Increase In Related Mortality Research Articles

Sex disparities of the effect of the COVID-19 pandemic on mortality among patients living with tuberculosis in the United States.

We aimed to determine the trend of TB-related deaths during the COVID-19 pandemic. TB-related mortality data of decedents aged ≥25 years from 2006 to 2021 were analyzed. Excess deaths were estimated by determining the difference between observed and projected mortality rates during the pandemic. A total of 18,628 TB-related deaths were documented from 2006 to 2021. TB-related age-standardized mortality rates (ASMRs) were 0.51 in 2020 and 0.52 in 2021, corresponding to an excess mortality of 10.22 and 9.19%, respectively. Female patients with TB demonstrated a higher relative increase in mortality (26.33 vs. 2.17% in 2020; 21.48 vs. 3.23% in 2021) when compared to male. Female aged 45-64 years old showed a surge in mortality, with an annual percent change (APC) of -2.2% pre-pandemic to 22.8% (95% CI: -1.7 to 68.7%) during the pandemic, corresponding to excess mortalities of 62.165 and 99.16% in 2020 and 2021, respectively; these excess mortality rates were higher than those observed in the overall female population ages 45-64 years in 2020 (17.53%) and 2021 (33.79%). The steady decline in TB-related mortality in the United States has been reversed by COVID-19. Female with TB were disproportionately affected by the pandemic.

Cardiovascular Toxicities Associated with Bispecific T-Cell Engagers

Background: Bispecific T-cell engagers (BTEs) are a novel class of drugs used to treat hematological malignancies that link endogenous tumor antigens to CD3 on the T-cell receptor, priming circulating T-cells to effectively target tumor cells. Although chimeric antigen receptor T-cell therapies, a closely related class, have been associated with cardiovascular toxicity, little is known about the cardiovascular toxicity of BTEs. As early clinical trials may have been underpowered for the detection of cardiovascular adverse events (CVAEs), we conducted a large-scale post-marketing surveillance study to identify safety signals that may have been missed. Methods: Leveraging the US Food and Drug Administration's Adverse Events Reporting System (FAERS), we identified adverse event (AE) reports in patients who received BTEs from October 2014 to March 2023. Eligible therapies included Blinatumomab (CD3/CD19 bispecific antibody) and Teclistamab (CD3/BCMA bispecific antibody). The primary outcome of the study was the frequency and fatality rates of CVAEs associated with BTEs. CVAEs included bleeding, hypotension or shock, thromboembolic disease, heart failure, conduction abnormalities (including tachyarrhythmia, bradyarrhythmia, QT-prolongation, and premature contractions), myocarditis, pericarditis, sudden death, and vasculitis. Secondary outcomes included the frequency and fatality rates of cytokine release syndrome (CRS), neurotoxicity (seizures, altered mental status [AMS], speech disorders, gait disorders, and tremors), and infections. We used multivariable logistic regression models, adjusting for age, sex, and disease status, to calculate adjusted reporting odds ratios (RORs). RORs represent the likelihood of reporting a given AE with BTEs compared to reporting the same AE with all other drugs in the database. Mortality rates for each AE are also reported. Results: Overall, 1,181 cases were reported to FAERS for BTE-associated AEs. Among these, 148 (12.5%) involved CVAEs. The most common CVAEs (non-exclusive) were bleeding (70 events), hypotension or shock (56 events), thromboembolic disease (37 events), heart failure (23 events), and tachyarrhythmias (11 events). Less common CVAEs included myocarditis (3 events), pericarditis (1 event), sudden death (1 event), and vasculitis (1 event) (Figure 1A). Of these, BTEs as a class were disproportionately associated with shock or hypotension (ROR: 1.37 [95% CI: 1.03 to 1.80]). Blinatumomab was associated with disproportionately high rates of thromboembolic disease (ROR: 1.48 [95% CI: 1.05 to 2.08]), particularly disseminated intravascular coagulation (DIC; ROR: 4.67 [95% CI: 2.85 to 7.63]). Teclistamab was associated with disproportionately high rates of myocarditis (ROR: 35.79 [95% CI: 10.47 to 122.41]), QT prolongation (ROR: 9.85 [95% CI: 1.33 to 73.08]), and sudden death (ROR: 8.62 [95% CI: 1.16 to 63.99]). Compared to non-cardiovascular AEs, CVAEs were associated with a 92% relative increase in mortality (25.9% vs 50.7%; risk ratio: 1.92 [95% CI: 1.53 to 2.42]). Among CVAEs, the highest mortality rates were reported for heart failure (82.4%), myocarditis (66.7%), bleeding (61.5%), shock or hypotension (57.1%), thromboembolic disease (42.3%), and tachyarrhythmias (37.5%) (Figure 1B). Non-cardiovascular AEs such as neurotoxicity (322 events), infection (277 events), and CRS (190 events) were reported more frequently but had lower mortality rates (28.3%, 48.4%, and 40.0% respectively). Blinatumomab was associated with disproportionately high rates of CRS (ROR: 6.54 [95% CI: 5.41 to 7.92]) and neurotoxicity (ROR: 2.94 [95% CI: 2.56 to 3.39]). Neurotoxicity included AMS (ROR: 2.47 [95% CI: 2.01 to 3.04]), seizures (ROR: 2.81 [95% CI: 2.09 to 3.77]), speech disorders (ROR: 5.72 [95% CI: 4.16 to 7.85]), and tremors (ROR: 6.94 [95% CI: 5.15 to 9.34]). Teclistamab was associated with CRS (ROR: 134.35 [95% CI: 74.45 to 242.47]), infections (ROR: 6.83 [95% CI: 4.63 to 10.07]), and neurotoxicity (ROR: 2.75 [95% CI: 1.53 to 4.94]). Conclusion: In the first large-scale post-marketing surveillance study of BTEs, CVAEs were not uncommon and were more likely to be fatal compared to non-CVAE. Heart failure and myocarditis in particular may portend worse outcomes. These safety signals warrant clinical vigilance and further investigation of their mechanisms, optimal surveillance strategies, and treatment options.

Excess All-Cause Mortality in China After Ending the Zero COVID Policy

In China, the implementation of stringent mitigation measures kept COVID-19 incidence and excess mortality low during the first years of the pandemic. However, China's decision to end its dynamic zero COVID policy (a proactive strategy that deploys mass testing and strict quarantine measures to stamp out any outbreak before it can spread) in December 2022 resulted in a surge in COVID-19 incidence and hospitalizations. Despite worldwide attention given to this event, the actual impact of this sudden shift in policy on population mortality has not been empirically estimated. To assess the association of the sudden shift in China's dynamic zero COVID policy with mortality using empirical and syndromic surveillance data. This cohort study analyzed published obituary data from 3 universities in China (2 in Beijing and 1 in Heilongjiang) and search engine data from the Baidu index (BI; weighted frequency of unique searches for a given keyword relative to the total search volume on the Baidu search engine) in each region of China from January 1, 2016, to January 31, 2023. Using an interrupted time-series design, analyses estimated the relative change in mortality among individuals 30 years and older in the universities and the change in BI for mortality-related terms in each region of China from December 2022 to January 2023. Analysis revealed a strong correlation between Baidu searches for mortality-related keywords and actual mortality burden. Using this correlation, the relative increase in mortality in Beijing and Heilongjiang was extrapolated to the rest of China, and region-specific excess mortality was calculated by multiplying the proportional increase in mortality by the number of expected deaths. Data analysis was performed from February 10, 2023, to March 5, 2023. The end to the dynamic zero COVID policy in December 2022 in China. Monthly all-cause mortality by region. An estimated 1.87 million (95% CI, 0.71 million-4.43 million; 1.33 per 1000 population) excess deaths occurred among individuals 30 years and older in China during the first 2 months after the end of the zero COVID policy. Excess deaths predominantly occurred among older individuals and were observed across all provinces in mainland China except Tibet. In this cohort study of the population in China, the sudden lifting of the zero COVID policy was associated with significant increases in all-cause mortality. These findings provide valuable insights for policy makers and public health experts and are important for understanding how the sudden propagation of COVID-19 across a population may be associated with population mortality.

Surviving Sepsis Campaign.

Surviving Sepsis Campaign.

Maternal Mortality in the United States: Trends and Opportunities for Prevention

Maternal mortality is unusually high in the United States compared to other wealthy nations and is characterized by major disparities in race/ethnicity, geography, and socioeconomic factors. Similar to other developed nations, the United States has seen a shift in the underlying causes of pregnancy-related death, with a relative increase in mortality resulting from diseases of the cardiovascular system and preexisting medical conditions. Improved continuity of care aimed at identifying reproductive-age women with preexisting conditions that may heighten the risk of maternal death, preconception management of risk factors for major adverse pregnancy outcomes, and primary care visits within the first year after delivery may offer opportunities to address gaps in medical care contributing to the unacceptable rates of maternal mortality in the United States.

Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID-19 pandemic.

The COVID-19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all-cause mortality during the COVID-19 pandemic, stratified by race and ethnicity. Administrative data from the Veterans Health Administration's Corporate Data Warehouse. We use pre-pandemic data to estimate mortality risk models using five-fold cross-validation and quasi-Poisson regression. Models were stratified by a combined race-ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects. We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016-2020. Veterans were excluded from analyses if they were missing county of residence or race-ethnicity data. Data were then aggregated to the county-year level and stratified by race-ethnicity. Overall, Veterans' mortality rates were 16% above normal during March-December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%-24%), while Native American Veterans had the highest increase (40%, 95% CI 17%-73%). Black Veterans (32%, 95% CI 27%-39%) and Hispanic Veterans (26%, 95% CI 17%-36%) had somewhat lower excess mortality, although these changeswere significantly higher compared to White Veterans. Disparities were smaller than in the general population. Minoritized Veterans experienced higher rates excess of mortality during the COVID-19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long-standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.

Abstract WP135: Impact Of End Stage Renal Disease On Outcomes After Intracerebral Hemorrhage - A Nationwide Analysis

Introduction: Intracerebral hemorrhage (ICH) is a devastating form of stroke that is usually related to chronic hypertension. End stage renal disease (ESRD) requiring renal replacement therapy (RRT) often leads to chronic hypotension, and fluid shifts during dialysis might increase the severity of brain edema. We sought to better understand the impact of ESRD on outcomes after ICH, with a focus of the presence of hypertension or hypotension during hospitalization. Methods: We analyzed the National Inpatient Sample (NIS) database and extracted all cases of ICH (ICD-9 431 or ICD-10 I61) between 2012 and 2017. Patients were classified as requiring RRT (ICD9: V56, V4511, 5856; ICD 10: N186, Z49, Z992) or not. We also noted the presence of codes for hypertension, hypotension, or cerebral herniation. The main outcome measure was death at discharge. Logistic regression was used to calculate odds ratios for mortality with adjustment for ICH severity using a compilation of codes for common complications. Results: 116,812 ICH patients were identified, 3,329 (2.8%) of whom received RRT. Mortality in the non-RRT group was 18% as opposed to 32% in the RRT group (severity adjusted odds ratio 2.1, 95% CI 2.0–2.3, P<0.001). Hypertension was common (67%) and hypotension uncommon (1.7%) in the non-RRT group. Hypotension was associated with much higher mortality (32%) than patients who were hypertensive (18%) or normotensive (23%) in non-RRT patients. By contrast, hypertension in the RRT group occurred much less frequently (21%) and hypotension was slightly more common in the RRT group (2.1%). There was no significant relationship between extremes of blood pressure and mortality in the RRT group. Compared to normotensive patients, herniation occurred more frequently in hypotensive non-RRT patients (28% vs 14%, OR 1.5, 95% CI 1.5–1.7, P<0.001). No relationship between BP and herniation was identified in patients with ESRD. Conclusion: ESRD requiring RRT is associated with a 78% relative increase in mortality after ICH. Whereas hypotension increases the risk of death in ICH patients with preserved renal function, hypotension is much more common in ESRD patients and does not confer the same hazard. Further research is needed to understand how ESRD increases mortality after ICH.

Did the Hospital Readmissions Reduction Program Reduce Readmissions without Hurting Patient Outcomes at High Dual-Proportion Hospitals Prior to Stratification?

Since the implementation of Medicare’s Hospital Readmissions Reduction Program (HRRP), safety-net hospitals have received a disproportionate share of financial penalties for excess readmissions, raising concerns about the fairness of the policy. In response, the HRRP now stratifies hospitals into five quintiles by low-income Medicare (dual Medicare–Medicaid eligible) stay proportion and compares readmission rates within quintiles. To better understand the potential effects of the revised policy, we used difference-in-differences models to compare changes in 30-day readmission, 30-day mortality, and 90th-day community-dwelling rates after discharge of fee-for-service Medicare beneficiaries hospitalized for acute myocardial infarction, heart failure and pneumonia during 2007-2014, for hospitals in the highest (N = 677) and lowest (N = 678) dual-proportion quintiles before and after the original HRRP implementation in fiscal year 2013. We find that high dual-proportion hospitals lowered readmissions for all three conditions, while their patients’ health outcomes remained largely stable. We also find that for heart failure, high dual-proportion hospitals reduced readmissions more than low dual-proportion hospitals, albeit with a relative increase in mortality. Contrary to concerns about fairness, our findings imply that, under the original HRRP, high dual-proportion hospitals improved readmissions performance generally without adverse effects on patients’ health. Whether these gains could be retained under the new policy should be closely monitored.

Prognostic value of natriuretic peptides in heart failure: systematic review and meta-analysis

Risk models, informing optimal long-term medical management, seldom use natriuretic peptides (NP) in ascertaining the absolute risk of outcomes for HF patients. Individual studies evaluating the prognostic value of NPs in HF patients have reported varying effects, arriving at best estimates requires a systematic review. We systematically summarized the best evidence regarding the prognostic value of brain natriuretic peptide (BNP) and NT-proBNP in predicting mortality and hospitalizations in ambulatory heart failure (HF) patients. We searched bibliographic databases from 2005 to 2018 and included studies evaluating the association of BNP or NT-proBNP with mortality or hospitalization using multivariable Cox proportional hazard models. We pooled hazard ratios using random-effect models, explored heterogeneity using pre-specified subgroup analyses, and evaluated the certainty of evidence using the Grading of Recommendations and Development Evaluation framework. We identified 67 eligible studies reporting on 76,178 ambulatory HF patients with a median BNP of 407pg/mL (261-574pg/mL). Moderate to high-quality evidence showed that a 100-pg/mL increase in BNP was associated with a 14% increased hazard of mortality (HR 1.14, 95% CI 1.06-1.22); a 1-log-unit increase was associated with a 51% increased hazard of mortality (HR 1.51, 95% CI 1.41-1.61) and 48% increased hazard of mortality or hospitalization (HR 1.48, 95% CI 1.29-1.69). With moderate to high certainty, we observed a 14% independent relative increase in mortality, translating to a clinically meaningful increase in absolute risk even for low-risk patients. The observed associations may help in developing more accurate risk models that incorporate NPs and accurately prognosticate HF patients.

Causes of mortality in a large population-based cohort of psychiatric patients in Southern Europe

The World Health Organization considers excess morbidity and mortality among people with mental disorders as a high public health priority. This study aims to estimate the mortality risk and causes of death among a large population-based cohort of psychiatric patients.All residents in Veneto (Northeastern Italy) aged between 18 and 84 years with a contact with Community Mental Health Centers in 2008 and a psychiatric diagnosis (n = 54,350) were followed-up for 10 years. Standardized Mortality Ratios (SMR) and excess mortality were computed, with the general regional population as a reference.Mortality was more than doubled (males SMR = 2.4; females SMR = 2.2) and the relative increase in mortality was much larger in young and middle-aged adults (18–44 and 45–64 years) across all diagnostic groups. The most frequent causes were circulatory diseases (27%) and neoplasms (26%). Although the risk was increased by about tenfold, deaths from suicide were limited to 6% and 4% of all decedents in males and females, respectively. Patients with schizophrenia showed a very high risk for mortality for diabetes and cardiovascular disorders. A large excess was found also for respiratory diseases and a two-fold increase for lung cancer in males and breast cancer in females.Although chronic physical disorders are known to be the main causes of mortality in such patients, they receive far less attention than suicide or accidents. Our results suggest that there is still a need to plan actions to prevent excess mortality and to improve the quality of life of patients with mental disorders.

Excess mortality in the first COVID pandemic peak: cross-sectional analyses of the impact of age, sex, ethnicity, household size, and long-term conditions in people of known SARS-CoV-2 status in England.

BackgroundThe SARS-CoV-2 pandemic has passed its first peak in Europe.AimTo describe the mortality in England and its association with SARS-CoV-2 status and other demographic and risk factors.Design and settingCross-sectional analyses of people with known SARS-CoV-2 status in the Oxford RCGP Research and Surveillance Centre (RSC) sentinel network.MethodPseudonymised, coded clinical data were uploaded from volunteer general practice members of this nationally representative network (n = 4 413 734). All-cause mortality was compared with national rates for 2019, using a relative survival model, reporting relative hazard ratios (RHR), and 95% confidence intervals (CI). A multivariable adjusted odds ratios (OR) analysis was conducted for those with known SARS-CoV-2 status (n = 56 628, 1.3%) including multiple imputation and inverse probability analysis, and a complete cases sensitivity analysis.ResultsMortality peaked in week 16. People living in households of ≥9 had a fivefold increase in relative mortality (RHR = 5.1, 95% CI = 4.87 to 5.31, P<0.0001). The ORs of mortality were 8.9 (95% CI = 6.7 to 11.8, P<0.0001) and 9.7 (95% CI = 7.1 to 13.2, P<0.0001) for virologically and clinically diagnosed cases respectively, using people with negative tests as reference. The adjusted mortality for the virologically confirmed group was 18.1% (95% CI = 17.6 to 18.7). Male sex, population density, black ethnicity (compared to white), and people with long-term conditions, including learning disability (OR = 1.96, 95% CI = 1.22 to 3.18, P = 0.0056) had higher odds of mortality.ConclusionThe first SARS-CoV-2 peak in England has been associated with excess mortality. Planning for subsequent peaks needs to better manage risk in males, those of black ethnicity, older people, people with learning disabilities, and people who live in multi-occupancy dwellings.

Excess Mortality and Its Association with SARS-CoV-2 Status During the First Pandemic Peak: Cross-Sectional Analyses of the English Primary Care Surveillance Network

Background: The SARS-CoV-2 pandemic has passed its first peak in many European countries. We describe the mortality peak in England and the association of known SARS-CoV-2 status and other demographic and risk factors with mortality. Methods: Pseudonymised, coded clinical data were uploaded from volunteer primary care providers who were members of a nationally representative sentinel network ((N=4,413,734) including SARS-CoV-2 status data (n=56,628, 1.3%). We compared all-cause mortality with the national rate for 2019, using a relative survival model, reporting relative hazard ratios (RHR) and 95% confidence intervals (CI). We conducted cross-sectional analyses of those with known SARS-CoV-2 status. We used multiple imputation to adjust for missing data and included an inverse probability analysis. We also complete cases analysis; presenting results as odds ratios (OR) with 95%CI. Results: Mortality peaked in week 16 of 2020. People residing in households of 9 or more had a five-fold increase in relative mortality (RHR:5.1,95%CI:4.87-5.31, p<0.0001). The OR of mortality for definite case was 8.9 (95%CI:6.7-11.8, p<0.0001) and for a probable case 9.7 (95%CI:7.1-13.2, p<0.0001), using a negative test as reference. Male gender, population density, black ethnicity (compared to white), and people with long term conditions including learning disability had higher odds of mortality. The adjusted mortality in people with a definite SARS-CoV-2 diagnosis was 18.1% (95CI:17.6-18.7). Discussion: There has been excess mortality in the first SARS-CoV-2 peak in England, planning for subsequent peaks needs to better manage risk in males, black ethnicity, older people, and people with learning disabilities and multi-occupancy dwellings. Funding Statement: CO and JD are funded by Wellcome Trust, which allowed their time to be repurposed for SARS-CoV-2 research. The Oxford RCGP RSC is principally funded by Public Health England. JPS receives funding from the Wellcome Trust/Royal Society via a Sir Henry Dale Fellowship (ref: 211182/Z/18/Z) and an NIHR Oxford Biomedical Research Centre (BRC) Senior Fellowship. BDN is funded by the NIHR. Declaration of Interests: The authors have no competing interests. SdeL is the Director of the Oxford RCGP RSC. Ethics Approval Statement: The Oxford RCGP RSC surveillance system and its work with respect to SARS-CoV-2 are approved by Public Health England’s Caldicott Guardian Committee under Regulation 3 of the Health Service Control Patient Information Regulations 2002. The study was approved by RCGP.

Excess Deaths Attributable to Influenza-Like Illness in the ESRD Population

Morbidity and mortality vary seasonally. Timing and severity of influenza seasons contribute to those patterns, especially among vulnerable populations such as patients with ESRD. However, the extent to which influenza-like illness (ILI), a syndrome comprising a range of potentially serious respiratory tract infections, contributes to mortality in patients with ESRD has not been quantified. We used data from the Centers for Disease Control and Prevention (CDC) Outpatient Influenza-like Illness Surveillance Network and Centers for Medicare and Medicaid Services ESRD death data from 2000 to 2013. After addressing the increasing trend in deaths due to the growing prevalent ESRD population, we calculated quarterly relative mortality compared with average third-quarter (summer) death counts. We used linear regression models to assess the relationship between ILI data and mortality, separately for quarters 4 and 1 for each influenza season, and model parameter estimates to predict seasonal mortality counts and calculate excess ILI-associated deaths. An estimated 1% absolute increase in quarterly ILI was associated with a 1.5% increase in relative mortality for quarter 4 and a 2.0% increase for quarter 1. The average number of annual deaths potentially attributable to ILI was substantial, about 1100 deaths per year. We found an association between community ILI activity and seasonal variation in all-cause mortality in patients with ESRD, with ILI likely contributing to >1000 deaths annually. Surveillance efforts, such as timely reporting to the CDC of ILI activity within dialysis units during influenza season, may help focus attention on high-risk periods for this vulnerable population.

Mortality due to cirrhosis and liver cancer in the United States, 1999-2016: observational study

ObjectiveTo describe liver disease related mortality in the United States during 1999-2016 by age group, sex, race, cause of liver disease, and geographic region.DesignObservational cohort study.SettingDeath certificate data from the...

41 Simultaneous trauma patients in emergency department’s: a difference in mortality?

BackgroundThe presentation of multiple simultaneous trauma patients in an Emergency Department, is likely to place significant stress and strain on trauma care resources. Currently there is limited data available to...

Gait Speed and Operative Mortality in Older Adults Following Cardiac Surgery.

Prediction of operative risk is a critical step in decision making for cardiac surgery. Existing risk models may be improved by integrating a measure of frailty, such as 5-m gait speed, to better capture the heterogeneity of the older adult population. To determine the association of 5-m gait speed with operative mortality and morbidity in older adults undergoing cardiac surgery. A prospective cohort study was conducted from July 1, 2011, to March 31, 2014, at 109 centers participating in the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The 5-m gait speed test was performed in 15 171 patients aged 60 years or older undergoing coronary artery bypass graft, aortic valve surgery, mitral valve surgery, or combined procedures. All-cause mortality during the first 30 days after surgery; secondarily, a composite outcome of mortality or major morbidity during the index hospitalization. Among the cohort of 15 171 patients undergoing cardiac surgery, the median age was 71 years and 4622 were female (30.5%). Compared with patients in the fastest gait speed tertile (>1.00 m/s), operative mortality was increased for those in the middle tertile (0.83-1.00 m/s; odds ratio [OR], 1.77; 95% CI, 1.34-2.34) and slowest tertile (<0.83 m/s; OR, 3.16; 95% CI, 2.31-4.33). After adjusting for the Society of Thoracic Surgeons predicted risk of mortality and the surgical procedure, gait speed remained independently predictive of operative mortality (OR, 1.11 per 0.1-m/s decrease in gait speed; 95% CI, 1.07-1.16). Gait speed was also predictive of the composite outcome of mortality or major morbidity (OR, 1.03 per 0.1-m/s decrease in gait speed; 95% CI, 1.00-1.05). Addition of gait speed to the Society of Thoracic Surgeons predicted risk resulted in a C statistic change of 0.005 and integrated discrimination improvement of 0.003. Gait speed is an independent predictor of adverse outcomes after cardiac surgery, with each 0.1-m/s decrease conferring an 11% relative increase in mortality. Gait speed can be used to refine estimates of operative risk, to support decision-making and, since incremental value is modest when used as a sole criterion for frailty, to screen older adults who could benefit from further assessment.

Intensive Care Unit Admission With Community-Acquired Pneumonia

There has been a dramatic increase in the use of intensive care units (ICUs) over the past 25 years. Greater use of validated measures of illness severity may better inform ICU admission decisions in patients with community-acquired pneumonia. This article examined predictors of ICU admission and hospitalization costs, including the pneumonia severity index (PSI) and CURB-65 (confusion, uremia, respiratory rate, blood pressure, age ≥65 years) scores. The study identified 422 patients hospitalized for community-acquired pneumonia, ascertaining patient characteristics by chart review and extraction of administrative data. Multivariate logistic regression was performed to quantify the association of the PSI, CURB-65 and comorbidities with ICU admission. The predictors of cost were estimated using a generalized linear model. Compared to 194 general medicine patients, certain clinical and radiographic findings were more common among 228 ICU patients. Compared to PSI reference group I/II/III, ICU admission was strongly associated with risk class IV (odds ratio [OR], 3.06; 95% confidence interval [CI], 1.63-5.72) and V (OR, 4.84; CI, 2.44-9.62), and also CURB-65 ≥3 (OR, 2.90; CI, 1.51-5.56). The relative increase in mortality among PSI risk class V (compared to IV) patients was 2.68 times higher in general medicine, compared with the ICU. Among ICU admissions, risk class V was associated with an additional cost of $14,548 (95% CI, $4,232 to $24,864). Illness severity and chronic pulmonary disease are strong predictors of ICU admission. More extensive use of the PSI may optimize site-of-care decisions, thereby minimizing mortality and unnecessary resource utilization.

Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture.

In suspected acute bacterial meningitis (ABM), cerebral computerized tomography (CT) is recommended before lumbar puncture (LP) if mental impairment. Despite guideline emphasis on early treatment, performing CT prior to LP implies a risk of delayed treatment and unfavorable outcome. Therefore, Swedish guidelines were revised in 2009, deleting impaired mental status as a contraindication for LP without prior CT scan. The aim of the present study was to evaluate the guideline revision. The Swedish quality registry for community-acquired ABM was analyzed retrospectively. Door-to-antibiotic time and outcome were compared among patients treated 2005-2009 (n=394) and 2010-2012 (n=318). The effect of different LP-CT sequences was analyzed during 2008-2012. Adequate treatment was started 1.2 hours earlier, and significantly more patients were treated <2 hours from admission 2010-2012 than 2005-2009. Compared with CT before LP, immediate LP resulted in 1.6 hours earlier treatment, significant increase in door-to-antibiotic times of <1 and <2 hours, and a favorable outcome. In 2010-2012, mortality was lower (6.9% vs 11.7%) and the risk of sequelae at follow-up decreased (38% vs 49%) in comparison with 2005-2009. Treatment delay resulted in a significantly increased risk for fatal outcome, with a relative increase in mortality of 12.6% per hour of delay. The deletion of impaired mental status as contraindication for prompt LP and LP without prior CT scan are associated with significantly earlier treatment and a favorable outcome. A revision of current international guidelines should be considered.

Trends in water level and flooding in Dhaka, Bangladesh and their impact on mortality.

Climate change is expected to impact flooding in many highly populated coastal regions, including Dhaka (Bangladesh), which is currently among the fastest growing cities in the world. In the past, high mortality counts have been associated with extreme flood events. We first analyzed daily water levels of the past 100 years in order to detect potential shifts in extremes. A distributed lag non-linear model was then used to examine the connection between water levels and mortality. Results indicate that for the period of 2003–2007, which entails two major flood events in 2004 and 2007, high water levels do not lead to a significant increase in relative mortality, which indicates a good level of adaptation and capacity to cope with flooding. However, following low water levels, an increase in mortality could be found. As our trend analysis of past water levels shows that minimum water levels have decreased during the past 100 years, action should be taken to ensure that the exposed population is also well-adapted to drought.

Mortality related to novel psychoactive substances in Scotland, 2012: An exploratory study

BackgroundThe growth of novel psychoactive substances (NPS) over the last decade, both in terms of availability and consumption, is of increasing public health concern. Despite recent increases in related mortality, the circumstances surrounding and characteristics of individuals involved in NPS deaths at a population level remain relatively unknown. MethodsThe Scottish National Drug Related Death Database (NDRDD) collects a wide-range of data relating to the nature and circumstances of individuals who have died a drug-related death (DRD). We conducted exploratory descriptive analysis of DRDs involving NPS recorded by the NDRDD in 2012. Statistical testing of differences between sub-groups was also conducted where appropriate. ResultsIn 2012, we found 36 DRDs in Scotland to have NPS recorded within post-mortem toxicology. However, in only 23 of these cases were NPS deemed by the reporting pathologist to be implicated in the actual cause of death. The majority of NPS-implicated DRDs involved Benzodiazepine-type drugs (13), mainly Phenazepam (12). The remaining 10 NPS-implicated deaths featured a range of different Stimulant-type drugs. The majority of these NPS-implicated deaths involved males and consumption of more than one drug was recorded by toxicology in all except one case.NPS-implicated deaths involving Benzodiazepine-type NPS drugs appeared to involve older individuals known to be using drugs for a considerable period of time, many of whom had been in prison at some point in their lives. They also typically involved combinations of opioids and benzodiazepines; no stimulant drugs were co-implicated.Deaths where stimulant-type NPS drugs were implicated appeared to be a younger group in comparison, all consuming two or more Stimulant-type drugs in combination. ConclusionThis exploratory study provides an important insight into the circumstances surrounding and characteristics of individuals involved in NPS deaths at a population level. It identifies important issues for policy and practice, not least the prominent role of unlicensed benzodiazepines in drug-related mortality, but also the need for a range of harm reduction strategies to prevent future deaths.