Higher Risk Of 30-day Mortality Research Articles

Features of in-hospital clinical course of pulmonary embolism in patients of different age groups

Aim.To study the clinical course and management of patients with pulmonary embolism (PE) of various age groups hospitalized in a cardiology hospital.Material and methods.This prospective single-center study in the period from 2016 to 2018 included 154 patients with PE verified by computed tomography. Statistical processing was conducted using the MedCalcVersion 16.2.1 software package (Softwa, Belgium).Results.In all groups, female patients dominated, but the highest number of women (70,7%) belonged to the group of senile patients, while in the group <60 years, only half of patients with PE were women. Comorbid cardiovascular disease and deep vein thrombosis was diagnosed in eldest patients significantly more often than in those <60 years of age. The highest prevalence of cancer and recurrent PE were identified in the group of elderly patients. Thrombolytic therapy was performed most often in patients 60-75 years old, since these patients had a high risk of 30-day mortality according to Pulmonary Embolism Severity Index, but did not have severe comorbidities, as patients older than 75 years. An increase of right atrium size was found in the group of elderly and senile patients in comparison with patients <60 years. The highest pulmonary artery systolic and diastolic pressure was observed in the patients older than 75 years.Conclusion.In the Kemerovo Oblast, PE most often develops in patients aged 60-75 years and is characterized by a more severe clinical course compared with patients younger than 60 years. Patients over the 60 years of age have severe cardiovascular comorbidity status, atrial fibrillation/flutter and recurrent PE. Surgical treatment for senile patients is limited due to the high risk of postoperative complications, which specifies high mortality. Patients <60 years of age are a third of all patients hospitalized with PE. They have a low risk of mortality, but have an unfavorable course of the hospital period.

Comparison of Prevalence, Presentation, and Prognosis of Acute Coronary Syndromes in ≤35 years, 36 – 54 years, and ≥ 55 years Patients

Whether very young patients (≤35-year-old) differ in the prevalence, presentation and prognosis of ACS is not well known. Of 43,446 patients who were referred to a tertiary care cardiac catheterization laboratory between January 1, 2006 and June 30, 2017, 26,545 patients were ACS (defined as ST Elevation MI, Non-ST Elevation MI or unstable angina pectoris). Detailed chart review was performed and characteristics at baseline were compared for ages ≤35 years, ages 36 to 54 years and ages ≥55 years. A total of 291 (1.1%) were ≤35-year-old, 7,649 (28.8) were 36 to 54-year-old and 18,605 (70.1%) were ≥55-year-old. ACS patients aged ≤35-year-old, were more likely to be men, Caucasian white, smoker, obese, and have family history of coronary artery disease and less likely to have comorbidities such as hypertension, diabetes mellitus, and hyperlipidemia compared with older patients. They were also more likely to present with elevated troponin levels than other groups. They also tended to present with late ST elevation myocardial infarction and were more likely to receive bare metal stents than older patients. The prevalence of 2- and 3-vessel disease was lower compared with older patients. They also had higher prevalence of cardiogenic shock. Compared with 36 to 54-year-old patients, ≤35-year-old were at significant higher risk of 30-day mortality in a multivariable adjusted regression model (Odds ratio 5.65, 95% confidence interval 2.49 to 12.82, p <0.001). Very young patients comprised ∼1% of all ACS cases but had much more prevalence of modifiable risk factors and significantly worse mortality. Modifying these risk factors may mitigate the risk in these patients and should be studied in the future.

Famotidine Use Is Not Associated With 30-day Mortality: A Coarsened Exact Match Study in 7158 Hospitalized Patients With Coronavirus Disease 2019 From a Large Healthcare System

Famotidine Use Is Not Associated With 30-day Mortality: A Coarsened Exact Match Study in 7158 Hospitalized Patients With Coronavirus Disease 2019 From a Large Healthcare System

Preoperative high-sensitivity troponin I and B-type natriuretic peptide, alone and in combination, for risk stratification of mortality after liver transplantation.

BackgroundGiven the severe shortage of donor liver grafts, coupled with growing proportion of cardiovascular death after liver transplantation (LT), precise cardiovascular risk assessment is pivotal for selecting recipients who gain the greatest survival benefit from LT surgery. We aimed to determine the prognostic value of pre-LT combined measurement of B-type natriuretic peptide (BNP) and high-sensitivity troponin I (hsTnI) in predicting early post-LT mortality.MethodsWe retrospectively evaluated 2,490 consecutive adult LT patients between 2010 and 2018. Cut-off values of BNP and hsTnI for predicting post-LT 90-day mortality were calculated. According to the derived cut-off values of two cardiac biomarkers, alone and in combination, adjusted hazard ratios (aHR) of post-LT 90-day mortality were determined using multivariate Cox regression analysis.ResultsMortality rate after 90 days was 2.9% (72/2,490). Rounded cut-off values for post-LT 90-day mortality were 400 pg/ml for BNP (aHR 2.02 [1.15, 3.52], P = 0.014) and 60 ng/L for hsTnI (aHR 2.65 [1.48, 4.74], P = 0.001), respectively. Among 273 patients with BNP ≥ 400 pg/ml, 50.9% of patients were further stratified into having hsTnI ≥ 60 ng/L. Combined use of pre-LT cardiac biomarkers predicted post-LT 90-day mortality rate; both non-elevated: 1.0% (21/2,084), either one is elevated: 9.0% (24/267), and both elevated: 19.4% (27/139, log-rank P < 0.001; aHR vs non-elevated 4.23 [1.98, 9.03], P < 0.001).ConclusionsConcomitant elevation of both cardiac biomarkers posed significantly higher risk of 90-day mortality after LT. Pre-LT assessment cardiac strain and myocardial injury, represented by BNP and hsTnI values, would contribute to prioritization of LT candidates and help administer target therapies that could modify early mortality.

Sex and Racial Disparities in the Treatment and Outcomes of Muscle-invasive Bladder Cancer

To identify racial and sex disparities in the treatment and outcomes of muscle-invasive bladder cancer (MIBC) using a nationwide oncology outcomes database. Using the National Cancer Database, we identified patients with muscle invasive bladder cancer from 2004 to 2014. Treatments analyzed included no treatment, cystectomy, neoadjuvant chemotherapy plus cystectomy ("optimal treatment"), cystectomy plus adjuvant chemotherapy, and chemoradiation. Propensity matching compared mortality outcomes between sexes. Logistic models evaluated predictors of receiving optimal treatment, as well as mortality. Forty seven thousand two hundred and twenty nine patients were identified. Most patients were male (73.4%) and underwent cystectomy alone (69.0%). Propensity score matching demonstrated increased 90-day mortality in women vs men (13.0% vs 11.6%, P = .009), despite adjusting for differences in treatments between sexes. Logistic regression models showed no difference in receipt of optimal treatment between sexes (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.83-1.22) although black patients were less likely to receive optimal treatment (OR 0.15, 95% CI 0.05-0.48). Logistic regression models confirmed increased 90-day mortality in female (OR 1.17, CI 1.08-1.27, P < .001) and black (OR 1.29, CI 1.11-1.50, P = .001) patients. Females had a lower overall survival on Cox regression analysis (Hazard Ratio 0.92, 95% CI 0.87-0.97). While there do not appear to be significant treatment disparities between sexes, women experience higher 90-day mortality and lower overall survival. Black patients are less likely to receive optimal treatment and have a higher risk of 90-day mortality. Additional research is needed to determine the variables leading to worse outcomes in females and identify impediments to black patients receiving optimal treatment.

Association of Low Muscle Mass and Low Muscle Radiodensity With Morbidity and Mortality for Colon Cancer Surgery

Given the risks of postoperative morbidity and its consequent economic burden and impairment to patients undergoing colon resection, evaluating risk factors associated with complications will allow risk stratification and the targeting of supportive interventions. Evaluation of muscle characteristics is an emerging area for improving preoperative risk stratification. To examine the associations of muscle characteristics with postoperative complications, length of hospital stay (LOS), readmission, and mortality in patients with colon cancer. This population-based retrospective cohort study was conducted among 1630 patients who received a diagnosis of stage I to III colon cancer from January 2006 to December 2011 at Kaiser Permanente Northern California, an integrated health care system. Preliminary data analysis started in 2017. Because major complication data were collected between 2018 and 2019, the final analysis using the current cohort was conducted between 2019 and 2020. Low skeletal muscle index (SMI) and/or low skeletal muscle radiodensity (SMD) levels were assessed using preoperative computerized tomography images. Length of stay, any complication (≥1 predefined complications) or major complications (Clavien-Dindo classification score ≥3), 30-day mortality and readmission up to 30 days postdischarge, and overall mortality. The mean (SD) age at diagnosis was 64.0 (11.3) years and 906 (55.6%) were women. Patients with low SMI or low SMD were more likely to remain hospitalized 7 days or longer after surgery (odds ratio [OR], 1.33; 95% CI, 1.05-1.68; OR, 1.39; 95% CI, 1.05-1.84, respectively) and had higher risks of overall mortality (hazard ratio, 1.40; 95% CI, 1.13-1.74; hazard ratio, 1.44; 95% CI, 1.12-1.85, respectively). Additionally, patients with low SMI were more likely to have 1 or more postsurgical complications (OR, 1.31; 95% CI, 1.04-1.65) and had higher risk of 30-day mortality (OR, 4.85; 95% CI, 1.23-19.15). Low SMD was associated with higher odds of having major complications (OR, 2.41; 95% CI, 1.44-4.04). Low SMI and low SMD were associated with longer LOS, higher risk of postsurgical complications, and short-term and long-term mortality. Research should evaluate whether targeting potentially modifiable factors preoperatively, such as preserving muscle mass, could reverse the observed negative associations with postoperative outcomes.

The Utility of the Modified Frailty Index in Outcome Prediction for Elderly Patients with Acute Traumatic Subdural Hematoma.

This study aimed to evaluate the utility of the 11-variable modified Frailty Index (mFI) in prognosticating elderly patients with traumatic acute subdural hematomas (aSDHs). A state-service level 1 trauma center registry was interrogated to investigate consecutive patients ≥65 years of age presenting with traumatic aSDH, with or without major extracranial injury, between January 2013 and December 2017. mFI on admission, demographics, and admission details, including Glasgow Coma Scale (GCS) and pupillary status and radiological findings, were retrospectively retrieved from institutional records. Clinical outcome data were retrieved from medical records and the Victorian State Trauma Registry (VSTR). Outcome measures were 1) 30-day mortality and 2) 6-month unfavorable outcome, defined by the Extended Glasgow Outcome Scale (GOS-E). Five hundred twenty-nine consecutive cases were identified from the registry. Demographic data included: 1) age (median; interquartile range) = 80.46; 74.17-85.89; 2) mFI (mean ± standard deviation) = 1.96 ± 1.42 of 11 variables. Four hundred sixteen cases (79%) had complete outcome data. As mFI increased from 0/11 variables to ≥5/11 variables (≥0.45), 30-day mortality risk increased from 17.72% to 39.29% (p = 0.023) and 6-month unfavorable outcome risk increased from 40.51% to 96.43% (p < 0.001). Multi-variate analysis showed that greater mFI score of ≥3/11 variables (≥0.27) suggested a significantly higher risk of 30-day mortality (p = 0.009) and unfavorable outcome (p < 0.001). We conclude that increasing frailty, as measured by the mFI, was associated with significantly higher risk of 30-day mortality and 6-month unfavorable outcome in elderly patients presenting with aSDH to a level 1 neurotrauma center. Assessment of mFI in elderly patients with aSDH may be a useful determinant of outcome for this rapidly growing population.

Relationship between "1-hour serum lactate" level and 30-day mortality in critical care patients in intensive care unit

To investigate the relationship between 1-hour lactate (1 h Lac) and 30-day mortality in critical care patients in intensive care unit (ICU). A retrospective, observational cohort study was performed with adult critical patients (age ≥ 16 years old) having lactate records within 1 hour after ICU admission from Medical Information Mart for Intensive Care-III database (MIMIC-III). According to the 1 h Lac level, the patients were divided into three groups: < 2 mmol/L, 2-4 mmol/L, and > 4 mmol/L groups. The baseline characteristics were analyzed. Multivariable Logistic regression analysis was performed to assess the association between 1 h Lac and 30-day mortality. The receiver operating characteristic (ROC) curve was used to analyze the predictive value of 1 h Lac for 30-day mortality, and Kaplan-Meier survival curve was performed according to the best cut-off value. In addition, sensitivity analysis was carried out for each classification variable. A total of 3 969 ICU patients were included, with 673 died in 30 days, and the total mortality was 16.95%. There were 1 664, 1 588, 717 patients in Lac < 2 mmol/L, 2-4 mmol/L and > 4 mmol/L group, respectively. There were significant differences in age, ICU duration, ICU type, heart rate, leukocyte count, hemoglobin, creatinine, sequential organ failure score (SOFA), ventilator application, vasoactive drug use and main diagnosis among the three groups. Multivariable Logistic regression analysis showed that a 1 mmol/L increment in Lac was associated with 0.24 times higher risk of 30-day mortality [odds ratio (OR) = 1.24, 95% confidence interval (95%CI) was 1.19-1.29, P < 0.000 1]. ROC curve analysis showed that the area under ROC curve (AUC) of 1 h Lac for predicting 30-day mortality of severe patients was 0.694 (95%CI was 0.669-0.718). The cut-off value was 3.35 mmol/L with sensitivity of 0.499 and specificity of 0.779, whilst positive likelihood ratio was 2.260, and negative likelihood ratio was 0.643. According to the cut-off value of 1 h Lac, the patients were divided into high lactate group (≥ 3.35 mmol/L) and low lactate group (< 3.35 mmol/L). In the two subgroups, 30-day mortality was 31.58% (336/1 064) and 11.60% (337/2 905), respectively. The Kaplan-Meier survival curve showed that the 30-day cumulative survival rate of high lactate group was significantly lower than that of low lactate group (Log-rank test: χ2 = 247.72, P < 0.000 1). Multiple Logistic regression analysis showed that the 30-day mortality rate of high lactate group was 2.34 times that the level of low lactate group (OR = 2.34, 95%CI was 1.90-2.88, P < 0.000 1), after the adjustment of age, time of admission, type of ICU, hemoglobin, leukocyte count, use of vasopressor, use of ventilator and main diagnosis of patients. Stratified analysis showed that the relationship between 1 h Lac and 30-day mortality was stable. 1 h Lac is associated with 30-day mortality in critical care patients. The risk of death was significantly increased in critically ill patients with 1 h Lac higher than 3.35 mmol/L.

Epidemiology of Adenovirus Infections and Outcomes of Cidofovir Treatment in Severely Ill Children.

An increase in human adenovirus (HAdV) infections among hospitalized children in Singapore was observed since 2013. Young age (<2 years) and significant comorbidities have been associated with severe HAdV infections which can result in significant morbidity and mortality. Cidofovir (CDV) has been used to treat severe HAdV infections despite limited data and efficacy. This is a retrospective, observational review of infants and children 1 month to 17 years of age with laboratory-confirmed severe HAdV infection, admitted to a pediatric tertiary care hospital in Singapore between January 2013 and September 2017. Severe infection was defined as requiring intensive care unit or high dependency care at any point during hospital admission. Clinical characteristics, potential risk factors for mortality, as well as the outcome of cases treated with CDV were examined. A total of 1167 children were admitted for HAdV infection, of which 85 (7.3%) were severe. For severe infections, the median age was 1.5 years (interquartile range: 0.72-3.2 years). The majority had comorbidities (69.4%) and presented with pneumonia (32.9%). Genotypes HAdV-7 (29.4%) and HAdV-3 (27.0%) were the most common HAdV genotypes identified. Thirteen (15.3%) patients died. Patients who died had a higher proportion of existing neurologic comorbidity (46.2% vs. 13.9%; P = 0.014) and presentation with pneumonia (69.2% vs. 26.4%; P = 0.008) compared with survivors. Patients who presented with pneumonia had a higher risk of 30-day mortality (odds ratio 4.3, 95% confidence interval: 1.0-28.6; P < 0.05). CDV was administered to 17 (20%) children for mainly viremia (47.1%) and/or pneumonia (41.2%). Mortality rate was 41.2% for severe HAdV cases treated with CDV. A significant proportion of patients who died when compared with recovered patients presented with pneumonia (6 of 7, 85.7% vs 1 of 10, 10%; P = 0.004). All 8 patients who had viremia received CDV and survived. Mortality can be high in pediatric patients with severe HAdV infections. HAdV-7 and HAdV-3 were the most common genotypes identified in our cohort with severe HAdV infection. Pneumonia is a potential risk factor for mortality in severe HAdV infections in our cohort. Early CDV administration may be considered in patients with severe HAdV infection and existing comorbidities but more studies are required.

Postoperative but not intraoperative transfusions are associated with respiratory failure after pneumonectomy.

Transfusion of blood products has been associated with increased risk of post-pneumonectomy respiratory failure. It is unclear whether intraoperative or postoperative transfusions confer a higher risk of respiratory failure. Our objective was to assess the role of transfusions in developing post-pneumonectomy respiratory failure. We performed a retrospective cohort study using prospectively collected data on consecutive pneumonectomies between 2005 and 2015. Patient records were reviewed for intraoperative/postoperative exposures. Univariable and multivariable analyses were performed. Of the 251 pneumonectomies performed during the study period, 24 (9.6%) patients suffered respiratory failure. Ninety-day mortality was 5.6% (n = 14) and was more likely in patients with respiratory failure (7/24 vs 7/227, P < 0.001). Intraoperative and postoperative transfusions occurred in 42.2% (n = 106) and 44.6% (n = 112) of patients, respectively and were predominantly red blood cells. On univariable analysis, both intraoperative (P = 0.03) and postoperative transfusion (P = 0.004) were associated with a higher risk of respiratory failure. The multivariable model significantly predicted respiratory failure with an area under curve (AUC) = 0.88 (P = 0.001). On multivariable analysis, the only independent predictors of respiratory failure were postoperative transfusions [adjusted odds ratio (aOR) 6.54, 95% confidence interval (CI) 1.74-24.59; P = 0.005] and lower preoperative forced expiratory volume (adjusted OR 0.96, 95% CI 0.93-0.99; P = 0.03). Estimated blood loss was not significantly different (P = 0.91) between those with (median 800 ml, interquartile range 300-2000 ml) and without respiratory failure (median 800 ml, interquartile range 300-2000 ml). Respiratory failure occurred in 9.6% of patients post-pneumonectomy and confers a higher risk of 90-day mortality. Postoperative (but not intraoperative) transfusion was the strongest independent predictor associated with respiratory failure. Intraoperative transfusion may be in reaction to active/unpredictable blood loss and may not be easily modifiable. However, postoperative transfusion may be modifiable and potentially avoidable. Transfusion thresholds should be assessed in light of potential cost-benefit trade-offs.

Surgical treatment of hip fracture in centenarians: Complications and independent risk factors of death

BackgroundThe increase in life expectancy has led to the appearance of a subgroup of hip fracture (HF) patients with special characteristics known as centenarians. The aim of the present study is to analyse the demographic characteristics, complications and mortality rate of this subgroup in order to identify the specific risk factors for mortality in these patients. MethodsRetrospective analysis of 69 patients (58 women and 11 men) aged 100 years or older admitted to a tertiary hospital for HF between 1999 and 2018. ResultsThe average age was 101.3 years (100-108, median 101). More than half (62.3%) of all patients presented with extracapsular fractures. The most common complications observed were delirium (52.3%) and urinary retention (27.7%). Haematoma (9.2%) was the most common surgical complication. Only 3 patients (7.3%) changed their place of residence after admission. In-hospital, 30-day and 1-year mortality rates were 13.8%, 21.5% and 54.2%, respectively. A high Charlson Comorbidity Index and baseline Functional Ambulation Classification (FAC) <3 were associated with a higher in-hospital mortality rate (OR = 1.95 95% CI [1.03–3.69] and OR = 5.7 95% CI [1.2–26.8]), respectively. The presence of more than 3 comorbidities and baseline FAC <3 were associated with a higher risk of 30-day mortality (OR = 6, 95% CI [1.4–24.7] and OR = 4, 95% CI [1.13–14.2]), respectively. Dementia has been associated with a higher risk of 30-day and 1-year mortality (OR = 4.6, 95% CI [1.2–16.7]) and OR = 5.11, 95% CI [1.6–21]) respectively. ConclusionFAC score, number of comorbidities, dementia and the Charlson Comorbidity Index have been shown to be risk factors of mortality in centenarians with HF.

Abstract TP180: Outcomes in the Elderly Post-Endovascular Therapy in a Community Setting

Background: Risks and benefits of thrombectomy in elderly stroke patients remained unclear. We evaluated outcomes in the elderly who underwent endovascular therapy (EST) in a large integrated healthcare system. Methods: In 2016, our integrated healthcare system launched a new standardized acute telestroke care workflow for all 21 stroke centers. It included immediate evaluation by a stroke neurologist via video, expedited IV alteplase treatment, rapid CT angiographic investigation, and expedited transfer and EST for patients with large vessel occlusion (LVO). From January 2016 through December 2018, our study cohort included adult members who had EST within our care system. We compared patient characteristics, door-to-needle (DTN) times, door-to-groin (DTG) times, inpatient and 90-day mortality between those treated with EST aged &lt;80 to those ≥80 years. Multivariable logistic regression model was used to assess whether being ≥80 years was associated with a higher 90-day mortality adjusting for demographics, co-morbidities, and DTG time. Results: There were 291 acute stroke patients who underwent EST [Table]. The older subgroup had a higher percentage of female and higher rates of atrial fibrillation. They were more likely to arrive by EMS, to have a higher initial NIHSS and to have a faster DTN time. Average DTG times and inpatient mortality rates were not different between groups. The elderly had a higher rate of 90-day mortality. In multivariate model, being elderly was associated with higher 90-day mortality (OR=2.56, 95% CI 1.29-5.09, p=0.007). Conclusions: For those who underwent EST in a large community setting with a standardized approach to acute stroke treatment, being elderly was associated with a higher risk of 90-day mortality. Further data analyses are being carried out with additional co-morbidities, inpatient complications, and 90-day functional outcome to better understand outcomes in older patients undergoing EST.

Spotlight in Plastic Surgery: April 2020

Spotlight in Plastic Surgery: April 2020

Association between Risk of&amp;nbsp;Venous Thromboembolism&amp;nbsp;and Mortality in Patients with COVID-19

Background: Hospitalized patients with COVID-19 appeared high risk of venous thromboembolism (VTE) defined by some risk assessment models (RAMs), which exhibited the predictor of mortality in patients with non-COVID-19. We aimed to investigate the association between risk of VTE with 30-day mortality in COVID-19 patients.Methods: In this retrospective cohort study, 1030 consecutive hospitalized patients, between January 26, 2020 and March 29, 2020, aged 14–98 years with a confirmed diagnosis of COVID-19-related pneumonia were recruited from Jinyintan Hospital and Union Hosptial, Wuhan, China. We collected baseline data on demographics, SOFA parameters, and VTE RAMs including Padua Prediction Score (PPS), IMPROVE RAM and Caprini RAM. The primary outcome of the study was 30-day mortality. The secondary outcome was the length of stay in hospital. Findings: Thirty-day mortality increased progressively from 2% in patients at low risk of VTE to 63% in those at high risk of VTE defined by PPS ≥ 4. Similar findings were also observed for risk of VTE defined by IMPROVE score ³ 2 and Caprini score ³ 5. Progressive increases in VTE risk also were associated with higher SOFA score. Our findings showed that the presence of high risk of VTE was independently associated with 30-day mortality regardless of adjusted gender, smoking status and some comorbidities with hazard ratios of 29.19 (95% CI 15.76 - 54.05), 37.37 (95% CI 18.43 - 75.78), 20.60 (95% CI 11.41 - 37.19) for PPS, IMPROVE RAM and Caprini RAM, respectively (P Interpretation: The presence of high risk of VTE identifies a group of patients with COVID-19 at higher risk for 30-day mortality. Furthermore, there is higher accuracy of VTE RAMs to predict 30-day mortality in COVID-19 hospitalized patients.Funding Statement: This study is funded by the National Nature Science Foundation of China (81870062 to Jinjun Jiang, 81900038 to Shujing Chen).Declaration of Interests: The authors have no conflict of interest to disclose.Ethics Approval Statement: The study was approved by Jinyintan Hospital Ethics Committee (KY2020-06.01) and Union Hospital Ethics Committee (2020-0039). Written informed consent was waived by the Ethics Commission.

P5481Predictors of mortality in patients with non-anterior ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abstract Background Previous studies have indicated that patients with non-anterior ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have a more favorable prognosis compared with anterior STEMI, especially in the short term. Purpose Our aim was to identify predictors of increased 30-day mortality in patients with non-anterior STEMI undergoing primary PCI. Methods This analysis included 8188 patients referred to primary PCI during 2009–2017, from a prospective electronic registry of a high-volume catheterization laboratory, for whom 30-day follow-up was available. Non-anterior infarction was defined as presence of ST-segment elevation in inferior and/or lateral ECG leads or true posterior MI. Multivariable Cox regression was used to assess the mortality risk at 30 days. Results 59.4% (n=4863) of the included patients presented with a non-anterior STEMI. Mortality rate was significantly lower in patients with non-anterior vs. anterior STEMI (4.2% vs. 8.3%, p&lt;0.001). Older age (&gt; median of 61, HR 2.2, p=0.002), baseline renal failure (eGFR &lt;60, HR 4.0, p&lt;0.001), Killip class ≥2 (HR 3.8, p&lt;0.001), previous stroke (HR 1.8, p=0.004), non-culprit chronic total occlusion (CTO, HR 2.0, p&lt;0.001) and final TIMI flow grade &lt;3 in the infarct-related artery (HR 3.1, p&lt;0.001) were independently associated with an increased risk of 30-day mortality in non-anterior STEMI. The presence of at least one of these high-risk factors was noted in 61.2% of patients with non-anterior STEMI and was associated with a significantly higher risk of 30-day mortality (HR 18.2, p&lt;0.001), similarly to the overall risk associated with anterior STEMI (HR 22.9, p&lt;0.001), as compared with patients with non-anterior STEMI but without any of the here identified high-risk factors (Figure). Figure 1 Conclusions Crude mortality rate was significantly lower in patients with non-anterior vs. anterior STEMI. However, the majority of non-anterior STEMI patients had at least one of the high-risk factors (older age, previous CVI, baseline renal failure, Killip class ≥2, non-culprit CTO or final TIMI flow &lt;3), which predisposed these patients to a similar increase in short-term mortality risk as in patients with anterior STEMI.

Impact of Aortoiliac Stenosis on Graft and Patient Survival in Kidney Transplant Recipients Using the TASC II Classification.

Patients with end-stage renal disease and aortoiliac stenosis are often considered ineligible for kidney transplantation, although kidney transplantation has been acknowledged as the best therapy for end-stage renal disease. The clinical outcomes of kidney transplantation in patients with aortoiliac stenosis are not well-studied. This study aimed to assess the impact of aortoiliac stenosis on graft and patient survival. This retrospective, single-center study included kidney transplant recipients transplanted between January 1, 2000, and December 31, 2016, who received contrast-enhanced imaging. Patients with aortoiliac stenosis were classified using the Trans-Atlantic Inter-Society Consensus (TASC) II classification and categorized as having TASC II A/B lesions or having TASC II C/D lesions. Patients without aortoiliac stenosis were functioning as controls. A total number of 374 patients was included in this study (n = 88 with TASC II lesions, n = 286 as controls). Death-censored graft survival was similar to the controls. Patient and uncensored graft survival was decreased in patients with TASC II C/D lesions (log-rank test P < 0.001). Patients with TASC II C/D lesions had a higher risk of 90-day mortality (hazard ratio, 3.96; 95% confidence interval, 1.12-14.04). In multivariable analysis, having a TASC II C/D lesion was an independent risk factor for mortality (hazard ratio, 3.25; 95% confidence interval, 1.87-5.67; P < 0.001). Having any TASC II lesion was not a risk factor for graft loss (overall P = 0.282). Kidney transplantation in patients with TASC II A/B is feasible and safe without increased risk of perioperative mortality. TASC II C/D decreases patient survival. Death-censored graft survival is unaffected.

Association between Severe Anemia and Outcomes of Hemodialysis Vascular Access

The vast majority of patients undergoing hemodialysis (HD) are anemic. The severity of anemia in these patients may influence the postoperative outcomes and the durability of vascular access. Thus, the purpose of this study is to assess the association between anemia and adverse outcomes in patients undergoing HD access placement (arteriovenous grafts and fistula). Patients with chronic kidney disease stages IV and V recorded in the Vascular Quality Initiative Hemodialysis database between 2011 and 2017 were included. Patients were divided into 3 study groups based on preoperative hemoglobin (Hgb) levels: normal/mild anemia (Hgb: females ≥10g/dL, males ≥12g/dL), moderate anemia (Hgb: females: 7-9.9g/dL, males: 9-11.9g/dL), and severe anemia (Hgb: females<7g/dL, males<9g/dL). Multivariable logistic and Cox regression analyses were implemented to evaluate the association between anemia and 30-day mortality and primary patency (PP) at 1year. A total of 28,000 patients undergoing HD access surgery were identified (normal/mild [42%], moderate [49%], and severe [9%] anemia). Postoperative bleeding (2.1% vs. 2.2% vs. 2.2%) and 30-day outcomes including swelling (0.4% vs. 0.5% vs. 0.7%) and wound infection (0.4% vs. 0.3% vs. 0.1%) were similar in mild/normal, moderate, and severe anemia groups, respectively (All P>0.05). However, 30-day mortality was significantly higher in patients with severe anemia compared with normal/mild and moderate anemia (2.1% vs. 1.1% and 1.1%, P<0.001). After adjusting for potential confounders, severe anemia was associated with 90% higher risk of 30-day mortality (odds ratio [95% confidence interval]: 1.90 [1.20-3.00], P=0.006) and 17% increase in PP loss at 1year (adjusted hazard ratio [95% confidence interval]: 1.17 [1.02-1.35], P=0.01) compared with the normal/mild anemia group. However, no significant difference was seen between normal/mild and moderate anemia. In this large study of patients undergoing HD access placement, severe anemia was associated with 90% increased risk of 30-day mortality and 17% increased risk of loss of PP compared with those with normal/mild anemia. Management of severe anemia before surgery might be indicated to reduce operative mortality and improve the durability of HD access.

Trauma-related mortality of patients with severe psychiatric disorders: population-based study from the French national hospital database.

Most research on mortality in people with severe psychiatric disorders has focused on natural causes of death. Little is known about trauma-related mortality, although bipolar disorder and schizophrenia have been associated with increased risk of self-administered injury and road accidents. To determine if 30-day in-patient mortality from traumatic injury was increased in people with bipolar disorder and schizophrenia compared with those without psychiatric disorders. A French national 2016 database of 144 058 hospital admissions for trauma was explored. Patients with bipolar disorder and schizophrenia were selected and matched with mentally healthy controls in a 1:3 ratio according to age, gender, social deprivation and region of residence. We collected the following data: sociodemographic characteristics, comorbidities, trauma severity characteristics and trauma circumstances. Study outcome was 30-day in-patient mortality. The study included 1059 people with bipolar disorder, 1575 people with schizophrenia and their respective controls (n = 3177 and n = 4725). The 30-day mortality was 5.7% in bipolar disorder, 5.1% in schizophrenia and 3.3 and 3.8% in the controls, respectively. Only bipolar disorder was associated with increased mortality in univariate analyses. This association remained significant after adjustment for sociodemographic characteristics and comorbidities but not after adjustment for trauma severity. Self-administered injuries were associated with increased mortality independent of the presence of a psychiatric diagnosis. Patients with bipolar disorder are at higher risk of 30-day mortality, probably through increased trauma severity. A self-administered injury is predictive of a poor survival prognosis regardless of psychiatric diagnosis.

Higher plasma C-type lectin-like receptor 2 concentrations for prediction of higher risk of 30-day mortality in isolated severe blunt traumatic brain injury

BackgroundPlatelet activation is implicated in secondary brain injury following traumatic brain injury (TBI). C-type lectin-like receptor 2 (CLEC-2) is extensively expressed on platelets and participates in platelet activation. We investigate dthe prognostic significance of plasma CLEC-2 in TBI patients. MethodsOne hundred and six patients with isolated severe blunt TBI and 106 healthy controls were prospectively investigated. Plasma CLEC-2 concentrations were detected and Glasgow coma scale (GCS) scores were recorded. The relationship between plasma CLEC-2 concentrations and 30-day mortality in addition to overall survival was determined using multivariate models. ResultsPatients exhibited a substantially higher concentration of plasma CLEC-2 than healthy controls. Among patients, plasma CLEC-2 concentrations were remarkably increased in the GCS scores- and Rotterdam computerized tomography classification- dependent manner. As compared with survivors within posttraumatic 30 days, plasma CLEC-2 concentrations were remarkably raised in non-survivors. Rising plasma CLEC-2 concentration was independently associated with an enhanced risk of 30-day mortality and short overall survival time. Plasma CLEC-2 concentrations had a significantly high area under receiver operating characteristic curve for predicting 30-day mortality. ConclusionsIncremental plasma CLEC-2 concentrations are intimately related to increasing trauma severity, in close association with increased 30-day death, indicating the prognostic role of plasma CLEC-2 in TBI.

Presentation and Mortality of Cryptococcal Infection Varies by Predisposing Illness: A Retrospective Cohort Study

BackgroundCryptococcal epidemiology is changing in the modern antiretroviral era, and immune status informs outcomes. We describe the differences in clinical presentation and mortality of cryptococcosis by immune status in the antiretroviral therapy era. MethodsWe conducted a single-center retrospective cohort study of patients diagnosed with cryptococcosis from 2002 through 2017. Data included demographics, clinical features, diagnostics, and mortality. ResultsWe identified 304 patients with Cryptococcus neoformans infections: 105 (35%) were people living with human immunodeficiency virus (HIV), 41 (13%) had a history of transplantation, and 158 (52%) were non-HIV nontransplant (NHNT). Age analysis showed that people living with HIV were younger (40 years) than transplant (53 years) and NHNT (61 years) (P < .001). Fevers and headache were more common in people living with HIV (70% and 57%) than in transplant (49% and 29%) and NHNT (49% and 38%) (P = .003 and P = .001), respectively. Meningitis was more common in people living with HIV (68%) than in transplant recipients (32%) or NHNT (39%, P < .001). Disseminated cryptococcosis was more common in people living with HIV (97%) as compared with transplant (66%) or NHNT (73%) (P < .001). Time to diagnosis from hospitalization was longer for transplant (median 2 days, interquartile range [IQR] ± 9 days) and NHNT patients (median 2 days, IQR ± 7 days) as compared with people living with HIV (median 1 day, IQR ± 2 days) (P = .003). NHNT patients had a higher risk of 90-day mortality (hazard ratio 3.3; 95% confidence interval, 1.9-5.8) as compared with people living with HIV. ConclusionsThe majority of cryptococcosis occurs in NHNT patients. NHNT patients had more localized pulmonary cryptococcosis and significantly higher 90-day mortality. Cryptococcosis in NHNT patients appears to be a distinct entity that needs further study and requires a higher level of clinical suspicion than it currently receives.