Independent Predictor Of Early Death Research Articles

Sex-Related Differences Between Patients Undergoing Surgery for Acute Type A Aortic Dissection.

Introduction This study aimed to evaluate the sex-specific characteristics and surgical outcomes in patients with acute type A aortic dissection (ATAAD). Materials and methods We reviewed the surgical records of patients who underwent ATAAD repair at our institution between 2004 and 2020 (n=213). Results Of the 213 patients, 100 (46.9%) were male, and 113 (53.1%) were female. Males were younger than females (62.5 vs. 72.9 years, p<0.0001). Females had more nonspecific symptoms (p=0.04), more frequently developed ATAAD before noon (45.0% vs. 53.1%, p=0.01), and had a significantly longer time from onset to surgery (425.1 vs. 595.8 min, p=0.03). The ascending aorta was replaced more frequently in females than in males (54.5% vs. 72.8%, p<0.01). No significant difference was observed in the in-hospital mortality rate between males and females (9.0% vs. 10.6%, p=0.69). The multivariable logistic analysis demonstrated that being male was not an independent predictor of operative mortality (OR, 0.96; 95% CI, 0.18-5.21; p=0.96). At 10 years, males had significantly better long-term survival rates in the unadjusted cohort than females (79.4% vs. 55.9%, p=0.02). Conclusions Male sex was not an independent predictor of early death in patients with ATAAD after surgery, although significant differences were noted in terms of age, onset time, chief complaint, imaging findings, and surgical procedures. A sex-based management strategy involving specific differences should be considered to improve outcomes.

Time and Risk Factors of Trauma-Related Mortality: A 5-Year Retrospective Analysis From a National Level I Trauma Center.

Background: We aimed to analyze in-hospital timing and risk factors for mortality in a level 1 trauma center. Methods: This is a retrospective analysis of all trauma-related mortality between 2013 and 2018. Patients were divided and analyzed based on the time of mortality (early (≤48 h) vs late (>48 h)), and within different age groups. Multivariate regression analysis was performed to predict in-hospital mortality. Results: 8624 trauma admissions and 677 trauma-related deaths occurred (47.7% at the scene and 52.3% in-hospital). Among in-hospital mortality, the majority were males, with a mean age of 35.8 ± 17.2 years. Most deaths occurred within 3-7 days (35%), followed by 33% after 1 week, 20% on the first day, and 12% on the second day of admission. Patients with early mortality were more likely to have a lower Glasgow coma scale, a higher shock index, a higher chest and abdominal abbreviated injury score, and frequently required exploratory laparotomy and massive blood transfusion (P < .005). The injury severity scores and proportions of head injuries were higher in the late mortality group than in the early group. The severity of injuries, blood transfusion, in-hospital complications, and length of intensive care unit stay were comparable among the age groups, whereas mortality was higher in the age group of 19 to 44. The higher proportions of early and late in-hospital deaths were evident in the age group of 24 to 29. In multivariate analysis, the shock index (OR 2.26; 95%CI 1.04-4.925; P = .04) was an independent predictor of early death, whereas head injury was a predictor of late death (OR 4.54; 95%CI 1.92-11.11; P = .001). Conclusion: One-third of trauma-related mortalities occur early after injury. The initial shock index appears to be a reliable hemodynamic indicator for predicting early mortality. Therefore, timely hemostatic resuscitation and appropriate interventions for bleeding control may prevent early mortality.

Right ventricular area predicts short-term mortality in acute pulmonary embolism based on CT pulmonary angiography: A retrospective study.

We performed this cohort study to assess the prognostic value of right ventricular size, including diameter, area, and volume, in short-term mortality of acute pulmonary embolism (APE) based on 256-slice computed tomography compared with D-dimer, creatine kinase muscle and brain isoenzyme, and Wells scores. A total of 225 patients with APE, who were followed up for 30 days were enrolled in this cohort study. Clinical data, laboratory indices (creatine kinase, creatine kinase muscle and brain isoenzyme, and D-dimer), and Wells scores were collected. The 256-slice computed tomography was used to quantify cardiac parameters (RVV/LVV, RVD/LVD-ax, RVA/LVA-ax, RVD/LVD-4ch, RVA/LVA-4ch) and the diameter of the coronary sinus. Participants were divided into non-death and death groups. The values mentioned above were compared between the 2 groups. The RVD/LVD-ax, RVA/LVA-ax, RVA/LVA-4ch, RVV/LVV, D-dimer, and creatine kinase levels were significantly higher in the death group than in the non-death group (P < .05). The active period of the malignant tumor, heart rate ≥ 100 beats/minutes, and RVA/LVA-ax were positively correlated with early death from APE (P < .05). Active stage of malignant tumor (OR:9.247, 95%CI:2.682-31.888, P < .001) and RVA/LVA-ax (OR:3.073, 95%CI:1.447-6.528, P = .003) were independent predictors of early death due to APE. According to the receiver operating characteristic curve, the cutoff point of RVA/LVA-ax was 1.68 with a sensitivity of 46.7% and specificity of 84.8%. The measurement of ventricular size in the short-axis plane is more convenient and reliable than that in the 4-chamber cardiac plane. RVA/LVA-ax is an independent predictor of early death from APE, and when RVA/LVA-ax > 1.68, the risk of early death from APE increases.

The impact of sarcopenia and acute muscle mass loss on long-term outcomes in critically ill patients with intra-abdominal sepsis.

BackgroundSarcopenia is a known risk factor for poor outcomes across many chronic diseases. The impact on outcomes of both pre‐existing sarcopenia and acute muscle wasting (AMW) in acute critical illness caused by sepsis remain unclear.MethodsWe conducted a prospective longitudinal cohort study of critically ill patients with intra‐abdominal sepsis utilizing abdominal computed tomography at sepsis onset to determine baseline skeletal muscle index (SMI). Biomarkers of inflammation and catabolism were measured through 28 days while hospitalized. We performed follow‐up evaluations of strength and physical function at 3, 6, and 12 months, with interval CT analyses at 3 and 12 months to evaluate changes in muscle mass. Measured clinical outcomes included development of chronic critical illness (≥14 days in intensive care with persistent organ dysfunction), long‐term functional status, and 1 year mortality.ResultsAmong 47 sepsis patients enrolled (mean age 53 ± 14 years), half (n = 23; 49%) were sarcopenic at baseline. Overall, sepsis patients exhibited acute and persistent muscle wasting with an average 8% decrease in SMI from baseline at 3 months (P = 0.0008). Sarcopenic (SAR) and non‐sarcopenic (NSAR) groups were similar in regards to age and comorbidity burden. SAR patients had greater acute physiologic derangement (APACHE II, 18 vs. 12.5), higher incidence of multiple organ failure (57% vs. 17%), longer hospital (21 vs. 12 days) and intensive care unit length of stays (13 vs. 4 days), and higher inpatient mortality (17% vs. 0%; all P < 0.05). Pre‐existing SAR was a strong independent predictor of early death or developing chronic critical illness (odds ratio 11.87, 95% confidence interval CI 1.88–74.9; P = 0.009, area under the curve 0.880) and was associated with significantly higher risk of 1‐year mortality (34.9% vs. 4.2%, p = 0.007). Lower baseline SMI was also predictive of poor functional status at 12 months (OR 0.89, 95% confidence interval 0.80–0.99; p = 0.039, area under the curve 0.867). Additionally, SAR patients had AMW with persistent muscle mass loss at 3 months that was associated with decreased health‐related quality of life and SF‐36 physical function domains (P < 0.05). Persistent AMW at 3 months was not predictive of mortality or poor functional status, with return to near‐baseline muscle mass among sepsis survivors by 6 months.ConclusionsCritically ill patients have an acute and persistent loss of muscle mass after intra‐abdominal sepsis, which is associated with decreased health‐related quality of life and physical function at 3 months. However, pre‐existing sarcopenia, rather than persistent acute muscle mass loss at 3 months after sepsis, is independently associated with poor long‐term functional status and increased 1 year mortality.

Clinical Characteristics of Patients with Severe and Critical COVID-19 in Wuhan: A Single-Center, Retrospective Study.

IntroductionThis retrospective, single-center study was performed to systemically describe the characteristics and outcomes of patients with severe and critical coronavirus disease 2019 (COVID-19) in Wuhan, analyze the risk factors, and propose suggestions for clinical diagnosis and treatment to guide the subsequent clinical practice.MethodsA total of 753 consecutive patients with COVID-19 admitted to the West Campus of Wuhan Union Hospital from January 22, 2020 to May 7, 2020 were enrolled in this study. Demographic, clinical, laboratory, and outcome data were extracted from the electronic medical records of Wuhan Union Hospital and were exhaustively analyzed using R (version 3.6.1).ResultsA total of 493 severe and 228 critical cases out of 753 COVID-19 cases were considered in this study. Among the critical cases, the death rate was 79.4%, and age was a risk factor for death. Compared to the severe disease group, the critical disease group had higher white blood cell (WBC) and neutrophil counts and a decreased lymphocyte count at admission. Compared to early death cases (death within 1 week after admission), a more prolonged course of the disease was associated with a higher risk of hypoproteinemia, liver injury, thrombocytopenia, anemia, disseminated intravascular coagulation (DIC), coagulation disorders, acute kidney injury (AKI), and infection. Higher creatine kinase (CK) and lactate dehydrogenase (LDH) levels were related to early death events, but univariate and multivariate analyses confirmed only LDH as an independent predictor of early death. Notably, anticoagulation therapy was associated with an improved prognosis of critical cases in this cohort.ConclusionOur results showed large differences between patients with severe and critical COVID-19. During the course of COVID-19 in the critical disease group, the incidence of hypoproteinemia, anemia, thrombocytopenia, and coagulation disorders increased significantly, which highlighted the importance of medical care in the first week after admission. LDH could act as an independent predictor of early death in critical cases, and anticoagulation therapy was correlated with an improved prognosis of patients with critical COVID-19.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-020-00379-2.

Disseminated Intravascular Coagulation Score Evolution in 48 Hours Predicts Early Death in Newly-Diagnosed Chemotherapy-Treated Acute Promyelocytic Leukemia Patients

Introduction Acute Promyelocytic Leukemia (APL) prognosis has largely improved over the past decades and is now the acute leukemia with the highest cure rates. However, its early death rate, which reaches 30% in several real-world studies, is the main obstacle to achieving lifelong remission in most patients. Several reports have suggested a potential role of the Disseminated Intravascular Coagulation (DIC) Score of the International Society of Thrombosis and Hemostasis as a marker of bleeding and death in APL. Since the APL-induced coagulopathy and hyperfibrinolysis are responsible for most early deaths, a method to assess the severity of the coagulopathy could guide the daily patient management and the intensity of the blood products used. We aimed to test the hypothesis of whether the improvement of the DIC Score through coagulopathy support can improve the rate of early death in APL. Methods This retrospective, single-center study, included consecutively admitted patients with newly diagnosed genetically confirmed Acute Promyelocytic Leukemia between 2000 and 2020, who were treated with ATRA + anthracycline protocols and prednisolone 0.5 mg/kg differentiation syndrome prophylaxis. All patients received platelets, fibrinogen, and/or fresh frozen plasma according to published clinical indications. Baseline demographics and clinical data were collected, and the DIC Score was calculated at diagnosis and after 48 hours for each patient, using fibrinogen, platelets, prothrombin time and d-dimers. "DIC Score improvement" was defined as an increase of ≥1 point in the calculated score at 48 hours; a stable or decreasing score were considered "no-improvement". A 30-day follow-up for each patient was conducted, and any death during this period was considered in the early-death group. Statistical analysis was performed using Stata, with chi-square test and Mann-Whitney test for differences between groups, and logistic regression for the analysis of predictors of early death. Results A total of 67 patients were included, after excluding 9 patients for missing coagulation values, 8 for first-line arsenic trioxide treatment, and 7 patients for death within 48 hours of hospital admission. The median age was 53 years (25-82), and 29.9% of patients were aged &amp;gt;60 years old. The 30-day mortality rate for this cohort was 31.3%. Comparing the baseline differences between the two groups, the only statistically significant difference detected was a less frequent improvement of the DIC Score over 48 hours in the early-death group (42.86% versus 76.09% in the remaining patients, p=0.008). There was no difference in the Sanz Risk distribution nor age between the two groups. The univariate analysis of predictors of death in 30 days (logistic regression) yielded age &amp;gt;60 years and 48h-improvement of the DIC Score as potential predictors of death. A multivariate analysis model was built incorporating these 2 variables with the Sanz Risk (the number of events in this study permitted only a 3-variable prognostic model), and it identified age&amp;gt;60 years (OR 4.84 [1.37-17.10]; p=0.014) and the lack of a 48-hour improvement in the DIC Score (OR 5.46 [1.61-18.47]; p=0.006) as independent predictors of early death. In patients under 60 years old, having no improvement in the DIC Score over 48 hours is still associated with almost five times superior odds of 30-day mortality (OR 4.55; p=0.038). Conclusion In this cohort, we identified a lack of DIC Score improvement and age&amp;gt;60 years as independent predictive factors of early death in APL. These findings identified a new independent predictor of early death using a dynamic DIC Score assessment, which is easily accessible and calculated, and illustrate how this score can be applied daily in the clinical care of APL patients. Together with the current APL treatment strategies, the intensification of measures to control the leukemia-associated coagulopathy in patients who do not show a DIC Score improvement in the first 48 hours after diagnosis could decrease the early death rate in this otherwise highly-curable leukemia. Disclosures Brioso Infante: Astellas: Speakers Bureau; Novartis: Speakers Bureau.

Epidemiological profile of mucosal melanoma in Brazil

Mucosal melanomas are primary malignant neoplasias originated from melanocytes within mucous membranes in any part of mucosal surface lining, more commonly, in the nasal cavity and accessory sinuses, oral cavity, lips, pharynx, vulvar, vaginal, cervix and anorectal mucosa. Epidemiology data regarding mucosal melanomas in Brazil is scarce, hence the motivation to conduct this research paper. The χ2 test was used to compare categorical variables. Forward stepwise logistic regression method was used in the multivariate analysis to identify independent predictors of early death. A total of 801 patients were included in the analysis. Surgical resection is frequently the first approach to primary tumours (65.3%), even though the utility of lymph node surgery and radiation therapy is not well established. Advanced stage was observed in more than two thirds of patients. Early death was observed in 28.3%. MM cases with regional or distant metastases as well as those located in unusual locations had almost 4 times more risk for early death. Besides that, MM located in lips, oral cavity and pharynx and those receiving chemotherapy had 2 times more risk of early death.

Predictors of an early death in patients diagnosed with colon cancer: a retrospective case–control study in the UK

ObjectiveDespite considerable improvements, 5-year survival rates for colon cancer in the UK remain poor when compared with other socioeconomically similar countries. Variation in 5-year survival can be partly explained by...

Conventional redo biological valve replacement over 20 years: Surgical benchmarks should guide patient selection for transcatheter valve-in-valve therapy

ObjectivesAlthough primary transcatheter valve interventions have demonstrated acceptable early- and intermediate-term outcomes, data are lacking to guide patient selection for transcatheter valve-in-valve therapy. Furthermore, very few surgical benchmarks have been established for repeat conventional biological valve replacement to refine momentum for broad application of transcatheter intervention for a degenerated bioprosthesis. MethodsFrom January 1993 to July 2014, 694 patients underwent repeat biological valve replacement at our clinic. Median age at repeat operation was 71 years (range, 26-95 years) and there were 437 men (63%). Hypertension was present in 453 patients (65%), diabetes in 128 patients (18%), prior myocardial infarction in 85 patients (12%), and prior stroke in 81 patients (12%). Prior coronary bypass grafting was performed in 212 patients (31%). Median left ventricular ejection fraction was 41% (range, 20-61) and New York Heart Association functional class III or IV was present in 529 patients (76%). ResultsBiological valve re-replacement included most commonly aortic valve in 464 patients (67%) and mitral valve in 170 (24%). Concomitant coronary bypass grafting was performed in 134 patients (19%). Mortality at 30 days occurred in 56 patients (8%). Multivariable analysis with backward stepwise regression identified New York Heart Association functional class (per 1 increment) (hazard ratio, 2.1; 95% confidence interval, 1.06-4.3; P = .03) and prior coronary bypass grafting (hazard ratio, 3.5; 95% confidence interval, 1.2-10.9; P = .03) as independent predictors of early death. Patients with the combination of prior coronary bypass grafting and New York Heart Association functional class III or IV accounted for 26 out of 56 early deaths (46%) and in the absence of this combination, early death in the cohort was 30 out of 694 (4%). Follow-up was available in 602 out of 638 early survivors (94%) for a median of 45 months (range, 1 month-23.4 years). Survival at 5 and 10 years was 63% and 34%, respectively. For patients who died during follow-up, 2-dimensional scatter plots demonstrate durable length of postoperative survival (median, 5.5 years; maximum, 22 years). ConclusionsIn a large population of patients undergoing repeat biological valve replacement, prior coronary bypass grafting and advanced New York Heart Association functional class were associated with increased 30-day mortality, with the remaining population having a low 30-day mortality of 4%. This study could serve as a surgical benchmark to guide patient selection for transcatheter valve-in-valve technology rather than employing a broader application of these techniques to those who may otherwise have low early risk of mortality and durable long-term survival after conventional valve surgery.

Preoperative single ventricle function determines early outcome after second-stage palliation of single ventricle heart

BackgroundSecond-stage palliation with hemi-Fontan or bidirectional Glenn procedures has improved the outcomes of patients treated for single-ventricle heart disease. The aim of this study was to retrospectively analyze risk factors for death after second-stage palliation of single-ventricle heart and to compare therapeutic results achieved with the hemi-Fontan and bidirectional Glenn procedures.Material and methodsWe analyzed 60 patients who had undergone second-stage palliation for single-ventricle heart. Group HF consisted of 23 (38.3%) children who had been operated with the hemi-Fontan method; Group BDG consisted of 37 (61.7%) who had been operated with the bidirectional Glenn method. The analysis focused on 30-day postoperative mortality rates, clinical and echocardiographic data, and early complications.ResultsThe patients’ ages at the time of repair was 33 ± 11.2 weeks; weight was 6.7 ± 1.2 kg. The most common anatomic subtype was hypoplastic left heart syndrome, in 36 (60%) patients. The early mortality rate was 13.3%. Significant preoperative atrioventricular valve regurgitation, single-ventricle heart dysfunction, pneumonia/sepsis, and arrhythmias were associated with higher mortality rates after second-stage palliation. Multivariate analysis identified significant preoperative single-ventricle heart dysfunction as an independent predictor of early death after second-stage palliation. No differences were found in the analyzed variables after bidirectional Glenn compared with hemi-Fontan procedures.ConclusionSignificant preoperative atrioventricular valve regurgitation, arrhythmias and pneumonia/sepsis are closely correlated with mortality in patients with single-ventricle heart after second-stage palliation. Preoperative significant single-ventricle heart dysfunction is an independent mortality predictor in this group of patients. There are no differences in clinical, echocardiographic data, or outcomes in patients treated with the hemi-Fontan compared with bidirectional Glenn procedures.

Clinical Predictors of Early Mortality in Colorectal Cancer Patients Undergoing Chemotherapy: Results From a Global Prospective Cohort Study.

BackgroundEarly mortality is a major problem in colorectal cancer (CRC). We have shown that Khorana Score is predictive of early mortality in other cancers. Here, we evaluated the value of this score and other prognostic variables in predicting early mortality in CRC.MethodsCANTARISK was a prospective, noninterventional, global cohort study in patients with CRC initiating a new chemotherapy regimen. Data were collected at zero, two, four, and six months. Early mortality was defined as death within six months of enrollment. All data were compiled centrally and analyzed after the study closed. Statistically significant univariate associations were tested in multivariable models; adjusted odds ratios (ORs) are presented. Statistical tests were two-sided.Results From 2011 to 2012, 1789 CRC patients were enrolled. The median age was 62 years; 71% were Caucasian. One-third (35%) had a rectal primary, and 65% had metastatic disease. There were 184 (10.3%) patients who died during their first six months in the study. For low, intermediate, and high Khorana Score, there were 8.1%, 11.2% and 32.5% deaths, respectively. In multivariable analyses, Khorana Score was an independent predictor of early death (OR for high/intermediate vs low score = 1.70, P = .0027), in addition to age (OR for each incremental year = 1.03, P = .0014), presence of metastatic disease (OR = 3.28, P < .0001), and Easter Cooperative Oncology Group Performance Status Score of 2 or higher (OR = 3.85, P < .0001).ConclusionsThis study demonstrates that Khorana Score is predictive of early mortality in CRC patients. Intermediate- or high-risk patients, as defined by this score, may benefit from additional interventions aimed at reducing early mortality.

Clinical predictors of early death from sepsis

PurposePatients with severe sepsis who experience rapid, early deterioration and death are of particular concern. Our objective was to identify predictors of early death in Emergency Department (ED) patients with severe sepsis. MethodsSecondary analysis of two prospective studies of adult ED patients with severe sepsis. The primary outcome was early death, defined as death within 24h of triage. ResultsOut of 410 severe sepsis admissions, 20 patients experienced early death. These patients demonstrated significantly higher initial lactate (7.3 versus 3.3mmol/L, p<0.001) and modified SOFA (mSOFA) scores (10 vs 6, p<0.001), were less likely to normalize their lactate (p<0.001), had lower initial pH (p<0.001), and more frequently had early positive blood cultures (p=0.021). Multivariable logistic regression identified initial serum lactate level (OR 1.19, 95% CI 1.06–1.35) and mSOFA score (OR 1.17, 95% CI 1.00–1.36) as independent predictors of early death. A repeat lactate≥5mmol/L had a sensitivity of 55% and specificity of 89% for early death. There were no significant treatment differences between groups. ConclusionInitial serum lactate and mSOFA score were independent predictors of mortality within 24h of ED admission in patients with severe sepsis.

Basal physical inactivity as an independent risk factor for early death in elderly cancer patients: A prospective Brazilian cohort study with 608 patients.

e21534 Background:With the aging of the population, cancer in the elderly people is becoming an increasingly common and complex health problem, particularly in low-middle-income countries, where physical inactivity and obesity have also been challenging and correlated with cancer and aging. The aim of this study is to determine whether the baseline physical inactivity per International Physical Activity Questionnaire(IPAQ) is an independent factor of premature death in the first six months.Methods: prospective cohort study of elderly patients (≥ 60 years). Participants with a recent diagnosis of cancer were from eight community hospitals and one cancer center in Northeast Brazil and were recruited during their first medical appointment at the outpatient oncologic clinic. Sociodemographic and clinical variables were determined and baseline comprehensive geriatric assessment (CGA) was conducted including IPAQ and Time Up and Go test. Data were analyzed using multivariate Cox proportional hazards models, overall survival was estimated using the Kaplan–Meier method and survival curves were compared using the Log rank test. Results:From 2015-2016, 608 patients, mean age 71.9 (SD ±7.4; range 60-96), 50.7% male, were enrolled. Main diagnoses were prostate cancer (29.1%), digestive system cancer (25.5%) and breast cancer (16.0%). 40.3% were considered obese/overweight (BMI ≥ 27). 42.1% were considered physically inactive per IPAQ. The mean of the Time Up and Go test on the physically inactive group by IPAQ was of 13.11s (SD ± 6.5), and of 22.72s (SD± 16.7) on the physically active one. After adjustment for age, site of cancer and cancer stage, the multivariate regression Cox model showed that being physically inactive is an independent predictor for early death (HR = 2.35, 95% CI: 1.50‒ 3.66, p &lt; 0.001).Conclusions:Physical inactivity at admission was identified as a significant predictor of risk for premature death in elderly cancer patients. The evaluation of the physical activity should be incorporated into regular geriatric assessment of elderly cancer patients.

Head Injury in the Elderly: What Are the Outcomes of Neurosurgical Care?

Epidemiologic studies show that an increasing proportion of those presenting with head trauma are elderly. This study details the outcomes of elderly patients with head trauma admitted to a regional United Kingdom neurosurgical unit. The notes and imaging were reviewed of all patients with head injury aged ≥75 years, admitted from 1 January 2007 to 31 December 2010, including mortality data up to at least 2 years after discharge. Outcomes comprised death as an inpatient, by 30 days and 1 year after discharge; Glasgow Outcome Score; discharge Glasgow Coma Scale (GCS) score; recurrence; readmission; reoperation; and complication. A total of 263 patients were admitted: 26 with acute subdural hematoma (ASDH); 175 with chronic subdural hematoma (CSDH); and 46 with mixed subdural collections (ACSDH). Sixteen patients had other head injury diagnoses. Patients with ASDH had a significantly lower survival rate than did those with CSDH or ACSDH: the odds of inpatient death for patients with ASDH was 15.38 (vs. those with CSDH). For all subdural hematomas (SDHs), low American Society of Anesthesiologists score was an independent predictor of early death. Death at 1 year was predicted by head injury severity measured by admission GCS score (P= 0.028), long anesthetic (P= 0.002), and the presence of bilateral SDH (P= 0.002). Unfavorable Glasgow Outcome Scale score (1-3) was predicted by age greater than 85 years (P= 0.029); larger depth of subdural (P < 0.001); and presence of any complication (P= 0.003). Those aged greater than 90 years with presentation GCS score lower than 10 all had poor outcomes. Most elderly patients admitted under neurosurgery after head injury have SDHs. Our results are better than many previously reported; however, the rate of death for those with ASDH is still high.

Slow Gait Speed Is an Independent Predictor of Early Death in Older Cancer Outpatients: Results from a Prospective Cohort Study.

To assess the predictive value of gait speed for early death in older outpatients with cancer. Prospective bicentric observational cohort study. The Physical Frailty in Elder Cancer patients (PF-EC) study (France). One hundred and ninety outpatients with cancer during the first 6 months of follow up in the PF-EC study. The association between usual gait speed over 4 m alone (GS) or included in the short physical performance battery (SPPB) and overall survival within 6 months following a comprehensive geriatric assessment (CGA). A Cox proportional-hazard regression model was performed in non-survivors for clinical factors from the CGA, along with c reactive protein (CRP). Two models were created to assess GS alone and from inclusion in the SPPB. The mean age was 80.6 years, and 50.5% of the participants were men. Death occurred in 11% (n=22) of the participants within the 6 month follow up period. Of these participants, 98% had solid cancers, and 33% had a metastatic disease. A GS < 0.8 m/s (HR=5.6, 95%CI=1.6-19.7, p=0.007), a SPPB < 9 (HR=5.8, 95%CI=1.6-20.9, p=0.007) and a CRP of 50 mg/l or greater (p<0.0001) were significantly associated with early death in the two multivariate analyses. Cancer site and extension were not significantly associated with early death. Walking tests are associated with early death within the 6 month follow up period after a CGA independent of cancer site and cancer extension. GS alone < 0.8 m/s is at least as efficacious as the SPPB in predicting this outcome. GS alone could be used routinely as a marker of early death to adapt oncologic therapeutics. Further studies are needed to validate these preliminary data.

Predictors of Early Death in Childhood Acute Promyelocytic Leukemia: Results of an International Retrospective Study

Background: Acute promyelocytic leukemia (APL) is a rare subtype of childhood acute myeloid leukemia (AML). Bleeding complications occur in 80% of patients at diagnosis and contribute to a higher incidence of early death (ED) in APL compared to other AML subtypes. However, estimates of ED in pediatric APL are imprecise and factors associated with ED in children with APL are unknown.Objectives: To determine the incidence and predictors of ED, defined as death within 60 days from presentation, in childhood APL.Methods: We conducted a retrospective international analysis of children diagnosed with APL between January 1993 and December 2013. The study included 236 patients from the Italian Associazione Italiana Ematologia/Oncologia Pediatrica(AIEOP) group, 148 from the Spanish Programa de Estudio y Tratamiento de las hemopatias Malignas (PETHEMA) group, 112 from the German Berlin-Frankfurt-Munster (BFM) group, 56 from Canadian pediatric centers, 25 from the Nordic Society of Paediatric Haematology/Oncology (NOPHO), 17 from the Dutch Children's Oncology group (DCOG), 14 from St. Jude Children's Research Hospital and 14 from the Australian and New Zealand Children's Hematology-Oncology Group (ANZCHOG). Factors examined included age, sex, ethnicity, body mass index, initial white blood cell (WBC)/peripheral blood (PB) blast and platelet (PLT) counts, initial coagulation parameters, microgranular variant (M3v), intracranial hemorrhage (ICH), time from hospital admission to first all-trans retinoic acid (ATRA) dose, induction treatment including ATRA, and steroid prophylaxis in high-risk patients. All patients had a molecular and/or cytogenetic diagnosis of APL. Univariate and multivariable binary logistic regression analyses were used to determine predictors of ED.Results: The study included 622 children with APL registered on, or treated as per, each group's clinical trial. Five hundred ninety-nine (96.3%) studies included patients registered on therapeutic trials whereas 23 (3.7%) were population based. Overall, the incidence of ED was at 5.6% (35/622) and ranged from 2.5% to 16%. In univariate logistic regression analysis, initial WBC and PB blast counts were predictive of ED, with odds ratios (OR) of 1.17 (95% confidence interval, CI:1.10-1.25, P < 0.001) and 1.24 (CI: 1.10-1.41, P = 0.001), respectively. M3v APL was an independent predictor of ED, with an OR of 3.72 (CI:1.65-8.35, P = 0.001). All other predictors were not statistically significant. Twenty-two/26 patients (84.6%) with ICH had ED as opposed to 9/571 (1.6%) who did not have ICH. Use of ATRA during induction was associated with a lower proportion of ED (4.3% compared to 38% without ATRA, OR = 0.07, CI:0.03-0.19, P<0.001), while the time interval from presentation to first ATRA dose was not predictive (OR = 1.00, CI:0.99-1.01, P = 0.8). WBC and M3v were included in a multivariable logistic regression, as they were the most clinically relevant and statistically significant univariate predictors of ED. Figure 1 illustrates ED probability plotted against WBC counts by APL subtype. Initial WBC was predictive of ED with an OR of 1.15 (CI:1.066-1.23, P < 0.001). There was a trend towards a higher incidence of ED in patients with M3v (OR = 2.18, CI:0.88-5.42, P = 0.093), although not statistically significant at the 5% level. Among 35 patients with ED, 33 occurred within the first 30 days from the start of induction and 2 between day 30 and 60 (due to infection). The most common cause of ED was ICH (n=20, 57.1%); two died before starting therapy. Other causes of ED were pulmonary hemorrhage (n=3), differentiation syndrome (n=3, all within the first 3 weeks of induction), infections (n=5, including the 2 deaths between day 30 and 60), renal failure (n=2), multi-organ failure (n=1) and cerebral thrombosis (n=1).Conclusions: In this largest international retrospective cohort study of ED in pediatric APL to date, we found that initial WBC was significantly associated with ED. APL patients with ICH had a significantly higher probability of ED. Novel measures to reduce hemorrhagic complications should be explored as a strategy to minimize ED in children with APL, especially in high-risk APL. Optimization of the management of coagulation disorders, as well as the use of arsenic trioxide during induction treatment, are expected to reduce the risk of ED in childhood APL. [Display omitted] DisclosuresKaspers:Janssen-Cilag: Research Funding.

Quality-of-life measures as predictors of post-esophagectomy survival of patients with esophageal cancer.

Improving survival after esophagectomy is an important issue in treating patients with esophageal cancer (EC). In addition to standard hospitalization management, periodic assessment of quality-of-life (QOL) measures may be useful to detect disease progression from patients' subjective reports. Therefore, this prospective longitudinal study was undertaken to identify prognostic factors for 3-year survival of EC patients after esophagectomy and to evaluate the impact of QOL measures on these prognostic factors. Patients with EC (n=67) who had a complete tumor resection and were alive 6months after esophagectomy were followed in this study for 3years. Data were collected on patients' sociodemographics, cancer characteristics, adjuvant therapy, general QOL and EC-specific QOL (before esophagectomy and 6months afterward), cancer recurrence, and death. Patients' independent risk factors for 3-year survival were investigated by multivariate Cox regression analysis. Of the 67 participants with EC, 26 had late mortality, with a median survival for the whole cohort of 38.2months (95% CI 31.97-44.35). Independent predictors of early death were early cancer recurrence (within 6months after surgery), poor cognitive function (95% CI 1.020-1.041), and worse dyspnea (95% CI 1.007-1.034). The most predictive factor for early death in EC patients after esophagectomy was cancer recurrence within 6months after surgery. However, QOL measures could be a tool to provide clinical information from patients' perspective suggesting cancer recurrence.

Improving 30-day case fatality after incident myocardial infarction in people with diabetes between 1998 and 2010

ObjectiveTo compare population-level trends in 30-day case fatality following incident myocardial infarction (MI) in people with diabetes and those without diabetes.MethodsWe identified all hospitalised incident MIs in 35–84 year olds...

Admission Glycaemia and Acute Insulin Resistance in Heart Failure Complicating Acute Coronary Syndrome

Few data are so far available on the relation between increased glucose values and insulin resistance and mortality at short-term in patients with acute heart failure (AHF). The present investigation, performed in 409 consecutive patients with AHF complicating acute coronary syndrome (ACS), was aimed at assessing the prognostic role of admission glycaemia and acute insulin resistance (as indicated by the Homeostatic Model Assessment - HOMA index) for death during Intensive Cardiac Care (ICCU) stay. Admission glucose tertiles were considered. In our series, diabetic patients accounted for the 33%. Patients in the third glucose tertiles exhibited the lowest LVEF (both on admission and at discharge), a higher use of mechanical ventilation, intra-aortic balloon pump and inotropic drugs and the highest in-ICCU mortality rate. In the overall population, hyperglycaemic patients (both diabetic and non diabetic) were 227 (227/409, 55.5%). Admission glycaemia was an independent predictor of in-ICCU mortality, together with admission LVEF and eGFR, while acute insulin resistance (as indicated by HOMA-index) was not associated with early death. The presence of admission hyperglycaemia in non-diabetic patients was independently associated with in-ICCU death while hyperglycaemia in diabetic patients was not. According to our results, hyperglycaemia is a common finding in patients with ACS complicated by AHF and it is an independent predictor of early death. Non-diabetic patients with hyperglycaemia are the subgroup with the highest risk of early death.

Associations of objectively assessed physical activity and sedentary time with all-cause mortality in US adults: the NHANES study.

BackgroundSedentary behavior is related to increased mortality risk. Whether such elevated risk can be offset by enhanced physical activity has not been examined using accelerometry data.Materials and MethodsWe examined the relations of sedentary time and physical activity to mortality from any cause using accelerometry data among 1,677 women and men aged 50 years or older from the National Health and Nutrition Examination Survey (NHANES) 2003–2004 cycle with follow-up through December 31, 2006.ResultsDuring an average follow-up of 34.67 months and 4,845.42 person-years, 112 deaths occurred. In multivariate Cox proportional hazard models, greater sedentary time (≥ median of 8.60 hours/day) was associated with increased risk of mortality from any cause (relative risk (RR) = 2.03; 95% confidence interval (CI) = 1.09-3.81). Low level of moderate to vigorous physical activity (< median of 6.60 minutes/day) was also related to enhanced all-cause mortality risk (RR = 3.30; 95% CI = 1.33-8.17). In combined analyses, greater time spent sedentary and low levels of moderate to vigorous physical activity predicted a substantially elevated all-cause mortality risk. As compared with the combination of a low sedentary level and a high level of moderate to vigorous physical activity, the risks of mortality from all causes were 4.38 (95% CI = 1.26-15.16) for low levels of both sedentary time and physical activity, 2.79 (95% CI = 0.77-10.12) for greater time spent sedentary and high physical activity level, and 7.79 (95% CI = 2.26-26.82) for greater time spent sedentary and low physical activity level. The interaction term between sedentary time and moderate to vigorous physical activity was not statistically significant (p = 0.508).ConclusionsBoth high levels of sedentary time and low levels of moderate to vigorous physical activity are strong and independent predictors of early death from any cause. Whether a high physical activity level removes the increased risk of all-cause mortality related to sedentariness requires further investigation.