Increase In Short-term Mortality Research Articles

Estimating the mutually adjusted health effects of short- and long-term exposure to PM2.5 on respiratory mortality in a population-based study

Short- and long-term exposure to ambient fine particulate matter (PM2.5) increased respiratory mortality. Previous studies have reported the dependence between short- and long-term effects, but most studies have estimated them independently. In this study, the mutually adjusted effects of PM2.5 exposure on respiratory mortality in Sichuan Province, China, were explored using a mixed quasi-Poisson regression model. After adjustment, the estimated effects on respiratory mortality decreased with both short- and long-term PM2.5 exposure, especially under short-term exposure, by 7.44%. A 10 μg/m3 increase in long-term PM2.5 exposure increased respiratory mortality by 10.42% (95% CI: 7.37%, 13.55%), which was significantly greater than the 1.12% (95% CI: 0.87%, 1.36%) increase in short-term mortality. Females and those under 65 years old suffered from a greater risk when exposed to PM2.5. Greater short-term effects in warm seasons (1.62%; 95% CI: 1.04%, 2.21%) and greater long-term effects in cold seasons (12.99%; 95% CI: 8.22%, 17.33%) were observed. In addition, a greater short-term effect was found using satellite-based PM2.5 concentrations than monitoring-based concentrations. This study indicated that when estimating the effects of short- and long-term PM2.5 exposure, their dependency could not be ignored; otherwise, both effects would be overestimated, especially for short-term effects. A decreasing PM2.5 concentration is beneficial to population health, especially for females and young people.

Emergent Esophagectomy in Patients with Esophageal Malignancy Is Associated with Higher Rates of Perioperative Complications but No Independent Impact on Short-Term Mortality.

Data on perioperative outcomes of emergent versus elective resection in esophageal cancer patients requiring esophagectomy are lacking. We investigated whether emergent resection was associated with increased risks of morbidity and mortality. Data on patients with esophageal malignancy who underwent esophagectomy from 2005 to 2020 were retrospectively analyzed from the American College of Surgeons National Surgical Quality Improvement Program database. Thirty-day complication and mortality rates were compared between emergent esophagectomy (EE) and non-emergent esophagectomy. Logistic regression assessed factors associated with complications and mortality. Of 10,067 patients with malignancy who underwent esophagectomy, 181 (1.8%) had EE, 64% had preoperative systemic inflammatory response syndrome, sepsis, or septic shock, and 44% had bleeding requiring transfusion. The EE group had higher American Society of Anesthesiologists (ASA) class and functional dependency. More transhiatal esophagectomies and diversions were performed in the EE group. After EE, the rates of 30-day mortality (6.1% vs. 2.8%), overall complications (65.2% vs. 44.2%), bleeding, pneumonia, prolonged intubation, and positive margin (17.7% vs. 7.4%) were higher, while that of anastomotic leak was similar. On adjusted logistic regression, older age, lower albumin, higher ASA class, and fragility were associated with increased complications and mortality. McKeown esophagectomy and esophageal diversion were associated with a higher risk of postoperative complications. EE was associated with 30-day postoperative complications (odds ratio, 2.39; 95% confidence interval, 1.66-3.43; p<0.0001). EE was associated with a more than 2-fold increase in complications compared to elective procedures, but no independent increase in short-term mortality. These findings may help guide data-driven critical decision-making for surgery in select cases of complicated esophageal malignancy.

Short-Term and Long-Term Effects of Ischemic Conditioning on Liver Transplantation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Although liver transplantation (LT) is one of the definitive treatments for patients with end-stage liver failure, it inevitably results in ischemic reperfusion injury. It is known that prognosis is improved when temporary ischemic conditioning (IC) is applied to patients with ischemic reperfusion injury. The objective of this meta-analysis was to determine the short-term and long-term effects of IC on the clinical outcomes of LT recipients. Randomized controlled studies on IC in patients with LTs were included. Patients were compared between an IC group and a sham group. Studies were retrieved from PubMed, Embase, and Cochrane Library. The risk of bias was evaluated using RoB 2.0. Mortality, graft function, and major complications were synthesized using RevMan 5.4.1. Among 316 papers, 17 articles (1196 patients) were included. There was an insignificant increase in short-term mortality (risk ratio [RR]: 3.00, 95% CI: 0.32-28.14, P=.34). However, long-term mortality was lower in the IC group than in the sham group, but not significantly (RR: 0.75; 95% CI: 0.47-1.20, P=.23). Short-term graft function (acute graft rejection and primary graft non-function) was not improved by IC. One-year graft loss tended to show better results in the IC group (RR: 0.53, 95% CI: 0.26-1.07, P=.08). Ischemic conditioning did not have a beneficial effect on LT. Although long-term outcomes appear to be better in the IC group than in the sham group, further randomized controlled trials are needed.

Comparison of the clinical outcomes after esophagectomy between intrathoracic anastomosis and cervical anastomosis: a systematic review and meta-analysis

ObjectivesEsophageal cancer is a high-mortality disease. Esophagectomy is the most effective method to treat esophageal cancer, accompanied with a high incidence of post-operation complications. The anastomosis has a close connection to many severe post-operation complications. However, it remains controversial about the choice of intrathoracic anastomosis (IA) or cervical anastomosis (CA). The study was conducted to compare the clinical outcomes between the two approaches.MethodsWe searched databases for both randomized controlled trials (RCTs) and cohort studies comparing post-operation outcomes between IA and CA. Primary outcomes were the incidences of anastomotic leakage and mortality. Secondary outcomes were the incidences of anastomotic stenosis, pneumonia and re-operation.ResultsTwenty studies with a total of 7,479 patients (CA group: n = 3,183; IA group: n = 4296) were included. The results indicated that CA group had a higher incidence of anastomotic leakage than IA group (odds ratio [OR] = 2.05, 95% confidence intervals [CI] = 1.61–2.60, I2 = 53.31%, P < 0.01). Subgroup analyses showed that CA group had higher incidences of type I (OR = 2.19, 95%CI = 1.05–4.57, I2 = 0.00%, P = 0.04) and type II (OR = 2.75, 95%CI = 1.95–3.88, I2 = 1.80%, P < 0.01) anastomotic leakage than IA group. No difference was found in type III anastomotic leakage (OR = 1.23, 95%CI = 0.82–1.86, I2 = 20.92%, P = 0.31). The 90-day mortality (OR = 1.66, 95%CI = 1.11–2.47, I2 = 0.0%, P = 0.01) in IA group were lower than that in CA group. No difference was found in in-hospital mortality (OR = 1.31, 95%CI = 0.91–1.88, I2 = 0.00%, P = 0.15) and 30-day mortality (OR = 1.08, 95%CI = 0.69–1.70, I2 = 0.00%, P = 0.74).ConclusionsIA might be a better anastomotic approach than CA, with a lower incidence of anastomosis leakage and no increase in short-term mortality. Significant heterogeneity and publication bias might limit the reliability of the results. More high-quality studies are needed to verify and update our findings.

Chest Radiography Should Not Be Routinely Performed Prior to Cardiac Catheterization in Patients With ST-elevation Myocardial Infarction

Acute ST-elevation myocardial infarction (STEMI) represents the most devastating form of acute coronary syndrome. Prompt reperfusion, ideally through percutaneous coronary intervention (PCI), optimizes outcomes among patients with STEMI. Delays in percutaneous coronary intervention, as measured by door-to-balloon time, are associated with a significant rise in mortality. Indeed, a recent Cochrane Review estimated that every 30-minute delay in door-to-balloon time results in a 17% relative increase in short-term mortality.

No Increase in Short-Term Mortality Following COVID-19 Vaccination Among Nursing Home Residents

Reports of fatal adverse events following mRNA-based vaccination for COVID-19 in Norwegian nursing home (NH) residents have raised concern regarding vaccine safety in very old and frail persons. A limitation of these reports, however, is the absence of contemporaneous control groups, particularly given the high baseline mortality in this population. Using electronic health records’ data on resident deaths, hospital transfer, vaccination, and daily census from Genesis Healthcare, a large NH provider spanning 24 U.S. states, we compared 7-day mortality and hospitalization rates for vaccinated versus unvaccinated NH residents. Between December 18, 2020 and December 31, 2020, 7006 residents across 118 NHs were vaccinated with the first dose. Mortality and hospital transfer rates within 7 days of vaccination were compared to rates for: (1) unvaccinated residents in the same facility within 7 days of the vaccine clinic (n=4414), and (2) residents in 166 yet-to-be-vaccinated facilities between December 25, 2020 and January 1, 2021 (n=17,076). We excluded residents with a positive SARS-CoV-2 diagnostic test within 20 days prior to their 7-day observation window. Mortality rates per 100,000 residents were lower among vaccinated (587, 95%CI: 431, 798) versus unvaccinated residents within the same facilities (984, 95%CI: 705, 1382), and compared to residents in not-yet-vaccinated facilities (912, 95%CI: 770-1080), with overlapping 95% CIs. Hospital transfers were lower among vaccinated residents than in either comparison group, but with overlapping CIs. Our findings suggest that short term mortality rates appear unrelated to vaccination for COVID-19 in NH residents, and should dispel concerns raised by previous reports.

Differences in clinical and echocardiographic variables and mortality predictors among older patients with pulmonary embolism.

An increase in short-term mortality can be found among older patients with hemodynamically stable acute pulmonary embolism (APE) who have signs of right ventricular (RV) dysfunction. This study was designed to assess whether any difference exists among clinical, laboratory, electrocardiography and echocardiography parameters between older and younger patients diagnosed with APE. The study sample included a total of 635 patients with confirmed APE who were divided into two groups of older (65years and older) and younger (younger than 65years) individuals. Comparisons were performed between these groups in terms of clinical, predisposing factors and laboratory, electrocardiographic and echocardiographic parameters. Analyses of 295 (46.4%) older and 340 (53.6%) younger patients diagnosed with APE were performed. Female sex, Pulmonary Embolism Severity Index score and baseline creatinine levels were higher in the older group. Also, the frequency of atrial fibrillation, RV outflow tract parasternal long-axis proximal diameter, RV end-diastolic diameter (RV-EDD) basal (apical four-chamber) and RV systolic pressure were significantly greater in older patients with APE. A total of 30 (4.7%) deaths were observed during the in-hospital period [21 (7.1%) older vs 9 (2.6%) younger patients; p < 0.01]. In the multivariate logistic regression analysis, age, white blood cell count (WBC), left ventricular ejection fraction (LVEF), RV-EDD basal and tricuspid annular plane systolic excursion (TAPSE) of less than 16mm were found to be independently associated with in-hospital mortality. Older patients might experience greater rates of RV dilatation, RV dysfunction and atrial fibrillation during APE. In addition to age; elevated WBC, low LVEF, increased RV-EDD basal and TAPSE of less than 16mm were independent predictors of mortality among study population.

Association of digoxin therapy with case fatality rate in acute pulmonary embolism

Despite wide usage of digoxin for various diseases in cardiology practice, its benefit is controversial and moreover it had been associated with unfavorable outcomes in some previous studies. The aim of this present study was to demonstrate whether digoxin usage was related with worse outcomes or not in patients with acute pulmonary embolisms. Atotal number of 1215 patients retrospectively enrolled for the study. Basic demographic features, pulmonary embolism severity index (PESI) scores, laboratory parameters and medications of patients who had been diagnosed with acute pulmonary embolism were recorded. Short (30 days) and long-term mortality were reported as the clinical outcomes. Total mortality was 15.4% in the study population and 78 of these subjects died within the first 30days. The frequency of digoxin treatment was 8% and most of these patients were prior users. According to the binary logistic regression analyses the PESI score, right ventricle (RV) diastolic diameter, systolic pulmonary arterial pressure (sPAP), brain natriuretic peptide (BNP), troponin and digoxin therapy (odds ratio, OR: 2.82 95% confidence interval, CI: 1.39-8.31, P = 0.03) were found as independent predictors of short-term mortality. Beside these findings; sPAP, PESI score, RV diastolic diameter and digoxin therapy (hazard ratio, HR: 2.11 95%CI: 1.22-7.31, P = 0.03) were determined as independent predictors of long-term mortality in Cox regression analyses. In subgroup analysis, we determined significantly greater increase in short-term mortality with use of digoxin among patients who had chronic renal disease, among patients under thrombolytic therapy and under high dosage of digoxin therapy and among female patients. Digoxin has been used extensively for decades in the treatment of heart failure and arrhythmias despite some controversies over its benefit. For the first time in the literature, we have demonstrated independent association of digoxin therapy with short-term and long-term mortality in patients with acute pulmonary embolism.

Incidence, risk factors and management of chylothorax post-oesophagectomy for oesophageal carcinoma in an Australian institution

Background: Chylothorax is a potentially fatal complication of oesophagectomy. This study aims to report the incidence, risk factors and management of chylothorax in patients undergoing oesophagectomy for oesophageal carcinoma. Methods: This study reviewed all patients who underwent oesophagectomy from 2009 to 2018 in an Australian institution. Preoperative, perioperative and postoperative data were collected retrospectively and analysed. Results: Chylothorax occurred in 13 out of 144 patients (9%). Pre-operative albumin [odds ratio (OR) 0.836, P=0.027) and the number of lymph nodes resected (OR 1.141, P=0.001) were significant predictors of chylothorax. Chylothorax was associated with increased reoperation rate (77% vs. 11%, P<0.001) and prolonged hospital stay (29 vs. 15 days, P=0.001), but no increase in short term mortality or other complications. Average chyle leak volume of multiple days were significantly different between the conservative and reoperation groups. Using the cut off value of 1,000 mL/day for average chest drain output of 2, 3, 4 and 5 days following the diagnosis of chylothorax, the sensitivity and specificity for reoperation were 75% and 100%, 75% and 80%, 71% and 100%, 86% and 100% respectively. Conclusions: Chylothorax is associated with increased reoperation rate and prolonged hospital stay. Preoperative albumin and the number of harvested lymph nodes were significant predictors of chylothorax following oesophagectomy. This study suggested that averaged chest drain output of multiple days would be a better representation of chyle leak volume than an isolated chest drain output. Reoperation should be considered when the average chyle leak output, of at least 2 consecutive days following the diagnosis of chylothorax, exceeds 1,000 mL/day.

The Epidemiology of HIV in Oman, 1984–2018: A Nationwide Study from the Middle East

We used population-based data on all diagnosed people living with Human Immunodeficiency (HIV) reported to the National AIDS Programme in 1984–2018 to describe the HIV epidemiology in Oman. A total of 3060 Omanis were diagnosed with HIV from 1984 to 2018. The proportions of new infections attributed to sexual contact accounted for 56.3% (376/668) in 1984–1996 compared with 80.7% (630/780) in 2013–2018. Of 1417 patients with a documented CD4 count at the entry of care, 45.3% had a baseline CD4 count of <200 cells/mm3. Compared with heterosexuals, homosexuals had higher rates of advanced HIV disease [42.7% (388/908) vs 50.4% (136/270), respectively]. Rates of advanced disease and death within a year of HIV diagnosis rose consistently with age at diagnosis. Approximately half (48.8%) of the patients diagnosed in 1984–2018 had died by December 2018. The majority (85.6%; 572/668) of people who were diagnosed in 1984–1997 had died compared with 12.7% (99/780) of those diagnosed in 2013–2018. However, people died more recently had a higher proportion of death within a year of HIV diagnosis [74.7% (74/99) in 2013–2018 compared with 13.8% (79/572) in 1984–1996]. This study shows that the HIV epidemic in Oman is a low-prevalence one. Of concern, a large proportion of new HIV diagnoses continued to present late, which has resulted in a substantial increase in short-term mortality over the past 20 years. Nevertheless, we observed a remarkable decline in overall mortality over time, which may be explained by the improvement in the quality of HIV care in Oman.

Obesity in acute alcoholic hepatitis increases morbidity and mortality.

BackgroundAlcohol and obesity synergise to increase the risk of liver-related mortality. We examined the influence of adiposity on clinical outcomes in alcoholic hepatitis (AH) and the underlying inflammatory crosstalk between adipose tissue (AT) and the liver.MethodsA cohort of 233 patients with AH from the UK and USA provided data to analyse the effects of obesity in AH. Body mass index was corrected for the severity of ascites, termed cBMI. Inflammatory and metabolic profiling was undertaken by proteome analysis of human serum samples. The effect of alcohol on adipose tissue and CXCL11 expression was studied in 3 T3-derived adipocytes and in mice using the high-fat diet-plus-binge ethanol model.FindingsObesity was common amongst patients with AH, seen in 19% of individuals. Obesity (HR 2.22, 95%CI 1.1–4.3, p = .022) and underweight (HR 2.38, 1.00–5.6, p = .049) were independently associated with mortality at 3 months. Proteome analysis demonstrated multiple metabolic and inflammatory factors differentially expressed in obese AH verse lean AH, with CXCL11 being the most elevated factor in obese AH. In vitro analysis of cultured adipocytes and in vivo analysis of mouse models showed that alcohol induced CXCL11 expression in AT, but not in liver.InterpretationObesity is common in AH and associated with a greater than two-fold increase in short-term mortality. Obese AH is associated with a different inflammatory phenotype, with the greatest elevation in CXCL11. These data confirm that adiposity is clinically important in acute alcohol-related liver disease and illustrate the adipose-liver inflammatory axis in AH.FundThis work was supported in part by an EASL Sheila Sherlock Physician Scientist Fellowship. The funder played no role in gathering or analysing data or writing the manuscript. This paper presents independent research supported by the NIHR Birmingham Biomedical Research Centre at the University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Obesity Increases Morbidity and Mortality in Alcoholic Hepatitis

Background: Alcohol and obesity synergise to increase the risk of liver-related mortality. We examined the influence of adiposity on clinical outcomes in alcoholic hepatitis (AH) and the underlying inflammatory crosstalk between adipose tissue (AT) and the liver. Methods: A cohort of patients with AH from the UK and USA provided data to analyse the effects of obesity in AH. Body mass index was corrected for the severity of ascites, termed cBMI. Inflammatory and metabolic profiling was undertaken by proteome analysis of human serum samples. The effect of alcohol on adipose tissue and CXCL11 expression was studied in 3T3-derived adipocytes and in mice using the high-fat diet-plus-binge ethanol model. Findings: Obesity was common amongst patients with AH, seen in 19% of individuals. cBMI correlated with volume AT (r2= 0.623, p<0.001), but not with volume of muscle (r2=0.03, p=0.215). Obesity (HR 2.22, 95%CI 1.1-4.3, p=0.022) and underweight (HR 2.38, 1.00-5.6, p=0.049) were independently associated with mortality at 3 months. Proteome analysis demonstrated multiple metabolic and inflammatory factors differentially expressed in obese AH verse lean AH, with CXCL11 being the most elevated factor in obese AH. In vitro analysis of cultured adipocytes and in vivo analysis of mouse models confirmed that alcohol induces CXCL11 expression in AT but not in liver. Interpretation: Obesity is common in AH and associated with a greater than two-fold increase in short-term mortality. Obese AH is associated with a different inflammatory phenotype, with the greatest elevation in CXCL11. These data confirm that adiposity is clinically important in acute alcohol-related liver disease and illustrate the adipose-liver inflammatory axis in AH. Funding: This work was supported in part by an EASL Sheila Sherlock Physician Scientist Fellowship. The funder played no role in gathering or analysing data or writing the manuscript. Declaration of Interest: No authors have any conflicts of interest to declare. Ethical Approval: The collection of samples was approved by research ethics committee (reference 06/Q27108/11).

Early mobilisation of patients with community-acquired pneumonia reduce length of hospitalisation-a pilot study.

[Purpose] To examine if length of stay was reduced following an early mobilisation programme in patients with community-acquired pneumonia, and secondary, if such a program influenced short-term rehospitalisation and mortality rates. [Participants and Methods] Ninety seven consecutive patients (51% men; over all mean ± SD age 71.9 ± 16.5 years) with community-acquired pneumonia were included in the intervention group, and compared with a historical control group of 97 patients, matching at case level. Early mobilisation was defined as more than 20 minutes out of bed within 24 hours of hospitalisation. [Results] Eighty out of 97 patients in the intervention group were mobilised within 24 hours and length of stay for all patients was reduced with an average of 1.5 (95%CI: −0.2; 3.2) days compared to the control group. There was no significant difference between the two groups according to 30-day rehospitalisation and mortality. [Conclusion] An early mobilisation program seem to reduce the length of stay for patients with community-acquired pneumonia, and without an increase in short-term mortality and re-hospitalisation rates.

Off-hours presentation is associated with short-term mortality but not with long-term mortality in patients with ST-segment elevation myocardial infarction: A meta-analysis.

BackgroundThe association between off-hours presentation and mortality in patients with ST-segment elevation myocardial infarction (STEMI) remains unclear. We performed a meta-analysis to assess the impact of off-hours presentation on short- and long-term mortality among STEMI patients.MethodsWe searched PubMed, EMBASE, and the Cochrane Library from their inception to 10 July 2016. Studies were eligible if they evaluated the relationship of off-hours (weekend and/or night) presentation with short- and/or long-term mortality.ResultsA total of 30 studies with 33 cohorts involving 192,658 STEMI patients were included. Off-hours presentation was associated with short-term mortality (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.02–1.12, P = 0.004) but not with long-term mortality (OR 1.00, 95% CI 0.94–1.07, P = 0.979). No significant heterogeneity was observed. The outcomes remained the same after sensitivity analyses and trim and fill analyses. Subgroup analyses showed that STEMI patients undergoing primary percutaneous coronary intervention do not have a higher risk of short-term mortality (OR 1.061, 95% CI 0.993–1.151). In addition, higher mortality was observed only during hospitalization (OR 1.072, 95% CI 1.022–1.125), not at the 30-day, 1-year or long-term follow-ups.ConclusionsOff-hours presentation was associated with an increase in short-term mortality, but not long-term mortality, among STEMI patients. Clinical approaches to decrease short-term mortality regardless of the time of presentation should be evaluated in future studies.

Kth-order Markov extremal models for assessing heatwave risks

Heatwaves are defined as a set of hot days and nights that cause a marked short-term increase in mortality. Obtaining accurate estimates of the probability of an event lasting many days is important. Previous studies of temporal dependence of extremes have assumed either a first-order Markov model or a particularly strong form of extremal dependence, known as asymptotic dependence. Neither of these assumptions is appropriate for the heatwaves that we observe for our data. A first-order Markov assumption does not capture whether the previous temperature values have been increasing or decreasing and asymptotic dependence does not allow for asymptotic independence, a broad class of extremal dependence exhibited by many processes including all non-trivial Gaussian processes. This paper provides a kth-order Markov model framework that can encompass both asymptotic dependence and asymptotic independence structures. It uses a conditional approach developed for multivariate extremes coupled with copula methods for time series. We provide novel methods for the selection of the order of the Markov process that are based upon only the structure of the extreme events. Under this new framework, the observed daily maximum temperatures at Orleans, in central France, are found to be well modelled by an asymptotically independent third-order extremal Markov model. We estimate extremal quantities, such as the probability of a heatwave event lasting as long as the devastating European 2003 heatwave event. Critically our method enables the first reliable assessment of the sensitivity of such estimates to the choice of the order of the Markov process.

When is heat ‘extreme’? The effect of definition choice on the association between extreme heat and cause-specific morbidity in Sydney, Australia

Introduction: Numerous studies have shown that extreme heat is associated with significant, short-term increases in mortality and morbidity. Despite this, there is no consistent definition used wit...

Is precipitation a predictor of mortality in Bangladesh? A multi-stratified analysis in a South Asian monsoon climate

While numerous studies have assessed the association between temperature and mortality in various locations, few have addressed the relationship between precipitation and mortality. Given the high amounts of rainfall in many tropical monsoon areas and the often seasonally pronounced differences, there might be a potentially strong impact on health outcomes and death. In this study, we investigated the association between precipitation and daily death counts in Bangladesh from 2003 to 2007 using regression models with a quasipoisson distribution adjusting for long-term time and seasonal trends, day of the month, age and perceived temperature. Effects were assessed for all ages, the elderly and by gender. During the dry season a sharp increase in death risk was found at very high precipitation amounts which are most likely to be cyclone-related. This cyclone effect was most pronounced for females at the immediate day with an increase of 18.7% (3.8–35.6%) in non-external cause mortality per mm precipitation above 5mm. At longer lags we found a negative association between precipitation and mortality indicating some kind of dry effect which was more pronounced for the elderly with a mortality increase of 4.4% (2.6–6.2%) per mm decrease in precipitation. During the rainy season, we observed a protective effect of rainfall which was strongest during periods of seasonally high equivalent temperatures with a decrease in mortality of 4.0% (2.3–5.6%) per mm increase in precipitation on the immediate day. The observed associations between precipitation and mortality differed by season, age and gender. Generally, a strong short-term increase in mortality was associated with cyclonic activity during the dry season, while ongoing low rainfall seemed to have an adverse impact at higher lags. During the rainy season, precipitation seemed to mitigate heat effects.

Reduced Red Blood Cell Transfusion in Cardiothoracic Surgery after Implementation of a Novel Clinical Decision Support Tool

Packed red blood cell (PRBC) transfusion can increase short- and long-term adverse outcomes and health care costs. We compared the transfusion practices in cardiothoracic surgery before and after implementation of a novel clinical decision support (CDS) tool. The transfusion CDS tool was implemented within computerized provider order entry of a multi-institutional urban hospital system in September 2012. Data were queried for 12 months pre-intervention and for another 12 months post-intervention to compare transfusion practices for all adult patients having isolated coronary artery bypass grafting (CABG) or isolated surgical aortic valve replacement (SAVR). The total number of patients undergoing either isolated CABG or isolated SAVR was 744 pre-intervention and 765 post-intervention (p= 0.84). There was no significant difference in age (64 ± 11.4 years vs 64.5 ± 11.2 years, p= 0.37) or sex (30.2% vs 32.2% female, p= 0.42) between the 2 groups. The number of postoperative transfusions (374 [50.3%] vs 312 [40.8%], p < 0.001), postoperative PRBC units given (1.59 ± 2.9 vs 1.25 ± 2.5, p= 0.01), pre-transfusion hemoglobin level (8.09 ± 1.5 g/dL vs 7.65 ± 1.4 g/dL, p < 0.001), and incidence of surgical site infection (3.1% vs 1.1%; p= 0.005) were significantly reduced after implementation of the transfusion CDS tool. There were no significant differences in intraoperative transfusions (206 [27.7%] vs 180 [23.5%], p= 0.06), intraoperative PRBC units given (0.73 ± 1.5 vs 0.65 ± 1.4, p= 0.28), ICU length of stay (3.29 ± 3.9 days vs 3.37± 4.8 days, p= 0.74), or in-hospital mortality (1.3% vs 1.4%, p= 0.87). Implementation of a transfusion CDS tool was associated with lower pre-transfusion hemoglobin levels, fewer transfusions, decreased infection rates, and decreased health care costs, without an increase in short-term mortality.

Right ventricular dysfunction as an echocardiographic prognostic factor in hemodynamically stable patients with acute pulmonary embolism: a meta-analysis.

BackgroundWe investigated whether right ventricular dysfunction (RVD) as assessed by echocardiogram can be used as a prognostic factor in hemodynamically stable patients with acute pulmonary embolism (PE). Short-term mortality has been investigated only in small studies and the results have been controversial.MethodsA PubMed search was conducted using two keywords, “pulmonary embolism” and “echocardiogram”, for articles published between January 1st 1998 and December 31st 2011. Out of 991 articles, after careful review, we found 12 articles that investigated the implications of RVD as assessed by echocardiogram in predicting short-term mortality for hemodynamically stable patients with acute PE. We conducted a meta-analysis of these data to identify whether the presence of RVD increased short-term mortality.ResultsAmong 3283 hemodynamically stable patients with acute PE, 1223 patients (37.3%) had RVD, as assessed by echocardiogram, while 2060 patients (62.7%) had normal right ventricular function. Short-term mortality was reported in 167 (13.7%) out of 1223 patients with RVD and in 134 (6.5%) out of 2060 patients without RVD. Hemodynamically stable patients with acute PE who had RVD as assessed by echocardiogram had a 2.29-fold increase in short-term mortality (odds ratio 2.29, 95% confidence interval 1.61-3.26) compared with patients without RVD.ConclusionsIn hemodynamically stable patients with acute PE, RVD as assessed by echocardiogram increases short-term mortality by 2.29 times. Consideration should be given to obtaining echocardiogram to identify high-risk patients even if they are hemodynamically stable.

Impact Of Comorbidity and Performance Status On Treatment Intent and Outcome In AML Patients. A Danish Population-Based Cohort Study

▪ BackgroundWith an aging population, the burden of comorbidity in AML patients is expected to increase. Evidence on how to integrate comorbidity and functional status into clinical decision making is sparse and prior studies have been predictive and limited by single center study design, and small sample sizes. ObjectivesTo examine the impact of comorbidity and WHO Performance Status (PS) on intent of treatment in Danish AML patients. Secondary, to determine the prognostic impact of comorbidity and PS on achievement of complete remission, short- and long-term mortality in AML patients treated with curative intent. MethodsIn a nationwide cohort study, we identified all AML (non-promyelocytic leukemia) patients diagnosed in Denmark from 2000-2013 using a population-based leukemia registry (n=2785) which prospectively collects clinical data. We excluded patients with unknown intent of treatment (n=25). We identified comorbid conditions through the Danish National Registry of Patients. Comorbidity was evaluated according to presence of 17 of the 19 chronic diseases (HIV and leukemia excluded) in the Charlson Comorbidity Index with separate adjustment for all diseases associated with secondary AML (modified CCI (mCCI)). Crude and adjusted odds ratios (OR) and corresponding 95% confidence intervals (CI) for receiving treatment with curative intent were estimated. We used Cox proportional hazards regression to assess the influence of comorbidity and performance status on 90-day and 90-day to 3-year mortality in patients treated with curative intent (n=1444) by estimating crude and adjusted mortality ratios (MRs) and corresponding 95% CIs. We adjusted for age, gender, leukocyte count, prior chemo-/radiotherapy, and prior hematological diseases. ResultsOf 2760 patients 52% were treated with curative intent. Median age was 69 years (palliative intent: 78 vs. curative intent: 58). Overall, 60% of patients did not have any comorbidity, 26% had 1 comorbid disease, and 13% had 2 or more comorbidities. In patients treated with curative intent, the corresponding prevalences were 76%, 19%, and 6%. Overall, 26% of patients had PS=0, 42% had PS=1, and 32% had PS ≥2. The corresponding figures in patients treated with curative intent were 33%, 47%, and 20%. Dementia and heart failure were the two individual comorbid diseases most strongly associated with opting-out of intensive treatment (prevalence ratio 0.11 (95%CI 0.01-0.67) and 0.24 (95%CI 0.15-0.37). In patients treated with curative intent, those with comorbidity had lower complete remission rate than those without comorbidity, 66% (95%CI 60.7-70.7) vs. 74% (95%CI 70.8-76.9) whereas choice of chemotherapy regimen and dose did not differ. Compared to patients without comorbidity (mCCI=0), the adjusted ORs for treatment with curative intent were 0.57 (95%CI 0.41-0.73) for patients with 1 comorbid disease and 0.32 (95%CI 0.22-0.47) for 2 or more. Compared to patients with PS=0, the adjusted ORs of treatment with curative intent were 0.80 (95%CI 0.58-1.09) for PS 1, 0.45 (95%CI 0.31-0.65) for PS 2, and 0.09 (95%CI 0.05-0.14) for PS≥3.Crude survival curves according to comorbidity and PS are shown below. Crude and adjusted MRs are listed in table 1.Table 1Crude and adjusted 90-day and 90-day to 3-year MRs according to mCCI and PS90-day mortality90-day to 3-year mortalitymCCInCrude MR (95%CI)Adjusted MR (95%CI)Crude MR (95%CI)Adjusted MR (95%CI)01≥210911641891.01.79 (1.26; 2.53)1.35 (0.94; 1.93)1.01.16 (0.77; 1.75)0.90 (0.57; 1.41)1.01.51 (1.20; 1.91)1.54 (1.23; 1.91)1.01.26 (0.97; 1.63)1.05 (0.81; 1.38)WHO PS01≥24806812831.01.54 (1.08; 2.21)4.19 (2.93: 6.00)1.01.29 (0.87; 1.93)3.80 (2.55; 5.65)1.01.21 (1.02; 1.44)1.46 (1.17; 1.83)1.01.11 (0.92; 1.34)1.41 (1.10; 1.80) ConclusionsThe chance of being allocated to intensive chemotherapy decreased dramatically with increasing number of comorbid diseases and increasing PS. Surprisingly, among patients treated with curative intent presence of comorbidity was not associated with an increase in short-term mortality, and if any, only a slight increase in long-term mortality. High PS was strongly associated with both short- and long-term mortality. Our findings may be explained by the selection process before treatment with curative intent and raises the question whether more patients with comorbidity and low PS at time of diagnosis may benefit from intensive treatment. [Display omitted] [Display omitted] Disclosures:No relevant conflicts of interest to declare.