Higher Odds Of Death Research Articles

Portal Hypertension: An Underestimated Entity?

The aim of this study is to evaluate portal hypertension as an independent risk factor in general surgical procedures. Data on the impact of portal hypertension in general surgical outcomes has been limited. Published literature has focused mainly on its effect in liver surgery. The Child Pugh score and Model for End Stage Liver Disease are utilized for surgical risk assessment in liver disease but they do not accurately reflect degree of portal hypertension. From 2005 to 2012, patients with esophageal varices (EV) in the National Surgical Quality Improvement Program (NSQIP) formed the portal hypertension cohort, and were case matched to patients without esophageal varices (NEV) based on sex, age, surgery type, and year of operation. Thirty day mortality and morbidity were analyzed using generalized estimating equations for binary outcomes. EV patients were also dichotomized by Model for End Stage Liver Disease (MELD) score (≤15 vs >15) and compared with NEV patients. One thousand five hundred and seventy-four EV patients were matched to 3148 NEV patients. In multivariable analysis, EV patients had a 3.01 higher odds of 30 day mortality (P < 0.001) and 1.28 higher odds of complications (P < 0.001) compared with NEV patients. EV patients with MELD >15 had 4.64 higher odds of death within 30 days (P < 0.001) and had 1.75 higher odds of complications within 30 days (P < 0.001) compared with NEV patients; EV patients with MELD 15 or less had 1.95 higher odds of 30 day mortality (P < 0.001) compared with NEV patients. Portal hypertension is associated with a significant mortality and morbidity risk in general surgery, and should not be underestimated even in patients with MELD 15 or less where the early mortality risk remained significant.

Invasive Mechanical Ventilation and Mortality in Pediatric Hematopoietic Stem Cell Transplantation

To establish the current respiratory practice patterns in pediatric hematopoietic stem cell transplant patients and investigate their associations with mortality across multiple centers. Retrospective cohort between 2009 and 2014. Twelve children's hospitals in the United States. Two hundred twenty-two pediatric allogeneic hematopoietic stem cell transplant recipients with acute respiratory failure using invasive mechanical ventilation. None. PICU mortality of our cohort was 60.4%. Mortality at 180 days post PICU discharge was 74%. Length of PICU stay prior to initiation of invasive mechanical ventilation was significantly lower in survivors, and the odds of mortality increased for longer length of PICU stay prior to intubation. A total of 91 patients (41%) received noninvasive ventilation at some point during their PICU stay prior to intubation. Noninvasive ventilation use preintubation was associated with increased mortality (odds ratio, 2.1; 95% CI, 1.2-3.6; p = 0.010). Patients ventilated longer than 15 days had higher odds of death (odds ratio, 2.4; 95% CI, 1.3-4.2; p = 0.004). Almost 40% of patients (n = 85) were placed on high-frequency oscillatory ventilation with a mortality of 76.5% (odds ratio, 3.3; 95% CI, 1.7-6.5; p = 0.0004). Of the 20 patients who survived high-frequency oscillatory ventilation, 18 were placed on high-frequency oscillatory ventilation no later than the third day of invasive mechanical ventilation. In this subset of 85 patients, transition to high-frequency oscillatory ventilation within 2 days of the start of invasive mechanical ventilation resulted in a 76% decrease in the odds of death compared with those who transitioned to high-frequency oscillatory ventilation later in the invasive mechanical ventilation course. This study suggests that perhaps earlier more aggressive critical care interventions in the pediatric hematopoietic stem cell transplant patient with respiratory failure requiring invasive mechanical ventilation may offer an opportunity to improve outcomes.

Timing of withdrawal of life-sustaining therapies in severe traumatic brain injury: Impact on overall mortality.

The care of patients with severe traumatic brain injury (TBI) is complex and confounded by uncertainty in prognoses. Studies have demonstrated significant unexplained variation in mortality between centers. Possible explanations include differences in the quality and intensity of care across centers, including the appropriateness and timing of withdrawal of life-sustaining therapies. We postulated that centers with a preponderance of early deaths might have a more pessimistic approach to the TBI patient, which would be reflected in an increased hospital TBI-related mortality. This is a retrospective cohort study. Time to death was used as a proxy for time to withdrawal of life-sustaining therapies. Centers were classified as early or late based on when the majority (75th percentile) of their TBI-related deaths occurred. We evaluated the association between adjusted mortality and center classification using a hierarchical multivariable model. Two hundred trauma centers contributing data to the American College of Surgeons Trauma Quality Improvement Program from 2010 through 2013 were involved. The cohort included 17,505 patients with severe isolated TBI. One hundred eight centers were classified as early centers. The 75th percentile for time to death was 4 days among early centers versus 7 days in late centers. Mortality was 34% and 33%, respectively. After adjustment for case mix, care in an early center was not associated with increased odds of death (adjusted odds ratio, 0.95; 95% confidence interval, 0.83-1.09). Higher odds of death were independently associated with age, Glasgow Coma Scale (GCS) score, head Abbreviated Injury Scale (AIS) score, multiple comorbidities, traumatic subarachnoid hemorrhage, intracerebral mass lesions, brainstem lesions, and signs of compressed or absent basal cisterns. Centers rendering early decisions related to withdrawal of life-sustaining therapies in TBI patients, as measured by time until death, do not have worse outcomes than those making later decisions. How and when these decisions are made requires further exploration to balance an opportunity for clinical improvement with appropriate resource use. Prognostic and epidemiologic study, level III.

Abstract WP360: Outcomes After Intracerebral Hemorrhage in Patients With Systemic Cancer: A Population-Based Study

Background: Single-center studies suggest that patients with cancer have similar outcomes after intracerebral hemorrhage as compared to patients without cancer. However, these studies were limited by small sample sizes and inclusion of patients with intratumoral hemorrhage. We hypothesized that systemic cancer patients without known brain involvement fare worse after ICH than patients without cancer. Methods: We used the ICD-9 code 431 to identify all patients diagnosed with spontaneous ICH from 2002 to 2011 in the Nationwide Inpatient Sample. Our predictor variable was systemic cancer; patients with primary brain tumors and known brain metastases were excluded. Our primary outcome was discharge disposition, which was dichotomized into favorable discharge (home/self-care or rehabilitation) or unfavorable discharge (nursing facility, hospice, or death). We used logistic regression to compare the demographics, comorbidities, and outcomes of patients with cancer versus those without cancer. We performed secondary analyses by cancer subtype (i.e., non-metastatic solid tumors, non-metastatic hematologic tumors, and metastatic solid or hematologic tumors). Results: Our cohort comprised 597,046 ICH patients, among whom 22,394 (3.8%) had systemic cancer. Stroke risk factors such as hypertension and diabetes mellitus were significantly more common in patients without cancer, while anticoagulant use and higher Charlson comorbidity scores were more common amongst cancer patients. In multivariate logistic regression adjusting for demographics, comorbidities, and hospital-level characteristics, patients with cancer had higher odds of death (OR 1.62, 95% CI 1.56-1.69) and lower odds of favorable discharge (OR 0.59, 95% CI 0.56-0.63) than patients without cancer. Our primary results were substantiated in our secondary analysis as patients with cancer did worse than patients without cancer regardless of cancer subtype. Amongst the cancer groups, patients with non-metastatic hematologic tumors and those with metastatic disease fared the worst. Conclusions: Patients with systemic cancer have higher mortality and less favorable discharge outcomes after ICH than patients without cancer. Cancer subtype may influence outcomes after ICH.

Relationship of Coronary Calcium on Standard Chest CT Scans With Mortality

ObjectivesThe aim of this study was to determine the correlation between coronary artery calcium (CAC) scores on 3 mm electrocardiography (ECG)-gated computed tomography (CT) scans and standard 6 mm chest CT scans, and to compare relative strength of associations of CAC on each scan type with mortality risk. BackgroundCoronary artery calcification predicts cardiovascular disease (CVD) and all-cause mortality, and is typically measured on ECG-gated 3 mm CT scans. Patients undergo standard 6 mm chest CTs for various clinical indications much more frequently, but CAC is not usually quantified. To better understand the usefulness of standard chest CTs to quantify CAC, we conducted a case-control study among persons who had both scan types. MethodsBetween 2000 and 2003, 4,544 community-living individuals self- or physician-referred for “whole-body” CT scans, had 3 mm ECG-gated CTs and standard 6 mm chest CTs, and were followed for mortality through 2009. In this nested case-control study, we identified 157 deaths and 494 controls frequency matched (1:3) on age and sex. The Agatston method quantified CAC on both scan types. Unconditional logistic regression determined associations with mortality, accounting for CVD risk factors. ResultsParticipants were 68 ± 11 years of age and 63% male. The Spearman correlation of CAC scores between the 2 scan types was 0.93 (p < 0.001); median CAC scores were lower on 6 mm CTs compared to 3 mm CTs (22 vs.104 Agatston units, p < 0.001). Adjusted for traditional CVD risk factors, each standard deviation higher CAC score on 6 mm CTs was associated with 50% higher odds of death (odds ratio: 1.5; 95% confidence interval: 1.2 to 1.9), similar to 50% higher odds on the 3 mm ECG-gated CTs (odds ratio: 1.5; 95% confidence interval: 1.1 to 1.9). ConclusionsCAC scores on standard 6 mm chest CTs are strongly correlated with 3 mm ECG-gated CTs and similarly predict mortality in community-living individuals. Chest CTs performed for other clinical indications may provide an untapped resource to garner CVD risk information without additional radiation exposure or expense.

Association of Co-Existing Impairments in Cognition and Self-Rated Vision and Hearing With Health Outcomes in Older Adults.

Objective: The objective of this study was to assess the relationship of disability (activities of daily living [ADL] and instrumental ADL [IADL]), self-rated health (SRH), and 6-year mortality with co-existing impairments in vision (self-rated), hearing (self-rated), and/or cognition (Short Portable Mental Status Questionnaire) in older adults. Method: The study sample comprised of 3,871 participants from the North Carolina Established Populations for Epidemiologic Studies of the Elderly study (NC EPESE). Results: Persons with all three impairments had increased odds of ADL/IADL disability and low SRH. Participants with combined visual and cognitive impairments had increased odds of mortality. Whereas sensory impairments were associated with poor SRH, cognitive impairment was not unless both sensory impairments were present. Conclusion: Co-existent sensory and cognitive impairments were associated with higher risk of impaired functional status. Self-rated auditory impairment alone was not associated with higher odds of death, but mortality was linked to visual and, particularly, cognitive impairment, alone or combined.

Transfusion practices for treatment of dogs undergoing splenectomy for splenic masses: 542 cases (2001-2012).

To describe transfusion practices for treatment of dogs undergoing splenectomy for splenic masses. Retrospective case series. 542 client-owned dogs. Medical records of dogs that underwent splenectomy for splenic masses at 2 referral institutions were reviewed. Variables of interest were compared between dogs that did and did not undergo transfusion. Multiple logistic regression analysis was performed to assess associations of transfusion with death during hospitalization and with 30- and 180-day survival rates. Transfusions were administered to 240 of 542 (44%) dogs; packed RBCs were the most frequently administered blood product. On admission, dogs that subsequently received transfusions had higher mean illness severity score, heart rate, respiratory rate, blood lactate concentration, and prothrombin time, with lower mean PCV, platelet count, serum total solids and albumin concentrations, and base deficit than dogs that did not receive transfusions. Hemoperitoneum and malignancy, especially hemangiosarcoma, were more common in the transfusion group. Overall, 500 of 542 (92%) dogs survived to discharge. Dogs that received transfusions had higher odds of death or euthanasia while hospitalized and lower odds of surviving to 30 or 180 days after hospital discharge than dogs that did not. Evidence of shock, anemia, and hypocoagulability were apparent triggers for the decision to perform blood transfusion in dogs undergoing splenectomy for splenic masses and were likely attributable to hemoperitoneum and related hypovolemia. Dogs undergoing transfusion more commonly had malignant disease and had greater odds of poor long-term outcome, compared with dogs that did not undergo transfusion.

Mortality Among Injured Children Treated at Different Trauma Center Types.

Trauma is the leading cause of death among US children. Whether pediatric trauma centers (PTCs), mixed trauma centers (MTCs), or adult trauma centers (ATCs) offer a survival benefit compared with one another when treating injured children is controversial. Ascertaining the optimal care environment will better inform quality improvement initiatives and accreditation standards. To evaluate the association between type of trauma center (PTC, MTC, or ATC) and in-hospital mortality among young children (5 years and younger), older children (aged 6-11 years), and adolescents (aged 12-18 years). In this retrospective cohort study, injured children aged 18 years or younger who were hospitalized in the United States from January 1, 2010, to December 31, 2013, were observed for the duration of their admission until discharge or death. We included patients with an Abbreviated Injury Score of 2 or greater in at least 1 body region. Random-intercept multilevel regression was used to evaluate the association between center type and in-hospital mortality after adjusting for confounders. Stratified analyses in young children, older children, and adolescents were performed. We conducted secondary analyses limited to patients with severe injuries (Injury Severity Score ≥25). Both analyses were performed between January 1 and August 31, 2014. Data were derived from 252 US level I and II trauma centers voluntarily participating in the American College of Surgeons adult or pediatric Trauma Quality Improvement Program. In-hospital mortality. We identified 175 585 injured children. Crude mortality rates were 2.3% for children treated at ATCs, 1.8% for children treated at MTCs, and 0.6% for children treated at PTCs. After adjustment, children had higher odds of dying when treated at ATCs (odds ratio [OR], 1.57; 95% CI, 1.15-2.14) and MTCs (OR, 1.45; 95% CI, 1.05-2.01) compared with those treated at PTCs. In stratified analyses, young children had higher odds of death when treated at ATCs vs PTCs (OR, 1.78; 95% CI, 1.05-3.40), but there was no association between center type and mortality among older children (OR, 1.17; 95% CI, 0.65-2.11) and adolescents (OR, 1.23; 95% CI, 0.82-1.85). Results were similar in analyses of severely injured children: those treated at ATCs (OR, 1.75; 95% CI, 1.25-2.44) and MTCs (OR, 1.62; 95% CI, 1.15-2.29) had higher odds of death when compared with those treated at PTCs. Injured children treated at ATCs and MTCs had higher in-hospital mortality compared with those treated at PTCs. This association was most evident in younger children and remained significant in severely injured children. Quality improvement initiatives geared toward ATCs and MTCs are required to provide optimal care to injured children.

Inequalities in non-small cell lung cancer treatment and mortality

BackgroundNon-small cell lung cancer (NSCLC) comprises approximately 85% of all lung cancer cases, and surgery is the preferred treatment for patients. The National Health Service established Primary Care Trusts (PCTs)...

Financial catastrophe, treatment discontinuation and death associated with surgically operable cancer in South-East Asia: Results from the ACTION Study

This study assessed the extent to which individuals with surgically operable cancer in Southeast Asia experience financially catastrophic out-of-pocket costs, discontinuation of treatment, or death. The ACTION study is a prospective, 8-country, cohort study of adult patients recruited consecutively with an initial diagnosis of cancer from public and private hospitals. Participants were interviewed at baseline and 3 months. In this paper, we identified 4,584 participants in whom surgery was indicated in initial treatment plans and assessed the following competing outcomes: death, financial catastrophe (out-of-pocket costs of >30% of annual household income), treatment discontinuation, and hospitalization without financial catastrophe incurred. We then analyzed a range of predictors using a multinomial regression model. Of the participants, 72% were female and 44% had health insurance at baseline. At 3 months, 31% of participants incurred financial catastrophe, 8% had died, 23% had discontinued treatment, and 38% were hospitalized but avoided financial catastrophe. Health insurance status was found to be associated with lower odds of treatment discontinuation (odds ratio [OR], 0.60; 95% CI, 0.47-0.77) relative to hospitalization without financial catastrophe. Women had greater odds of financial catastrophe than men (OR, 1.35; 95% CI, 1.05-1.74), whereas lower socioeconomic status (range of indicators) was generally found to be associated with higher odds of death, treatment discontinuation, and financial catastrophe. Priority should be given to measures such as programs to extend social health insurance to offset the out-of-pocket costs associated with surgery for cancer faced in particular by women, the uninsured, and individuals of low socioeconomic status in Southeast Asia.

Pedestrian Injury Outcome as a Function of Vehicle Market Group in Victoria, Australia

Objective: Pedestrians are among the most vulnerable road users in terms of their risk of serious injury when involved in a collision with a vehicle. In Australia, around 200 pedestrians are killed in road crashes annually and over 2,000 are seriously injured. The objective of the current study was to analyze pedestrian death and injury risk by body region across 10 light passenger and commercial vehicle market groups in Victoria, Australia.Methods: This study utilized police-reported crash data linked to insurance injury compensation claims data during the period 2001–2010 to determine whether pedestrian injury outcome is a function of colliding vehicle type. Logistic regression models were developed to measure the risk of pedestrian death or injury as a function of vehicle market group for 4 body region groupings, namely, all body regions; the head, face, or neck; the thorax; and the lower extremities (including pelvis).Results: Analysis focused on head, face, or neck injury found that pedestrians struck by small cars, people movers, large sport utility vehicles (SUVs), vans, or utility vehicles had statistically significantly higher odds of death or injury compared to large cars. When the analysis focused on thoracic injury, it was again found that pedestrians struck by large SUVs and vans had statistically significantly higher odds of death injury compared to large cars. In particular, the odds of death or thoracic injury is 74.4% higher for large SUVs compared to large cars. Analysis focused on lower extremity injury found no market group with statistically significant different odds of death or injury compared to large cars at the 5% level; however, medium cars and vans were found to have statistically significantly lower odds of death or lower extremity injury at the 10% level.Conclusions: The results suggest that the increasing popularity of vehicles such as SUVs has the potential to lead to an increase in the level of pedestrian road trauma. With the general trend toward the use of larger vehicles, the results provide validation of the importance of improved vehicle design and the incorporation of new pedestrian safety features.

188. Long-term Effects of Primary Care Provider Training in Screening, Assessment, and Treatment of Adolescent Depression

with public insurance (OR1⁄41.51, 95% CI:1.40-1.64, vs. private). In both adolescents and young adults, comorbid conditions of alcoholism and obesity were associated with increased odds of SII (OR1⁄42.08, 95% CI:1.74-2.48 (alcoholism); OR1⁄41.59, 95% CI:1.222.09 (obesity)). Adolescents and young adults with a SII had higher odds of death compared to those visiting for other injuries (OR1⁄47.80, 95% CI: 7.01-8.66 (adolescents); OR1⁄45.51, 95% CI:5.165.88, (young adults)). Odds of death differed by SII mechanism. Adolescents and young adults with cut/pierce injuries had a dramatically reduced risk of death compared to those with other SIIs (OR1⁄40.04, 95% CI:0.03-0.05). Young adults were more likely to have a SII compared to early adolescents (OR1⁄43.88, 95% CI:3.584.20) and late adolescents (OR1⁄41.36, 95% CI: 1.30-1.42). Young adults were more likely to self-pay for their hospitalization compared to adolescents (28.9% vs. 9.2%), and were less likely to have private insurance (20.1% vs. 32.8%). Conclusions: Our finding that cut/pierce was the most common mechanism in both adolescents and young adults differs from trends in earlier years and may reflect an increase in self-mutilation behavior with no suicidal intent in these age groups. Young adults had a higher likelihood of SII compared to adolescents, indicating that the transition to young adulthood may be an important time for the monitoring and prevention of self-harming behavior. Sources of Support: Internal Children’s Hospitals and Clinics of Minnesota.

Racial/ethnic disparities in emergency general surgery: explained by hospital-level characteristics?

BackgroundTo quantify racial/ethnic differences in outcome after emergency general surgery (EGS). MethodsPatients receiving a representative EGS (colectomy, small bowel resection, or ulcer repair operation) performed within the first 24 hours of hospital admission were identified in the Nationwide Inpatient Sample between 2000 and 2008. Multivariable logistic regression was used to estimate the overall disparity in odds of death between African Americans (AAs) and Caucasians. Hierarchical models were then used to evaluate association of hospital-level factors and death after EGS. ResultsA total of 116,344 patients were identified. AA patients had 10% higher odds of dying after EGS than Caucasian patients (adjusted odds ratio 1.10, P = .02). All patients treated at hospitals with greater than 6% AA EGS patients had higher odds of death than those at hospitals with fewer percentage of AA EGS patients (adjusted odds ratio 1.16 to 1.42, P < .002). ConclusionThere is racial/ethnic disparity in outcome after selected EGS; however, this disparity is explained by hospital-level factors.

Mortality outcome among medically underserved women screened through a publicly funded breast cancercontrol program, 1997-2007.

The purpose of this study was to assess treatment and mortality differences between women diagnosed with breast cancer through Nebraska's Every Woman Matters (EWM) program and women diagnosed through other sources. A retrospective analysis was performed using 10years of Nebraska Cancer Registry and EWM program data on women aged 40-74years. This study used chi-square and multivariate logistic regressionwith mortality as the outcome of interest. From 1997 to 2007, 4,739 women were diagnosed with breast cancer, 435 (9.1%) of whom were diagnosed through EWM. The EWM and non-EWM groups differed significantly in age, race, marital status, location of residence at the time of diagnosis, neighborhood poverty level at the time of diagnosis, tumor stage at diagnosis, and chemotherapy. No significant differences were found between the two groups in radiation therapy, surgical resection, and hormone therapy. In both 1- and 5-year multivariate mortality models,the odds of dying for those in the EWM program were not statistically significantly different from the odds of dying for those not in the EWM program. In the 1-year mortality model, residents of urban metropolitan counties (OR 2.079; 95% CI 1.663-2.598)had an increased odds of dying compared to residents of rural counties. In the 5-year mortality model, black women (OR 2.239; 95% CI 1.453-3.450), residents of areas with a high (more than 20%) neighborhood poverty level at the time of diagnosis (OR 1.589; 95% CI 1.204-2.097), and unmarried women (OR 1.334; 95% CI 1.164-1.528) had higher odds of death. Both groups have received similar treatments. Targeted outreach to vulnerable groups for cancer screening may improve cancer outcomes and reduce disparities.

Identifying Cirrhosis Patients for Intensive Disease Management

Our healthcare system is based on the disease model prevalent at the beginning of the 20th century, in which people would typically develop acute illnesses, get hospitalized, and either die or full recover, with little emphasis placed on the management of chronic diseases. In contrast, chronic illnesses now account for more than 75% of total health care expenditures,1 as such, the episodic, symptom-driven nature of our health care system is poorly structured to manage this increasing burden of chronic conditions, of which cirrhosis, affecting approximately 750,000 adults in the United States, with a median time from diagnosis to death of 10 years, serves as a useful disease example.2 In similar conditions such as heart failure, advances in chronic disease management have substantially improved patient outcomes. These advances include relatively simple concepts such as patient education, medication reconciliation, and telephone management between visits.3 Recent pilot data suggests that similar interventions might also improve outcomes in cirrhosis.4,5 (Figure 1) Since none of these interventions come without a cost, they would be most efficiently applied by targeting patients who are most likely to develop problems. Figure 1 Results of a randomized pilot study demonstrating improved survival among cirrhosis patients receiving chronic disease management4 In this issue of Digestive Diseases and Sciences, Johnson et al. present a study that identifies patient characteristics associated with increased likelihood of hospitalization for complications of cirrhosis. Among a cohort of 395 ambulatory cirrhosis patients, 142 (36%) were hospitalized for a cirrhosis-related complication during a median of 3.7 years of follow-up, with 78 (19.7%) being hospitalized within the first year. Using multivariable analysis, independent predictors of hospitalization were Model for End-stage Liver Disease (MELD) score at baseline, the presence of hepatocellular carcinoma, prior hospitalization, marital status, and diuretic usage. As a single-center study performed at a liver transplant center, the patient population may have been somewhat sicker than at non-transplant centers. Despite these usual caveats, however, this study is important because it is the first to predict hospitalization in outpatients with cirrhosis. Hospitalizations not only serve as a marker for many of the important complications of cirrhosis, but can also identify vulnerable patients at risk for mortality.6 Therefore, the risk factors identified in this study may be used in the future to select patients for more intensive disease management interventions. Most of the identified risk factors, such as MELD score, do not come as a surprise to any practicing gastroenterologist, but one that does stand out is marital status. On multivariate analysis, unmarried patients had a 1.9-fold higher odds of hospitalization during the first year of follow-up, which was almost as strong a risk factor as having a MELD score >15. Furthermore, being unmarried was independently associated with a 2.5-fold higher odds of death over a 2- year follow-up period (p=0.01). This is a striking finding that deserves further attention because marital status may be a surrogate for social support, and thus something that is potentially remediable. Several recent studies have documented the burden that friends and family face when caring for a loved one with cirrhosis,7,8 with one other population-based study reporting an association between marital status and survival among patients with cirrhosis.9 With such a major impact on mortality, further investigation of social support systems in cirrhosis management is warranted. For example, at our center, we are currently pilot testing an automated phone management system which sends email updates to caregivers who live geographically distant from the patient – thus potentially broadening the net of social support for unmarried or widowed patients. In summary, the study by Johnson et al. reports that one-fifth of ambulatory patients with cirrhosis will be hospitalized within a year for complications of their disease. Rather than waiting for complications, physicians should try to predict and prevent them. Patients at higher than average risk include those with higher MELD scores, hepatocellular carcinoma, prior hospitalizations, diuretic usage, and single marital status; these individuals may benefit from more intensive outpatient management.

Epidemiology of Respiratory Syncytial Virus-Associated Acute Lower Respiratory Tract Infection Hospitalizations Among HIV-Infected and HIV-Uninfected South African Children, 2010-2011

There are limited data on respiratory syncytial virus (RSV) infection among children in settings with a high prevalence of human immunodeficiency virus (HIV). We studied the epidemiology of RSV-associated acute lower respiratory tract infection (ALRTI) hospitalizations among HIV-infected and HIV-uninfected children in South Africa. Children aged <5 years admitted to sentinel surveillance hospitals with physician-diagnosed neonatal sepsis or ALRTI were enrolled. Nasopharyngeal aspirates were tested by multiplex real-time polymerase chain reaction assays for RSV and other viruses. Associations between possible risk factors and severe outcomes for RSV infection among HIV-infected and uninfected children were examined. The relative risk of hospitalization in HIV-infected and HIV-uninfected children was calculated in 1 site with population denominators. Of 4489 participants, 4293 (96%) were tested for RSV, of whom 1157 (27%) tested positive. With adjustment for age, HIV-infected children had a 3-5-fold increased risk of hospitalization with RSV-associated ALRTI (2010 relative risk, 5.6; [95% confidence interval (CI), 4.5-6.4]; 2011 relative risk, 3.1 [95% CI, 2.6-3.6]). On multivariable analysis, HIV-infected children with RSV-associated ALRTI had higher odds of death (adjusted odds ratio. 31.1; 95% CI, 5.4-179.8) and hospitalization for >5 days (adjusted odds ratio, 4.0; 95% CI, 1.5-10.6) than HIV-uninfected children. HIV-infected children have a higher risk of hospitalization with RSV-associated ALRTI and a poorer outcome than HIV-uninfected children. These children should be targeted for interventions aimed at preventing severe RSV disease.

Preoperative Hematocrit Is a Powerful Predictor of Adverse Outcomes in Coronary Artery Bypass Graft Surgery: A Report From The Society of Thoracic Surgeons Adult Cardiac Surgery Database

Small series have identified a relationship between preoperative hematocrit (HCT) and outcomes in coronary artery bypass graft (CABG) surgery. The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) began collecting preoperative HCT data in 2008. In this study, analyses were performed to determine the impact of preoperative HCT on perioperative morbidity and mortality among patients undergoing isolated CABG. Data were collected on 182,599 patients who underwent primary isolated on-pump CABG between 2008 and 2009 and were included in the STS ACSD. Data were included only from centers that performed more than 100 on-pump cases per year during the period of study. Dialysis patients as well as those with previous cardiovascular operations or missing data for HCT were excluded. We then performed multivariable analysis using the 2008 STS CABG risk model as a guide, including HCT as a predictor. Logistic regression was performed for operative mortality and other adverse outcomes. Overall operative mortality was 1.6% (3,005 of 182,599). Compared with patients with anemia (HCT <33%), patients with HCT of at least 42% had lower mortality (1.1% versus 3.4%; p < 0.0001) and lower rates of renal failure (2.0% versus 7.8%; p < 0.0001), stroke (0.9% versus 1.8%; p < 0.0001), prolonged ventilation (8.4% versus 17.5%; p < 0.0001), and deep sternal wound infection (0.3% versus 0.6%; p < 0.0001). In adjusted analyses, each 5-point decrease in preoperative HCT was associated with an 8% higher odds of death (odds ratio, 1.08; p = 0.0003), a 22% increase in the odds of postoperative renal failure (odds ratio, 1.22; p < 0.0001), and a 10% increase in the risk of deep sternal wound infection (odds ratio, 1.10; p < 0.01). Similar results were observed among patients (n = 74,292) undergoing elective CABG. The percentage of patients receiving perioperative blood transfusion decreased from 88.5% in the anemic group (HCT <33%) to 32.5% in patients with HCT of at least 42% (p < 0.0001). Preoperative HCT is a powerful independent predictor of perioperative mortality as well as renal failure and deep sternal wound infection in patients undergoing isolated primary CABG operations. These findings should prompt investigation of strategies to increase preoperative HCT.

Infected primary knee arthroplasty: Risk factors for surgical treatment failure

ObjectiveTo present epidemiological data and risk factors associated with surgical outcomes favorable or unfavorable for the treatment of infection in infected total knee arthroplasty. MethodsWe reviewed medical records of 48 patients who underwent treatment of primary total knee arthroplasty for infection between January 1994 and December 2008, in the Orthopedics and Traumatology Department of the Santa Casa de Misericórdia de São Paulo. The variables associated with favorable outcome of surgical treatment (debridement and retention or exchange arthroplasty in two days) or unfavorable (arthrodesis or death) infection. ResultsA total of 39 cases of infection after primary total knee arthroplasty, 22 progressed to 17 for a favorable outcome and unfavorable outcome. Early infections (OR: 14.0, 95% CI 1.5–133.2, p=0.016) and diabetes (OR: 11.3, 95% CI 1.4–89.3, p=0.032) were associated with arthrodesis joint and death respectively. ConclusionPatients with early infection had a higher risk of developing surgical procedure with unfavorable outcome (arthrodesis) and diabetics had higher odds of death after infection of primary knee arthroplasties.

Artroplastia primária de joelho infectada: fatores de risco para falha na terapia cirúrgica

ObjectiveTo present epidemiological data and risk factors associated with surgical outcomes favorable or unfavorable for the treatment of infection in infected total knee arthroplasty. MethodsWe reviewed medical records of 48 patients who underwent treatment of primary total knee arthroplasty for infection between January 1994 and December 2008, in the Orthopedics and Traumatology Department of the Santa Casa de Misericórdia de São Paulo. The variables associated with favorable outcome of surgical treatment (debridement and retention or exchange arthroplasty in two days) or unfavorable (arthrodesis or death) infection. ResultsA total of 39 cases of infection after primary total knee arthroplasty, 22 progressed to 17 for a favorable outcome and unfavorable outcome. Early infections (OR: 14.0, 95% CI 1.5 to 133.2, p=0.016) and diabetes (OR: 11.3, 95% CI 1.4 to 89.3, p=0.032) were associated with arthrodesis joint and death respectively. ConclusionPatients with early infection had a higher risk of developing surgical procedure with unfavorable outcome (arthrodesis) and diabetics had higher odds of death after infection of primary knee arthroplasties.

Short and Long Term Mortality Rates after a Lower Limb Amputation

To determine mortality rates after a first lower limb amputation and explore the rates for different subpopulations. Retrospective cohort study of all people who underwent a first amputation at or proximal to transtibial level, in an area of 1.7 million people. Analysis with Kaplan-Meier curves and Log Rank tests for univariate associations of psycho-social and health variables. Logistic regression for odds of death at 30-days, 1-year and 5-years. 299 people were included. Median time to death was 20.3 months (95%CI: 13.1; 27.5). 30-day mortality = 22%; odds of death 2.3 times higher in people with history of cerebrovascular disease (95%CI: 1.2; 4.7, P = 0.016). 1 year mortality = 44%; odds of death 3.5 times higher for people with renal disease (95%CI: 1.8; 7.0, P < 0.001). 5-years mortality = 77%; odds of death 5.4 times higher for people with renal disease (95%CI: 1.8; 16.0,P = 0.003). Variation in mortality rates was most apparent in different age groups; people 75-84 years having better short term outcomes than those younger and older. Mortality rates demonstrated the frailty of this population, with almost one quarter of people dying within 30-days, and almost half at 1 year. People with cerebrovascular had higher odds of death at 30 days, and those with renal disease and 1 and 5 years, respectively.