Higher Risk Of 1-year Mortality Research Articles

Metoprolol use is associated with improved outcomes in patients with sepsis-induced cardiomyopathy: an analysis of the MIMIC-IV database

BackgroundMetoprolol is commonly administered to critically ill patients; however, its effect on mortality in patients with sepsis-induced cardiomyopathy (SICM) remains uncertain. This study aimed to investigate the relationship between metoprolol use and mortality in patients with SICM.MethodsAdults with SICM were identified from the MIMIC-IV database. The exposure of interest was metoprolol treatment. The outcomes assessed were 30-day mortality, 1-year mortality, and in-hospital mortality. Kaplan–Meier survival analysis evaluated the effect of metoprolol on these outcomes. Multivariable Cox proportional hazards and logistic regression analyses were performed to determine the correlation between metoprolol treatment and mortality in patients with SICM.Results1163 patients with SICM were identified, with 882 receiving metoprolol treatment (MET group) and 281 not receiving metoprolol treatment (NOMET group). Overall, the 30-day, 1-year, and in-hospital mortality rates were 10.2%, 18.2%, and 8.9%, respectively. Significant differences in mortality existed between the groups. Multivariable Cox analysis revealed that patients in the NOMET group had a higher risk of 1-year mortality (adjusted hazard ratio [HR] 2.493; 95% confidence interval [CI] 1.800–3.451; P < 0.001) and 30-day mortality (adjusted HR 4.280; 95%CI 2.760–6.637; P < 0.001). Metoprolol treatment was associated with lower in-hospital mortality (odds ratio [OR] 5.076; 95% CI 2.848–9.047; P < 0.001). Subgroup analysis supported these findings.ConclusionMetoprolol treatment is associated with reduced all-cause mortality in patients with SICM. Prospective studies are required to validate these findings.

The Korean Organ Transplant Registry (KOTRY): Third Official Adult Heart Transplant Report.

The Korean Organ Transplant Registry (KOTRY) provided data for this third official report on adult heart transplantation (HT), including information from 709 recipients. Data from HTs performed at seven major centers in Korea between March 2014 and December 2020 were analyzed, focusing on immunosuppression, acute rejection, cardiac allograft vasculopathy (CAV), post-transplant survival, and mechanical circulatory support (MCS) usage. The median ages of the recipients and donors were 56.0 and 43.0 years, respectively. Cardiomyopathy and ischemic heart disease were the most common preceding conditions for HT. A significant portion of patients underwent HT at waiting list status 1 and 0. In the multivariate analysis, a predicted heart mass mismatch was associated with a higher risk of 1-year mortality. Patients over 70 years old had a significantly increased risk of 6-year mortality. The risk of CAV was higher for male donors and donors older than 45 years. Acute rejection was more likely in patients with panel reactive antibody levels above 80%, while statin use was associated with a reduced risk. The employment of left ventricular assist device as a bridge to transplantation increased from 2.17% to 22.4%. Pre-transplant extra-corporeal membrane oxygenation was associated with worse post-transplant survival. In this third KOTRY report, we analyzed changes in the characteristics of adult HT recipients and donors and their impact on post-transplant outcomes. The most notable discovery was the increased use of MCS before HT and their impact on post-transplant outcomes.

Beta Blockers are Associated with Increased Mortality Without a Decrease in Reinterventions After Endovascular Abdominal Aortic Repair (EVAR)

ObjectivePredictors of sac behavior after EVAR and the impact of sac behavior on long-term survival are not well known. There are limited multicenter trials studying the impact of beta-blockers (BB) on sac behavior. Beta-blockers have consistently failed to show a benefit on AAA sac regression in patients with connective tissue disorders and the general population. This study aims to assess the association between BBs and sac behavior after endovascular aortic aneurysm repair (EVAR). MethodsPatients undergoing EVAR registered in Vascular Quality Initiative (VQI) (2003-2021) stratified by BB and no BB on discharged after an index procedure were assessed at follow-up of 30-days and 1-year. The primary outcomes included mortality and reintervention at 30-days and 1-year. The causes of reintervention were also studied at the defined time endpoints. Categorical and continuous variables were analyzed separately for association between the two groups. A p-value of <0.05 was considered statistically significant. ResultsA total of 50,411 patients, stratified by BB (28,866; 57.3%), and No BB (21,545; 42.7%) were studied. Patients with hypertension, diabetes, COPD, coronary artery disease, prior history of coronary artery bypass graft or percutaneous coronary intervention, prior angioplasty or stent, lower extremity bypass, carotid surgery, major amputation, and smokers were more likely to be on a BB at the time of discharge (p<0.05). There was no significant difference in reinterventions when comparing patients with and without BB (p=0.061). At 30-day follow up, there was no significant difference between the two groups for any cause of reintervention. At 1-year follow up, patients on BB were less likely to need reintervention for graft occlusion (no BB 18.70%, BB 11.77%, p=0.002). There was no significant difference in reintervention for all other causes at 1-year follow up. There was an increase in 30-day (no BB 0.20%, BB 0.33%, p=0.007) and 1-year mortality (no BB 2.35%, BB 3.19%, p<0.001) in patients on beta-blockers. A time to event adjusted analysis based on Cox proportional hazard model revealed a 26% higher risk of 1-year mortality for patients on BB (HR:1.26 [1.10-1.41] p<0.001) ConclusionDespite theoretical benefits of beta-blockers on aneurysm behavior, review of the largest national vascular surgery database shows that patients on beta-blockers do not have lower incidence of endovascular reinterventions after EVAR while additionally showing a higher mortality in this patient population.

Uric acid elevation in pediatric patients with dilated cardiomyopathy and prediction of mortality.

Pediatric dilated cardiomyopathy (DCM) is a primary cause of heart failure, highlighting the urgent need for effective prognostic markers. We performed a single-center retrospective study involving 145 children diagnosed with DCM, with a median follow-up period of 4.0 months (interquartile range: 6.2-108.4 months). The relationship between serum uric acid (SUA) levels and all-cause mortality was assessed using Kaplan-Meier survival curves, multivariate Cox proportional hazard models, and restricted cubic spline (RCS) models. Of the 145 children with DCM (median age 5.7 years; 61.4% male), 45 (31%) died within 1 year, and 65 (44.8%) died during the maximum follow-up period. In adjusted multivariate Cox regression models, each log2 SUA increase was linked to a higher risk of 1-year mortality [hazard ratio (HR), 2.66; 95% confidence interval (CI), 1.41-5.01] and overall mortality (HR, 1.97; 95% CI, 1.15-3.37). The highest SUA tertile showed a greater risk of mortality at 1 year (HR, 4.26; 95% CI: 1.5-12.06) and during the maximum follow-up (HR, 2.56; 95% CI: 1.06-6.16) compared with the lowest tertile. RCS models indicated an inverted L-shaped association between baseline SUA levels and overall mortality risk, with age-stratified analyses revealing a linear and U-shaped relationship in children ≤10 and >10 years, respectively. Further age-stratified analyses highlighted the modifying effect of age on this association. Elevated SUA levels are a significant predictor of mortality in pediatric DCM, with a pronounced impact on children under 10 years of age. Therefore, SUA levels could serve as potential biomarkers for risk stratification in this population.

One-year mortality and readmission risks following hospitalization for acute exacerbation of chronic obstructive pulmonary disease based on the types of acute respiratory failure: An observational study.

Few studies have examined the risk factors associated with the type of acute respiratory failure (ARF) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). This study evaluated the clinical characteristics and prognosis of patients hospitalized for acute exacerbation of COPD based on the type of ARF. The medical charts of hospitalized patients with acute exacerbation of COPD between 2016 and 2021 were retrospectively reviewed. We classified ARF into 2 types: type 1 ARF with PaO2 < 60 mm Hg in room air or a ratio of arterial partial pressure to fractional inspired oxygen < 300, and type 2 ARF with PaCO2 > 45 mm Hg and arterial pH < 7.35. A total of 435 patients were enrolled in study, including 170 participants without ARF, 165 with type 1 ARF, and 100 with type 2 ARF. Compared with the non-ARF group, the frequency of high-flow nasal cannula, noninvasive ventilation, intensive care unit admissions, and in-hospital deaths was higher in the ARF group compared with the non-ARF group. The ARF group had higher 1-year mortality group (hazard ratio [HR], 2.809; 95% confidence interval [CI], 1.099-7.180; P = .031) and readmission within 1-year rates (HR, 1.561; 95% CI, 1.061-2.295; P = .024) than the non-ARF group. The type 1 ARF group had a higher risk of 1-year mortality (HR, 3.022; 95% CI, 1.041-8.774; P = .042) and hospital readmission within 1-year (HR, 2.053; 95% CI, 1.230-3.428; P = .006) compared with the non-ARF group. There was no difference in mortality and readmission rates between the type 1 and type 2 ARF groups. In conclusion, patients with type 1 ARF rather than type 2 ARF had higher mortality and readmission rates than those without ARF. The prognoses of patients with type 1 and type 2 ARF were similar.

One-year mortality risk in older individuals with femoral intertrochanteric fracture: a tertiary center in China

BackgroundThe accelerated growth of older individuals worldwide has increased the number of patients presenting with fragility hip fractures. Having a hip fracture can cause excess mortality, and patients with hip fracture have a higher risk of death than those without hip fracture. Most studies have treated hip fracture as a single, homogeneous condition, but hip fracture includes two major anatomic types: intertrochanteric fracture and femoral neck fracture. Few studies have specifically evaluated 1-year mortality risk in older individuals with femoral intertrochanteric fracture. The aim of this study was to evaluate 1-year mortality and factors associated with mortality in older individuals with femoral intertrochanteric fracture.MethodsA retrospective review was conducted of 563 patients ≥ 65 years old who underwent surgery for femoral intertrochanteric fractures at our institution between January 2010 and August 2018. Patient demographics, comorbidities, and treatment were collected by retrospective chart review. Age, sex, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) classification, Charlson comorbidity index (CCI), Arbeitsgemeinschaft Für Osteosynthesefragen (AO) fracture classification, haemoglobin value at admission, time to surgery, operation time, and intraoperative blood loss were risk factors to be tested. Multivariable logistic regression was used to evaluate associations between variables and death.ResultsAmong the 563 patients, 49 died within 1 year after surgery, and the 1-year mortality rate was 8.7%. Multivariate analysis identified age > 80 years (OR = 4.038, P = 0.011), haemoglobin < 100 g/l (OR = 2.732, P = 0.002), ASA score ≥ 3 (OR = 2.551, P = 0.005), CCI ≥ 3 (OR = 18.412, P = 0.018) and time to surgery > 14 d (OR = 3.907, P = 0.030) as independent risk factors for 1-year mortality. Comorbidities such as myocardial infarction and chronic pulmonary disease were associated with 1-year mortality after adjusting for age > 80 years and time to surgery > 14 days.ConclusionsPatients over 80 years old with haemoglobin < 100 g/l, ASA score ≥ 3, CCI ≥ 3, and multiple comorbidities, especially myocardial infarction and chronic pulmonary disease before surgery, are at a higher risk of 1-year mortality. Doctors should pay more attention to these vulnerable patients, and a surgical delay greater than 14 days should be avoided.

Which medicare advantage enrollees are at highest one-year mortality risk?

BackgroundWhile a number of tools exist to predict mortality among older adults, less research has described the characteristics of Medicare Advantage (MA) enrollees at higher risk for 1 year mortality. ObjectivesTo describe the characteristics of MA enrollees at higher mortality risk using patient survey data. Research DesignRetrospective cohort. SubjectsMA enrollees completing the 2019 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. MeasuresLinked demographic, health, and mortality data from a sample of MA enrollees were used to predict 1-year mortality risk and describe enrollee characteristics across levels of predicted mortality risk. ResultsThe mortality model had a 0.80 c-statistic. Mortality risks were skewed: 6 % of enrollees had a ≥ 10 % 1-year mortality risk, while 45 % of enrollees had 1 % to < 5 % 1-year mortality risk. Among the high-risk (≥10 %) group, 47 % were age 85+ versus 12 % among those with mortality risk <5 %. 79 % were in fair or poor self-rated health versus 29 % among those with mortality risk of <5 %. 71 % reported needing urgent care in the prior 6 months versus 40 % among those with a mortality risk of 1 to<5 %. ConclusionsRelatively few older adults enrolled in MA are at high 1-year mortality risk. Nonetheless, MA enrollees over age 85, in fair or poor health, or with recent urgent care needs are far more likely to be in a high mortality risk group.

Cardiovascular events following vascular endothelial growth factor inhibitor therapy with sunitinib or pazopanib in patients with renal cell carcinoma - a nationwide registry-based follow-up study

Abstract Background Use of oral vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKIs) with focus on sunitinib and pazopanib approved for treatment of patients with renal cell carcinoma (RCC) may be associated with cardiovascular events. However, there are limited data on the risk related to treatment with sunitinib or pazopanib. Purpose The aim of this study was to examine the risk of cardiovascular events in patients with RCC treated with sunitinib and pazopanib compared with age- and sex-matched population control subjects without cancer (1:2 ratio). Methods Patients with RCC treated with sunitinib or pazopanib from 2011 through 2018 were identified within the Danish National Patient Registry. Multivariable Cox regression standardized to the age, sex, selected comorbidity and pharmacotherapy distributions of all included subjects were used to derive absolute one-year risks of selected cardiovascular events. Results A total of 3,642 patients were included in the analysis, of whom 1,214 had RCC treated with sunitinib or pazopanib, and 2,428 were population control subjects without cancer. Differences in age, sex, prior acute coronary syndrome (ACS), chronic obstructive pulmonary disease, and peripheral artery disease were insignificant (all P&amp;gt;0.05), whereas patients with RCC more frequently had prior hypertension (51.2% vs. 35.2%), diabetes (17.1% vs. 10.3%), and transient ischemic attack (TIA) or stroke (7% vs. 4.5%), all P&amp;lt;0.05. Absolute risk of ACS was 1.4% for patients with RCC vs. 1.0% for controls (P=0.54), stroke/TIA 1.7% vs. 0.8% (P=0.10), and ventricular arrhythmia 0.3% vs. 0.1% (P=0.70). In contrast, risk of hypertension was significantly elevated with 50.7% vs. 41.8% for patients with RRC vs. controls (P&amp;lt;0.001), and this risk was similarly elevated when excluding patients with prior hypertension (30.7% vs. 5.4%, P&amp;lt;0.001). Similarly, risks of atrial fibrillation or flutter (AF) with 5.6% vs. 2.8% (P&amp;lt;0.001) and heart failure (HF) with 0.7% vs. 0.3% (P&amp;lt;0.001) were significantly elevated in patients with RCC versus controls.Risk of venous thromboembolism (VTE) was 5.6% vs. 0.9% (P&amp;lt;0.001) for patients with RCC versus controls. All-cause mortality risk was 40.1% vs. 2.6% (P&amp;lt;0.001). The corresponding relative risks for one-year outcomes are shown in Figure 1. Conclusions Patients with RCC treated with sunitinib or pazopanib did not have a significantly higher risk of ACS, stroke/TIA or ventricular arrhythmia when compared to age- and sex-matched controls. In contrast, risks of hypertension, AF, HF, and VTE at 1 year compared with population control subjects were significantly elevated. Risk of HF risk was however limited in absolute numbers and the clinical significance of the evaluated risk of this endpoint as well as other endpoints should be interpreted in the context of a significantly high 1-year mortality risk of around 40% in patients with RCC versus only around 2.5% in population controls.Figure 1

New Onset Geriatric Syndromes and One-year Outcomes Following Elective Gastrointestinal Cancer Surgery.

To assess whether older adults who develop geriatric syndromes following elective gastrointestinal surgery have poorer 1-year outcomes. Within 10 years, 70% of all cancers will occur in older adults ≥65 years old. The rise in older adults requiring major surgery has brought attention to age-related complications termed geriatric syndromes. However, whether postoperative geriatric syndromes are associated with long-term outcomes is unclear. A population-based retrospective cohort study using the New York State Cancer Registry and the Statewide Planning and Research Cooperative System was performed including patients >55 years with pathologic stage I-III esophageal, gastric, pancreatic, colon, or rectal cancer who underwent elective resection between 2004 and 2018. Those aged 55 to 64 served as the reference group. The exposure of interest was a geriatric syndrome [fracture, fall, delirium, pressure ulcer, depression, malnutrition, failure to thrive, dehydration, or incontinence (urinary/fecal)] during the surgical admission. Patients with any geriatric syndrome within 1 year of surgery were excluded. Outcomes included incident geriatric syndrome, 1-year days alive and out of the hospital, and 1-year all-cause mortality. In this study, 37,998 patients with a median age of 71 years without a prior geriatric syndrome were included. Of those 65 years or more, 6.4% developed a geriatric syndrome. Factors associated with an incident geriatric syndrome were age, alcohol/tobacco use, comorbidities, neoadjuvant therapy, ostomies, open surgery, and upper gastrointestinal cancers. An incident geriatric syndrome was associated with a 43% higher risk of 1-year mortality (hazard ratio, 1.43; 95% confidence interval, 1.27-1.60). For those aged 65+ discharged alive and not to hospice, a geriatric syndrome was associated with significantly fewer days alive and out of hospital (322 vs 346 days, P < 0.0001). There was an indirect relationship between the number of geriatric syndromes and 1-year mortality and days alive and out of the hospital after adjusting for surgical complications. Given the increase in older adults requiring major surgical intervention, and the establishment of geriatric surgery accreditation programs, these data suggest that morbidity and mortality metrics should be adjusted to accommodate the independent relationship between geriatric syndromes and long-term outcomes.

Risk stratification and predictive value of serum sodium fluctuation for adverse prognosis in acute coronary syndrome patients

BackgroundSerum sodium fluctuation (SF) as an indicator of the extent of changes in serum sodium is associated with increased mortality in hospitalized patients. However, there is no consensus on diagnostic criteria for SF, and its impact on the outcome of patients with acute coronary syndrome (ACS) remains uncertain. We defined SF and assessed its association with adverse prognosis in hospitalized ACS patients. MethodsPatients diagnosed with ACS were consecutively recruited. The serum SF rate (SFR) was defined as the ratio of the difference between the highest and lowest serum sodium levels during hospitalization to the initial serum sodium level on admission. The Cox proportional hazards model was performed to evaluate the association between SFR and mortality. The dose–response relationships of SFR with mortality was characterized by restricted cubic splines (RCS) model. The predictive performance of SF for mortality was assessed by the area under the receiver operating characteristic curves (AUCs). ResultsThe study retrospectively enrolled 1856 ACS patients, of which 36 (1.94%) patients dead within 1 year. Multivariate Cox analysis showed that SFR was independently associated with higher risk of 1-year mortality (HR = 1.17, 95% CI: 1.111–1.244, P < 0.001). RCS analysis showed the optimal threshold for SFR was 5%, and the 1-year cumulative mortality was higher in the abnormal SF group (SFR ≥ 5%) compared with the normal SF group (SFR < 5%, P < 0.01). The AUCs of SF for predicting mortality within 1 month, 6 months, and 1 year were 0.842 (95% CI: 0.781–0.904), 0.830 (95% CI:0.736–0.926), 0.703 (95% CI:0.595––0.811), respectively. Even in patients with normal baseline serum sodium, abnormal SF group demonstrated a significantly higher 1-year mortality compared to normal SF group (HR = 4.955, 95% CI: 1.919–12.795). ConclusionThe SFR during hospitalization is an adequate predictor of adverse outcomes in ACS patients, independent of serum sodium level at admission. Additional research is warranted to ascertain whether interventions targeting SF confer measurable clinical benefits.

Persistent poverty impacts access to minimally invasive surgery among patients with hepatopancreatobiliary cancer.

Minimally invasive surgery (MIS) has been successfully adopted in hepatopancreatobiliary (HPB) cancer, and has been associated with improved perioperative and comparable oncological outcomes. We sought to define the impact of county-level duration of poverty on access to MIS and clinical outcomes among patients with HPB cancer undergoing surgical treatment. Data on patients diagnosed with HPB cancer were obtained from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data (2010-2016). County-level poverty data wereobtained from the American Community Survey and the U.S. Department of Agriculture, and categorized into three groups: never high poverty (NHP), intermittent high poverty (IHP), and persistent poverty (PP). Multivariable regression was used to assess the relationship between PP and MIS. Among 8098 patients, 82% (n = 664) resided in regions with NHP, 13.6% (n = 1104) resided in regions with IHP, and 4.4% (n = 350) resided in regions with PP. Median age at the diagnosis was 71 years (interquartile range [IQR]: 67-77). Patients from IHP and PP counties had lower odds of undergoing MIS (IHP/PP vs. NHP,odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.36-0.96, p = 0.034) and being discharged home (IHP/PP vs.NHP, OR: 0.64, 95% CI: 0.43-0.99, p = 0.043), as well as a higher risk of 1-year mortality (IHP/PP vs. NHP, HR: 1.51, 95% CI: 1.036-2.209, p = 0.032) compared with patients residing in NHP counties. Duration of county-level poverty was associated with lower receipt of MIS and unfavorable clinical and survival outcomes among patients with HPB cancer. There is a need to improve access to modern surgical treatment options among vulnerable, PP populations.

Abstract 12743: Patient Satisfaction and Determinants of 1-Year Mortality Following Acute Coronary Syndrome

Introduction: The association of patient satisfaction with hospital ACS care and risk for long-term outcomes is incompletely described. This is particularly relevant to the Gulf region, where the ACS burden is high and literature on patient satisfaction and outcomes is lacking. The aim was to compare determinants of 1-year mortality based on patient satisfaction with ACS care in the Gulf region. Methods: In a prospective registry of 3566 ACS patients from Bahrain, Kuwait, Oman, and UAE (Gulf COAST registry), we grouped patients by their self-reported overall satisfaction with ACS care reported at 1-month following ACS (low satisfaction [n=1654] vs. high satisfaction [n=1912]; Table). We examined associations of baseline characteristics and risk for 1-year mortality in logistic regression models adjusted for Global Registry of Acute Coronary Events (GRACE) score. Results: Mortality at 1-year following ACS was higher in patients reporting low satisfaction (8.8%; n=146/1654) vs. high satisfaction (5.4%; n=103/1912) ( P &lt;.0001). Women, compared with men, had higher 1-year mortality risk in both satisfaction groups, and statistically significant risk in the low satisfaction group (aOR 1.45 [1.01–2.07]; P &lt;.05). Lack of employment (vs. any employment) was associated with higher 1-year mortality risk in both the low satisfaction (aOR 6.44 [2.58–16.03]) and high satisfaction (aOR 2.58 [1.35–4.93]) groups with borderline significant interaction ( P interaction = .08). In both satisfaction groups, lack of education, hypertension and prior angina were associated with higher 1-year mortality risk, whereas dyslipidemia and diabetes showed no association. Conclusions: Low patient satisfaction with ACS care was associated with higher 1-year mortality risk. Socioeconomic factors such as employment and education were associated with higher 1-year mortality, independent of patient satisfaction, and may guide mortality reduction interventions.

Triggering goals of care conversations in heart failure patients.

Goals of care conversations (GoCCs) are essential discussions, for those with chronic diseases, to identify a health care surrogate, initiate and review advance directives, and refer for palliative care. Prognosis with pulmonary hypertension (PH) related to heart failure (HF) remains challenging due to variation in trajectory of disease progression. The Gagne Combined Comorbidity score, an electronic prognostication score (E-Gagne), can be used to identify patients with high (>10%) 1-year mortality. Implementation of E-Gagne tool to identify HF patients with high 1-year mortality risk and trigger GoCCs. Plan-Do-Study-Act cycles were used throughout nine-week pre- and postintervention in an outpatient setting. Descriptive statistics and Chi-square analysis were used to compare GoCCs pre and post intervention. Using the E-Gagne tool, PH patients with high mortality risk were identified, within 1 week of their scheduled appointments. GoCCs education was provided to all stakeholders. Medical records were reviewed for four aspects of GoCCs: presence and review of advanced directive, documented health care surrogates, and referral for palliative care. Documentation of GoCCs was greater postintervention compared with preintervention (0%, n = 0/47 and 88%, n = 35/40 respectively, p < .001). Documentation of each of the four aspects of GoCCs was variable with the greatest improvement in documentation of health care surrogate and review of advance directives. There were no referrals for palliative care (0%, n = 0/47 and 0%, n = 0/40). Implementation of the E-Gagne tool, an electronic prognostication tool, identified high-risk PH HF patients and was effective in increasing documentation of GoCCs.

Evaluating frailty, mortality, and complications associated with metastatic spine tumor surgery using machine learning-derived body composition analysis.

Cancer patients with spinal metastases may undergo surgery without clear assessments of prognosis, thereby impacting the optimal palliative strategy. Because the morbidity of surgery may adversely impact recovery and initiation of adjuvant therapies, evaluation of risk factors associated with mortality risk and complications is critical. Evaluation of body composition of cancer patients as a surrogate for frailty is an emerging area of study for improving preoperative risk stratification. To examine the associations of muscle characteristics and adiposity with postoperative complications, length of stay, and mortality in patients with spinal metastases, the authors designed an observational study of 484 cancer patients who received surgical treatment for spinal metastases between 2010 and 2019. Sarcopenia, muscle radiodensity, visceral adiposity, and subcutaneous adiposity were assessed on routinely available 3-month preoperative CT images by using a validated deep learning methodology. The authors used k-means clustering analysis to identify patients with similar body composition characteristics. Regression models were used to examine the associations of sarcopenia, frailty, and clusters with the outcomes of interest. Of 484 patients enrolled, 303 had evaluable CT data on muscle and adiposity (mean age 62.00 ± 11.91 years; 57.8% male). The authors identified 2 clusters with significantly different body composition characteristics and mortality risks after spine metastases surgery. Patients in cluster 2 (high-risk cluster) had lower muscle mass index (mean ± SD 41.16 ± 7.99 vs 50.13 ± 10.45 cm2/m2), lower subcutaneous fat area (147.62 ± 57.80 vs 289.83 ± 109.31 cm2), lower visceral fat area (82.28 ± 48.96 vs 239.26 ± 98.40 cm2), higher muscle radiodensity (35.67 ± 9.94 vs 31.13 ± 9.07 Hounsfield units [HU]), and significantly higher risk of 1-year mortality (adjusted HR 1.45, 95% CI 1.05-2.01, p = 0.02) than individuals in cluster 1 (low-risk cluster). Decreased muscle mass, muscle radiodensity, and adiposity were not associated with a higher rate of complications after surgery. Prolonged length of stay (> 7 days) was associated with low muscle radiodensity (mean 30.87 vs 35.23 HU, 95% CI 1.98-6.73, p < 0.001). Body composition analysis shows promise for better risk stratification of patients with spinal metastases under consideration for surgery. Those with lower muscle mass and subcutaneous and visceral adiposity are at greater risk for inferior outcomes.

Long-term outcomes in patients who received veno-venous extracorporeal membrane oxygenation and renal replacement therapy: a retrospective cohort study

BackgroundAcute kidney injury (AKI) is a frequent complication in patients with severe respiratory failure receiving extracorporeal membrane oxygenation (ECMO). However, little is known of long-term kidney function in ECMO survivors. We aimed to assess the long-term mortality and kidney outcomes in adult patients treated with veno-venous ECMO (VV-ECMO).MethodsThis was a single-centre retrospective study of adult patients (≥ 18 years old) who were treated with VV-ECMO at a commissioned ECMO centre in the UK between 1st September 2010, and 30th November 2016. AKI was defined and staged using the serum creatinine and urine output criteria of the Kidney Diseases: Improving Global Outcomes (KDIGO) classification. The primary outcome was 1-year mortality. Secondary outcomes were long-term mortality (up to March 2020), 1-year incidence of end-stage kidney disease (ESKD) or chronic kidney disease (CKD) among AKI patients who received renal replacement therapy (AKI-RRT), AKI patients who did not receive RRT (AKI-no RRT) and patients without AKI (non-AKI).ResultsA total of 300 patients [57% male; median age 44.5; interquartile range (IQR) 34–54] were included in the final analysis. Past medical histories included diabetes (12%), hypertension (17%), and CKD (2.3%). The main cause of severe respiratory failure was pulmonary infection (72%). AKI occurred in 230 patients (76.7%) and 59.3% received renal replacement therapy (RRT). One-year mortality was 32% in AKI-RRT patients vs. 21.4% in non-AKI patients (p = 0.014). The median follow-up time was 4.35 years. Patients who received RRT had a higher risk of 1-year mortality than those who did not receive RRT (adjusted HR 1.80, 95% CI 1.06, 3.06; p = 0.029). ESKD occurred in 3 patients, all of whom were in the AKI-RRT group. At 1-year, 41.2% of survivors had serum creatinine results available. Among these, CKD was prevalent in 33.3% of AKI-RRT patients vs. 4.3% in non-AKI patients (p = 0.004).ConclusionsVV-EMCO patients with AKI-RRT had high long-term mortality. Monitoring of kidney function after hospital discharge was poor. In patients with follow-up creatinine results available, the CKD prevalence was high at 1 year, especially in AKI-RRT patients. More awareness about this serious long-term complication and appropriate follow-up interventions are required.

The association between blood albumin level and cardiovascular complications and mortality risk in ICU patients with CKD

BackgroundStudies involving the association of blood albumin with prognosis in patients with chronic kidney disease (CKD) during intensive care unit (ICU) were scarce.AimWe investigated whether reduced blood albumin level independently associated with an increased risk of cardiovascular (CV) complications and 1-year mortality risk in ICU patients with CKD.MethodsThe Medical Information Mart for Intensive Care III (MIMIC-III) database was used. Disease diagnosis and death information among a number of 925 ICU patients with CKD, who have been measured for blood biochemistry, were recorded. Here, multivariable logistic regression Models were structured to evaluate the associations between blood albumin levels (first value on admission, maximum and minimum value during ICU) and risks for CV complications and 1-year mortality among these CKD patients.ResultsIn 925 CKD patients, the number of CV complication with heart failure (HF), myocardial infarction (MI) or stroke was 470 (50.8%). 406 (43.9%) patients were dead during the follow-up of 1 year after patients were discharged. Our smooth curve results suggested a curvilinear relation on association between blood albumin level and risk of CV complications. The “inflection point” of blood albumin level that patients were at highest risk of CV complications was 3.4 g/dL. The almost linear relationship with a downward trend was observed on the association between blood albumin level and 1-year mortality risk. We found that reduced blood albumin level contributed to lower risk for CV complications and higher risk for 1-year mortality respectively when blood albumin levels in CKD patients were below 3.4 g/dL. Additionally, albumin therapy had an obvious modifying effect on the independent association, suggesting a possible improved effect of albumin therapy on risk of CV complications and 1-year mortality risk in these CKD patients.ConclusionsOur study reported that reduced blood albumin levels in CKD patients during ICU were related to lower risk for CV complications and increased risk of 1-year mortality.

The prognostic value of admission lymphocyte-to-monocyte ratio in critically ill patients with acute myocardial infarction

BackgroundInflammation plays a critical role in acute myocardial infarction (AMI). Recent studies have shown the value of hematologic indicators in MI risk stratification and prognostic assessment. However, the association between lymphocyte-to-monocyte ratio (LMR) and the long-term mortality of critically ill MI patients remains unclear.MethodsClinical data were extracted from the Medical Information Mart for Intensive Care III database. Patients diagnosed with AMI on admission in the intensive care units were include. The optimal cutoff value of LMR was determined by X-tile software. The Cox proportional hazard model was applied for the identification of independent prognostic factors of 1-year mortality and survival curves were estimated using the Kaplan–Meier method. In order to reduce selection bias, a 1:1 propensity score matching (PSM) method was performed.ResultsA total of 1517 AMI patients were included in this study. The cutoff value for 1-year mortality of LMR determined by X-Tile software was 3.00. A total of 534 pairs of patients were matched after PSM. Multivariate analysis (HR = 1.369, 95%CI 1.110–1.687, P = 0.003) and PSM subgroups (HR = 1.299, 95%CI 1.032–1.634, P = 0.026) showed that 1-year mortality was significantly higher in patients with LMR < 3.00 than patients with LMR ≥ 3.00 in Cox proportional hazard models. The survival curves showed that patients with LMR < 3.00 had a significantly lower 1-year survival rate before (63.83 vs. 81.03%, Log rank P < 0.001) and after PSM (68.13 vs. 74.22%, Log rank P = 0.041).ConclusionIn this retrospective cohort analysis, we demonstrated that a low admission LMR (< 3.00) was associated with a higher risk of 1-year mortality in critically ill patients with AMI.

Association of preprocedural ultrashort-term heart rate variability with clinical outcomes after transcatheter aortic valve replacement: A nested, case-control, pilot study.

ABSTRACTBackground:Because heart rate variability (HRV) has been linked to important clinical outcomes in various cardiovascular disease states, we investigated whether preprocedural ultrashort-term HRV (UST-HRV) differs between 1-year survivors and nonsurvivors after transcatheter aortic valve replacement (TAVR).Methods:In our single-center, retrospective, nested pilot study, we analyzed data from patients with severe aortic stenosis undergoing TAVR. All patients had preprocedural UST-HRV measured before the administration of any medications or any intervention. To investigate whether preprocedural HRV is associated with 1-year survival, we performed a logistic regression analysis controlling for Kansas City Cardiomyopathy Questionnaire 12 score.Results:In our parent cohort of 100 patients, 42 patients (28 survivors and 14 nonsurvivors) were included for analysis. Root mean square of successive differences (RMSSD) and standard deviation of NN intervals (SDNN) were lower in patients who survived to 1-year post TAVR compared to nonsurvivors [10 (IQR 8–23) vs 23 (IQR 17–33), P = 0.04 and 10 (IQR 7–16) vs 17 (IQR 11–40), P = 0.03, respectively]. Logistic regression demonstrated a trend in the association of preprocedure RMSSD with 1-year mortality and a 5% higher risk of 1-year mortality with each unit increment in UST-HRV using SDNN (OR 1.05; 95%CI 1.01–1.09, P = 0.02).Conclusion:Our data suggest an inverse relationship between preprocedural UST-HRV and 1-year survival post-TAVR. This finding highlights the potential complexity of HRV regulation in chronic vs acute illness. Prospective studies are needed to validate our findings and to determine whether UST-HRV can be used for risk stratification in patients with severe aortic stenosis.

One-Year Ischemic and Bleeding Events According to Renal Function in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes Treated With Percutaneous Coronary Intervention and Third-Generation Antiplatelet Drugs

The optimal antiplatelet therapy of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and chronic kidney disease (CKD) remains unknown. This study included 2,364 patients with NSTE-ACS undergoing predominantly percutaneous coronary intervention (PCI), who were randomized to ticagrelor or prasugrel in the ISAR-REACT 5 trial. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. The primary end point was 1-year mortality. Overall, there were 85 deaths (3.6%): 6 deaths (17.1%) in patients with eGFR <30, 31 deaths (6.9%) in patients with eGFR 30 to <60, 34 deaths (3.0%) in patients with eGFR 60 to <90, and 14 deaths (2.0%) in patients with eGFR ≥90ml/min/1.73m2; adjusted hazard ratio (HR)=1.15, 95% confidence interval (CI) 1.01 to 1.31; p=0.033 for 10ml/min/1.73m2 decrement in the eGFR. Bleeding occurred in 129 patients (5.5%): 7 bleeds (20.2%) in patients with eGFR <30, 36 bleeds (8.0%) in patients with eGFR 30 to <60, 64 bleeds (5.6%) in patients with eGFR 60 to <90, and 22 bleeds (3.1%) in patients with eGFR ≥90ml/min/1.73m2; adjusted HR=1.11 (1.01 to 1.23); p=0.045 for 10ml/min/1.73m2 decrement in the eGFR. One-year mortality and bleeding did not differ significantly between ticagrelor and prasugrel in all categories of impaired renal function. In conclusion, in patients with NSTE-ACS undergoing PCI with drug-eluting stents and third-generation antiplatelet drugs, impaired renal function was independently associated with higher risk of 1-year mortality and bleeding. The ischemic and bleeding risks appear to differ little between ticagrelor and prasugrel in all categories of impaired renal function.

When is Significant Left Ventricular Hypertrophy Acceptable for Donor Heart Selection

<h3>Purpose</h3> Extended criteria of donors for heart transplant (HTx) include many factors, such as left ventricular hypertrophy (LVH), decreased LVEF, older donor age, inotrope dependence, as well as gender and size mismatch. It has also been reported that various combinations of extended criteria risk factors appear to have worse outcomes depending on severity of the extended criteria characteristic. We sought to assess if severity of LVH with acceptable donor age and ischemic time is associated with increased mortality. <h3>Methods</h3> Between 2010 and 2020, we assessed 156 donor hearts with varying degrees of LVH defined as left ventricular septal thickness greater than 1.2 cm. Donor hearts were then divided into those that had IVS between 1.2 to <1.3 cm, 1.3 to <1.5 cm, ≥1.5 cm. In addition, an assessment was made for the same LVH groups versus donor age categorized as donor age ≥50 years old and donor ischemic time >240minutes. <h3>Results</h3> Severity of LVH with donor age <50 years and ischemic time <240 min appear to have acceptable 1-year survival. However, older donor age/long ischemic time with LVH are higher risk for 1-year mortality. (see table) <h3>Conclusion</h3> Severe LVH (IVS >1.5 cm) in donor hearts appears to be acceptable with donor age <50 years and ischemic time <240 minutes.