Differences In Mortality Risk Research Articles

Association of Oral Microbiome Diversity and All-Cause Mortality in the General US Population and in Individuals With Chronic Diseases: A Prospective Cohort Study.

To investigate whether oral microbiome diversity is associated with all-cause mortality in the general US population and in individuals with chronic diseases. We included 8224 individuals with oral microbiome diversity data from the National Health and Nutrition Examination Survey (2009-2012), representing 164,000,205 US adults, using a survey-weighted analysis method. Cox regression analyses were performed to identify the association between oral microbiome diversity and all-cause mortality. During a survey-weighted mean follow-up period of 8.86 years, 429 all-cause deaths (survey-weighted number: 7,124,920) occurred in 8224 participants. Cox regression analysis revealed that higher oral microbiome diversity was significantly associated with a lower all-cause mortality risk. Significant differences in all-cause mortality risk were observed among the different clusters based on oral microbiome β-diversity (log-rank p < 0.001). Subgroup analyses revealed that the oral microbiome diversity was independently associated with all-cause mortality in individuals with diabetes mellitus and hypertension. A multivariate logistic regression model showed that current smoking and antibiotic use were significantly associated with lower oral microbiome α diversity. Higher oral microbiome diversity was significantly associated with a lower all-cause mortality risk in the general US population and in individuals with diabetes mellitus and hypertension.

The impact of peptide receptor radionucleotide therapy with Lutetium-177 DOTATATE on cardiac metastases in neuroendocrine tumors

Abstract Background Cardiac metastasis from neuroendocrine tumors (NET) is rare and has been thought to potentially result in life threatening sequalae. Peptide receptor radionucleotide therapy (PRRT), such as Lutetium-177 (Lu-177) DOTATATE, has been validated as effective treatment for patients with NET who have progressed on somatostatin analogue (SSA) therapy and more recently suggested for use in SAA-naïve higher risk grade 2 and grade 3 NETs. However, Lu-177 DOTATATE therapy has been found to have potentially serious adverse effects both locally and systemically. Overall, the clinical significance of cardiac metastasis of NET, as well as the safety and efficacy of Lu-177 DOTATATE in this cohort, has not been thoroughly evaluated. Purpose This study assessed the outcomes and clinical consequences of cardiac metastatic involvement in patients with NET. Furthermore, this study investigated the safety of Lu-177 DOTATATE therapy in patients with cardiac metastases from NET. Methods All patients who underwent 68Ga-DOTATATE positron emission tomography for evaluation of NET across three tertiary centers between 2016 and 2022 were retrospectively evaluated. Patients with evidence of cardiac metastasis were further evaluated. Baseline characteristics, treatment modality, and clinical outcomes including mortality, arrhythmia or conduction disease, carcinoid heart disease, and heart failure admissions were recorded. Patients with cardiac metastases were grouped and compared based on therapeutic modality (conservative therapy with surveillance or SSA, Lu-177 DOTATATE therapy, or surgical resection of metastases). Results From 3253 patients with NET, 51 patients were identified to have cardiac metastases (mean age 66.7 ± 12.2 years, 54% male). Three patients underwent surgical resection of cardiac metastases, and in two of whom this was concomitant while undergoing valve surgery for carcinoid heart disease. Patients with cardiac metastasis had significantly higher mortality than patients without cardiac metastasis (HR 2.12, 95%CI 1.00 – 4.52, p = 0.049, Figure 1A). Median follow-up from diagnosis of cardiac metastasis was 3.64 years [IQR 1.59 – 5.64]. There was no significant difference in clinical outcomes between patients that received Lu-177 DOTATATE therapy (n = 27) and conservative therapy (n = 21). Specifically, there was no significant difference in mortality risk at five years post the diagnosis of cardiac metastasis between these groups (p = 0.47, Figure 1B). Conclusion Patients with cardiac metastasis from NETs have worse clinical outcomes than NET patients without cardiac metastatic involvement. Lu-177 DOTATATE therapy appears to be safe in patients with cardiac metastasis from NET.Figure 1AFigure 1B

Sex differences in clinical characteristics, phenotypes, management, and long-term outcomes of myocardial injury: an international cohort study

Abstract Background Several studies have demonstrated sex differences in patients presenting to the emergency department (ED) with myocardial infarction, heart failure or syncope. Whether sex-specific differences in chest pain patients with myocardial injury exist is unknown. Purpose To determine whether sex-specific differences in the clinical characteristics, phenotypes, management, and long-term outcomes of patients with myocardial injury exist. Methods Patients presenting to the ED with chest pain suggestive of MI were consecutively enrolled into a prospective multicenter international diagnostic study. Final diagnoses were centrally adjudicated by two independent cardiologists, applying the fourth universal definition of myocardial infarction, using all available medical records, including serial hs-cTn and cardiac imaging. Follow-ups were performed at 3 months, 1-, 2- and 5-years. The primary outcome was 5-year all-cause mortality. Secondary outcomes included 5-year cardiovascular mortality and non-cardiovascular mortality. Multivariable flexible parametric (Royston-Parmar) models assuming proportional hazards were fitted. Models were adjusted for age, history of coronary artery disease, history of malignancy, diabetes, hypertension, smoking status, history of liver disease, and renal function. Results Among 8046 chest pain patients presenting to the ED, 1158 (14.4%) had myocardial injury, of which 358 (31%) were females and 800 (69%) males. Women were older (79 years, vs. 73 years), had fewer cardiovascular risk factors and comparable non-cardiovascular comorbidities except for lung disease which was more commonly found in men. Myocardial injury phenotypes varied between sexes (Figure). The most common phenotype in both sexes was heart failure, yet it was more common in men (37.2%) than in women (22.3%). The second most common phenotype in women was hypertension (15.4%) and arrhythmia (15.4 %), while in men was myocarditis (17.8 %), followed by arrhythmia (15.8%). Women underwent less invasive coronary angiography (19.8% vs 26.9%) or stress testing (12% vs 21.5%). In the angiographic findings, women presented more often with normal findings (30.4% vs. 19.6%) or mild CAD (20.3% vs. 11.2%) whereas men displayed more frequently 3-vessel disease (14.5% vs. 36.4%), Table. After adjusting for known confounders, women were associated with a lower 5-years risk for all-cause mortality (HR 0.69; 95%CI: 0.56–0.83) and cardiovascular mortality (HR 0.61; 95%CI: 0.46–0.79). No statistically significant difference in non-cardiovascular mortality risk was found (HR 0.79; 95%CI: 0.59-1.04). Conclusions Women presenting with chest pain to the ED and having myocardial injury were less likely than men to undergo coronary angiography or non-invasive cardiac imaging. Long-term risk for all-cause or cardiovascular mortality was lower for women compared to men.Myocardial Injury phenotypesPatient management

Comorbidities, Tobacco Exposure, and Geography: Added Risk Factors of Heat and Cold Wave Related Mortality among United States Veterans with COPD.

Understanding the health risks associated with extreme weather events is needed to inform policies to protect vulnerable populations. To address this need, we estimated heat and cold wave related mortality risks in a cohort of veteran patients with chronic obstructive pulmonary disease (COPD) and explored disparities among strata of comorbidities, tobacco exposure, and urbanicity. We designed a time stratified case-crossover study among deceased patients with COPD between 2016 to 2021 in the Veterans Health Administration system. Distributed lag models with conditional logistic regression estimated incidence rate ratios (IRR) of heat and cold wave associated mortality risk from lag days 0 to 3 for heatwaves and 0 to 7 for cold waves. Attributable risks (AR) per 100,000 patients were also calculated. Of the 377,545 deceased patients with COPD, the largest heatwave related mortality risk was in patients with COPD and asthma, AR: 14,016 (95% CI: -326, 30,706) across lag days 0 to 3. The largest cold wave related mortality burden was in patients with COPD with no other reported comorbidities, AR: 1,704 (95% CI: 759, 2,686) across lag days 0 to 7. Patients residing in urban settings had the greatest heatwave, AR: 1,062 (95% CI: (576, 1,559), and cold wave AR: 1,261 (95% CI: 440, 2,105) related mortality risk (across lag days 0 to 1 and 0 to 7 respectively). There were no differences in mortality risk by tobacco exposure. Our findings show individuals with COPD are susceptible to heat and cold waves. This information can inform clinical practice and public health policy about the mortality risk vulnerable populations experience with respect to extreme weather conditions. Furthermore, our results may be used in the development and refinement of future extreme weather warning systems designed for public health purposes.

Heterogeneity in the Effect of Early Goal-Directed Therapy for Septic Shock: A Secondary Analysis of Two Multicenter International Trials.

The optimal approach for resuscitation in septic shock remains unclear despite multiple randomized controlled trials (RCTs). Our objective was to investigate whether previously uncharacterized variation across individuals in their response to resuscitation strategies may contribute to conflicting average treatment effects in prior RCTs. We randomly split study sites from the Australian Resuscitation of Sepsis Evaluation (ARISE) and Protocolized Care for Early Septic Shock (ProCESS) trials into derivation and validation cohorts. We trained machine learning models to predict individual absolute risk differences (iARDs) in 90-day mortality in derivation cohorts and tested for heterogeneity of treatment effect (HTE) in validation cohorts and swapped these cohorts in sensitivity analyses. We fit the best-performing model in a combined dataset to explore roles of patient characteristics and individual components of early goal-directed therapy (EGDT) to determine treatment responses. Eighty-one sites in Australia, New Zealand, Hong Kong, Finland, Republic of Ireland, and the United States. Adult patients presenting to the emergency department with severe sepsis or septic shock. EGDT vs. usual care. A local-linear random forest model performed best in predicting iARDs. In the validation cohort, HTE was confirmed, evidenced by an interaction between iARD prediction and treatment (p < 0.001). When patients were grouped based on predicted iARDs, treatment response increased from the lowest to the highest quintiles (absolute risk difference [95% CI], -8% [-19% to 4%] and relative risk reduction, 1.34 [0.89-2.01] in quintile 1 suggesting harm from EGDT, and 12% [1-23%] and 0.64 [0.42-0.96] in quintile 5 suggesting benefit). Sensitivity analyses showed similar findings. Pre-intervention albumin contributed the most to HTE. Analyses of individual EGDT components were inconclusive. Treatment response to EGDT varied across patients in two multicenter RCTs with large benefits for some patients while others were harmed. Patient characteristics, including albumin, were most important in identifying HTE.

EP.17B.04 Racial/Ethnic Differences in Risk of Mortality of Men and Women with Lung Cancer

EP.17B.04 Racial/Ethnic Differences in Risk of Mortality of Men and Women with Lung Cancer

Disparities in cancer mortality outcomes among adult immigrants in the United States.

134 Background: The “immigrant health paradox” posits that immigrants are generally healthier than US natives of similar demographic and socioeconomic background. However, immigrant noncitizens with cancer face unique barriers to care, including limited access to routine screening and continuous healthcare coverage, which may portend worse outcomes. Methods: The 2011-2018 National Health Interview Survey Linked Mortality Files were used to identify all adult (age ≥18 years) US natives, foreign-born citizens, and noncitizens with a cancer history. Differences by group were assessed using the chi-squared test with Rao &amp; Scott’s second-order correction. Cox-proportional hazards models tested associations between nativity/citizenship status and cancer-specific (CSM) and all-cause mortality (ACM), adjusted by age, gender, and survey year. Sequential models separately tested the added effects of individual patient-level covariates selected a priori —including race/ethnicity, smoking status, region, educational attainment, employment, insurance status, and having a usual source of care. Results: A total of 23,603,743 US natives, 1,647,188 foreign-born citizens and 477,861 noncitizens met criteria for inclusion. Compared to US natives, immigrants had significantly greater distribution of gastroesophageal (2.3%, noncitizens vs 2.3%, foreign-born citizens vs 1.0%, US natives, p &lt;0.001), head &amp; neck (8.4% vs 6.2% vs 4.4%, p =0.003), and lung cancers (3.1% vs 4.2% vs 2.8%, p =0.03). Of the1,302,0771 US natives, 105,258 foreign-born citizens, and 21,937 noncitizens who died during the study period, cancer was the primary cause of death for 52% of noncitizens and 62% of foreign-born citizens (vs 44%, p &lt;0.001). Lung cancer was the most common diagnosis in this group, accounting for 40% of cancer deaths among non-citizens (vs 19% vs 13%; p =0.03). Relative to US natives, foreign-born citizens had a significantly lower risk of all-cause (adjusted HR [95%CI], 0.67 [0.54-0.83]) but not cancer-specific mortality (0.94 [0.71-1.23]); no differences in mortality risk among noncitizens were observed. On subset analysis limited to adults with lung cancer, noncitizens had over twice the hazard of cancer death (2.72 [1.22-6.09]) as well as death from any cause (2.14 [1.01-4.55]). While the association with ACM was no longer significant in sequential models, the association remained significant for CSM. Importantly, insurance status attenuated but did not eliminate the risk of lung cancer death for noncitizens (2.63 [1.16-5.96]). Conclusions: Although immigrant noncitizens did not have a significantly greater risk of cancer death overall, those with lung cancer were more than twice as likely to die from their disease, even after adjustment for patient-level variables, including insurance status and having a usual source of care. Future research is warranted to identify root causes and potential points for intervention.

The influence of COVID-19 on short-term mortality in acute ischemic stroke: A systematic review and meta-analysis.

To evaluate the differences in short-term mortality risk between acute ischemic stroke (AIS) patients with and without SARS-CoV-2 infection. PubMed, EMBASE, Scopus, and Cochrane Databases were systematically searched from December 1, 2019 to May 20, 2022 using the keywords coronavirus disease 2019 (COVID-19), COVID-19, SARS-CoV-2, and ischemic stroke. A random-effects model was estimated, and subgroup analysis and meta-regressions were performed. The quality of eligible studies was assessed using the Newcastle-Ottawa Scale. A total of 26 eligible studies with 307,800 patients were included in this meta-analysis. The overall results show that in-hospital and 90-day mortality was 3.31-fold higher in AIS with SARS-CoV-2 patients compared with those without SARS-CoV-2. When matched for age and National Institutes of Health Stroke Scale score at admission, the risk ratio of in-hospital mortality from AIS among patients with SARS-CoV-2 versus without decreased to 2.83. Reperfusion therapy and endovascular thrombectomy may further reduce the risk of death in patients to some extent but do not increase the incidence of symptomatic intracerebral hemorrhage. Meta-regression showed that in-hospital mortality decreased with increasing National Institutes of Health Stroke Scale score in AIS with SARS-CoV-2 compared to those without SARS-CoV-2 and that the difference in mortality risk between the 2 was independent of age and sex. The results of this study suggest that AIS patients with SARS-CoV-2 have higher short-term mortality compared to AIS patients without SARS-CoV-2, and reperfusion and endovascular thrombectomy therapy may reduce the risk of short-term mortality to some extent. The differences in in-hospital mortality risk were similar across ages and sexes. Focused attention is therefore needed on AIS patients with SARS-CoV-2 to control mortality.

Socioeconomic and Urban-Rural Disparities in Genome-Matched Treatment Receipt and Survival after Genomic Tumor Testing.

Emerging cancer treatments are often most available to socially advantaged individuals. This study examines the relationship of patient educational attainment, income level, and rurality to the receipt of genome-matched treatment (GMT) and overall survival. Survey and clinical data were collected from patients with cancer (n = 1258) enrolled in the Maine Cancer Genomics Initiative. Logistic regression models examined whether receipt of GMT differed by patient education, income, and rurality. Kaplan-Meier curves and Cox regression were conducted to evaluate 12-month mortality. We completed additional exploratory analyses using Kaplan-Meier curves and Cox models stratified by receipt of GMT. Both logistic and Cox regression models were adjusted for age and gender. Educational attainment, income level, and rurality were not associated with GMT receipt. Of 1258 patients, 462 (36.7%) died within 365 days of consent. Mortality risk was associated with lower educational attainment (hazard ratio (HR): 1.30; 95% CI: 1.06 to 1.59; p = .013). No statistically significant differences in mortality risk were observed for income level or rurality. Exploratory models suggest that patients who did not receive GMT with lower educational attainment had higher mortality risk (HR = 1.36, 95% CI: 1.09 to 1.69, p = .006). For patients who did receive GMT, there was no difference in mortality risk between the education groups (HR: 1.01, 95% CI: 0.56 to 1.81, p > .9). While there were no disparities in who received GMT, we found a disparity in mortality associated with education level, which was more pronounced for patients who did not receive GMT. Future research is warranted to investigate the intersectionality of social disadvantage with clinical outcomes to address survival disparities.

Unveiling the female experience through adult mortality and survivorship in Milan over the last 2000 years

This study challenges historical paradigms using a large-scale integrated bioarchaeological approach, focusing on the female experience over the last 2,000 years in Milan, Italy. Specifically, 492 skeletons from the osteological collection of Milan were used to elucidate female survivorship and mortality by integrating bioarchaeological and paleopathological data, paleoepidemiological analyses, and historical contextualization. Findings revealed changes in female longevity, with a notable increase from Roman to contemporary eras, albeit plateauing in the Middle Ages/modern period. Significant sex-specific differences in mortality risk and survivorship were observed: females had higher mortality risk and lower survivorship in the Roman (first-fifth century AD) and Modern (16th-18th century AD) eras, but this trend reversed in the contemporary period (19th-20th century AD). Cultural and social factors negatively impacted female mortality in Roman and modern Milan, while others buffered it during the Middle Ages (sixth-15th century AD). This study underscored the importance of bioarchaeological inquiries in reconstructing the past, providing answers that may challenge historical assumptions and shedding light on how the interplay of cultural, social, and biological factors shaped the female experience across millennia.

WP3.12 - The influence between frailty, sarcopenia and physical status on mortality in patients undergoing emergency laparotomy

Abstract Aims Frailty and sarcopenia predict mortality in emergency laparotomy (EmLap) and both can be indicative of poor physical status. We aim to assess the prevalence of frailty, sarcopenia and physical status in EmLap and explore the relationship between these factors and 30-day, 90-day and 1-year mortality. Methods Retrospective analysis was performed on two Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) databases (2017-2019) which included patients ≥18years. Clinical frailty scale was used to classify frailty (score ≥4 as frail). Sarcopenia was assessed via total psoas index. Poor physical status (PPS) was defined by American Society of Anaesthesiologists physical status classification (ASA)≥4. One-way ANOVA and logistic regression were used for statistical analysis. Results 215 patients were included with 57.2% female and median age of 64years. Frailty was present in 17.2%, sarcopenia in 25.1% and 14.5% had PPS; 3.3% had all three factors. Frail patients had significantly higher risk for 30-day (p=0.003), 90-day (p=0.006) and 1-year mortality (p=0.032). Sarcopenic patients did not show significant differences in mortality risks up to 1 year. Patients with PPS had significantly higher mortality rates at 30-day (p&amp;lt;0.001), 90-day (p&amp;lt;0.001) and 1-year (p=0.001). Patients with all three factors had higher 30-day (p&amp;lt;0.001), 90-day (p=0.005) and 1-year mortality (p=0.049) than patients who have none of the factors. Conclusions Frailty, sarcopenia and PPS are prevalent in EmLap. Frailty and PPS were independently associated with short and long-term mortality but not sarcopenia. While overlap exists between frailty, sarcopenia and PPS, more studies are required to understand the complex interplay.

All-cause and cause-specific mortality risk among men and women with hepatitis C virus infection.

Hepatitis C virus (HCV) infection affects men and women differently, yet few studies have investigated sex differences in long-term mortality risk among the HCV-infected population. We conducted a population-based study to elucidate all-cause and cause-specific mortality among men and women with HCV infection. The study population consisted of adult participants from the 1999-2018 National Health and Nutrition Examination Survey, including 945 HCV-infected and 44,637 non-HCV-infected individuals. HCV infection was defined as either HCV seropositivity or detectable HCV RNA. Participants were followed until the date of death or December 31, 2019, to determine survival status. The HCV-infected population, both male and female, tended to be older, more likely to be Black, single, have lower income, lower BMI, higher prevalence of hypertension, and were more likely to be current smokers. During a median follow-up of 125.0 months, a total of 5,309 participants died, including 1,253 deaths from cardiovascular disease (CVD) and 1,319 deaths from cancer. The crude analysis showed that the risk of death from all causes and from cancer, but not from CVD, was higher in the HCV-infected population. After adjusting for potential confounders, we found that both HCV-infected men (HR 1.41, 95% CI 1.10-1.81) and women (HR 2.03, 95% CI 1.36-3.02) were equally at increased risk of all-cause mortality compared to their non-HCV infected counterparts (p for interaction > 0.05). The risk of cancer-related mortality was significantly increased in HCV-infected women (HR 2.14, 95% CI 1.01-4.53), but not in men, compared to non-HCV-infected counterparts. Among HCV-infected population, there was no difference in the risks of all-cause, CVD-related, or cancer-related death between men and women. Both men and women with HCV infection had an increased risk of death from all causes compared to their non-HCV infected counterparts, but we did not observe a significant sex difference.

The Relationship Between Age and 30-Day Outcomes Following Unicompartmental Versus Total Knee Arthroplasty

BackgroundAn enhanced understanding of the short-term complication profile following unicompartmental knee arthroplasty (UKA) versus total knee arthroplasty (TKA) can improve surgical decision-making and subsequent patient outcomes. This study aimed to determine if the difference in risk of 30-day morbidity and mortality between UKA and TKA varied as a function of patient age. MethodsThis retrospective study of a national quality improvement database using data from 2014 to 2020 included 403,342 patients undergoing UKA (n = 12,324) or TKA (n = 391,018). A generalized additive model (GAM) evaluated non-linear relationships between primary outcome and predictors (age, procedure type, and procedure type x age interaction) using a 1:5 UKA to TKA matched sample. Probabilities and odds ratios (95% CI [confidence interval]) estimated the relative risk of complications across the age spectrum. ResultsIn the GAM, TKA patients relative to UKA had 1.30 higher odds (95% CI 1.19 to 1.43, P < 0.001) of 30-day morbidity and mortality. There was a significant, non-linear relationship between age and the primary outcome (P = 0.02), such that the odds were lowest at younger ages. They increased slowly until about age 65 years, at which point the slope became steeper. The interaction terms for age and procedure type were not significant (P = 0.30). The 30-day probability for short-term complications of a 65-, 75-, and 85-year-old undergoing UKA was 2.1% (95% CI, 1.8 to 2.3), 2.4% (95% CI, 2.0 to 2.8), and 3.2% (95% CI, 2.3 to 4.1), respectively. Conversely, the probability of a 65-, 75-, and 85-year-old undergoing TKA was 2.9% (95% CI, 2.7 to 3.0), 3.6% (95% CI, 3.3 to 3.8), and 5.5% (95% CI, 4.7 to 6.3). ConclusionsPatients undergoing UKA had a quantifiable lower likelihood of morbidity or mortality than TKA at all ages. These data can provide individualized risk for UKA and TKA across the age spectrum and could be helpful in counseling patients regarding their risk for perioperative complications.

Lower or Higher Oxygenation Targets in Patients With COVID-19 in the ICU: A Secondary Bayesian Analysis of the Handling Oxygenation Targets in COVID-19 Trial

BackgroundIn the Handling Oxygenation Targets in COVID-19 (HOT-COVID) trial, a partial pressure of arterial oxygen (PaO2) target of 60 mmHg compared to 90 mmHg resulted in more days alive without life support at 90 days in adult ICU patients with coronavirus disease 2019 (COVID-19) and hypoxemia. The trial was stopped after enrolling 726 of 780 planned patients due to slow recruitment. Here, we present the preplanned Bayesian analysis of the HOT-COVID trial. Research QuestionWhat are the probabilities of any and of clinically relevant benefits from a PaO2 target of 60 mmHg versus 90 mmHg in adult ICU patients with COVID-19 and hypoxemia, and is there heterogeneity of treatment effects (HTE) according to selected baseline characteristics? Study Designand Methods We analyzed days alive without life support and 90-day mortality in the HOT-COVID intention-to-treat population (n=697) using Bayesian general linear models to assess probabilities for benefit or harm, including clinically relevant benefits defined as >1 day alive without life support and >2 percentage points lower 90-day mortality. HTE was evaluated based on baseline SOFA scores, PaO2:FiO2, norepinephrine doses, and lactate concentrations. ResultsThe mean difference in days alive without life support was 5.7 days (95% credible interval (CrI): 0.2 to 11.2), with a 95.2% probability of clinically relevant benefit and a 98.0% probability of any benefit from the lower PaO2 target. The risk difference in 90-day mortality was -4.6 percentage points (95% CrI: -11.8 to 2.6), with a 76.5% probability of a clinically relevant benefit from the lower target. HTE analyses revealed potential interaction with baseline norepinephrine dose and lactate concentrations for both outcomes. InterpretationIn ICU patients with COVID-19 and hypoxemia, we found high probability for a clinically relevant benefit of targeting a PaO2 of 60 mmHg vs. 90 mmHg on number of days alive without life support.

Elevated care at home: An alternative to traditional levels of care.

Elevated care at home (ECH) is a novel in-home care model supporting early hospital discharge and providing an alternative to institutional postacute care. This study compares patient characteristics, mortality, and readmission outcomes of hospitalized patients who transitioned to ECH to patients who transitioned to skilled nursing facilities (SNF) and skilled home health services (SHH). A retrospective study of patients between May 2020 and January 2022 transitioned from the hospital to ECH, SNF, or SHH. The analysis compared patient characteristics, 30-day mortality, and readmission stratified by COVID-19 infection status. Outcomes were assessed using logistic regression after propensity score matching. Of 32,132 eligible patients, 6.3% were transitioned to ECH, 39.7% to SNF, and 54.0% to SHH. After matching, all baseline characteristics except for age were balanced between groups. Postmatch and adjusting for age differences, ECH patients experienced lower risk of death compared to SNF (adjusted odds ratio [AOR] 0.61, 95% confidence interval [CI] 0.40, 0.92) and similar risk of hospital readmission compared to SNF patients (AOR 1.08, 95% CI 0.89, 1.31) and SHH patients (AOR 0.96, 95% CI 0.80, 1.16). COVID-19-negative ECH patients compared to matched SNF patients were more likely to readmit (AOR 1.30, 95% CI 1.02, 1.65) with no significant difference in risk of mortality (AOR 0.72, 95% CI 0.44, 1.18). ECH had similar or improved outcomes relative to SNF and SHH. COVID-19-negative ECH patients experienced higher readmissions relative to SNF. ECH supported patients to return home from the hospital and provided an alternative to an institutional postacute setting.

How Electrical Storms Recur Over Time in Patients With Implantable Cardioverter Defibrillators - Subanalysis of the Nippon Storm Study.

Electrical storms (E-storms), defined as multiple fatal ventricular arrhythmias over a short period, negatively affect the prognosis of patients receiving an implantable cardioverter defibrillator or cardiac resynchronization therapy with a defibrillator (ICD/CRT-D). However, the prognostic impact of recurrent E-storms has not been well elucidated. We analyzed the association between E-storm recurrences and mortality using data from 1,274 participants in the Nippon Storm Study, a prospective observational study conducted at 48 ICD/CRT-D centers in Japan. Differences in E-storm recurrences by patient characteristics were evaluated using the mean cumulative function (MCF), which is the cumulative number of E-storm episodes per patient as a function of time. Patients with multiple E-storms had a 3.39-fold higher mortality risk than those without E-storms (95% confidence interval 1.82-6.28; P<0.01). However, there was no significant difference in mortality risk between patients with a single E-storm and those without E-storms. The MCF curve exhibited a slower ascent in patients who received primary prevention ICD/CRT-D than in those who received secondary prevention ICD/CRT-D. However, when analyzing only patients with E-storms, the MCF curves demonstrated comparable trajectories in both groups. E-storm recurrences may have a negative impact on prognosis. Once patients with primary prevention experience an E-storm episode, they face a similar risk of subsequent recurrent E-storms as patients with secondary prevention.

Benzodiazepine Initiation Effect on Mortality Among Medicare Beneficiaries Post Acute Ischemic Stroke.

Despite guideline warnings, older acute ischemic stroke (AIS) survivors still receive benzodiazepines (BZD) for agitation, insomnia, and anxiety despite being linked to severe adverse effects, such as excessive somnolence and respiratory depression. Due to polypharmacy, drug metabolism, comorbidities, and complications during the sub-acute post-stroke period, older adults are more susceptible to these adverse effects. We examined the impact of receiving BZDs within 30 days post-discharge on survival among older Medicare beneficiaries after an AIS. Using the Medicare Provider Analysis and Review (MedPAR) dataset, Traditional fee-for-service Medicare (TM) claims, and Part D Prescription Drug Event data, we analyzed a random 20% sample of TM beneficiaries aged 66 years or older who were hospitalized for AIS between July 1, 2016, and December 31, 2019. Eligible beneficiaries were enrolled in Traditional Medicare Parts A, B, and D for at least 12 months before admission. We excluded beneficiaries who were prescribed a BZD within 90 days before hospitalization, passed away during their hospital stay, left against medical advice, or were discharged to institutional post-acute care. Our primary exposure was BZD initiation within 30 days post-discharge, and the primary outcome was 90-day mortality risk differences (RD) from discharge. We followed a trial emulation process involving cloning, weighting, and censoring, plus we used inverse-probability-of-censoring weighting to address confounding. In a sample of 47,421 beneficiaries, 826 (1.74%) initiated BZD within 30 days after discharge from stroke admission or before readmission, whichever occurred first, and 6,392 (13.48%) died within 90 days. Our study sample had a median age of 79, with an inter-quartile range (IQR) of 12, 55.3% female, 82.9% White, 10.1% Black, 1.7% Hispanic, 2.2% Asian, 0.4% American Native, 1.5% Other and 1.1% Unknown. After standardization based on age, sex, race/ethnicity, length of stay in inpatient, and baseline dementia, the estimated 90-day mortality risk was 159 events per 1,000 (95% CI: 155, 166) for the BZD initiation strategy and 133 events per 1,000 (95% CI: 132, 135) for the non-initiation strategy, with an RD of 26 events per 1,000 (95% CI: 22, 33). Subgroup analyses showed RDs of 0 events per 1,000 (95% CI: -4, 11) for patients aged 66-70, 3 events per 1,000 (95% CI: -1, 13) for patients aged 71-75, 10 events per 1,000 (95% CI: 3, 23) for patients aged 76-80, 27 events per 1,000 (95% CI: 21, 46) for patients aged 81-85, and 84 events per 1,000 (95% CI: 73, 106) for patients aged 86 years or older. RDs were 34 events per 1,000 (95% CI: 26, 48) and 20 events per 1,000 (95% CI: 11, 33) for males and females, respectively. RDs were 87 events per 1,000 (95% CI: 63, 112) for patients with baseline dementia and 18 events per 1,000 (95% CI: 13, 21) for patients without baseline dementia. Initiating BZDs within 30 days post-AIS discharge significantly increased the 90-day mortality risk among Medicare beneficiaries aged 76 and older and for those with baseline dementia. These findings underscore the heightened vulnerability of older adults, especially those with cognitive impairment, to the adverse effects of BZDs.

Preoperative Thyroid-Stimulating Hormone Levels and Three-Year Mortality in Elderly Hip Fracture Patients: Insights from a Prospective Cohort Study.

BACKGROUND It is unclear whether preoperative thyroid-stimulating hormone (TSH) level is correlated with long-term mortality in the elderly after hip fracture surgery. We aimed to assess the association between TSH levels and 3-year mortality in these patients. MATERIAL AND METHODS We enrolled patients aged 65 and above who had hip fracture surgery and thyroid function tests upon admission from 2018 to 2019. Patients were categorized based on TSH median value, quartiles, or thyroid function status. The median follow-up time was 3.1 years. Cox proportional hazards models were used to examine the correlation between TSH levels and mortality, adjusting for covariates. RESULTS Out of 799 eligible patients, 92.7% (741/799) completed the follow-up, with 20.6% (153/741) of those having died by the end of the follow-up. No statistically significant differences in mortality risks were found when stratified by TSH median value (HR 0.88, 95% CI 0.64-1.22, P=0.448) or quartiles (HR ranging from 0.90 to 1.13, P>0.05). Similarly, when categorized based on admission thyroid function status, patients who presented with hypothyroidism, subclinical hypothyroidism, hyperthyroidism, and subclinical hyperthyroidism upon admission did not demonstrate a statistically significant difference in mortality risk compared to those who were considered euthyroid (HR 1.34, 95% CI 0.72-2.49, P=0.359; HR 0.77, 95% CI 0.38-1.60, P=0.489; HR 1.15, 95% CI 0.16-8.30, P=0.890; HR 1.07, 95% CI 0.34-3.38, P=0.913, respectively). CONCLUSIONS Admission TSH is not significantly associated with 3-year mortality in geriatric patients after hip fracture surgery.

Torsemide versus Furosemide Therapy in Patients with Chronic Heart Failure: An updated Meta-analysis

Introduction: Torsemide’s oral bioavailability and half-life theoretically render it a more efficient diuretic than Furosemide, but the clinical outcomes of torsemide compared with furosemide remain unclear. A rigorous meta-analysis performed by Bishoy et al 2019 showed Torsemide as compared to Furosemide improved hospitalization though it was not statistically significant. We performed an updated meta-analysis to evaluate the effects of Torsemide vs. Furosemide in heart failure hospitalization and mortality. Methods: In addition to the studies included in previous meta-analyses, we performed a literature search using Medline from 2019 till 07/25/2023. We used the MESH term ‘Torsemide’ AND ‘Furosemide[Mesh]) AND ‘Heart Failure’. Eligible studies were 1) Randomized control studies (RCT), non-RCT, and observational prospective and retrospective cohort studies, 2) with English abstract 3) compared torsemide with furosemide, and 4) assessed outcomes of all-cause hospitalization or all-cause mortality. When studies reported both short-term and long-term outcomes, a preference was given to long-term outcomes. Study quality was assessed by the Ottawa scale. RevMan 5.4 was used for analysis. Study results were analyzed using a random effects model. I2 statistics were applied to assess the between-study heterogeneity. Further subgroup analysis was performed for RCTs only. Results: In addition to the previous studies, our literature search returned 27 studies. Two studies met the inclusion criteria. A total of twenty studies (8 randomized control trials [RCTs] and 12 observational studies) with a total of 22,749 patients were included. New-Castle Ottawa scale was used to assess the quality of each study, score of each study ranged from 7 to 9 which reflected high quality. Intra-study risks of bias were also assessed. During a mean follow-up duration of 12 months, risk of hospitalization due to heart failure in patients treated with Torsemide was not different from those treated with Furosemide (odds ratio [OR] 0.80, 95% confidence interval [CI] [0.59, 1.07], p&lt; 0.23, I2 = 24%) also no difference in risk of all-cause mortality (odds ratio [OR] 0.94, 95% confidence interval [CI] [0.87, 1.02], p&lt; 0.001, I2 = 96%, respectively) noted between the two groups. The results remained consistent when subgroup analysis was conducted using only RCTs. Conclusions: Compared with Furosemide, Torsemide use was not associated with a significant difference in hospitalization for heart failure or all-cause mortality in patients with heart failure. The studies included in hospitalization analyses showed lower heterogeneity while for all-cause mortality a higher heterogeneity was noted.

Minimally invasive versus open central pancreatectomy: A systematic review and meta-analysis.

To compare the procedural outcomes of minimally invasive and open central pancreatectomy. A systematic review in compliance with PRISMA statement standards was conducted to identify and analyze studies comparing the procedural outcomes of minimally invasive (laparoscopic or robotic) central pancreatectomy with the open approach. Random effects modeling using intention to treat data, and individual patient as unit of analysis, was used for analyses. Seven comparative studies including 289 patients were included. The two groups were comparable in terms of baseline characteristics. The minimally invasive approach was associated with less intraoperative blood loss (mean difference [MD]: -153.13 mL, p = 0.0004); however, this did not translate into less need for blood transfusion (odds ratio [OR]: 0.30, p = 0.06). The minimally invasive approach resulted in less grade B-C postoperative pancreatic fistula (OR: 0.54, p = 0.03); this did not remain consistent through sensitivity analyses. There was no difference between the two approaches in operative time (MD: 60.17 minutes, p = 0.31), Clavien-Dindo ≥ 3 complications (OR: 1.11, p = 0.78), postoperative mortality (risk difference: -0.00, p = 0.81), and length of stay in hospital (MD: -3.77 days, p = 0.08). Minimally invasive central pancreatectomy may be as safe as the open approach; however, whether it confers advantage over the open approach remains the subject of debate. Type 2 error is a possibility, hence adequately powered studies are required for definite conclusions; future studies may use our data for power analysis.