Independent Determinants Of Mortality Research Articles

Postoperative atrial fibrillation following non-cardiac surgery: Predictors and risk of mortality

BackgroundPostoperative atrial fibrillation (POAF) is a major complication that follows both cardiac and non-cardiac procedures. Many studies have explored POAF after cardiac procedures, however POAF following non-cardiac procedures has been understudied. MethodsNational Inpatient Sample database was utilized to conduct a retrospective study of hospitalizations with diagnosis of POAF following non-cardiac procedures between 2010 and 2015. Results294,112 patients met the inclusion criteria. Advanced age, male gender, colonic resections, coagulopathy, fluid and electrolyte disorders and history of congestive heart failure are major predictors of POAF and in-hospital mortality. Race, type of insurance, income quartile and weekend admissions are independent determinants of mortality following POAF. ConclusionsDevelopment of POAF and mortality is dependent upon a wide range of factors not limited to age and medical comorbidities. Although a patient may be at an increased risk for POAF this does not mean they are at an increased risk for mortality.

Radiation-Free myeloablative allogeneic hematopoietic stem cell transplantation for adult acute lymphoblastic leukemia: A comparison of outcomes between patients with and without central nervous system involvement

For patients with acute lymphoblastic leukemia (ALL) undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), total body irradiation (TBI) has been particularly advocated as a part of the conditioning regimen in case of extramedullary involvement in sanctuary sites such as the central nervous system (CNS), to ensure greater tissue penetration. In resource-limited countries lacking TBI facilities; however, ALL patients undergo radiation-free myeloablative conditioning, though its impacts on post-HSCT outcomes of the patients with pre-HSCT CNS involvement have not been analyzed. In this 14-year series of 278 adult (> 18 y) ALL patients undergoing TBI-free busulfan/cyclophosphamide conditioning allo-HSCT, we found that the long-term probabilities of overall survival, disease free survival, relapse and non-relapse mortality were not significantly different between CNS-involved and CNS-spared patients. Moreover, there was no statistically significant difference in the incidence of post-HSCT CNS relapse between CNS-involved and CNS-spared patients. Pre-HSCT cranial radiation therapy (CRT) showed no significant preventive effect on the likelihood of post-HSCT CNS relapse. Through multivariable regression analysis, grade III-IV acute graft-versus-host disease (GvHD), extensive chronic GvHD and post-HSCT relapse were ascertained as independent determinants of mortality (Adj.R2 = 53.9 %, F(12,265) = 28.1, P < 0.001), while other parameters including Philadelphia translocation, pre-HSCT CNS involvement and CRT were found to have no independent effect. Although this study was not an attempt to compare TBI-based vs. non-TBI conditioning, the TBI-free myeloablative allo-HSCT was shown to be feasible and an option for adult ALL patients with CNS involvement, considering the comparable outcomes between patients with and without CNS involvement.

Plasma Cystine and Nitrite Levels are Synergistic Determinants of Arterial Stiffness and Mortality in Heart Failure

Background Endothelial dysfunction plays a key role in heart failure with reduced ejection fraction (HFrEF) pathogenesis, and is determined via the balance between oxidative stress (OS) and nitric oxide (NO) bioavailability. Higher cystine levels indicate increased OS. Nitrite is a major oxidative metabolite of NO. We sought to examine the relationship between OS, NO metabolism and vascular function, and their association with clinical outcomes in HFrEF patients. Methods Cystine, nitrite and vascular function were measured in 130 HFrEF patients (mean age: 54.6 ± 12.7 yrs, 59.2% black, 48.5% female). Plasma cystine was quantified by high performance liquid chromatography. Plasma nitrite was determined by ion chromatography (ENO20 Analyzer, Eicom). Arterial stiffness was assessed as Augmentation index (Aix) using pulse wave analysis (SphygmoCor, AtCor Medical). Patients were categorized by median cystine (97.39 μM) and nitrite (0.26 μM) values. Linear regression was used to determine the association between cystine, nitrite and Aix, adjusting for age, gender, race, height, weight and mean arterial pressure. Cox regression was used to estimate the association of cystine, nitrite and Aix, with all-cause mortality, adjusting for age, gender, race, BNP and history of MI. Results: Cystine, nitrite and Aix Patients with higher levels of both cystine and nitrite (>median, n=31) had higher Aix (adjusted β =5.7, p=0.006, mean Aix= 27.6 ± 10.3) than those that had either elevated cystine (n=33) (p=0.1, mean Aix= 21.4 ± 7.9) or nitrite (n=33) (p=0.5, mean Aix= 18.9 ± 10.3), or neither (n=33) (P=0.9, mean Aix=22.1 ± 1.0). Cystine, nitrite and mortality There were 14 deaths during a median follow up of 375 (IQR 188.5, 696) days. Patients with higher levels of both cystine and nitrite (>median) had a higher mortality (adjusted HR=15.2, 95% CI: 1.8-129.7, p=0.01) than those with elevation of either cystine or nitrite, or neither (Figure 1). Cystine did not correlate with BNP (p=0.2), while nitrite had a weak positive correlation with BNP (r=0.21, p=0.04). Aix and mortality Higher Aix tended to be associated with mortality (adjusted HR: 1.2, 95% CI: 1.0-1.3, p=0.06), but was not a significant predictor when cystine and nitrite were added to the model (adjusted HR: 1.1, 95% CI: 0.9-1.2, p=0.5). Conclusions Higher levels of OS and NO metabolites are synergistic determinants of arterial stiffness, and are independent determinants of mortality in HFrEF even after adjusting for BNP.

Cardiac arrhythmias, electrolyte abnormalities and serum cardiac glycoside concentrations in yellow oleander (Cascabela thevetia) poisoning – a prospective study

Background: Consumption of yellow oleander (Cascabela thevetia) is a popular method of intentional self-harm in South India.Objectives: The objectives of this study were to identify the cardiac arrhythmias and electrolyte abnormalities in yellow oleander poisoning and to identify the association between electrolyte abnormalities, cardiac glycoside concentrations at admission and the severity of cardiotoxicity. This study was also designed to identify clinical and biochemical parameters at presentation which predict serious arrhythmias and determinants of mortality.Materials and methods: This was a prospective study among 192 patients who attended our Emergency department after consuming yellow oleander seeds. Patients were monitored with serial ECGs. Serious cardiac arrhythmias included sinus bradycardia <40/min, sinus arrest/exit block, second or third degree AV block, atrial tachyarrhythmias and ventricular tachyarrhythmias. Serum sodium, potassium, magnesium, total calcium and cardiac glycoside concentrations were measured at presentation for all 192 patients. Serial estimation of cardiac glycoside concentration was done in 43 patients who presented within 24 hours of consuming at least five seeds.Results: At presentation, 46 patients had serious arrhythmias and on follow-up, 11 developed new-onset serious arrhythmia. Sinus bradycardia (27%) was the most common arrhythmia followed by second-degree AV block (17%); multiple arrhythmias were observed in 18%. Digoxin effect in ECG correlated significantly with hyperkalemia. Mortality rate was 5%. Serum sodium, total calcium and magnesium levels did not correlate with cardiotoxicity. Cardiac glycoside concentration was of relatively modest clinical utility to discriminate patients with serious dysrhythmias (AUC: 0.719, 95% CI: 0.63–0.81). Prolonged PR interval and digoxin effect in ECG were significantly associated with an increased likelihood of serious dysrhythmias. Increase in 0.4 number of seed intake increased the odds of mortality by 1.5 times when all other independent variables were kept constant.Conclusion: Cardiac glycoside concentration at the time of presentation predicted the development of new-onset serious arrhythmias. Although serum potassium correlated significantly with cardiac glycoside concentration at admission and overall serious dysrhythmias, it did not predict the development of new-onset serious arrhythmia. On the whole, serious dysrhythmias were significantly associated with higher number of seeds ingested, hypotension at admission, PR interval prolongation, presence of digoxin effect in ECG, hyperkalemia and higher cardiac glycoside concentration. The independent determinants of mortality were larger number of seeds ingested and hypotension at admission. Cardiac glycoside concentration and hyperkalemia failed to be independent markers of serious dysrhythmias as well as mortality.

Do-not-resuscitate orders as part of advance care planning in patients with COPD.

There is growing awareness of the need for advance care planning in patients with chronic obstructive pulmonary disease (COPD). However, do-not-resuscitate (DNR) order implementation remains a challenge in clinical practice.We retrospectively analysed an observational cohort of 569 COPD patients with 2.5–8 years of follow-up in secondary care, to evaluate potential determinants and the prognostic significance of DNR order implementation and specification.345 patients (61%) had no DNR order, of whom 27% died during a median (interquartile range (IQR)) follow-up of 1935 (1290–2448) days. 194 (39%) patients had a DNR order, of whom 17 had the order at baseline and 82% died (median (IQR) follow-up 528 (137–901) days), while 177 received an order during follow-up and 76% died (median (IQR) follow-up 1322 (721–2018) days). 88% of DNR orders were implemented during hospitalisation. 58% of the patients with a DNR order died within the first year after admission; of them, 66% died in the hospital. Age, forced expiratory volume in 1 s, chronic oxygen dependency and previous mechanical ventilation were significantly and independently associated with DNR order implementation. DNR order specification was significantly associated with increased mortality, even after adjustment for age and disease severity.These findings identify DNR orders as independent determinants of mortality, mainly implemented just before death.

Clinical, Biological and Ct Predictors of In-Hospital Mortality in Ischemic Stroke Patients in Central Africa

Background: Stroke a major public health problem, its management remains a challenge for the medical professionals. We investigated the clinical, simple biological and tomographic determinants of outcome in patients suffering of ischemic stroke. Materials and methods: This prospective study was conducted at Kinshasa university hospital from January 2011 to June 2014. A total of 104 consecutive patients with first-ever ischemic stroke confirmed by computed tomography examination were enrolled for the study. The parameters of interest were clinical, routine biochemical and radiological data within the 3 first days of symptom onset. Logistic regression was used to identify independent determinants of mortality risk. Results: The average age of patients was 62 ± 14 years old with 68% of male. Among the 22 patients (21%) who died, in univariate analysis, factors associated with lethality were the Glasgow score 40 mm/1h, higher leukocytosis > 10.000 elements/mm3 and non-lacunar brain infarct. On multiple logistic regression analysis, higher elevated erythrocyte sedimentation rate (OR 1.8; 95% CI 1.22 to 89.35; p=0.032), lesion located in infra-tentorial area (OR 4.7; 95% CI 1.30 to 16.38; p=0.017) and hemorrhagic infarct (OR 10.6; 95% CI 2.21 to 77.89; p=0.005) were essentially independent determinants of ischemic stroke mortality. Conclusion: The study seems to determine factors associated with mortality in patients suffering from cerebral infarction. Glasgow score and routine biomarkers may be useful in low setting area to assess mortality in ischemic stroke patient.

Mortality Predictors in Acute Respiratory Distress Syndrome Renal Transplant Recipients With ESKAPE/rESKAPE Pneumonia

BackgroundA sustained immunosuppressive state in renal transplant recipients is a factor that can contribute to increased incidence of acute respiratory distress syndrome (ARDS) due to pneumonia. ARDS renal recipients with ESKAPE (E. faecium, S. aureus, K. pneumoniae, A. baumannii, P. aeruginosa, and Enterobacter spp.) pneumonia are probably related to high morbidity and mortality. We therefore sought to investigate the frequency of ESKAPE and resistant ESKAPE (rESKAPE) pathogens isolated from respiratory tract specimens of renal recipients with ARDS and determine the risk factors for mortality. MethodsA retrospective analysis of ARDS renal recipients with ESKAPE/rESKAPE pneumonia was reviewed. Multiple logistic regression analysis was conducted to identify the independent risk factors associated with infection-related mortality. ResultsDuring the study period, 88 ESKAPE pathogens obtained from respiratory tract specimens of 54 ARDS renal recipients were documented including 33 A. baumannii, 24 P. aeruginosa, 17 S. aureus, 6 K. pneumoniae, 8 Enterobacter species, and 0 E. Faecium. Among these ESKAPE organisms, 61.4% (54/88) were antimicrobial resistant. The risk factors for mortality independently associated with ARDS renal recipients with ESKAPE pneumonia were severe ARDS (odds ratio [OR] 4.3 (95% confidence interval [CI] 1.1–16.4), P = .032), serum creatinine level >1.5 mg/dL (OR 4.2 95% CI (1.0–17.9), P = .05) and body temperature less than 38°C (OR 5.0 (95% CI 1.3–19.6), P = .02) at ARDS onset. The independent determinants of mortality were associated with ARDS renal recipients with rESKAPE pneumonia were serum creatinine level >1.5 mg/dL (OR 13.7, 95% CI 1.3–142.1, P = .028) and body temperature less than 38°C (OR 5.5 (95% CI 1.1–26.6) at ARDS onset, P = .035). ConclusionsThe majority of EPKAPE isolates were antimicrobial resistant. Mortality in ARDS renal recipients with ESKAPE/rESKAPE pneumonia was associated with the severity of ARDS, elevated serum creatinine level, or depressed febrile response at ARDS onset.

Risk factors for mortality in childhood pneumonia in a rural West African region

Pneumonia is a major killer of children worldwide. It is responsible for 19% of under-five-year-old mortality, of which 70% occurs in sub-Saharan Africa and South East Asia. A substantial proportion of deaths attributed to pneumonia is caused by failure to recognise factors at presentation that affect prognosis. The present study was aimed to assess for factors at presentation that determine mortality among children with WHO ARI defined severe pneumonia. This was a prospective observational study of consecutive children aged 2 to 59 months admitted with severe pneumonia at a major health centre in rural Gambia to de- termine the risk factors for mortality using logistic regression analysis. Four hundred and twenty (27.6%) out of the 1517 under- five admissions during the study period fulfilled the criteria of severe pneumonia using the WHO ARI criteria. Fifteen of the 420 cases died giving case fatality of 36 per 1000 admissions, with pneumonia accounting for 21.4% of all 70 deaths during the period. Although age ranges 12-23 months and 36-47 months, overcrowding, hypothermia at presentation, oedematous PEM, severe wasting, grunting respiration, convulsion, somnolence and hypoxaemia were significantly associated with mortality (p < 0.05); only convulsions ( OR = 16.64, 95% CI 1.028-1.033) and severe wasting (OR = 5.05, 95% CI 1.459-20.484,) were independent determinants of mortality. We conclude that children with severe pneumonia who in addition have severe wasting and convulsion are at increased risks of dying and should be managed in better equipped secondary or tertiary health facilities.

Mortality trend and predictors of mortality in dysphagic stroke patients postpercutaneous endoscopic gastrostomy.

Background:Percutaneous endoscopic gastrostomy (PEG) feeding is widely used in stroke patients suffering from persistent dysphagia; however, predicting the risks and benefits of PEG insertion in the individual patient is difficult. The aim of our study was to investigate if candidate risk factors could predict short-term mortality risk in poststroke patients who had PEG tube insertion for persistent dysphagia.Methods:This was a retrospective study of 3504 consecutive stroke patients admitted to two metropolitan hospitals during the period January 2005 to December 2013 and who also underwent PEG insertion for feeding due to persistent dysphagia.Results:A total of 102 patients were included in the study. There were 22 deaths in 6 months after insertion of PEG tubes and 20 deaths of those occurred within 3 months post PEG. Those who survived beyond 6 months showed significantly lower mean age (75.9 ± 9.0 years vs. 83.0 ± 4.9 years, P < 0.001), a lower mean American Society of Anesthesia (ASA) score (3.04 ± 0.63 vs. 3.64 ± 0.58, P < 0.001) compared to nonsurvivors. In multiple Logistic, age (P = 0.004, odds ratio [OR] = 1.144; 95% confidence interval [CI]: 1.044–1.255); ASA (P = 0.002, OR = 5.065; 95% CI: 1.815–14.133) and albumin level pre-PEG insertion (P = 0.033, OR = 0.869; 95% CI: 0.764–0.988) were the independent determinants of mortality respectively.Conclusions:We propose that age, ASA score and albumin level pre-PEG insertion to be included as factors to assist in the selection of patients who are likely to survive more than 3 months post PEG insertion.

Abstract P3-07-09: Trends and determinants of breast cancer survival among unscreened women: A population-based study

Abstract Background: Breast cancer mortality has been declining in many western countries, including Switzerland,since the late 1980s. This has largely been credited to mammography screening and improved treatment. However, mortality trends are also decreasing among unscreened women, though most breast cancer deaths still occur in that population. Objective: The objective of this study was to analyse trends in,and factors affecting the survival of, women whose breast cancer was not detected by screening in the Geneva female population from 1990 to 2007. In Geneva an organized screening programme started in 2001 while opportunistic screening has existed since the beginning of the 1990s. Methods: The study population comprised1696 women aged 50-69 years oldwith invasive breast cancer that was not detected by screening and that was recorded at the population-based Geneva cancer registry. We studied tumour characteristics and prognostic factors across 6 time periods through chi square and trend tests. To assess whether breast cancer specific survival had improved over time, we calculated 5-year specific survival and performed multivariate Cox proportional hazard models to assess independent determinants of mortality. Results:Median age of the women at diagnosis was 59 years. During the 18 year study periodthere was a decrease in the proportion of diagnoses among women of low social class (25.8% in 1990-92 vs 17.3% in 2005-07, p=0.001). No change in the distribution of stage at diagnosisor hormone receptor status was observed, while between the first and last period there was an increase in cancers with lobular morphology (6.8% vs. 19.0%, p&amp;lt;0.001), and a decrease in poorly or undifferentiated cancers (36.7% vs 28.7%, p&amp;lt;0.001). The use of breast conserving surgery with radiotherapy (BCS), chemotherapy and endocrine therapy increased significantly along the period (41.2% to 58.8%, p&amp;lt;0.001; 41.6% to 52.8, p=0.030; and 34% to 69.9%, p&amp;lt;0.001, respectively). Five year breast cancer-specific survival was 82% in 1990-92 (95% Confidence Intervals [95%CI] 77-87) and 89% in 2005-07 (95% CI: 83-92; log rank test=8.68, p=0.122). In the Cox multivariate model there was a trend towards improved survival, but it was only statistically significant when comparing the period 2005-07 to the first period (Hazard Ratio 0.47, 95%CI: 0.22-0.98). Increasing age, stage, and grade, hormone receptor–negative disease, and not receiving BCS or endocrine therapy were all independently associated with a worse breast cancer–specific survival. Conclusions:We observed an improvement in survival only in recent years among women whose breast cancers were not detected by screening; this appears to be associated with improved treatment. This suggests that the breast cancer mortality reduction observed in Switzerland since the late 1980s is not likely attributable to changes in treatment before 2005, but rather to the generalization of screening. Citation Format: Elisabetta Rapiti, Thomas Agoritsas, Massimo Usel, Robin Schaffar, Hyma Schubert, Christine Bouchardy. Trends and determinants of breast cancer survival among unscreened women: A population-based study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-07-09.

Abstract P3-07-08: Don't mix apples and oranges: Not all non-screen-detected breast cancers belong to the same category in a cancer registry dataset

Abstract Background: In population-based datasets breast cancers are often classified as screen-detected or not screen-detected (or symptoms-detected) without further information, resulting in substantial heterogeneity in the latter group. In fact, this group includes symptoms-detected and fortuitously detected cancers,as well as ‘interval breast cancers’ (i.e. detected between screenings), all of which have different morphological characteristics than screen-detected cancers. Objective: To compare the demographic features, tumour characteristics and survival of women with not-screen detected breast cancer according to whether or not they reported previous mammography screening. Methods: The study population comprised1696 women aged 50-69 years oldwith non-screen detected invasive breast cancer recorded at the Geneva cancer registry between 1990 and 2007. According to the information on the variable "previous mammography screening" the women were classified as those never having had a screening test and those having had one. We comparedtumour characteristics and prognostic factors through chi square test, and calculated 5-year breast cancer specific survival and multivariate Cox proportional hazard models to assess independent determinants of mortality. Results:Among the non-screen detected breast cancers there were 904 womenwho never had a screening mammography and 792 who declared to have had at least one. Women previously screened were more often 55-59 years old, diagnosed after 1996, of high social class, treated in the private sector and had a positive family history. These women had smaller tumours (mean 21.6 mm vs. 27.2, p&amp;lt;0.001), more often lobular cancers (18.4% vs 10.4%, p&amp;lt;0.001), less often poorly or undifferentiated cancers (22.8% vs 34.2%, p&amp;lt;0.001), and less often stage III or IV cancers (13.4% vs. 24.3%, p&amp;lt;0.001). Previously screened women more often received breast conserving surgery with radiotherapy (70.7% vs 49.1%, p&amp;lt;0.001), and endocrine therapy (73.0% vs 55.8%, p&amp;lt;0.001). Five year breast cancer-specific survival was 83% among never screened women (95% Confidence Intervals [95%CI] 81-86) and 91% among those previously screened (95% CI: 89-93; log rank test=20.62, p&amp;lt;0.001). In the Cox multivariate model adjusted for all confounders and for prognosis and treatment variables, the difference in breast cancer mortality risk between women with and without a previous mammography screening disappeared (Hazard Ratio for previously screened women 1.06, 95%CI: 0.73-1.54). Conclusions:Within the category of non-screen detected breast cancers co-exist at least two distinct groups of patients, with different tumours and, potentially, treatments and prognoses. Comparing women with screen-detected breast cancer against this heterogeneous group of women could produce biased results. Recording information about screening use before the breast cancer diagnosis would help to correctly classify these women. Citation Format: Elisabetta Rapiti, Massimo Usel, Robin Schaffar, Hyma Schubert, Christine Bouchardy. Don't mix apples and oranges: Not all non-screen-detected breast cancers belong to the same category in a cancer registry dataset [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-07-08.

The impact of warfarin on the rate of progression of aortic stiffness in hemodialysis patients: a longitudinal study.

Accelerated progression of aortic stiffness in patients with advanced chronic kidney disease is not well explained by the traditional cardiovascular risk factors. We hypothesized that vitamin K deficiency may result in an accelerated progression of aortic stiffness in the pro-calcifying uremic milieu. Eighteen hemodialysis (HD) patients on warfarin were matched to 54 HD patients without warfarin (control). Aortic stiffness was determined by carotid-femoral pulse wave velocity (cf-PWV) at baseline and after a mean follow-up of 1.2 years. In the control group, spontaneous vitamin K deficiency was defined as proteins induced by vitamin K deficiency/absence-II >median. At baseline, clinical characteristics and cf-PWV were similar. Adjusted cf-PWV increased by 0.86 ± 1.87 m/s in control and by 2.24 ± 2.68 m/s in warfarin group (P = 0.024). After adjustments for confounders, warfarin therapy was independently associated with progression of aortic stiffness (P = 0.016). The rate of progression of aortic stiffness showed a linear trend in response to vitamin K status and warfarin therapy, suggesting that at least part of the effects are mediated through reduced availability of vitamin K. The unadjusted and adjusted hazard ratio (HR) of warfarin therapy on mortality were, respectively, 2.40 (P = 0.006) and 2.53 (P = 0.006). In a forward conditional Cox regression analysis, age, albumin, augmentation index (AIx) and a cf-PWV > 13.8 m/s at the time of follow-up (HR: 2.11, P = 0.05) were independent determinants of mortality, whereas warfarin use was not retained as an independent factor. Finally, control patients with poor vitamin K status had an intermediate survival as compared with controls with better vitamin K status and patients with warfarin (P = 0.01). This is the first study to show a temporal association between warfarin, functional vitamin K deficiency and progression of aortic stiffness in HD patients. These findings suggest that the net cardiovascular benefit of long-term warfarin therapy may need to be reevaluated in this population.

Predicting 1-Year Mortality Rate for Patients Admitted With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease to an Intensive Care Unit: An Opportunity for Palliative Care

The objective of this study was to develop a model to aid clinicians in better predicting 1-year mortality rate for patients with an acute exacerbation of chronic obstructive pulmonary disease admitted to the medical intensive care unit (ICU) with the goal of earlier initiation of palliative care and end-of-life communications in this patient population. This retrospective cohort study included patients from a medical ICU from April 1, 1995, to November 30, 2009. Data collected from the Acute Physiology and Chronic Health Evaluation III database included demographic characteristics; severity of illness scores; noninvasive and invasive mechanical ventilation time; ICU and hospital length of stay; and ICU, hospital, and 1-year mortality. Statistically significant univariate variables for 1-year mortality were entered into a multivariate model, and the independent variables were used to generate a scoring system to predict 1-year mortality rate. At 1-year follow-up, 295 of 591 patients died (50%). Age and hospital length of stay were identified as independent determinants of mortality at 1 year by using multivariate analysis, and the predictive model developed had an area under the operating curve of 0.68. Bootstrap analysis with 1000 iterations validated the model, age, and hospital length of stay, entered the model 100% of the time (area under the operating curve=0.687; 95% CI, 0.686-0.688). A simple model using age and hospital length of stay may be informative for providers willing to identify patients with chronic obstructive pulmonary disease with high 1-year mortality rate who may benefit from end-of-life communications and from palliative care.

Survival on antiretroviral treatment among adult HIV-infected patients in Nepal: a retrospective cohort study in far-western Region, 2006–2011

BackgroundThough financial and policy level efforts are made to expand antiretroviral treatment (ART) service free of cost, survival outcome of ART program has not been systematically evaluated in Nepal. This study assesses the mortality rates and determinants among adult HIV-infected patients on ART in Far-western region of Nepal.MethodsThis retrospective cohort study included 1024 (51.2% men) HIV-infected patients aged ≥15 years, who started ART between May 15th 2006 and May 15th 2011 in five ART sites in the Far-western region, Nepal. Follow-up time was calculated from the date of ART initiation to date of death or censoring (loss to follow-up, transferred out, or 15 November 2011). Mortality rates (per 100 person-years) were calculated. Kaplan-Meier and Cox-regression models were used to estimate survival and explore determinants of mortality.ResultsThe median follow-up time was 19.1 months. The crude mortality rate was 6.3 (95% confidence interval (CI) 5.3-7.6) but more than three-times higher in first 3 months after ART initiation (21.9 (95% CI 16.6- 28.8)). About 12% (83% men) of those newly initiated on ART died during follow-up. The independent determinants of mortality were male sex (hazard ratio (HR) 4.55, 95% CI 2.43-8.51), poor baseline performance scale (bedridden <50% of the day during the past month, HR 2.05, 95% CI 1.19-3.52; bedridden >50% of the day during the past month, HR 3.41, 95% CI 1.67-6.98 compared to normal activity), one standard deviation decrease in baseline bodyweight (HR 1.04, 95% CI 1.01-1.07), and poor WHO clinical stage (stage III, HR 2.96, 95% CI 1.31-6.69; stage IV, HR 3.28, 95% CI 1.30-8.29 compared to WHO clinical stage I or II).ConclusionsHigh mortality was observed within the first 3 months of ART initiation. Patients with poor baseline clinical characteristics had higher mortality, especially men. Earlier initiation of ART through expanded testing and counselling should be encouraged in HIV-infected patients.

C-Reactive Protein and B-Type Natriuretic Peptide Yield Either a Non-Significant or a Modest Incremental Value to Traditional Risk Factors in Predicting Long-Term Overall Mortality in Older Adults

BackgroundNew biomarkers may aid in preventive and end-of-life decisions in older adults if they enhance the prognostic ability of traditional risk factors. We investigated whether C-reactive protein (CRP) and/or B-type natriuretic peptide (BNP) improve the ability to predict overall mortality among the elderly of the Bambuí, Brazil Study of Aging when added to traditional risk factors.MethodsFrom 1997 to 2007, 1,470 community-dwelling individuals (≥60 years) were followed-up. Death was ascertained by continuous verification of death certificates. We calculated hazard ratios per 1 standard deviation change (HR) of death for traditional risk factors only (old model), and traditional risk factors plus CRP and/or BNP (new models) and assessed calibration of the models. Subsequently, we compared c-statistic of each of the new models to the old one, and calculated integrated discriminative improvement (IDI) and net reclassification improvement (NRI).Results544 (37.0%) participants died in a mean follow-up time of 9.0 years. CRP (HR 1.28, 95% CI 1.17-1.40), BNP (HR 1.31 95% CI 1.19-1.45), and CRP plus BNP (HR 1.26, 95% CI 1.15-1.38, and HR 1.29, 95% CI 1.16-1.42, respectively) were independent determinants of mortality. All models were well-calibrated. Discrimination was similar among the old (c-statistic 0.78 [0.78-0.81]) and new models (p=0.43 for CRP; p=0.57 for BNP; and p=0.31 for CRP plus BNP). Compared to the old model, CRP, BNP, and CRP plus BNP models led to an IDI of 0.009 (p<0.001), -0.005 (p<0.001) and -0.003 (p=0.84), and a NRI of 0.04 (p=0.24), 0.07 (p=0.08) and 0.06 (p=0.10), respectively.ConclusionsDespite being independent predictors of long-term risk of death, compared to traditional risk factors CRP and/or BNP led to either a modest or non-significant improvement in the ability of predicting all-cause mortality in older adults.

Weekend diagnosis of Escherichia coli urinary tract infection does not predict poor outcome

It has been suggested that mortality is higher in patients admitted to hospitals during the weekend. The objective of this study was to compare outcomes in patients with E. coli urinary tract infection (UTI) depending on the hospital admission day. For this purpose, a secondary analysis of data from a prospective cohort of patients with E. coli UTI was conducted. Weekend diagnosis of UTI was not associated with higher mortality. However, mortality was associated with sepsis, sepsis-induced hypotension and intensive care unit (ICU) admission. Sepsis-induced hypotension and ICU admission were independent determinants of mortality. The results indicate that indicators of severity of illness are associated with higher mortality in patients with UTI rather than the time of diagnosis.

Determinants of Mortality among HIV Positives after Initiating Antiretroviral Therapy in Western Ethiopia: A Hospital-Based Retrospective Cohort Study

Studies revealed that there are various determinants of mortality among HIV positives after ART initiation. These determinants are so variable with context and dynamic across time with the advancement of cares and treatments. In this study we tried to identify determinants of mortality among HIV positives after initiating ART. A retrospective cohort study was conducted among 416 ART attendees enrolled between July 2005 to January 2012 in Nekemte Referral Hospital, Western Ethiopia. Actuarial table was used to estimate survival of patients after ART initiation and log rank test was used to compare the survival curves. Cox proportional-hazard regression was applied to determine the independent determinants of time to death. The estimated mortality was 4%, 5%, 6%, 7%, and 7% at 6, 12, 24, 36 and 48 months respectively with mortality incidence density of 1.89 deaths per 100 person years (95% CI 1.74, 3.62). Forty years and above AHR = 3.055 (95% CI 1.292, 7.223), low baseline hemoglobin level (AHR = 0.523 (95% CI .335, 0.816)), and poor ART adherence (AHR 27.848 (95% CI 8.928, 86.8)) were found to be an independent determinants of mortality. These determinants of mortality have to be taken into account to enhance better clinical outcomes of ART attendees.

Surgical outcomes of severe tricuspid regurgitation: predictors of adverse clinical outcomes

BackgroundAlthough recent studies contributed to an improved understanding of the prognosis of patients undergoing tricuspid valve (TV) surgery, the data are limited to certain causes of tricuspid regurgitation (TR) or...

Determinants of mortality in trauma patients following massive blood transfusion

Aim:This study was designed to find out the factors influencing mortality in trauma patients receiving massive blood transfusion (MBT).Materials and Methods:Records of all patients admitted during December 2007 to November 2008 at a Level I Trauma Center emergency and who underwent massive transfusion (≥10 units of packed red cells in 24 h) were retrospectively analyzed. Death during the hospital stay was considered as the study outcome and various demographic, laboratory, and clinical parameters were included as its potential determinants.Statistical Analysis:Bivariate and multivariate logistic regression analyses were done to identify the risk factors associated with mortality.Results:Of the 4054 transfused patients who were admitted to the trauma center during the study period, 71 (1.8%) patients underwent massive transfusion. Of this, there were 37 survivors and 34 nonsurvivors (48%). The median overall ISS was 27 (22–34). The patients who died had shorter mean length of hospital stay, shorter mean duration of intensive care unit (ICU) stay, and low admission Glasgow Coma Scale (GCS) compared to the survivors (P < 0.01). The mean prothrombin time (PT) and the mean activated partial thromboplastin time was significantly high (P < 0.01) among nonsurvivors. Total leukocyte count (TLC ≥ 10,000 cells/cubic mm), GCS ≤ 8, the presence of coagulopathy and major vascular surgery were the four independent determinants of mortality in multivariate logistic regression analysis. The FFP:PRBC (fresh frozen plasma:packed red cells) ratio and PC:PRBC (platelet concentrate:packed red cells) ratio calculated in our study was not statistically significant in correlation to the in hospital mortality.Conclusions:Overall mortality among the MBT patients was comparable with the studies in the literature. Mortality is not affected by the amount of packed red cells given in the first 12 h and the total number of packed red cells transfused. Prospective studies are required to further validate the determinants of mortality and establish guidelines for MBT.

Factors associated with mortality in adult hospitalized burn patients in Tehran

The mortality rate following burn is an important outcome parameter. This study aimed to identify factors associated with mortality in adult hospitalized burn patients in Tehran, Iran. This cross-sectional study was performed during a one-year period in two referral burn centers in Tehran. During the study period, 1321 adult (> 15 years) hospitalized burn patients were enrolled. Univariate and multivariate (logistic regression) analyses were performed to identify factors associated with mortality. The mean age of the patients was 33.1 ± 14.9 years. By far, the majority of burns were accidental (n = 1076, 81.5%). Regarding the mechanism of burn, burn with petroleum products was the most frequent. Mean percent burned total body surface area (TBSA) was 39.9% ± 25.8%. The mortality rate was 33%. Sepsis was the most common cause of mortality. The results of the present study indicated that non work-related burns, burned TBSA and body surface area affected by second- or third-degree burns were independent determinants of mortality among adult hospitalized burn patients. The present study showed a high mortality rate in the studied burn centers. Patients with identified risk factors should be categorized as high risk at the time of admission and need special attention and care during hospitalization.