulin, respectively. As patient glucose values increased, in-hospital mortality increased in nondiabetic patients, with odds ratios (ORs) of 4.4 (95% confidence interval [CI], 1.8-11), 10.0 (95% CI, 2.5-40), and 9.3 (95% CI, 1.9-44.0). Conversely, hyperglycemia did not confer an increased risk of adverse outcomes in diabetic patients. Likewise, increased risk for unplanned intensive care unit admission from the floor demonstrated ORs of 2.2 (95% CI, 1.1-4.3), 2.0 (95% CI, 0.45-8.9), and 6.3 (95% CI, 1.9-20.6) in nondiabetic patients, whereas no increased risk was found in diabetic patients.ConclusionsIn this cohort of acutely infected patients without established severe sepsis or shock, higher glucose concentrations within the first 72 hours in the nondiabetic population were associated with worse hospital outcomes and were less likely to be treated with insulin compared with diabetic patients.     

The impact of prior heart failure hospitalizations on long-term mortality differs by baseline risk of death

BackgroundHospitalizations for decompensated heart failure (HF) are thought to increase long-term mortality. However, previous reports focus on newly hospitalized HF patients or clinical trial populations and do not always adjust for baseline mortality risk. We hypothesized that the number of HF hospitalizations within the prior 12 months would improve overall mortality risk stratification, particularly in otherwise “low-risk” HF inpatients.MethodsWe studied 2221 HF patients admitted to 14 Michigan community hospitals during 2002-2004. We estimated 1-year mortality using the multivariable (Enhanced Feedback For Effective Cardiac Treatment [EFFECT]) model and classified patients as low (EFFECT <90), moderate (90-120), and high risk (>120). We used logistic regression and stratified Cox proportional hazard modeling to explore the overall EFFECT model performance and the influence of HF hospitalizations within the prior 12 months on mortality risk.ResultsThe EFFECT model adequately predicted and stratified for 1-year mortality (odds ratio 1.35 [95% confidence interval (CI), 1.30-1.40] per 10 points, P <.001, C-statistic 0.698), with low-, moderate-, and high-risk group mortality 18%, 35%, and 58%, respectively. The number of prior HF hospitalizations only modestly improved overall discrimination (C-statistic 0.704, P = .04). However, in low-risk patients the number of prior HF hospitalizations progressively increased the hazard for 1-year mortality (none: mortality 13%; 1: mortality 20%, hazard ratio [HR] 1.50 (95% CI, 0.86-2.60), P = .15; 2 or 3: mortality 27%, HR 2.24 (95% CI, 1.39-3.60); P = .001; 4 or more: mortality 31%, HR 2.80 (95% CI, 1.70-4.63); P <.001; P <.001 for trend). There was no consistent relationship between prior HF hospitalizations and 1-year mortality in moderate- or high-risk HF patients.ConclusionIn otherwise “low-risk” HF inpatients, a history of 2 or more HF hospitalizations within the prior 12 months markedly increases 1-year mortality risk. This easily obtained information could help allocate specialized HF resources to the subset of “low-risk” patients most likely to benefit.     

NT-proBNP for risk stratification of pulmonary embolism

IntroductionPulmonary embolism (PE) is an entity with high mortality and morbidity, in which risk stratification for adverse events is essential. N-terminal brain natriuretic peptide (NT-proBNP), a right ventricular dysfunction marker, may be useful in assessing the short-term prognosis of patients with PE.AimsTo characterize a sample of patients hospitalized with PE according to NT-proBNP level at hospital admission and to assess the impact of this biomarker on short-term evolution.MethodsWe performed a retrospective analysis of consecutive patients admitted with PE over a period of 3.5 years. Based on the median NT-proBNP at hospital admission, patients were divided into two groups (Group 1: NT-proBNP < median and Group 2: NT-proBNP ≥ median). The two groups were compared in terms of demographic characteristics, personal history, clinical presentation, laboratory, electrocardiographic and echocardiographic data, drug therapy, in-hospital course (catecholamine support, invasive ventilation and in-hospital death and the combined endpoint of these events) and 30-day all-cause mortality. A receiver operating characteristic (ROC) curve was constructed to determine the discriminatory power and cut-off value of NT-proBNP for 30-day all-cause mortality.ResultsNinety-one patients, mean age 69 ± 16.4 years (51.6% aged ≥75 years), 53.8% male, were analyzed. Of the total sample, 41.8% had no etiological or predisposing factors for PE and most (84.6%) were stratified as intermediate-risk PE. Median NT-proBNP was 2440 pg/ml. Patients in Group 2 were significantly older (74.8 ± 13.2 vs. 62.8 ± 17.2 years, p = 0.003) and more had a history of heart failure (35.5% vs. 3.3%, p = 0.002) and chronic kidney disease (32.3% vs. 6.7%, p = 0.012). They had more tachypnea on initial clinical evaluation (74.2% vs. 44.8, p = 0.02), less chest pain (16.1% vs. 46.7%, p = 0.01) and higher creatininemia (1.7 ± 0.9 vs. 1.1 ± 0.5 mg/dl, p = 0.004). Group 2 also more frequently had right chamber dilatation (85.7% vs. 56.7%, p = 0.015) and lower left ventricular ejection fraction (56.4 ± 17.6% vs. 66.2 ± 13.5%, p = 0.036) on echocardiography. There were no significant differences in drug therapy between the two groups. Regarding the studied endpoints, Group 2 patients needed more catecholamine support (25.8% vs. 6.7%, p = 0.044), had higher in-hospital mortality (16.1% vs. 0.0%, p = 0.022) and more frequently had the combined endpoint (32.3% vs. 10.0%, p = 0.034). All-cause mortality at 30 days was seen only in Group 2 patients (24.1% vs. 0.0%, p = 0.034). By ROC curve analysis, NT-proBNP had excellent discriminatory power for this event, with an area under the curve of 0.848. The best NT-proBNP cut-off value was 4740 pg/ml.ConclusionElevated NT-proBNP levels identified PE patients with worse short-term prognosis, and showed excellent power to predict 30-day all-cause mortality. The results of this study may have important clinical implications. The inclusion of NT-proBNP measurement in the initial evaluation of patients with PE can add valuable prognostic information.