Clinical Risk Factors For Death Research Articles

Clinical Risk Factors for Death in Patients With Empyema and Active Malignancy.

Background Pleural infection is a common clinical problem resulting in prolonged hospitalization and increased mortality. In patients with active malignancy, management decisions are based on the need for further immunosuppressive therapies, the ability to tolerate surgery, and consideration of the limited life expectancy. Identifying patients at risk for death or poor outcomes is very important as it will guide care. Study design and methods This is a retrospective cohort study of all patients with active malignancy and empyema. The primary outcome was time to death from empyema at three months. The secondary outcome was surgery at 30 days.Standard Cox regression model and cause-specific hazard regression model were used to analyze the data. Results A total of 202 patients with active malignancy and empyema were included. The overall mortality rate at three months was 32.7%. On multivariable analysis, female gender and higher urea were associated with an increased risk of death from empyema at three months. The area under the curve (AUC) of the model was 0.70. The risk factors for surgery at 30 days included the presence of frank pus and postsurgical empyema. The AUC of the model was 0.76. Interpretation Patients with active malignancy and empyema have a high probability of death. In our model, the risk factors for death from empyema included female gender and higher urea.

Supracardiac total anomalous pulmonary venous connection type Ib: Morphology and outcomes

BackgroundSupracardiac total anomalous pulmonary venous connection is the most common subtype of total anomalous pulmonary venous connection. We aimed to describe the morphological spectrum of supracardiac total anomalous pulmonary venous connection and to identify risk factors for death and postoperative pulmonary venous obstruction. MethodsFrom February 2009 to June 2019, 241 patients diagnosed with supracardiac-Ia (left-sided vertical vein, n = 185) or supracardiac-Ib (right-sided connection directly to superior vena cava, n = 56) total anomalous pulmonary venous connection underwent initial surgical repair at our institute. Cases with functionally univentricular circulations or atrial isomerism were excluded. Patients' postoperative survival was described by Kaplan–Meier curves. Cox proportional hazards models and competing risk regression models were used to identify clinical risk factors for death and postoperative pulmonary venous obstruction. ResultsThere were 8 early deaths and 4 late deaths. The overall survivals at 30 days, 1 year, and 10 years were 97.1%, 94.8%, and 94.8%, respectively, in the supracardiac-Ia group (2.7%, 5/185) (hazard ratio, 4.8; P = .003). Five patients required reoperation for pulmonary venous obstruction, including 2 patients who required reintervention for superior vena cava syndromes (all in the supracardiac-Ib group). One patient required superior vena cava balloon dilation for superior vena cava syndromes. Multivariable analysis showed that the supracardiac-Ib group (12.5%, 7/56) had a significantly higher mortality rate than the supracardiac-Ia group (adjusted hazard ratio, 8.5, P = .008). Surgical weight less than 2.5 kg (adjusted hazard ratio, 10.8, P = .023), longer duration of cardiopulmonary bypass (adjusted hazard ratio, 1.15 per 10 minutes, P = .012), and supracardiac-Ib subtype (adjusted hazard ratio, 4.7, P = .037) were independent risk factors associated with death. The supracardiac-Ib subtype (adjusted hazard ratio, 4.8, P = .003) was an incremental risk factor associated with postoperative pulmonary venous obstruction. ConclusionsMorphological features of supracardiac total anomalous pulmonary venous connection, especially the supracardiac-Ib subtype, were risk factors associated with postoperative pulmonary venous obstruction and survival. Patients with unique anatomic subtypes might require more individualized surgical planning.

Bacteremia complicating urinary tract infection by Pseudomonas aeruginosa: Mortality risk factors

To examine the clinical risk factors for death within 30days of diagnosis of Pseudomonas aeruginosa-causing bacteremia after a urinary tract infection. A total of 62 patients with Pseudomonas aeruginosa isolated from both urine and blood at the same episode from January 2009 to December 2016 were enrolled in the present study. We retrospectively investigated clinical risk factors for death by comparison between surviving patients and those who died within 30days after diagnosis of P.aeruginosa bacteremia. The comparison for risk factors for bacteremia-related death included 31 categories, such as age, laboratory data, underlying diseases, clinical history, history of surgery, care in the intensive care unit, P.aeruginosa susceptibility to the antibiotics used at the time of bacteremia diagnosis and consultation with urological department. The study included 48 men and 14 women aged 71.3±10.4years. Nine patients (14.5%) died of P.aeruginosa bacteremia. Statistical analysis showed that non-survivors had significantly lower albumin levels than survivors (2.07±0.62 vs 2.62±0.65; P=0.023). The non-survivors had significantly higher rates of ventilator use, history of heart disease, septic shock and lower rates of consultation with urological departments after diagnosis (P<0.05). Patients with bacteremia complicating urinary infection by P.aeruginosa have a low death rate. Earlier intervention by urologists might improve patients' outcome. Lower albumin levels, ventilator use, history of heart disease and septic shock are factors associated with higher mortality rate.

Radiological findings associated with the death of newborns with necrotizing enterocolitis.

ObjectiveThe aim of this study was to identify radiological and clinical risk factors for death in newborns with necrotizing enterocolitis.Materials and MethodsThis was a retrospective cohort study, based on radiological examinations and medical charts of 66 infants with necrotizing enterocolitis, as confirmed by a finding of intestinal pneumatosis (stage IIA, according to modified Bell’s staging criteria). Radiological and clinical variables were evaluated.ResultsOf the 66 infants evaluated, 14 (21.2%) presented pneumatosis in the large and small bowel; 7 (10.6%) presented air in the portal system; and 12 (18.2%) died. Bivariate analysis revealed that the following variables were associated with death: bowel perforation; pneumatosis in the large and small bowel; air in the portal system; earlier gestational age; longer time on mechanical ventilation before the identification of pneumatosis; and longer time on mechanical ventilation before discharge or death. In the multivariate regression, the following variables remained as predictors of death: pneumatosis in the large and small intestines (odds ratio [OR] = 12.4; 95% confidence interval [95% CI] = 1.2-127.4; p = 0.035), perforation (OR = 23.2; 95% CI = 2.2-246.7; p = 0.009), and air in the portal system (OR = 69.7; 95% CI = 4.3-[not calculated]; p = 0.003).ConclusionThe set of factors most strongly associated with death in infants with necrotizing enterocolitis comprised extensive pneumatosis, pneumoperitoneum, and air in the portal system. Our findings confirm the importance of radiological imaging in the diagnosis and monitoring of necrotizing enterocolitis.

Risk factors for death in children during inpatient treatment of severe acute malnutrition: a prospective cohort study ,

Children who receive in-hospital treatment of severe acute malnutrition often have high mortality rates, and the reasons are not well understood. We assessed risk factors for death in children who were treated for malnutrition in a hospital. In a prospective observational study of 120 children who were receiving in-hospital treatment of severe acute malnutrition in Uganda with therapeutic formulas F-75 and F-100, we collected data on symptoms, clinical findings, plasma markers of refeeding syndrome (electrolytes and phosphate), and acute phase reactants, and recorded the nutritional therapy given in hospital. Seventeen children (14%) died. Clinical risk factors for death were the presence of oral thrush (HR: 5.0; 95% CI: 1.6, 15.2), a caretaker-reported severity of illness on a visual analog scale (HR: 1.7; 95% CI: 1.1, 2.6), impaired consciousness (HR: 16.7; 95% CI: 3.1, 90.4), and a capillary refill time >2 s (HR: 3.9; 95% CI: 1.4, 11.3). HIV infection was not associated with mortality (HR: 3.0; 95% CI: 0.7, 12.4), which was most likely due to low power. Biochemical risk factors were a plasma C-reactive protein concentration >15 mg/L on admission and low plasma phosphate that was measured on day 2 (HR: 8.7; 95% CI: 2.5, 30.1), particularly in edematous children. The replacement of F-75 with unfortified rice porridge to ameliorate diarrhea was associated with a higher risk of death, particularly if given during the first 2 d (HR: 5.0; 95% CI: 1.9, 13.3), which was an association that remained after adjustment for potential confounders (HR: 69.5; 95% CI: 7.0, 694.6). Refeeding syndrome may occur in children who are treated for malnutrition, even with moderately low plasma phosphate, and, in particular, in children with edematous malnutrition. The replacement of F-75 with unfortified rice porridge is associated with increased risk of death, which is possibly mediated by lowering plasma phosphate. The identified clinical risk factors may potentially improve the triage of children with malnutrition. This trial was registered at www.isrctn.com as ISRCTN55092738.

Clinical risk factors for death after release from prison in Washington State: a nested case-control study.

While mortality rates after prison release are high, little is known about clinical risk factors for death. We sought to identify risk and protective factors for all-cause and accidental poisoning (overdose) death. Nested case-control study of people released from prison. Washington State Department of Corrections, Washington, USA. Cases (699 all-cause deaths, of which 88 were among women, and 196 additional overdose deaths, of which 76 were among women) between 1999 and 2009 matched 1 : 1 to controls on sex, age and year of release using risk set sampling. Prison medical charts were abstracted for clinical information. Independent associations between clinical characteristics and all-cause and overdose mortality were assessed using conditional logistic regression. Key independent risk factors for all-cause mortality included homelessness [odds ratio (OR) = 1.53, 95% confidence interval (CI) = 1.06, 2.23], injection drug use (OR = 1.54, 95% CI = 1.16, 2.06), tobacco use (OR = 1.51, 95% CI = 1.07, 2.13), cirrhosis (OR = 4.42, 95% CI = 1.63, 11.98) and psychiatric medications before release (OR = 2.38, 95% CI = 1.71, 3.30). Independent risk factors for overdose mortality included substance use disorder (OR = 2.33, 95% CI = 1.32, 4.11), injection drug use (OR = 2.43, 95% CI = 1.53, 3.86), panic disorder (OR = 3.87, 95% CI = 1.62, 9.21), psychiatric prescriptions before release (OR = 2.44, 95% CI = 1.55, 3.85) and problems with opiates/sedatives (OR = 2.81, 95% CI = 1.40, 5.63). Substance use disorder treatment during the index incarceration was protective for all-cause (OR = 0.67, 95% CI = 0.49, 0.91) and overdose (OR = 0.57, 95% CI = 0.36, 0.90) mortality. Injection drug use and substance use disorders are risk factors for death after release from prison. In-prison substance use disorder treatment services may reduce the risk.

Clinical and Immunologic Predictors of Death After an Acute Opportunistic Infection: Results from ACTG A5164

Background: In the pre–antiretroviral therapy (ART) era, markers of increased disease severity during an acute opportunistic infection (OI) were associated with mortality. Even with ART, mortality remains high during the first year after an OI in persons with advanced HIV infection, but it is unclear whether previous predictors of mortality remain valid in the current era. Objective: To determine clinical and immunological predictors of death after an OI. Methods: We used clinical data and stored plasma from ACTG A5164, a multicenter study evaluating the optimal timing of ART during a nontuberculous OI. We developed Cox models evaluating associations between clinical parameters and plasma marker levels at entry and time to death over the first 48 weeks after the diagnosis of OI. We developed multivariable models incorporating only clinical parameters, only plasma marker levels, or both. Results: The median CD4+ T-cell count in study participants at baseline was 29 cells/µL. Sixty-four percent of subjects had Pneumocystis jirovecii pneumonia (PCP). Twenty-three of 282 (8.2%) subjects died. In univariate analyses, entry mycobacterial infection, OI number, hospitalization, low albumin, low hemoglobin, lower CD4, and higher IL-8 and sTNFrII levels and lower IL-17 levels were associated with mortality. In the combined model using both clinical and immunologic parameters, the presence of an entry mycobacterial infection and higher sTNFrII levels were significantly associated with death. Conclusions: In the ART era, clinical risk factors for death previously identified in the pre-ART era remain predictive. Additionally, activation of the innate immune system is associated with an increased risk of death following an acute OI.

Cardiac Magnetic Resonance Parameters Predict Transplantation-Free Survival in Patients With Fontan Circulation

Several clinical risk factors for death and heart transplantation have been identified in patients with Fontan circulation. It is unknown whether cardiac magnetic resonance (CMR) measurements of ventricular size and function are independently associated with these outcomes and further improve risk stratification. Data on patients with Fontan circulation who had a CMR study from January 2002 to January 2011 were retrospectively reviewed. The end point was time to death or listing for heart transplantation after the CMR study. The median age of the 215 patients was 18.3 years (25th, 75th percentiles: 14, 26) with a median age at Fontan of 3.6 years (2.3, 7.1). During a median post-CMR follow-up period of 4.1 years (2.6, 6.2), 24 patients (11%) reached the end point: 20 deaths, 3 transplantations, and 1 transplantation listing. In a multivariable Cox regression model with clinical parameters only, protein-losing enteropathy was associated with death or listing for transplant. A multivariable model, including clinical and CMR parameters, showed that in addition to protein-losing enteropathy, ventricular indexed end-diastolic volume >125 mL/body surface area raised to the 1.3 power was associated with the endpoint. A likelihood-ratio test comparing the 2 models showed that the addition of indexed end-diastolic volume resulted in a significantly improved end point prediction (P<0.001)-C-index increased from 0.63 to 0.79. CMR-derived ventricular indexed end-diastolic volume is an independent predictor of death or transplant in patients late after the Fontan operation and adds incremental value over clinical symptoms alone for risk stratification.

Stop Light: Mortality Risk In Adult Sickle Cell Disease and Criteria For Hematopoietic Stem Cell Transplant

▪ IntroductionThe integration of prognostic information into the clinical care of adults with sickle cell disease (SCD) assumes greater importance as more intensive therapeutic strategies are being developed, including hematopoietic stem cell transplantation (HSCT). In addition, more high-risk alternate donor options predominate in SCD, since allogeneic HSCT candidates seldom have matched sibling donors (MSD). We wanted to integrate individual clinical risk factors for death, such as white blood cell count (Platt, NEJM, 1994) or Tricuspid Regurgitant Jet Velocity (TRV), (Gladwin, NEJM, 2004) into eligibility criteria for HSCT. MethodsBaseline demographics, laboratory values, high-risk TRV (greater than 3.0 m/s), and 2-year mortality data on adults with SCD, available from the multi-centered Walk-PHaSST study (n=468 HbSS, 19 deaths), were used to estimate one- and two-variable positive predictive values (PPVs) for short-term mortality (Figure 1A). Using these data, we suggest the basis for a graded (‘stop light') HSCT eligibility schema in which patients with morbid disease and <10% 2-year mortality (green light, ‘low risk' disease) could be considered for standard-risk HSCT (e.g. reduced-intensity MSD) (Figure 1B). 10-15% mortality (yellow light, ‘moderate risk') or highly morbid disease could be considered for alternate donor transplants in which there is published experience in adults (e.g. reduced intensity haploidentical, Bolanos-Meade, Blood 2012). >15% mortality (red light, ‘high risk' disease) could be considered for high-risk alternate donor transplants (without published experience in adults, e.g. cord blood). We then applied this method for estimating HSCT eligibility to HbSS adults followed at University Hospitals Case Medical Center in Cleveland, Ohio (n=122), and contrasted this with criteria based on published recommendations (Hseih, NEJM, 2009), (STRIDE trial: http://clinicaltrials.gov/show/NCT01565616). ResultsWe developed a simple mortality-based prognostic scale with which to estimate SCD severity prior to referring for HSCT. In Walk-PHASST, multiple clinical variables contributed to high risk SCD (red boxes, Figure 1A). The Cleveland population is young (median age 28 years). Nonetheless, 23% (28 of 122) were high risk (red) patients, and 52% (64 of 122) were moderate risk (yellow) or had highly morbid disease. 12% (15 of 122) had low risk (green) SCD and morbid disease, based on our proposed ‘stop light' eligibility schema. Published eligibility criteria, which do not stratify based on SCD prognosis, identify 75-86% of adults in our center as having ≥1 indications for HSCT. [Display omitted] ConclusionsAlthough estimation of risk from transplant is evolving, we believe the proposed ‘stop light' graded eligibility may aid in the selection of appropriate patients and in risk-benefit counseling. We recognize the limitations of a scale based on a modest number of deaths. Nonetheless our simple mortality based prognostic scale is a tool with which to approach the integration of disease severity and HSCT risk in SCD.Yellow: Patients at moderate risk for 2-year (10-15%) mortality (yellow boxes, Figure 1A) or with highly morbid disease (>5 hospitalizations per year, h/o CVA, h/o silent infarct, estimated GFR <90 mL/min, macroalbuminuria, ≥2 ACS within 5 years, or sickle hepatopathy) are eligible for alternate donors with which there is published experience in adults (e.g. haploidentical as well as MSD).Green: Patients with 2-year mortality (<10%) but with morbid disease (>2 hospitalizations per year for two or more years, or acute chest within the past five years) are eligible for standard-risk HSCT (MSD only). Disclosures:No relevant conflicts of interest to declare.

The biomarker plasma galectin-3 in advanced heart failure and survival with mechanical circulatory support devices

During screening of heart transplantation (HTx) candidates supported by ventricular assist devices (VADs) for plasma biomarkers we found that galectin-3 (Gal-3) was increased pre-operatively in patients who later died during VAD support. Therefore, we analyzed the predictive value of plasma Gal-3 in the context of other potential clinical risk factors for death on device (DOD) in a cohort of 175 VAD patients. We analyzed numerous clinical factors and plasma Gal-3 levels of 175 VAD patients before device implantation. Eighty VAD patients were successfully bridged to HTx (BTT, 45.7%), 80 (45.7%) died on VAD, 2 recovered on device (BTR, 1.1%) and 13 (7.4%) were still on device. Uni- and multivariate analyses were performed to assess the importance of Gal-3 with respect to other clinical factors. Myocardial gene expression of Gal-3 was investigated in apex samples by RT-PCR (n = 30) and Western blotting (n = 45). Plasma Gal-3 levels were higher in VAD patients than in controls (16.6 ± 9.3 vs 9.5 ± 3.9 ng/ml, p < 0.0001). Cox regression showed several clinical factors and type of VAD as independent outcome predictors, but Gal-3 was not among them. Using the regression equation we grouped patients according to their factor constellation for prediction of survival on VAD. We propose a calculation method for VAD survival prediction. Gal-3 mRNA and protein were detectable in failing myocardium, but did not correlate with its plasma concentration. Galectin-3 levels are associated with severe heart failure but do not provide sufficient discrimination for prediction of outcomes after VAD implantation. Importantly, we were unable to confirm myocardial tissue as a primary source for the observed plasma elevations of Gal-3.

Acute mediastinitis: evaluation of clinical risk factors for death in surgically treated patients

Acute mediastinitis (AM) is the most lethal form of infection within the thorax. The authors of this study, using statistical tools, made an attempt to determine the most important clinical risk factors in retrospective material of patients treated surgically due to AM. A total of 44 consecutive patients with AM were subjected to surgery. The aetiology was differentiated: iatrogenic (19), traumatic (11), descending mediastinitis (9) and neoplastic (5). A statistical analysis was performed using chi-square test with Yates correction and analysis of variance test to investigate the correlation between mortality and selected risk factors such as age, gender, aetiology, microbiology, delay between the diagnosis and surgery, coexisting diseases and the kind and number of post-operative complications. The general death rate was 31.82%. Aetiology was associated with mortality: neoplastic (100%), descending (33.3%), iatrogenic (26.3%) and post-traumatic (9.1%). The following types of bacteria were isolated: aerobes (65.9%), anaerobes (25%) and mixed flora (9.1%). The prognosis was not related to age, gender or the kind of the pathogen. The risk of death increased depending on the number of preoperative co-morbidities (P = 0.0446), particularly on the occurrence of a neoplasm (P = 0.0104). Early qualification for surgery (<24 h) resulted in lower death rate (P = 0.085). Manifestation of more than two post-operative complications (P = 0.0007) should be listed as one of the most negative risk factors. The knowledge of negative prognostic factors can appear to be a crucial tool enabling one to work out a better therapeutic strategy for high-risk patients with AM.