Predictor Of Mortality In Adults Research Articles

Systematic review and meta-analysis of non-SCORTEN predictors of mortality in Stevens-Johnson syndrome and toxic epidermal necrolysis.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, severe cutaneous adverse reactions that result in in-hospital death in 12-49% of cases. The severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is the most widely used mortality prognosis score; however, it has been shown to have critical limitations. Other mortality predictors not incorporated in SCORTEN or other predictor tools are being increasingly reported. This systematic review and meta-analysis aimed to synthesize and evaluate the predictors of mortality in adults with Stevens-Johnson syndrome and toxic epidermal necrolysis not included in SCORTEN. It was registered with the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) and conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Potential bias was assessed using the National Institutes of Health (NIH) criteria. Forty articles describing results from 52,398 cases were included. Sixteen predictors were reported in five or more articles, and thirty-three were reported in two to four articles. Meta-analysis showed preexisting renal disease (odds ratio (OR): 3.14, 95% confidence interval (CI): 1.99-4.97, P < 0.0001, I2 = 21%), renal involvement (OR: 5.62, 95% CI: 2.29-13.77, P = 0.0002, I2 = 36%), respiratory involvement (OR: 3.14, 95% CI: 1.25-7.92, P = 0.015, I2 = 66%), diabetes mellitus (OR: 1.87, 95% CI: 1.21-2.89, P = 0.005, I2 = 19%), sepsis (OR: 5.64, 95% CI: 2.81-11.29, P < 0.0001, I2 = 63%), comorbidity (OR: 9.13, 95% CI: 4.60-18.12, P < 0.0001, I2 = 0%), and time to hospitalization (OR: 2.56, 95% CI: 1.15-5.65, P = 0.021, I2 = 93) increased risk of mortality. This systematic review and meta-analysis support several clinical and laboratory parameters not included in SCORTEN (preexisting renal disease, renal involvement, respiratory involvement, diabetes mellitus, sepsis, comorbidities, and time to hospitalization) as predictors of mortality in adults with SJS/TEN. The future utilization of these factors may improve mortality prognostication in adults with SJS/TEN.

Clinical manifestations and biomarkers to predict mortality risk in adults with invasive Streptococcus dysgalactiae subsp. equisimilis infections

PurposeThe incidence of invasive Streptococcus dysgalactiae subsp. equisimilis (iSDSE) infections is increasing in developed countries, but studies on the risk factors for death in iSDSE infections are scant. Here, we aimed to clarify risk factors and predictors of mortality in adults with iSDSE infections.MethodsA multicentre observational study of adults with iSDSE infections was conducted to investigate the effects of host factors, disease severity, biomarkers, and antibiotic regimens, and bacterial factors on 28-day mortality.ResultsThe overall mortality rate of 588 patients was 10.4%, with a significant increase in those aged ≥ 60 years. Most of the patients (97.4%) had underlying diseases. The mortality rate (70.4%) of patients with severe disease was significantly higher than that of patients with mild-to-moderate disease (4.3%; p < 0.001). The risk factors for death identified using multivariable analysis were age ≥ 60 years (hazard ratio [HR], 3.4; 95% confidence interval [CI], 1.0–11.3, p = 0.042); severe disease (HR, 15.0; 95% CI 7.7–29.2, p < 0.001); bacteraemia without primary focus (HR, 20.5; 95% CI 2.8–152.3, p = 0.003); serum creatinine ≥ 2.0 mg/dL (HR, 2.2; 95% CI 1.2–4.0, p = 0.010); serum creatine kinase ≥ 300 IU/L (HR, 2.1; 95% CI 1.1–3.8, p = 0.019); and macrolide resistance (HR, 1.8; 95% CI 1.0–3.3, p = 0.048). Treatment regimens and emm types were not associated with poor outcomes.ConclusionEvaluation of clinical manifestations and biomarkers on admission is important to predict invasive SDSE infection prognosis.

Unfavorable social determinants of health and risk of mortality in adults with diabetes: findings from the National Health Interview Survey

IntroductionUnderstanding the role of social determinants of health as predictors of mortality in adults with diabetes may help improve health outcomes in this high-risk population. Using population-based, nationally representative data,...

Impact of COVID-19 infection on patients admitted with nonvariceal upper gastrointestinal bleeding: an analysis from the National Inpatient Sample

Background Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a medical emergency that has significant morbidity and mortality. The available data about the impact of COVID-19 infection on mortality in patients with NVUGIB is limited. Methods We identified all hospitalizations with a principal diagnosis of NVUGIB in 2020. The baseline characteristics and clinical outcomes of patients with COVID-19 infection were compared to those without COVID-19 infection. Results NVUGIB patients with COVID-19 infection had higher mortality (5% vs 2%, P < 0.0001), a longer mean length of stay (6.85 vs 4.48 days, P < 0.0001), and a lower rate of esophagogastroduodenoscopy utilization (40% vs 51%, P < 0.0001) than those without COVID-19 infection. Multivariate logistic regression analysis showed that COVID-19 infection was associated with a higher mortality rate (odds ratio 2.2, 95% confidence interval, 1.4–3.4). Conclusions COVID-19 infection is an independent predictor of mortality in adults hospitalized with NVUGIB.

Predictors of Mortality in Adults With Sickle Cell Disease Admitted to the Intensive Care Unit in King Saud Medical City, Saudi Arabia.

Background Sickle cell disease (SCD) is the most common genetic blood disorder in Saudi Arabia. A limited number of studies have been conducted on SCD patients regarding their intensive care unit (ICU) admissions. We aimed to identify the cause of ICU admission in SCD patients and to identify predictors of mortality. Methodology We identified 64 patients with SCD, aged 14 years and older, who were admitted to the ICU of King Saud Medical City, Riyadh, Kingdom of Saudi Arabia, from January 1, 2017, to December 31, 2020. Results Acute chest syndrome was the most frequent primary diagnosis for ICU admission in 29 (45.3%) patients followed by vaso-occlusive crisis in 23 (35.9%) patients. Pregnancy in eight (12.5%) patients was the most prevalent co-existing condition. The median age was 29 years, with males comprising 45.3% and females comprising 54.7% of the study population. Arterial blood gas pH less than 7.2 on ICU admission (p= <0.001), hemodialysis support (p= 0.049), the use of vasopressors (p= 0.016), intubation (p= <0.001), and being intubated within the first 24 hours of ICU stay (p= 0.04) had a statistically significant association with mortality at ICU discharge out of all the variables tested. Mortality on ICU discharge was 7 (10.9%). Conclusion This was a retrospective study carried out in King Saud Medical City. Comparing the results of the study to those of similar ones conducted around the world revealed a low SCD ICU mortality rate. This low mortality may be a result of improved overall ICU care. We recommend a multi-center, prospective study in future.

NT-proBNP Is a Predictor of Mortality in Adults with Pulmonary Arterial Hypertension Associated with Congenital Heart Disease.

About 5-10% of adults with congenital heart disease (ACHD) will develop pulmonary arterial hypertension (PAH), which is associated with significant mortality. Studies on risk factors for poor outcome in a contemporary cohort of these patients with PAH associated with CHD (PAH-CHD) are rare. In this retrospective, single-center study, adult patients with the diagnosis PAH-CHD who had at least one contact as an outpatient or inpatient at the German Heart Centre Munich during the period January 2010-September 2019 were included. Patients with PAH without a CHD were excluded. The primary endpoint was all-cause mortality. Altogether, 158 patients (mean age 39.9 ± 15.4 years, female 64.6%) were included in the study. A pre-tricuspid shunt was present in 17.7%, other shunts in 51.3%, PAH associated with complex CHD in 22.8%, and segmental PAH in 8.2%. An NT-proBNP measurement at baseline was available in 95 patients (60.1%). During a median follow-up of 5.37 years [IQR 1.76-8.63], the primary endpoint occurred in 10 patients (6.7%). On univariate analysis, CRP (log) (HR 3.35, 95% CI (1.07-10.48), p = 0.037), NT-proBNP (log) (HR: 7.10, 95% CI: 1.57-32.23, p = 0.011), and uric acid (HR: 1.37, 95% CI: 1.05-1.79, p = 0.020) were predictors of the primary endpoint. On multivariate analysis, only NT-proBNP (log) (HR: 6.91, 95% CI: 1.36-35.02, p = 0.0196) remained as an independent predictor. NT-proBNP is an independent predictor of all-cause mortality in a contemporary cohort of PAH-CHD patients. The role of CRP and uric acid should be further assessed in future studies.

Predictors of Mortality in Adults with Acute Kidney Injury Requiring Dialysis: A Cohort Analysis.

Introduction Acute kidney injury (AKI) requiring renal replacement therapy is accompanied by considerable mortality. This present study evaluated predictors of mortality at initiation of hemodialysis (HD) in AKI patients in Goma (in the Democratic Republic of the Congo (DRC)). Methods A single-centre cohort survey evaluated the clinical profile and survival rates of AKI patients admitted to HD in the only HD centre in Goma, North Kivu province (DRC). Data were collected from patients who underwent HD for AKI. Patient demographics, comorbidities, clinical presentation, laboratory tests, and mortality were reviewed and analyzed. The survival study used the Kaplan–Meier curve. Predictors of mortality were evaluated using Cox regression. Results Of the 131 eligible patients, the mean age was 43.69 ± 16.56 years (range: 18–90 years). Men represented 54.96% of the cohort. The overall HD mortality rate was 25.19% (n = 33). In multivariate analysis, independent predictors of mortality in AKI stage 3 patients admitted to HD were as follows: age ≥ 60 years (adjusted hazard ratio (AHR) = 15.89; 95% CI: 3.98–63.40; p < 0.0001), traditional herbal medicine intake (AHR = 5.10; 95% CI: 2.10–12.38; p < 0.0001), HIV infection (AHR = 5.55; 95% CI: 1.48–20.73; p=0.011), anemia (AHR = 9.57; 95% CI: 2.08–43.87; p=0.004), hyperkalemia (AHR = 6.23; 95% CI: 1.26–30.72; p=0.025), respiratory distress (AHR = 4.66; 95% CI: 2.07–10.50; p < 0.0001), and coma (AHR = 11.39; 95% CI: 3.51–36.89; p < 0.0001). Conclusion Initiation of hemodialysis with AKI has improved survival in patients with different complications.

Decline in Ventilatory Ratio as a Predictor of Mortality in Adults With ARDS Receiving Prone Positioning.

Prone positioning reduces mortality in patients with moderate/severe ARDS. It remains unclear which physiological parameters could guide clinicians to assess which patients are likely to benefit from prone position. This study aimed to determine the association between relative changes in physiological parameters at 24 h of prone positioning and ICU mortality in adult subjects with ARDS. We conducted a cohort study using the VENTILA database, including adults with ARDS receiving prone positioning. We used multivariable logistic regression to assess the association between relative changes in physiological parameters (PaO2 /FIO2 , dynamic driving pressure, PaCO2 , and ventilatory ratio defined as [minute ventilation [mL/min] × PaCO2 [mm Hg]]/[predicted body weight × 100 [mL/min] × 37.5 [mm Hg] with ICU mortality) (primary outcome). We report adjusted odds ratios with 95% CI as measures of association. We included 156 subjects of which 82 (53%) died in the ICU. A relative decline in the ventilatory ratio at 24 h was associated with lower ICU mortality (odds ratio 0.80 [95% CI 0.66-0.97], every 10% decrease). Relative changes in PaO2 /FIO2 (odds ratio 0.89 [95% CI 0.77-1.03], every 25% increase), PaCO2 (odds ratio 0.97 [95% CI 0.82-1.16], every 10% decrease), and dynamic driving pressure (odds ratio 0.98 [95% CI 0.89-1.07], every 10% decrease) were not associated with ICU mortality. In subjects with ARDS receiving prone positioning, a relative decline in the ventilatory ratio at 24 h was associated with lower ICU mortality.

Simple Coagulation Profile as Predictor of Mortality in Adults Admitted with COVID-19: A Meta-analysis

Context: COVID-19 severe manifestations must be detected as soon as possible. One of the essential poor characteristics is the involvement of coagulopathy. Simple coagulation parameters, including prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), and platelet, are widely accessible in many health centers. Objectives: This meta-analysis aimed to determine the association between simple coagulation profiles and COVID-19 in-hospital mortality. Method: We systematically searched five databases for studies measuring simple coagulation parameters in COVID-19 on admission. The random-effects and inverse-variance weighting were used in the study, which used a standardized-mean difference of coagulation profile values. The odds ratios were computed using the Mantel-Haenszel formula for dichotomous variables. Results: This meta-analysis comprised a total of 30 studies (9,175 patients). In our meta-analysis, we found that non-survivors had a lower platelet count [SMD = -0.56 (95% CI: -0.79 to -0.33), P &lt; 0.01; OR = 3.00 (95% CI: 1.66 to 5.41), P &lt; 0.01], prolonged PT [SMD = 1.22 (95%CI: 0.71 to 1.72), P &lt; 0.01; OR = 1.86 (95%CI: 1.43 to 2.43), P &lt; 0.01], prolonged aPTT [SMD = 0.24 (95%CI: -0.04 to 0.52), P = 0.99], and increased INR [SMD = 2.21 (95%CI: 0.10 to 4.31), P = 0.04] than survivors. Conclusions: In COVID-19 patients, abnormal simple coagulation parameters on admission, such as platelet, PT, and INR, were associated with mortality outcomes.

Outcomes of Venoarterial Extracorporeal Membrane Oxygenation for Cardiac Arrest in Adult Patients in the United States.

BackgroundFactors associated with poor prognosis following receipt of extracorporeal membrane oxygenation (ECMO) in adults with cardiac arrest remain unclear. We aimed to identify predictors of mortality in adults with cardiac arrest receiving ECMO in a nationally representative sample.Methods and ResultsThe US Healthcare Cost and Utilization Project's National Inpatient Sample was used to identify 782 adults hospitalized with cardiac arrest who received ECMO between 2006 and 2014. The primary outcome of interest was all‐cause in‐hospital mortality. Factors associated with mortality were analyzed using multivariable logistic regression. The overall in‐hospital mortality rate was 60.4% (n=472). Patients who died were older and more often men, of non‐White race, and with lower household income than those surviving to discharge. In the risk‐adjusted analysis, independent predictors of mortality included older age, male sex, lower annual income, absence of ventricular arrhythmia, absence of percutaneous coronary intervention, and presence of therapeutic hypothermia.ConclusionsDemographic and therapeutic factors are independently associated with mortality in patients with cardiac arrest receiving ECMO. Identification of which patients with cardiac arrest may receive the utmost benefit from ECMO may aid with decision‐making regarding its implementation. Larger‐scale studies are warranted to assess the appropriate candidates for ECMO in cardiac arrest.

Hypertension and Heart Failure as Predictors of Mortality in an Adult Congenital Heart Defect Population

Early intervention to prevent premature mortality is vital for adults with congenital heart defects (CHD). Anatomic complexity and comorbid conditions are thought to contribute to CHD mortality. Since hypertension (HTN) and heart failure (HF) are the comorbid conditions among the most prevalent causes of death in the United States, and commonly accompany CHD, it is crucial to evaluate whether they are reliable predictors of mortality for adults with CHD (ACHD) independent of anatomic CHD complexity. A retrospective cross-sectional analysis of ACHD, aged 18–64, with concomitant HTN and/or HF and at least one health care encounter during 2008–2010 were assessed. Of 5,397 ACHD patients (18.3% HTN without HF, 4.4% HF without HTN, 8.3% with both), 3.0% died (n = 163) during the study period. Overall, the sample was 45.1% white, 61.4% female, and 29.0% had a complex CHD. Among those who died, 23.3% had HTN without HF, 17.2% had HF without HTN, and 42.3% had both. Crude analyses revealed that older age, male gender, black race, and having public health insurance were associated with increased mortality during the three-year study period compared to ACHD patients who were younger, female gender, white race, and covered by private health insurance. ACHD patients diagnosed with non-complex CHD lesions (i.e., shunts, valves, or shunts + valves) were at greater risk of dying compared to those with severe complex CHDs. When CHD type was assessed separately, those with valve lesions were more likely to die compared to those with complex CHD lesions. After adjustment for age, gender, race, insurance and CHD complexity, ACHD patients with HF, with or without HTN, were equally likely to die during the study period. However, ACHD patients with HF, without or without HTN, who had valve defects were more likely to die during the three-year study period compared to patients with complex CHDs.

Predictors of Mortality in Adults Admitted with COVID-19: Retrospective Cohort Study from New York City.

IntroductionRapid spread of coronavirus disease 2019 (COVID-19) in the United States, especially in New York City (NYC), led to a tremendous increase in hospitalizations and mortality. There is very limited data available that associates outcomes during hospitalization in patients with COVID-19.MethodsIn this retrospective cohort study, we reviewed the health records of patients with COVID-19 who were admitted from March 9–April 9, 2020, to a community hospital in NYC. Subjects with confirmed reverse transcriptase-polymerase chain reaction (RT-PCR) of the nasopharyngeal swab for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were included. We collected data related to demographics, laboratory results, and outcome of hospitalization. Outcome was measured based on whether the patient was discharged home or died during hospitalization.ResultsThere were 888 consecutive admissions with COVID-19 during the study period, of which 513 were excluded with pending outcome or incomplete information. We included a total of 375 patients in the study, of whom 215 (57%) survived and 160 (43%) died during hospitalization. The majority of patients were male (63%) and of Hispanic origin (66%) followed by Blacks (25%), and others (9%). Hypertension (60%) stands out to be the most common comorbidity followed by diabetes mellitus (47%), cardiovascular disease (17%), chronic kidney disease (17%), and human immunodeficiency virus/acquired immunodeficiency syndrome (9%). On multiple regression analysis, increasing odds of mortality during hospitalization was associated with older age (odds ratio [OR] 1.04; 95% confidence interval [CI], 1.01–1.06 per year increase; p < 0.0001), admission D-dimer more than 1000 nanograms per milliliter (ng/mL) (OR 3.16; 95% CI, 1.75–5.73; p<0.0001), admission C-reactive protein (CRP) levels of more than 200 milligrams per liter (mg/L) (OR 2.43; 95% CI, 1.36–4.34; p = 0.0028), and admission lymphopenia (OR 2.63; CI, 1.47–4.69; p 0.0010).ConclusionIn this retrospective cohort study originating in NYC, older age, admission levels of D-dimer of more than 1000 ng/mL, CRP of more than 200 mg/L and lymphopenia were associated with mortality in individuals hospitalized for COVID-19. We recommend using these risk factors on admission to triage patients to critical care units or surge units to maximize the use of surge capacity beds.

0850 Self-report And Polysomnography Sleep And Mortality In Adults: A Machine Learning Replication Analysis

Abstract Introduction Individual sleep health characteristics (e.g. efficiency, timing, duration, architecture) and signs and symptoms of sleep disorders (e.g., difficulty falling and staying asleep, apnea hypopnea index, measures of oxygen desaturation) predict mortality in adults using traditional regression methods. However, it is important to examine and compare their predictive abilities in context of other established non-sleep predictors using high-dimensional methods that better reflect the complexity of the data. Therefore, we applied a novel random forest machine learning (RFML) hypothesis-testing framework to data from the Sleep Heart Health Study (SHHS) and the Wisconsin Sleep Cohort (WSC) to determine which risk factor domains (sleep, physical health, sociodemographic factors, medications, health behaviors, mental health) and sleep subdomains (self-report and polysomnography sleep health characteristics and signs and symptoms of sleep disorders) predict time to mortality in adults. Methods We harmonized 82 predictors across SHHS and WSC (32 sleep, 24 physical health, 8 sociodemographic, 9 medications, 4 mental health, 5 health behaviors) and fit sociodemographic-adjusted and fully-adjusted RFML models in each cohort to test the overall predictive importance of each domain and sleep subdomain. Permutation-based p-values and unbiased variable importance metrics (change in Harrell’s C *100, ΔC) were computed and summarized with medians across 20 independent subsampled testing sets in each cohort. Results In the fully-adjusted SHHS and WSC models, the most predictive domains were physical health (SHHS p&amp;lt;0.001, ΔC=1.48; WSC p=0.002, ΔC=2.68) and sleep (SHHS p=0.008, ΔC=0.71; WSC p=0.044, ΔC=1.65). Sleep subdomains were not significant in the fully adjusted model. However, the sociodemographic-adjusted models indicated that the predictive importance of sleep may be driven by polysomnography sleep health characteristics in SHHS (p=0.026, ΔC =0.77) and polysomnography signs of sleep apnea in WSC (p&amp;lt;0.001, ΔC=3.20). Conclusion Sleep is a strong predictor of mortality in adults that should be considered among other more routinely used predictors. Future research should examine differences and similarities between SHHS and WSC that may explain the finding that different aspects of sleep were important in each cohort. Support NIA grant AG056331, NHLBI grant HL114473, NHLBI grant R01HL62252, NIA grant R01AG036838, NIA grant R01AG058680.

Rates, causes, place and predictors of mortality in adults with intellectual disabilities with and without Down syndrome: cohort study with record linkage

ObjectivesTo investigate mortality in adults with intellectual disabilities: rates, causes, place, demographic and clinical predictors.DesignCohort study with record linkage to death data.SettingGeneral community.Participants961/1023 (94%) adults (16–83 years; mean=44.1 years; 54.6%...

All-cause mortality and survival in adults with 22q11.2 deletion syndrome

PurposeGiven limited data available on long-term outcomes in 22q11.2 deletion syndrome (22q11.2DS), we investigated mortality risk in adults with this microdeletion syndrome. MethodsWe studied 309 well-characterized adults (age ≥17 years) with 22q11.2DS and their 1014 unaffected parents and siblings, using a prospective case–control design. We used Cox proportional hazards regression modeling and Kaplan–Meier curves to investigate effects of the 22q11.2 deletion and its associated features on all-cause mortality and survival. ResultsThe 22q11.2 deletion (hazard ratio [HR] 8.86, 95% CI 2.87–27.37) and major congenital heart disease (CHD; HR 5.03, 95% CI 2.27–11.17), but not intellectual disability or psychotic illness, were significant independent predictors of mortality for adults with 22q11.2DS compared with their siblings. Amongst those with 22q11.2DS, there were 31 deaths that occurred at a median age of 46.4 (range 18.1–68.6) years; a substantial minority had outlived both parents. Probability of survival to age 45 years was approximately 72% for those with major CHD, and 95% for those with no major CHD (p < 0.0001). ConclusionFor adults with 22q11.2DS, the 22q11.2 deletion and more severe forms of CHD both contribute to a lower life expectancy than family-based expectations. The results have implications for genetic counseling and anticipatory care.

Mortality in adult patients with culture-positive and culture-negative meningitis in the Botswana national meningitis survey: a prevalent cohort study

SummaryBackgroundCNS infections are a leading cause of HIV-related deaths in sub-Saharan Africa, but causes and outcomes are poorly defined. We aimed to determine mortality and predictors of mortality in adults evaluated for meningitis in Botswana, which has an estimated 23% HIV prevalence among adults.MethodsIn this prevalent cohort study, patient records from 2004–15 were sampled from the Botswana national meningitis survey, a nationwide audit of all cerebrospinal fluid (CSF) laboratory records from patients receiving a lumbar puncture for evaluation of meningitis. Data from all patients with culture-confirmed pneumococcal and tuberculous meningitis, and all patients with culture-negative meningitis with CSF white cell count (WCC) above 20 cells per μL were included in our analyses, in addition to a random selection of patients with culture-negative CSF and CSF WCC of up to 20 cells per μL. We used patient national identification numbers to link CSF laboratory records from the national meningitis survey to patient vital registry and HIV databases. Univariable and multivariable Cox proportional hazards models were used to evaluate clinical and laboratory predictors of mortality.FindingsWe included data from 238 patients with culture-confirmed pneumococcal meningitis, 48 with culture-confirmed tuberculous meningitis, and 2900 with culture-negative CSF (including 1691 with CSF WCC of up to 20 cells per μL and 1209 with CSF WCC above 20 cells per μL). Median age was 37 years (IQR 31–46), 1605 (50%) of 3184 patients were male, 2188 (72%) of 3023 patients with registry linkage had documentation of HIV infection, and median CD4 count was 139 cells per μL (IQR 63–271). 10-week and 1-year mortality was 47% (112 of 238) and 49% (117 of 238) for pneumococcal meningitis, 46% (22 of 48) and 56% (27 of 48) for tuberculous meningitis, and 41% (1181 of 2900) and 49% (1408 of 2900) for culture-negative patients. When the analysis of patients with culture-negative CSF was restricted to those with known HIV infection, WCC (0–20 cells per μL vs >20 cells per μL) was not predictive of mortality (average hazard ratio 0·93, 95% CI 0·80–1·09).InterpretationMortality from pneumococcal, tuberculous, and culture-negative meningitis was high in this setting of high HIV prevalence. There is an urgent need for improved access to diagnostics, to better define aetiologies and develop novel diagnostic tools and treatment algorithms.FundingNational Institutes of Health, President's Emergency Plan for AIDS Relief, National Institute for Health Research.

Platelet Count upon Acute Hospital Admission to Internal Medicine Units Is a Predictor of Mortality in Adults: A Danish Cohort Study

Introduction: Aside of their hemostatic role, platelets have pleiotropic effects and play a role in acute conditions, including host defense against various pathogens. Therefore, the initial platelet count upon acute hospital admission might be a prognostic marker for mortality. This prediction study assessed the relation between platelet count upon acute admission to internal medicine units and mortality.Methods: We included all adults (>15 years old) in the North and Central Denmark Regions who had a first-time acute admission to an internal medicine unit during 2006-2012. We categorized the patients according to their platelet count measurements within +/- 24 hours of admission, as follows: severe (<50 x 109/L), moderate (50-99 x 109/L), and mild thrombocytopenia (100-149 x 109/L); and mild (401-499 x 109/L) and severe (≥500 x 109/L) thrombocytosis. Within the normal range (150-400 x 109/L), we categorized platelet counts by 50 x 109/L groups. We assessed the association between platelet count and in-hospital, 30-day, 90-day, and 365-day mortality using age- and sex-adjusted Cox models including categories of platelet counts and also using spline regression. We stratified additional analyses by presence of comorbidity (yes/no), defined as any condition in the Charlson Comorbidity Index. We also restricted an analysis to patients with a primary discharge diagnosis of cardiovascular disease vs. infection. In sensitivity analyses, we adjusted for hemoglobin level and leukocyte count upon admission.Results: Among the 274,148 patients, 6.8% had thrombocytopenia and 7.8% had thrombocytosis. The association between platelet count and mortality took the form of an asymmetric U-shaped curve, more marked for thrombocytopenia (Figure). For 30-day mortality, the hazard ratios (HRs) were 5.24 (95%CI 4.60-5.97), 3.77 (95%CI 3.43-4.14), and 1.63 (95%CI 1.52-1.74) for severe, moderate, and mild thrombocytopenia, respectively; and 1.91 (95%CI 1.79-2.04) and 2.50 (95%CI 2.33-2.69) for mild and severe thrombocytosis (reference group: normal platelet range). Compared with patients in the 200-249 x 109/L category, mortality was at least slightly higher in patients with a platelet count between 150-199 x 109/L (HR 1.13, 95%CI 1.06-1.21), between 250-299 x 109/L (HR 1.12, 95%CI 1.05-1.19), between 300-349 x 109/L (HR 1.38, 95%CI 1.29-1.47), and between 350-400 x 109/L (HR 1.82, 95%CI 1.69-1.96). A similar pattern was observed for in-hospital, 90-day, and 365-day mortality, among patients with and without comorbidity, and among those with a primary discharge diagnosis code of cardiovascular disease. Among patients with a primary discharge diagnosis code of infection, a platelet count between 150-199 x 109/L was associated with decreased mortality. Sensitivity analyses adjusted for hemoglobin level and leukocyte count upon admission yielded similar results.Conclusions: Both thrombocytopenia and thrombocytosis are markers of increased mortality up to one year after hospitalization in an internal medicine unit. Even within the normal range, low and high platelet counts were associated with slightly increased mortality. The lower mortality in patients with infectious diseases who had a platelet count between 150-199 x 109/L may reflect appropriate platelet consumption in host defense against pathogens. [Display omitted] DisclosuresChristiansen:Amgen: Research Funding.

Predictors of mortality in adults on treatment for human immunodeficiency virus-associated tuberculosis in Botswana: A retrospective cohort study.

Mortality in patients with human immunodeficiency virus (HIV)-associated tuberculosis (TB) is high, particularly in sub-Saharan Africa. This study aimed to compare mortality and predictors of mortality in those who were antiretroviral therapy (ART) naïve to those with prior ART exposure.This retrospective cohort study was conducted in Serowe/Palapye District, Botswana, a predominantly urban district with a large burden of HIV-associated TB with a high case fatality. Between January 1, 2013 and December 31, 2013, patients confirmed with HIV-associated TB were enrolled and followed up. Kaplan–Meier and Cox proportional hazard modeling was undertaken to identify predictors of mortality, with ART initiation included as time-updated variable.Among the 300 patients enrolled in the study, 131 had started ART before TB diagnosis (44%). There were 45 deaths. There was no difference in mortality between ART-naïve patients and those with prior ART exposure. In the multivariate analysis, no ART use during TB treatment (hazard ratio [HR] = 5.6, 95% confidence interval [CI] = 2.9–11; P < .001), opportunistic infections other than TB (HR = 8.5, 95% CI = 4–18.4; P = .013), age ≥60 years (HR = 4.8, 95% CI = 1.8–13; P = .002), hemoglobin <10 g/dL (HR = 2.4, 95% CI = 1.3–4.5) and hepatotoxicity (HR = 5, 95% CI = 1.6–17; P = .007) were associated with increased mortality. In the subgroup analysis, among ART-naïve patients, no ART use during TB treatment (HR = 8.1, 95% CI = 3.4–19.4; P < .001), opportunistic infections other than TB (HR = 16, 95% CI = 6.2–42; P < .001), and hepatotoxicity (HR = 8.3, 95% CI = 2.6–27; P < .001) were associated with mortality. Among patients with prior ART exposure, opportunistic infections other than TB (HR = 6, 95% CI = 2.6–27; P < .001) were associated with mortality.Mortality in patients with HIV-associated TB is still high. To reduce mortality, close clinical monitoring of patients together with initiation of ART during TB treatment is indicated.

Mechanisms underlying abnormal cardiorespiratory response in Fontan patients

Low peak oxygen consumption (peak VO 2 ) is a strong predictor of mortality in adults with congenital heart diseases. In univentricular hearts, after Fontan procedure, peak VO 2 is known low at 59% of predicted value for the 50th percentile. But the mechanisms underlying this abnormal cardiorespiratory response to exercise are not well known. We aimed to determine which parameters can predict low peak VO 2 (< 59% of predicted value) in Fontan patients. Twenty-one patients (mean age 23 ± 8 years) underwent cardiopulmonary exercise testing (CPX) with arterial blood gas measurements. As expected, peak VO 2 was low (24.4 mL/kg/min). All patients, despite oxygen saturation, had resting shunt with PaO 2 + PaCO 2 <120 mmHg (mean 96 ±8 mmHg). Twelve patients had peak VO 2 < 59% of predicted value, which is considered < 50th percentile in Fontan population. In this group, resting oxygen saturation was lower (94.3 ± 1.8% vs. 96.7 ± 1.4%, P = 0.02), alveolar–arterial gradient was higher at rest (52 ± 9 mmHg vs. 44 ± 5 mmHg, P = 0.03) and at exercise (58 ± 10 mmHg vs. 50 ± 6 mmHg, P = 0.04). Secondly, these patients had lower exercise heart rate (122 ± 38 bpm vs. 169 ± 25 bpm, P = 0.002), lower chronotropic reserve (49 ± 31 bpm vs. 79 ± 17 bpm, P = 0.009) and had more often pacemakers (3 patients versus 0, P = 0.05). Finally, in this group with altered peak VO 2 , we found more Fontan procedures (or modified Fontan) than extracardiac total cavopulmonary connections (5 patients or 42% vs 1 or 11%, P = 0.03), patients were older (27.6 ± 7 years vs. 16.8 ± 6.4 years, P = 0.0009), and converted to extracardiac cavopulmonary connection later (at 21.1 ± 13.9 years old vs. 3.8 ± 2.4 years old, P = 0.002). Severe alteration of aerobic capacity evaluated by peak VO 2 measurement in Fontan patients is correlated to the importance of cyanosis, the limited capacity to raise heart rate at exercise and the type of surgery.

Religion, a social determinant of mortality? A 10-year follow-up of the Health and Retirement Study.

The social determinants of health framework has brought a recognition of the primary importance of social forces in determining population health. Research using this framework to understand the health and mortality impact of social, economic, and political conditions, however, has rarely included religious institutions and ties. We investigate a well-measured set of social and economic determinants along with several measures of religious participation as predictors of adult mortality. Respondents (N = 18,370) aged 50 and older to the Health and Retirement Study were interviewed in 2004 and followed for all-cause mortality to 2014. Exposure variables were religious attendance, importance, and affiliation. Other social determinants of health included gender, race/ethnicity, education, household income, and net worth measured at baseline. Confounders included physical and mental health. Health behaviors and social ties were included as potential explanatory variables. Cox proportional hazards regressions were adjusted for complex sample design. After adjustment for confounders, attendance at religious services had a dose-response relationship with mortality, such that respondents who attended frequently had a 40% lower hazard of mortality (HR = 0.60, 95% CI 0.53–0.68) compared with those who never attended. Those for whom religion was “very important” had a 4% higher hazard (HR = 1.04, 95% CI 1.01–1.07); religious affiliation was not associated with risk of mortality. Higher income and net worth were associated with a reduced hazard of mortality as were female gender, Latino ethnicity, and native birth. Religious participation is multi-faceted and shows both lower and higher hazards of mortality in an adult US sample in the context of a comprehensive set of other social and economic determinants of health.