In-hospital Mortality In Women Research Articles

Levels of mannose-binding lectin (MBL) associates with sepsis-related in-hospital mortality in women

BackgroundMannose-binding lectin (MBL) mediates the innate immune response either through direct opsonisation of microorganisms or through activation of the complement system. There are conflicting data whether MBL deficiency leads to increased susceptibility to infections or not. The aim of this study was to determine if low levels of mannose-binding lectin (MBL) predict sepsis development, sepsis severity and outcome from severe sepsis or septic shock.MethodPatients aged 18 years or more with documented sepsis within 24 h after admission to the intensive care unit were included if they had participated in a health survey and donated blood samples prior to the sepsis event. A subset of these patients had stored plasma also from the acute phase. Two matched referents free of known sepsis were selected for each case. Plasma levels MBL were determined in stored samples from health surveys (baseline) and from ICU admission (acute phase). The association between MBL and sepsis, sepsis severity and in-hospital mortality were determined with 1300 ng/mL as cut-off for low levels.ResultsWe identified 148 patients (61.5% women) with a first-time sepsis event 6.5 years (median with IQR 7.7) after participation in a health survey, of which 122 also had samples from the acute septic phase. Both high MBL levels in the acute phase (odds ratio [95% confidence interval]) (2.84 [1.20–6.26]), and an increase in MBL levels from baseline to the acute phase (3.76 [1.21–11.72]) were associated with increased risk for in-hospital death in women, but not in men (0.47 [0.11–2.06]). Baseline MBL levels did not predict future sepsis, sepsis severity or in-hospital mortality.ConclusionsAn increase from baseline to the acute phase as well as high levels in the acute phase associated with an unfavourable outcome in women.

Acute myocardial infarction in the young - National Trend Analysis with gender-based difference in outcomes

IntroductionAlthough acute myocardial infarction (AMI) is a disease predominantly affecting adults >60 years of age, a significant proportion of the young population who have different risk profiles, are also affected. We undertook a retrospective analysis using National Inpatient Sample (NIS) 2010 to 2014 to evaluate gender differences in characteristics, treatments, and outcomes in the younger AMI population. MethodsThe NIS 2010–2014 was used to identify all patient hospitalizations with AMI between 18 to <45 years using ICD-9-CM codes. We demonstrated a gender-based difference of in-hospital all-cause mortality, other complications, and revascularization strategies in the overall AMI population and other subgroups of AMI [anterior wall ST-segment elevation MI (STEMI), and non-anterior wall STEMI and non-STEMI (NSTEMI)]. ResultsA total of 156,018 weighted records of AMI hospitalizations were identified, of which 111,894 were men and 44,124 were women. Young women had a higher prevalence of anemia, chronic lung disease, obesity, peripheral vascular disease, and diabetes. Conversely, young men had a higher prevalence of dyslipidemia, smoking, and alcohol. Among non-traditional risk factors, women had a higher prevalence of depression and rheumatologic/collagen vascular disease. There was no difference in all-cause in-hospital mortality in women compared to men [2.03% vs 1.48%; OR 1.04, CI (0.84–1.29); P = .68], including in subgroup analysis of NSTEMI, anterior wall STEMI, and non-anterior wall STEMI. Women with AMI were less likely to undergo percutaneous coronary intervention [47.13% vs 61.17%; OR 0.66, 95% CI (0.62–0.70; P < .001] and coronary artery bypass grafting [5.6% vs 6.0%; OR 0.73, 95% CI 0.64–0.83; P < .001] compared to men. Women were also less likely to undergo percutaneous coronary intervention within 24 h of presentation (38.47% vs 51.42%, P < .001). ConclusionDespite higher baseline comorbidities in young women with AMI, there was no difference in in-hospital mortality in women compared to men. Additional studies are needed to evaluate the impact of gender on clinical presentation, treatment patterns, and outcomes of AMI in young patients.Clinical significance1)No gender difference in all-cause mortality in young with myocardial infarction.2)Women had lower odds of getting revascularization with stent placement.3)Lower odds of stent placement within 24 h of admission, and bypass in women.4)Higher odds of mitral regurgitation and complete heart block in young women.

Risk Factors and Outcomes During a First Acute Myocardial Infarction in Breast Cancer Survivors Compared with Females Without Breast Cancer

PurposeThe purpose of this research was to study the differences in epidemiology and outcomes of a first myocardial infarction in breast cancer survivors compared with the general female population in the United States. MethodsWe retrospectively analyzed the US National Inpatient Sample years 2005-2015 to identify adult women with a first myocardial infarction. In this cohort, breast cancer survivors were identified. Outcomes evaluated were the differences in baseline demographics, comorbidities, and adjusted in-hospital mortality in women with and without breast cancer. ResultsAmong 1,644,032 first myocardial infarction cases in adult women, there were 56,842 (3.5%) breast cancer survivors. Compared with women without breast cancer, breast cancer survivors were 6 years older (mean age 77 vs 71 years, P < .001), had significantly higher prevalence of dyslipidemia and hypertension, and lower prevalence of obesity, diabetes mellitus, and smoking. Breast cancer survivors were more likely to have a non-ST segment elevation acute myocardial infarction and less likely to receive mechanical revascularization. In-hospital mortality was lower in breast cancer survivors (7.1%) compared with those without (7.9%, P < .001), findings that persisted after risk adjustment (odds ratio 0.89; 95% CI, 0.82-0.94). ConclusionsBreast cancer survivors had a first acute myocardial infarction at an older age and had small but favorable differences in cardiovascular disease risk factors and outcomes compared with women without breast cancer. The favorable impact of health education, preventative medical care, greater motivation for a healthier lifestyle, and participation in cancer survivorship programs on these seemingly paradoxical findings in breast cancer survivors should be further explored.

Routine use of bilateral internal thoracic artery grafting in women does not increase in-hospital mortality and could improve long-term survival

BackgroundBilateral internal thoracic artery (BITA) grafting is underused in women. MethodsOutcomes of 798 consecutive women with multivessel coronary disease who underwent isolated coronary surgery (1999–2016) using BITA (n=530, 66.4%) or single internal thoracic artery (SITA) grafting (n=268, 33.6%) were reviewed retrospectively. Differences between BITA and SITA cohort were adjusted by propensity score matching. For both series, late survival was estimated with the Kaplan-Meier method. ResultsOne-to-one propensity score matching resulted in 247 BITA/SITA pairs with similar baseline characteristics and risk profile. According to the propensity matching, BITA grafting was associated with a trend towards reduced in-hospital mortality (3.2% vs. 5.7%, p=0.19). However, BITA women had an increased chest tube output (p=0.0076) as well as higher rates of any (13% vs. 5.3%, p=0.003) and deep sternal wound infections (9.3% vs. 4.9%, p=0.054), this translating in a longer in-hospital stay (10 vs. 9days, p=0.029). Test for interaction showed that body mass index >30kg/m2 and extracardiac arteriopathy were associated with a higher risk of deep sternal wound infection in BITA than in SITA women (23.4% vs. 13.7%, p<0.001 and 23.9% vs. 3.4%, p=0.001, respectively). Freedom from all-cause death and cardiac or cerebrovascular death were improved in BITA cohort, even though the differences were not quite significant (p=0.16 and 0.076, respectively). ConclusionsWhen routinely performed, BITA grafting does not increase in-hospital mortality in women and could improve long-term survival. However, its use should be avoided in obese women with extracardiac arteriopathy because of increased risk of deep sternal wound infection.

Gender Differences in Presentation, Treatment, and In-Hospital Outcome of Patients Admitted With Heart Failure Complicated by Atrial Fibrillation (from the Get With the Guidelines—Heart Failure [GWTG-HF] Registry)

Almost 25% of patients with heart failure (HF) have coexisting atrial fibrillation (AF), the latter of which may increase morbidity and mortality. Despite the high prevalence of HF with concomitant AF, this subgroup of patients remains understudied. This study examines gender differences in presentation, treatment and in-hospital outcome of patients with HF and AF. The Get With the Guidelines-Heart Failure (GWTG-HF) database enrolled 6,496 patients with HF who presented to Cooper University Hospital from 2005 to 2012. Twenty-four percent (1,561 patients) had concomitant AF. Pearson chi-square tests and the Student T-tests were used to compare patient characteristics by gender. Multivariate logistic regression was used to predict in-hospital mortality. Six hundred sixty-nine (42.8%) patients with HF and AF were women. Women were older (p <0.001), had a higher ejection fraction (p <0.001), had systolic hypertension (p <0.001), and were more likely to have health insurance (p <0.001). Despite a higher CHADS2 score in women (p = 0.007), there was no gender difference in percent of anticoagulation medications prescribed before admission. Women were less likely to present with dizziness, lightheadedness, or syncope, and were more likely to be compliant with medications and diet recommendations before admission. Despite differences in presentation, co-morbidities, and therapy, in-hospital mortality was similar between men and women. Decreased appetite or early satiety predicted in-hospital mortality in women, whereas age, chest pain on admission, and decreased appetite or early satiety predicted in-hospital mortality in men. In conclusion, women presenting with HF complicated by AF clinically differ from men, but despite these differences, both groups shared similar symptom presentation and in-hospital mortality rates.

Risk prediction model for in-hospital mortality in women with ST-elevation myocardial infarction: A machine learning approach

BackgroundStudies had shown that mortality due to ST-elevation myocardial infarction (STEMI) is higher in women compared with men. The purpose of this study is to develop and validate prediction models for all-cause in-hospital mortality in women admitted with STEMI using logistic regression and random forest, and to compare the performance and validity of the different models. MethodsData from the National Inpatient Sample (NIS) data years 2011–2013 were used to identify women admitted with STEMI. The main outcome was all-cause in-hospital mortality. Patients were divided into development and validation cohorts, and trained models were internally validated using 20% of the 2012 data, and externally validated using 2011 and 2013 NIS data. ResultsThree main models were developed and compared; multivariate logistic regression, full and reduced random forest models. In the multivariate logistic regression, 11 variables were included in the final model based on backward elimination. The full random forest model contained 32 variables, and the reduced model contained 17 variables selected based on individual variable importance. In the internal validation cohort, the C-index was 0.84, 0.81, and 0.80 for the multivariate logistic regression, full, and reduced random forest models, respectively. The models showed good stability in the external validation cohorts with a C-index for the logistic regression, full, and reduced random forest models of 0.84, 0.85, and 0.81 for year 2011, and 0.82, 0.81, and 0.81 for year 2013, respectively. ConclusionsRandom forest was comparable to logistic regression in predicting in-hospital mortality in women with STEMI, and can be a useful and accurate tool in clinical practice.

Sex-related differences in the risk factors for in-hospital mortality and outcomes of ischemic stroke patients in rural areas of Taiwan

Background and purposeSex-related differences in the clinical presentation and outcomes of stroke patients are issues that have attracted increased interest from the scientific community. The present study aimed to investigate sex-related differences in the risk factors for in-hospital mortality and outcome in ischemic stroke patients.MethodsA total of 4278 acute ischemic stroke patients admitted to a stroke unit between January 1, 2007 and December 31, 2014 were included in the study. We considered demographic characteristics, clinical characteristics, co-morbidities, and complications, among others, as factors that may affect clinical presentation and in-hospital mortality. Good and poor outcomes were defined as modified Ranking Score (mRS)≦2 and mRS>2. Neurological deterioration (ND) was defined as an increase of National Institutes of Health Stroke Score (NIHSS) ≥ 4 points. Hemorrhagic transformation (HT) was defined as signs of hemorrhage in cranial CT or MRI scans. Transtentorial herniation was defined by brain edema, as seen in cranial CT or MRI scans, associated with the onset of acute unilateral or bilateral papillary dilation, loss of reactivity to light, and decline of ≥ 2 points in the Glasgow coma scale score.ResultsOf 4278 ischemic stroke patients (women 1757, 41.1%), 269 (6.3%) received thrombolytic therapy. The in hospital mortality rate was 3.35% (139/4278) [4.45% (80/1757) for women and 2.34% (59/2521) for men, p < 0.01]. At discharge, 41.2% (1761/4278) of the patients showed good outcomes [35.4% (622/1757) for women and 45.2% (1139/2521) for men]. Six months after stroke, 56.1% (1813/3231) showed good outcomes [47.4% (629/1328) for women and 62.2% (1184/1903) for men, p < 0.01]. Atrial fibrillation (AF), diabetes mellitus, stroke history, and old age were factors contributing to poor outcomes in men and women. Hypertension was associated with poor outcomes in women but not in men in comparison with patients without hypertension. Stroke severity and increased intracranial pressure were associated with increased in-hospital mortality in men and women. AF was associated with increased in-hospital mortality in women but not in men compared with patients without AF.ConclusionThe in-hospital mortality rate was not significantly different between women and men. Functional outcomes at discharge and six months after stroke were poorer in women than in men. Hypertension is an independent factor causing poorer outcomes in women than in men. AF is an independent factor affecting sex differences in hospital mortality in women.

P4420Differential impact of cigarette smoking on in-hospital mortality in women compared with men among patients with acute myocardial infarction

P4420Differential impact of cigarette smoking on in-hospital mortality in women compared with men among patients with acute myocardial infarction

Association of ventricular arrhythmia and in-hospital mortality in stroke patients in Florida: A nonconcurrent prospective study.

Stroke remains one of the leading causes of death in the United States. Current evidence identified electrocardiographic abnormalities and cardiac arrhythmias in 50% of patients with an acute stroke. The purpose of this study was to assess whether the presence of ventricular arrhythmia (VA) in adult patients hospitalized in Florida with acute stroke increased the risk of in-hospital mortality.Secondary data analysis of 215,150 patients with ischemic and hemorrhagic stroke hospitalized in the state of Florida collected by the Florida Agency for Healthcare Administration from 2008 to 2012. The main outcome for this study was in-hospital mortality. The main exposure of this study was defined as the presence of VA. VA included the ICD-9 CM codes: paroxysmal ventricular tachycardia (427.1), ventricular fibrillation (427.41), ventricular flutter (427.42), ventricular fibrillation and flutter (427.4), and other – includes premature ventricular beats, contractions, or systoles (427.69). Differences in demographic and clinical characteristics and hospital outcomes were assessed between patients who developed versus did not develop VA during hospitalization (χ2 and t tests). Binary logistic regression was used to estimate unadjusted and adjusted odds ratios and 95% confidence intervals (CIs) between VA and in-hospital mortality.VA was associated with an increased risk of in-hospital mortality after adjusting for all covariates (odds ratio [OR]: 1.75; 95% CI: 1.6–1.2). There was an increased in-hospital mortality in women compared to men (OR: 1.1; 95% CI: 1.1–1.14), age greater than 85 years (OR: 3.9, 95% CI: 3.5–4.3), African Americans compared to Whites (OR: 1.1; 95% CI: 1.04–1.2), diagnosis of congestive heart failure (OR: 2.1; 95% CI: 2.0–2.3), and atrial arrhythmias (OR: 2.1, 95% CI: 2.0–2.2). Patients with hemorrhagic stroke had increased odds of in-hospital mortality (OR: 9.0; 95% CI: 8.6–9.4) compared to ischemic stroke.Identifying VAs in stroke patients may help in better target at risk populations for closer cardiac monitoring during hospitalization. The impact of implementing methods of quick assessment could potentially reduce VA associated sudden cardiac death.

RISK PREDICTION FOR IN-HOSPITAL MORTALITY IN WOMEN WITH ST-ELEVATION MYOCARDIAL INFARCTION: A MACHINE LEARNING APPROACH

Background: Mortality due to ST-elevation myocardial infarction (STEMI) is higher in women compared with men. We aimed to develop and validate prediction models for in-hospital mortality in women with STEMI. In particular, we compared traditional logistic regression (LR) with a machine learning

Early Invasive Versus Initial Conservative Strategies for Women with Non–ST-Elevation Acute Coronary Syndromes: A Nationwide Analysis

BackgroundStudies conducted largely in men have shown improved outcomes with an early invasive strategy with non–ST-elevation acute coronary syndrome. In contrast, data have been less conclusive in women, with some trials demonstrating potential harm. This study aims to assess whether an early invasive strategy in women is associated with better outcomes in real-world data. MethodsWomen admitted with a primary diagnosis of non–ST-elevation myocardial infarction or unstable angina were identified from the National Inpatient Sample years 2012 and 2013. The incidence of in-hospital mortality in women with non–ST-elevation acute coronary syndrome undergoing an early invasive strategy versus an initial conservative strategy was compared using a propensity score–matched analysis. ResultsAmong 372,080 women with non–ST-elevation acute coronary syndrome, 153,680 (41.3%) were managed with an early invasive strategy and 218,400 (58.7%) were managed with an initial conservative strategy. Propensity score–matched 19,965 women were treated with an early invasive strategy, and 20,009 women were treated with an initial conservative strategy. The risk of in-hospital mortality was lower with an early invasive strategy (2.1% vs 3.8%; odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49-0.62). This benefit was noted in women presenting with non–ST-segment elevation myocardial infarction (OR, 0.52; 95% CI, 0.46-0.58) and was not observed in women with unstable angina (OR, 5.14; 95% CI, 0.47-56.9), Pinteraction = .06. A propensity-adjusted analysis yielded similar results (OR, 0.51; 95% CI, 0.45-0.57). ConclusionsIn this large contemporary observational analysis of women with non–ST-elevation acute coronary syndrome, an early invasive strategy was associated with lower in-hospital mortality. This benefit was observed in women presenting with non–ST-elevation myocardial infarction but not with unstable angina. These findings provide evidence supporting the guideline recommendations for an early invasive strategy in women with non–ST-elevation acute coronary syndrome and high-risk features (eg, troponin positive).

Longer pre-hospital delays and higher mortality in women with STEMI: the e-MUST Registry.

The mortality rate in patients with STEMI is higher in women than in men. This higher mortality rate is partly accounted for by certain known characteristics inherent in the female population (age, diabetes). Using data from the e-MUST registry on STEMI patients in the Greater Paris area, we assessed the differences between men and women treated with reperfusion strategies. Patients presenting within 24 hours of pain onset between 2006 and 2010 were included in the study. The male and female subpopulations were compared according to their baseline characteristics, their management delays and their early outcomes. Five thousand eight hundred and forty males (78.9%) and 1,557 females (21.1%) were included in the study. In-hospital mortality was significantly higher in women than in men, 143 (9.4%) vs. 254 (4.4%), p<0.0001, with a longer time to treatment initiation, symptoms to call (2.7±3.6 vs. 2.2±3.4 hours, p<0.0001), symptoms to first medical contact (FMC) (3.1±3.7 vs. 2.6±3.4 hours, p<0.0001), and call to FMC (25.6±23.5 vs. 23.6±18.3 min, p=0.02). After adjustment for clinical factors, severity criteria, myocardial infarction (MI) location and delays, mortality remained higher in women than in men with an odds ratio of 1.40 [1.06-1.84], p=0.017. We demonstrated longer pre-hospital delays and higher in-hospital mortality in women. The increase in the time to treatment alone does not completely explain the persistent increase in mortality. Further studies, public awareness programmes and physician education are necessary to reduce delays and improve the prognosis of STEMI in women.

Gender Difference in Presentation, Management and Inhospital Mortality in St Elevation Myocardial Infarction in a Tertiary Cardiac Center

Background: Studies have shown that women are less likely to receive reperfusion therapy and have higher inhospital death in ST Elevation myocardial infarction(STEMI) as compared to men. This study aims to examine presentation, acute therapy, and inhopital mortality in women admitted with diagnosis of acute STEMI in a tertiary care cardiac center.Methods: Patients admitted with diagnosis of acute STEMI from 1st June 2013 to 31st May 2015 were included in the study. Gender difference in baseline characterstics, comorbidities, prehospital delay, type of treatment received and inhospital death were measured. Variables that might have impact on inhospital deaths were analyzed on multivariate regression analysis to find out other variables adjusted effect of gender on inhospital deaths.Results : Majority of the patients were men (Men 69% vs women 31%). Women were older, were more likely to be diabetics and smoker. Prehospital delay was more in women ( women 22 hours vs men 12 hours, p value-0.02).About 46% of both men and women received reperfusion therapy. There was more inhospital mortality in women (women 13.5% vs men 6.5%, p value – 0.02). Women had more inhospital mortality even after adjustment with other covariables (OR = 3.110, 95% CI = 1.411-6.902, p value-0.005).Conclusion : Women were more likely to be elderly, diabetics, smoker and presented later than men after symptoms onset. Women received reperfusion therapy similar to that of men. After adjustment with other covariates, women remained a significant variable to inhospital death.Journal of Nobel College of Medicine Vol.4(1) 2015: 6-11

Incidence, surgical procedures, and outcomes of hip fracture among elderly type 2 diabetic and non-diabetic patients in Spain (2004-2013).

Hip fracture is a serious public health problem. We used Spanish hospital discharge data to examine trends in 2004-2013 in the incidence of hip fracture among elderly patients. We found that hip fracture incidence is higher in subjects with than without diabetes and is much higher among women than men. This study aimed to describe trends in the incidence of hip fracture hospitalizations, use of surgical procedures, and hospital outcomes among elderly patients with and without type 2 diabetes mellitus (T2DM) in Spain, 2004-2013. We selected all patients with a discharge primary diagnosis of hip fracture using the Spanish national hospital discharge database. Discharges were grouped by diabetes status: Incidences were calculated overall and stratified by diabetes status and year. We analyzed surgical procedures, length of hospital stay (LOHS), and in-hospital mortality (IHM). Multivariate analysis was adjusted by age, year, comorbidity, and in-hospital complications (IHC). From 2004 to 2013, 432,760 discharges with hip fracture were identified (21.3% suffered T2DM). Incidence among diabetic men and women increased until year 2010 and then remained stable. Diabetic women have three times higher incidence than diabetic men. Incidences and IHC were higher among patients with diabetes beside sex. The proportion of patients that underwent internal fixation increased for all groups of patients and the arthroplasty repair decreased. After multivariate analysis, IHM has improved over the study period for all patients. Suffering diabetes was associated to higher IHM in women (odds ratio (OR) 1.12; 95% confidence interval (CI) 1.07-1.17). Hip fracture incidence is higher in subjects with than without diabetes and is much higher among women than men. In diabetic patients, incidence rates increased initially but have leveled from 2010 onwards. For all groups, the use of internal fixation has increased overtime and IHM and LOHS have decreased from 2004 to 2013.

Gender Disparities in Outcomes and Resource Utilization for Acute Pulmonary Embolism Hospitalizations in the United States

Current data regarding gender disparities in outcomes after acute pulmonary embolism (PE) are limited and controversial. We sought to assess the gender-specific rates and trends in treatment, outcomes, and complications after acute PE. We used the 2003 to 2011 Nationwide Inpatient Sample database for this analysis. All hospital admissions with a principal diagnosis of acute PE were identified using the International Classification of Diseases, Ninth Edition, codes. Inhospital mortality and discharge to nursing facility were co-primary outcomes of our study. Secondary outcomes included shock, transfusion of blood products, utilization of thrombolysis, inferior vena cava filter placement, and cost of hospitalization. Over a 9-year period, a total of 276,484 discharges with acute PE were identified. Compared with men, there was significantly higher inhospital mortality in women admitted with acute PE (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.03 to 1.15). In addition, there was a significantly higher need for discharge to nursing facility among women compared with men (OR 1.30, 95% CI 1.27 to 1.34). Besides this, women experienced a higher need for transfusion (OR 1.38, 95% CI 1.33 to 1.44) and occurrence of shock (OR 1.10, 95% CI 1.01 to 1.18) during hospitalization. Furthermore, there was a significantly lower utilization of vena cava filters (OR 0.86, 95% CI 0.84 to 0.89) in women compared with men. Among patients in shock who were eligible for thrombolysis (age <75years, no previous stroke, no bleeding on presentation, and not pregnant), the utilization of thrombolysis was similar between men and women (OR 1.19, 95% CI 0.93 to 1.53). Lastly, the cost of hospitalization after acute PE was significantly higher in men than women (adjusted mean difference $425, 95% CI $304 to $546). In conclusion, among patients admitted with acute PE, women tend to have more adverse outcomes and higher incidence of complications compared with men.

In‐Hospital Hip Fracture Mortality Trends in Older Adults: The National Hospital Discharge Survey, 1988–2007

To the Editor: Older adults have a 5- to 8 times greater risk of all-cause mortality during the first 3 months after hip fracture, with almost half of the mortality risk during the first year attributed to in-hospital deaths.1, 2Although hip fracture rates have decreased in older adults in the United States since the mid-1990s,3 there is little information about nationwide trends in in-hospital hip fracture mortality in older adults. A recent hip fracture–related mortality study in Texas demonstrated that in-hospital hip fracture–related deaths decreased 1.8% per year, from 75.4% in 1990 to 60.1% in 2007.4 The aim of the current study was to examine nationwide trends in in-hospital hip fracture mortality in older adults between 1988 and 2007. The National Hospital Discharge Survey (NHDS) database was used to generate unbiased national estimates of hip fracture hospitalizations. Only general hospitals and hospitals with an average length of stay of fewer than 30 days for all patients are included in the survey.5 Hospitalizations for hip fractures as the primary diagnosis were defined according to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 820.xx to 820.9. The in-hospital case-fatality rate was calculated as the proportion of hospital deaths that occurred within 30 days of hip fracture hospitalization. Trends in in-hospital hip fracture mortality according to selected characteristics were examined across 5-year periods using the Cochrane-Armitage test. The Charlson Comorbidity Index (CCI) was used to evaluate trends in in-hospital hip fracture mortality according to comorbidities.6 For an estimated 5.3 million hip fracture hospitalizations in the United States between 1988 and 2007, in-hospital hip fracture mortality was 4.9% (95% confidence interval (CI) = 4.2–5.7) in men and 2.6% (95% CI = 2.3–2.9) in women. In individuals with hip fracture who died in the hospital, cardiac arrhythmia, congestive heart failure (CHF), acute myocardial infarction (MI), chronic obstructive pulmonary disease (COPD), and electrolyte disorders were the leading listed secondary diagnoses. In general, in-hospital hip fracture mortality was higher in men and increased gradually with advancing age and higher comorbidity scores. As shown in Table 1, in-hospital hip fracture mortality decreased significantly over time in men, those aged 85 and older, blacks, older adults hospitalized in the northeastern and southern regions of the country, and those with a CCI score of 2 or greater. In-hospital mortality in women remained steady over the study period. The results of this study indicate that in-hospital hip fracture mortality decreased in older adults in the United States between 1988 and 2007. The downward trend in in-hospital hip fracture mortality was predominantly attributed to a decrease in deaths of the oldest old, men, blacks, and those with higher CCI scores. The present findings are similar to those of a hip fracture–related mortality study in Texas reporting downward trends in the proportion of hip fracture deaths that occurred in the hospital, in men, and in those aged 85 and older between 1990 and 2007.4 Likewise, nationwide studies from France and England have described a decrease in in-hospital hip fracture mortality for both sexes between 2002 and 2008 and between 1998 and 2009, respectively.7, 8 Older age, male sex, and comorbidities are factors reported to be associated with greater risk of in-hospital hip fracture mortality, which are consistent with the present findings.9 The marked sex differences in mortality in individuals with hip fracture have been observed during the first weeks and persist for at least 2 years after the fracture event.10 Moreover, men with hip fracture seem to be prone to acute postoperative complications, which may increase the risk of mortality.10 A previous study also demonstrated that, in 3,981 individuals with hip fracture, the prevalence of postoperative pneumonia, ischemic heart disease, cardiac arrhythmias, and sepsis was significantly higher in men than in women.9 Several limitations must be mentioned in interpreting these results. First, in-hospital hip fracture mortality may be underestimated because the NHDS does not include federal, military, or Veteran Affairs hospitals. Second, the NHDS does not collect data about other reported risk factors associated with in-hospital hip fracture mortality such as delay in surgery, early mobilization, place of residence, and dependency in activities of daily living. Third, the NHDS staff did not clinically verify the discharge ICD-9-CM codes. Despite these limitations, the present study found nationwide temporal trends in in-hospital hip fracture mortality in older adults. The downward trend in in-hospital hip fracture mortality seen during the study period was predominantly attributed to better survival among the oldest old, men, and those with a high comorbidity burden. Conflict of Interest: The author reports no conflict of interest. Author Contribution: Carlos H. Orces is responsible for the entire letter. Sponsor's Role: None.

Gender inequality in the clinical outcomes of equally treated acute coronary syndrome patients in Saudi Arabia

BACKGROUND AND OBJECTIVESGender associations with acute coronary syndrome (ACS), remain inconsistent. Gender-specific data in the Saudi Project for Assessment of Coronary Events registry, launched in December 2005 and currently with 17 participating hospitals, were explored.DESIGN AND SETTINGSA prospective multicenter study of patient with ACS in secondary and tertiary care centers in Saudi Arabia were included in this analysis.PATIENTS AND METHODSPatients enrolled from December 2005 until December 2007 included those presented to participating hospitals or transferred from non-registry hospitals. Summarized data were analyzed.RESULTSOf 5061 patients, 1142 (23%) were women. Women were more frequently diagnosed with non ST-segment elevation myocardial infarction (NSTEMI [43%]) than unstable angina (UA [29%]) or ST-segment elevation myocardial infarction (STEMI [29%]). More men had STEMI (42%) than NSTEMI (37%) or UA (22%). Men were younger than women (57 vs 63 years) who had more diabetes, hypertension, and hyperlipidemia. More men had a history of coronary artery disease. More women received angiotensin receptor blockers (ARB) and fewer had percutaneous coronary intervention (PCI). Gender differences in the subset of STEMI patients were similar to those in the entire cohort. However, gender differences in the subset of STEMI showed fewer women given β-blockers, and an insignificant PCI difference between genders. Thrombolysis rates between genders were similar. Overall, in-hospital mortality was significantly worse for women and, by ACS type, was significantly greater in women for STEMI and NSTEMI. However, after age adjustment there was no difference in mortality between men and women in patients with NSTEMI. The multivariate-adjusted (age, risk factors, treatments, door-to-needle time) STEMI gender mortality difference was not significant (OR=2.0, CI: 0.7–5.5; P=.14).CONCLUSIONThese data are similar to other reported data. However, differences exist, and their explanation should be pursued to provide a valuable insight into understanding ACS and improving its management.

Sex Differences in Hospital Mortality in Adults With Congenital Heart Disease: The Impact of Reproductive Health

The study objectives were to analyze sex differences in hospital mortality of adult patients with congenital heart disease (CHD) and to determine the impact of health services associated with pregnancy on outcomes in women. The determinants of sex differences in the demographic distribution of CHD are poorly understood. The Quebec CHD database and the Dutch CONCOR (CONgenital CORvitia) registry were used to identify patients with CHD aged 18 to 65 years who were hospitalized between 1996 and 2005. Regression analyses were used to compare 30-day in-hospital mortality in men versus women and in women aged 18 to 45 years with versus without a pregnancy history, after adjustment for age, CHD severity, comorbidities, and admission diagnosis. Of 39,776 patients followed for 259,741 patient years, 19,099 patients (48%) had 54,195 admissions (62% among women). In those aged 18 to 45 years, 30-day in-hospital mortality was higher in men compared with women with nonpregnancy admissions (adjusted rate ratio: 1.36; 95% confidence interval: 1.02 to 1.81). The adjusted rate ratio for 30-day in-hospital mortality in women with a pregnancy history compared with those without was 0.49 (95% confidence interval: 0.24 to 0.99). A history of pregnancy was not associated with an overall increase in medical encounters. We demonstrated a protective effect of sex on in-hospital mortality in women with CHD of reproductive age that did not correlate with increased medical surveillance. Future studies need to explore other mechanisms to account for our observations. Understanding the determinants of the sex distribution of adults with CHD is important for our ability to predict demographic changes in the population with CHD.

Gender Differences in Acute Coronary Syndrome in Arab Emirati Women—Implications for Clinical Management

Gender differences exist in many aspects of acute coronary syndrome (ACS), including presentation and delay in diagnosis and treatment. The aim of the study was to evaluate gender-related differences in ACS patients in the United Arab Emirates (UAE). We analyzed a subset (n = 1697) of the Gulf Registry of Acute Coronary Events (Gulf RACE) data collected in 2007 of patients with ACS from 18 UAE hospitals. Women were significantly older (mean age: 64.0 ± 12.4 years for females and 50.9 ± 10.6 years for males, P < .001), more often had cardiac risk factors and were significantly less treated with β-blockers and reperfusion therapy. The adjusted mortality rate of women was 4.6% versus 1.2% in men (P < .001). Heart failure was higher in females compared with men (24.6% vs 12.5%; P < .001). Reasons for the high in-hospital mortality in women need to be investigated further.

Abstract P188: Quality of Care and Outcomes in Women Hospitalized for Heart Failure

Background: Although women account for a significant portion of the heart failure (HF) hospitalizations, data on the quality of care and in-hospital mortality in women are scarce. Methods: We analyzed 99,841 HF admissions from 1/05 to 6/09 at 248 hospitals participating in Get With The Guidelines-HF. Using multivariable logistic or linear regression we assessed the association of sex with HF performance measures [discharge instructions, left ventricular function assessment, ACEI/ARB in LVSD, smoking cessation counseling], length of stay, and in-hospital mortality. Results: Women accounted for 50% of HF admissions; they were older (mean age 74 ± 14 vs. 69 ± 14 yrs), more likely to have hypertension (77% vs. 72%), and less likely to have CAD (43% vs. 53%) or renal insufficiency (18% vs. 23%) than men (all p&lt; 0.01). The presenting symptoms were similar to men, but women had higher admission systolic blood pressure (144 ± 31 vs. 137 ± 30 mmHg) and EF (44 ± 17% vs. 34± 16%), both p&lt;0.01. In multivariate analyses, women were less likely than men to have measurement of EF, receive anticoagulation for atrial fibrillation or ICD implant, but as likely to receive instructions, ACEI/ARB, beta-blockers and smoking cessation counseling at discharge (Table). Although the median length or stay was 4 days, women were more likely than men to be hospitalized longer than 4 days (adjusted OR, 1.13; 95% CI, 1.08-1.17) and longer than 7 days (adjusted OR, 1.07; 95% CI, 1.04-1.11). Conclusions: Compared to men, women hospitalized for HF have similar characteristics and clinical presentations, received similar quality of care for most but not all measures, and experienced an increased length of stay. Performance measures and other quality metrics in women compared to men Measure (% of eligible) Women Men Unadjusted OR 95% CI Multivariable adjusted OR * 95% CI Complete set of written instructions at time of discharge 85 87 0.95 0.92-0.97 0.97 0.94-1.01 Documentation of evaluation of left ventricular function 95 96 0.91 0.88-0.94 0.81 0.76-0.86 ACE - I or ARB prescription for LVSD 89 89 1.01 0.94-1.07 1.03 0.96-1.11 Adult smoking cessation counseling 94 94 1.01 0.94-1.09 1.06 0.95-1.19 Beta-blocker prescription for LVSD 92 93 0.89 0.84-0.95 0.94 0.87-1.03 Warfarin at discharge for patients with atrial fibrillation 59 64 0.85 0.81-0.89 0.91 0.86-0.96 ICD in patients with LVEF ≤ 30% (before admission or placed during admission) 32 45 0.61 0.56-0.67 0.65 0.6-0.7 All-or-none measure (100% compliance with all 5 primary measures) 80 79 1.13 1.1-1.16 0.98 0.95-1.01 * Multivariable logistic regression of sex effect on performance measures; adjusted for age, race, body mass index, heart rate, systolic blood pressure, ejection fraction, chronic obstructive pulmonary disease, diabetes, prior heart failure, hypertension, dyslipidemia, prior myocardial infarction, peripheral vascular disease, renal insufficiency, stroke, hospital region, number of hospital beds, academic status of hospital.