Heightened Mortality Risk Research Articles

Homeless Vulnerability During an Opioid Epidemic: Assessing the Mortality Risk Among People Experiencing Homelessness in Southern California.

People experiencing homelessness suffer from a risk of mortality three to four times that of the general population, with drug-induced overdose replacing HIV as the emerging epidemic. This study assessed markers of mortality among people experiencing homelessness (N=157) in Orange County, CA during the Fall of 2016. We utilized the Vulnerability Index, an eight-question survey, to identify factors that may affect mortality risk among individuals experiencing homelessness and included two additional questions to identify potential risk of drug-induced overdose. Eighty-three percent of participants reported more than one heightened mortality risk marker and 64% may be at higher risk of drug-induced overdose. Given the state of the opioid epidemic, there is pressing need to couple public health interventions targeting people experiencing homelessness with harm reduction efforts including naloxone distribution (opioid-induced overdose reversal medication) and syringe exchange programs.

Thirty-day outcomes of open abdominal aortic aneurysm repair by proximal clamp level in patients with normal and impaired renal function

ObjectiveOpen surgical repair (OSR) of abdominal aortic aneurysms (AAAs) has often been reserved in contemporary practice for complex aneurysms requiring a suprarenal or supraceliac proximal clamp level. The present study investigated the associated 30-day outcomes of different proximal clamp levels in OSR of complex infrarenal/juxtarenal AAA in patients with normal renal function and those with chronic renal insufficiency (CRI). MethodsAll patients undergoing elective OSR of infrarenal and juxtarenal AAA were identified in the American College of Surgeons National Surgical Quality Improvement Program–targeted AAA database from 2012 to 2018. The patients were stratified into two cohorts (normal renal function [estimated glomerular filtration rate, ≥60 mL/min] and CRI [estimated glomerular filtration rate, <60 mL/min and no dialysis]) before further substratification into groups by the proximal clamp level (infrarenal, inter-renal, suprarenal, and supraceliac). The 30-day outcomes, including mortality, renal and pulmonary complications, and major adverse cardiovascular event rates, were compared within each renal function cohort between proximal clamp level groups using the infrarenal clamp group as the reference. Supraceliac clamping was also compared with suprarenal clamping. ResultsA total of 1284 patients with normal renal function and 524 with CRI were included in the present study. The proximal clamp levels for the 1808 patients were infrarenal for 1080 (59.7%), inter-renal for 337 (18.6%), suprarenal for 279 (15.4%), and supraceliac for 112 (6.2%). In the normal renal function cohort, no difference was found in 30-day mortality with any clamp level. Increased 30-day acute renal failure was only observed in the supraceliac vs infrarenal clamp level comparison (5.9% vs 1.5%; adjusted odds ratio [aOR], 3.97; 95% confidence interval [CI], 1.04-5.18; P = .044). In the CRI cohort, supraceliac clamping was associated with an increased rate of renal composite complications (22.7% vs 5.6%; aOR, 8.81; 95% CI, 3.17-24.46; P < .001) and ischemic colitis (13.6% vs 3.0%; aOR, 4.78; 95% CI, 1.38-16.62; P = .014) compared with infrarenal clamping and greater 30-day mortality (13.6% vs 2.4%; aOR, 6.00; 95% CI, 1.14-31.55; P = .034) and renal composite complications (22.7% vs 10.8%; aOR, 2.87; 95% CI, 1.02-8.13; P = .047) compared with suprarenal clamping. Suprarenal clamping was associated with greater renal dysfunction (10.8% vs 5.6%; aOR, 2.77; 95% CI, 1.08-7.13; P = .035) compared with infrarenal clamping, with no differences in mortality. No differences were found in 30-day mortality or morbidity for inter-renal clamping compared with infrarenal clamping in either cohort. No differences were found in major adverse cardiovascular events with higher clamp levels in either cohort. ConclusionsIn elective OSR of infrarenal and juxtarenal AAAs for patients with CRI, this study found a heightened mortality risk with supraceliac clamping and increased renal morbidity with suprarenal clamping, though these effects were not present for patients with normal renal function. Every effort should be made to keep the proximal clamp level as low as possible, especially in patients with CRI.

Race, death of a child, and mortality risk among aging parents in the United States.

The death of a child is a stressful and traumatic life event that has been linked to increased mortality risk among parents. Tragically, black parents are significantly more likely than white parents to lose a child in the United States; however, prior research has not addressed this racial disadvantage in relation to parents' mortality risk. In this study, we focus on the racial context of the United States to suggest that black parents already face higher mortality rates compared to white parents, and the unequal burden of child death adds to their mortality risk. Using discrete-time event history models, we consider whether the death of a child by midlife is associated with increased mortality risk for black parents and for white parents in mid- to later-life using longitudinal data from the Health and Retirement Study (HRS; 1996-2016). Descriptive results show that by midlife, black parents, especially black mothers, experience substantially higher child mortality compared with white parents. At the same time, we find that losing a child prior to midlife is associated with heightened mortality risk for aging black mothers and white mothers. Controlling for educational attainment explains the association between child death and parental mortality risk among white mothers, whereas heightened biopsychosocial and behavioral risk factors explain the association for black mothers. Overall, the death of a child is associated with increased mortality risk for black mothers and for white mothers, but the processes linking child death to parental mortality seem to differ for black and white parents. These findings have implications for policies and interventions that address increased mortality risk for parents following the death of a child.

DEATH OF A CHILD AND MORTALITY RISK OVER THE LIFE COURSE: RACIAL DISADVANTAGE IN THE U.S.

Numerous studies show that bereavement, including bereavement following the death of a minor child, increases mortality risk in white populations. The death of a child prior to midlife has received much less attention. Moreover, recent research shows that black Americans are substantially more likely to lose a child compared to white Americans, but this racial disadvantage is largely unexplored. Losing a child is a traumatic event that may activate biopsychosocial and behavioral risk factors that add to mortality risk. We analyze longitudinal data from the Health and Retirement Study (1992-2014) to assess the association of child loss prior to midlife with mortality risk in mid to later life, and the possible biopsychosocial and behavioral covariates linking child death to mortality. The analytic sample includes 20,489 non-Hispanic white respondents and 5,328 non-Hispanic black respondents who have ever given birth to or fathered at least one child. Findings suggest that that the death of a child prior to midlife is associated with increased mortality risk, net of sociodemographic controls. Psychological (e.g., depressive symptoms), behavioral (e.g., alcohol use, smoking), and social (e.g., income, marital status) factors explain this heightened mortality risk. Although the heightened mortality risk for child loss is similar for black and white parents, black parents experience a greater disadvantage as they are almost twice as likely as white parents to lose a child prior to midlife. Child loss and the resulting health risks disproportionately burden black families, functioning as a unique source of disadvantage for black Americans.

Racial and Ethnic Differences in Pediatric Pulmonary Hypertension: An Analysis of the Pediatric Pulmonary Hypertension Network Registry

To investigate racial and ethnic differences in pulmonary hypertension subtypes and survival differences in a pediatric population. This was a retrospective analysis of a cohort of patients with pulmonary hypertension (aged ≤18years) enrolled in the Pediatric Pulmonary Hypertension Network registry between 2014 and 2018, comprising patients at eight Pediatric Centers throughout North America (n=1417). Among children diagnosed after the neonatal period, pulmonary arterial hypertension was more prevalent among Asians (OR, 1.83; 95% CI, 1.21-2.79; P=.0045), lung disease-associated pulmonary hypertension among blacks (OR, 2.09; 95% CI, 1.48-2.95; P<.0001), idiopathic pulmonary arterial hypertension among whites (OR, 1.58; 95% CI, 1.06-2.41; P=.0289), and pulmonary veno-occlusive disease among Hispanics (OR, 6.11; 95% CI, 1.34-31.3; P=.0184). Among neonates, persistent pulmonary hypertension of the newborn (OR, 4.07; 95% CI, 1.54-10.0; P=.0029) and bronchopulmonary dysplasia (OR, 8.11; 95% CI, 3.28-19.8; P<.0001) were more prevalent among blacks, and congenital diaphragmatic hernia was more prevalent among whites (OR, 2.29; 95% CI, 1.25-4.18; P=.0070). An increased mortality risk was observed among blacks (HR, 1.99; 95% CI, 1.03-3.84; P=.0396), driven primarily by the heightened mortality risk among those with lung disease-associated pulmonary hypertension (HR, 2.84; 95% CI, 1.15-7.04; P=.0241). We found significant racial variability in the prevalence of pulmonary hypertension subtypes and survival outcomes among children with pulmonary hypertension. Given the substantial burden of this disease, further studies to validate phenotypic differences and to understand the underlying causes of survival disparities between racial and ethnic groups are warranted.

Moodivate: A self-help behavioral activation mobile app for utilization in primary care-Development and clinical considerations.

Depressive symptoms are highly prevalent and are associated with considerable functional impairment, significant public health costs, and heightened mortality risk. Individuals experiencing impairment due to depressive symptomatology are most likely to report their symptoms to a primary care provider. As such, national guidelines highlight the need to assess and effectively treat depression via primary care. Despite these guidelines, the dissemination of evidence-based psychotherapy via primary care is limited, likely due to both provider- and patient-level treatment barriers. Mobile health (mHealth) technologies are promising for addressing these barriers and for promoting uptake of evidence-based depression treatment. Among evidence-based psychotherapies for depression, brief Behavioral Activation Treatment for Depression (BATD) has shown great promise and is particularly amenable to mHealth delivery. Herein, we discuss the development of a BATD mobile application, Moodivate, that was developed in order to disseminate BATD via primary care. This paper focuses on description of (1) rationale for Moodivate treatment development, (2) Moodivate treatment components, (3) ongoing clinical trial evaluation of Moodivate, and (4) clinical considerations for incorporating Moodivate into clinical practice.

Mean platelet volume and mortality risk in a national incident hemodialysis cohort

BackgroundHigher mean platelet volume (MPV) is an indicator of larger, reactive platelets, and has been associated with a higher risk of thrombosis and cardiovascular events in the general population. Hemodialysis patients have a higher risk for cardiovascular death and predisposition to platelet dysfunction (thrombosis and bleeding diathesis), but the relationship between MPV and mortality in this population is unknown. MethodsAmong a 5-year cohort (1/2007–12/2011) of 149,118 incident hemodialysis patients from a large national dialysis organization, we examined the association between MPV and all-cause mortality. In primary analyses, we granularly analyzed MPV across five categories: 7.2–7.5, >7.5–9.5, >9.5–11.5, >11.5–13.5, and >13.5–15.0fL. In secondary analyses, we examined MPV categorized as low, normal, and high based on thresholds in the general population: 7.2–7.5, >7.5–11.5, and >11.5fL, respectively. Associations between baseline and time-dependent MPV with mortality were estimated using traditional and time-dependent Cox models in order to determine long-term and short-term exposure—mortality associations, respectively, using three adjustment levels: unadjusted, case-mix, and case-mix+laboratory models. ResultsIn primary analyses, higher baseline and time-dependent MPV levels were associated with incrementally higher death risk in case-mix+laboratory analyses (reference: >9.5–11.5fL). In secondary analyses, high baseline and time-dependent MPV levels were associated with higher mortality, whereas low MPV was associated with lower death risk across all multivariable models (reference: normal MPV). ConclusionsHemodialysis patients with higher MPV have heightened mortality risk. Further studies are needed to determine the pathophysiologic basis for the higher risk, and if modification of MPV ameliorates mortality in this population.

Sex differences in the effects of juvenile and adult diet on age-dependent reproductive effort.

Sexual selection should cause sex differences in patterns of resource allocation. When current and future reproductive effort trade off, variation in resource acquisition might further cause sex differences in age-dependent investment, or in sensitivity to changes in resource availability over time. However, the nature and prevalence of sex differences in age-dependent investment remain unclear. We manipulated resource acquisition at juvenile and adult stages in decorated crickets, Gryllodes sigillatus, and assessed effects on sex-specific allocation to age-dependent reproductive effort (calling in males, fecundity in females) and longevity. We predicted that the resource and time demands of egg production would result in relatively consistent female strategies across treatments, whereas male investment should depend sharply on diet. Contrary to expectations, female age-dependent reproductive effort diverged substantially across treatments, with resource-limited females showing much lower and later investment in reproduction; the highest fecundity was associated with intermediate lifespans. In contrast, long-lived males always signalled more than short-lived males, and male age-dependent reproductive effort did not depend on diet. We found consistently positive covariance between male reproductive effort and lifespan, whereas diet altered this covariance in females, revealing sex differences in the benefits of allocation to longevity. Our results support sex-specific selection on allocation patterns, but also suggest a simpler alternative: males may use social feedback to make allocation decisions and preferentially store resources as energetic reserves in its absence. Increased calling effort with age therefore could be caused by gradual resource accumulation, heightened mortality risk over time, and a lack of feedback from available mates.

Nonsupportive parenting affects telomere length in young adulthood among African Americans: mediation through substance use.

Telomere length (TL) is an indicator of age-related changes at the cellular level associated with heightened mortality risk. The effect of nonsupportive parenting (NSP) during late adolescence and young adulthood on TL 5 years later was examined in a sample of N = 183 young adult African Americans to determine if effects of NSP on TL were mediated by substance use. Results indicated that the effect of caregiver reported NSP on diminished TL was mediated by escalation of drinking and smoking in young adulthood, even after controlling effects of socioeconomic status risk, gender, BMI, young adult stress, and intervention status. Results suggest that prevention of NSP may influence later physical health consequences by influencing substance use trajectory.

Prognostic utility of coronary artery calcium scoring in active smokers: A 15-year follow-up study

Prognostic utility of coronary artery calcium scoring in active smokers: A 15-year follow-up study

Prognostic Value of Elevated Serum Ceruloplasmin Levels in Patients With Heart Failure

BackgroundCeruloplasmin (Cp) is a copper-binding acute-phase protein that is increased in inflammatory states and deficient in Wilson's disease. Recent studies demonstrate that increased levels of Cp are associated with increased risk of developing heart failure. Our objective was to test the hypothesis that serum Cp provides incremental and independent prediction of survival in stable patients with heart failure. Methods and ResultsWe measured serum Cp levels in 890 patients with stable heart failure undergoing elective cardiac evaluation that included coronary angiography. We examined the role of Cp levels in predicting survival over 5 years of follow-up. Mean Cp level was 26.6 ± 6.9 mg/dL and demonstrated relatively weak correlation with B-type natriuretic peptide (BNP; r = 0.187; P < .001). Increased Cp levels were associated with increased 5-year all-cause mortality (quartile [Q] 4 vs Q1 hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.4–2.8; P < .001). When controlled for coronary disease traditional risk factors, creatinine clearance, dialysis, body mass index, medications, history of myocardial infarction, BNP, left ventricular ejection fraction (LVEF), heart rate, QRS duration, left bundle branch blockage, and implantable cardioverter-defibrillator placement, higher Cp remained an independent predictor of increased mortality (Q4 vs Q1 HR 1.7, 95% CI 1.1–2.6; P < .05). Model quality was improved with addition of Cp to the aforementioned covariables (net reclassification improvement of 9.3%; P < .001). ConclusionsCeruloplasmin is an independent predictor of all-cause mortality in patients with heart failure. Measurement of Cp may help to identify patients at heightened mortality risk.

Prevention Effects Ameliorate the Prospective Association Between Nonsupportive Parenting and Diminished Telomere Length

Telomere length (TL) is an indicator of general systemic aging, with diminished TL associated with several chronic diseases of aging and with heightened mortality risk. Research has begun to focus on the ways in which stress contributes to telomere attrition. The purposes of this study were (a) to establish whether exposure to nonsupportive parenting, defined as high levels of conflict and rancor with low levels of warmth and emotional support, at age 17 would forecast TL 5years later; and (b) to determine whether participation in an efficacious family-centered prevention program could ameliorate any associations that emerged. Rural African American adolescents participated in the Adults in the Making (AIM) program or a control condition. Primary caregivers provided data on nonsupportive parenting during a pretest when adolescents were age 17. Adolescents provided data on anger at the pretest and at a posttest administered 7months later. When the youths were age 22, TL was assayed from a blood draw. The results indicated that heightened nonsupportive parenting forecast diminished TL among young adults in the control condition but not among those who participated in AIM; socioeconomic status risk, life stress, and the use of alcohol and cigarettes at age 17, and blood pressure and body mass index at age 22, were controlled. Subsequent exploratory analyses suggested that AIM-induced reductions in adolescents' anger served as a mediator connecting group assignment to TL. The results suggest that the cellular-level sequelae of nonsupportive parenting and stress are not immutable.

Diastolic Stress Test for the Evaluation of Exertional Dyspnea

Recent studies have highlighted that dyspneic patients comprise a high-risk subgroup of patients referred for cardiac stress testing. Even after adjusting for the presence and degree of coronary artery disease the risk of cardiac and all-cause mortality is at least three- to fivefold higher in dyspneic patients compared to asymptomatic or those with chest pain. Stress echocardiography is uniquely positioned to characterize all potential cardiovascular etiologies of dyspnea from global and regional systolic dysfunction, myocardial ischemia to valvular heart disease, pulmonary hypertension and diastolic dysfunction. Various data point to diastolic dysfunction and associated heart failure as the major potential etiology for dyspnea as well as the likely cause of the heightened mortality risk. Doppler echocardiography at rest and with stress can now characterize the hemodynamics of diastolic dysfunction and close the loop on the comprehensive assessment of the patient who has exertional shortness of breath. This review discusses the role of the Doppler echocardiographic diastolic stress test in the evaluation of patients with cardiac dyspnea.

A Comparison of Dynamic-State-Dependent Models of the Trade-Off Between Growth, Damage, and Reproduction

Fast growth can be costly, so trade-offs between growth and fitness are to be predicted when organisms adjust their growth to compensate for earlier environmental conditions. We developed four generic models of increasing complexity with different processes to predict the indeterminate growth of vertebrate ectotherms, which is sensitive to ambient temperature even when food is not limiting. We contrast the predictions of the models with observed experimental data on growth trajectories, feeding activity, and reproductive investment of three-spined sticklebacks and inferred patterns of accumulation of biomolecular damage arising from activity and growth. All models predicted observed patterns of compensatory growth (both accelerating and decelerating) in response to earlier temperature perturbations, but the more complex models provided the best fit to experimental data. Growth trajectories influenced future reproductive investment regardless of final body size at breeding. Our findings suggest that while models with fewer parameters can predict basic patterns of growth in stable conditions, they cannot capture the costly long-term effects of deviations from steady growth trajectories. In contrast, models in which foraging activity is assumed to carry costs are capable of predicting the complex patterns of feeding, growth, and reproductive investment seen in animals, with the cost of a heightened mortality risk (e.g., through predation) being more important than the cost of increased physiological damage.

Reflections on the stress model: A response to Turner

Higher mean platelet volume (MPV) is an indicator of larger, reactive platelets, and has been associated with a higher risk of thrombosis and cardiovascular events in the general population. Hemodialysis patients have a higher risk for cardiovascular death and predisposition to platelet dysfunction (thrombosis and bleeding diathesis), but the relationship between MPV and mortality in this population is unknown.Among a 5-year cohort (1/2007–12/2011) of 149,118 incident hemodialysis patients from a large national dialysis organization, we examined the association between MPV and all-cause mortality. In primary analyses, we granularly analyzed MPV across five categories: 7.2–7.5, > 7.5–9.5, > 9.5–11.5, > 11.5–13.5, and > 13.5–15.0 fL. In secondary analyses, we examined MPV categorized as low, normal, and high based on thresholds in the general population: 7.2–7.5, > 7.5–11.5, and > 11.5 fL, respectively. Associations between baseline and time-dependent MPV with mortality were estimated using traditional and time-dependent Cox models in order to determine long-term and short-term exposure—mortality associations, respectively, using three adjustment levels: unadjusted, case-mix, and case-mix + laboratory models.In primary analyses, higher baseline and time-dependent MPV levels were associated with incrementally higher death risk in case-mix + laboratory analyses (reference: > 9.5–11.5 fL). In secondary analyses, high baseline and time-dependent MPV levels were associated with higher mortality, whereas low MPV was associated with lower death risk across all multivariable models (reference: normal MPV).Hemodialysis patients with higher MPV have heightened mortality risk. Further studies are needed to determine the pathophysiologic basis for the higher risk, and if modification of MPV ameliorates mortality in this population.

Childbearing and Women's Survival: New Evidence from Rural Bangladesh

Effects of childbearing on women's mortality and the implications of family planning programs in reducing these effects are examined in a 20‐year prospective study of more than 2,000 women in Matlab, Bangladesh. Maternal mortality is defined as a death occurring in the six weeks after childbirth. But childbearing may affect women's survival beyond this brief period. Additional hypotheses considered relate to 1) cumulative exposure to childbearing, whether measured by parity or pace of childbearing, 2) age at first birth, and 3) effects beyond the reproductive ages. The results offer no support to cumulative exposure hypotheses, showing no link between parity or pace of childbearing and mortality risk. Instead, we identify an extended period of heightened mortality risk associated with each birth—the year of the birth and the two subsequent years. Family planning programs, by reducing the number of children and therefore a woman's exposure to extended maternal mortality risk, potentially increase survival. Research is needed to identify and address the specific causes of extended maternal mortality risk so that appropriate ameliorative programs may be developed.

Serious mental illness and mortality rates.

As has been found in a variety of other studies, the mortality rate for the seriously mentally ill population was more than twice the mortality rate for individuals in a comparable general population. Furthermore, although the increased mortality rate for the seriously mentally ill population was not constant across all causes of death, it was at least double that of the general population in seven of eight categories. The difference was greater for unnatural causes of death than for natural causes (SMRs=4.4 and 1.7, respectively), with the rates of deaths related to HIV showing the largest difference (SMR=6.1). The only cause of death that showed a greater(but nonsignificantly greater) rate in the general population was neoplasms (SMR=O.6). The finding that the seriously mentally ill population has a higher mortality rate than the general population is of less importance than is future research to identify the underlying reasons for this heightened mortality risk. This research is necessary before we can...

Maternal mortality, its definition and assessment. Report of maternal mortality at the Bamberg Gynecologic Clinic 1963-1988

During the period of observation from 1963-1988 (26 years) 16 maternal deaths during pregnancy, birth and post partum were registered among 59,681 births at the Departm. of Obstetr. and Gynaec. Bamberg. This corresponds to a maternal mortality ratio of 0.26%. Thirteen of the deaths were direct material deaths, three cases of death belong in the category of indirect deaths. In this timeframe 4,257 (7.13%) C-sections were done. The rate of C-sections has almost tripled during the last 26 years, increasing from 3.6% in 1963 to 10.1% in 1988. In 10 cases maternal death followed a C-section. Taking the complete period of observation into account, the mortality rate after C-section of 2.34% is about 20 times higher than the mortality risk after vaginal delivery. This heightened mortality risk after C-section is clearly diminishing. In the years 1973-1982 the C-section mortality rate was only 6 times higher than maternal deaths after vaginal deliveries.