Higher Risk Of Mortality Research Articles

Thiazide-Associated Hyponatremia and Mortality Risk: A Cohort Study.

There are likely over 42 million patients with hypertension taking thiazides in the United States and many more worldwide. Hyponatremia is a common complication of thiazide therapy. It is not currently known if thiazide-associated hyponatremia is also associated with increased mortality. The objective of this study was to determine if outpatients who start thiazide diuretic treatment and develop early hyponatremia are at increased risk of mortality when compared with those who do not develop hyponatremia after starting a thiazide. A retrospective cohort study. This study used data from the TriNetX federated health research network comprising deidentified electronic medical records of ∼93 million patients from 76 health care organizations located primarily in the United States. The study population was adult patients 40-90 years old, with essential hypertension and who started on a thiazide diuretic between January 1, 2010, and December 31, 2021. The patients were then subdivided into a hyponatremia cohort and a control cohort. 22,057 patients met the inclusion criteria for the hyponatremia cohort, and 234,466 patients met the inclusion criteria for the control cohort. After propensity score matching, 22,052 remained in both cohorts. The primary outcome is one-year mortality. The hyponatremia cohort developed early hyponatremia defined as a serum sodium≤135mmol/L within 6 months after initiation of thiazide versus a control that had a serum sodium 136-144mmol/L after initiation of thiazide. Primary outcome is mortality. Secondary outcomes include development of sepsis, pneumonia, urinary tract infection, cellulitis, myocardial infarction, stroke, congestive heart failure, ataxia, fall, and hip fracture. The design is a retrospective cohort study, propensity score matched. Patients in the hyponatremia cohort had a higher hazard of mortality than patients in control, HR 1.96 (95% CI, 1.72-2.28; P<0.001). In addition, patients in the hyponatremia cohort had higher hazard of developing sepsis, pneumonia, urinary tract infection, cellulitis, myocardial infarction, stroke, congestive heart failure, ataxia, and hip fracture. The study had a retrospective design. Patients who develop early hyponatremia (serum sodium≤135mmol/L) following initiation of a thiazide diuretic have a higher risk of mortality when compared with those who do not develop hyponatremia after initiation of a thiazide diuretic.

Expression of Trop2, Nectin-4, and FOLR1 cell surface markers in biliary tract cancers: Is it time to repurpose drugs?

637 Background: Biliary tract cancers (BTC), including gall bladder cancer, intrahepatic and extrahepatic cholangiocarcinoma are aggressive malignancies, with poor prognosis. Despite advances in frontline setting, and in biomarker selected population (IDH1, FGFR2, Her2, BRAF, HRD), there is a dire need to advance therapy in subsequent lines. Methods: We identified BTC patients (pts) at Roswell Park Cancer Center who underwent curative intent surgery between 01/2006-01/2020. After excluding duplicate samples and those with insufficient tissue, we found 78 pts with adequate follow up for analysis. Expression of trophoblast cell surface antigen 2 (Trop2), nectin4, folate receptor alpha (FOLR1) was assessed by immunohistochemistry and correlated with clinical outcomes. H score, a weighted index score that factor in, the % of cells across different intensity was calculated. H scores were classified as negative (0) and positive (&gt;1). Positive H scores were grouped as weak (1-100), intermediate (101-200) and strong (201-300). Descriptive statistics were conducted, and multivariate analyses performed (R studio) to study any correlation between expression of markers and survival outcomes. Results: The median age of our cohort was 67.5 years (range 40-87) with 58% male; 24.4%, 30.8%, 20.5%, 7.7% had stages I, II, III, IV disease. Staging information was missing in 16.7% of pts. Of 73 analyzable samples for Trop2, all were positive for Trop2, with a mean H score of 86, SD of 68.9. 56.4% of patients had a weak H score, 30.8% had an intermediate H score and 6.4% had a strong H score for Trop2. Median overall survival (mOS) among low, intermediate and high expressing group of pts with Trop2 was 48.9 months (m), 23.9 m, and 41.9 m with median Progression Free Survival (mPFS) of 37.8m, 15.3 m, and 37.4 m, respectively. Of 75 analyzable samples for FOLR1 and Nectin4, FOLR1 was expressed in 51.3% with a mean H score of 6.97 (SD 21.9). Nectin4 was expressed in 78.2%, with a mean H score of 13.7 (SD 26.3). Pts with Trop2 expression had a mOS of 39.5 m and a mPFS of 28.7 m. There were no significant differences in mOS (48.9 m vs 33.3 m, p =0.14) and mPFS (37.8 m vs 26.2 m, p =0.35) among patients with positive vs negative FOLR1 respectively. There was no difference in mOS (41.6 m vs 38.3 m, p=0.92) and mPFS (32.8 vs 26.4 m, p-value=0.5) in patients with positive vs negative Nectin4. Multivariate analyses showed that pts with intermediate Trop2 (H score=101-200) had a high risk of death (HR 21.44, CI 2.81-163.4, p= 0.003). Conclusions: Though no difference was seen in clinical outcomes in pts with strong Trop2 expression, FOLR1, and Nectin4 expression, this could be explained by the small sample size. Trop2 is frequently expressed in BTCs and patients with Intermediate Trop2 H score had lower mOS and mPFS, with a higher risk of mortality. This warrants further investigation into potential use of Antibody Drug conjugates against Trop2 in BTC.

Comparative analysis of demographics and outcomes in hospitalized patients with young- versus average-onset colorectal cancer in New York state (2017-2022).

27 Background: Recent studies have shown an increasing incidence of colorectal cancer (CRC) among young patients. This study investigates clinical outcomes and healthcare utilization among young (&lt;50) versus average onset (≥50) CRC patients admitted to hospitals in New York State (NYS). Methods: We performed a retrospective analysis using the Statewide Planning and Research Cooperative System (SPARCS) database from 2017 to 2022. Patients were divided into two groups: young-onset colorectal cancer patients (YOCRC, &lt;50 years) and average onset colorectal cancer patients (AOCRC, ≥50 years). The study population was further stratified by demographic and clinical characteristics. All associations were compared using the Kruskal-Wallis test, along with multivariate linear and logistic regression in RStudio version 4.4.1, at a significance level of ≤0.05. Clinical characteristics, including severity of illness and risk of mortality, were defined using the All Patient Refined (APR) grading system. Results: A total of 9,904 patients were identified (948 YOCRC and 8,956 AOCRC) with a primary admitting diagnosis of CRC from 2017 to 2022. In comparing the two age groups, AOCRC patients had a higher proportion of White, and female patients, whereas the YOCRC group included a higher proportion of Black and male patients (p&lt;0.001). The median length of stay was greater for AOCRC patients (5 days) compared to YOCRC patients (4 days), p&lt;0.001. Both age groups showed an upward trend in total cost of stay in the recent years. AOCRC patients were more likely to have increased severity of illness graded as major-extreme (60% vs 48%), while a higher proportion of YOCRC patients were classified as minor-moderate disease (51% vs 40%), p&lt;0.001. Similarly, AOCRC patients experienced a higher risk of mortality compared to YOCRC patients (p&lt;0.001). Regarding procedures, AOCRC patients needed more transfusions (13%) than YOCRC patients (9.3%), p&lt;0.001. YOCRC patients were also more likely to be discharged home (71% vs 46%), while AOCRC patients often required home health services or skilled nursing (p&lt;0.001). Notably, while the risk of mortality was higher for AOCRC patients, it has been decreasing overall from 2017 to 2022 [OR 0.92 (95% CI: 0.84-0.99), p=0.039]. Conclusions: AOCRC patients experienced greater severity of disease, higher mortality risk, and required more assistive care at discharge compared to YOCRC patients. The total cost of hospital stays has been rising for both groups. Policies focused on earlier outpatient interventions may help reduce the burden of inpatient care and rising costs.

Cardiovascular MRI-derived Right Atrial Strain for Improved Risk Stratification in Patients with Severe Aortic Stenosis.

Purpose To assess the prognostic implications of cardiac MRI-derived imaging markers in individuals with severe aortic stenosis (AS). Materials and Methods This prospective study (German Clinical Trials Register, DRKS00024479) enrolled individuals with severe AS who underwent cardiac MRI before transcatheter aortic valve replacement (TAVR) from January 2017 to March 2022. Image analyses included myocardial volumes, cardiac MRI feature tracking-derived left atrial (LA) and right atrial (RA) as well as left ventricular (LV) and right ventricular (RV) strain, myocardial T1 mapping, and late gadolinium enhancement analyses. Cardiovascular (CV) mortality was defined as primary clinical end point. Cox proportional hazards models were used to determine the association between cardiac MRI-derived parameters and CV mortality. Results The final analysis included 145 participants (median age, 80 years [IQR, 75-83 years]; 91 male). Participants who experienced CV death during follow-up had significantly enlarged RV end-diastolic volumes (median, 82.9 [IQR, 70.8-96.0] mL/m2 vs 62.8 [54.7-76.0] mL/m2; P < .001) and impaired strain values of all cardiac chambers compared with those who survived (LV global longitudinal strain [GLS], -18.1% [-13.1% to -20.4%] vs -22.5% [-16.1% to -27.3%], P = .02; RV GLS, -22.9% [-18.6% to -25.4%] vs -27.9% [-22.9% to -32.0%], P = .002; LA atrial reservoir strain [Es], 9.5% [7.2%-15.4%] vs 14.3% [9.0%-18.1%], P = .04; RA Es, 12.4% [6.8%-14.4%] vs 16.2% [11.2%-22.1%], P < .001). RA reservoir strain independently helped predict CV mortality after adjustment for other cardiac MRI markers and clinical parameters of heart failure (hazard ratio, 0.82 [95% CI: 0.71, 0.95]; P = .008). Within the subgroup of participants with high extracellular volume values, RA strain further identified participants with AS at high risk for CV mortality (P = .001 on log-rank testing). Conclusion In individuals with AS undergoing TAVR, several cardiac MRI parameters were significantly associated with CV mortality. RA strain was an independent predictor of CV mortality and may provide more optimized patient management. Keywords: Cardiac MRI, Aortic Stenosis, TAVR, Risk Assessment, Strain Analyses German Clinical Trials Register no. DRKS00024479 Supplemental material is available for this article. © RSNA, 2025.

Using a Serious Game to Teach Central Line Care in Pediatric Critical Care Nursing.

Central venous catheters (CVCs) are used in pediatric patients to deliver IV fluids, blood products, medications, and nutrients. Potential complications include central line infection, which carries a high risk of morbidity and mortality in this population. Pediatric critical care nurses play a crucial role in helping to reduce the risk of infection. The aim of this study was to develop, implement, and evaluate the effectiveness of a serious, simulated, gaming-based intervention to improve the skills and knowledge of RNs in the early stages of their career regarding central line insertion, care, and infection prevention. A single-arm, pre- and postinterventional pilot study was conducted at the Riley Hospital for Children at Indiana University Health, from July 2021 to July 2022. The study participants were bedside pediatric critical care nurses who were provided with education and skills training regarding CVC placement and maintenance through a so-called serious game-essentially, a video game with a purpose. A simulation session and multiple-choice knowledge test were used to assess skills and knowledge retention both before and after the intervention. A total of 32 pediatric critical care nurses participated in the study; however, 1 nurse did not complete the follow-up assessment. The study revealed a statistically significant increase in the overall mean (SD) global performance score from 4.06 (2.11) before the intervention to 5.97 (1.80) afterward. Specific areas of performance also showed significant improvement: handwashing prior to the procedure (P = 0.04), covering the procedure site (P = 0.01), cleaning the site properly (P < 0.01), and ensuring central line placement before use (P < 0.01). However, there was no statistically significant difference in the nurses' performance on the multiple-choice knowledge test before and after the intervention. This study suggests that serious games have the potential to improve nursing education, particularly in complex procedures like central line insertion and maintenance. Our findings indicate that serious gaming is effective in engaging learners and enhancing their skills. More research is needed to evaluate the long-term impact of serious games on learning outcomes and patient care.

Advanced Reconstructive Techniques Following Orbital Exenteration: The Role of LCFA Free Flaps

BackgroundOrbital exenteration is a severe and disabling surgical procedure that involves the removal of all orbital contents. Effective reconstruction is crucial to managing the resulting defects. This study aims to propose a reconstructive algorithm utilizing free flaps derived from the lateral circumflex femoral artery (LCFA) system for orbital exenteration defects, based on our clinical experience. Patients and MethodsBetween January 2013 and January 2022, patients who underwent orbital exenteration and subsequent reconstruction using LCFA-based free flaps were included in this study. ResultsA total of 44 patients underwent orbital exenteration followed by LCFA free flap reconstruction. The choice of reconstructive technique varied according to defect type and dura mater exposure, adhering to the proposed algorithm. The procedures included 20 standard ALT flaps, 13 chimeric ALT flaps, 1 SALT chimeric flap with skin grafting, 7 SALT flaps with skin grafting, and 3 buried SALT flaps. Complications were recorded in 10 cases at the recipient site and in 2 cases at the donor site. ConclusionOrbital exenteration presents significant challenges both surgically and reconstructively, with a high risk of local recurrence and postoperative mortality. The reconstruction algorithm using LCFA-based free flaps, as proposed in this study, may guide surgeons in selecting the most appropriate technique, tailored to the specific defect and considering postoperative treatments such as adjuvant radiotherapy.

Prognostic factors in severe dengue patients: A multi-center retrospective cohort study.

Early detection of severe dengue (SD) and appropriate management are crucial in reducing the case fatality rate. The objective of this study was to investigate the clinical characteristics of SD and identify independent risk factors associated with mortality among SD patients. A retrospective study was conducted at two medical center hospitals between 2002 and 2019, involving patients aged ≧18 years with laboratory-confirmed SD. This study included 294 patients with SD, of whom 203 (69%) survived and 91 (31%) died. Among the 294 SD patients, 103 (35%) experienced acute kidney injury, 54 (18.4%) had pneumonia, and 19 (6.5%) had bacteremia. Among the 286 patients with available alanine aminotransferase (ALT) data, 41 (14.3%) experienced severe hepatitis (ALT>1000U/L). The median time from illness onset to death among the 91 SD patients who died was 5 days. Multivariable regression analysis revealed increasing odds of death associated with older age (odds ratio [OR], 1.037; 95% confidence interval [CI], 1.009-1.066), altered consciousness (OR, 8.591; 95% CI, 2.914-25.330), gastrointestinal bleeding (OR, 1.939; 95% CI, 1.037-3.626), and leukocytosis (OR, 2.504; 95% CI, 1.124-5.578) upon arrival, as well as organ impairment during hospitalization, including acute kidney injury (OR, 2.627; 95% CI, 1.373-5.028), severe hepatitis (OR, 5.324; 95% CI, 2.199-12.889), and pneumonia (OR, 2.250; 95% CI, 1.054-4.802). Our findings underscore the importance of early recognition and intervention by frontline physicians in identifying SD patients at high risk of mortality. This information can significantly contribute to reducing fatalities and improving the overall management of SD cases.

Effect of SMARCA4 mutations on the outcomes of patients with advanced EGFR mutant lung adenocarcinoma

Objective: To investigate the impact of SMARCA4 mutations on the outcomes of patients with advanced lung adenocarcinoma with epidermal growth factor receptor (EGFR) mutations. Methods: In the Memorial Sloan Kettering Cancer Center (MSK) MetTropism study, 960 patients with advanced EGFR-mutated lung adenocarcinoma were screened and included in the MSK cohort, composing of 313 males and 647 females, with a median [M(Q1, Q3)] age of 64 (56, 72) years. A retrospective analysis was conducted on the data of 178 patients with advanced EGFR-mutated lung adenocarcinoma who received EGFR tyrosine kinase inhibitors (TKIs) treatment in the Department of Oncology, the First Affiliated Hospital of Nanjing Medical University, from January 2018 to December 2022. Among these patients, 69 were males and 109 were females, with a median age of 63 (54, 69) years. The follow-up of patients from the First Affiliated Hospital of Nanjing Medical University was conducted up to December 31, 2023, with a median follow-up time of 26.6 (95%CI: 24.6-28.6) months for the entire cohort, and 29 patients were lost to follow-up. Survival curves were plotted using the Kaplan-Meier method, and the log-rank test was used to compare the relationship between SMARCA4 gene alternations and prognosis. Results: In the 960 patients of the MSK cohort with advanced EGFR-mutated lung adenocarcinoma, the SMARCA4 gene alternations rate was 4.2% (40/960). The median overall survival (OS) for patients without SMARCA4 gene alternations was 41.5 (95%CI: 35.6-47.3) months, which was superior to that of patients with SMARCA4 gene alternations [15.6 (95%CI: 7.9-23.4) months, P<0.001]. Patients with SMARCA4 gene alternations had a higher risk of mortality, with an HR (95%CI) of 1.97 (1.35 to 2.88). Among the 178 patients with advanced EGFR-mutated lung adenocarcinoma from the First Affiliated Hospital of Nanjing Medical University, the SMARCA4 gene alternations rate was 4.5% (8/178). The median progression-free survival (PFS) for patients without SMARCA4 gene alternations was 16.1 (95%CI: 12.2-20.0) months, which was superior to the median PFS of patients with SMARCA4 gene alternations [6.0 (95%CI: 1.3-10.7) months, P<0.001]. The median OS for patients without SMARCA4 gene alternations was 50.1 (95%CI: 28.1-72.1) months, which was also superior to the median OS of patients with SMARCA4 gene alternations [17.6 (95%CI: 15.4-19.8) months, P=0.001]. Conclusion: SMARCA4 alternation is an important factor associated with poor prognosis in patients with advanced EGFR-mutant lung adenocarcinoma.

Adverse birth outcome and associated factors among mothers with antepartum hemorrhage in public hospitals Tigray, northern Ethiopia, 2020

BackgroundAdverse birth outcome is a major public health problem in the world and in Ethiopia. Antepartum hemorrhage complicates 3–5% of pregnancies and is a primary cause of perinatal and maternal mortality worldwide. One in five of all preterm babies are born in association with antepartum hemorrhage. Preterm birth, low birth weight and asphyxiated babies are at high risk for mortality, morbidity and developmental problems Thus, the aim of this study was to assess adverse birth outcomes and associated factors among mothers with antepartum hemorrhage in Tigray public hospitals, northern Ethiopia.MethodsInstitution based cross sectional study design was conducted from February to April 2020 among randomly selected 309 charts of mothers with chart completeness of 95.4%. A simple random sampling technique was used to select hospitals and charts of study participants. A Pretested check list was used to collect data. Data were analyzed using SPSS version 20. Logistic regression was computed and variables which have a P-value less than 0.2 on bivariable analysis were taken to multivariable analysis. A P-value of less than 0.05 and 95% confidence level was used as a cut-off point for statistical significance in multivariable analysis.ResultsThe magnitude of adverse birth outcome was 46.3% at 95% CI and 15.2% of the neonates were admitted to neonatal intensive care unit due to preterm birth and low birth weight. Rural residence [AOR = 2.16, 95%CI (1.069, 4.38)], three and below antenatal care follow-up visits [AOR = 6.6, 95%CI (3.345,13.10)], bad obstetric history [AOR = 2.8, 95%CI (1.044,7.691)], and having less than or equal 11 g/dl hemoglobin level at admission were [AOR = 3.7,95%Cl (1.93,6.914)] found as predictors of adverse birth outcome in this study.Conclusion and recommendationadverse birth outcomes were higher in magnitude and the higher public health problem in the Tigray region. Predictors could be minimized by strengthening antenatal care follow up, ensuring early arrival to health institution, and focusing on rural area.

Health-related quality of life across heart failure categories: associations with clinical characteristics and outcomes.

The study aims to examine characteristics and outcomes associated with health-related quality of life (HRQoL) in patients with heart failure (HF) with preserved, mildly reduced and reduced ejection fraction (EF) (HFpEF, HFmrEF and HFrEF). Data on HRQoL were collected in the Swedish Heart Failure Registry (SwedeHF; 2000-2021) using the EuroQoL 5-dimensional visual analogue scale (EQ 5D-vas). Baseline EQ 5D-vas scores were categorized as 'best' (76-100), 'good' (51-75), 'bad' (26-50) and 'worst' (0-25). Independent associations between patients' characteristics and EQ 5D-vas, as well as between EQ 5D-vas and outcomes were assessed. Of 40809 patients (median age 74years; 32% female), 29% were in the 'best', 41% in the 'good', 25% in the 'bad' and 5% in the 'worst' EQ 5D-vas categories, similarly distributed across all EF categories. Higher New York Heart Association (NYHA) class was strongly associated with lower EQ 5D-vas regardless of EF categories, followed by chronic obstructive pulmonary disease, smoking, body mass index, higher heart rate, anaemia, previous stroke, ischaemic heart disease, use of diuretics and living alone, whereas higher income, male sex, outpatient status and higher systolic blood pressure were inversely associated with lower EQ 5D-vas categories. Patients in the 'worst' EQ 5D-vas category as compared with the 'best' had the highest risk of all-cause death [adjusted hazard ratios 1.97, 95% confidence interval (CI) 1.64-2.37 in HFrEF, 1.77, 95% CI 1.30-2.40 in HFmrEF and 1.43 95% CI 1.02-2.00 in HFpEF]. Most patients were in the two highest EQ 5D-vas categories. Higher NYHA class had the strongest association with lower EQ 5D-vas categories, across all EF categories. Patients in the worst EQ 5D-vas category were at the highest risk of mortality.

Association of liver fibrosis with aneurysm size and mortality risk in patients undergoing open abdominal aortic aneurysm repair

Abdominal Aortic Aneurysm (AAA) poses a significant health risk due to its silent nature and high mortality upon rupture. The Fib-4 index, initially designed for liver fibrosis assessment, presents potential beyond its scope. This study aims to investigate the association of FIB-4 with aneurysm size and mortality risk, exploring its utility as a risk predictor for enhanced clinical management. This retrospective longitudinal research studied 141 AAA open repair surgery patients (92% male, mean age of 70 years (SD: 11.5)) from October 2016 to September 2021 for a median follow-up 35 months (IQR: 0.7 – 56.6). All-cause mortality was the primary outcome. Adjusted hazard ratios (aHR) were calculated for each Fib-4 cut-off between 1.5 and 3.25. FIB-4 cut-off range of 2.58–2.74 was associated with higher mortality risk in adjusted HR. Specifically, FIB-4 ≥ 2.67 increased mortality by 78% (aHR:1.78, 95% CI: 1.06 – 3.00). Furthermore, FIB-4 ≥ 2.67 was significantly associated with a baseline aneurysm size ≥ 8cm (aOR: 2.67, 95% CI: 1.17 – 6.09). FIB-4 was independently associated with a higher mortality risk and higher aneurysm size. These findings suggest that FIB-4 assessment in clinical practice may enhance risk profiling, aiding in more precise stratification and management strategies for AAA patients.

Advances in Diagnosis, Treatment and Prognostic in Aortoiliac Occlusive Disease - A Narrative Review.

Aortoiliac disease (AID) is a variant of peripheral artery disease involving the infrarenal aorta and iliac arteries. Similar to other arterial diseases, aortoiliac disease obstructs blood flow through narrowed lumens or by embolization of plaques. AID, when symptomatic, may present with a triad of claudication, impotence, and absence of femoral pulses, a triad also referred as Leriche Syndrome (LS). The authors aim to review the available evidence on the management of the aortoiliac occlusive disease and describe its clinical characteristics, diagnosis and treatment management. A comprehensive review of the literature was carried out to collect data from relevant studies concerning patients with moderate to severe symptomatic aortic occlusive disease. The data was identified by a search using PubMed and Google Scholar with the keywords / MESH terms "aortoiliac occlusive disease". For this study, the authors included papers published in the past two decades, written in English. The diagnosis and evaluation of extensive aortoiliac disease involves several important considerations: vascular imaging plays a fundamental role in confirming the diagnosis of peripheral artery disease (PAD), evaluating the severity and extent of the disease and directing the planning of revascularization procedures. It provides essential information to select the most appropriate treatment modality. Despite successful revascularization, patients are at high risk of mortality and numerous life-threatening complications. Clinical and imagiologic factors may be used for risk stratification in order to select appropriate patients for revascularization and to better counsel patients about expected postoperative outcomes.

Combination of clinical frailty score and myostatin concentrations as mortality predictor in hemodialysis patients.

Frailty is common among hemodialysis (HD) patients. Its assessment is usually based on clinical criteria. In the present work, we evaluated the interest of combining clinical frailty score and biomarkers to predict mortality of chronic HD patients. Four biomarkers were assessed: myostatin, insulin-like growth factor-1 (IGF-1), dehydroepiandrosterone sulfate (DHEA-S) and serum creatinine-to-cystastin C ratio (SCr/SCys). Prevalent HD patients were enrolled from September 2016 to October 2017 in two centers in this observational prospective study and followed up for 5 years. Serum levels of myostatin, IGF-1, DHEA-S and SCr/SCys were measured at baseline. Frailty was assessed using Fried frailty score (≥3 indicates frailty). The ability to predict 5-year mortality was assessed by calculating Cox regression analyses and areas under the curve (AUC). We included 125 HD patients with the following characteristics: median age of 67 [53;78] years; 40 % of women; 41% of diabetics and median dialysis vintage of 30 [16;54] months. Among them, 46% were classified as "Frail" according to Fried score. Mortality rate at 5 years was 56%. The median follow up was 49 [19;60] months. Cox univariate analysis showed that higher age, frailty phenotype and decreased concentrations of myostatin, IGF-1, DHEA-S and SCr/SCys were associated with higher mortality. In multivariate analysis, only myostatin remained significant among the biomarkers. The AUC of Fried score and myostatin to predict mortality was significant and comparable: 0.72 (95% CI: 0.63 to 0.80) and 0.72 (95% CI: 0.64 to 0.80), respectively. Combining myostatin with Fried score improved significantly the AUC (AUC = 0.79, 95% CI: 0.71 to 0.86) compared to Fried score alone or myostatin alone (p=0.0049 and p=0.0035 respectively). Decreased concentrations of myostatin seem to be independently associated with higher risk of mortality. Combining Fried frailty score with myostatin concentration could improve the prediction of five-year mortality in chronic HD patients.

Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) and mortality among survivors of liver cirrhosis: a prospective cohort study

BackgroundCirrhosis is a medical condition marked by persistent liver damage, which leads to the development of fibrous tissue and compromised liver function. In the present study, we decided to investigate the possibility of a connection between the consumption of fermentable olig-, di-, monosaccharides, and polyols (FODMAPs) and mortality rates in cirrhotic patients by utilizing data obtained from a prospective cohort study.MethodsThis cohort study enrolled 166 ambulatory patients from two hospitals in Tehran, Iran, between 2016 and 2018, and followed them up for 5 48 months until April 30, 2022. During the 3,955 person-months of follow-up, 43 fatalities were recorded (36 men and 7 women). The study classified participants into three groups based on their FODMAPs consumption and assessed the risk of mortality using Cox proportional hazards regression models.ResultsTotal FODMAPs intake was associated with increased overall mortality risk (T3 vs. T1, HR = 3.5; 95%CI: 1.05, 11.7; P-trend = 0.036). This significant trend was also observed for total fructans (T3 vs. T1, HR = 5.15; 95% CI: 1.15, 23.2; P-trend = 0.006) and fructose (T3 vs. T1, HR = 5.55; 95% CI: 0.54, 57.14; P-trend = 0.018). Mortality risk was U-shaped with galactooligosaccharide intake, a lower mortality risk was observed with lactose intake and a higher mortality risk with polyols intake, although these associations did not reach statistical significance.ConclusionIn conclusion, this study highlights a higher risk of mortality with higher intake of fructans, excess fructose and total FODMAPs.

The severely injured older patient: identifying patients at high risk for mortality using the Dutch National Trauma Registry

PurposeThe incidence of severely injured older trauma patients is increasing globally, portraying high mortality rates. Exploring the demographics and clinical outcomes of this subgroup is essential to further improve specialised care at the right place. This study was performed to identify severely injured older patients at high risk for mortality by examining their characteristics and identifying prognostic factors contributing to mortality.MethodsA retrospective cohort study was conducted using data from the Dutch National Trauma Registry to identify all trauma patients aged 70 years and older from 2016 to 2022. Subgroup analyses for characteristics and outcomes were performed based on Injury Severity Score (ISS) 16–24 and ISS ≥ 25, as well as age groups of 70–79, 80–89 and ≥ 90 years. A logistic, backwards regression analysis was performed to identify predictors for mortality within each ISS groups.ResultsIn total, 10,901 patients were included. The mean age was comparable between the ISS groups (80.48 ± 6.8 vs. 80.54 ± 6.6 years). The main trauma mechanisms in both the ISS 16–24 and ISS ≥ 25 were low energy falls and bicycle accidents. The head and thorax were the most frequently injured body regions, with a significantly higher proportion of severe head injuries in the ISS ≥ 25 group (32.6% vs. 73.4%). Mortality rates increased significantly with higher injury severity (13.9% vs. 48.9%) and advancing age (22.6% vs. 32.4% vs. 35.8%). The most significant predictors of mortality in the ISS 16–24 group were an increase in ASA score and a GCS 3–8 at arrival (OR for GCS: 7.2 (95% CI 5.7–9.1), AUC 0.76). Similarly, in the ISS ≥ 25 group, an increased ASA score and a GCS 3–8 at arrival were the most significant predictors of mortality as well (OR for GCS: 10.8 (9.1–12.9), AUC 0.79). Although increasing age was also associated with a higher risk of mortality in both ISS groups, its impact was less significant than the aforementioned variables.ConclusionSevere injuries in older patients are predominantly caused by low energy falls and bicycle accidents, leading to high mortality rates. A low GCS at arrival and high ASA scores are most strongly associated with an increased risk for mortality. Notably, despite the prevalence of severe injuries among the oldest patients, the proportion of intensive care unit admissions decreases markedly with age. This raises the question what feasible care for these often frail patients should comprise of and where this care should be provided, especially for those with severe pre-existent comorbidities.Level of evidence and study typeLevel III, prognostic/epidemiological.

Uric acid to albumin ratio is a novel predictive marker for all-cause and cardiovascular death in diabetic patients: a prospective cohort study

BackgroundDiabetes is one of the leading causes of death with an increasing prevalence worldwide. Diabetes-related premature mortality is largely preventable and reversible if identified and managed early. Accordingly, we intend to investigate the predictive value of uric acid to albumin ratio (UAR) for all-cause and cardiovascular death in diabetic patients.MethodsUnivariate and multivariate Cox regression analyses were performed to identify risk factors for all-cause death of diabetic patients. The receiver operating characteristic (ROC) curves and nomogram model were used to evaluate the predictive ability of variables. Kaplan-Meier survival analysis was used to display the progression risks of diabetic patients.ResultsA total of 804 diabetic patients were enrolled in the study. During the 5-year follow-up, all-cause death was found in 80 participants (9.95%) and cardiovascular death was found in 24 participants (2.99%). Age, UAR, and hsCRP were independent risk factors for all-cause death in diabetic patients after adjusting for potential confounding factors. Age and UAR had good predictive value for 1-, 3-, and 5-year all-cause death in diabetic patients, and the combination of UAR and age had the highest predictive value. An easy and intuitive prognostic nomogram model with good predictive accuracy was constructed based on age and UAR. Patients in higher quantiles of age and UAR had more rapid progression to all-cause death and higher mortality risk than patients in the lower quantiles. UAR also had good predictive value for cardiovascular death in diabetic patients.ConclusionsUAR may be a simple, cost-effective, and reliable predictive marker for all-cause and cardiovascular death in U.S. diabetic patients. The clinical utility of UAR and nomogram based on age and UAR can help physicians identify individuals at higher risk and therefore promote prevention strategies.

High mortality among elderly with surgical treated femoral fracture in comparison to other surgical treated lower extremity fractures. A population-based register study from the Danish National Patient Registry.

Proximal femoral fractures has been associated with high mortality risk, while little is known about more distal lower extremity fractures. The aim was to report 30- and 365-days mortality in surgically treated lower extremity fractures in individuals above 65 years. We extracted data from the Danish National Patient Register on all surgically treated lower extremity fracture in the period 1998-2017. The primary outcome was mortality reported by fracture site defined by ICD-10 codes (femur S72*, tibia S82*, foot/ankle S92*S825-8). The secondary outcomes were mortality divided on sex, age groups (5-year span), and comorbidity. This study was conducted using descriptive statistics. We identified 182,013 operatively treated lower extremity fractures of which 73 % occurred in females. The 30-day mortality was 10 % for patients with femoral fractures, 2 % for tibia and 1 % for foot/ankle. The 30-day mortality were similar in femoral fractures regardless of location in the femur (8-11 %). The 365-day mortality was 29 % for femoral fractures, 8 % for tibia and 6 % for foot/ankle. Men with a femoral fracture had higher mortality (15 % at 30 days, 37 % at 356 days) in comparison to women (8.2 % at 30 days, 26 % at 356 days). For the above 85+ year age group, the fracture location was less important for 365-day mortality. There was an observed high risk of mortality in surgically treated femoral fractures. The mortality risks seems to rapidly decline when the fractures are below the knee.

Machine Learning-based Prediction of Mortality Among Malnourished Patients Hospitalized With Inflammatory Bowel Disease.

Malnourished patients hospitalized with inflammatory bowel disease (IBD) have a high risk of morbidity and mortality. Risk stratification can help identify patients who are most in need of medical and nutritional intervention. This study aimed to develop a machine-learning model that accurately predicts mortality in hospitalized IBD patients with protein-calorie malnutrition (PCM). Hospitalized adults with IBD and PCM were identified in the 2016 to 2019 National Inpatient Sample (NIS). Random Forest Classifier (RFC) and Extreme Gradient Boosting (XGB) models were constructed using a 70% randomly sampled training set from the years 2016 to 2018, tested using the remaining 30% of 2016 to 2018 data, and externally validated using 2019 data. Patient characteristics were evaluated using weighted estimates that accounted for the complex sampling design of the NIS. Among 879,730 malnourished patients hospitalized for IBD, 1930 (0.2%) died. Compared with malnourished patients who survived, those who died were generally older, White, had ulcerative colitis with multiple comorbidities, and admitted on the weekend. The accuracy, precision, sensitivity, and specificity for both models were 0.99, 0.98, 0.99, and 0.99, respectively. The area under the receiver operating characteristic curve was 0.91 for both models. Machine learning models can accurately predict mortality in malnourished patients hospitalized with IBD, while solely relying on readily available clinical data. Further integration of these tools into clinical practice could improve risk stratification of IBD patients with PCM and potentially reduce mortality in this high-risk population by prompting earlier intervention.

Increasing Serious Illness Conversations in Patients at High Risk of One-Year Mortality Using Improvement Science: A Quality Improvement Study.

Background: Serious illness conversation (SIC) in an important skillset for clinicians. A review of mortality meetings from an urban academic hospital highlighted the need for early engagement in SICs and advance care planning (ACP) to align medical treatments with patient-centered outcomes. The aim of this study was to increase SICs and their documentation in patients with low one-year survival probability identified by updated Charlson Comorbidity Index (CCI) scores. Methods: This was a quality improvement study with data collected pre- and post-intervention at a large urban level one trauma center in Virginia, which also serves as a primary teaching hospital to about 400 residents and fellows. Patient chart reviews were completed to assess medical records and hospitalization data. Chi square tests were used to identify statistical significance with the alpha level set at <0.05. Integrated care managers were trained to identify and discuss high CCI scores during interdisciplinary rounds. Providers were encouraged to document SICs with identified patients in extent of care (EOC) notes within the hospital's cloud-based electronic health record known as EPIC. Results: Sixty-two patients with high CCI scores were documented, with 16 (25.81%, p = 0.0001) having EOC notes. Patients with documented EOC notes were significantly more likely to change their focus of care, prompting palliative care (63.04% vs. 50%, p = 0.007) and hospice consults (93.48% vs. 68.75%, p = 0.01), compared to those without. Post-intervention surveys revealed that although 50% of providers conducted SICs, fewer used EOC notes for documentation. Conclusion: This initial intervention suggests that the documentation of SICs increases engagement in ACP, palliative care, hospice consultations, and do not resuscitate decisions.

Value of serum tryptophan in stratified management of 90-day mortality risk in patients with hepatitis B virus-related acute-on-chronic liver failure: a multicenter retrospective study.

To explore the correlation of serum tryptophan level with 90-day mortality risk in patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF). This retrospective study was conducted among 108 patients with HBV-ACLF, whose survival outcomes within 90 days after diagnosis were recorded. The correlation of baseline serum tryptophan levels measured by high-performance liquid chromatography with 90-day mortality of the patients was analyzed, and the predictive value of serum tryptophan for 90-day mortality was explored. Within 90 days after diagnosis, 53 (29.4%) of the patients died and 127 (70.6%) survived. The deceased patients had significantly lower baseline serum tryptophan levels than the survivors (7.31±3.73 pg/mL vs 13.32±7.15 pg/mL, P<0.001). Multivariate analysis suggested that serum tryptophan level was an independent factor correlated with mortality of HBV-ACLF after adjustment for confounding variables. The patients with serum tryptophan levels below the median level (10.14 pg/mL) at admission had significantly higher 90-day mortality risks than those with higher tryptophan levels (43.3% vs 15.6%, HR: 3.157, 95% CI: 1.713-5.817), and the complication by kidney dysfunction further increased the risk to 73.3% as compared with patients with higher serum tryptophan levels with normal kidney function (15.0%; HR: 7.558, 95% CI: 3.369-16.960). Serum tryptophan levels had an area under the receiver operating characteristic curve of 0.771 (95% CI: 0.699-0.844) for predicting 90-day mortality. Serum tryptophan level is closely correlated with the survival outcomes of patients with HBV-ACLF, and a decreased tryptophan level indicates a high 90-day mortality risk, which can be further increased by the complication by kidney dysfunction.