Determinants Of Late Mortality Research Articles

Impact of Therapeutic Strategies on the Prognosis of Candidemia in the ICU*

To determine the epidemiology of Candida bloodstream infections, variables influencing mortality, and antifungal resistance rates in ICUs in Spain. Prospective, observational, multicenter population-based study. Medical and surgical ICUs in 29 hospitals distributed throughout five metropolitan areas of Spain. Adult patients (≥ 18 yr) with an episode of Candida bloodstream infection during admission to any surveillance area ICU from May 2010 to April 2011. Candida isolates were sent to a reference laboratory for species identification by DNA sequencing and susceptibility testing using the methods and breakpoint criteria promulgated by the European Committee on Antimicrobial Susceptibility Testing. Prognostic factors associated with early (0-7 d) and late (8-30 d) mortality were analyzed using logistic regression modeling. We detected 773 cases of candidemia, 752 of which were included in the overall cohort. Among these, 168 (22.3%) occurred in adult ICU patients. The rank order of Candida isolates was as follows: Candida albicans (52%), Candida parapsilosis (23.7%), Candida glabrata (12.7%), Candida tropicalis (5.8%), Candida krusei (4%), and others (1.8%). Overall susceptibility to fluconazole was 79.2%. Cumulative mortality at 7 and 30 days after the first episode of candidemia was 16.5% and 47%, respectively. Multivariate analysis showed that early appropriate antifungal treatment and catheter removal (odds ratio, 0.27; 95% CI, 0.08-0.91), Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.11; 95% CI, 1.04-1.19), and abdominal source (odds ratio, 8.15; 95% CI, 1.75-37.93) were independently associated with early mortality. Determinants of late mortality were age (odds ratio, 1.04; 95% CI, 1.01-1.07), intubation (odds ratio, 7.24; 95% CI, 2.24-23.40), renal replacement therapy (odds ratio, 6.12; 95% CI, 2.24-16.73), and primary source (odds ratio, 2.51; 95% CI, 1.06-5.95). Candidemia in ICU patients is caused by non-albicans species in 48% of cases, C. parapsilosis being the most common among these. Overall mortality remains high and mainly related with host factors. Prompt adequate antifungal treatment and catheter removal could be critical to decrease early mortality.

Intramucosal esophageal adenocarcinoma: Primum non nocere

Intramucosal esophageal cancer treatment is evolving. Less-invasive therapies have emerged, necessitating review of safety, effectiveness, and determinants of long-term outcome after esophagectomy to clarify the role of this traditional, maximally invasive, and potentially harmful therapy. From January 1983 to January 2011, 164 patients underwent esophagectomy alone for intramucosal adenocarcinoma. Cancers were subdivided by depth of invasion: lamina propria 50 (30%) and muscularis mucosa 114 (70%; inner 42 [26%], middle 16 [10%], and outer 56 [34%]). We assessed complications and esophagectomy-related mortality (safety) and cancer recurrence (effectiveness), and identified determinants of long-term outcomes. Barrett esophagus (P=.005), larger cancers (P<.001), worse histologic grade (P<.001), lymphovascular invasion (P<.001), and overstaging (P=.02) were associated with deeper cancers. One patient had regional lymph node metastases (0.6%). Seventy-five patients (46%) had complications. Seven of 9 deaths within 6 months were esophagectomy related, 6 from respiratory failure. Seven patients had recurrence, all within 4 years. Five-, 10-, and 15-year survivals were 82%, 69%, and 60%, respectively, which were similar to those of a matched general population. Determinants of late mortality were older age (P=.004), poorer lung function (P<.0001), longer cancer (P=.04), postoperative pneumonia (P=.06), cancer recurrence (P<.0001), and second cancers (P<.0001). Survival after esophagectomy for intramucosal adenocarcinoma is excellent, determined more by patient than cancer characteristics. Patient selection and respiratory function are crucial to minimize harm. Considering the outcome of emerging therapies, esophagectomy should be reserved for patients with a long intramucosal adenocarcinoma or those in whom endoscopic therapies fail or are inappropriate.

Anatomical risk factors for mortality and cardiac morbidity after arterial switch operation

Background. The arterial switch operation (ASO) is the treatment of choice for transposition of the great arteries. Methods. Anatomical risk factors on mortality and morbidity were analyzed retrospectively in 312 patients who underwent ASO between 1982 and 1997. Results. Survival was 95%, 92%, and 92% after 30 days, 5, and 10 years, respectively. Operative survival improved after 1990 to 97% ( p < 0.001). Risk factors for operative mortality were complex anatomy ( p = 0.018), coronary anomalies ( p = 0.008), and prolonged bypass time ( p < 0.001). Determinants of late mortality were coronary distribution ( p = 0.03), position of the great arteries ( p = 0.0095), bypass time ( p = 0.047), and aortic coarctation ( p = 0.046). After a follow-up of 3.6 ± 2.7 years (0.1 to 14.9 years), 98% had good left ventricle function, 94% were in sinus rhythm, 2.4% had moderate to severe pulmonary stenosis, 0.3% had significant aortic regurgitation, and 1% had coronary stenosis. Freedom from reoperation was 100%, 96%, and 94% after 1, 5, and 10 years, respectively. No preoperative anatomic parameter correlated with long-term morbidity. Conclusions. ASO can be performed with low operative mortality (< 5%) and long-term morbidity. Malformations associated with complex transposition of the great arteries influence early and late mortality.

Reoperations on heart valve prostheses: An analysis of operative risks and late results

To evaluate risks and complications of reoperations on heart valve prostheses, we reviewed data on 183 patients who underwent reoperation because of prosthetic valve malfunction. The incremental effect of the redo procedure on hospital mortality and morbidity was studied by comparing primary and reoperatiye procedures and analyzing a series of possible predisposing factors. Late survival after first and second reoperations was computed, and possible determinants of late mortality were examined. Overall operative mortality was 8.7%; emergency operation ( p = 0.0001), previous thromboembolism ( p = 0.05), and advanced New York Heart Association functional class ( p = 0.031) were the independent determinants. In a series of 1,355 patients having primary or secondary isolated valve replacement, the redo procedure was a significant risk factor in the univariate analysis ( p = 0.025) but not in the multivariate analysis except for the subset of patients having mitral valve replacement ( p = 0.052). The postoperative course was quite complicated, as evidenced by the long mean stay in the intensive care unit (mean stay, 3.8 days; longer than 2 days for 26% of the survivors). Nevertheless, postoperative complications were not significantly greater after a redo procedure than after a primary operation. Actuarial survival at 7 years was 57.3% ± 8%. A comparison with a nonhomogeneous series from our institution did not demonstrate significant differences. In the subset of 16 patients having a second reoperation, late survival was 37.8% ± 16% at 2 years. Advanced New York Heart Association class ( p = 0.0001), double prosthetic valve dysfunction ( p = 0.003), and any indication other than primary tissue failure ( p = 0.06) were determinants of late mortality. The surgical risk of reoperation on heart valve prostheses is higher than that of the primary operation, but there is no conclusive evidence that the difference is statistically significant. Life expectancy may be reduced, but late survival can be improved if conditions leading to myocardial damage are prevented, ie, reoperation is prompt when necessary.