Predictors Of Lower Survival Research Articles

Survival predictors after pacemaker implantation in a very elderly population

Abstract Background Electrophysiological studies and ablation procedures are the most prevalent activities in electrophysiology. However, device implantation represents a great deal of the daily activity. In several European regions, aging populations are becoming a big concern, not only increasing the number of pacemakers implantations but also raising the age threshold for implantation. Purpose Assessment of survival rates after device implantations on patients over ninety years of age. Are there any markers that could help us infer survival rates? How prevalent are complications? What key performance indicators should be paying attention to? Methods Observational retrospective study of a cohort of 903 patients referred to the arrhythmia unit of our institution for pacemaker implantation, during the period from 2016 to 2019. Cox regression analysis performed over that cohort. Hazard-ratio (HR) and confidence intervals (CI 95%)calculated. Survival curves represented with Kaplan-Meier method and statistical significance estimated with log-rank test. Results Out of the 903 patients, 82 (9.1%) are nonagenarians. Follow-up was 3.97 ± 4.98 years. The mean age at the time of pacemaker implantation was 78.94 ± 10.11 years. Some complications were observed in 9.9% of patients under 90 years of age, compared to 4.9% in those over that age. At the time of the follow-up, 82.5% of the patients were alive. In the univariate analysis, the following predictors of mortality were identified: age; atrial fibrillation (AF); renal function; anemia; comorbidity, estimated by Charlson score; underlying heart disease; type of pacemaker implanted; and, whether the patient was institutionalized. In the multivariate analysis, the following were independent predictors of mortality: age (HR 1.129; 95% CI 1.1-1.159; p<0.001), comorbidity reflected as a Charlson score ≥ 5 (HR 4.116; 95% CI 2.349 -7.212; p<0.001); heart disease (HR 2.496; 95% CI 1.725-3.612; p<0.001); institutionalization of the patient (HR 2.794; 95% CI 1.632-4.783; p<0.001); and the single-chamber pacemaker (HR 2.201; 95% CI 1.455-3.329; p<0.001). In the group of nonagenarian patients, the univariate analysis showed the following variables as predictors of lower survival: age; serum creatinine; comorbidity, estimated by the Charlson score; and, underlying heart disease. In the multivariate analysis, the following were identified as independent predictors of mortality: comorbidity, reflected as a Charlson score ≥ 5 (HR 7.299; 95% CI 2.468-21.589; p<0.001); age (HR: 1.193; 95% CI 1.063- 1.339; p 0.003) and institutionalization of the patient (HR 3.033; 95% CI 1.237- 7.439; p 0.015). Conclusions Comorbility estimated by Charlson score is the most powerful survival predictor after pacemaker implantation, both in the general population and in those over 90 years of age. Being institutionalized is an independent survival predictor in both groups. Nonagenarian patients do not show a higher complication rate.Baseline characteristics >90 y.o.Survival curves K-M

Assessment of biomarkers and clinical parameters as predictors of survival in patients with chagasic heart failure.

Chagas disease, endemic in Latin America and spreading globally due to emigration, has a significant health burden, particularly in relation to chagasic heart failure (HF). Chagasic cardiomyopathy (CCM) is characterized by chronic inflammatory myocardial disease. This study aimed to identify inflammatory parameters and biomarkers that could aid in the management of patients with chagasic HF. A cohort study was conducted at a tertiary cardiology single-center over a mean follow-up period of 2.4 years. The study included patients with HF secondary to CCM enrolled between October 2013 and July 2017. Various clinical parameters, echocardiography findings, parasitemia status, brain natriuretic peptide (BNP) and troponin T (TnT) levels, and inflammatory biomarkers (IL-6, IL-10, IL-12p70, IL-17A, adiponectin, and IFN-γ) were assessed. The study encompassed a cohort of 103 patients, with a median age of 53 years and 70% being male. The left ventricular ejection fraction (LVEF) was 28%, with 40% of patients classified as NYHA II functional class. The median BNP level was 291 pg/ml. The observed mortality rate during the study period was 38.8%. Predictors of lower survival were identified as elevated levels of BNP, TnT, reduced LVEF, and increased adiponectin (thresholds: BNP > 309 pg/ml, TnT > 27.5 ng/ml, LVEF < 25.5%, adiponectin > 38 μg/mL). Notably, there was no evidence indicating a relationship between parasitemia and the inflammatory parameters with lower survival in these patients, including INF-γ, IL-6, IL-10, IL12-(p70), and IL17a. Despite the presence of a chronic inflammatory process, the evaluated inflammatory biomarkers in this cohort were not predictive of survival in patients with chagasic HF with reduced ejection fraction (HFrEF). However, reduced LVEF, elevated BNP, adiponectin levels, and troponin T were identified as predictors of lower survival in these patients.

Utility of 18F-FDG-PET/CT in management and prognostication of treatment naïve late-stage soft tissue sarcomas.

This study evaluated the utility of 18F-fluorodexoyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in staging, grading, and prognostication of Stage III and IV soft tissue sarcomas (STSs). Forty patients (Median age = 32.5 years; 25 men) with histologically proven STSs, prospectively underwent 18F-FDG-PET/CTs at baseline. Three-dimensional region of interests were drawn encompassing the lesions to calculate standardized uptake values (SUVs) and metabolic tumor volumes (MTVs). After segmentation, Haralick statistical texture analysis was performed. Follow-up was available for 35 patients. Survival at 6 months was 71.4% and at 1 year was 57.1%. American Joint Committee on Cancer Stage III was seen in 23 and Stage IV in 17 patients. None of the baseline quantitative and semi-quantitative parameters could predict response or progression. Only reduction in SUVmax in interim PET/CT correlated with baseline SUVmax (Spearman's Rho = 0.533; P = 0.019). Textural parameters namely 'contrast' in CT (P = 0.039) and 'difference entropy' in PET/CT (P = 0.051) could differentiate intermediate from high-grade lesions, with corresponding area under curves being 0.736 (0.533-0.889) and 0.700 (0.518-0.882). M1 disease [Hazard ratio (HR): 3.184 (1.179-8.595); P = 0.022], absence of surgical treatment [HR 0.305 (0.106-0.873), P = 0.027 with surgery], lower MTV/total tumor volume (TTV) [HR: 0.975 (0.953-0.997; P = 0.028] and progressive disease in interim PET/CT [3.483 (0.898-13.515); P = 0.056] were predictors of lower survival in univariate analysis. Only M1 disease was found to be reaching significance in multivariate analysis [HR = 2.683 (0.949-7.580); P = 0.063]. Baseline PET/CT changed management in 12.5% of patients [compared to local-imaging and high-resolution CT chest]; with detection of extra-pulmonary metastases. Though, interim and end of treatment PET/CTs detected more metastatic lesions, management was not impacted. 18F-FDG-PET/CT allows for more accurate M-staging in late-stage STSs, which in turn influences the option of curative surgical resection and thus impacts patient prognosis. Lower baseline MTV/TTV and progression in interim PET/CT are also associated with lower survival. Textural analysis may have a role in noninvasive grading.

Pulselessness After Initiation of Cardiopulmonary Resuscitation for Bradycardia in Hospitalized Children.

Cardiopulmonary resuscitation (CPR) is initiated in hospitalized children with bradycardia and poor perfusion. However, their rate of progression to pulseless cardiac arrest despite CPR and the differences in survival compared with initially pulseless arrest are unknown. We examined the prevalence and predictors of survival of children who progress from bradycardia to pulseless in-hospital cardiac arrest despite CPR. Pediatric patients >30 days and <18 years of age who received CPR at hospitals participating in Get With The Guidelines-Resuscitation during 2000 to 2016 were included. Each CPR event was classified as bradycardia with pulse, bradycardia with subsequent pulselessness, and initial pulseless cardiac arrest. We assessed risk-adjusted rates of survival to hospital discharge using multilevel Poisson regression models. Overall, 5592 pediatric patients were treated with CPR, of whom 2799 (50.1%) received CPR for bradycardia with poor perfusion and 2793 (49.9%) for initial pulseless cardiac arrest. Among those with bradycardia, 869 (31.0%, or 15.5% of cohort) became pulseless after a median of 3 minutes of CPR (interquartile range, 1-9 minutes). Rates of survival to discharge were 70.0% (1351 of 1930) for bradycardia with pulse, 30.1% (262 of 869) for bradycardia progressing to pulselessness, and 37.5% (1046 of 2793) for initial pulseless cardiac arrest (P for difference across groups <0.001). Children who became pulseless despite CPR for bradycardia had a 19% lower likelihood (risk ratio, 0.81 [95% CI, 0.70, 0.93]; P=0.004) of surviving to hospital discharge than those who were initially pulseless. Among children who progressed to pulselessness despite CPR for bradycardia, a longer interval between CPR and pulselessness was a predictor of lower survival (reference, <2 minutes; for 2-5 minutes, risk ratio, 0.54 [95% CI, 0.41-0.70]; for >5 minutes, risk ratio, 0.41 [95% CI, 0.32-0.53]). Among hospitalized children in whom CPR is initiated, half have bradycardia with poor perfusion at the initiation of chest compressions, and nearly one-third of these progress to pulseless in-hospital cardiac arrest despite CPR. Survival was significantly lower for children who progress to pulselessness despite CPR compared with those who were initially pulseless. These findings suggest that pediatric patients who lose their pulse despite resuscitation attempts are at particularly high risk and require a renewed focus on postresuscitation care.

Abstract 108: Pulselessness Despite Cardiopulmonary Resuscitation for Bradycardia in Hospitalized Children: Prevalence, Predictors of Survival, and Implications for Hospital Profiling

Background: Cardiopulmonary resuscitation (CPR) is initiated in hospitalized children with bradycardia and poor perfusion. However, it is unknown how often these children progress to pulseless in-hospital cardiac arrest (IHCA) despite CPR, and whether survival differs from primary pulseless IHCA. Methods: In Get With The Guidelines-Resuscitation (2000-2016), we identified all pediatric patients (age&gt;30 days, &lt;18 years) receiving CPR, and assessed the prevalence and predictors of survival among those progressing from bradycardia to pulselessness after initiation of CPR using multilevel Poisson regression that accounted for the pulseless rhythm. Results: Overall, 5592 pediatric patients were treated with CPR, of whom over half (2799) were for bradycardia with poor perfusion and the remaining 2793 were primary pulseless IHCAs. Among those with bradycardia, 869 (31%, or 16% of entire cohort) progressed to pulselessness after a median of 3 min of CPR (IQR 1- 9). Survival to discharge was 70% for bradycardia without pulselessness, 30% with bradycardia progressing to pulselessness, and 38% with primary pulseless IHCA (P&lt;.001). Children who became pulseless while receiving CPR for bradycardia had a 19% lower likelihood (RR 0.81 [0.70 - 0.93]) of surviving to hospital discharge than those initially pulseless. Among children who progressed to pulselessness while receiving CPR for bradycardia, longer time to pulselessness was an independent predictor of lower survival (ref: &lt;2 min, for 2-5 min: RR 0.54 [0.41 - 0.70]; for &gt;5 min: RR 0.41 [0.32 - 0.53], Figure ). Conclusions: Among non-neonatal pediatric patients in whom CPR is initiated, half have bradycardia with poor perfusion, and nearly one-third of these progress to IHCA despite CPR. Survival was lower for pediatric patients who subsequently became pulseless as compared to those who were initially pulseless. These findings have implications for care delivery and profiling hospital performance for pediatric IHCA.

Predictors of survival in parotid adenocarcinoma not otherwise specified: a National Cancer Database study of 3155 patients

Parotid adenocarcinoma not otherwise specified (PANOS) is a common parotid cancer, but studies specifically on this subject are limited. We conducted a retrospective review of the National Cancer Database. Ten percent of all parotid cancers were PANOS (n = 3155). Median age was 67 years. Most patients were men (62.8%) with high-grade histology (67.2%). Regional metastasis was common (35.9%), whereas occult nodal metastasis (20.2% overall) was less frequent in non-high-grade lesions (8.5% vs 31.6%; p < .001). Distant metastasis was rare (7.9%). Five-year overall survival (OS) was 47%. In multivariate analysis, age, regional metastasis, distant metastasis, high-grade, and T classification were predictors of lower survival. Patients with stage III to IV disease receiving surgery and radiotherapy had a better OS than those receiving surgery alone (51% vs 41%; p < .001). PANOS is an aggressive disease with frequent regional metastasis and low survival. Numerous variables are associated with worse survival. © 2016 Wiley Periodicals, Inc. Head Neck 38:1208-1212, 2016.

Prognostic Factors in Myoepithelial Carcinoma of the Major Salivary Glands.

(1) Identify all cases of myoepithelial carcinoma of the major salivary glands from the National Cancer Data Base (NCDB). (2) Analyze the effect of grade, stage, and regional nodal metastasis on survival in myoepithelial carcinoma of the major salivary glands. Retrospective review of NCDB. Multicenter data pooled from 1998 to 2012 in the NCDB. We identified all reported cases of myoepithelial carcinomas of the major salivary glands from the United States from 1998 to 2012 in the NCDB. Clinical parameters were then examined and analyzed for predictors of survival. A total of 473 cases of myoepithelial carcinoma were identified. Of the reported cases, 38.1% were low grade; 26.7%, intermediate grade; and 35.2%, high grade. When presenting stage was examined, 24.4% were stage I; 30.6%, stage II; 22.5%, stage III; 12.2%, stage IVa; 3.0%, stage IVb; and 4.1%, stage IVc. At presentation, 18.7% of patients had regional nodal disease, and 4.5% had distant metastases. The 3- and 5-year survival rates were 73% and 64%, respectively. The presence of nodal disease significantly reduced mean survival time versus those without (64 vs 108 months, P < .001), as did high-grade disease compared with low grade (67 vs 114 months, P < .001) and stage III/IV compared with stage I/II disease (61 vs 118 months, P < .001). The presence of regional nodal disease, high-grade disease, and advanced stage are predictors of lower survival in myoepithelial carcinoma. Further studies based on types of treatment are warranted.

Extramammary Paget's disease of the penis and anogenital area: SEER analysis.

220 Background: Extramammary Paget's disease (EMPD) is a rare cancer with poorly described outcomes comprising primarily single-institution small case series. We used the Surveillance, Epidemiology, and End Results (SEER) registries to further define survival and predictors of survival in EMPD. Methods: 17 SEER registries were queried for male patients diagnosed with EMPD from 1973 to 2007. Patients were categorized by: penis and anogenital structures (anorectum, scrotum, and skin). Descriptive analyses were conducted to characterize each group including age, year of diagnosis, race, tumor stage, and treatment. Kaplan-Meier and multivariate Cox regression analyses were performed. Results: The cohort consisted of 328 patients. Overall survival based on primary sites of EMPD were: anorectum (24.3%), scrotum (62.4%), penis (62.5%), skin (50.8%). Controlling for patient and disease characteristics, significant factors negatively impacting survival were primary site in the anorectal region compared to scrotum, penis and skin (p&lt;0.001, p=0.008, p=0.005 respectively), presence of distant disease versus localized disease (p=0.01) and radiation only (RT) treatment versus surgery alone (p=0.016). Survival benefit was not increased in patients who underwent combined RT and surgery treatment, as compared to those who were treated with surgery alone (p=0.61). Conclusions: Predictors of lower survival in men with EMPD in this cohort include anorectal location, distant disease and RT-only treatment. RT in addition to surgery does not appear to confer increased survival. [Table: see text] No significant financial relationships to disclose.

Expression of S100A8 in leukemic cells predicts poor survival in de novo AML patients

Cytogenetic stratification remains insufficient for almost half of the acute myeloblastic leukemia (AML) cases, with AML patients requiring subsequent molecular investigation. In our study, we used mass spectrometry (MS)-based proteomic approaches to characterize de novo AML. Fifty-four samples (mononuclear cells from bone marrow or peripheral blood mononuclear cells collected and frozen before treatment) from two independent cohorts of newly diagnosed AML patients were analyzed. We showed that the protein signature of leukemic cells defined two clusters that displayed significant variation for overall and disease-free survival (P=0.001 and 0.0004, respectively). This proteomic classification refines the cytogenetic classes. AML patients with intermediate and unfavorable cytogenetic classifications could be subdivided according to their protein profiles into subgroups with significantly different survival rates. Among the proteins expressed by leukemic cells, we isolated a 10,800-Da marker that retained the highest discriminative value between living and deceased patients. The 10,800-Da marker was identified by MS peptide sequencing as S100A8 (also designated MRP8 or calgranulin A). Western blot analysis confirmed its expression mainly in AML patients with the worst prognosis, arguing for a selective deregulation associated with poor prognosis. These results suggest that the expression of S100A8 in leukemic cells is a predictor of low survival.

Expression of S100A8 in Leukemic Cells Predicts Poor Survival in De Novo AML Patients.

Abstract 276Treatment strategies of acute myeloid leukaemia (AML) largely depend on their cytogenetic status. However this stratification remains insufficient for almost half of the patients, requiring subsequent molecular investigations. In our study, we used mass spectrometry-based proteomic approaches to characterize de novo-AML. Samples (blood mononuclear cells collected and frozen before any treatment) were retrospectively selected from two independent sets of newly diagnosed AML patients, included in prospective clinical trials of the GOELAMS (Groupe d'Etude Ouest-Est des Leucémies aigues). We showed that protein signature of leukemic cells defined 2 groups of patients that displayed significant variation of overall and disease free survival (Fig-1A). This proteomic classification refined cytogenetic classes. Combination of proteomic and cytogenetic allowed a new stratification highly correlated with outcome. In particular, AML with intermediate and high risk cytogenetic could be respectively subdivided according to their protein profiles in two subgroups with significantly different survival (Fig-1B). Interestingly in both type 2 and type 3 cytogenetic groups, a good proteomic profile identified subsets of patients with significantly increased probability of survival, suggesting that the weigh of a good proteomic risk might predominate over a bad predictive cytogenetic. Among proteins expressed by leukemic cells, we isolated a 10800 Da marker that retained the highest discriminative value between alive and deceased patients. The median intensity of the 10800 peak was 94.3 ± 97.7 (7.5-368.7) in living patients compared to 214.2 ± 163.7 (9.0-693.4) in dead patients (p= 0.009). Among normal cytogenetic patients, intensity levels of the marker was also significantly different between dead (217.4 ± 155.7 range 10.4-612.8) and alive patients (26.0 ± 73.1, range 6-168.1; p= 0.008) (Fig-1C). Using a thresholds of 100 (calculated by ROC curves) we were able to correctly identify 82% of patients who died (patients greater than 100) and 70% of patients who stayed alive (patients lower than 100) with a specificity of 65% and 82% respectively. These data were confirmed in a second independent set of patients. 10800 Da marker was identified by MS peptide sequencing as S100A8 (also designated MRP8 or calgranulin A), a cytosolic protein of mature granulocytes. Western blot analysis confirmed its expression mainly in AML patients with the worst prognostic but not in all AML patients, neither in some leukemic and lymphoma cell lines, arguing for a selective deregulation associated with poor prognosis. These results show that expression of S100A8 in leukemic cells at diagnosis might be considered as a predictor of low survival. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Abstract 4290: Risk Factors and Prognostic Implications of Mitral Regurgitation in Severe Aortic Stenosis

Introduction: Mitral regurgitation (MR) is present in nearly half of the patients with severe aortic stenosis (AS). Risk factors for its development and its prognostic implications are not clear. Methods: Search of our echocardiographic database between 1993 to 2003 yielded 740 patients with severe AS defined as aortic valve area (AVA) ≤ 0.8cm2. Thorough chart reviews were conducted to collect clinical and pharmacological data. Mortality data was obtained from National death index. Results: Patient characteristics: age 74±13 years; females 60%, EF 54±20%, aortic valve area 0.67±0.17 cm2. MR grade ≥2+ were present in 339 (46%) patients: 2+ in 166 (22%), 3+ in 115 (16%) and 4+ in 58 (8%). There was a progressive decrease in survival with each grade of MR in the whole cohort as well as the surgically and medically treated subsets (p&lt;0.0001, figure ). Presence of 3 and 4+ MR was associated with a larger LV (p&lt;0.0001), lower EF (p&lt;0.0001), greater age (p=0.0001), a smaller aortic valve area (p=0.001) and female gender (p=0.003). It remained an independent predictor of lower survival after adjusting for group differences using the Cox regression model. There was a lower AVR rate in those with 3 or 4+ MR compared to the rest (32 vs. 41%, p=0.03) despite a distinct independent survival advantage with AVR (RR 0.40, p&lt;0.0001). Conclusion: Significant MR is present in nearly half of the patients with severe AS. The risk factors for its development include age, greater AS severity and LV dysfunction. It is an independent predictor of reduced survival.