Risk Factors For 6-month Mortality Research Articles

Low thoracic skeletal muscle is a risk factor for 6-month mortality of severe community-acquired pneumonia in older men in intensive care unit

BackgroundPatients with severe community-acquired pneumonia (sCAP) admitted to the intensive care unit (ICU) often exhibit muscle catabolism, muscle weakness, and/or atrophy, all related to an increased morbidity and mortality. However, the relationship between thoracic skeletal muscle mass and sCAP-related mortality has not been well-studied. Early recognition of sarcopenia in ICU patients with sCAP would benefit their prognosis.MethodsA retrospective study was conducted in Taizhou Hospital of Zhejiang Province, involving 101 patients with sCAP admitted in the ICU between December 2022 and February 2023. We measured the cross-sectional aera of the pectoralis, intercostal, paraspinal, serratus, and latissimus muscles at the T4 vertebral level (T4CSA) using chest computed tomography. Discriminatory thresholds were established by performing receiver operating characteristic curve analysis, with a designated cutoff value of 96.75 cm2 for male patients. This cohort was classified into mortality and survival groups based on a 6-month post-admission outcome. Univariate and multifactorial logistic regression analyses were performed to validate the correlation between low thoracic skeletal muscle area and prognostic outcomes.ResultsThe mean age of the patients was 75.39 ± 12.09 years, with an overall 6-month mortality of 73.27%. T4CSA of the 6-month survival group was significantly larger than that in the mortality group for overall cohort. The T4CSA in the survival group was significantly larger than that in the mortality group (104.29 ± 23.98cm2 vs. 87.44 ± 23.0cm2, p = 0.008). T4CSA predicted the 6-month mortality from sCAP in males with an AUC of 0.722 (95% confidence interval (CI), 0.582–0.861). The specificity and sensitivity were 71.4% and 71.1%, respectively, (p < 0.05). No significant difference was observed between the two groups in terms of T4CSA.ConclusionsThis study revealed that low thoracic skeletal muscle mass increased the risk of all-cause 6-month mortality in ICU patients with sCAP, particularly among male patients.

DECIPHERING GUT MICROBIOTA IN PATIENTS WITH SEVERE SEPSIS AND SEPTIC SHOCK.

Introduction: Gut microbiota dysbiosis is associated with susceptibility to sepsis and poor outcomes. However, changes to the intestinal microbiota during sepsis and their value as biomarkers are unclear. In this study, we compared the intestinal microbiota of patients with sepsis and healthy controls. Methods: Stool was collected from patients with sepsis (subdivided according to mortality) and controls. Microbiome diversity and composition were analyzed by 16S rRNA gene pyrosequencing. The α-diversity of the intestinal microbiome was determined using operational taxonomic unit counts and the Chao1, Shannon, and ACE indices. Adjusted Cox regression analyses assessed 6-month mortality risk factors. Results: Fifty-nine patients (14 in-hospital deaths) and 29 healthy controls were enrolled. Operational taxonomic unit counts and Chao1 and ACE indices were lower in the nonsurvivor than in the other groups. The controls showed a higher Shannon and lower Simpson index than did the sepsis group. The genus Blautia was more abundant in controls than in the sepsis group, and Faecalibacterium less abundant in the nonsurvivor than in the other groups. Regression analysis associated low Shannon index with 6-month mortality. Conclusions: Survivors of sepsis, nonsurvivors, and healthy controls have different gut microbiomes, and a low Shannon index is a risk factor for 6-month mortality.

Decrease in cell counts and alteration of phenotype characterize peripheral NK cells of patients with anti-MDA5-positive dermatomyositis

ObjectiveTo investigate the levels and phenotypes of peripheral natural killer (NK) cells in anti-MDA5+ dermatomyositis (DM) patients, and their association with clinical features. MethodsPeripheral NK cell counts (NKCCs) were retrospectively collected from 497 patients with idiopathic inflammatory myopathies and 60 healthy controls. Multi-color flow cytometry was used to determine the NK cell phenotypes in additional 48 DM patients and 26 healthy controls. The association of NKCC and NK cell phenotypes with the clinical features and prognosis were analyzed in anti-MDA5+ DM patients. ResultsNKCC was significantly lower in anti-MDA5+ DM patients than in those with other IIM subtypes and healthy controls. A significant decrease in NKCC was associated with disease activity. Furthermore, NKCC < 27 cells/μL was an independent risk factor for 6-month mortality in anti-MDA5+ DM patients. In addition, identification of the functional phenotype of NK cells revealed significantly increased expression of the inhibitory marker CD39 in CD56brightCD16dimNK cells of anti-MDA5+ DM patients. CD39+NK cells of anti-MDA5+ DM patients showed increased expression of NKG2A, NKG2D, Ki-67, decreased expression of Tim-3, LAG-3, CD25, CD107a, and reduced TNF-α production. ConclusionDecreased cell counts and inhibitory phenotype are significant characteristics of peripheral NK cells in anti-MDA5+ DM patients.

Risk factors for super-refractory and mortality in generalized convulsive status epilepticus: a 10-year retrospective cohort study.

Generalized convulsive status epilepticus (GCSE) is one of the most challenging life-threatening neurological emergencies. If GCSE becomes super-refractory, it is associated with significant mortality. Although aggressive management of prolonged status epilepticus was conducted, the mortality has not decreased since the late 1990s. The present study aimed to explore the risk factors for progression to super-refractory in patients with generalized convulsive status epilepticus (GCSE). Moreover, we illustrated the risk factors for mortality in GCSE patients. An observational retrospective cohort study. We conducted a retrospective study of patients with GCSE admitted to our neurocritical unit, in Guangzhou, China, from October 2010 to February 2021. The data of sociodemographic information, etiology, laboratory results, treatment, and prognosis were collected and analyzed. A total of 106 patients were enrolled; 51 (48%) of them developed super-refractory status epilepticus (SRSE). Multivariate logistic regression analysis demonstrated that patients with autoimmune encephalitis (p = 0.015) and intracranial infection (p = 0.019) are likely to progress to SRSE. The in-hospital mortality was 11.8% and 9.1% for patients in the SRSE and non-SRSE groups, respectively (p = 0.652). Multivariate logistic regression analysis showed that neutrophil-to-lymphocyte ratios (NLR) at admission were independently associated with in-hospital mortality. Up to 31.4% of SRSE patients and 29.1% of non-SRSE patients died within 6 months after discharge (p = 0.798). Multivariate logistic regression analysis showed that plasma exchange (PE) was a protective factor for 6-month mortality. A high NLR at discharge was a risk factor for 6-month mortality. In the current study, about 48% of GCSE patients progressed to SRSE. Regarding etiology, autoimmune encephalitis or intracranial infection was prone to SRSE. No significant differences were observed in the in-hospital and 6-month mortality between SRSE and non-SRSE groups. Multivariate logistic regression analysis showed that NLR at admission and discharge was an independent predictor of in-hospital and 6-month mortality, respectively. Moreover, PE significantly reduced the 6-month mortality.

Prognostic implications of elevated pulmonary artery systolic pressure on 6-month mortality in elderly patients with acute myocardial infarction

Abstract Background Pulmonary artery systolic pressure (PASP) has often been evaluated as an indicator of heart failure, but the relationship between PASP and the prognosis of elderly patients with acute myocardial infarction (AMI) is not well understood. Methods The medical data of 3460 hospitalized elderly patients diagnosed with AMI between January 2013 and June 2018 were reviewed. PASP was calculated using transthoracic color Doppler ultrasonography. Patients were grouped according to their admission PASP results as follows: Group A, PASP ≤30 mmHg; Group B, 30 mmHg &lt;PASP ≤50 mmHg; and Group C, PASP ≥51 mmHg. The primary endpoint was all-cause death 6 months following AMI. Multiple Cox regression analysis was used to identify independent risk factors for 6-month mortality in elderly patients with AMI. Results PASP was associated with age, Killip classification, AMI site, and decreased ejection fraction in elderly patients. After adjusting for clinical and echocardiographic parameters in the Cox model, PASP was found to be significantly related to all-cause mortality. In receiver operating characteristic analysis, a PASP of &gt;34 mmHg had a sensitivity of 62.3% and specificity of 65.7% for predicting 6-month all-cause death after AMI. Conclusion PASP at admission is a useful marker for predicting short-term mortality in elderly patients with AMI. This finding could be used to help identify high-risk patients and make appropriate clinical decisions.

Short- and Long-Term Mortality and Mortality Risk Factors among Nursing Home Patients after COVID-19 Infection.

ObjectiveTo assess short- and long-term mortality and risk factors in nursing home patients with COVID-19 infection.DesignRetrospective 2-center cohort study.Setting and ParticipantsDutch nursing home patients with clinically suspected COVID-19 infection confirmed by reverse transcription-polymerase chain reaction testing.MethodsData were gathered between March 2020 and November 2020 using electronic medical records, including demographic characteristics, comorbidities, medical management, and symptoms on the first day of suspected COVID-19 infection. Mortality at 30 days and 6 months was assessed using multivariate logistic regression models and Kaplan-Meier analysis. At 6 months, a subgroup analysis was performed to estimate the mortality risk between COVID-negative patients and patients who survived COVID-19. Risk factors for mortality were assessed through multivariate logistic regression models.ResultsA total of 321 patients with suspected COVID-19 infection were included, of whom 134 tested positive. Sixty-two patients in the positive group died at 30 days, with a short-term mortality rate of 2.9 (95% CI 1.7–5.3). Risk factors were fatigue (OR 2.6, 95% CI 1.3–6.2) and deoxygenation (OR 2.9, 95% CI 1.3–7.6). At 6 months, the mortality risk was 2.1 (95% CI 1.3–3.7). Risk factors for 6-month mortality were shortness of breath (OR 2.7, 95% CI 1.3–7.0), deoxygenation (OR 2.5, 95% CI 1.1–6.5) and medical management (OR 4.5, 95% CI 1.7–25.8). However, among patients who survived COVID-19 infection, the long-term mortality risk was not sustained (OR 1.0, 95% CI 0.4–2.7).Conclusions and ImplicationsOverall, COVID-19 infection increases short- and long-term mortality risk among nursing home patients. However, this study shows that surviving COVID-19 infection does not lead to increased mortality in the long term within this population. Therefore, advanced care planning should focus on quality of life among nursing home patients after COVID-19 infection.

Increased serum levels of sCD40L were associated with rapidly progressive interstitial lung disease in idiopathic inflammatory myopathies.

Whether coagulopathy exists in development of idiopathic inflammatory myopathies associated rapidly progressive interstitial lung disease (IIMs-RPILD) is unclear. In this study, we aimed to investigate soluble CD40 ligand and D-dimer levels in RPILD patients. Patients with IIMs-ILD were enrolled and classified as RPILD and stable-ILD group. Clinical data, laboratory examinations including coagulation-associated parameters and the myositis antibodies status, chest high-resolution computed tomography (HRCT) findings and treatment regimens were collected and serum levels of sCD40L were detected by ELISA. Univariable and adjusted multivariable cox regression were performed to identify risk factors for 6-month mortality, and further to select predictors for establishing predictive model for RPILD. Eighty patients with IIMs-ILD were enrolled and 34 of them were diagnosed as RPILD while 46 as stable-ILD. Multivariable cox regression showed that albumin<32.4 g/L and sCD40L<1658.55 pg/ml were independent risk factors of short-term mortality in RPILD. A SMAD model consisting of serum sCD40L>1054 pg/ml, anti-MDA5 positivity, albumin<32.4 g/L and D-dimer>0.865 mg/L were generated. The odds for RPILD with SMAD score of 0, 1, 2, 3 and 4 were 0, 26.9%, 66.7%, 91.7% and 100%. The 6-month survival stratified by mild (SMAD score 0), moderate (SMAD score 1 and 2) and severe group (SMAD score 3 and 4) were 100%, 79.5% and 20%, respectively. We established a predictive model for IIMs-RPILD, which provided a clue that coagulopathy might exist in IIMs-RPILD and could help to better treat patients with RPILD. This model awaits further validations.

Clinical Predictors of Lung Transplant Outcomes in Patients with Scleroderma Compared with Pulmonary Fibrosis

Purpose Primary Graft Disfunction (PGD) is the leading cause of early morbidity and mortality after lung transplant. We sought to identify risk factors for PGD and survival in patients with scleroderma undergoing lung transplant compared to patients with pulmonary fibrosis. Methods This was a single center retrospective cohort study, of patients that underwent lung transplantation for scleroderma or pulmonary fibrosis from 2007 to 2020. Propensity scores were used to match the scleroderma group with the pulmonary fibrosis group based on lung allocation score and age at lung transplant. Univariable analyses identified factors associated with the development of PGD 72 hours posttransplant, and six-month survival. Survival rates were compared using Kaplan-Meier analysis. Results We compared 104 patients with scleroderma to 389 patients with pulmonary fibrosis who underwent lung transplant. After propensity matching, compared with pulmonary fibrosis, scleroderma patients had reduced 90-day survival (99.0% vs 90.2%, p=0.007). However, there was no statistically significant difference in 1 year (84.4% vs 79.1%, p=0.23) or 5-year survival (64.9% vs 52.9%, p=0.98). Scleroderma patients were more likely to have PGD 72 hours posttransplant (29.4% vs 11.8%, p=0.01). Scleroderma patients who developed PGD had higher volumes of intraoperative transfusion of blood products (p=0.02), plasma (p=0.04), platelets (p=0.03), but not red blood cells (p=0.28). Preoperative history of chronic kidney disease (p<0.001) and postoperative Acute Kidney Injury [AKI] (p=0.028) were also associated with the development of PGD. Donor factors for developing PGD in scleroderma patients were traumatic brain injury as cause of donor death (p=0.015) and donor history of smoking (p=0.02). Risk factors for 6-month mortality were postoperative right ventricular dysfunction (p=0.02) or dilation (p=0.003), stroke (p=0.02), atrial fibrillation (p=0.01), PGD (p<0.001), AKI (p=0.005) and decreased glomerular filtration rate 3 months posttransplant (p=0.04). Conclusion Scleroderma had higher rates of post lung transplant PGD compared to pulmonary fibrosis. Kidney function plays a prominent role in the risk of developing PGD and mortality in this population. Despite reduced 90-day posttransplant survival in scleroderma patients, 1- and 5-year survival rates were similar. Primary Graft Disfunction (PGD) is the leading cause of early morbidity and mortality after lung transplant. We sought to identify risk factors for PGD and survival in patients with scleroderma undergoing lung transplant compared to patients with pulmonary fibrosis. This was a single center retrospective cohort study, of patients that underwent lung transplantation for scleroderma or pulmonary fibrosis from 2007 to 2020. Propensity scores were used to match the scleroderma group with the pulmonary fibrosis group based on lung allocation score and age at lung transplant. Univariable analyses identified factors associated with the development of PGD 72 hours posttransplant, and six-month survival. Survival rates were compared using Kaplan-Meier analysis. We compared 104 patients with scleroderma to 389 patients with pulmonary fibrosis who underwent lung transplant. After propensity matching, compared with pulmonary fibrosis, scleroderma patients had reduced 90-day survival (99.0% vs 90.2%, p=0.007). However, there was no statistically significant difference in 1 year (84.4% vs 79.1%, p=0.23) or 5-year survival (64.9% vs 52.9%, p=0.98). Scleroderma patients were more likely to have PGD 72 hours posttransplant (29.4% vs 11.8%, p=0.01). Scleroderma patients who developed PGD had higher volumes of intraoperative transfusion of blood products (p=0.02), plasma (p=0.04), platelets (p=0.03), but not red blood cells (p=0.28). Preoperative history of chronic kidney disease (p<0.001) and postoperative Acute Kidney Injury [AKI] (p=0.028) were also associated with the development of PGD. Donor factors for developing PGD in scleroderma patients were traumatic brain injury as cause of donor death (p=0.015) and donor history of smoking (p=0.02). Risk factors for 6-month mortality were postoperative right ventricular dysfunction (p=0.02) or dilation (p=0.003), stroke (p=0.02), atrial fibrillation (p=0.01), PGD (p<0.001), AKI (p=0.005) and decreased glomerular filtration rate 3 months posttransplant (p=0.04). Scleroderma had higher rates of post lung transplant PGD compared to pulmonary fibrosis. Kidney function plays a prominent role in the risk of developing PGD and mortality in this population. Despite reduced 90-day posttransplant survival in scleroderma patients, 1- and 5-year survival rates were similar.

Infective Endocarditis in Patients on Chronic Hemodialysis

BackgroundInfective endocarditis (IE) is a common and serious complication in patients receiving chronic hemodialysis (HD). ObjectivesThis study sought to investigate whether there are significant differences in complications, cardiac surgery, relapses, and mortality between IE cases in HD and non-HD patients. MethodsProspective cohort study (International Collaboration on Endocarditis databases, encompassing 7,715 IE episodes from 2000 to 2006 and from 2008 to 2012). Descriptive analysis of baseline characteristics, epidemiological and etiological features, complications and outcomes, and their comparison between HD and non-HD patients was performed. Risk factors for major embolic events, cardiac surgery, relapses, and in-hospital and 6-month mortality were investigated in HD-patients using multivariable logistic regression. ResultsA total of 6,691 patients were included and 553 (8.3%) received HD. North America had a higher HD-IE proportion than the other regions. The predominant microorganism was Staphylococcus aureus (47.8%), followed by enterococci (15.4%). Both in-hospital and 6-month mortality were significantly higher in HD versus non–HD-IE patients (30.4% vs. 17% and 39.8% vs. 20.7%, respectively; p < 0.001). Cardiac surgery was less frequently performed among HD patients (30.6% vs. 46.2%; p < 0.001), whereas relapses were higher (9.4% vs. 2.7%; p < 0.001). Risk factors for 6-month mortality included Charlson score (hazard ratio [HR]: 1.26; 95% confidence interval [CI]: 1.11 to 1.44; p = 0.001), CNS emboli and other emboli (HR: 3.11; 95% CI: 1.84 to 5.27; p < 0.001; and HR: 1.73; 95% CI: 1.02 to 2.93; p = 0.04, respectively), persistent bacteremia (HR: 1.79; 95% CI: 1.11 to 2.88; p = 0.02), and acute onset heart failure (HR: 2.37; 95% CI: 1.49 to 3.78; p < 0.001). ConclusionsHD-IE is a health care–associated infection chiefly caused by S. aureus, with increasing rates of enterococcal IE. Mortality and relapses are very high and significantly larger than in non–HD-IE patients, whereas cardiac surgery is less frequently performed.

Prospective Cohort Study of Infective Endocarditis in People Who Inject Drugs

BackgroundInfective endocarditis (IE) in people who inject drugs (PWID) is an emergent public health problem. ObjectivesThe purpose of this study was to investigate IE in PWID and compare it with IE in non-PWID patients. MethodsTwo prospective cohort studies (ICE-PCS and ICE-Plus databases, encompassing 8,112 IE episodes from 2000 to 2006 and 2008 to 2012, with 64 and 34 sites and 28 and 18 countries, respectively). Outcomes were compared between PWID and non-PWID patients with IE. Logistic regression analyses were performed to investigate risk factors for 6-month mortality and relapses amongst PWID. ResultsA total of 7,616 patients (591 PWID and 7,025 non-PWID) were included. PWID patients were significantly younger (median 37.0 years [interquartile range: 29.5 to 44.2 years] vs. 63.3 years [interquartile range: 49.3 to 74.0 years]; p < 0.001), male (72.5% vs. 67.4%; p = 0.007), and presented lower rates of comorbidities except for human immunodeficiency virus, liver disease, and higher rates of prior IE. Amongst IE cases in PWID, 313 (53%) episodes involved left-side valves and 204 (34.5%) were purely left-sided IE. PWID presented a larger proportion of native IE (90.2% vs. 64.4%; p < 0.001), whereas prosthetic-IE and cardiovascular implantable electronic device-IE were more frequent in non-PWID (9.3% vs. 27.0% and 0.5% vs. 8.6%; both p < 0.001). Staphylococcus aureus caused 65.9% and 26.8% of cases in PWID and non-PWID, respectively (p < 0.001). PWID presented higher rates of systemic emboli (51.1% vs. 22.5%; p < 0.001) and persistent bacteremia (14.7% vs. 9.3%; p < 0.001). Cardiac surgery was less frequently performed (39.5% vs. 47.8%; p < 0.001), and in-hospital and 6-month mortality were lower in PWID (10.8% vs. 18.2% and 14.4% vs. 22.2%; both p < 0.001), whereas relapses were more frequent in PWID (9.5% vs. 2.8%; p < 0.001). Prior IE, left-sided IE, polymicrobial etiology, intracardiac complications, and stroke were risk factors for 6-month mortality, whereas cardiac surgery was associated with lower mortality in the PWID population. ConclusionsA notable proportion of cases in PWID involve left-sided valves, prosthetic valves, or are caused by microorganisms other than S. aureus.

Incidence and outcome of refeeding syndrome in neurocritically ill patients

Neurocritically ill patients are more likely to be comatose and suffer from dysphagia, conditions that inevitably require nutritional support. Inappropriate nutritional support may lead to refeeding syndrome (RFS). This study aimed to explore the incidence and outcome of RFS in neurocritically ill patients. We conducted a retrospective study among neurocritically ill patients who received total enteral nutrition for >72h in a university-affiliated hospital. RFS was defined as the occurrence of new-onset hypophosphatemia (<0.65mmol/L) within 72h of the commencement of nutritional support. The primary outcome was 6-month mortality. The secondary outcomes included 30-day mortality, neurocritical care unit (NCU) stay, and hospital length of stay. A total of 328 patients were enrolled, and 56 (17.1%) of them developed RFS within 72h of nutrition support. Significantly, we found that patients with high malnutrition universal screening tool (MUST) and sequential organ failure assessment (SOFA) scores were more likely to develop RFS. The occurrence of RFS was associated with a longer NCU stay, higher 30-day mortality and 6-month mortality, and poorer 6-month functional outcome. Moreover, RFS was identified as an independent risk factor for 6-month mortality. RFS is not rare in neurocritically ill patients and is more likely to occur in patients with nutritional risk and more severe conditions. RFS is an independent risk factor for 6-month mortality in neurocritically ill patients.

Epidemiology of sepsis in Korea: a population-based study of incidence, mortality, cost and risk factors for death in sepsis.

ObjectiveTo investigate the epidemiology of sepsis in Korea and identify risk factors for death in sepsis.MethodsWe conducted a longitudinal, population-based epidemiological study of sepsis in Korea from 2005 to 2012 using the National Health Insurance Service-National Sample Cohort, a population-based cohort representing 2.2% of the Korean population. The primary objective was to assess the incidence, mortality and cost of sepsis. The secondary objective was to identify the risk factors for death in sepsis. Claim records of admitted adult patients (aged ≥15 years) were analyzed. Sepsis was defined as 1) bacterial or fungal infection or the conditions they often complicate, 2) prescription of intravenous antibiotics, and 3) presence of any organ dysfunction. Comorbidities were defined using the Charlson/Deyo method. Risk factors for 6-month mortality were assessed using multivariable logistic regression.ResultsA total of 22,882 cases were identified. Both incidence and 6-month mortality increased from 265.7 (95% confidence interval [CI], 254.7 to 277.1) to 453.1 (95% CI, 439.0 to 467.5) per 100,000 person-years (P-trend <0.001) and from 26.5% (95% CI, 24.4% to 28.8%) to 30.1% (95% CI, 28.4% to 31.9%), respectively. After standardization, the increasing trend of incidence was slower but still significant (P-trend <0.001), while that for mortality was not (P-trend 0.883). The average cost increased by 75.5% (P-trend <0.001). Multivariable logistic regression identified various risk factors for mortality.ConclusionThe burden of sepsis in Korea was high and is expected to increase considering the aging population. Proactive measures to curtail this increase should be sought and implemented.

Serum levels of NLRP3 and HMGB-1 are associated with the prognosis of patients with severe blunt abdominal trauma

OBJECTIVES:To investigate the relationship between the serum levels of NLRP3 and HMGB-1 and the prognosis of patients with severe blunt abdominal trauma.METHODS:In total, 299 patients were included in the current study from July 2014 to December 2015. All patients were divided into the mild/moderate blunt abdominal trauma group and the severe blunt abdominal trauma group according to their injury severity scores. Serum levels of NLRP3 and HMGB-1 were measured upon admission (0 h) and at 12 h, 24 h, 48 h, 72 h and 7 days after admission.RESULTS:Compared with the healthy controls, both the mild/moderate and severe blunt abdominal trauma groups had higher serum levels of NLRP3 and HMGB-1 at admission. At all points, the serum levels of NLRP3 and HMGB-1 were significantly higher in the severe group than in the mild/moderate group. The serum levels of both NLRP3 and HMGB-1 were significantly higher in the deceased patients than in the living patients. The Kaplan-Meier curve showed that compared with patients with higher levels of NLRP3 or HMGB-1, those with lower levels had longer survival times. The serum levels of both NLRP3 and HMGB-1 were independent risk factors for 6-month mortality in severe blunt abdominal trauma patients.CONCLUSION:The serum levels of NLRP3 and HMGB-1 were significantly elevated in severe blunt abdominal trauma patients, and the serum levels of both NLRP3 and HMGB-1 were correlated with 6-month mortality in severe blunt abdominal trauma patients.

Derivation of data-driven triggers for palliative care consultation in critically ill patients

PurposeTo examine the ability of existing triggers for intensive care unit (ICU) palliative care consultation to predict 6-month mortality, and derive new triggers for consultation based on risk factors for 6-month mortality. Materials and methodsRetrospective cohort study of NY state residents who received intensive care, 2008–2013. We examined sensitivity and specificity of existing triggers for predicting 6-month mortality and used logistic regression to generate patient subgroups at high-risk for 6-month mortality as potential novel triggers for ICU palliative care consultation. ResultsOf 1,019,849 patients, 195,847 (19.2%) died within 6 months of admission. Existing triggers were specific but not sensitive for predicting 6-month mortality, (sensitivity 0.3%–11.1%, specificity 96.5–99.9% for individual triggers). Using logistic regression, patient subgroups with the highest predicted probability of 6-month mortality were older patients admitted with sepsis (age 70–79 probability 49.7%, [49.5–50.0]) or cancer (non-metastatic cancer, age 70–79 probability 51.5%, [51.1–51.9]; metastatic cancer, age 70–79 probability 60.3%, [59.9–60.6]). Sensitivity and specificity of novel triggers ranged from 0.05% to 9.2% and 98.6% to 99.9%, respectively. ConclusionsExisting triggers for palliative care consultation are specific, but insensitive for 6-month mortality. Using a data-driven approach to derive novel triggers may identify subgroups of patients at high-risk of 6-month mortality.

Relationship of calcitonin gene-related peptide with disease progression and prognosis of patients with severe traumatic brain injury.

Calcitonin gene-related peptide (CGRP) has been implicated in multiple functions across many bioprocesses; however, whether CGRP is associated with severe traumatic brain injury (TBI) remains poorly understood. In this study, 96 adult patients with TBI (enrolled from September 2015 to December 2016) were divided into a mild/moderate TBI group (36 males and 25 females, aged 38 ± 13 years) and severe TBI group (22 males and 13 females, aged 38 ± 11 years) according to Glasgow Coma Scale scores. In addition, 25 healthy individuals were selected as controls (15 males and 10 females, aged 39 ± 13 years). Radioimmunoassay was used to detect serum levels of CGRP and endothelin-1 at admission and at 12, 24, 48, 72 hours, and 7 days after admission. CGRP levels were remarkably lower, but endothelin-1 levels were obviously higher in the severe TBI group compared with mild/moderate TBI and control groups. Levels of CGRP were remarkably lower, but endothelin-1 levels were obviously higher in deceased patients compared with patients who survived. Survival analysis and logistic regression showed that both CGRP and endothelin-1 levels were associated with patient mortality, with each serving as an independent risk factor for 6-month mortality of severe TBI patients. Moreover, TBI patients with lower serum CGRP levels had a higher risk of death. Thus, our retrospective analysis demonstrates the potential utility of CGRP as a new biomarker, monitoring method, and therapeutic target for TBI.

Low BMI and Weight Loss Both Impact 6-Month Nursing Home Mortality

A low body mass index (BMI) and weight loss greater than 5 kg in the past year were both independent and “equally relevant” risk factors for the 6-month mortality of nursing home residents in a large international cross-sectional survey. And when both were present, the mortality risk was disproportionately increased. “On the basis of previous interventional trials [showing beneficial effects of oral nutritional supplements] and these observational data, any weight loss in nursing home residents, even if small, should be avoided to the greatest extent possible, as long as nutritional therapy is considered to be useful and without harm,” reported Rainer Wirth, MD, PhD, of the department of internal medicine and geriatrics at St. Marien-Hospital Borken, Germany, and his colleagues. “Residents with a low BMI and weight loss should receive particular attention and nutritional care as soon as weight loss occurs,” they added (Clin Nutr 2016;35:900–6). These findings come from the “nutritionDay” project in which nursing homes and hospital wards around the world have volunteered to participate in an annual one-day cross sectional survey, or audit, of nutritional status (http://www.nutritionday.org). Dr. Wirth and his coinvestigators analyzed data collected from 2007–2012 on 10,298 residents of 191 nursing homes in 13 Western developed countries, including the United States. Their questionnaires asked whether weight loss was present in the last year and what was the amount of weight loss per defined categories (1–5 kg, 5–15 kg, and >15 kg). The answers were combined to focus on weight loss greater than 5 kg. A BMI of less than 20 kg/m2 was defined as relevantly low for older individuals in concordance with definitions in the nutrition guidelines of the European Society for Clinical Nutrition and Metabolism. Approximately 18% of residents had a BMI below 20 kg/m2, and 11% had lost more than 5 kg in the previous year. These residents were at least 65 years old and had a mean age of 85. A low BMI and greater than a 5-kg weight loss were both independent and significant risk factors for 6-month mortality. In residents with weight loss greater than 5 kg and a BMI greater than 20 kg/m2, mortality was 17.4%, and in those without such weight loss but with a low BMI, mortality was 19.8%. When both features were present, mortality increased disproportionately to 35.7%, which suggests an interaction between BMI and weight loss, the investigators wrote. There was a strong dose–effect relationship between each feature and mortality, they noted. Weight loss and low BMI are both well-known risk factors for poor outcomes in the older population, but “their nature is substantially different,” they wrote. Weight loss is “predominantly associated with disease and frailty,” whereas a low BMI “might be a permanent characteristic of a person or a consequence of previous weight loss.” Previous studies did not specify whether individuals with a low BMI also had recent weight loss — and thus it was unclear whether it was primarily the low BMI that had increased the mortality risk or whether the main source of risk was the unknown weight loss, the authors said. The nutritionDay study allowed for the analysis of both risk factors in one data set. Weight loss of less than 5 kg was significantly more prevalent in the group with a low BMI compared with those with a higher BMI, but the association between BMI and mortality remained after adjusting for weight loss. “There’s no doubt that a low BMI, per se, is as predictive for mortality as weight loss,” Dr. Wirth and his associates wrote. Christine Kilgore is a freelance writer in Falls Church, VA.

Increased serum concentrations of signal peptide-Cub-Egf domain-containing protein-1 in patients with aneurysmal subarachnoid hemorrhage

BackgroundSignal peptide-Cub-Epidermal growth factor domain-containing protein 1 (SCUBE1), a marker for coagulation, is correlated with prognosis of some critical illnesses. The current study was designed to investigate the potential prognostic value of serum SCUBE1 concentrations in patients with aneurysmal subarachnoid hemorrhage (aSAH). MethodsSerum SCUBE1 concentrations of 125 patients and 125 controls were determined. Multivariate analyses were performed to identify independent risk factors for 6-month mortality, overall survival and unfavorable outcome (Glasgow Outcome Scale score of 1–3). ResultsSerum SCUBE1 concentrations were significantly higher in patients than in controls (17.7±7. vs. 1.2±0.4ng/ml, P<0.001) and were associated highly with World Federation of Neurological Surgeons (WFNS) scores (t=5.109, P<0.001) and modified Fisher scores (t=4.329, P<0.001). SCUBE1 emerged as an independent predictor for 6-month clinical outcomes. It had similar area under receiver operating characteristic curve (AUC) to WFNS scores and modified Fisher scores. Moreover, it could markedly improve the AUC of WFNS scores and modified Fisher scores to predict 6-month unfavorable outcome. ConclusionEnhanced SCUBE1 concentrations are correlated with increasing severity and poor outcomes of aSAH patients, indicating SCUBE1 might have the potential to identify aSAH patients at risk of poor prognosis.

Characteristics, causes, and outcome of 54 episodes of bloodstream infections in a cohort of HIV patients

Background: Patients infected with human immunodeficiency virus (HIV) have an increased risk for bloodstream infections (BSIs). Published recent data on characteristics, etiology, and outcome of BSIs in HIV patients in high income countries are scarce. Methods: Blood cultures from 2001 to 2011 from adult HIV patients were retrieved. Blood cultures considered to be contamination based on isolates and clinical context were excluded. Clinical and microbiological characteristics of BSIs and patients were described, those of community-acquired and nosocomial episodes were compared, and risk factors for 6-month mortality were analyzed. Results: We found 54 episodes of true BSI in 46 patients. Demographics were similar to those of the source cohort of all patients followed between 2001 and 2011. In 63% there was prior AIDS, in 91% a CD4 nadir below 200/mm3, and in 72% a latest CD4 count < 200/mm3. In 13% of patients BSI preceded a new HIV diagnosis within 1 week. Main causative microorganisms were coagulase-negative staphylococci (26%), Streptococcus pneumoniae (20%), and Enterococcus spp. (13%). The most frequent diagnoses were pneumonia (28%) and catheter-related BSI (CRBSI) (28%); 56% of episodes were nosocomial. The 1-month mortality rate was 17%, with a cause of death apparently unrelated to the BSI in five of nine episodes. The 6-month mortality was 28%. Factors of co-morbidity or immunodeficiency other than HIV were significantly associated with 6-month mortality. Conclusions: BSIs in HIV-infected patients occur predominantly in patients with advanced HIV infection. Community-acquired bacteremic pneumococcal pneumonia and nosocomial staphylococcal CRBSIs are the main causes. Mortality following BSI is high, and seems to be driven by underlying complicated HIV infection.

Postoperative delirium and pre-fracture disability predict 6-month mortality among the oldest old hip fracture patients.

Age is one of the most robust risk factors for hip fracture. Recent projections indicate that almost half of hip fractures are occurring with an increasing trend among the "oldest old" (i.e., in those aged >85years). To compare clinical characteristics, outcomes, and risk factors for 6-month mortality in two groups of "oldest old" patients (group 1=85-89, group 2>90years), after hip fracture surgery. Observational prospective cohort study with 6-month follow-up, performed in an Orthogeriatric Unit of an academic hospital between March 2007 and November 2012. Two hundred seventy-five patients (group 1: N=171; group 2: N=104) underwent a comprehensive geriatric assessment, including demographics, clinical, functional, nutritional, and mental status. The 6-month rehospitalization and mortality rates after surgery were assessed through structured telephone interviews with patient's caregivers. Multivariate logistic regression models were used to evaluate predictors of 6-month mortality, adjusting for relevant covariates. Fifty-eight patients died at follow-up. The in-hospital and 6-month mortality rates were significantly higher for patients of group 2 than for those of group 1. After adjusting for covariates, the multivariate logistic regressions showed that severe disability (OR 2.24, 95% CI 1.08-4.65) and postoperative delirium (POD) (OR 3.80, 95% CI 1.72-8.39) were predictors of 6-month mortality. Patients aged >90years who underwent hip fracture surgery are more likely to die at 6months than those aged 85-89years. Pre-fracture disability and POD are predictors of this excess of mortality.

Prevalence and impact of frailty on mortality in elderly ICU patients: a prospective, multicenter, observational study

Frailty is a recent concept used for evaluating elderly individuals. Our study determined the prevalence of frailty in intensive care unit (ICU) patients and its impact on the rate of mortality. A multicenter, prospective, observational study performed in four ICUs in France included 196 patients aged ≥65 years hospitalized for >24 h during a 6-month study period. Frailty was determined using the frailty phenotype (FP) and the clinical frailty score (CFS). The patients were separated as follows: FP score <3 or ≥3 and CFS <5 or ≥5. Frailty was observed in 41 and 23% of patients on the basis of an FP score ≥3 and a CFS ≥5, respectively. At admission to the ICU, the Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores did not differ between the frail and nonfrail patients. In the multivariate analysis, the risk factors for ICU mortality were FP score ≥3 [hazard ratio (HR), 3.3; 95% confidence interval (CI), 1.6-6.6; p < 0.001], male gender (HR, 2.4; 95% CI, 1.1-5.3; p = 0.026), cardiac arrest before admission (HR, 2.8; 95% CI, 1.1-7.4; p = 0.036), SAPS II score ≥46 (HR, 2.6; 95% CI, 1.2-5.3; p = 0.011), and brain injury before admission (HR, 3.5; 95% CI, 1.6-7.7; p = 0.002). The risk factors for 6-month mortality were a CFS ≥5 (HR, 2.4; 95% CI, 1.49-3.87; p < 0.001) and a SOFA score ≥7 (HR, 2.2; 95% CI, 1.35-3.64; p = 0.002). An increased CFS was associated with significant incremental hospital and 6-month mortalities. Frailty is a frequent occurrence and is independently associated with increased ICU and 6-month mortalities. Notably, the CFS predicts outcomes more effectively than the commonly used ICU illness scores.