Clinical and Surgical Evaluations of Reoperation After Mechanical Mitral Valve Replacement Due to Different Etiologies

Background:This study aimed to evaluate the clinical and surgical characteristics of patients who required reoperation after mechanical mitral valve replacement (MVR).Methods:We retrospectively identified 204 consecutive patients who underwent reoperation after mechanical MVR between 2009 and 2018. Patients were categorized according the reason for reoperation (perivalvular leakage, thrombus formation, or pannus formation). The patients' medical and surgical records were studied carefully and the rates of in-hospital complications were calculated.Results:The mean age was 51±12 years and 44% of the patients were male. The reasons for reoperation were perivalvular leakage (117 patients), thrombus formation (35 patients), and pannus formation (52 patients). The most common positions for perivalvular leakage were at the 6–10 o'clock positions (proportions of ≥25% for each hour position). Most patients had an interval of >10 years between the original MVR and reoperation. The most common reoperation procedure was re-do MVR (157 patients), and 155 of these patients underwent concomitant cardiac procedures. There were 10 in-hospital deaths and 32 patients experienced complications. The 10-year survival rate was 82.2 ± 3.9% in general, and the group of lowest rate was patients with PVL (77.5 ± 5.2%). The independent risk factors were “male” (4.62, 95% CI 1.57–13.58, P = 0.005) and “Hb <9g/dL before redo MV operation” (3.45, 95% CI 1.13–10.49, P = 0.029).Conclusion:Perivalvular leakage was the most common reason for reoperation after mechanical MVR, with a low survival rate in long term follow-up relatively.

National trends in the proportion of in-hospital deaths by cause of death among older adults with long-term care: a nationwide observational study in Japan from 2007 to 2017

Background Japan has promoted end-of-life care at home and in long-term care facilities, and the total proportion of in-hospital deaths has decreased recently. However, the difference in trends of in-hospital deaths by the cause of death remains unclear. We investigated the variation in trends of in-hospital deaths among older adults with long-term care from 2007 to 2017, by cause of death and place of care. Methods Using the national long-term care insurance registry, long-term care claims data, and national death records, we identified people aged 65 years or older who died between 2007 and 2017 and used long-term care services in the month before death. Using a joinpoint regression model, we evaluated time trends of the proportion of in-hospital deaths by cause of death (cancer, heart diseases, cerebrovascular diseases, pneumonia, and senility) and place of care (home, long-term care health facility, or long-term care welfare facility). Results Of the 3,261,839 participants, the mean age was 87.0 ± 8.0 years, and 59.2% were female. Overall, the proportion of in-hospital deaths decreased from 66.2% in 2007 to 55.3% in 2017. By cause of death, the proportion of in-hospital deaths remained the highest for pneumonia (81.6% in 2007 and 77.2% in 2017) and lowest for senility (25.5% in 2007 and 20.0% in 2017) in all types of places of care. The joinpoint regression analysis showed the steepest decline among those who died of senility, especially among long-term care health facility residents. Conclusions The findings of this nationwide study suggest that there was a decreasing trend of in-hospital deaths among older adults, although the speed of decline and absolute values varied widely depending on the cause of death and place of care.

Legalization of Medical Cannabis and Site of Death: Evidence From National Vital Statistics Mortality Data

We examined whether Medical Marijuana Legislation (MML) was associated with site of death. Using state-level data (1992–2018) from the National Vital Statistics System (NVSS), we employed difference-in-differences method to compare changes in death rate among older adults at four sites—nursing home (NH), hospital, home, hospice/other—over time in states with and without MML. Heterogeneity analyses were conducted by timing of MML adoption, and by decedent characteristics. Results show a negative association between MML implementation and NH deaths. Among early adopters (states with weakly regulated programs) and decedents with musculoskeletal disorders, there was a positive association between MML implementation and hospital deaths, whereas among late adopters (states with “medicalized” programs), there was a positive association between MML implementation and hospice deaths. Decline in NH deaths may reflect increased likelihood of transfers due to threat of Federal enforcement, penalties for poor outcomes, and liability concerns. Future studies should examine these associations further.

The impact of COVID-19 pandemic course in the number and severity of hospitalizations for other natural causes in a large urban center in Brazil

The COVID-19 pandemic may indirectly impact hospitalizations for other natural causes. Belo Horizonte is a city with 2.5 million inhabitants in Brazil, one of the most hardly-hit countries by the pandemic, where local authorities monitored hospitalizations daily to guide regulatory measures. In an ecological, time-series study, we investigated how the pandemic impacted the number and severity of public hospitalizations by other natural causes in the city, during 2020. We assessed the number and proportion of intensive care unit (ICU) admissions and in-hospital deaths for all-natural causes, COVID-19, non-COVID-19 natural causes, and four disease groups: infectious, respiratory, cardiovascular, and neoplasms. Observed data from epidemiological week (EW) 9 (first diagnosis of COVID-19) to EW 48, 2020, was compared to the mean for the same EW of 2015–2019 and differences were tested by Wilcoxon rank-sum test. The five-week moving averages of the studied variables in 2020 were compared to that of 2015–2019 to describe the influence of regulatory measures on the indicators. During the studied period, there was 54,722 hospitalizations by non-COVID-19 natural causes, representing a 28% decline compared to the previous five years (p<0.001). There was a concurrent significant increase in the proportion of ICU admissions and deaths. The greater reductions were simultaneous to the first social distancing decree or occurred in the peak of COVID-19 hospitalizations, suggesting different drivers. Hospitalizations by specific causes decreased significantly, with greater increase in ICU admissions and deaths for infectious, cardiovascular, and respiratory diseases than for neoplasms. While the first reduction may have resulted from avoidance of contact with healthcare facilities, the second reduction may represent competing causes for hospital beds with COVID-19 after reopening of activities. Health policies must include protocols to address hospitalizations by other causes during this or future pandemics, and a plan to face the rebound effect for elective deferred procedures.

Serum Lactate/Albumin as a Predictor of In-Hospital Mortality in ICU Pancreatitis Patients: an Analysis of the MIMIC-III Database

Background: Acute pancreatitis (AP) is a common serious illness, and is characterized by rapid deterioration and a high mortality rate. Several biomarkers can evaluate and guide the treatment of acute pancreatitis, but there is currently no consensus on which markers are the most effective, simple, and economical for treating early-onset AP. In this study, we used the MIMIC III database to conduct a retrospective study on the relationship between early lactate/albumin (LAC/ALB), in-hospital mortality, and complication rates in patients with acute pancreatitis in the ICU.Methods: Basic data and indicators of laboratory tests, hospital deaths, and hospitalization days of acute pancreatitis patients were extracted from the database, after which the relationship between LAC/ALB and hospital mortality, ICU hospitalization days, and organ failure were evaluated using a t-test, a rank-sum test, a chi-square test or Fisher's exact probability method, and a Cox proportional hazard model.Results: 894 patients met the requirements and were selected from the MIMIC III database. They were subsequently grouped according to the lower limit ratio of the LAC/ALB normal value of 0.7. The group with LAC/ALB>0.7 showed higher hospital mortality rates, and the Lac, Inr, nitrogen, blood sugar, AKI incidence, Tbil, Sapsii score, and Sofa scores were all higher than the group with LAC/ALB<0.7. A multivariate Cox regression analysis model was used to explore the relationship between LAC/ALB levels and inpatient mortality. After including different adjustment variables, we determined that LAC/ALB is a risk factor for in-hospital death. The results of the subgroup analysis of LAC/ALB levels and mortality of hospitalized patients indicate that higher levels of LAC/ALB are risk factors for in-hospital deaths in patients with acute pancreatitis.

The Effects of Integrative Palliative Oncology on Hospital Time, Hospice Referrals, and Advanced Care Planning

Background: Integrative palliative oncology incorporates mental, physical, and familial aspects of care into standard cancer treatment. Patients in these programs have access to a doctor, nurse, psychologist, social worker, and chaplain who are all trained in palliative oncology whereas standard oncology does not have this team. Integrative programs improve well-being while reducing futile treatments. We hypothesize that emergency department (ED) visits, inpatient admissions, intensive care unit (ICU) stays, hospital deaths, hospice referrals, and advanced care planning (ACP) are affected by these programs. Methods: A retrospective chart review analyzed patients from Parkview Regional Medical Center. Cohort A included 100 patients from a palliative oncology program. Cohort B included 100 patients who received standard oncology care. Cohorts were matched on gender, age, cancer type, and stage. Number of ED visits, ICU admissions, and inpatient stays were analyzed. Hospice referrals, hospital deaths, and ACP documents were also compared. Results: A T-test showed no difference between ED visits, ICU stays, or inpatient admissions between cohorts. A chi-square analysis also showed no difference in hospice referrals or hospital deaths. However, there were significantly more ACP documents on file for cohort A (p = 0.000132). This suggests that palliative oncology programs do not strongly affect hospital time or hospice referrals but may impact advanced care planning. Conclusion: Since the benefits of palliative oncology programs do not seem related to hospital time or hospice care, another factor must be responsible for improving patients’ quality of life. These programs emphasize family involvement and planning thus explaining the significant increase in ACP documents. Perhaps this extra support and preparedness also improves patients’ moods and well-being. Impact: Future studies should involve a larger sample size and focus on psychological aspects of these programs to determine why they benefit patient health, specifically mental health, and what improvements can be made.

Survival after COVID-19-associated organ failure among inpatients with systemic lupus erythematosus in France: a nationwide study

ObjectiveWe analysed the incidence of, the specific outcomes and factors associated with COVID-19-associated organ failure (AOF) in patients with systemic lupus erythematosus (SLE) in France.MethodsWe performed a cohort study using the French national medical/administrative hospital database for the January 2011–November 2020 period. Each patient with SLE diagnosed in a French hospital with a COVID-19-AOF until November 2020 was randomly matched with five non-SLE patients with COVID-19-AOF. We performed an exact matching procedure taking age ±2 years, gender and comorbidities as matching variables. COVID-19-AOF was defined as the combination of at least one code of COVID-19 diagnosis with one code referring to an organ failure diagnosis.ResultsFrom March to November 2020, 127 380 hospital stays in France matched the definition of COVID-19-AOF, out of which 196 corresponded with patients diagnosed with SLE. Based on the presence of comorbidities, we matched 908 non-SLE patients with COVID-19-AOF with 190 SLE patients with COVID-19-AOF. On day 30, 43 in-hospital deaths (22.6%) occurred in SLE patients with COVID-19-AOF vs 198 (21.8%) in matched non-SLE patients with COVID-19-AOF: HR 0.98 (0.71–1.34). Seventy-five patients in the SLE COVID-19-AOF group and 299 in the matched control group were followed up from day 30 to day 90. During this period, 19 in-hospital deaths occurred in the SLE group (25.3%) vs 46 (15.4%) in the matched control group; the HR associated with death occurring after COVID-19-AOF among patients with SLE was 1.83 (1.05–3.20).ConclusionsCOVID-19-AOF is associated with a poor late-onset prognosis among patients with SLE.

The Relationship Between Place of Death and Immigrant Status

Increasing attention is being paid to improving care at the end-of-life, including developing a better understanding of where individuals die, and factors related to place of death. The older immigrant population in the United States is increasing rapidly, and while prior research suggests they may differ in their end-of-life experiences, we know relatively little about foreign-born differences in where people die. This study investigates how the place of death (home, hospital, and nursing home) differs between the U.S.-born and foreign-born. We used data on 9,180 U.S.-born and 969 foreign-born respondents from the nationally representative Health and Retirement Study (HRS) for who end-of-life surveys were conducted with a proxy between 2002 and 2016. Approximately one-third of deaths occurred in nursing homes in both groups. Hospital deaths were more common in US-Born decedents (31.9%) than foreign-born decedents (25.2%), while death at home was lower for US-born (35.5%) than foreign-born (40.2%). We used multinominal logistic regression analysis to determine whether sociodemographic characteristics, cause of death, or receipt of family caregiving explained the observed differences in place of death by foreign-born status. Results from fully adjusted multivariate models indicate the foreign-born differences in place of death cannot be explained by socioeconomic, health, or family factors. Our research shows key differences in the end-of-life experience between US-born and foreign-born older adults and highlights the importance of examining end-of-life experiences for this small, but rapidly growing segment of the older U.S. population.

Older adults show biomarker evidence of PICS after sepsis

Background Hospital deaths after sepsis have decreased substantially and most young adult survivors rapidly recover (RAP). However, many older survivors develop chronic critical illness (CCI) with poor long-term outcomes. The etiology of CCI is multifactorial and the relative importance remains unclear. Sepsis is caused by a dysregulated immune response and biomarkers reflecting a persistent inflammation, immunosuppression and catabolism syndrome (PICS) have been observed in CCI after sepsis. Therefore, the purpose of this study was to compare serial PICS biomarkers in a) older (versus young) adults and b) older CCI (versus older RAP) patients to gain insight into underlying pathobiology of CCI in older adults. Methods Prospective longitudinal study with young (≤ 45 years) and older (≥ 65 years) septic adults who were characterized by a) baseline predisposition, b) hospital outcomes, c) serial SOFA organ dysfunction scores over 14 days, d) Zubrod Performance status at three, six and 12-month follow-up and e) mortality over 12 months. Serial blood samples over 14 days were analyzed for selected biomarkers reflecting PICS. Results Compared to the young, more older adults developed CCI (20% vs 42%) and had markedly worse serial SOFA scores, performance status and mortality over 12 months. Additionally, older (versus young) and older CCI (versus older RAP) patients had more persistent aberrations in biomarkers reflecting inflammation, immunosuppression, stress metabolism, lack of anabolism and anti-angiogenesis over 14 days after sepsis. Conclusion Older (versus young) and older CCI (versus older RAP) patient subgroups demonstrate early biomarker evidence of the underlying pathobiology of PICS.

Impact of polymyxin B hemoperfusion therapy on high endotoxin activity level patients after successful infection source control: a prospective cohort study

We sought to evaluate the clinical implication of endotoxin levels in gram-negative bacilli (GNB)-induced abdominal septic shock patients with polymyxin B-hemoperfusion (PMX-HP) treatment. A prospective cohort of 60 patients who received surgical infectious source control for abdominal sepsis from January 2019 to December 2020 was included in the study. Endotoxin activity (EA) levels and Sequential Organ Failure Assessment (SOFA) scores were assessed immediately after surgery (baseline), 24, and 48 h post baseline. With receiver operating characteristic curves, the patients were stratified into two groups by the EA cut-off value (high-risk group vs low-risk group) and the clinical outcomes were compared. Logistic regression was performed to identify the clinical impact of PMX-HP on in-hospital death. Among the 31 high-risk patients (EA level ≥ 0.54), 16 patients (51.6%) received PMX-HP treatment and showed significant decreases in EA levels compared to patients who underwent conventional treatment only (− 0.34 vs − 0.12, p = 0.01). SOFA scores also showed significant improvement with PMX-HP treatment (12.8–8.9, p = 0.007). Fourteen in-hospital deaths occurred (45.2%), and PMX-HP treatment had a protective effect on in-hospital death (odds ratio (OR) 0.04, p = 0.03). In 29 low-risk patients (EA level < 0.54), seven patients (24.1%) received PMX-HP treatment and showed significant decreases in EA levels (0.46–0.16, p = 0.018). However, SOFA scores and in-hospital deaths were not improved by PMX-HP treatment. EA level significantly decreased after PMX-HP treatment and it may represent a therapeutic option to improve organ impairment and in-hospital death in septic shock patients with EA levels exceeding 0.54.