Predictor Of 1-year Mortality Research Articles

The Pandora"s box of frailty assessments, which is the best for clinical purpose? A critical review

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Assessment of frailty is recommended for patients undergoing elective transcatheter aortic valve implantation (TAVI) to appreciate post-interventional prognosis. Several studies investigated frailty in this population using single markers (e.g. gait speed), clinical judgment scales (e.g. Rockwood) or composite indexes (e.g. Fried). However, there is a lack of consensus on the most appropriate tool for assessment of frailty in clinical practice. Purpose To evaluate which frailty assessment is the most used and meaningful for post-interventional prognosis in older TAVI patients. Methods A systematic search was performed in PubMed (May 2020). We included randomized controlled trials or observational studies (prospective or retrospective) without time restrictions investigating the association of frailty and 1-year all-cause mortality in older (≥70 years) TAVI-patients. Results 60 studies (151,723 patients) were included. Studies heterogeneity (methods) was considerable. 40 different frailty assessments were identified. The most used single marker (Table) was gait speed (5-meter walk test), investigated in 16 observational studies (8/8 prospective/retrospective with 5,747/40,535 patients). 11 studies found mortality prediction by reduced gait speed, with hazard ratios (HR) between 1.36 (95% confidence interval (CI) 1.23-1.50) and 14.71 (95%CI 6.50-33.30) as well as an Odds Ratio (OR) of 2.34 (95%CI 1.03-5.32). Frailty in composite indexes (Table) predicted mortality in 10 of 11 observational studies 4-items index: HR 1.84 (95%CI 1.23-2.69) to 3.05 (95%CI 1.24-7.46), 5-items index: OR 1.63 (95 CI 1.12-2.37) to 2.75 (95%CI 1.55-4.87). Conclusion Predominantly, single markers, especially gait speed, are used to assess frailty in TAVI-patients. Composite indexes seem to be relieble as well and should be considered for prediction of 1-year mortality. Review results Single marker of frailty Total studies Predictive for 1-y mortality Gait speed (GS) 16 (46582) 11 (41376) Activities of Daily Living (ADL) 14 (6600) 6 (1405) Serum albumin (SA) 15 (49334) 13 (48729) Handgrip strength 10 (5912) 5 (1105) Composite indexes 4-items (GS, HG, SA, ADL) 6 (1957) 6 (1957) 5-items (GS, HG, exhaustion, low PA, weight loss) 5 (3014) 5 (3014) Clinical judgment scale Clinical Frailty Scale (CFS) 9 (6415) 5 (4316) Numbers indicate number of studies and (number of patients)

The predictive value of creatinine clearance for mortality in patients undergoing revascularization

BackgroundRenal function plays a significant role in the prognosis and management of patients with multi-vessel coronary artery disease (CAD) referred for revascularization. Current data lack precise risk stratification using estimated glomerular filtration rate (eGFR) and creatinine clearance.MethodsThis prospective study includes a three-year follow-up of 1112 consecutive patients with multi-vessel CAD enrolled in the 22 hospitals in Israel that perform coronary angiography.ResultsThe Mayo formula yielded the highest mean eGFR (90 ± 26 mL/min per 1.73m2) and chronic kidney disease-epidemiology collaboration (CKD-EPI) the lowest (76 ± 24 mL/min per 1.73m2). Consequently, the Mayo formula classified more patients (56%) as having normal renal function. There was a significant and strong correlation between the values obtained from all five formulas using Cockcroft-Gault as the reference formula: Mayo: r = 0.80, p < 0.001; CKD-EPI: r = 0.87, p < 0.001; modification of diet in renal disease (MDRD): r = 0.84, p < 0.001; inulin clearance-based: r = 0.99, p < 0.001). Multivariable analysis demonstrated that decreased renal function is an independent predictor of 3-year mortality in all five formulas, with risk increasing by 15–25% for each 10-unit decrease in eGFR. Despite the similarities between the formulas, the ability to predict mortality was highest in the Mayo formula and lowest in MDRD.ConclusionsOur data suggest that while the Mayo formula is not currently recommended by any nephrology guidelines, it may be an alternative formula to predict mortality among patients with multivessel CAD, including to the widely used MDRD formula.

Incidence and Prognostic Significance of Hypoxemia in Fibrotic Interstitial Lung Disease: An International Cohort Study

Hypoxemia is a cardinal feature of fibrotic interstitial lung disease (ILD). The incidence, progression, and prognostic significance of hypoxemia in patients with fibrotic ILD currently is unknown. What are the epidemiologic features of hypoxemia and its additive prognostic value in a current risk prediction model of fibrotic ILD? We identified 848 patients with fibrotic ILD (258 with idiopathic pulmonary fibrosis [IPF]) in five prospective ILD registries from Australia, Canada, and Switzerland. Cumulative incidence of exertional and resting hypoxemia from the time of diagnosis was estimated at 1-year intervals in patients with baseline 6-min walk tests, adjusted for competing risks of death and lung transplantation. Likelihood ratio tests were used to determine the prognostic significance of exertional and resting hypoxemia for 1-year mortality or transplantation when added to the ILD-GAP model. The cohort was divided into derivation and validation subsets to evaluate performance characteristics of the extended model (the ILD-GAP-O2 model), which included oxygenation status as a predictor. The 1-, 2-, and 5-year overall cumulative incidence was 6.1%, 17.3%, and 40.1%, respectively, for exertional hypoxemia and 2.4%, 5.6%, and 16.5%, respectively, for resting hypoxemia, which were significantly higher in patients with IPF compared with patients without IPF (P< .001 for both). Addition of exertional or resting hypoxemia to the ILD-GAP model improved 1-year mortality and transplantation prediction (P< .001 for both). The ILD-GAP-O2 model showed improved discrimination (C-index, 0.80 vs0.75) and model fit (Akaike information criteria, 400 vs422) in the validation cohort, with comparable calibration. Patients with IPF have higher cumulative incidence of exertional and resting hypoxemia than patients without IPF. The extended ILD-GAP-O2 model provides additional risk stratification for 1-year prognosis in fibrotic ILD.

Role of transient elastography in the prediction of de novo recurrence of hepatocellular carcinoma after radiofrequency ablation: single-center Egyptian study

BackgroundRadiofrequency is one of the curative treatment options for hepatocellular carcinoma (HCC). Despite the progressive improvements in the efficacy of radiofrequency, the survival of patients with HCC who undergo radiofrequency remains disappointing, mainly due to frequent intrahepatic recurrence of HCC after radiofrequency. We aimed to evaluate the role of transient elastography (TE) in the prediction of de novo recurrence of HCC after radiofrequency and to compare between transient elastography and the serological fibrosis indices in the prediction of de novo recurrence of HCC.ResultsThirty HCC patients underwent baseline transient elastography for preinterventional assessment of the degree of fibrosis. Also noninvasive serum fibrosis indices were calculated from baseline data, including age platelet index (API), cirrhosis discrimination score (CDS), and FIB-4 index. Patients achieving complete response after 1 month post radiofrequency ablation were followed for further 12 months by triphasic abdominal CT scan to detect de novo lesions according to modified RECIST criteria. Baseline means of CDS, FIB4, and API were 6.03 ± 1.5, 3.98 ± 2.58, and 1.24 ± 1.08, respectively. Transient elastography revealed 28 patients with F4 and only 2 patients with F3 (mean liver stiffness 22.45 ± 10.36 Kba). There was a significant negative correlation between liver stiffness (LS) and de novo recurrence of HCC (mean of LS in patients with a complete response was 17.19 ± 3.32 while in those with de novo recurrence was 36.94 ± 5.93, with the best cut off value ≥24.65 (p value < 0.001). There was no significant correlation between CDC, FIB4, API scores, and de novo recurrence of HCC. It was found that the liver stiffness was significantly associated with the prediction of hepatic decompensation (p value <0.001). Also, liver stiffness at the cutoff value > 42.75 (p value = 0.031) was significantly associated with the prediction of 1-year mortality after radiofrequency ablation.ConclusionOur data suggested that liver stiffness measurement in hepatocellular carcinoma patients was a useful predictor of de novo recurrence, overall survival, and possibility of hepatic decompensation after radiofrequency ablation.

Death after discharge: prognostic model of 1-year mortality in traumatic brain injury patients undergoing decompressive craniectomy

BackgroundDespite advances in decompressive craniectomy (DC) for the treatment of traumatic brain injury (TBI), these patients are at risk of having a poor long-term prognosis. The aim of this study was to predict 1-year mortality in TBI patients undergoing DC using logistic regression and random tree models.MethodsThis was a retrospective analysis of TBI patients undergoing DC from January 1, 2015, to April 25, 2019. Patient demographic characteristics, biochemical tests, and intraoperative factors were collected. One-year mortality prognostic models were developed using multivariate logistic regression and random tree algorithms. The overall accuracy, sensitivity, specificity, and area under the receiver operating characteristic curves (AUCs) were used to evaluate model performance.ResultsOf the 230 patients, 70 (30.4%) died within 1 year. Older age (OR, 1.066; 95% CI, 1.045–1.087; P < 0.001), higher Glasgow Coma Score (GCS) (OR, 0.737; 95% CI, 0.660–0.824; P < 0.001), higher d-dimer (OR, 1.005; 95% CI, 1.001–1.009; P = 0.015), coagulopathy (OR, 2.965; 95% CI, 1.808–4.864; P < 0.001), hypotension (OR, 3.862; 95% CI, 2.176–6.855; P < 0.001), and completely effaced basal cisterns (OR, 3.766; 95% CI, 2.255–6.290; P < 0.001) were independent predictors of 1-year mortality. Random forest demonstrated better performance for 1-year mortality prediction, which achieved an overall accuracy of 0.810, sensitivity of 0.833, specificity of 0.800, and AUC of 0.830 on the testing data compared to the logistic regression model.ConclusionsThe random forest model showed relatively good predictive performance for 1-year mortality in TBI patients undergoing DC. Further external tests are required to verify our prognostic model.

Predicting Long-Term Mortality in TAVI Patients Using Machine Learning Techniques.

Background: Whereas transcatheter aortic valve implantation (TAVI) has become the gold standard for aortic valve stenosis treatment in high-risk patients, it has recently been extended to include intermediate risk patients. However, the mortality rate at 5 years is still elevated. The aim of the present study was to develop a novel machine learning (ML) approach able to identify the best predictors of 5-year mortality after TAVI among several clinical and echocardiographic variables, which may improve the long-term prognosis. Methods: We retrospectively enrolled 471 patients undergoing TAVI. More than 80 pre-TAVI variables were collected and analyzed through different feature selection processes, which allowed for the identification of several variables with the highest predictive value of mortality. Different ML models were compared. Results: Multilayer perceptron resulted in the best performance in predicting mortality at 5 years after TAVI, with an area under the curve, positive predictive value, and sensitivity of 0.79, 0.73, and 0.71, respectively. Conclusions: We presented an ML approach for the assessment of risk factors for long-term mortality after TAVI to improve clinical prognosis. Fourteen potential predictors were identified with the organic mitral regurgitation (myxomatous or calcific degeneration of the leaflets and/or annulus) which showed the highest impact on 5 years mortality.

The risk and predictors of mortality in octogenarians undergoing emergency laparotomy: a multicentre retrospective cohort study

This study aims to evaluate the risk of postoperative mortality in octogenarians undergoing emergency laparotomy. In compliance with STROCSS guideline for observational studies, we conducted a multicentre retrospective cohort study. All consecutive patients aged over 80 with acute abdominal pathology requiring emergency laparotomy between April 2014 and August 2019 were considered eligible for inclusion. The primary outcome measure was 30-day postoperative mortality, and the secondary outcome measures were in-hospital mortality and 1-year mortality. Statistical analyses included simple descriptive statistics, binary logistic regression analyses, and Kaplan-Meier survival statistics. A total of 523 octogenarians were eligible for inclusion. Emergency laparotomy in octogenarians was associated with 21.8% (95% CI 18.3-25.6%) 30-day postoperative mortality, 22.6% (95% CI 19.0-26.4%) in-hospital mortality, and 40.2% (95% CI 35.9-44.5%) 1-year mortality. Binary logistic regression analysis identified ASA status (OR, 2.49; 95% CI 1.82-3.38, P < 0.0001) and peritoneal contamination (OR, 2.00; 95% CI 1.30-3.08, P = 0.002) as predictors of 30-day postoperative mortality. The ASA status (OR, 1.92; 95% CI 1.50-2.46, P < 0.0001), peritoneal contamination (OR, 1.57; 95% CI 1.07-2.48, P = 0.020), and presence of malignancy (OR, 2.06; 95% CI 1.36-3.10, P = 0.001) were predictors of 1-year mortality. Log-rank test showed significant difference in postoperative survival rates among patients with different ASA status (P < 0.0001) and between patients with and without peritoneal contamination (P = 0.0011). Emergency laparotomies in patients older than 80 years with ASA status more than 3 in the presence of peritoneal contamination carry a high risk of immediate postoperative and 1-year mortality. This should be taken into account in communications with patients and their relatives, consent process, and multidisciplinary decision-making process for operative or non-operative management of such patients.

Timing of Gastrografin administration in the management of adhesive small bowel obstruction (ASBO): Does it matter?

BackgroundGastrografin challenge is increasingly used as a diagnostic tool to predict patients who may benefit from nonoperative management in adhesive small bowel obstruction. This study explores the optimal timing of Gastrografin in the management of adhesive small bowel obstruction by comparing early versus late Gastrografin challenge. MethodsA retrospective chart review from January 2016 to January 2018 identified patients with adhesive small bowel obstruction who underwent Gastrografin challenge. A receiver operating characteristic curve, to predict a duration of stay less than 5 days, calculated a 12-hour limit which separated early and late groups. Nonoperative and operative patients were compared separately. Our primary outcome was duration of stay. Secondary outcomes included operative requirement, time to the operating room, complication rate, and 1-year mortality. In a separate analysis, multivariable logistic regression identified independent risk factors for 1-year mortality. ResultsOne hundred thirty-four patients were identified (58 early, 76 late). In nonoperative patients, the early group had a shorter duration of stay (3.2 days vs 5.4 days), fewer complications, and a lower complication and 1-year mortality rate (P < .05). In operative patients, the early group had a shorter preoperative duration of stay (1.8 days vs 3.9 days) (P < .05). On multivariable regression, congestive heart failure, any postoperative complication, and operative requirement were the best predictors of 1-year mortality (R2 = 0.321; P < .05). ConclusionGastrografin administration within 12 hours of adhesive small bowel obstruction diagnosis had favorable outcomes in terms of duration of stay, complications, and mortality in nonoperative patients. Moreover, in operative patients, preoperative duration of stay was shortened. Our findings suggest protocolizing early Gastrografin challenge may be an important principle in adhesive small bowel obstruction management.

Predictors of 1-year Mortality After Hip Fracture Surgery in Patients with Age 50years and Above: An Indian Experience.

Hip fractures are considered as a major cause of mortality worldwide. Even after being the second most populous country in world and facing huge burden of hip fractures, there is scarcity of data from India. For the first time in Indian context, we analysed the predictors of mortality after hip fracture surgery in patients with age 50years and above. In this prospective cohort study, patients with age ≥ 50years and having hip fractures presented to our institute from January 2018 through October 2018 were enrolled after meeting including and excluding criteria. Patients were followed-up for minimum 1year after surgery. Association between 1-year mortality and different affecting variables were analysed. Significant variables were further analysed using logistic regression to find independent predictors. Out of 87 patients followed-up for 1year, 25 patients died within 1year of surgery. Age > 75years, road traffic accident as mode of injury, delay in surgery > 48h, > 2 co-morbidities, haemoglobin level ≤ 10 at the time of admission and osteoporosis are significantly associated with high mortality. When these significant variables were further analysed using logistic regression, age > 75years and > 2 co-morbidities were only factors associated independently with high mortality. In patients with age 50years and above, following hip fracture surgery, age > 75years and > 2 co-morbidities are the predictors of 1-year mortality when adjusted for other variable. A better designed multi-centric study can be more helpful in understanding the things in Indian context.

Prolonged QTc interval predicts long-term mortality in cirrhosis: a propensity score matching analysis

Background Prolonged corrected QT (QTc) interval is a hallmark of cirrhotic cardiomyopathy (CCM) and has been ascertained to predict mortality in cirrhosis. However, some critical issues remain to be addressed including unanimous cut-off, calculation approach and applicable population. Methods A total of 274 patients with cirrhosis were included. The prolonged QTc interval over 440 ms according to adjusted Fridericia’s formula was used to stratify enrolled subjects. Independent predictors of 3-year mortality were identified with Cox regression model. The Kaplan–Meier method was implemented to obtain survival curves. To reduce impact of selection bias and possible confounders, a propensity score matching (PSM) analysis was used. Results QTc > 440 ms was an independent risk factor in the entire cohort and PSM subset (HR 2.532, 95% CI 1.431–4.480, p=.001; HR 2.802, 95% CI 1.171–6.701, p=.021, respectively). Subgroup analysis showed that QTc > 440 ms was an independent predictor in cirrhotics with age ≤60 years (HR = 1.02, p=.035) and in the presence of ascites (HR = 1.01, p=.008). Conclusions The prolonged QTc interval might help to identify patients with high-risk of all-cause mortality.

Updated external validation of the SORG machine learning algorithms for prediction of ninety-day and one-year mortality after surgery for spinal metastasis

Surgical decompression and stabilization in the setting of spinal metastasis is performed to relieve pain and preserve functional status. These potential benefits must be weighed against the risks of perioperative morbidity and mortality. Accurate prediction of a patient's postoperative survival is a crucial component of patient counseling. To externally validate the SORG machine learning algorithms for prediction of 90-day and 1-year mortality after surgery for spinal metastasis. Retrospective, cohort study PATIENT SAMPLE: Patients 18 years or older at a tertiary care medical center treated surgically for spinal metastasis OUTCOME MEASURES: Mortality within 90 days of surgery, mortality within 1 year of surgery METHODS: This is a retrospective cohort study of 298 adult patients at a tertiary care medical center treated surgically for spinal metastasis between 2004 and 2020. Baseline characteristics of the validation cohort were compared to the derivation cohort for the SORG algorithms. The following metrics were used to assess the performance of the algorithms: discrimination, calibration, overall model performance, and decision curve analysis. Sixty-one patients died within 90 days of surgery and 133 died within 1 year of surgery. The validation cohort differed significantly from the derivation cohort. The SORG algorithms for 90-day mortality and 1-year mortality performed excellently with respect to discrimination; the algorithm for 1-year mortality was well-calibrated. At both postoperative time points, the SORG algorithms showed greater net benefit than the default strategies of changing management for no patients or for all patients. With an independent, contemporary, and geographically distinct population, we report successful external validation of SORG algorithms for preoperative risk prediction of 90-day and 1-year mortality after surgery for spinal metastasis. By providing accurate prediction of intermediate and long-term mortality risk, these externally validated algorithms may inform shared decision-making with patients in determining management of spinal metastatic disease.

Prognostic value of a comprehensive geriatric assessment for predicting one-year mortality in presumably frail patients with symptomatic aortic stenosis.

Despite suffering a severe aortic stenosis, some patients are denied either surgical or transcatheter aortic valve implantation (TAVI) therapy because of a frail condition. We aimed to identify whether a comprehensive geriatric assessment (CGA) might be useful to predict the prognosis of presumably frail patients with severe aortic stenosis. Between March 2011 and July 2016, 818 patients were consecutively and prospectively enrolled. 161 had a CGA and were considered for analysis. Considering combined CGA and heart team recommendations, 102 TAVI procedures were performed (TAVI group) and 59 patients constituted the no-TAVI group. The primary endpoint was all-cause mortality at 1 year. There was no difference between the TAVI and the no-TAVI groups considering morphometric data, cardiovascular risk factors or symptoms. The no-TAVI group had higher surgical risk (logistic EuroSCORE1 33.4 ±17.8 vs. 22.7 ±14.9; p < 0.001) and more moderate renal insufficiency (82% vs. 57%; p = 0.001). One-year mortality was 16% in the TAVI group and 46% in the no-TAVI group (p < 0.001). Multivariate analysis revealed that history of pulmonary edema, moderate renal failure, and not having a TAVI were associated with 1-year mortality. There was an interaction between the Five-Times-Sit-to-Stand-Test (FTSST) and the effect of TAVI on mortality (p = 0.049), as FTSST was the only predictor for 1-year mortality in the no-TAVI group (HR = 0.18, 95% CI: 0.04-0.76; p = 0.019). One-year mortality was higher in geriatric-assessed frail patients who did not undergo TAVI. FTSST, which assesses patients' mobility, was the only prognostic marker for 1-year mortality, on top of the usual medical parameters.

De Ritis ratio as a predictor of 1-year mortality after burn surgery

BackgroundBurn is an overwhelming injury. The De Ritis ratio, defined as aspartate aminotransferase to alanine aminotransferase ratio, can be used to predict poor outcomes. We evaluated the risk factors, including the De Ritis ratio, associated with 1-year mortality after burn surgery. MethodsPatients who underwent burn surgery from 2009 to 2019 were retrospectively evaluated. Multivariate Cox regression analysis was conducted to evaluate the risk factors for 1-year mortality after burn surgery. Receiver operating characteristic (ROC) curve analysis of the De Ritis ratio was performed to predict postoperative 1-year mortality. Kaplan–Meier survival analysis was also conducted. Other postoperative outcomes, such as durations of hospital and intensive care unit stays, acute kidney injury, and major adverse cardiac events, were evaluated. ResultsOne-year mortality after burn surgery occurred in 247 (19.9%) of 1244 patients. The risk factors for 1-year mortality after burn surgery were the De Ritis ratio, age, American Society of Anesthesiologists physical status, diabetes mellitus, total body surface area burned, inhalation injury, serum creatinine level, and serum albumin level. The area under the ROC curve for the De Ritis ratio was 0.716 (optimal cutoff=1.9). The 1-year mortality rate after burn surgery was significantly higher in patients with a De Ritis ratio >1.9 than in those with a De Ritis ratio ≤1.9 (35.8% vs. 11.8%, P<0.001). The survival rate was significantly higher in patients with a De Ritis ratio ≤1.9 than in those with a De Ritis ratio >1.9 (log-rank test, P<0.001). Intensive care unit stay, acute kidney injury, and major adverse cardiac events were significantly higher in patients with a De Ritis ratio >1.9 than in those with a De Ritis ratio ≤1.9 (P=0.006, P<0.001, and P<0.001, respectively). ConclusionsThe preoperative De Ritis ratio was a risk factor for 1-year mortality after burn surgery. The De Ritis ratio >1.9 was significantly associated with an increased 1-year mortality after burn surgery. These findings emphasized the importance of identifying burn patients with an increased De Ritis ratio to reduce the mortality after burn surgery.

Prognosis of patients with severe left ventricular dysfunction after transvenous lead extraction and the need for additional hemodynamic support in the perioperative period

Transvenous lead extraction (TLE) is necessary because of system infection, lead malfunction, or system upgrade. Patients with severe left ventricular dysfunction (SLVD) undergoing TLE may be at a higher risk because hemodynamic parameters may change unfavorably during or after TLE; however, this has not yet been clarified. The purpose of this study was to examine whether patients with SLVD undergoing TLE have higher mortality. All patients who underwent TLE were stratified as follows: patients with ejection fraction ≤ 35% (SLVD group) and those with ejection fraction > 35% (non-SLVD group). We assessed the data of 200 patients [SLVD group, 36 (18%); non-SLVD group, 164 (82%)]). Brain natriuretic peptide level and cardiac resynchronization therapy rate were higher in the SLVD group than in the non-SLVD group. There were no significant between-group differences in major complications and clinical success rates. Patients with SLVD were more likely to require additional hemodynamic support, such as catecholamine infusion, temporary atrium-ventricle sequential pacing, and temporary cardiac resynchronization therapy pacing (27.8% vs 1.2%; P < .001). The survival rate was not significantly different between the groups at 30 days and 1 year after TLE (SLVD vs non-SLVD: 30 days: 97.2% vs 99.4%; P = .215; 1 year: 80.6% vs 91.5%; P = .053). Multivariate Cox regression analysis revealed log brain natriuretic peptide and serum hemoglobin levels as predictors for 1-year mortality. The prognosis after TLE was comparable between patients with and without SLVD. However, additional hemodynamic support was often necessary for patients with SLVD.

A mortality risk score for septuagenarians undergoing orthotopic heart transplantation.

With septuagenarians undergoing orthotopic heart transplantation (OHT) more frequently, we aimed to develop a risk score for 1-year mortality in this population. Septuagenarian OHT recipients were identified from the UNOS registry between 1987 and 2018. The primary outcome was 1-year post-OHT mortality. Patients were randomly divided into derivation and validation cohorts. Associated covariates were entered into a multivariable logistic regression model. A risk score was created using the magnitudes of the odds ratios from the derivation cohort, and its 1-year post-OHT mortality prediction capacity was tested in the validation cohort. A total of 1156 septuagenarians were included, and they were randomly divided into derivation (66.7%, n=771) and validation (33.3%, n=385) cohorts. An 11-point risk score incorporating 4 variables was created, which included mechanical ventilation, serum bilirubin, serum creatinine, and donor age. The predicted 1-year mortality ranged from 4.2% (0 points) to 48.1% (11-points) (p<.001). After cross-validation, the c-index was 0.67 with a Brier score of 0.10. Risk scores above 3 points portended a survival disadvantage at 1-year follow-up (p<.001). This 11-point risk score for septuagenarians is predictive of mortality within 1-year of OHT and has potential utilization in improving recipient evaluation and selection of elderly patients.

Developing a Simpler Prognosticating Tool: Comparing the Combined Assessment of Risk Encountered in Surgery Score with Deyo-Charlson Comorbidity Index and The American Society of Anesthesiologists Physical Status Score in Predicting 2 years Mortality after Hip Fracture Surgery

Background: The use of risk stratification tools in identifying high-risk hip fracture patients plays an important role during treatment. The aim of this study was to compare our locally derived Combined Assessment of Risk Encountered in Surgery (CARES) score with the the American Society of Anesthesiologists physical status (ASA-PS) score and the Deyo–Charlson Comorbidity Index (D-CCI) in predicting 2-year mortality after hip fracture surgery. Methods and Material: A retrospective study was conducted on surgically treated hip fracture patients in a large tertiary hospital from Jan 2013 through Dec 2015. Age, gender, time to surgery, ASA-PS score, D-CCI, and CARES score were obtained. Univariate and multivariable logistic regression analyses were used to assess statistical significance of scores and risk factors, and area under the receiver operating characteristic (ROC) curve (AUC) was used to compare ASA-PS, D-CCI, and CARES as predictors of mortality at 2 years. Results: 763 surgically treated hip fracture patients were included in this study. The 2-year mortality rate was 13.1% (n = 100), and the mean ± SD CARES score of surviving and demised patients was 21.2 ± 5.98 and 25.9 ± 5.59, respectively. Using AUC, CARES was shown to be a better predictor of 2-year mortality than ASA-PS, but we found no statistical difference between CARES and D-CCI. A CARES score of 23, attributable primarily to pre-surgical morbidities and poor health of the patient, was identified as the statistical threshold for “high” risk of 2-year mortality. Conclusion: The CARES score is a viable risk predictor for 2-year mortality following hip fracture surgery and is comparable to the D-CCI in predictive capability. Our results support the use of a simpler yet clinically relevant CARES in prognosticating mortality following hip fracture surgery, particularly when information on the pre-existing comorbidities of the patient is not immediately available.

Prognostication in Home-Dwelling Patients with Advanced Dementia: The Palliative Support DEMentia Model (PalS-DEM)

ObjectiveDifficulties with prognostication prevent more patients with advanced dementia from receiving timely palliative support. The aim of this study is to develop and validate a prognostic model for 6-month and 1-year mortality in home-dwelling patients with advanced dementia. DesignProspective cohort study. Setting and ParticipantsThe data set of 555 home-dwelling patients with dementia at Functional Assessment Staging Test stage 7 was split into derivation (n = 275) and validation (n = 280) cohorts. MethodsCox proportional hazards regression modeled survival in the derivation cohort using prognostic variables identified in univariate analysis. The model was validated internally and using 10-fold cross-validation. Area under the receiver operating characteristic curve measured the accuracy of the final model. ResultsFour hundred nineteen (75.5%) patients died with a median follow-up of 47 days [interquartile range (IQR) 161]. Prognostic variables in the multivariate model included serum albumin level, dementia etiology, number of homecare admission criteria fulfilled, presence of moderate to severe chronic kidney disease, peripheral vascular disease, quality of life in late-stage dementia scores, housing type, and the Australian National Sub-Acute and Non-Acute Patient palliative care phase.The model was refined into a parsimonious 6-variable model [Palliative Support DEMentia Model (PalS-DEM)] consisting of age, dementia etiology, Functional Assessment Staging Test stage, Charlson Comorbidity Index scores, Australian National Sub-Acute and Non-Acute Patient palliative care phase, and 30-day readmission frequency for the prediction of 1-year mortality. The area under the receiver operating characteristic curve was 0.65 (95% confidence interval 0.59–0.70). Risk scores categorized patients into 3 prognostic groups, with a median survival of 175 days (IQR 365), 104 days (IQR 246), and 19 days (IQR 88) for the low-risk (0‒1 points), moderate-risk (2‒4), and high-risk (≥5) groups, respectively. Conclusions and ImplicationsThe PalS-DEM identifies patients at high risk of death in the next 1 year. The model produced consistent survival results across the derivation, validation, and cross-validation cohorts and will help healthcare providers identify patients with advanced dementia earlier for palliative care.

CT fatty muscle fraction as a new parameter for muscle quality assessment predicts outcome in venovenous extracorporeal membrane oxygenation

Impaired skeletal muscle quality is a major risk factor for adverse outcomes in acute respiratory failure. However, conventional methods for skeletal muscle assessment are inapplicable in the critical care setting. This study aimed to determine the prognostic value of computed tomography (CT) fatty muscle fraction (FMF) as a biomarker of muscle quality in patients undergoing extracorporeal membrane oxygenation (ECMO). To calculate FMF, paraspinal skeletal muscle area was obtained from clinical CT and separated into areas of fatty and lean muscle based on densitometric thresholds. The cohort was binarized according to median FMF. Patients with high FMF displayed significantly increased 1-year mortality (72.7% versus 55.8%, P = 0.036) on Kaplan–Meier analysis. A multivariable logistic regression model was built to test the impact of FMF on outcome. FMF was identified as a significant predictor of 1-year mortality (hazard ratio per percent FMF, 1.017 [95% confidence interval, 1.002–1.033]; P = 0.031), independent of anthropometric characteristics, Charlson Comorbidity Index, Simplified Acute Physiology Score, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction Score, and duration of ECMO support. To conclude, FMF predicted 1-year mortality independently of established clinical prognosticators in ECMO patients and may have the potential to become a new muscle quality imaging biomarker, which is available from clinical CT.

Addition of routine blood biomarkers to TIMI risk score improves predictive performance of 1-year mortality in patients with ST-segment elevation myocardial infarction

BackgroundSeveral biomarkers have been proposed as independent predictors of poor outcomes in ST-segment elevation myocardial infarction (STEMI). We investigated whether adding information obtained from routine blood tests including hypoxic liver injury (HLI), dysglycemia, anemia, and high neutrophil to lymphocyte ratio (NLR) could improve the prognostic performance of the TIMI risk score for the prediction of 1-year mortality.MethodsA total of 1057 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) between 2007 and 2014 were retrospectively enrolled from 4-regional hospitals. HLI and dysglycemia were defined as serum transaminase > twice the normal upper limit and glucose < 90 or > 250 mg/dL, respectively. The effect of adding biomarkers to the TIMI risk score on its discriminative ability was assessed using c-statistic, net reclassification improvement (NRI), and integrated discrimination improvement (IDI).ResultsThe 1-year mortality rate was 7.1%. The best cutoff value of NLR for the prediction of 1-year mortality was 4.3 (sensitivity, 67%; specificity, 65%). HLI (HR 2.019; 95% CI 1.104–3.695), dysglycemia (HR 2.535; 95% CI 1.324–3.923), anemia (HR 2.071; 95% CI 1.093–3.923), and high NLR (HR 3.651; 95% CI 1.927–6.918) were independent predictors of 1-year mortality. When these 4 parameters were added to the TIMI risk score, the c-statistic significantly improved from 0.841 to 0.876 (p < 0.001), and the NRI and IDI were estimated at 0.203 (95% CI 0.130–0.275; p < 0.001) and 0.089 (95% CI 0.060–0.119; p < 0.001), respectively.ConclusionsThe addition of HLI, dysglycemia, anemia, and high NLR to the TIMI risk score may be useful for very early risk stratification in patients with STEMI receiving primary PCI.

Abstract 14216: Predictors of 30-day and 1-year Mortality After Transvenous Lead Extraction for Device Infection

Introduction: The incidence of device infection is constantly increasing; requiring transvenous lead extraction (TLE). Data regarding predictors of short and long-term mortality after TLE for infection are limited. Methods: We collected data regarding 30-day and 1-year mortality of patients undergoing TLE at a university hospital between April 2004 and June 2015. Patients with less than 30-day follow up were excluded. Results: Out of total 1223 TLE procedures, 700 were performed for infectious indications. 30-day follow-up was available for 620 patients (88.6%) and 1-year follow up was available for 541 patients (77.3%). Overall 30-day mortality was 9% (4.3% for pocket infection, 12.3% for systemic infection) and 1-year mortality was 27.5% (16% for pocket infection, 35.8% for systemic infection). Patient age, end-stage renal disease, history of valve replacement, atrial fibrillation, Staphylococcus aureus infection, systemic infection, any procedural complication, elevated WBC count, low hemoglobin, need for CCU admission, need for pressor support, acute kidney injury, cardiogenic shock and need for blood transfusion were predictors of both 30-day and 1-year mortality in univariate analysis. Any retained fragment was predictor of 30-day mortality. Peripheral vascular disease and low platelet count were predictors of 1-year mortality. Patient age, history of valve replacement, need for pressor support and low hemoglobin were independent predictors of 30-day as well as 1-year mortality in multivariate analysis. End-stage renal disease, atrial fibrillation, elevated WBC count and need for CCU admission were independent predictors of 30-day mortality. Systemic infection, low platelet count and need for blood transfusion were predictors of 1-year mortality. Strongest predictor of 30-day mortality was history of valve replacement (Odds ratio 4.23) and strongest predictor of 1-year mortality was need for pressor support (Odds ratio 3.12). Conclusions: In conclusion, 30-day and 1-year mortality after device infection remains high despite successful TLE. Patient age, history of valve replacement, need for pressor support and low hemoglobin are independent predictors of both short and long-term mortality in multivariate analysis.