Higher Risk Of Mortality Research Articles

Gender differences in the relationship between the systemic immune-inflammation index and all-cause and cardiovascular mortality among adults with hypertension: evidence from NHANES 1999-2018.

There are gender differences in hypertension and the effect of gender on the relationship between systemic immune-inflammation index (SII) and mortality in hypertensive patients is unclear. Hypertensive patients (n=7444) from ten cycles of the National Health and Nutrition Examination Survey (NHANES) spanning 1999 to 2018 were enrolled in this study. The maximally selected rank statistics method was employed to identify the optimal cut-off value for the SII. Survey-weighted Cox regression analysis was utilized to explore the links between SII and all-cause and cardiovascular mortality. Kaplan-Meier method and time-dependent receiver operating characteristic curve analysis was conducted to assess the predictive accuracy of SII for mortality. Whether SII was considered as a numerical variable or as a binary variable (higher- and lower-SII groups), higher SII levels were associated with a higher risk of all-cause and cardiovascular mortality in female hypertensive patients (all P < 0.001), but no such association was observed in the males. The area under the curve of the SII was 0.602, 0.595, and 0.569 for 3-, 5-, and 10-year all-cause mortality, respectively, in females, but was 0.572, 0.548, and 0.554 in males. High SII levels interacted with the poverty income ratio and physical activity to affect mortality in the male population (P for interaction < 0.05), and there was an interaction between race and SII in the female cardiovascular mortality rate (P for interaction < 0.05). Higher levels of SII may be closely related to the high risk of all-cause and cardiovascular mortality in hypertensive patients, and the results showed that this relationship is more significant and stable in the female group. High SII interacts with PIR, physical activity, and race to affect the mortality rate in different gender populations.

SARS-CoV-2 RNAemia as a reliable predictor of long-term mortality among older adults hospitalized in pulmonary intermediate care units: a prospective cohort study

BackgroundSARS-CoV-2 viremia is associated with disease severity and high risk for in-hospital mortality. However, the impact of SARS-CoV-2 viremia on long-term outcomes in hospitalized patients with COVID-19 is poorly understood.MethodsWe conducted a prospective cohort study and recruited a group of older adult patients with COVID-19 admitted to pulmonary intermediate care units of Peking University Third Hospital during December 2022 and January 2023. The plasma level of SARS-CoV-2 RNA was determined by a standardized RT-PCR technique, and SARS-CoV-2 RNAemia was defined as a plasma viral load ≥ 50 copies/ml. In-hospital and follow-up (180-day) outcome data were collected.ResultsA total of 101 patients with an average of 80.4 years were recruited, and 63.4% of them were severe or very severe cases. Twenty-eight patients (27.7%) had SARS-CoV-2 RNAemia, with a median viral RNA load of 422.1 [261.3, 1085.6] copies/ml. Patients with SARS-CoV-2 RNAemia were more likely to develop critical cases and had a higher incidence of sepsis. Accordingly, they had a higher 180-day mortality (57.1% vs. 19.7%, P < 0.001), as well as in-hospital mortality (50.0% vs. 13.7%, P < 0.001), independent of age, disease severity, sepsis, lymphocyte count and C-Reactive protein. In addition, the risk for 180-day mortality increased with the SARS-CoV-2 RNA load in plasma. Plasma cytokines, including IL-6, IL-8 and IL-10, were higher in patients with SARS-CoV-2 RNAemia.ConclusionsOur study indicates that SARS-CoV-2 RNAemia serves as a useful biomarker for predicting mortality, especially long-term mortality, in older adult patients hospitalized in pulmonary intermediate care units.Trial registrationChinese Clinical Trial Registry website (No. ChiCTR2300067434).

Spontaneous Wing Tip Edema in Captive Birds of Prey: Review of 41 Cases in the United Kingdom (2004-2022).

There is limited literature regarding wing tip edema (WTE) in raptors, and much of our current understanding of the condition is based on anecdotal reports. The aims of this retrospective study were to describe the clinical features of WTE in birds of prey, to identify prognostic factors for return to flight and patient survival following diagnosis, and to develop and assess the clinical significance of a novel WTE grading system. Between 2004 and 2022, 41 cases of WTE were identified in 39 captive birds. No cases were found in wild birds. Harris's hawks (Parabuteo unicinctus), lanner falcons (Falco biarmicus), and peregrine falcons (Falco peregrinus) had the highest frequencies of WTE, and all cases presented between October and May. Increasing days of air frost per month and colder median monthly temperatures were significant risk factors for the development of WTE. Of the cases where patient outcomes were known, 23/31 (74.2%) cases returned to normal flight and 29/34 (85.3%) cases survived. End-stage disease, represented by primary flight feather loss and metacarpal ischemic (dry) gangrene, and enalapril use were associated with poor patient outcomes. Presentation within 24 hours of disease onset, isoxsuprine use, and physiotherapy were associated with improved patient outcomes. This study showed that WTE is an infrequently encountered but clinically significant condition in captive raptors and is associated with an overall high morbidity and moderate mortality risk.

Clinical features and prognostic factors of AIDS-associated diffuse large B-cell lymphoma

To explore the general clinical features and treatment outcomes of patients with AIDS-related diffuse large B-cell lymphoma (AIDS-DLBCL) and provide a theoretical basis for diagnosis and treatment, survival prognosis, prevention and management of AIDS-DLBCL patients. AIDS-DLBCL patients who received combined antiretroviral therapy (cART) at Changsha First Hospital from January 2017 to January 2020 were selected in this study. The survival curves were plotted using the Kaplan-Meier method, and the Cox proportional hazards regression model was used to analyze the association between AIDS-DLBCL specific variables and progression-free survival and overall survival. Correlation analysis was conducted based on the clinical features of the patients. A total of 50 AIDS-DLBCL patients were included. Their median age (Q1, Q3) was 52 (44, 59) years, of whom 46 (92%) were male. About 20 (40%) patients received treatment with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), while 23 patients (46%) received treatment with rituximab combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP). Survival curve analysis showed that the 2-year progression-free survival rate and overall survival rate of AIDS-DLBCL patients were 56.9% and 61.6%, respectively. Patients with RCHOP protocol combined with EBV-DNA≥1 000 copies/ml had higher progression-free survival rate (χ2=3.844, P=0.043) and overall survival rate (χ2=4.662, P=0.031) than those with CHOP protocol combined with EBV-DNA≥1 000 copies/ml. A multivariate analysis showed that male (HR=2.70, 95%CI:1.10-6.80), EB viral load≥1 000 copies/ml (HR=1.75, 95%CI:1.12-2.84), HIV-RNA≥200 copies/ml (HR=4.64, 95%CI: 1.73-12.15), ECOG PS score of 2 to 4 points (HR=3.54, 95%CI:1.62-7.33), and international prognostic index (IPI) score of 3 to 5 points (HR=5.21, 95%CI:1.39-20.14) were at a higher risk of disease progression. Patients with EB viral load≥1 000 copies/ml (HR=0.07, 95%CI:0.05-0.93) on the RCHOP regimen had a small risk of disease progression. Males (HR=2.87, 95%CI:1.65-9.17), EB viral load≥1 000 copies/ml (HR=1.61, 95%CI:4.02-9.36), HIV-RNA≥200 copies/ml (HR=1.19, 95%CI:1.58-2.74), ECOG PS score of 2 to 4 (HR=6.42, 95%CI:2.55-14.33), IPI score of 3 to 5 points (HR=2.78, 95%CI:1.41-12.96) had a high risk of mortality. Patients with EB viral load≥1 000 copies/ml (HR=0.24, 95%CI:0.64-0.90) on the RCHOP regimen had a low risk of mortality. In summary, males, ECOG physical status score of 2 to 4 points, IPI score of 3 to 5 points, EB viral load≥1 000 copies/ml and HIV viral load≥200 copies/ml are risk factors affecting progression-free survival and overall survival of AIDS-DLBCL patients. RCHOP regimen combined with EB viral load≥1 000 copies/ml is a protective factor affecting progression-free survival and overall survival in AIDS-DLBCL patients.

7839 Assess Management of Adrenal Insufficiency in Melanoma Patients Treated with Cancer Immunotherapy

Abstract Disclosure: W. Lin: None. L. Min: None. Despite high prevalent of adrenal insufficiency in melanoma patients treated with cancer immunotherapy, no study has examined the management of adrenal insufficiency in these patients. We performed this retrospective, longitudinal cohort study at Mass General Brigham, Boston, aims to characterize the management of adrenal insufficiency in melanoma patients. Patients were identified through our RPDR search tool, and medical record reviews were conducted. Three patient groups were analyzed: Melanoma with secondary adrenal insufficiency group (Mel_SAI, n=74), Melanoma matched control group (Mel_Con, n=69), and Pituitary macroadenoma-related adrenal insufficiency matched control group (Pit_Con, n=37). We compared self-perceived quality of life, glucocorticoid replacement dose, and clinic visit. Mel_SAI patients exhibited significantly higher incidences of anxiety (43.1%, 95%CI: 32.3-54.6), fatigue (73.6%, 95%CI: 62.4-82.4), pain (58.3%, 95%CI: 46.8-69.0), and insomnia (36.1%, 95%CI: 26.0-47.6), as compared to Pit_Con group (21.6%, 11.4-37.2; 24.3, 13.4-40.1; 29.7%, 17.5-45.8; 5.4%, 1.5-17.7, respectively). The initial hydrocortisone dose was higher for Mel_SAI (30mg qd, 95%CI: 20.5-25.1) compared to Pit_Con (15mg qd, 95%CI: 12.8-18.3). Additionally, the Mel_SAI group had fewer endocrinology clinic visits (3, 95%CI: 3.40-5.04) than the Pit_Con group (9, 95%CI: 7.35-10.9). Subgroup analysis indicated a higher mortality risk (HR 2.61, 95% CI 1.11-6.13) in Mel_SAI patients with fewer than three endocrinology visits over five years. Compared to the Mel_Con group, Mel_SAI patients also showed higher incidences of fatigue (71.6%, 95%CI: 60.5-80.6; Mel_Con: 55.1%, 95%CI: 43.4%-66.2%), but lower rates of depression (25.7%, 95%CI: 17.1-36.7; Mel_Con: 43.5%, 95%CI: 32.4-55.2) and appetite loss (24.3%, 95%CI: 16.0-35.2; Mel_Con: 47.8%, 95%CI: 36.4-59.4). No significant difference in other self-perspective symptoms. Furthermore, Mel-SAI patients had more oncological clinic visits (71, 95%CI: 74.0-109.2) than those in the Mel_Con group (41, 95%CI: 42.1-64.1). Our study suggests that most self-perceived quality of life in the Mel_SAI group is related to melanoma rather than adrenal insufficiency. Therefore, a higher initiating dose of hydrocortisone in melanoma patients with adrenal insufficiency may not be necessary. However, increasing endocrine clinic visits in cancer patients with cancer immunotherapy-related adrenal insufficiency may improve their survival outcomes. Presentation: 6/3/2024

8473 Prediabetes As A Risk Factor For All-Cause And Cause-Specific Mortality In 117,227 Diabetes-Free Adults In Mexico City

Abstract Disclosure: C.A. Fermin-Martinez: None. O.Y. Bello-Chavolla: None. N.E. Antonio-Villa: None. D. Ramirez Garcia: None. J.A. Seiglie: None. Background: Prediabetes has been consistently linked to high risk of diabetes progression, cardiovascular disease, and all-cause mortality. However, no large-scale studies have been conducted in Mexico or Latin America examining these associations despite the growing prevalence of this condition in low- and middle-income countries. Methods: We analyzed data from 117,227 adults without diabetes aged ≥35 years who participated in the Mexico City Prospective Study (1998-2004). Individuals with self-reported chronic comorbidities at baseline were excluded to mitigate reverse causation. Participants were followed-up until January 1st, 2021 for cause-specific mortality. We defined prediabetes according to the American Diabetes Association (ADA, HbA1c ≥5.7%) and the International Expert Committee (IEC, HbA1c ≥6.0%) definitions. Cox regressions were used to estimate prediabetes-related risk for all-cause and cause-specific mortality, stratified by sex and age-at-risk and adjusted for municipality of residence, education level, physical activity, smoking, alcohol consumption, and adiposity markers. Results: Compared to individuals with normoglycemia, participants with IEC-defined prediabetes had a higher risk of all-cause (HR 1.16, 95%CI 1.05-1.27), cardiac (HR 1.29, 95%CI 1.05-1.59), renal (HR 1.59, 95%CI 1.14-2.23), and acute diabetes-related (HR 2.60, 95%CI 1.52-4.43) mortality at ages 40-74 years compared to normoglycemic participants. HRs were attenuated at older ages. Results were broadly similar irrespective of the definition of prediabetes except for cardiac deaths, in which the risk was non-significant using the ADA cutoff (HR 1.14, 95%CI 0.99-1.31). Long-term effects of prediabetes (IEC-defined) accounted for ∼37% of renal deaths and ∼61% of acute diabetes-related deaths in Mexican adults without diabetes at baseline. Conclusion: Prediabetes is an important risk factor that accounts for a significant fraction of all-cause, cardiac, renal, and acute diabetes-related deaths among Mexican adults, particularly when using the higher threshold of IEC-defined prediabetes. Endpoint-driven definitions of prediabetes should be considered for widespread implementation of screening and preventive strategies that minimize overdiagnosis and improve cardiometabolic outcomes in this population. Presentation: 6/1/2024

9253 Prediabetes As A Risk Factor For All-Cause And Cause-Specific Mortality In 117,227 Diabetes-Free Adults In Mexico City

Abstract Disclosure: C.A. Fermin-Martinez: None. O.Y. Bello-Chavolla: None. N.E. Antonio-Villa: None. D. Ramirez Garcia: None. J.A. Seiglie: None. Background: Prediabetes has been consistently linked to high risk of diabetes progression, cardiovascular disease, and all-cause mortality. However, no large-scale studies have been conducted in Mexico or Latin America examining these associations despite the growing prevalence of this condition in low- and middle-income countries. Methods: We analyzed data from 117,227 adults without diabetes aged ≥35 years who participated in the Mexico City Prospective Study (1998-2004). Individuals with self-reported chronic comorbidities at baseline were excluded to mitigate reverse causation. Participants were followed-up until January 1st, 2021 for cause-specific mortality. We defined prediabetes according to the American Diabetes Association (ADA, HbA1c ≥5.7%) and the International Expert Committee (IEC, HbA1c ≥6.0%) definitions. Cox regressions were used to estimate prediabetes-related risk for all-cause and cause-specific mortality, stratified by sex and age-at-risk and adjusted for municipality of residence, education level, physical activity, smoking, alcohol consumption, and adiposity markers. Results: Compared to individuals with normoglycemia, participants with IEC-defined prediabetes had a higher risk of all-cause (HR 1.16, 95%CI 1.05-1.27), cardiac (HR 1.29, 95%CI 1.05-1.59), renal (HR 1.59, 95%CI 1.14-2.23), and acute diabetes-related (HR 2.60, 95%CI 1.52-4.43) mortality at ages 40-74 years compared to normoglycemic participants. HRs were attenuated at older ages. Results were broadly similar irrespective of the definition of prediabetes except for cardiac deaths, in which the risk was non-significant using the ADA cutoff (HR 1.14, 95%CI 0.99-1.31). Long-term effects of prediabetes (IEC-defined) accounted for ∼37% of renal deaths and ∼61% of acute diabetes-related deaths in Mexican adults without diabetes at baseline. Conclusion: Prediabetes is an important risk factor that accounts for a significant fraction of all-cause, cardiac, renal, and acute diabetes-related deaths among Mexican adults, particularly when using the higher threshold of IEC-defined prediabetes. Endpoint-driven definitions of prediabetes should be considered for widespread implementation of screening and preventive strategies that minimize overdiagnosis and improve cardiometabolic outcomes in this population. Presentation: 6/1/2024

8273 ACTH-Dependent Cushing's Syndrome Due To Metastatic Cervical Cancer: A Case Report

Abstract Disclosure: T.D. Bertolacini da Silva: None. V.D. Kamura: None. P.D. Buchalla: None. A.G. Simoes: None. S. Glina: None. Z.M. Campos: None. I.S. Rosa: None. P.X. Santi: None. Background: The association of dependent Cushing's ACTH Syndrome with certain types of cancer is well known, such as small cell lung cancer, enteropancreatic tumors, thymoma, thyroid cancer, however, in association with cervical cancer there are almost no cases described. Clinical Case: A 39-year women, showed about 2.5 years ago with abnormal uterine bleeding, being submitted to colposcopy with the presence of exophytic, friable and hardened lesion in the anterior region of the cervix. Biopsies revealed adenocarcinoma, endometrioid type and immunohistochemistry (IHC) positive for: Ki-67 80%, vimentin and CEA. Patient underwent initial treatment with chemotherapy and radiotherapy, losing follow-up with Oncology. After 1 year, the patient was admitted to a hospital with behavioral alteration, including suicidal ideation, muscle weakness, breast enlargement and hair growth on the face. On physical examination, there was the presence of hypertension, hyperglycemia, centripetal obesity, legs edema and hirsutism. Due to the typical symptoms, the hypothesis of Cushing's Syndrome was made and laboratory and imaging tests were requested. Initial tests: K 1.9 mmol/L (3.5-5.6 mmol/L), Na 146 mmol/L (137-145 mmol/L), TSH 0.25 uIU/mL (0.49-5.58 uIU/mL/mL), free T4 0.78 ng/dL (0.89-1.53 ng/dL), pH 7.57 (7.36-7.41), HCO3 43.1 mmol/L (23-27 mmol/L), LH 0.15 mIU/mL (1.9-12.5 mIU/mL), FSH 1.02 mIU/mL (2.5-10 mIU/mL), estradiol 84.1 pg/mL (&amp;lt; 32.2 pg/mL), ACTH 365.0 pg/mL and 98.6 pg/mL (&amp;lt; 46 pg/mL), cortisol &amp;gt; 75 ug/dL (5.27-22.5 ug/dL), urinary cortisol 3790 ug/24h (4-60 ug/24h), testosterone 333 ng/dL (12 - 59 ng/dL), free testosterone 10.12 ng/dL (0.08-1.1 ng/dL), dehydrotestosterone 1,620 pg/mL (&amp;lt; 596 pg/mL), androstenedione &amp;gt; 10 ng/mL (0.3-3.3 ng/mL). The dosages of ACTH and cortisol were performed after the dexamethasone suppression test and a pituitary MRI was normal. The MRI of the abdomen and pelvis showed multiple solid nodular lesions in liver with varying sizes compatible with metastatic disease, in addition, showed the increase in the bilateral volume of the adrenals. Liver biopsy was performed exhibiting carcinoma infiltration with IHC compatible with neuroendocrine tumor, positive for: CDX-2, SATB2, chromogranin A and synaptophysin (waiting for ACTH). Other primary sites were ruled out. The patient was initially treated with Etomidate in a continuous infusion, without tolerance and little control of hypercortisolism, after initiating Ketoconazole which was suspended due to hepatotoxicity, and then underwent bilateral adrenalectomy. Unfortunately, she died 4 days after surgery due to septic shock. Conclusion: This case report brings a very rare association of Cushing's syndrome by ectopic ACTH due to cervical cancer, with less than 10 cases reported, in which we highlight the diagnostic difficulty, the complexity of treatment and the high risk of morbidity and mortality. Presentation: 6/1/2024

Psychosocial burden and quality of life of parents with children with univentricular hearts compared to ASD parents and parents of heart-healthy children.

Patients with univentricular hearts can only be palliated by a staged surgical procedure that carries a high morbidity and mortality risk. The aim of this study was to examine the emotional demands, psychosocial burden, and quality of life of parents with children with univentricular hearts compared to parents of children with a simple heart defect, those with no heart defect and children with chronic diseases. An anonymous questionnaire was created to interview parents about their quality of life, stressors, needs, strategies for coping with illness, and partnership satisfaction. 73 families participated in the study. Parents of children with univentricular hearts experience a significantly higher psychosocial burden, limitations in daily life, and distress in family interactions, as well as greater emotional distress compared to the other study groups. When comparing the families of children with other chronic diseases (e.g. cystic fibrosis, chronic arthritis and diabetes), these differences remained significant. The study confirms a higher psychosocial burden, restrictions in daily life and a lower quality of life of parents with children with univentricular hearts, compared to parents of children with simple heart defects and parents of heart-healthy children or those with other chronic diseases. Since this condition persists until adolescence and adulthood, the families are exposed to special challenges and stresses throughout their lives. This has yet to be adequately addressed in the management of these families.

Association of metabolic score for visceral fat with all-cause mortality, cardiovascular mortality, and cancer mortality: A prospective cohort study.

Our study aimed to evaluate the association between the metabolic score for visceral fat (METS-VF) and mortality. We conducted a cohort study comprising 11,120 participants. We employed weighted multivariable Cox regression analysis to assess the relationship between METS-VF and mortality. Restricted cubic spline analyses were used to investigate potential non-linear associations. Receiver operating characteristic curves were used to evaluate the predictive value of METS-VF and other obesity-related indicators for mortality. Subgroup analysis and sensitivity analysis were performed to confirm the robustness of the results. Mendelian randomization analysis was utilized to assess potential causality. Over a median follow-up duration of 83 months, a total of 1014 all-cause deaths, 301 cardiovascular deaths,and 262 cancer deaths occurred. For every 0.2-unit increase in METS-VF, the hazard ratios(HRs)of all-cause mortality, cardiovascular mortality, and cancer mortality were 1.13 [95% confidence interval (CI): 1.06, 1.20], 1.18 (95% CI: 1.06, 1.31), and 1.13 (95% CI: 1.03, 1.25), respectively. In addition, restricted cubic spline analyses revealed no significant non-linear associations between METS-VF and all-cause mortality, cardiovascular mortality, and cancer mortality. In multivariate Cox regression models, hazard ratios of all-cause mortality, cardiovascular mortality and cancer mortality were higher in the highest METS-VF group compared to the reference group. Subgroup and sensitivity analyses confirmed that our results were robust. Receiver operating characteristic curves indicated that METS-VF predicted mortality better than other obesity-related indicators. Mendelian randomization analysis confirmed significant causal relationships. METS-VF was positively associated with all-cause mortality, cardiovascular mortality, and cancer mortality. These findings suggest that METS-VF could serve as a straightforward, reliable, and cost-effective marker for identifying individuals at high risk of mortality.

Coronary artery bypass grafting in octogenarians: a nomogram for predicting all-cause mortality

BackgroundThe benefits and risks of coronary artery bypass grafting (CABG) in octogenarians remain unclear. This study aimed to identify the predictors of increased risk of all-cause mortality in octogenarian patients after CABG.MethodsWe retrospectively analyzed the data of 1636 octogenarians who underwent isolated elective on-pump CABG between 2007 and 2016. The primary endpoint was mortality from any cause. The Kaplan–Meier curve was generated for mortality. A univariate Cox regression was performed for preprocedural and procedural variables. The Akaike information criterion (AIC) using the Cox proportional hazard model was applied to determine the strongest predictors. We designed a nomogram based on the selected variables to calculate the mortality risk after one, five, and ten years. The bootstrap resampling based on the C-index was performed to validate the final model. Calibration plots were created at different time points.ResultsThe mean age of the patients was 82.03 years (SD = 1.74), and 74% were male. In a median follow-up of 9.2 (95% CI 9.0,9.5) years, 626 (38.2%) patients died. After the selection of best predictors based on AIC, the multivariable Cox regression showed that ejection fraction < 40 (HR 1.41, 95% CI 1.21–1.65, P < 0.001), two-vessel disease (HR: 0.59, 95% CI 0.40–0.89, P = 0.012), peripheral vascular disease (HR 1.52, 95% CI 1.05–2.21, P = 0.027), and valvular heart disease (HR 1.45, 95% CI 1.24–1.69, P < 0.001) were the significant predictors of all-cause mortality.ConclusionOctogenarians who undergo CABG have a high mortality risk, influenced by several preprocedural and procedural risk factors. The proposed nomogram can be considered for optimizing the management of this vulnerable age group.Clinical registration number IR.TUMS.THC.REC.1400.081.Graphical abstract

Caregivers' and nurses' perceptions of the Smart Discharges Program for children with sepsis in Uganda: A qualitative study.

Sepsis arises when the body's response to an infection injures its own tissues and organs. Among children hospitalized with suspected sepsis in low-income country settings, mortality rates following discharge are high, similar to mortality rates in hospital. The Smart Discharges Program uses a mobile health (mHealth) platform to identify children at high risk of post-discharge mortality to receive enhanced post-discharge care. This study sought to explore the perceptions and experiences of the caregivers and nurses of children enrolled into the Smart Discharges Program and the program's effect on post-discharge care. We conducted an exploratory qualitative study, which included in-person focus group discussions (FGDs) with 30 caregivers of pediatric patients enrolled in the Smart Discharges Program and individual, semi-structured interviews with eight Smart Discharges Program nurses. The study was carried out at four hospitals in Uganda in 2019. Following thematic analysis, three key themes pertaining to the Smart Discharges program were identified: (1) Facilitators and barriers to follow-up care after discharge; (2) Changed caregiver behavior following discharge; and (3) Increased involvement of male caregivers. Facilitators included telephone/text message reminders, positive nurse-patient relationship, and the complementary aspects of the program. Barriers included resource constraints and negative experiences during post-discharge care seeking. With regards to behavior, when provided with relevant and well-timed information, caregivers reported increased knowledge about post-discharge care and improvements in their ability to care for their child. Enrolment in the Smart Discharges Program also increased male caregiver involvement, increased provision of resources and improved communication within the family and with the healthcare system. The Smart Discharges approach is an impactful strategy to improve pediatric post-discharge care, and similar approaches should be considered to improve the hospital to home transition in similar low-income country settings.

Amiodarone or Implantable Cardioverter-Defibrillator in Chagas Cardiomyopathy

Over 10 000 people with Chagas disease experience sudden cardiac death (SCD) annually, mostly caused by ventricular fibrillation. Amiodarone hydrochloride and the implantable cardioverter-defibrillator (ICD) have been empirically used to prevent SCD in patients with chronic Chagas cardiomyopathy. To test the hypothesis that ICD is more effective than amiodarone therapy for primary prevention of all-cause mortality in patients with chronic Chagas cardiomyopathy and moderate to high mortality risk, assessed by the Rassi score. CHAGASICS is an open-label, randomized clinical trial. The study enrolled patients from 13 centers in Brazil from May 30, 2014, to August 13, 2021, with the last follow-up November 8, 2021. Patients with serological findings positive for Chagas disease, a Rassi risk score of at least 10 points (intermediate to high risk), and at least 1 episode of nonsustained ventricular tachycardia were eligible to participate. Data were analyzed from May 3, 2022, to June 16, 2023. Patients were randomized 1:1 to receive ICD or amiodarone (with a loading dose of 600 mg after randomization). The primary outcome was all-cause mortality, and secondary outcomes included SCD, hospitalization for heart failure, and necessity of a pacemaker during the entire follow-up. The study was stopped prematurely for administrative reasons, with 323 patients randomized (166 in the amiodarone group and 157 in the ICD group), rather than the intended 1100 patients. Analysis was by intention to treat at a median follow-up of 3.6 (IQR, 1.8-4.4) years. Mean (SD) age was 57.4 (9.8) years, 185 patients (57.3%) were male, and the mean (SD) left ventricular ejection fraction was 37.0% (11.6%). There were 60 deaths (38.2%) in the ICD arm and 64 (38.6%) in the amiodarone group (hazard ratio [HR], 0.86 [95% CI, 0.60-1.22]; P = .40). The rates of SCD (6 [3.8%] vs 23 [13.9%]; HR, 0.25 [95% CI, 0.10-0.61]; P = .001), bradycardia requiring pacing (3 [1.9%] vs 27 [16.3%]; HR, 0.10 [95% CI, 0.03-0.34]; P < .001), and heart failure hospitalization (14 [8.9%] vs 28 [16.9%]; HR, 0.46 [95% CI, 0.24-0.87]; P = .01) were lower in the ICD group compared with the amiodarone arm. In patients with chronic Chagas cardiomyopathy at moderate to high risk of mortality, ICD did not reduce the risk of all-cause mortality. However, ICD significantly reduced the risk of SCD, pacing need, and heart failure hospitalization compared with amiodarone therapy. Further studies are warranted to confirm the evidence generated by this trial. ClinicalTrials.gov Identifier: NCT01722942.

Comparison of risk assessment scores in patients with pulmonary embolism

Background Pulmonary embolism (PE) is one of the most fatal emergencies with a high risk of mortality. Multiple risk stratification scores have been developed to assess a patient’s overall mortality risk. Objective This study aimed to validate modified FAST and modified Bova scores for risk stratification and predicting the risk of early mortality in patients presenting with acute PE. Patients and methods Patients admitted to Assiut University Hospital with PE were sequentially included. Pulmonary Embolism Severity Index (PESI), modified Bova, and modified FAST scores were calculated for all included patients. Results A total of 100 patients with PE were sequentially included. It was found that predictors of in-hospital mortality in patients with PE were; chronic heart failure [odds ratio (OR)= 1.87], chronic respiratory disease (OR= 1.99), chronic kidney disease (OR= 2.01), hypotension (OR= 2.99), intermediate-high risk- PESI (simplified version; OR=2.76), intermediate-high risk modified Bova score (OR= 3.01) and intermediate-high risk modified FAST score (OR= 3.90).It was found that the modified FAST score had the best diagnostic accuracy (89.2%) with an area under the curve (AUC) 0.962, followed by the modified Bova score with accuracy 76.8% and AUC 0.761. The two scores had higher accuracy than that for PESI score (53.4%, AUC= 0.627). Conclusion Modified FAST and modified Bova scores are simple and reliable tools for risk stratification of patients with acute PE.

Exploring Recidivism in Cardiac Surgical ICU: Can this Understanding Translate to Enhanced Patient Outcomes?

The need for reinstitution of intensive care unit (ICU) care ("recidivism") in post-cardiac surgery patients is associated with increased morbidity, mortality, resource use, and healthcare costs. Recidivism is propounded as a quality indicator of ICU care. There is a paucity of studies from India regarding cardiac surgical ICU readmissions, their outcomes, and risk factors. Nested case-control study including 1,711 consecutive adult patients who underwent cardiac surgery over a two-year period at a tertiary care institute. The patients were grouped into recidival (R) and control (C) groups. The reasons for readmission, outcomes, and predictive risk factors were analyzed. Fifty-four of 1,711 (3.1%) patients were readmitted to ICU, main reasons being cardiac arrhythmias (24, 41%), pericardial effusion (9, 15.2%), and infection (8, 13.5%). Readmission was significantly higher for valvular interventions (39 patients, 24.3%, mitral valve 25 patients) than coronary artery bypass grafting (13, 10.6%), P value 0.003*. On multivariate analysis, EuroSCORE 2 (>5), age, surgical reexploration, postoperative pulmonary complications, and infections were independently associated with a need for ICU readmission. The mortality rate among the readmitted patients was 7.4% compared to 1.4% overall mortality. The mean total postoperative length of stay was significantly longer for recidival patients (17.6 ± 14 days vs 7.6 ± 2.4 days; P < 0.0001). Recidivism is associated with longer hospital stay, suboptimal outcomes as well higher risk of mortality. Postoperative cardiac dysrhythmia was the most common cause of recidivism in our cohort. Early identification of patients at risk for recidivism and timely management of cardiopulmonary complications can translate to better outcomes.

Patient- and Areal-Level Risk Factors Associated With Lung Cancer Mortality in Victoria, Australia: A Bayesian Spatial Survival Analysis.

In Australia, lung cancer is the leading cause of cancer-related deaths. In Victoria, the mortality risk is assumed to vary across Local Government Areas (LGAs) due to variations in socioeconomic advantage, remoteness, and healthcare accessibility. Thus, we applied Bayesian spatial survival models to examine the geographic variation in lung cancer survival in Victoria. Data on lung cancer cases were extracted from the Victorian Lung Cancer Registry (VLCR). To account for spatial dependence and risk factors of survival in lung cancer patients, we employed a Bayesian spatial survival model. Conditional Autoregressive (CAR) prior was assigned to model the spatial dependence. Deviance Information Criterion (DIC), Watanabe Akaike Information Criterion (WAIC), and Log Pseudo Marginal Likelihood (LPML) were used for model comparison. In the final best-fitted model, the Adjusted Hazard Ratio (AHR) with the 95% Credible Interval (CrI) was reported. The outcome variable was the survival status of lung cancer patients, defined as whether they survived or died during the follow-up period (death was our interest). Our study revealed substantial variations in lung cancer mortality in Victoria. Poor Eastern Cooperative Oncology Group (ECOG) performance status, diagnosed at a regional hospital, Small Cell Lung Cancer (SCLC), advanced age, and advanced clinical stage were associated with a higher risk of mortality, whereas being female, presented at Multidisciplinary Team (MDT) meeting, and diagnosed at a metropolitan private hospital were significantly associated with a lower risk of mortality. Identifying geographical disparities in lung cancer survival may help shape healthcare policy to implement more targeted and effective lung cancer care services.

Associations of serial negative income shock and all-cause mortality: a longitudinal study in China

IntroductionWith a precarious economic outlook and increasing income volatility in current times, understanding the association between negative income shock and health is crucial. However, few studies have examined such associations...

The relationship between serum uric acid and gastrointestinal bleeding in peritoneal dialysis patients: a propensity score analysis

Purpose Gastrointestinal bleeding is an important gastrointestinal complication among peritoneal dialysis patients and correlated with a higher risk of mortality. Increased uric acid levels are a significant complication for peritoneal dialysis patients and have been associated with an increased risk of hemorrhagic stroke. The objective of the present study was to investigate the relationship between serum uric acid levels and gastrointestinal bleeding in peritoneal dialysis patients. Methods A total of 2498 peritoneal dialysis patients were recruited. Based on the optimal uric acid cutoff value, two groups of patients were divided. We constructed a propensity-score-matched population of 1762 patients by matching sex, age, and body mass index. Survival outcomes between the two groups were compared using adjusted Kaplan–Meier curves. We constructed the restricted cubic splines regression to assess the correlation between levels of uric acid and gastrointestinal bleeding. A multivariate Cox proportional hazards regression was performed to test whether higher levels of uric acid are an independent risk factor for gastrointestinal bleeding. We performed a forest plot to show interaction effects in different subgroups. Results According to restricted cubic splines regression, uric acid levels were positively correlated with the risk of gastrointestinal bleeding events. After adjusted different confounding factors, patients with high levels of uric acid were prone to experience gastrointestinal bleeding (HR 1.868, 95%CI 1.001–3.486). In subgroups, the interaction between higher levels of uric acid and utilizing proton pump inhibitors was significant (P for interaction = 0.034). Further research found that taking proton pump inhibitors could decrease the risk of gastrointestinal bleeding in peritoneal dialysis patients accompanied high levels of uric acid. Conclusion The baseline high levels of uric acid are an independent risk factor for gastrointestinal bleeding in patients undergoing peritoneal dialysis.

Patient and clinician perspectives on the timing of serious illness conversations in oncology.

223 Background: Serious illness conversations (SICs) about patients’ values and care preferences are tied to improved outcomes and quality of life. However, SICs can be hard to implement early in the cancer care journey, and questions remain about how and when to start. Following a pragmatic trial testing behavioral nudges to promote SICs in oncology (NCT04867850), we used an explanatory-sequential mixed methods design to gauge patient and clinician perspectives on the best communication strategy for SICs. Methods: Thirty patients with cancer at high mortality risk and 16 oncology clinicians were recruited from our academic cancer center. Guided by the Consolidated Framework for Implementation Research, our interviews systematically assessed multi-level factors shaping SIC implementation. In addition to interviews, patients completed a structured survey with validated measures on patient-focused communication and care planning. Survey data were studied descriptively, interviews were analyzed thematically, and both were integrated to triangulate qualitative and quantitative results. Results: Participants described two SIC types, which we classified as event-triggered and phased . Clinicians identified event-triggered SICs as prompted by acute incidents (e.g., disease stage transition) and more likely to lead to EHR documentation. However, they were seen as prohibitively time-consuming, and as such, did not become a top priority until a crisis arose. Patients were also uncomfortable with extensive early SICs, wanting to keep hope and avoid information overload soon after a diagnosis. They preferred not to discuss “turns for the worse” until they faced an acute challenge, at which point they valued thorough SICs. In surveys, almost all patients reported asking about benefits (96%), risks (93%), and quality of life (81%) tied to treatment, but few raised sensitive topics like planning for if things got worse (44%). By contrast, phased SICs were described as ongoing, progressive conversations not prompted by specific events and that arose early but deepened over time as a patient and care team nurtured their relationship. Patients and clinicians described phased SICs as better at promoting person-centered care and an essential foundation for SICs prompted by potential transitions. However, since these discussions occur gradually, clinicians reported challenges documenting them, reducing their value at informing future decisions and the ability to know whether conversations occurred at all. Conclusions: Interventions to increase SICs often focus on acute moments in the care trajectory. However, our study suggests that ongoing, staged approaches to SICs are vital for goal-concordant care as well and may be more easily integrated into busy clinical workflows. Further work should investigate ways to support clinicians in both SIC types, such as flexible documentation tools aligned with each approach.

Predicting Survival Among Colorectal Cancer Patients: Development and Validation of Polygenic Survival Score.

Colorectal cancer is the second leading cause of cancer-related death in the United States. A multi-omics approach has contributed in identifying various cancer-specific mutations, epigenetic alterations, and cells response to chemotherapy. This study aimed to determine the factors associated with colorectal cancer survival and develop and validate a polygenic survival scoring system (PSS) using a multi-omics approach. Data were obtained from the Cancer Genome Atlas (TCGA). Colon Adenocarcinoma (TCGA-COAD) data were used to develop a survival prediction model and PSS, whereas rectal adenocarcinoma (TCGA-READ) data were used to validate the PSS. Cox proportional hazards regression analysis was conducted to examine the association between the demographic characteristics, clinical variables, and mRNA gene expression. Overall accuracy of PSS was also evaluated. The median overall survival for TCGA-COAD patients was 7 years and for TCGA-READ patients was 5 years. The multivariate Cox proportional hazards model identified age, cancer stage, and expression of nine genes as predictors of colon cancer survival. Based on the median PSS of 0.38, 48% of TCGA-COAD patients had high mortality risk. Patients in the low risk group had significantly higher 5-year survival rates than those in the high group (p <0.0001). The PSS demonstrated a high overall accuracy in predicting colorectal cancer survival. This study integrated clinical and transcriptome data to identify survival predictors in patients with colorectal cancer. PSS is an accurate and valid measure for estimating colorectal cancer survival. Thus, it can serve as an important tool for future colorectal cancer research.