Cox Regression Model For Mortality Research Articles

New Perspectives in the Association between Anthropometry and Mortality: The Role of Calf Circumference.

Considering the impact of sarcopenia on mortality, and the difficulty to assessment of body composition, the hypothesis of the study is that calf circumference (CC) is closely related to mortality in older patients. The aim of the study was to analyze the potential role of CC to predict mortality in old individuals at 3, 6 and 12 months after discharge from hospital. Patients aged >65 years were recruited for this retrospective study from September 2021 to March 2022. Their physical and body composition characteristics (including Body Mass Index-BMI and Mini Nutritional Assessment-MNA) were measured; data on mortality at 3 (T3), 6 (T6) and 12 (T12) months after discharge were recorded. Sarcopenia was diagnosed according to the 2019 European Consensus criteria. Participants were 192 older adults (92 women), with a mean age of 82.8±7.0 years. Sarcopenic people were 41. The mortality rate was higher in sarcopenic people only at T3 and T6. CC had comparable validity in predicting mortality to that of MNA and ASMMI (Appendicular Skeletal Muscle Mass), and was better than BMI and serum albumin at each time point. Youden's index showed that the best cut-off for CC for predicting mortality was 30.6 cm both at T3 (sensitivity: 74%; specificity: 75%) and T6 (sensitivity: 75%; specificity: 67%). At the Cox regression model for mortality, high values of CC (HR 0.73, CI95% 0.60-0.89/p<0.001) and ADL scores (HR 0.72, CI95% 0.54-0.96/p=0.04) were protective factors at T6 and T12 respectively; at T12 high comorbidity rate was a risk factor (HR 1.28, IC95% 1.02-1.62/p=0.04). CC has a validity comparable to MNA and ASMMI in predicting mortality at 3, 6 and 12 months after hospital discharge. Moreover, it can be considered an independent predictor of medium-term mortality in the hospitalized older population. CC can be an effective method for the prognostic stratification of these patients, due to its simplicity and immediacy.

Apathy Symptoms, Physical and Cognitive Function, Health-Related Quality of Life, and Mortality in Older Patients With CKD: A Longitudinal Observational Study

Apathy reflects diminished motivation, goal-directed behavior, and emotions, as well as less engagement in social interactions. Apathy overlaps with depression and is associated with cognitive decline. In the older individuals with chronic kidney disease (CKD), both depression and cognitive impairments are common, but apathy symptoms have been underreported. We investigated the occurrence of apathy symptoms and their associations with physical and cognitive functioning, health-related quality of life (HRQoL), and mortality in older patients with CKD. Prospective observational cohort study. 180 outpatients aged≥65 years with estimated glomerular filtration rate≤20mL/min/1.73m2 from 5 Dutch nephrology centers. Apathy symptoms at baseline were considered present when a Geriatric Depression Scale's 3-item apathy subscale score was≥2 points. Physical and cognitive functioning, HRQoL (assessed in annual geriatric assessments), and 4-year mortality. Linear regression for cross-sectional associations, linear regression models for longitudinal associations, and Cox regression models for mortality over 4 years of observation. Apathy symptoms were present in 64 patients (36%; 67% men; median age 75.5 years), of whom 32 (50%) had no depressive symptoms. At baseline, the presence of apathy symptoms was associated with significantly more frailty, more functional dependence, less physical capacity, lower visuoconstructive performance, worse delayed recall, and lower HRQoL scores. The presence of apathy symptoms at baseline was also associated with a higher mortality risk (hazard ratio, 2.3 [95% CI, 1.3-4.2], P=0.005 adjusted for age, sex, and high education level), but not with changes in physical and cognitive functioning or HRQoL during the follow-up period. Risk of selection bias and residual confounding. Apathy symptoms were highly prevalent and associated with concurrent lower physical and cognitive status, lower HRQoL, and increased mortality. These findings highlight apathy as a potentially important clinical phenotype in older CKD patients. We observed that older kidney patients often present apathy symptoms, such as less motivation, fewer goal-directed behaviors, fewer emotions, and less social engagement. Prior research has not extensively described apathy in kidney disease. We investigated the link between apathy symptoms and poor outcomes. We measured physical functioning, cognitive functioning, and quality of life. We learned that one-third of our older kidney patients showed symptoms of apathy, only half of whom had symptoms of depression. Patients with apathy symptoms showed lower quality of life and lower physical and cognitive performance. They also had a higher risk of death. These findings highlight the need for awareness of apathy symptoms in older kidney patients.

Abstract 10108: SuPAR, Galectin-3 and ST2 Are Associated With Chronic Kidney Disease Progression in Patients With Heart Failure With Reduced Ejection Fraction

Introduction: Patients with heart failure with reduced ejection fraction (HFrEF) are at risk for both acute and progressive kidney disease. Elevated levels of the circulating soluble urokinase plasminogen activator receptor (suPAR), Galectin-3, and soluble suppression of tumorigenicity 2 (ST2) have been associated with kidney disease progression in those with CKD. However, there is little known about their predictive value for glomerular filtration rate (GFR) decline in populations with HFrEF. Methods: We aimed to determine whether these biomarkers were associated with decline in GFR and death in patients with HFrEF. We included 310 participants from the Registry Evaluation of Vital Information for Ventricular Assist Devices in Ambulatory Life in whom baseline suPAR, Galectin-3, and ST2 and repeated measures of GFR were obtained. The primary outcome was change in 2021 CKD-EPI creatinine-based GFR over 2 years. Secondary outcome was mortality. A joint cox regression model for mortality controlled for age, sex, race, NYHA class, and change in GFR and accounted for competing risks of ventricular assist device (VAD) implantation and heart transplantation. Results: Participants were followed for 2 years or until VAD, transplant, or death. Mean age was 59 years (standard error of mean 0.7) and 36% had diabetes mellitus. Median GFR was 60 ml/min/1.73m 2 with 58% NYHA Class III. Of these, 45 died, 33 received LVAD, and 25 were transplanted. Higher baseline suPAR (β coefficient -0.22 √(ml/min/1.73m 2 ); 95%CI -0.29, -0.15; P&lt;0.001), Galectin-3 (β coefficient -0.02 √(ml/min/1.73m 2 ); 95%CI -0.04, -0.01; P=0.012), and ST2 (β coefficient -0.01 √(ml/min/1.73m 2 ); 95%CI -0.02, -0.01, -0.19; P&lt;0.001) plasma concentrations were associated with a decline in eGFR over time in multivariable models. Only ST2 (HR 1.02 per ng/mL increase; 95%CI 1.01, 1.03; P&lt;0.001) was associated with mortality, after controlling for longitudinal change in GFR. Conclusions: Higher baseline suPAR, Galectin-3, and ST2 were associated with GFR decline over 2 years in patients with HFrEF. ST2 was associated with a greater risk of mortality, while suPAR and Galectin-3 were not. These biomarkers may be incremental tools used to predict GFR decline in patients with advanced heart failure.

136 Ambulatory Follow-up After Emergency Department Discharge and Association With Outcomes Among Older Adults With Alzheimer’s Disease and Related Dementia

136 Ambulatory Follow-up After Emergency Department Discharge and Association With Outcomes Among Older Adults With Alzheimer’s Disease and Related Dementia

The role of tocilizumab therapy in critically ill patients with severe acute respiratory syndrome coronavirus 2.

Tocilizumab (TCZ), an interleukin-6 (IL-6) receptor antagonist, has been approved for use in rheumatoid arthritis and cytokine storm syndrome (CSS) associated with chimeric antigen receptor Tcells treatment. Although TCZ is currently utilized in the treatment of critically ill coronavirus 2019 (COVID-19) patients, data on survival impact is minimal. To assess the mortality rate of patients presenting with COVID-19 who received TCZ for suspected CSS. This retrospective cohort study was conducted at Henry Ford Health System between March 10, 2020 and May 18, 2020. Data collection began in May 2020 and was completed in June 2020. Patients included in the study required hospital admission and had positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction on nasopharyngeal swab. Eligibility criteria to receive TCZ, per hospital protocol, included any of the following: persistent fever, defined as 38.0°C for at least 6hours; a diagnosis of the acute respiratory distress syndrome (ARDS); serum ferritin≥1,000 (ng/mL) or doubling within 24hours; D-Dimer≥5 (mg/L); serum lactate dehydrogenase≥500 (IU/L); or interlukin-6 level≥5 times the upper limit of normal. Dosing was initially determined by weight, then changed to a fixed 400mg per hospital protocol. A comparator cohort was created from patients with COVID-19 and ARDS who did not receive TCZ. Patient survival was analyzed using the Kaplan-Meier method and compared by log rank test. A multivariable cox regression was applied to evaluate the association between TCZ and mortality. One hundred and thirty patients were evaluated in the study, 54 (41.5%) of whom received TCZ. Patients who received TCZ were younger (mean age, 63.8 vs. 69.4years; p=0.0083) and had higher body mass indices (mean, 33.9 vs. 30.4; p=0.005). Of the comorbid conditionsevaluated, heart disease was more common in the comparator group than the TCZ group (27 patients [35.5%] vs. 10 patients [18.5%]; p=0.034). A Kaplan-Meier survival curve demonstrated no difference in survival between TCZ and comparator patients (log rank p=0.495). In the multivariable Cox regression model for mortality at 30days, treatment with TCZ was not associated with decreased mortality (hazard ratio, 1.1; 95% confidence interval, 0.53-2.3; p=0.77). Lower mean C-reactive protein (CRP) levels were demonstrated within 48hours of disposition in the TCZ group (mean TCZ, 4.9 vs. mean comparator, 13.0; p=<0.0001). In this cohort study, no difference in survival was observed in critically ill patients treated with TCZ.

C-Terminal-Pro-Endothelin-1 Adds Incremental Prognostic Value for Risk Stratification After Ischemic Stroke.

Background and Aims: Endothelins have shown to play a role in the pathophysiology of ischemic stroke. We aimed at evaluating the incremental prognostic value of C-terminal-pro-endothelin-1 (CT-pro-ET-1) in a well-described cohort of acute stroke patients.Methods: We performed serial measurements of CT-pro-ET-1 in 361 consecutively enrolled ischemic stroke patients and assessed functional outcome and mortality after 90 days. As we found peak levels of CT-pro-ET-1 and the most prominent association with mortality on day 1 after admission (n = 312), we focused on this time point for further outcome analyses. We calculated logistic regression and cox proportional hazards models to estimate the association of CT-pro-ET-1 with our outcome measures after adjusting for demographic and clinical risk factors. To evaluate the incremental value of CT-pro-ET-1, we calculated the area under the receiver operating characteristics (AUC) curve and the continuous net reclassification index (cNRI) comparing the model with and without the biomarker CT-pro-ET-1.Results: In the univariate analysis CT-pro-ET-1 with a peak on day 1 after admission was associated with unfavorable outcome with an OR of 1.32 (95% CI, 1.16–1.51, p < 0.001) and with mortality with a HR of 1.45 (95% CI, 1.29–1.63, p < 0.001). After adjusting, CT-pro-ET-1 remained an independent predictor of mortality with an adjusted HR of 1.50 (95% CI, 1.29–1.74, p < 0.001), but not for functional outcome. Adding CT-pro-ET-1 to the cox-regression model for mortality, the discriminatory accuracy improved from 0.89 (95% CI, 0.84–0.94) to 0.92 (95% CI, 0.88–0.96) p < 0.001, and the cNRI was 0.72 (95% CI, 0.17–1.13).Conclusion: CT-pro-ET-1 with a peak level on day 1 was an independent predictor of mortality adding incremental prognostic value beyond traditional risk factors.

Assessment of clinical features and determinants of mortality among cancer patients with septic shock of pulmonary origin: a prospective analysis

BackgroundPneumonia-associated septic shock (PASS) in patients with cancer inflicts healthcare burden attributed to high morbidity and mortality. Current study was aimed to evaluate the clinical outcomes, microbiological characteristics, risk factors...

Utility of procalcitonin in predicting mortality among cases of hospital-acquired pneumonia: a North Indian study

Bckground Data regarding the role of biomarkers like procalcitonin (PCT) in predicting treatment outcomes in hospital-acquired pneumonia (HAP) are limited in an Indian setting. We set out to determine the usefulness of PCT in predicting mortality among the cases of nosocomial pneumonia, at an 800-bed, apex tertiary care centre, in Kashmir (North India). Patients and methods Of the 318 confirmed cases of HAP, 60 consenting cases were selected randomly. Quantitative determination of PCT was done using immunofluorescence assays. Levels greater than 0.5 ng/ml were taken as positive. Data were collected on clinical parameters, and Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores pneumonia severity index were calculated. Appropriate blood and respiratory cultures were performed. Results Of the 60 cases included in the study, 19 (32%) died during the hospital stay, of which 14 (74%) deaths occurred in PCT-positive cases (P=0.001). The median PCT level was higher in the in-hospital mortality group (1.07 vs. 0.25), with a mean value of 1.2±2.8 vs. 1.2±2.5 in the group with no mortality (P=0.000). Using multivariate analysis, positive PCT level was strongly associated with in-hospital mortality (odds ratio: 6.767, 95%CI: 1.992–22.984, P=0.002) and APACHE-II score greater than 20 (n=14, odds ratio=4.5, 95%CI=1.448–13.984, P=0.009). Using receiver operating characteristic analysis, PCT had apropos discrimination power for in-hospital mortality (0.713 of area under the curve) and higher APACHE-II scores (0.753 of area under the curve). Using Cox regression model for mortality in PCT-positive group, the calculated hazard ratio was 3.273 (95%CI: 1.076–9.951, P=0.037). Conclusion PCT might have a vital role in the management of HAP, as a predictor of the poor treatment outcome.

Posttransplant Anemia as a Prognostic Factor of Mortality in Kidney-Transplant Recipients.

Background. Findings on the association between posttransplant anemia (PTA) and mortality in posttransplant patients are scarce. This study explored whether PTA shortly after kidney transplantation (KT) predicts mortality at up to 10 years' follow-up, stratified for chronic kidney disease (CKD) stages. Methods. PTA was divided into 3 categories according to the hemoglobin (Hb) value: severe (Hb < 10 g/dl), mild (10.0 g/dl ≤ Hb < 11.9 g/dl), or no PTA (Hb ≥ 12 g/dl). CKD stages were estimated using the CKD-EPI formula and divided into 2 groups: CKD1-2 and CKD3–5. Cox regression, stratified according to CKD, was performed to identify whether different categories of PTA predicted mortality in KT recipients. Results. Age, being female, and both mild and severe PTA contributed significantly to the Cox regression model on mortality in CKD1-2. In the Cox regression model for mortality in CKD3–5, age and severe PTA contributed significantly to this model. Conclusion. PTA shortly after KT increased the risk of mortality at up to 10 years' follow-up. Even mild PTA is associated with a 6-fold higher risk of mortality and severe PTA with a 10-fold higher risk of mortality in CKD1-2. Clinical evaluation and treatment of anemia might reduce the higher risk of mortality in patients with PTA in early stages of CKD after KT.

Predictors of short- and long-term mortality in hospitalized veterans with elevated troponin.

Cardiac troponin elevation is associated with mortality. We compared the mortality risk related to elevated troponin from acute coronary syndrome (ACS) and non-ACS causes in a hospitalized elderly veteran population. As part of a quality initiative at our Veterans Affairs hospital, all patients with elevated troponin were evaluated by a cardiologist to determine if ACS was present and to recommend management. We selected a sample (n = 761) of consecutive patients studied between February 2006 and February 2007 and examined all-cause mortality over extended follow-up. Nearly all were men (99.1%), and about half had coronary disease (n = 385, 50.5%) and diabetes (n = 339, 44.4%). ACS patients had lower mortality that non-ACS patients. Mortality began to diverge at 30 days; at 1 year it was 42.0% versus 29.0% (odds ratio [OR]: 0.56, 95% confidence interval [CI]: 0.41-0.78) and at 6 years 77.7% versus 58.7% (OR: 0.41, 95% CI: 0.30-0.56). Cox regression models for mortality at multiple time points yielded several independent factors associated with mortality; however, the distribution of the factors was not sufficient to explain the observed difference in mortality. In this elderly, male veteran population, mortality related to an elevated troponin was higher at 1 and 6 years for non-ACS patients compared with ACS patients. Factors independently associated with a higher mortality risk were predominantly markers of general systemic illness, but did not elucidate the reasons why troponin elevation secondary to non-ACS causes carries this higher risk. A better understanding of these cardiac troponin elevations and implications for future mortality requires additional investigation. Journal of Hospital Medicine 2016;11:773-777. © 2016 Society of Hospital Medicine.

Risk of Mortality and of Atherosclerotic Events Among Patients Who Underwent Hemodialysis and Subsequently Developed Retinal Vascular Occlusion: A Taiwanese Retrospective Cohort Study.

Retinal vascular occlusion is considered a risk factor for cardiovascular diseases in the general population. However, the long-term outcomes of patients who undergo incident hemodialysis and subsequently develop retinal vascular occlusion have not been examined. To determine the mortality rate and subsequent prevalence of systemic vascular diseases associated with retinal vascular occlusion among patients undergoing hemodialysis in Taiwan. Data from the Taiwan National Health Institutes research database were used, and we identified 105,956 patients undergoing hemodialysis during the period from January 1997 to December 2008. In total, 113 patients with retinal artery occlusion and 463 patients with retinal vein occlusion were enrolled and matched for age, sex, and the duration of hemodialysis (at a 1:5 ratio) with patients without ocular disorders. Mortality and atherosclerotic events. A multivariate Cox regression model for mortality and a competing risk regression model for atherosclerotic events were used for this population-based retrospective cohort study. Of 113 patients with retinal artery occlusion and 463 patients with retinal vein occlusion, 66 (58.4%) and 245 (52.9%) were females, respectively (ranging in age from ≤40 to 80 years). Our study showed there was a significant risk of mortality among patients undergoing hemodialysis who subsequently developed retinal artery occlusion or retinal vein occlusion compared with patients undergoing hemodialysis without ocular disorders. Patients with retinal artery occlusion had higher risks of ischemic stroke (adjusted hazard ratio [HR], 3.35 [95% CI, 2.00-5.59]; P < .001), coronary artery disease (adjusted HR, 1.70 [95% CI, 1.23-2.36]; P = .001), acute coronary syndrome (adjusted HR, 2.03 [95% CI, 1.24-3.33]; P = .002), and peripheral arterial occlusive disease (adjusted HR, 2.15 [95% CI, 1.26-3.66]; P = .002) than did patients without ocular disorders. Patients with retinal vein occlusion had higher risks of hemorrhagic stroke (adjusted HR, 2.54 [95% CI, 1.50-4.30]; P = .001), coronary artery disease (adjusted HR, 1.55 [95% CI, 1.31-1.83]; P < .001), and acute coronary syndrome (adjusted HR, 1.53 [95% CI, 1.14-2.06]; P = .002) than did patients without ocular disorders. Our data demonstrate that the risks of mortality and atherosclerotic events were increased among patients undergoing incident hemodialysis who subsequently developed retinal vascular occlusion.

Value of the SYNTAX score in patients treated by primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: The MI SYNTAXscore study

The aims of this study were to evaluate the SYNTAX score (SXscore) calculated at 2 stages during a primary percutaneous intervention (PPCI), that is, SXscore I (diagnostic) and SXscore II (postwiring), and assess its additional value to standard clinical risk scores in acute myocardial infarction. SXscores I and II were applied to 736 consecutive acute ST-elevation myocardial infarction patients referred for PPCI between November 2006 and February 2008. SXscore changed significantly before (I: 16, interquartile range 9.5-23) and after wiring (II: 11, interquartile range 6-19), P < .001. Kaplan-Meier methods were used to compare the primary end point major adverse coronary events (MACE; composite of repeat MI, target vessel revascularization [TVR], and mortality) and secondary end point mortality at 1.5 years in tertiles of SXscore I and SXscore II. Major adverse coronary event was highest in the higher SXscore I tertile (11% vs 15% vs 23%, log-rank <0.01), driven primarily by increased rate of mortality (9% vs 11% vs 17%, log-rank 0.02). Major adverse coronary event was also highest in SXscore II tertile, by a combination of increased mortality and also TVR (TVR rate 2% vs 3% vs 9%, log-rank <0.01). Predictive Cox regression models for mortality and MACE were significantly and similarly improved by the addition of either SXscore I or SXscore II (hazard ratio 1.63, 95% CI 1.18-2.26, P < .01 for MACE) with respective c indices of 0.61 and 0.63 for MACE and 0.60 and 0.61 for mortality. SXscore during PPCI is a useful tool that provides additional risk stratification to known risk factors of long-term mortality and MACE in patients with ST-elevation myocardial infarction.