Higher 1-year Mortality Research Articles

An evaluation of the representativeness of a national spinal cord injury registry: a population-based cohort study.

Population-based cohort study for the western part of Quebec. To determine the impact of declining to participate in a national spinal cord injury (SCI) registry on patient outcomes and continuum of care. Level-1 trauma center specialized in SCI care in Montreal, Canada. This cohort study compared the outcomes of 444 patients who were enrolled in the Rick Hansen SCI registry and 140 patients who refused. Logistic regression analyses were performed to assess the association between voluntary participation and the outcomes, while adjusting for confounding factors. The main outcomes were: attendance to follow-up 6- to 12-month post injury, 1-year mortality, and the occurrence of pressure injury during acute care. Declining to be enrolled in the registry was a significant predictor of lower attendance to specialized follow-up (adjusted odds ratio [OR] 0.04, 95% confidence interval [CI] 0.02-0.08). It was also associated with a higher 1-year mortality rate (OR 12.50, CI 4.50-33.30) and higher occurrence of pressure injury (OR 2.56, CI 1.56-4.17). This study sheds invaluable insight on individuals that researchers and clinicians are usually blind to in SCI cohort studies. This study suggests that decline to participate in a registry during the care hospitalization may be associated with worsened health, poorer outcomes, and reduced follow-up to specialized care. Declining the enrollment to voluntary registry could represent a potential prognostic factor for future research.

Impact of body mass index on outcomes in patients undergoing transfemoral transcatheter aortic valve implantation

ObjectiveThis study sought to investigate the effect of body mass index on outcomes in patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation. MethodsA total of 12,381 patients undergoing transfemoral transcatheter aortic valve implantation were divided into body mass index categories: underweight (<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obesity (>30 kg/m2). Primary endpoints were differences in 30-day and 1-year all-cause mortality. Secondary endpoints included all other clinical endpoints such as stroke. Univariate and multivariate odds ratios were calculated using logistic and cox regression analyses. ResultsTwo percent (n = 205) of patients were underweight, 29% (n = 3564) were normal weight, 44% (n = 5460) were overweight, and 25% (n = 3152) were obese. Thirty-day mortality was lower in overweight (5.3%, odds ratio, 0.73; 95% confidence interval, 0.61-0.88; P = .001) and obese patients (5.2%, odds ratio, 0.74; 95% confidence interval, 0.60-0.92; P = .006), but higher in underweight (9.8%, odds ratio, 1.51; 95% confidence interval, 0.92-2.47; P = .010) as compared to normal weight patients (6.9%). After multivariate adjustment, 30-day mortality was not significantly different across body mass index categories. However, 1-year mortality was higher in underweight patients (hazard ratio, 1.52; 95% confidence interval, 1.10-2.09; P = .011). Stroke rates were comparable between body mass index groups. ConclusionsFor overweight and obese patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation, there was no 30-day difference in mortality compared with patients with normal weight. However, underweight patients showed higher rates of 1-year mortality after transcatheter aortic valve implantation.

Cardiac device-related infective endocarditis in the Czech Republic: Prospective data from the ESC EORP EURO-ENDO registry.

Understanding cardiac electronic device infective endocarditis epidemiology is essential for the management of this serious complication. Only monocentric and limited data have been published regarding patients in the Czech republic so far. The aim of this study was to describe the current profile, microbiology and clinical characteristics of this population. National data from the prospective ESC-EORP EURO-ENDO registry were collected. 57 consecutive patients with a diagnosis of cardiac device-related infective endocarditis (CDRIE) from 11 Czech centres were included. Staphylococcus spp. was responsible for 43.9% of isolates, whereas Culture negative endocarditis was documented in 26.3% episodes. The most frequent complications under therapy were acute renal failure (17.5%), septic shock and heart failure (both 10.5%). Extraction of device was performed in 75.4% of all patients, and the 1-year mortality was 22.5%. The high proportion of culture-negative endocarditis is alarming and warrants further investigation. Cardiac device related infective endocarditis is a serious complication with a high 1-year mortality in a highly polymorbid spectrum of patients.

FLT3-ITD Allelic Burden and Acute Promyelocytic Leukemia Risk Stratification.

Simple SummaryAround 12–38% of acute promyelocytic leukemia (APL) patients carry the FLT3-ITD mutation, which has been associated with several poor-prognosis indicators such as high white blood cell counts, M3v variant morphology, and the bcr3 isoform. We aimed to retrospectively study the impact of FLT3-ITD mutations in APL patients in regard to clinical features, treatment courses, and outcomes. We demonstrate that Sanz high-risk status APL correlates with high FLT3-ITD allelic burdens, with every 1% increase in allelic burden correlating with a 0.6 × 109/L increase in white blood cell count (WBC). The presence of FLT3-ITD was associated with decreased remission rates and higher 5-year mortality from the time of diagnosis. These findings provide novel revelations regarding the features of FLT3-ITD APL, particularly in regard to allelic burden, that warrant further study.The significance of FLT3-ITD in acute promyelocytic leukemia (APL) is not well-established. We performed a bi-center retrospective study of 138 APL patients, 59 (42.8%) of whom had FLT3-ITD. APL patients with FLT3-ITD had higher baseline white blood cell counts (WBCs) (p < 0.001), higher hemoglobin, (p = 0.03), higher aspartate aminotransferase (p = 0.001), lower platelets (p = 0.004), lower fibrinogen (p = 0.003), and higher incidences of disseminated intravascular coagulation (p = 0.005), M3v variant morphology (p < 0.001), and the bcr3 isoform (p < 0.001). FLT3-ITD was associated with inferior post-consolidation complete remission (CR) (p = 0.02) and 5-year overall survival (OS) of 79.7%, compared to 94.4% for FLT3-WT (wild-type) (p = 0.02). FLT3-ITD was strongly associated with baseline WBCs ≥ 25 × 109/L (odds ratio (OR): 54.4; 95% CI: 10.4–286.1; p < 0.001). High FLT3-ITD allelic burdens correlated with high-risk (HR) Sanz scores and high WBCs, with every 1% increase in allelic burden corresponding to a 0.6 × 109/L increase in WBC. HR APL was associated with a 38.5% increase in allelic burden compared with low-risk (LR) APL (95% CI: 19.8–57.2; p < 0.001). Our results provide additional evidence that FLT3-ITD APL is a distinct subtype of APL that warrants further study to delineate potential differences in therapeutic approach.

Predicted Heart Mass in Obese Heart Transplant Donors and Recipients: An Analysis of the ISHLT Registry

<h3>Purpose</h3> Predicted heart mass (PHM) was neither derived nor validated in an obese population. Our objectives were to determine survival according to size mismatch defined by actual PHM and recalculated PHM using ideal body weight (IBW) in obese recipients or recipients of obese donors, and to evaluate whether size mismatch using IBW-adjusted PHM improves risk assessment. <h3>Methods</h3> We included HT recipients (≥18 y) with BMI ≥30 kg/m² or recipients of donors with BMI ≥30 kg/m² from the ISHLT registry between 2008-2017. IBW was calculated using Devine's formula. Donor-recipient PHM was evaluated as a continuous variable and according to established groups: <-30%, -30 to -20%, -20 to 20%, 20 to 30% and >30%. We used Kaplan-Meier survival and multivariable Cox PH analyses to evaluate post-HT mortality by actual/IBW-adjusted PHM groups. We compared the 2 models using net reclassification index (NRI). <h3>Results</h3> We included 10,817 HT recipients, age 55 (IQR 46-62) yrs, 23% female, BMI 31 kg/m² (28-33) with follow up of 3.1 (1.2-6.0) yrs. Included donors were 34 (24-44) yrs, 31% female, and BMI 31 kg/m² (26-34). 692 (6%) and 335 (3%) recipient-donor pairs were reclassified as undersized by 20-30% and >30% respectively using IBW-adjusted PHM. 462 (4%) and 431 (4%) recipient-donor pairs were reclassified as oversized by 20-30% and >30% respectively when using IBW-adjusted PHM. Actual PHM was associated with lower 1-year survival (<i>p</i><0.001); however, differences in 1-year survival between IBW-adjusted PHM groups were not discernible (<i>p</i>=0.25). Undersizing using actual PHM was associated with higher 1-year mortality (<i>p</i><0.001), not seen with IBW-adjusted PHM (p=0.15 Fig). Models based on IBW-adjusted PHM had worse risk quantification for post-HT mortality than using actual PHM (category-free NRI -0.078, 95% CI -0.158, 0.006). <h3>Conclusion</h3> Calculation of PHM using IBW was not associated with post-HT survival. Actual PHM can be used for size matching when assessing mortality risk in recipients of obese donors or obese recipients.

CLI is a Major Public Health Concern With Prognosis Worse Than Many Types of Cancer

Despite advancing technologies available to treat CLI, we clearly have a long journey ahead of us on behalf of our patients. With the Journal of Critical Limb Ischemia, we are pleased to be able to provide a forum for original CLI work that will be reviewed by multidisciplinary, international CLI experts who understand the complex nature of CLI. The Editorial Board of Journal of Critical Limb Ischemia comprises physicians from across the globe who understand the difficulty and complexity of gathering CLI data. They are vascular surgeons, interventional cardiologists and radiologists, podiatrists, angiologists, and wound care experts. These experts are well aware of the reality of the advanced and complex nature of CLI disease with high 5-year mortality. Because of this, we believe that CLI trials should be modeled after diseases that have a high mortality rate over a short period of time. We must be able to capture the true nature of the disease and its impact on patients affected by it. If we continue to model CLI studies under the conventional nature of vascular disease in general we will never be able to achieve meaningful and convincing data to change the course of therapy. We desperately need new technologies to treat CLI to reduce the incidence of unnecessary amputations occurring in the United States and throughout the world. We clearly can, and must, do better. Our patients are demanding progress.

Ratio of Overhydration and Extracellular Water Versus Ratio of Extracellular Water and Body Cell Mass in the Assessment of Fluid Status in Patients With Acute Kidney Injury Requiring Kidney Replacement Therapy: A Cohort Study

The aim of this study is to analyze the association between the ratio of overhydration and extracellular water (OH/ECW) and the ratio of extracellular water and body cell mass (ECW/BCM) measured by bioelectrical impedance and outcomes of patients with acute kidney injury (AKI) requiring kidney replacement therapy (KRT). Patients with severe AKI treated with KRT in our hospital between September 2016 and August 2018 were enrolled. These patients were assessed using a body composition monitor before KRT, and on the 3rd day and the 7th day after initiation of KRT. The predictors mainly included OH/ECW and ECW/BCM. The association between all-cause mortality and predictors were analyzed using Cox regression. A total of 152 patients were included in this study with a median follow-up of 39 (interquartile range 8-742) days. The 28-day mortality, 90-day mortality, and 1-year mortality were 46.7%, 54.6%, and 60.5%, respectively. A high ratio of OH/ECW (adjusted hazard ratio per standard deviation, 1.45; 95% confidence interval=1.15-1.82, P=.002) and a high ratio of ECW/BCM (adjusted hazard ratio per standard deviation, 1.33, 95% confidence interval=1.07-1.64, P=.009) before KRT were associated with all-cause mortality during follow-up. Higher ECW/BCM rather than OH/ECW at 7th day was associated with poorer outcomes. Furthermore, a reduction of OH/ECW with an increase of ECW/BCM had higher 1-year mortality as compared to others (85.7% vs. 51.2%, P=.004) in patients who survived 7days after KRT initiation. ECW/BCM performed better than OH/ECW in assessment of fluid status in AKI patients requiring KRT. This study suggested that a simple reduction of OH/ECW without decreasing ECW/BCM may not improve outcomes.

A240 HOME PARENTERAL NUTRITION IN OLDER VERSUS YOUNGER PATIENTS: CLINICAL CHARACTERISTICS AND OUTCOMES

Abstract Background There is a demographic shift toward older patients receiving home parenteral nutrition (HPN) but there is little data on their clinical characteristics and outcomes versus younger HPN patients. Aims The objective of this study was to determine if there are any differences between older (&amp;gt; 60 years) and younger (18–59 years) HPN patients in regard to HPN indications, prescriptions and outcomes over the first 2 years receiving HPN. Methods This was a retrospective analysis of prospectively collected data from HPN adult patients entered in the password protected web-based Canadian HPN Registry. New HPN patients enrolled between 2003 and 2017 and receiving HPN for 2 years were selected from 8 participating programs across Canada. Data included demographics, anthropometrics, PN prescriptions, line sepsis events, survival and quality of life based on the Karnofsky Performance Status (KPS). Results 402 patients met the inclusion criteria: 184 patients were 60 years old or above (older group) and 219 patients were between 18 and 59 years old (younger group). Around 64% of both groups were female. There were no significant differences in the main indications for HPN, body mass index (BMI), and PN prescriptions at baseline. At 2-years, younger patients received more calories from PN than older patients (27.88 vs 19.56 Kcal/kg respectively, p &amp;lt;0.001) but BMI remained comparable between groups. There were less line sepsis in the older group versus the younger group (20% vs 36%, p=0.0023) but 78% of younger patients remained alive versus 69 % in the older group (p=0.0401). In those alive, the proportion of patients remaining on HPN was comparable (older group: 77%; younger; group 81%, p=0.4709) and the proportion of patients with a reasonable quality of life (KPS &amp;gt; 60) was similar (older group: 58%; younger group: 63%, p=0.2156). Conclusions Older HPN patients have similar clinical characteristics as younger patients but with reduced line sepsis events and higher 2-year mortality. Funding Agencies Ontario Medical Supply, Takeda, Fresenius Kabi and Baxter Inc

Abstract PD12-10: Patient reported outcomes and health care utilization of UPMC breast cancer survivorship clinic patients

Abstract Background. The number and longevity of cancer survivors is growing due to aging of the population, improving cancer treatments, and earlier detection. The Institute of Medicine has recommended creation of guideline-concordant models of cancer survivorship care and clinics for this growing population with unique needs. There is currently little data on how cancer survivors seen at a survivorship clinic fare compared to those seen in routine oncology clinics in terms of quality of life and health care utilization. At the University of Pittsburgh Medical Center (UPMC), we performed a descriptive analysis of healthcare utilization and patient reported outcomes (PROs) of cancer survivors seen at survivorship clinic compared to at oncology clinics. Methods. The population consisted of breast cancer patients who received care at UPMC survivorship or oncology clinics (control) between January 2012 and December 2018. PROs were collected at each clinic visit and included the SF-12, the Edmonton Symptom Assessment Scale (ESAS), Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) scales. Cancer diagnoses and staging were obtained from the UPMC Network Cancer Registry. Patient demographics, mortality, ED visits and inpatient stays were extracted from the electronic medical record. ED utilization and inpatient admissions were examined one-year prior to survivorship care compared to 90-days after the start of survivorship care. Categorical and continuous data were examined by Wilcoxon rank sum tests and likelihood-ratio chi-squared tests, respectively. A p-value &amp;lt;0.05 was considered statistically significant. Results. Data from 680 cancer survivors were included, of which 285 patients received their follow-up care in survivorship clinic and 395 patients received their follow up care in oncology clinics. Baseline demographics were comparable between the two groups, except survivorship clinic patients (SCPs) had higher 1-year mortality (3.5% vs. 0.5%, p=0.003) and cancer stage (62% vs. 48% ≥ stage II, p=0.044). SCPs had significantly more ED visits at baseline and their number of ED visits remained higher than control once enrolled in survivorship clinic, although this trended down after 90 days in survivorship clinic (table 1). Inpatient visits were significantly increased for SCPs as compared to controls at 90 days after enrollment in survivorship clinic (6.4% with ≥ 1 inpatient admission vs. 1.8%, p=0.003). SCPs had consistently worse PROs compared to controls. Prior to enrolling in survivorship clinic, SCPs had higher rates of moderate to severe depression (22.4% with PHQ-9 score of 10-24 vs. 7.8%, p=0.002) and anxiety (20.6% with GAD-7 scores of 10 - 21 vs. 9.2 %, p&amp;lt;0.001) and this remained elevated at all time points compared to controls, although these rates appeared to decrease over time. SCPs also rate their overall health lower than controls on the SF-12 and they have higher symptom severity across most ESAS symptoms. Conclusions. Cancer survivors who are referred to and receive care in survivorship clinic have poorer quality of life and higher health care utilization at baseline and over time when compared to patients who receive care in oncology clinics. This observation suggests that survivorship clinics may be seeing cancer survivors with higher symptom burden and health care needs. This warrants future efforts to better understand, support, and prevent morbidity of survivorship clinic patients. Table 1. ED and Hospital Utilization Among Survivorship Clinic Patients and Controls.Pre-Survivorship ClinicAfter Enrollment in Survivorship Clinic1 Year90 Days# ED VisitsControl (%)Survivorship (%)PControl (%)Survivorship (%)P0345 (87.3)199 (69.8)&amp;lt;0.001382 (96.7)250 (87.7)&amp;lt;0.0011+50 (12.7)86 (30.2)13 (3.3)35 (12.3)# Inpatient Admissions0319 (80.8)225 (79.0)0.341388 (98.2)267 (93.7)0.0031+76 (19.3)60 (21.0)7 (1.8)18 (6.4) Citation Format: Kristine Gade, Stefanie C. Altieri Dunn, Ellen Ormond, Andrew Bilderback, Jill W Brufsky, Emily M. Geramita, G J van Londen. Patient reported outcomes and health care utilization of UPMC breast cancer survivorship clinic patients [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD12-10.

Prognostic Implications of Declining Hemoglobin Content in Patients Hospitalized With Acute Coronary Syndromes

BackgroundContemporary definitions of bleeding endpoints are restricted mostly to clinically overt events. Whether hemoglobin drop per se, with or without overt bleeding, adversely affects the prognosis of patients with acute coronary syndrome (ACS) remains unclear. ObjectivesThe aim of this study was to examine in the MATRIX (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) trial the incidence, predictors, and prognostic implications of in-hospital hemoglobin drop in patients with ACS managed invasively stratified by the presence of in-hospital bleeding. MethodsPatients were categorized by the presence and amount of in-hospital hemoglobin drop on the basis of baseline and nadir hemoglobin values and further stratified by the occurrence of adjudicated in-hospital bleeding. Hemoglobin drop was defined as minimal (<3 g/dl), minor (≥3 and <5 g/dl), or major (≥5 g/dl). Using multivariate Cox regression, we modeled the association between hemoglobin drop and mortality in patients with and without overt bleeding. ResultsAmong 7,781 patients alive 24 h after randomization with available hemoglobin data, 6,504 patients (83.6%) had hemoglobin drop, of whom 5,756 (88.5%) did not have overt bleeding and 748 (11.5%) had overt bleeding. Among patients without overt bleeding, minor (hazard ratio [HR]: 2.37; 95% confidence interval [CI]: 1.32 to 4.24; p = 0.004) and major (HR: 2.58; 95% CI: 0.98 to 6.78; p = 0.054) hemoglobin drop were independently associated with higher 1-year mortality. Among patients with overt bleeding, the association of minor and major hemoglobin drop with 1-year mortality was directionally similar but had wider CIs (minor: HR: 3.53 [95% CI: 1.06 to 11.79]; major: HR: 13.32 [95% CI: 3.01 to 58.98]). ConclusionsAmong patients with ACS managed invasively, in-hospital hemoglobin drop ≥3 g/dl, even in the absence of overt bleeding, is common and is independently associated with increased risk for 1-year mortality. (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox; NCT01433627)

Coronary Revascularization and Postoperative Outcomes in People With and Without Alzheimer's Disease.

BackgroundLittle is known on the incidence and postoperative outcomes of revascularizations according to electivity in persons with Alzheimer’s disease (AD).MethodsThe Medication Use and Alzheimer’s disease (MEDALZ) cohort includes 70 718 community dwellers diagnosed with incident AD during 2005–2011 in Finland. For each person with AD, 1–4 age-, sex-, and hospital district-matched comparison persons without AD were identified. Altogether 448 persons with AD and 5909 without AD underwent revascularization during the follow-up. The outcomes were 30-day and 90-day re-admission rate after discharge, and all-cause 1-year and 3-year mortality. Risk of outcomes in persons with AD were compared to those without AD using Cox proportional hazard models adjusted with age, sex, comorbidities, statin use, revascularization type, length of stay, and support at discharge.ResultPeople with AD had less revascularizations (adjusted hazard ratio 0.24, 95% confidence interval 0.22–0.27). Emergency procedures were more common (42.6% vs 33.1%) than elective procedures (34.2% vs 48.6%) among people with AD. There was no difference in 30-day readmissions (0.97, 0.80–1.17) or 1-year mortality (1.04, 0.75–1.42) and 90 days readmission risk was lower in persons with AD (0.85, 0.74–0.98). People with AD had higher 3-year mortality (1.42, 1.15–1.74), but the risk increase was observed only for emergency (1.71, 1.27–2.31), not for elective procedures (0.96, 0.63–1.46).ConclusionPeople with AD did not have worse readmission and mortality outcomes following elective revascularization. These findings in conjunction with lower revascularization rate especially for elective procedures raise questions on the threshold for elective procedures in people with AD.

Impact of preoperative nutritional scores on 1-year postoperative mortality in patients undergoing valvular heart surgery

ObjectiveMalnutrition is a well-recognized risk factor for poor prognosis and mortality. We investigated whether preoperative malnutrition diagnosed with objective nutritional scores affects 1-year mortality in patients undergoing valvular heart surgery. MethodsIn this retrospective cohort observational study, we evaluated the association among the Controlling Nutritional Status score, Prognostic Nutritional Index, and Geriatric Nutritional Risk Index with 1-year mortality in 1927 patients undergoing valvular heart surgery. We identified factors for mortality using multivariable Cox proportional hazard analysis and investigated the utility of nutritional scores for risk stratification. ResultsMalnutrition, as identified by a high Controlling Nutritional Status score and low Prognostic Nutritional Index and Geriatric Nutritional Risk Index, was significantly associated with higher 1-year mortality. Kaplan–Meier survival curve showed that mortality significantly increased as the severity of malnutrition increased (log-rank test, P < .001). The predicted discrimination (C-index) was 0.79 with the Controlling Nutritional Status score, 0.77 with the Prognostic Nutritional Index, and 0.73 with the Geriatric Nutritional Risk Index. Each nutritional index (Controlling Nutritional Status; hazard ratio, 1.31, 95% confidence interval, 1.21-1.42, P < .001), the European System for Cardiac Operative Risk Evaluation II (hazard ratio, 1.07, 95% confidence interval, 1.04-1.09, P < .001), and chronic kidney disease (hazard ratio, 2.26, 95% confidence interval, 1.31-3.90, P = .003) were independent risk factors for mortality. The Controlling Nutritional Status score added to the European System for Cardiac Operative Risk Evaluation II significantly increased the predictive discrimination ability for mortality (C-index 0.82, 95% confidence interval, 0.78-0.87, P = .014) compared with the Controlling Nutritional Status or European System for Cardiac Operative Risk Evaluation II alone. ConclusionsPreoperative malnutrition as assessed by objective nutritional scores was associated with 1-year mortality after valvular heart surgery. The Controlling Nutritional Status score had the highest predictive ability and, when added to the European System for Cardiac Operative Risk Evaluation II, provided more accurate risk stratification.

Characteristics of frequent emergency department users in British Columbia, Canada: a retrospective analysis.

Background:Frequent emergency department users disproportionately account for rising health care costs. We aimed to characterize frequent emergency department users in British Columbia, Canada.Methods:We performed a retrospective analysis using health administrative databases. We included patients aged 18 years or more with at least 1 emergency department visit from 2012/13 to 2015/16, linked to hospital, physician billing, prescription and mortality data. We used annual emergency department visits made by the top 10% of patients to define frequent users (≥ 3 visits/year).Results:Over the study period, 13.8%–15.3% of patients seen in emergency departments were frequent users. We identified 205 136 frequent users among 1 196 353 emergency department visitors. Frequent users made 40.3% of total visits in 2015/16. From 2012/13 to 2015/16, their visit rates per 100 000 BC population showed a relative increase of 21.8%, versus 13.1% among all emergency department patients. Only 1.8% were frequent users in all study years. Mental illness accounted for 8.2% of visits among those less than 60 years of age, and circulatory or respiratory diagnoses for 13.3% of visits among those aged 60 or more. In 2015/16, frequent users were older and had lower household incomes than nonfrequent users; the sex distribution was similar. Frequent users had more prescriptions (median 9, interquartile range [IQR] 5–14 v. 1, IQR 1–3), primary care visits (median 15, IQR 9–27 v. 7, IQR 4–12) and hospital admissions (median 2, IQR 1–3 v. 1, IQR 1–1), and higher 1-year mortality (10.2% v. 3.5%) than nonfrequent users.Interpretation:Emergency department use by frequent users increased in BC between 2012/13 and 2015/16; these patients were heterogenous, had high mortality and rarely remained frequent users over multiple years. Our results suggest that interventions must account for heterogeneity and address triggers of frequent use episodes.

Relationship between admission neutrophil/lymphocyte, thrombocyte/lymphocyte, and monocyte/lymphocyte ratios and 1-year mortality in geriatric hip fractures: Triple comparison.

Elderly patients with hip fractures have a high post-operative 1-year mortality rate. The aim of this study was to investigate the relationship of the neutrophil/lymphocyte ratio (NLR), thrombocyte/lymphocyte ratio (TLR), and monocyte/lymphocyte ratio (MLR) with mortality. The data of 350 patients who suffered femoral intertrochanteric fractures between January 2015 and January 2020 were examined, and the demographic data of 124 patients who met the study criteria were evaluated. During the 1-year follow-up, 92 patients (74%) who continued their lives and 32 patients (25%) who died were divided into two groups: Group 1 (survivors) and Group 2 (non-survivors). NLR, TLO, MLO, presence of comorbidities, age, sex, American Society of Anesthesiologists Physical Status Classification, length of hospital stay, fracture type, and fracture pattern values were statistically compared between the two groups. NLR, TLR, and MLR are the laboratory parameters assessed within the scope of the study. Preoperatively, the mean NLR was 6.59 (1.61-26.29), mean TLR was 197.94 (86-516), and mean MLR was 0.73 (0.19-15.68). In this study, a significant relationship was found between NLR, TLR, and MLR values and the occurrence of post-operative 1-year mortality (p=0.01). In addition, the result was significant in the correlation between these parameters. Cutoff values were found to be 7.53 for NLR, 192 for TLR, and 0.54 for MLR in receiver operator characteristic curve analysis (p<0.01). NLR, TLR, and PLR are significant predictors of 1-year mortality in patients aged over 60 years with hip fractures.

Prognostic factors for 1-year functional outcome, quality of life, care demands, and mortality after surgery in Taiwanese geriatric patients with a hip fracture: a prospective cohort study.

Background:Hip fractures are a major public health concern among elderly individuals. This study aimed to investigate potential perioperative factors that predict 1-year functional outcome, quality of life (QoL), care demands, and mortality in geriatric patients with a hip fracture.Methods:We prospectively enrolled geriatric patients who had undergone hip fracture surgery in one medical center from December 2017 to December 2019. Basic demographic data, handgrip strength, and responses to questionnaires for QoL and activities of daily living (ADL) before the injury were collected at baseline. QoL, ADL, additional care demands other than family support, and mortality events were monitored at 1 year after the operation.Results:Among 281 patients with a hip fracture, 39 (13.9%) died within 1 year of the index operation. The mean follow-up interval for the survivors was 403.3 (range: 358–480) days. Among the 242 survivors, ADL and QoL considerably decreased at approximately 1 year following hip surgery. Up to 33.9% of the participants became severely dependent and needed additional care at 1-year follow up. Prefracture ADL status was the crucial predictor for functional outcome, QoL, and additional care demand at 1-year follow up. Cox regression models indicated that male sex, low preoperative serum creatinine, handgrip strength, long surgical delay after a falling accident, and high Charlson Comorbidity Index were considerably associated with a high 1-year mortality risk in the geriatric hip fracture population.Conclusion:Hip fracture has long-lasting effects (e.g. functional loss, decline in QoL, increased care demands, and high postoperative mortality rate) on the geriatric population. A robust screening method must be developed for identifying potential prognostic factors, and a stratified care approach must be used that accounts for personalized risks to improve functional outcomes and reduce mortality after hip fracture in geriatric patients, especially in Taiwan.

Frailty in Elderly Gastric Cancer Patients Undergoing Gastrectomy

Introduction: There is a dearth of literature on frailty specifically in elderly (aged ≥65 years) gastric cancer patients undergoing gastrectomy. We aim to assess the effects of frailty on postoperative outcomes. Methods: A review of a prospective database was performed from November 2011 to April 2019. Frailty was assessed by multidimensional frailty score (MFS). Outcomes assessed were early postoperative complications and mortality, and length of stay. Results: 289 patients were included. The mean age was 77.3 (range 66–94) years. 183 (63.3%) were males and 172 (59.5%) had early cancer. 275 (95.2%) underwent minimally invasive gastrectomy. 79 (27.3%) patients suffered early postoperative complications, with 47 (16.3%) suffering from Clavien-Dindo grade ≥2 complications. One-year, 90-day, 30-day, and inhospital mortality were 6.6, 1.4, 0.7, and 0%, respectively. 111 (38.4%) of patients were classified as “frail” based on MFS > 5. “Frail” patients were associated with higher 1-year mortality (odds ratio (OR) 4.51, 95% CI 1.57–12.98, p = 0.005) on univariate analysis. On multivariate analysis, “frail” patients did not have significantly increased 1-year mortality. However, when definition of “frail” was changed from MFS > 5 to MFS > 6, frailty was significantly associated with increased 1-year mortality (OR 3.73, 95% CI 1.11–12.53, p = 0.033). Conclusions: Elderly gastric cancer patients undergoing gastrectomy with MFS > 5 do not have increased mortality risk. The influence of frailty on postoperative outcomes may vary based on the risk of the surgical procedure.

High soluble transferrin receptor in patients with heart failure: a measure of iron deficiency and a strong predictor of mortality.

Iron deficiency (ID) is frequent in heart failure (HF), linked with exercise intolerance and poor prognosis. Intravenous iron repletion improves clinical status in HF patients with left ventricular ejection fraction (LVEF) ≤45%. However, uncertainty exists about the accuracy of serum biomarkers in diagnosing ID. The aims of this study were (i) to identify the iron biomarker with the greatest accuracy for the diagnosis of ID in bone marrow in patients with ischaemic HF, and (ii) to establish the prevalence of ID using this biomarker and its prognostic value in HF patients. Bone marrow was stained for iron in 30 patients with ischaemic HF with LVEF ≤45% and 10 healthy controls, and ID was diagnosed for 0-1 grades (Gale scale). A total of 791 patients with HF with LVEF ≤45% were prospectively followed up for 3 years. Serum ferritin, transferrin saturation, soluble transferrin receptor (sTfR) were assessed as iron biomarkers. Most patients with HF (n=25, 83%) had ID in bone marrow, but none of the controls (P < 0.001). Serum sTfR had the best accuracy in predicting ID in bone marrow (area under the curve 0.920, 95% confidence interval 0.761-0.987, for cut-off 1.25 mg/L sensitivity 84%, specificity 100%). Serum sTfR was ≥1.25 mg/L in 47% of HF patients, in 56% and 46% of anaemics and non-anaemics, respectively (P < 0.05). The reclassification methods revealed that serum sTfR significantly added the prognostic value to the baseline prognostic model, and to the greater extent than plasma N-terminal pro B-type natriuretic peptide. Based on internal derivation and validation procedures, serum sTfR ≥1.41 mg/L was the optimal threshold for predicting 3-year mortality, independent of other established variables. High serum sTfR accurately reflects depleted iron stores in bone marrow in patients with HF, and identifies those with a high 3-year mortality.

Renal-function change after transjugular intra-hepatic portosystemic shunt placement and its relationship with survival: a single-center experience.

BackgroundThe effect of transjugular intra-hepatic portosystemic shunt (TIPS) placement on renal function and the correlation of post-TIPS Cr with mortality remain unclear. This study aimed to assess the effect of TIPS placement on renal function and to examine the relationship between post-TIPS Cr and mortality risk.MethodsA total of 593 patients who underwent de novo TIPS placement between 2004 and 2017 at a single institution were included in the study. The pre-TIPS Cr level (T0; within 7 days before TIPS placement) and post-TIPS Cr levels, at 1–2 days (T1), 5–12 days (T2), and 15–40 days (T3), were collected. Predictors of Cr change after TIPS placement and the 1-year mortality rate were analysed using multivariable linear-regression and Cox proportional-hazards models, respectively.ResultsOverall, 21.4% of patients (n = 127) had elevated baseline Cr (≥1.5 mg/dL; mean, 2.51 ± 1.49 mg/dL) and 78.6% (n = 466) had normal baseline Cr (<1.5 mg/dL; mean, 0.92 ± 0.26 mg/dL). Patients with elevated pre-TIPS Cr demonstrated a decrease in post-TIPS Cr (difference, −0.60 mg/dL), whereas patients with normal baseline Cr exhibited no change (difference, <0.01 mg/dL). The 30-day, 90-day, and 1-year mortality rates were 13%, 20%, and 32%, respectively. Variceal bleeding as a TIPS-placement indication (hazard ratio = 1.731; P = 0.036), higher T0 Cr (hazard ratio = 1.834; P = 0.012), and higher T3 Cr (hazard ratio = 3.524; P < 0.001) were associated with higher 1-year mortality risk.ConclusionTIPS placement improved renal function in patients with baseline renal dysfunction and the post-TIPS Cr level was a strong predictor of 1-year mortality risk.

PIN57 Burden of NON-Tuberculous Mycobacterial LUNG Disease (NTMLD) in France: A Claim Database Analysis

The objective of the study was to describe the epidemiology, management and cost of Non-tuberculous mycobacteria lung disease (NTMLD) in France. A retrospective analysis was performed using the SNIIRAM database over 2010-2017. NTMLD patients were identified based on the ICD10 codes during hospitalizations and/or specific antibiotics treatment regimens. The study population was matched (age, gender and region) to a control group (1: 3) without NTMLD. 5,628 NTMLD patients (men: 52.9%, mean age=60.9y) were identified. 1,433 patients (25.5%) were treated with antibiotics. The proportion of patients still treated at 6 and 12 months was 40% and 22%, respectively. NTMLD patients had more co-morbidities as compared to controls - the mean Charlson comorbidity index score was 1.6 (versus 0.2 for controls; p <0.0001). Risk factors comparisons between NTMPD cases and control group were statistically significant (p<0.0001): corticosteroids (57.3% vs 33.8%), Chronic lower respiratory diseases (34.4% vs 2.7%), other infectious pneumonia (24.4% vs 1.4%), malnutrition (22.0% vs 2.0%), tuberculosis (14.1% vs 0.1%), HIV (8.7% vs 0.2%), lung cancer and graft (5.7% vs 0.4%), cystic fibrosis (3.2% vs 0.0%), gastro-esophageal reflux disease (2.9% vs 0.9%) and bone marrow transplant (1.3% vs 0.0%). A higher 5-year mortality rate was observed in subjects with NTMLD: 19.7% versus 5.5% (p<0.0001, Log-Rank). Annual total expenses the year following the infection in a societal perspective were € 24,083 (SD: 29,358) in NTMLD subjects versus € 3,402 (SD: 8,575) in controls (p<0.0001). Main driver of the total expense for NTMLD patients was hospital expense (>50% of the total expense). NTMLD patients have high comorbidity burden, mortality and healthcare expenses. Only minority of patients get treated with antibiotics and many stop therapies before the infection can be successfully eradicated. These results underline the high burden associated with NTMLD and the need for appropriate management of this condition.

Renal profiling based on estimated glomerular filtration rate and spot urine sodium identifies high-risk acute heart failure patients.

In acute heart failure (AHF), assessment of renal function comprises estimation of glomerular filtration rate (eGFR), which does not provide any information about renal sodium/water handling. We describe the interactions between urinary sodium concentration and eGFR to better characterize AHF patients. In 219 patients with AHF, spot urine sodium (UNa+ ) and eGFR were assessed on admission, day 1 and day 2 of hospitalization. We found no correlation between UNa+ and eGFR (calculated on each consecutive day, as an average of all three values, and as changes from baseline; all P> 0.05). The population was subsequently divided into four profiles based on eGFR (preserved vs. impaired; cutoff of 60 mL/min/1.73 m2 ) and UNa+ (sodium excreter vs. non-excreter; cutoff of 60 mmol/L). At day 1, there were 70 (31.9%) patients classified as preserved eGFR/sodium excreter, 37 (16.8%) as impaired eGFR/sodium non-excreter, 72 (32.9%) as impaired eGFR/sodium excreter, and 40 (18%) as preserved eGFR/sodium non-excreter. Both sodium non-excreter profiles were associated with an increased risk of in-hospital heart failure worsening [odds ratio (OR) 2.8, 95% confidence interval (CI) 1.3-6.4], inotrope use (OR 2.6, 95% CI 1.1-6.7) and rehospitalization due to AHF (OR 3.2, 95% CI 1.6-6.2; all P< 0.05). The preserved eGFR/sodium non-excreter profile was associated with highest 1-year mortality (52.5%) and remained an independent prognosticator after adjustment for other prognosticators (hazard ratio 2.9, 95% CI 1.7-5.2; P< 0.0005). In AHF, values of spot UNa+ and eGFR are not interrelated. Concomitant assessment of eGFR and spot UNa+ may be useful for better clinical and therapeutic profiling of patients.