Clinical Predictors Of Mortality Research Articles

A simple score for predicting mortality in patients with pneumatosis intestinalis

Background and aimThis study was conducted to identify simple computerized tomography (CT) and clinical predictors of mortality in patients with pneumatosis intestinalis (PI). Thus, the clinical characteristics and outcomes of PI were assessed and the predictors of mortality were identified. MethodsThe medical records of 123 patients with PI were reviewed retrospectively. Multivariate logistic regression models were constructed to determine independent predictors of mortality. These data were used to develop a simple score that would predict mortality on the first and seventh day after diagnosis. ResultsThe median age at diagnosis was 62 (range, 20–91) years. The most common cause of PI was mesenteric vascular ischemia (n=43, 35.0%). Twenty-nine (23.6%) disease-related deaths occurred during the index admission. Both signs of peritoneal irritation on physical examination and decreased or absent enhancement of the bowel wall were associated with increased mortality. If both factors were absent, the in-hospital mortalities on both the first and seventh days after the diagnosis of PI were less than 5%. However, if both factors were present, the in-hospital mortality was 57% on the first day and 59% on the seventh day. ConclusionsA simple and novel risk score that predicts mortality in patients with PI was proposed. Patients with both peritoneal irritation and decreased or absent enhancement of bowel wall on CT should be observed vigilantly and early intervention should be instituted.

Mid‐region pro‐adrenomedullin adds predictive value to clinical predictors and Framingham risk score for long‐term mortality in stable outpatients with heart failure

The aim of this study was to evaluate the long-term prognostic utility of mid-region prohormone adrenomedullin (MR-proADM) in stable outpatients with heart failure (HF). Echocardiogram and serum for MR-proADM and BNP levels were obtained in 724 stable outpatients. These patients were followed for up to 6 years for the primary endpoint of all-cause mortality. There were 198 stage A patients, 328 stage B patients, and 200 stage C/D patients, with an average age of 68 ± 12 years. There were 195 deaths during the 6-year follow-up period. MR-proADM was predictive of mortality in the overall patient population. The predictive value of MR-proADM for long-term mortality was independent of BNP, echocardiographic indices of structural heart disease, clinical predictors of mortality, and the Framingham risk score. Patients with elevated MR-proADM had significantly increased risk for mortality in stage A and stage C/D HF, with hazard ratio (HR) 3.780, P < 0.001 and HR 2.744, P < 0.001, respectively. There was a trend toward increased mortality in patients with elevated MR-proADM and stage B HF (HR 1.579, P = 0.05005). MR-proADM added incremental predictive value to clinical predictors and the Framingham risk score. MR-proADM was a potent independent predictor of long-term all-cause mortality in stable outpatients with stage A-D HF, especially in patients in stage A and stage C/D HF. MR-proADM added incremental predictive value to clinical predictors and the Framingham risk score.

Clinical Predictors of Mortality and Outcomes in Patients with Transthyretin Cardiac Amyloidosis

Clinical Predictors of Mortality and Outcomes in Patients with Transthyretin Cardiac Amyloidosis

Indications for hospitalization and in-hospital mortality in Thai systemic sclerosis

This study aimed to identify the indications for hospitalization, hospital mortality rate, predictors of hospital mortality, and clinical parameters affecting length of stay (LOS) among Thai systemic sclerosis (SSc). A retrospective study was performed in SSc patients admitted in Khon Kaen University, Thailand, between January 2008 and December 2010. The respective clinical factors affecting LOS and predictors of mortality were analyzed using the Spearman's rank correlation and the Cox regression model. There were 202 hospital admissions among 131 SSc patients. The female-to-male ratio was 1.6:1. The median age at admission was 54.7 years (interquartile range (IQR) 49.2-62.9), the duration of disease at admission was 2.9 years (IQR 1.1-7.8), and the LOS was 5 days (IQR 2-10). The indications for hospitalization were divided equally between SSc-related and non-SSc-related events (53.5 vs. 46.5 %, respectively). The most common indication for hospitalization was infection (23.3 %) and pneumonia is the most common cause of infection (58.0 %). Prolonged LOS was related to fatigability status (p < 0.01), intestinal involvement (p < 0.01), electrolyte disorders (p < 0.01), multiple comorbidities (p < 0.01), modified Rodnan skin score ≥20 points (p = 0.01), disease duration under 5 years (p = 0.02), cardiac arrhythmia (p = 0.04), and deficiency anemia (p = 0.04). Hospital mortality was 16.8 per 100 person-years (95 % confidence interval (95 % CI) 10.8-24.3). Infection (59.1 %) was the most common cause of death, particularly from bacterial pneumonia. Clinical predictors of mortality were: disseminated intravascular coagulation related to infection (hazard ratio (HR) 52.73; 95 % CI 1.26-403.74), cardiac arrhythmia (HR 32.89; 95 % CI 3.00-359.95), electrolyte disorders (HR 15.66; 95 % CI 2.04-119.98), renal crisis (HR 13.38; 95 % CI 1.80-99.36), intestinal involvement (HR 10.42; 95 % CI 2.58-42.01), admission due to a non-SSc-related condition (HR 8.93; 95 % CI 2.21-36.13), and disease duration under 5 years (HR 6.67; 95 % CI 1.21-36.52). Infection was the most common cause of hospitalization. Prolonged LOS and hospital mortality should be warning signs in patients with shorter disease duration, presence of intestinal involvement, cardiac arrhythmia, and multiple comorbidities.

A prospective cohort study of stroke characteristics, care, and mortality in a hospital stroke registry in Vietnam.

BackgroundAs low and middle-income countries such as Vietnam experience the health transition from infectious to chronic diseases, the morbidity and mortality from stroke will rise. In line with the recommendation of the Institute of Medicine’s report on “Promoting Cardiovascular Health in the Developing World” to “improve local data”, we sought to investigate patient characteristics and clinical predictors of mortality among stroke inpatients at Da Nang Hospital in Vietnam.MethodsA stroke registry was developed and implemented at Da Nang Hospital utilizing the World Health Organization’s Stroke STEPS instrument for data collection.Results754 patients were hospitalized for stroke from March 2010 through February 2011 and admitted to either the intensive care unit or cardiology ward. Mean age was 65 years, and 39% were female. Nearly 50% of strokes were hemorrhagic. At 28-day follow-up, 51.0% of patients with hemorrhagic stroke died whereas 20.3% of patients with ischemic stroke died. A number of factors were independently associated with 28-day mortality; the two strongest independent predictors were depressed level of consciousness on presentation and hemorrhagic stroke type. While virtually all patients completed a CT during the admission, evidence-based processes of care such as anti-thrombotic therapy and carotid ultrasound for ischemic stroke patients were underutilized.ConclusionsThis cohort study highlights the high mortality due in part to the large proportion of hemorrhagic strokes in Vietnam. Lack of hypertension awareness and standards of care exacerbated clinical outcomes. Numerous opportunities for simple, inexpensive interventions to improve outcomes or reduce recurrent stroke have been identified.

Clinical Predictors of Mortality and Cause of Death in Lymphangioleiomyomatosis: A Population-based Registry

Lymphangioleiomyomatosis (LAM) is a rare, progressive, frequently lethal cystic lung disease that almost exclusively affects women. Prognostic information in LAM has been limited by small numbers and heterogeneous study methodology. Early retrospective cohorts cited 5- and 10-year mortality of 40 and 80 %, respectively. More recently, mortality at 10 years has been estimated to be approximately 10-20 % from the onset of symptoms and 30 % at 10 years from the time of lung biopsy but varies widely in individual patients. Given the heterogeneous disease course, it would be useful to establish which clinical characteristics are associated with survival to develop prediction models for disease outcome. The LAM Foundation maintains a population-based registry of 1,149 registered self-identified LAM patients. Of these, 590 have completed a "General Information/Clinical History Questionnaire" with limited demographic and clinical data, 410 of whom were identified as U.S. residents and provided date of birth. Vital status was obtained on all 410 participants through December 31, 2007 by linking patient identifiers and the National Death Index. Survival time was calculated as the time since first lung-related symptom or physician diagnosis until censoring (still alive, received lung transplant, or died). Cox proportional hazard analysis evaluated the association of demographic and clinical features with survival. Among the 410 subjects, there were 50 deaths and 55 lung transplantations during a median of 10.4 years of observation time. The estimated median transplant-free survival time for LAM patients in the United States is 29 years from symptom onset and 23 years from diagnosis. The estimated 10-year survival transplant-free was 86 %. Age at disease onset, smoking status, race, presence of tuberous sclerosis, occurrence of pneumothorax, and pregnancy did not demonstrate an association with survival or transplant. Greater age at presentation and presence of angiomyolipoma were associated with less risk of mortality. Treatment with hormonal therapy was associated with an increased risk of death/transplant (hazard ratio (HR) 2.93; 95 % confidence interval (CI), 1.54-5.58; p = 0.001), particularly progesterone therapy (HR 2.17; 95 % CI 1.26-3.75, p = 0.005), and may represent confounding by indication. Patients who required oxygen therapy had a worse outcome (HR 4.53; 95 % CI 2.76-7.42; p < 0.001). Our population-based study showed that the median survival in patients with LAM from the onset of symptoms or diagnosis is much longer than previously described. This has important implications for life choices and treatment decisions regarding medication use and lung transplantation for patients with LAM.

Impact of Acute Kidney Injury on One-Year Survival After Surgery for Aortic Dissection

Surgical treatment is an option for both type A aortic dissection and complicated type B aortic dissection. Acute kidney injury (AKI) influences the disease course after surgery. Our hypothesis was that AKI should be an important prognostic factor for aortic dissection after surgical treatment. Between July 2005 and October 2010, 268 patients (mean age 53 ± 14 years; range, 16 to 88) underwent open surgery for aortic dissection. We reviewed the clinical presentations, surgical variables, and postoperative outcomes to identify the risk factors of death. The 256 patients were divided into groups, with and without AKI, within 24 hours after operation according to the RIFLE (acronym for risk, injury, failure, loss, end stage) criteria. The in-hospital mortality rate was 17.9%, the 1-year mortality rate was 18.7%, and the major adverse cardiac events rate within 1 year was 29.9%. In multivariate analysis, patients more than 70 years of age (hazard ratio [HR] 2.390, p = 0.029), cardiogenic shock (HR 2.895, p = 0.005), preoperative ventilator use (HR 4.137, p = 0.018), operation at midnight (HR 2.295, p = 0.028), longer bypass time (HR 1.007, p < 0.001), and AKI (HR 2.552, p = 0.041) were clinical predictors of mortality. Kaplan-Meier analysis showed that the survival rate was strongly correlated with the severity of AKI by the RIFLE criteria. The independent predictors of AKI included hypertension (odds ratio 2.340, p = 0.027), sepsis (odds ratio 2.594, p = 0.043), and lower limb malperfusion (odds ratio 4.558, p = 0.022). Our study provides outcomes of postoperative aortic dissection. We found that AKI was a predictor of 1-year mortality by using the RIFLE criteria. Factors associated with increased 1-year mortality and AKI should be taken into consideration for surgery and postoperative care.

Clinical Predictors of Mortality in Adults with Intellectual Disabilities with and without Down Syndrome

Background. Mood, baseline functioning, and cognitive abilities as well as psychotropic medications may contribute to mortality in adults with and without Down Syndrome (DS). Methods. Population-based (nonclinical), community-dwelling adults with intellectual disabilities (IDs) were recruited between 1995 and 2000, assessed individually for 1–4 times, and then followed by yearly phone calls. Results. 360 participants (116 with DS and 244 without DS) were followed for an average of 12.9 years (range 0–16.1 years as of July 2011). 108 people died during the course of the followup, 65 males (31.9% of all male participants) and 43 females (27.6% of all female participants). Cox proportional hazards modeling showed that baseline practical skills, seizures, anticonvulsant use, depressive symptoms, and cognitive decline over the first six years all significantly contributed to mortality, as did a diagnosis of DS, male gender, and higher age at study entry. Analysis stratified by DS showed interesting differences in mortality predictors. Conclusion. Although adults with DS have had considerable improvements in life expectancy over time, they are still disadvantaged compared to adults with ID without DS. Recognition of potentially modifiable factors such as depression may decrease this risk.

Risk Factors for Pre-Treatment Mortality among HIV-Infected Children in Rural Zambia: A Cohort Study

BackgroundMany HIV-infected children in sub-Saharan Africa enter care at a late stage of disease. As preparation of the child and family for antiretroviral therapy (ART) can take several clinic visits, some children die prior to ART initiation. This study was undertaken to determine mortality rates and clinical predictors of mortality during the period prior to ART initiation.MethodsA prospective cohort study of HIV-infected treatment-naïve children was conducted between September 2007 and September 2010 at the HIV clinic at Macha Hospital in rural Southern Province, Zambia. HIV-infected children younger than 16 years of age who were treatment-naïve at study enrollment were eligible for analysis. Mortality rates prior to ART initiation were calculated and risk factors for mortality were evaluated.Results351 children were included in the study, of whom 210 (59.8%) were eligible for ART at study enrollment. Among children ineligible for ART at enrollment, 6 children died (mortality rate: 0.33; 95% CI:0.15, 0.74). Among children eligible at enrollment, 21 children died before initiation of ART and their mortality rate (2.73 per 100 person-years; 95% CI:1.78, 4.18) was significantly higher than among children ineligible for ART (incidence rate ratio: 8.20; 95% CI:3.20, 24.83). In both groups, mortality was highest in the first three months of follow-up. Factors associated with mortality included younger age, anemia and lower weight-for-age z-score at study enrollment.ConclusionsThese results underscore the need to increase efforts to identify HIV-infected children at an earlier age and stage of disease progression so they can enroll in HIV care and treatment programs prior to becoming eligible for ART and these deaths can be prevented.

Abstract 8416: Clinical Predictors of Short- and Long-Term Mortality Among Patients with Cardiovascular Implantable Electronic Device Infection

Device infection is associated with increased mortality in cardiovascular implantable electronic device (CIED) recipients. However, published data regarding clinical predictors of mortality in patients with CIED infection are limited. In current investigation, we sought to identify patient and device-related factors associated with mortality in CIED infection cases. We performed a retrospective review of all cases of CIED infection admitted to Mayo Clinic Rochester from 1991 to 2008. Survival data were obtained from hospital medical records and United Sates Social Security Index. Key data regarding patient demographics, device features, comorbid conditions, clinical presentation, echocardiographic findings and management strategies were abstracted. Potential risk factors for short (30-day) and long-term mortality were analyzed using univariate and multivariable logistic and Cox proportional hazards regression models, respectively. 415 cases of CIED infection were identified from the institutional database. The mean duration of follow-up for the 243 patients who were alive at last follow-up was 6.9 years. In multivariable model, congestive heart failure (CHF, Odds ratio 9.31, 95% CI 2.08-41.67), chronic corticosteroid use (OR 4.04, 1.40-11.60) and presentation with CIED-related infective endocarditis (CIED-IE), (OR 5.6, 2.25-13.92) were associated with increased odds of short-term mortality. Independent predictors of long-term mortality on multivariable model included patients' age (hazard ratio for 10-year increase 1.2, 95% CI 1.06-1.36), CHF (HR 2.01, 1.42-2.86), metastatic malignancy (HR 5.99, 1.67-21.53), corticosteroid use (HR 1.97, 1.22-3.18), renal failure (HR 1.94, 1.37-2.74) and CIED-IE (HR 1.68, 1.17-2.41). Our investigation provides some novel insights into predictors of short- and long-term mortality in CIED infection cases. While comorbid conditions and immunocompromised host status were primary determinants of both short- and long-term mortality, complicated device infection (CIED-IE) is the only predictor that presents an opportunity for intervention where mortality may be reduced by early diagnosis and expedited device removal.

Low Free Testosterone Predicts Mortality from Cardiovascular Disease But Not Other Causes: The Health in Men Study

Low testosterone is associated with all-cause mortality, but the relationship with cause-specific mortality is uncertain. Our objective was to explore associations between testosterone and its related hormones and cause-specific mortality. This was a population-based cohort study. Demographic and clinical predictors of mortality, and testosterone, SHBG, and LH were measured from 2001-2004 in 3637 community-dwelling men aged 70-88 yr (mean, 77 yr). Cause of death was obtained via electronic record linkage until December 31, 2008. During a mean follow-up period of 5.1 yr, there were 605 deaths. Of these, 207 [34.2%; 95% confidence interval (CI) = 30.4-38.1%] were due to cardiovascular disease (CVD), 231 to cancer (38.2%; 95% CI = 34.3-42.1%), 130 to respiratory diseases (21.5%; 95% CI = 18.2-24.8%), and 76 to other causes (12.6%; 95% CI = 9.9-15.2%). There were 39 deaths attributable to both cancer and respiratory diseases. Lower free testosterone (hazard ratio = 1.62; 95% CI = 1.20-2.19, for 100 vs. 280 pmol/liter), and higher SHBG and LH levels were associated with all-cause mortality. In cause-specific analyses, lower free testosterone (sub-hazard ratio = 1.71; 95% CI = 1.12-2.62, for 100 vs. 280 pmol/liter) and higher LH predicted CVD mortality, while higher SHBG predicted non-CVD mortality. Higher total testosterone and free testosterone levels (sub-hazard ratio = 1.96; 95% CI = 1.14-3.36, for 400 vs. 280 pmol/liter) were associated with mortality from lung cancer. Low testosterone predicts mortality from CVD but is not associated with death from other causes. Prevention of androgen deficiency might improve cardiovascular outcomes but is unlikely to affect longevity otherwise.

Thrombomodulin Gene Variants Are Associated With Increased Mortality After Coronary Artery Bypass Surgery in Replicated Analyses

We tested the hypothesis that genetic variation in thrombotic and inflammatory pathways is independently associated with long-term mortality after coronary artery bypass graft (CABG) surgery. Two separate cohorts of patients undergoing CABG surgery at a single institution were examined, and all-cause mortality between 30 days and 5 years after the index CABG was ascertained from the National Death Index. In a discovery cohort of 1018 patients, a panel of 90 single-nucleotide polymorphisms (SNPs) in 49 candidate genes was tested with Cox proportional hazard models to identify clinical and genomic multivariate predictors of incident death. After adjustment for multiple comparisons and clinical predictors of mortality, the homozygote minor allele of a common variant in the thrombomodulin (THBD) gene (rs1042579) was independently associated with significantly increased risk of all-cause mortality (hazard ratio, 2.26; 95% CI, 1.31 to 3.92; P=0.003). Six tag SNPs in the THBD gene, 1 of which (rs3176123) in complete linkage disequilibrium with rs1042579, were then assessed in an independent validation cohort of 930 patients. After multivariate adjustment for the clinical predictors identified in the discovery cohort and multiple testing, the homozygote minor allele of rs3176123 independently predicted all-cause mortality (hazard ratio, 3.6; 95% CI, 1.67 to 7.78; P=0.001). In 2 independent cardiac surgery cohorts, linked common allelic variants in the THBD gene are independently associated with increased long-term mortality risk after CABG and significantly improve the classification ability of traditional postoperative mortality prediction models.

Risk models including high-risk cardiovascular procedures: clinical predictors of mortality and morbidity

While isolated coronary artery bypass grafting (CABG) poses major risks as well as benefits to cardiovascular surgery, procedures such as thoracic aortic surgery and combined CABG surgeries are also important contributors to mortality and morbidity. The objective of this study was to create and validate risk models including high-risk cardiovascular procedures to improve quality. The Japan Cardiovascular Surgery Database of patients enrolled cardiovascular surgical patients between January 2005 and December 2007. Data were collected at presentation and by physician review of clinical records and were verified through third-party surgeons' auditing. We analyzed 36780 procedures in 120 hospitals. Using logistic regression, risk models were generated and validated by split-sample validation. In this analysis, 11948 procedures were isolated CABG, 11760 were valve surgeries, and 8440 were thoracic aortic surgeries. In a 30-day operative mortality risk model, 37 variables were significantly associated with outcome. In comparison to isolated CABG, the odds ratios (ORs) for a 30-day mortality were 1.81 for valve surgery (2.62 in mitral valve replacement and 2.72 in aortic valve plus mitral valve procedures) and 2.36 for thoracic aortic surgery (4.34 if indicated by rupture, 3.16 if involving only arch, 4.38 if involving distal aorta, 3.75 if descending, and 5.97 if thoraco-abdominal aorta). CABG combined with other procedures (n=3599) had increased risks in each morbidity risk model (OR: 1.21 in reoperation, 1.60 in stroke, 1.23 in dialysis, 1.97 in infection, and 1.40 in prolonged ventilation). The predictive power of our models is valued by a C-statistic of 0.830 for a 30-day postoperative mortality, 0.639 for reoperation, 0.726 for stroke, 0.817 for dialysis, 0.692 for infection, and 0.796 for prolonged ventilation. Though performance of isolated CABG surgery was stable in this era, CABG combined with valve or thoracic aortic surgery was still a high-risk procedure. Given better recognition of high patient risk from these models, earlier targeted perioperative interventions may reduce adverse effects.

Chromosome 9p21 Variant Predicts Mortality After Coronary Artery Bypass Graft Surgery

Recent genome-wide association studies have identified several chromosome 9p21 single nucleotide polymorphisms associated with coronary artery disease and myocardial infarction in nonsurgical populations. We have recently demonstrated an independent association between these 9p21 variants and perioperative myocardial injury after isolated primary coronary artery bypass graft (CABG) surgery. This study investigated the association of a 9p21 variant with mortality in patients after CABG surgery and its prognostic value to improve the EuroSCORE. In a 2-center, prospective, observational study of 846 white primary CABG surgery patients, we genotyped rs10116277, the 9p21 variant with the strongest association to perioperative myocardial injury in our cohort. To estimate the utility of rs10116277 for predicting all-cause mortality within 5 years after surgery, a Cox proportional hazard model was constructed to estimate the hazard ratios (HR) and 95% confidence intervals (CI) while adjusting for demographics and clinical covariates. The homozygote minor allele of rs10116277 was associated with significantly increased risk of all-cause mortality even after adjusting for other clinical predictors of mortality in a Cox proportional hazards model (HR, 1.7; 95% CI, 1.1-2.7; P=0.026). Addition of rs10116277 to the logistic EuroSCORE also significantly improved model prediction for mortality (HR, 1.82; 95% CI, 1.15-2.88; P=0.01). The 9p21 variant rs10116277 is independently associated with all-cause mortality after primary CABG surgery in whites and significantly improves the predictive value of the logistic EuroSCORE. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00281164.

Significant decrease in in-hospital mortality and major adverse cardiac events in Swiss STEMI patients between 2000 and December 2007.

To evaluate the in-hospital outcome of STEMI (ST elevation myocardial infarction) patients admitted to Swiss hospitals between 2000 and December 2007, and to identify the predictors of in-hospital mortality and major cardiac events. Data from the Swiss national registry AMIS Plus (Acute Myocardial Infarction and Unstable Angina in Switzerland) were used. All patients admitted between January 2000 and December 2007 with STEMI or a new LBBB (left bundle branch block) were included in the registry. We studied 12 026 STEMI patients admitted to 68 hospitals. The mean age was 64 +/- 13 years and 73% of the patients were male. Incidence of in-hospital death was 7.6% in 2000 and 6% in 2007. Reinfarction fell from 3.7% in 2000 to 0.9% in 2007. Thrombolysis decreased from 40.2% in 2000 to 2% in 2007. Clinical predictors of mortality were: age >65 years, Killips class III or IV, diabetes, Q wave myocardial infarction (at presentation). Patients undergoing percutaneous coronary intervention (PCI) had lower mortality and reinfarction rates (3.9% versus 11.2% and 1.1% versus 3.1% respectively, p <0.001) over time, although their numbers increased from 43% in 2000 to 85% in 2007. Patients admitted to hospitals with PCI facilities had lower mortality than patients hospitalised in hospitals without it, but the demographic characteristics differ widely between the two groups. Both in-hospital mortality and reinfarction decreased significantly over the time, parallel to an increased number of PCI. PCI was also the strongest predictor of survival. In-hospital mortality and reinfarction rate have decreased significantly in Swiss STEMI patients in the last seven years, parallel to a significant increase in the number of percutaneous coronary interventions in addition to medical therapy. Outcome is not related to the site of admission but to PCI access.

Significant decrease in in-hospital mortality and major adverse cardiac events in Swiss STEMI patients between 2000 and December 2007.

To evaluate the in-hospital outcome of STEMI (ST elevation myocardial infarction) patients admitted to Swiss hospitals between 2000 and December 2007, and to identify the predictors of in-hospital mortality and major cardiac events. Data from the Swiss national registry AMIS Plus (Acute Myocardial Infarction and Unstable Angina in Switzerland) were used. All patients admitted between January 2000 and December 2007 with STEMI or a new LBBB (left bundle branch block) were included in the registry. We studied 12 026 STEMI patients admitted to 68 hospitals. The mean age was 64 +/- 13 years and 73% of the patients were male. Incidence of in-hospital death was 7.6% in 2000 and 6% in 2007. Reinfarction fell from 3.7% in 2000 to 0.9% in 2007. Thrombolysis decreased from 40.2% in 2000 to 2% in 2007. Clinical predictors of mortality were: age >65 years, Killips class III or IV, diabetes, Q wave myocardial infarction (at presentation). Patients undergoing percutaneous coronary intervention (PCI) had lower mortality and reinfarction rates (3.9% versus 11.2% and 1.1% versus 3.1% respectively, p <0.001) over time, although their numbers increased from 43% in 2000 to 85% in 2007. Patients admitted to hospitals with PCI facilities had lower mortality than patients hospitalised in hospitals without it, but the demographic characteristics differ widely between the two groups. Both in-hospital mortality and reinfarction decreased significantly over the time, parallel to an increased number of PCI. PCI was also the strongest predictor of survival. In-hospital mortality and reinfarction rate have decreased significantly in Swiss STEMI patients in the last seven years, parallel to a significant increase in the number of percutaneous coronary interventions in addition to medical therapy. Outcome is not related to the site of admission but to PCI access.

Elevated Troponin Levels are Predictive of Mortality in Surgical Intracerebral Hemorrhage Patients

Elevated troponin levels are a common occurrence after ischemic stroke and subarachnoid hemorrhage (SAH), and have been described as a neurogenic form of myocardial injury. The prognostic significance of this event is controversial with numerous studies citing conflicting results. The importance of cardiac stress is of particular relevance in the operative management of intracerebral hemorrhage (ICH). To this end, we investigated whether troponin levels were an independent predictor of in-hospital mortality from all causes in surgically treated ICH patients. We performed a retrospective analysis of 110 patients admitted to Columbia Presbyterian hospital between 1999 and 2007 for ICH and subsequent clot evacuation. Those with angina or recent myocardial infarction were excluded. CT scans were reviewed to determine hematoma size, location, presence of intraventricular hemorrhage (IVH) or SAH, hydrocephalus, and midline shift. Hospital records were examined for known demographic and clinical predictors of mortality. Univariate analysis was used to screen for predictive factors (P <or= 0.20) and these variables were entered into the final multivariable logistic regression model along with gender and age. Of 110 patients, 10 were excluded due to insufficient records or pre-existing cardiovascular disease. Ninety-five patients had at least one troponin level and 83 had multiple levels. Univariate analysis revealed nine factors that predicted in-hospital mortality (P < 0.20): smoking, volume of hemorrhage, midline shift, IVH, neurological status on admission, admission troponin, post-surgical troponin, warfarin use, and international normalized ratio. Only two factors were significant in the final multi-variate model: admission troponin and volume of hemorrhage. Admission troponin levels were a significant risk factor for in-hospital mortality even after controlling for hemorrhage volume, gender, and age. Elevated cardiac troponin levels are predictive of mortality in surgically treated ICH patients and should be considered in management decisions. Implementation of cardio-protective strategies may improve outcomes in this patient population.

Serum Surfactant Protein-A Is a Strong Predictor of Early Mortality in Idiopathic Pulmonary Fibrosis

Serum surfactant protein (SP) A and SP-D had prognostic value for mortality in patients with idiopathic pulmonary fibrosis (IPF) in prior studies before the reclassification of the idiopathic interstitial pneumonias. We hypothesized that baseline serum SP-A and SP-D concentrations would be independently associated with mortality among patients with biopsy-proven IPF and would improve a prediction model for mortality. We evaluated the association between serum SP-A and SP-D concentrations and mortality in 82 patients with surgical lung biopsy-proven IPF. Regression models with clinical predictors alone and clinical and biomarker predictors were used to predict mortality at 1 year. After controlling for known clinical predictors of mortality, we found that each increase of 49 ng/mL (1 SD) in baseline SP-A level was associated with a 3.3-fold increased risk of mortality (adjusted hazard ratio, 3.27; 95% confidence interval, 1.49 to 7.17; adjusted p = 0.003) in the first year after presentation. We did not observe a statistically significant association between serum SP-D and mortality (adjusted hazard ratio, 2.04; p = 0.053). Regression models demonstrated a significant improvement in the 1-year mortality prediction model when serum SP-A and SP-D (area under the receiving operator curve [AROC], 0.89) were added to the clinical predictors alone (AROC, 0.79; p = 0.03). Increased serum SP-A level is a strong and independent predictor of early mortality among patients with IPF. A prediction model containing SP-A and SP-D was substantially superior to a model with clinical predictors alone.

Baseline BAL Neutrophilia Predicts Early Mortality in Idiopathic Pulmonary Fibrosis

The prognostic value of BAL fluid cell count differential in patients with idiopathic pulmonary fibrosis (IPF) is unknown. We hypothesized that baseline BAL fluid cell count differential (ie, elevated levels of neutrophils and eosinophils, or reduced levels of lymphocytes) would predict higher mortality among persons with IPF. We evaluated the association of BAL fluid cell count differential and mortality among 156 persons with surgical lung biopsy-proven IPF who underwent bronchoscopy with BAL and cell count differential measurements at presentation. Vital status was obtained among all participants. Cox regression analysis evaluated the association of BAL fluid cell count differential and mortality. After controlling for known clinical predictors of mortality, we found that each doubling of baseline BAL fluid neutrophil percentage was associated with a 30% increased risk of mortality (adjusted hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.01 to 1.62; adjusted p = 0.04) in the first year after presentation. We observed no association with BAL fluid lymphocyte percentage and mortality (adjusted HR per doubling, 0.99; 95% CI, 0.76 to 1.29; p = 0.93) or eosinophil percentage and mortality (adjusted HR per doubling, 0.99; 95% CI, 0.69 to 1.40; p = 0.95). Increased BAL fluid neutrophil percentage is an independent predictor of early mortality among persons with IPF. Alternatively, BAL fluid lymphocyte and eosinophil percentages were not associated with mortality. The clinical utility of BAL at the time of diagnosis of IPF should be reconsidered.

Predictors of mortality in ARDS patients referred to a tertiary care centre

In order to identify parameters predicting intensive care unit mortality in patients transferred to a specialized tertiary centre because of progressive acute respiratory distress syndrome, an observational pilot study was carried out involving 94 patients. Forty-one patients (43.6%) died. Survival was defined as intensive care unit discharge. Survivors were younger (32.0 +/- 11.8 vs. 39.1 +/- 12.4 yr, P = 0.008), at admission they had a lower acute physiology and chronic health evaluation (APACHE) II score (21.7 +/- 5.4 vs. 25.4 +/- 5.2, P = 0.0009), higher PaO2/FiO2 (122 +/- 79 vs. 79 +/- 42 mmHg, P = 0.002), lower positive end-expiratory pressure (10.6 +/- 3.1 vs. 12.5 +/- 3.7 cmH2O, P = 0.02) and a lower Murray score (2.8 +/- 0.63 vs. 3.0 +/- 0.62, P = 0.04). No differences were observed for tidal volumes and peak inspiratory pressures. Days of hospitalization and mechanical ventilation prior to transferral were not related to survival. Multivariate analysis of variables assessed on admission detected only differences for age (P = 0.014) and APACHE II (P = 0.005). Odds ratio was 1.06 (95% confidence interval (CI): 1.013-1.119) for age and 1.21 (CI: 1.059-1.381) for APACHE II. Multivariate analysis of changes in respiratory parameters, APACHE II and Murray score during the first 3 days after transferral revealed a significant difference only for positive end-expiratory pressure (P < 0.008). Corresponding odds ratio was 2.40 (CI: 1.25-4.58) for an increase of 1 cmH2O/24 h. Age-related mortality in this small, but highly selected group of patients with established ARDS increased early in life even in a population with an overall mean age of 35.1 yr. APACHE II was the only clinical predictor for mortality on admission. The need for a substantial increase in positive end-expiratory pressure after transferral markedly reduced the chance to survive.