Risk Factors For Early Mortality Research Articles

Outcomes of Truncus Arteriosus Repair in Children: 35 Years of Experience From a Single Institution

We evaluated the long-term outcomes following repair of truncus arteriosus (TA) from a single institution. We conducted a retrospective review of children (n = 171) who underwent TA repair between 1979 and 2014. Early mortality rate was 11.7% (20/171). There were 19 late deaths. Most deaths (74%, 29/39) occurred within the first year following surgery. The 1-year mortality rate in 1979-2004 was 18% (25/136) and decreased to 11% (4/35) in 2005-2014. The overall survival rate was 73.6% at 30 years. Multivariate analysis identified postoperative extracorporeal membrane oxygenation (P = 0.003), operative weight <2.5kg (P = 0.012), prior surgical intervention (P = 0.018), and coronary artery anomaly (P = 0.037) as risk factors for early mortality. A Cox regression model identified DiGeorge syndrome (P = 0.008) as a risk factor for late mortality. Freedom from right ventricular outflow tract reoperation was 4.6% at 20 years. Concomitant truncal valve (TV) repair or replacement was undertaken in 20 patients. Additionally, 14 patients underwent late TV repair or replacement. The overall survival rate in patients who underwent TV operation was 76.9% at 20 years. A total of 19 patients had concomitant interrupted aortic arch with a survival rate of 89.5% at 20 years. Median follow-up was 19 years (mean = 17 years, range: 1-34 years). All patients were in New York Heart Association Class I/II at last follow-up. Following repair of TA, patients had good long-term functional status but had high reoperation rates. Repair of interrupted aortic arch and TV were not risk factors for mortality. Postoperative extracorporeal membrane oxygenation, operative weight <2.5kg, prior surgical intervention, and coronary artery anomaly were risk factors for early death. DiGeorge syndrome was associated with late death, most commonly from infection.

Predictors of 30-day post-transplant mortality in patients bridged to transplantation with continuous-flow left ventricular assist devices—An analysis of the International Society for Heart and Lung Transplantation Transplant Registry

Continuous-flow (CF) left ventricular assist devices (LVADs) are standard of care for bridging patients to cardiac transplantation. However, existing data about preoperative factors influencing early post-transplant survival in these patients are limited. We sought to determine risk factors for mortality using a large international database. All patients in the International Society for Heart and Lung Transplantation Transplant Registry who were bridged to transplantation with CF LVADs between June 2008 and June 2012 were included. Risk factors for mortality within 30 days of transplant were identified. Statistical analysis included multivariable analysis and Kaplan-Meier survival analysis. During the study period, 2,152 patients with CF LVADs underwent heart transplantation. Post-transplant survival was 95.5% at 30 days. Risk factors for mortality during this window included ventilator support at transplant (hazard ratio [HR] = 5.00, 95% confidence interval [CI] = 1.51-16.58), female recipient/male donor (compared with all other combinations, HR = 3.29, 95% CI = 1.90-5.72), history of hemodialysis (HR = 2.51, 95% CI = 1.14-5.51), and history of coronary bypass grafting (HR = 1.89, 95% CI = 1.19-3.00). Increasing recipient age (p = 0.002), body mass index (p = 0.002), creatinine (p = 0.004), and total bilirubin (p < 0.001) also were associated with an increase in mortality. In patients supported with CF LVADs, risk factors for early mortality can be identified before transplant, including ventilator support, female recipient/male donor, increasing recipient age, and body mass index. Despite the inherent complexities of a reoperative surgery, patients bridged to transplant with CF LVADs have excellent peri-operative survival.

Risk factors for early mortality after AIDS in the cART era: A population-based cohort study in Italy.

BackgroundDespite the dramatically improved survival due to combination antiretroviral therapies (cART), life expectancy of people with HIV/AIDS remains lower than that of the general population. This study aimed to estimate, at a population level, the survival experience of Italian people with AIDS (PWA) and to quantify the prognostic role of selected factors at diagnosis in the risk of early mortality (i.e., within six months from AIDS diagnosis).MethodsA population-based, retrospective-cohort study was conducted among Italian PWA diagnosed between 1999 and 2009 and recorded in the national AIDS registry. The vital status, up to December 2010, of 14,552 PWA was ascertained through a record linkage procedure with the Italian mortality database. Survival probabilities were estimated through Kaplan-Meier method. To identify risk factors for early mortality from any cause, odds ratios (ORs) and corresponding 95 % confidence intervals (CIs), adjusted for major confounders, were computed using multivariate logistic regression models.ResultsOf the 5,706 deaths registered among the 14,552 PWA included in the study, 2,757 (18.9 %) occurred within six months from AIDS diagnosis. The probability of surviving six months increased from 81.2 % in PWA diagnosed in 1999–2000 to 82.9 % in 2009, while the 5-year survival augmented from 60.7 % in PWA diagnosed in 1999–2000 to 65.4 % for PWA diagnosed in 2005–2006. Elevated risks of early mortality were associated to older age (OR = 5.28; 95 % CI: 4.41-6.32 for age ≥60 vs. <35 years), injecting drug use (OR = 1.71; 95 % CI: 1.53-1.91 vs. heterosexual intercourse), and CD4 count <50 cells/mm3 at AIDS diagnosis (OR = 1.87, 95 % CI: 1.55-2.27 vs. ≥350). Elevated ORs for early mortality also emerged for PWA diagnosed with primary brain lymphoma (OR = 11.66, 95 % CI: 7.32-18.57), or progressive multifocal leukoencephalopathy (OR = 4.21, 95 % CI: 3.37-5.27).ConclusionsOur study documented, among Italian PWA, the high - though slightly decreasing - frequency of early mortality in the full cART era. These findings indicate the need for enduring and ameliorating preventive actions aimed at timely HIV testing among all individuals at risk for HIV infection and/or those who present diseases known to be related with HIV infection.

Poor prognostic factors in patients who underwent surgery for acute non-occlusive ischemic colitis.

IntroductionIschemic colitis (IC) is a disease with high postoperative morbidity and mortality. Knowledge of the risk factors for postoperative mortality could be helpful in clinical decision making and in optimizing postoperative treatment.MethodsFrom a prospective database, we conducted a retrospective medical record review of 50 patients who underwent surgery for IC between 2003 and 2011 at our institution. We analyzed the causes and potential risk factors for early mortality after surgery for IC.ResultsThe early postoperative mortality and morbidity rates were 30.0% (15/50) and 54% (27/50), respectively. The two most common causes of death were multi-organ failure (66.7%, 10/15) and fulminant septic shock (20.0%, 3/15). Univariate analysis showed that postoperative mortality was significantly associated with preoperative nephropathy, coronary artery disease, a previous history of cardiovascular surgery, an ASA score ≥ 4, surgical delay ≥ 3 days, preoperative hemodynamic instability, and use of pre- and intraoperative adrenergic vasopressors. In the multivariate analysis, a previous history of cardiovascular surgery (odds ratio [OR], 8.2; 95% confidence interval [CI], 1.2–56.5) and surgical delay ≥ 3 days (OR, 5.7; 95% CI, 1.2–27.9) were identified as independent risk factors for postoperative mortality.ConclusionsBecause surgical delay is an avoidable determinant of early mortality, a high index of suspicion and early surgical intervention can increase survival. A routine postoperative evaluation for IC may be helpful in patients with a previous history of cardiovascular surgery.

Weight Gain in the First 10 Days after Hematopoietic Stem Cell Transplantation (HSCT) Is a Risk Factor for Early Mortality

▪Introduction: Hematopoietic stem cell transplantation (HSCT) is an effective treatment option for patients with hematological and neoplastic diseases. Despite recent improvements, HSCT is still associated with a significant risk of mortality. Determining risk factors for death within the first 100 days after HSCT could help to identify patients who would benefit from interventions in order to decrease that risk. We have previously reported that increased fluid accumulation during conditioning chemotherapy and in the early period after HSCT was associated with decreased survival (Costa EMM et al, ASH 2013Abstract #4512). Herein, we expand that series of patients and we further analyze the impact of weight gain on early (100-days) mortality in patients who underwent HSCT at our institution.Objective: To determine the impact of weight gain during the first 10 days post-HSCT on 100 days mortality.Methods:We retrospectively reviewed the medical charts of 331 patients who underwent HSCT at our institution from January, 2007 until December, 2013. Information on patients’ body weight (BW) was measured daily, starting at admission. The highest BW recorded until until the first 10 days post-SCT (D+10) was used to calculate the BW increase in relation to the baseline BW. Based on our previous study, we used a cutoff of 6% gain in BW to identify a group of patients with increased risk of complications. The primary endpoint was mortality within 100 days post HSCT. Overall survival (OS) was estimated from the time of HSCT until death, and surviving patients were censored at last follow-up. A logistic regression model and a Cox model were fit to determine variables that predicted death within 100 days and OS, respectively. Statistical analysis was performed with STATA (v11.0) and alfa error was defined as 5%.Results: Median age was 43 years old (range <1 year-76 years) and 60% were male. HSC sources included autologous (46%), matched related donors (16%), matched unrelated donors (12%), cord blood units (16%) and mismatched related/unrelated donors (10%). Diagnosis included acute leukemia or chronic myeloid disorders (34%), lymphoma/multiple myeloma (42%) and non-malignant hematological disorders (24%). Twenty-one percent of patients had a ≥6% gain in BW until the first 10 days post-HSCT. These patients had developed an increased inflammatory state after the start of the conditioning regimen: there was no difference in baseline levels of C-reactive protein (4.8 mg/L vs. 7.4, p=0.37), but by D+10 patients who gained more BW had higher CRP (116.7 mg/L vs. 178.6 mg/L; p=0.01). Patients with increased gain in BW until D+10 had a decreased OS (HR 2.33, p<0.0001, 95% CI 1.45-3.73). The mortality within 100 days was 47% in the increased BW vs. 17% in the control group (p<0.0001). Among 18 patients who died within 100 days and had a ≥6% BW gain by D+10, causes of death included pneumonia (N=4), septic shock (N=9), fungal endocarditis (N=1), ischemic stroke (N=1) and disease progression (N=3). In a logistic regression analysis, after adjusting for age, sex, diagnosis and type of SCT, a ≥6% BW gain by D10 was associated with an increased risk of being dead within 100 days (coefficient 1.75; p<0.0001; 95% CI 0.90-2.61). Similarly, in a multivariate Cox analysis after adjusting for age, sex, diagnosis and type of SCT, a ≥6% BW gain by D10 was an independent risk factor for survival (HR 2.72, p<0.0001, 95% CI 1.65-4.48). A landmark analysis at D+100 revealed that the negative impact of weight gain by D+10 on survival was restricted to the first 100 days, as after this time point there was no survival difference between the two groups (HR 1.35; p=0.41; 95% CI 0.65-2.83).Conclusion: A ≥6% BW gain by D+10 is a risk factor for early mortality in both autologous and allogeneic HSCT. The most common cause of death in these patients is infectious-related complications. An increase in BW is related to the development of an inflammatory state, probably induced by the conditioning regimen. BW gain is a simple variable that can be easily used to determine prognosis of patients post-allogeneic HSCT, and further studies are needed to determine its etiology. DisclosuresNo relevant conflicts of interest to declare.

Evidence for a Dominant Negative Effect Conferred By the APOL1 G2 Sickle Cell Nephropathy Risk Allele in an in Vivo Model

BACKGROUND: Sickle cell disease (SCD) patients have a heterogeneous clinical course, and as patient survival has improved, end-organ damage has become an emergent clinical priority. End stage renal disease (ESRD), occurring in 5-18% of SCD patients, is a particular concern, because it is a major risk factor for early mortality (Platt et al. 1994). Detection of SCD nephropathy (SCDN) relies on relatively late-stage markers, namely proteinuria and reduced glomerular filtration rate (GFR). Consequently, at-risk SCD patients are not identified prior to end-organ damage. In non-SCD nephropathy, ESRD risk among African American individuals has been attributed to coding variants (termed G1 and G2) in apolipoprotein L1 (APOL1). The G1 allele consists of two nonsynonymous variants in perfect LD, rs73885319 and rs60910145 (encoding S384G and I384M), while the G2 variant consists of a six base pair deletion removing amino acids N388 and Y389 (~21% and ~13% allelic frequency in African Americans for G1 and G2, respectively). We demonstrated that these variants in APOL1 are strong predictors of risk for proteinuria in SCD (Ashley-Koch et al. 2011). Here, we use zebrafish as an in vivo model to both examine the role of apol1 in glomerular development and pronephric filtration and also to test the effects of APOL1 G1 and G2 expression in the developing kidney.METHODS: A morpholino (MO) was designed by Gene Tools, LLC (Philomath, OR) to target the translation initiation site of zebrafish apol1. APOL1 G1 and G2 allelic constructs were synthesized from a wild-type (WT) APOL1 human open reading frame clone (GenBank: BC112943) using site-directed mutagenesis (Stratagene, QuikChange II), subsequently transcribed (mMESSAGE mMACHINE®, Life Technologies) into capped mRNA and co-injected with apol1-MO into zebrafish embryos. To assay glomerular filtration, 70 kDa FITC-conjugated dextran was injected into the cardiac venous sinus of 48 hour post-fertilization embryos. The eye vasculature of individual fish was imaged at two, 12, and 36 hours after dextran injection. The average fluorescence intensity was measured across the eye, and changes in intensity relative to the 2-hour post-injection measurements were calculated for comparison. Electron microscopy sections of five days post-fertilization embryos were cut on a Leica-Reichert Ultracut E ultramicrotome, and semi-thin sections (1.0μm) were stained and examined on a Phillips CM12 electron microscope.RESULTS: As we showed previously (Anderson et al., ASH 2013), MO-induced suppression of apol1 in zebrafish embryos results in pericardial edema, glomerular filtration defects, and extensive podocyte loss. Importantly, complementation of apol1 morphants with WT human APOL1 mRNA rescues the observed kidney defects. However, we now show that neither APOL1 G1 nor G2 risk alleles ameliorate defects caused by apol1 suppression. Notably, injection of APOL1 G2 alone results in renal defects, as indicated by increased dextran clearance and the presence of microvillus protrusions in the urinary space. Injection of APOL1 G1 alone, however, does not induce noticeable kidney dysfunction. Furthermore, when APOL1 G2 injected embryos were titrated with increasing concentrations of human APOL1 WT mRNA, we observed a significant reduction of edema formation in developing embryos, suggesting a possible dominant-negative effect of the altered protein.CONCLUSIONS: Unlike the WT APOL1 mRNA, neither the APOL1 G1 or G2 risk alleles could rescue kidney dysfunction due to knockdown of apol1 in zebrafish embryos, suggesting that these SCDN risk alleles impact the normal function of APOL1 in the kidney. Furthermore, development of edema with concomitant defects in glomerular ultrastructure in zebrafish embryos injected with APOL1 G2 mRNA alone suggest that this allele may act in a dominant-negative manner to induce kidney defects. Interestingly, it has been shown that APOL1 may cause toxic renal effects through programmed cell death pathways leading to glomerulosclerosis (Wan et al. 2008). Thus, apol1 suppression could result in the dysregulation of autophagic pathways, causing podocyte malformation and thereby affecting the susceptibility of the pronephros to glomerular injury. In summary, these data provide essential insight into the biological mechanisms by which APOL1 variants confer disease risk in human SCDN and other nondiabetic nephropathies. DisclosuresNo relevant conflicts of interest to declare.

Prevalence of risk factors at presentation and early mortality in patients aged 80 years or older with ST-segment elevation myocardial infarction.

BackgroundElderly patients with ST-segment elevation myocardial infarction (STEMI) are at high risk for complications and early mortality; still, they are underrepresented in clinical trials and observational studies. We studied the risk profiles at presentation and early mortality in elderly (≥80 years) versus younger (<80 years) STEMI patients.DesignThis was a prospective cohort study.MethodsThe study population comprised 4,092 consecutive STEMI patients admitted to Oslo University Hospital, Ulleval from 2006 to 2010. Baseline characteristics at admission were recorded, as well as in-hospital mortality. Etiologic strategy was used in the analyses.ResultsPatients ≥80 years of age (n=536) were more likely to be women and have prior myocardial infarction, angina, and stroke, but were less likely to be current smokers. The crude in-hospital mortality was 16.2% in patients aged 80 years and older versus 3.5% in those younger than 80 years. The adjusted odds ratio for mortality in patients aged 80 years and older versus those younger than 80 years increased with increasing levels of serum creatinine and total cholesterol. In patients with low levels of serum creatinine and total cholesterol, the odds ratio was 3.01 (95% confidence interval, 1.86–4.93; P=0.0001); increasing to 11.72 (95% confidence interval, 5.26–26.3; P=0.001) in patients with high levels.ConclusionHigh levels of serum cholesterol and creatinine were important risk factors for early mortality in elderly patients. Depending on the levels of cholesterol and creatinine, in-hospital mortality in patients aged 80 years and older varied from a threefold to an almost twelvefold risk compared with younger patients.

Clinical outcomes of allogeneic hematopoietic stem cell transplantation patients with co-activation of cytomegalovirus and Epstein-Barr virus

To evaluate the impact of cytomegalovirus (CMV) and Epstein-Barr virus (EBV) co-activation on the prognosis of allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients. We retrospectively analyzed 330 consecutive allo-HSCT patients at First Affiliated Hospital of Soochow University from December 2011 to August 2013. CMV and EBV DNA were regularly monitored by quantitative polymerase chain reaction (PCR) from the engraftment of granuloCyte within one year after transplantation. The incidences of viremia and clinical outcomes were analyzed by χ(2) test and Kaplan-Meier analysis. After a median follow-up period of 16 (7-25) months, a total of 113 (34.2%) patients were identified with CMV viremia (CMV+) alone, 82 (24.8%) with EBV viremia (EBV+) alone and 32 (9.7%) with CMV and EBV co-activation (CMV/EBV+). The proportion of patients undergoing HLA mismatched transplantation and ones with acute graft-versus-host disease (aGVHD) in CMV/EBV+ group was significantly higher than CMV+ group or EBV+ group (78.1% (25/32) vs 58.5% (48/82) or 50.4% (57/113), P = 0.047,0.008; 56.3% (18/32) vs 32.9% (27/82) or 34.5% (39/113) , P = 0.022, 0.026) . The incidence of post-transplant lymphoproliferative disorder (PTLD) was similar to EBV+ group (12.5% (4/32) vs 11.0% (9/82) , P = 0.802) and so did the incidence of CMV disease when compared with CMV+ group (9.4% (3/32) vs 7.1% (8/113) , P = 0.665). The 2-year overall survival (OS) of CMV+, EBV+ and CMV/EBV+ groups was 68.7%, 61.5% and 62.4% respectively. And no significant difference existed between CMV/EBV+ and the other two groups (P = 0.598, 0.717). However, the 6-month non-relapse mortality (NRM) of CMV/EBV+ group was significantly higher than that of CMV+ or EBV+ group (18.7% vs 8.9%, P = 0.036; 18.7% vs 8.1%, P = 0.032). HLA mismatch transplants and aGVHD are frequent in CMV and EBV co-activation group. When compared with EBV+ or CMV+ patients, the CMV/EBV+ patients have similar incidence of PTLD or CMV disease and 2-year OS.However, the 6-month NRM is significantly higher in CMV/EBV+ group. It suggests that CMV and EBV co-activation is a risk factor for early mortality of allo-HSCT patients.

Risk Factors for Early Mortality on Antiretroviral Treatment of Elderly People Infected with HIV in Burkina Faso.

Age is a key determinant of mortality due to diseases including HIV infection. A retrospective and descriptive cohort study used a computerized database to compare HIV-infected patients diagnosed in late adulthood to a group of patients diagnosed before their 49 years of age, without matching the characteristics of HIV infection. The study included patients who visited the day hospital (outpatient clinic) of the Sanou Souro Teaching Hospital of Bobo-Dioulasso, in Burkina Faso, from January 2007 to December 2011. Older adults were defined as those aged 50 years and more. Participants in the study consisted of 2572 patients (265 older adults and 2307 young patients living with HIV. Based on Markov chain method, 32.1% of the older adults living with HIV were found to be seroconvert at 50 years or older. The median follow-up time on antiretroviral treatment (ART) was 32.7 months (range 0.03-65.4 months). Two hundred and ninety-five (11.5%) patients died, including 21.1% of older adults and 10.4% of young (P < .01). World Health Organization stage 3 or 4 and the lowest CD4 count reached <200 cells/mm(3) were the factors associated with early mortality of older adults on ART. Mortality rate of older adult patients living with HIV in Burkina Faso is high. Early diagnosis, early treatment, and primary prevention of HIV infection in the older adults are the main keys that could help reduce such mortality.

190 * REDO AFTER ACUTE TYPE A AORTIC DISSECTION: EARLY RESULTS FROM A MULTICENTRE REAL-WORLD EXPERIENCE

Objectives: To provide early results of repetitive surgical procedures after first operation for acute type A aortic dissection (AAD) and to identify risk factors for mortality. Methods: Between May 1998 and January 2014, 117 aortic reoperations after initial operation for AAD (mean time from the first procedure was 3.98 years, range 0.1–20.87) were performed in 110 patients (mean age 59.8 ± 12.6 years) in 7 real-world institutions. Proximal causes for reoperation were aortic root aneurysm in 20, root re-dissection in 17, aortic valve insufficiency in 27 and proximal anastomotic pseudoaneurysm in 26 patients. Distal causes were arch re-dissection in 18, arch dilatation in 15, anastomotic pseudoaneurysm in 25 patients. Results: A total of 74 isolated proximal, 30 isolated distal and 13 combined procedures were performed. There were 23 (19.66%) in-hospital deaths (elective/urgent 11.11%, emergency 66.67%). Causes of death were cardiac in 8, neurological in 3, multiorgan failure in 5, sepsis in 2, bleeding in 3 and lung failure in 2 patients. Multivariate logistic regression analyses revealed that risk factors for mortality were emergency operation (P < 0.0001), previous distal procedure (P = 0.04) and new elephant trunk procedure (P = 0.03). New proximal procedures were not found to be risk factors for early mortality (P = 0.15). Conclusion: This multicentre experience shows that redo surgery after AAD operations remains a challenging procedure especially in emergency settings and after surgery of the distal aorta. Proximal reoperation does not affect mortality; therefore initial aortic root preservation for AAD should not be considered a concern for late reoperations.

Predictors of early and medium-term outcome of 200 consecutive aortic valve and root repairs

Advantages of aortic valve repair and root reconstruction include maintenance of natural valve hemodynamic parameters and avoidance of prosthetic valve-related complications. However, general acceptance of valve reconstruction may be limited by paucity of long-term follow-up data from only a few centers. This report is intended to supplement existing outcome information for aortic valve repair. Between 2003 and 2013, 200 consecutive patients (149 men, 51 women; mean age, 52.1 years) with significant aortic regurgitation and aortic root enlargement underwent aortic valve repair and associated root reconstruction. The same prospective selection criteria and systematic valve repair approaches were followed throughout the study. Root management consisted of either root remodeling or reimplantation with Dacron prostheses. Kaplan-Meier techniques were used to assess major end points of all-cause mortality, reoperation, and repair failure. Univariable log-rank testing was used to identify associations between risk factors and major events. Early mortality was 2% (4 patients), and early repair failure was 3% (6 patients). New York Heart Association functional class was found to be a risk factor for early mortality and morbidity (odds ratio, 3.3; P=.03), whereas crossclamp time and cardiopulmonary time were risk factors for early mortality (odds ratio, 1.04; 95% confidence interval, 1-1.07; P=.01 and odds ratio, 1.02; 95% confidence interval, 1-1.03; P=.02), respectively. Survival at a mean follow-up of 48.6 ± 34.3 months (median follow-up, 43.6 months; range, 17.8-78 months) was 94%, with a freedom from reoperation of 91%. Univariable risk factors for mortality were preoperative New York Heart Association functional class and requirement for root replacement. Repair failure and reoperation were associated with bicuspid valve anatomy, subcommissural annuloplasty, and complex leaflet repair. Freedom from repair failure was associated with aortic reimplantation. Data from a prospective cohort of patients undergoing aortic valve repair and root reconstruction reinforce the satisfactory medium-term results obtained with valve reconstruction. Further analysis of these patient outcomes is necessary to draw definitive conclusions on operative techniques.

Prognostic determinants of community-acquired bloodstream infection in type 2 diabetic patients in ED

ObjectivesThe objective of the study is to describe the epidemiology and outcome of community-acquired bloodstream infection (BSI) in type 2 diabetic patients in emergency department (ED). MethodsAll patients admitted to the ED of the university hospital from June 2010 to June 2011 with a history of type 2 diabetes mellitus and microbiologically documented BSI were retrospectively enrolled. Demographic characteristics, Charlson comorbidity index, antibiotic therapy, clinical severity, microbiological etiology, and diabetes-related complications were recorded in a standardized form. The major outcome measure was 30-day survival. χ2 Or Student t test was used for univariate analysis, and Cox proportional hazards models were used for multivariate analysis. ResultsAmong 250 enrolled emergency patients with BSI, the overall 30-day mortality rate was 15.5%. Twenty-seven patients (10.7%) developed diabetic ketoacidosis (DKA), and 22 patients (8.8%) developed hyperosmolar hyperglycemic state. On univariate analysis, DKA rather than hyperosmolar hyperglycemic state was associated with adverse outcome. Other risk factors include higher mean glycated hemoglobin level, presence of underlying malignancy, long-term use of steroids, lower respiratory tract infection, and higher Charlson scores. Multivariate analysis identified 3 independent risk factors for early mortality when severity, comorbidity, age, and sex were under control: DKA (hazard ratio, 3.89; 95% confidence interval, 1.6-8.9), inappropriate antibiotics (2.25, 1.05-4.82), and chronic use of steroid (3.89, 1.1-13.2). ConclusionIn type 2 diabetic patients with BSI, a substantial proportion of patients developed DKA. This condition was probably underrecognized by clinicians and constituted an independent risk factor for short-term mortality. Other identified risk factors are potentially correctable and may allow preventive efforts to individuals at greatest potential benefit.

Clinical characteristics and outcomes of clostridial bacteraemia in cancer patients

Clostridial bacteraemia is usually associated with substantial morbidity and mortality in cancer patients. However, clinical characteristics and risk factors for early mortality in this population are poorly described. We retrospectively studied cancer patients with clostridial bacteraemia treated between January 1996 and December 2011. We compared clinical manifestations between patients with solid tumour and haematological malignancy and assessed risk factors for 7-day mortality. In all, 164 cancer patients developed clostridial bacteraemia during the study period—85 (52%) with solid tumour and 79 (48%) with haematological malignancy. Common isolates were Clostridium perfringens (27%), Clostridium septicum (19%) and Clostridium tertium (14%). Solid tumour malignancy patients were more likely to have a focal gastrointestinal source for bacteraemia and were more likely to undergo subsequent surgery. Haematological malignancy patients were more often neutropenic and more often had no focal source of bacteraemia. Seven-day mortality was 20% (33/164) and did not vary based on malignancy type. The adjusted odds ratio of dying within 7 days of clostridial bacteraemia among patients with hypotension (40/164) was 7.2 (95% CI, 2.9–18.1) and in patients with acute haemolysis (7/164) was 10.5 (95% CI, 1.3–85.2). Clostridial species also impacted mortality; no patient with C. tertium bacteraemia died within 7 days. In conclusion, clinical manifestations of clostridial bacteraemia differed between patients with solid tumour and haematological malignancy, but 7-day mortality was similar. Patients with hypotension and haemolysis at time of bacteraemia were at increased risk for early death.

Outcomes of cardiac surgery in patients weighing

A recent Society of Thoracic Surgeons database study showed that low weight (<2.5 kg) at surgery was associated with high operative mortality (16%). We sought to assess the outcomes after cardiac repair in patients weighing <2.5 kg versus 2.5 to 4.5 kg in an institution with a dedicated neonatal cardiac program and to determine the potential role played by prematurity, the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) risk categories, uni/biventricular pathway, and surgical timing. We analyzed the outcomes (hospital mortality, early reintervention, postoperative length of stay, mortality [at the last follow-up point]) in patients weighing <2.5 kg at surgery (n = 146; group 1) and 2.5 to 4.5 kg (n = 622; group 2), who had undergone open or closed cardiac repairs from January 2006 to December 2012 at our institution. The statistical analysis was stratified by prematurity, STAT risk category, uni/biventricular pathway, and usual versus delayed surgical timing. Univariate versus multivariate risk analysis was performed. The mean follow-up was 21.6 ± 25.6 months. Hospital mortality in group 1 was 10.9% (n = 16) versus 4.8% (n = 30) in group 2 (P = .007). The postoperative length of stay and early unplanned reintervention rate were similar between the 2 groups. Late mortality in group 1 was 0.7% (n = 1). In group 1, early outcomes were independent of the STAT risk category, uni/biventricular pathway, or surgical timing compared with group 2. A lower gestational age at birth was an independent risk factor for early mortality in group 1. A dedicated multidisciplinary neonatal cardiac program can yield good outcomes for neonates and infants weighing <2.5 kg independently of the STAT risk category and uni/biventricular pathway. A lower gestational age at birth was an independent risk factor for hospital mortality.

Cardiac myxomas: a 27-year surgical experience

Amac: Bu calismada merkezimizde yapilan cerrahi kardiyak miksoma rezeksiyonunun sonuclari bildirildi. Ca­lis­ma­pla­ni:­Ocak 1985 Aralik 2012 tarihleri arasinda miksoma tanisiyla ameliyat edilen 99 hasta (67 kadin, 32 erkek, ort. yas 49.8±16 yil; dagilim 5-76 yil) retrospektif olarak incelendi. Ameliyat oncesi tani transtorasik ekokardiyografi ile konuldu. Son takip vizitine kadar gecen ortalama sure 123.4±85.7 ay idi. Bul gu lar: Tum hastalar median sternotomi ile ameliyat edildi. Tumorun kokeni 92 hastada sol atriyum olup, en sik yerlesim yeri 85 hastada interatriyal septumdu. Bir hasta haric tum hastalarda total rezeksiyon yapildi. Kirk bes hastaya (%45.5) papiller miksoma, 54 hastaya (%54.5) solid miksoma tanisi konuldu. Embolik olay riski papiller tip miksomalarda, solid tipe kiyasla, anlamli oranda yuksek bulundu (%44.4’e kiyasla %9.3, p<0.01). Erken mortalite %5 idi. Tek degiskenli analiz sonuclarina gore ileri yas (p=0.04), ameliyat oncesi atriyal fibrilasyon varligi (p=0.02), periferik emboli (p=0.03) ve ameliyat sonrasi inotropik destek ihtiyaci (p=0.008) erken mortalite icin risk faktorleri olarak belirlendi. Bes, 10 ve 20 yillik aktueryal sagkalim oranlari sirasi ile %98, %94 ve %89 idi. Sagkalanlarda nuks orani %1.2 olarak tespit edildi. So­nuc:­Kardiyak miksoma cerrahisi, dusuk ameliyat riski tasimakla birlikte, mukemmel kisa ve uzun donem sonuclar ile iliskilendirilir. Ancak, uzun donemde dusuk nuks riskine ragmen, hastalar yillik ekokardiyografi ile takip edilmelidir. Anah tar soz cuk ler: Kardiyak tumor; miksoma; cerrahi; sagkalim. Background:­ In this study, we reported the outcomes of surgical resection of cardiac myxomas performed in our center. Methods: A retrospective review of 99 patients (67 females, 32 males, mean age 49.8±16 years; range 5 to 76 years) who were operated for myxoma between January 1985 and December 2012 was conducted. Preoperative diagnosis was established by transthoracic echocardiography. The mean time to the last follow-up visit was 123.4±85.7 months. Results:­ All patients were operated through median sternotomy. The site of origin of the tumor was left atrium in 92 patients and the most common implantion site was interatrial septum in 85 patients. A complete resection of the tumor was performed in all patients except one. Forty five patients (45.5%) were diagnosed with a papillary myxoma, while 54 patients (54.5%) were diagnosed with a solid myxoma. The risk of embolic events in papillary type of myxoma was significantly higher than the solid type (44.4% vs. 9.3%, p<0.01). Early mortality was 5%. Univariant analysis showed advanced age (p=0.04), preoperative presence of atrial fibrillation (p=0.02), peripheral embolism (p=0.03), and need for postoperative inotropic support (p=0.008) as the risk factors for early mortality. Actuarial survival rate was 98%, 94% and 89% at five, 10 and 20 years, respectively. The rate of recurrence was 1.2% in survivors. Conclusion:­Surgical treatment of cardiac myxoma carries a low operative risk and is associated with excellent short and long-term results. However, despite low risk of recurrence in the long-term, the patients should be followed with annual echocardiography.

The Influence of Body Mass Index and Weight Loss on Outcome of Elderly Patients Undergoing Lung Cancer Resection

The aim of the study was to evaluate the influence of nutritional status on outcome of elderly patients resected for lung cancer. A total of 117 consecutive patients aged ≥ 70 years undergoing lung cancer resection were enrolled. In addition to routine preoperative evaluations, other variables such as body mass index, weight loss, serum albumin, lymphocytes, and transferrin were counted. According to the body mass index value, patients were divided into Group A (≤ 18.5, underweight) and Group B (> 18.5) and risk factors for morbidity and mortality were analyzed. Group A and Group B counted 21 and 96 patients, respectively. The mean age was 74.9 ± 2.6; body mass index of Group A was significantly lower than that of Group B (16.7 ± 1.3 vs. 23.5 ± 1.7, respectively, p < 0.0001). On multivariate analysis, significant risk factors for complications were pneumonectomy (p = 0.001), stage (p = 0.006), predictive postoperative flow expiratory volume in 1 second (ppoFEV1%) (p = 0.003), and coronary disease (p = 0.04) and significant risk factors for early mortality were pneumonectomy (p = 0.0002), ppoFEV1% (p < 0.0001), BMI (0.02), and weight loss (0.007). The median survival time of Group A and Group B was 41 versus 54 months, respectively (p = 0.1). However, body mass index of less than 18.5 (p = 0.01) and weight loss of > 5% before operation (p = 0.01) were independent risk factors for 1 year mortality. In elderly patients, malnutrition was a significant additional risk factor for early death. Nutritional assessment should be included in the routine preoperative selection. In malnourished patients, nutritional support before and after operation and a careful postdischarge care might be beneficial, but it should be corroborated by further prospective studies.

Surgical outcomes of 380 patients with double outlet right ventricle who underwent biventricular repair

The study objective was to report the outcomes of biventricular repair in patients with double outlet right ventricle. Patients with double outlet right ventricle who underwent biventricular repair at Fuwai Hospital from January 2005 to December 2012 were included. Patients were excluded if double outlet right ventricle was combined with atrioventricular septal defect, heterotaxy syndrome, atrioventricular discordance, or univentricular physiology. A total of 380 consecutive patients with a mean age of 1.9 ± 2.1 years (range, 1 month to 6 years) were included. Varied types of biventricular repair were customized individually. Follow-up was 90.4% complete, and the mean follow-up time was 3.4 ± 3.9 years. There were 17 (4.5%) early deaths and 7 (2.1%) late deaths. Preoperative pulmonary hypertension was the only risk factor for early mortality. Postoperative significant left ventricular outflow tract obstruction was present in 9 survivors. Patients with noncommitted ventricular septal defect had a longer crossclamp time, longer cardiopulmonary bypass time, and higher incidence of postdischarge left ventricular outflow tract obstruction. There were 4 reoperations, all of which were caused by subaortic left ventricular outflow tract obstruction. All of the pressure gradients were decreased to less than 20 mm Hg after the modified Konno procedure with an uneventful postoperative course. Optimal results of varied types of biventricular repair for double outlet right ventricle have been acquired. Although noncommitted ventricular septal defect is technically difficult, the outcomes of patients are favorable. Late-onset left ventricular outflow tract obstruction is the main reason for reoperation but can be successfully relieved by the modified Konno procedure.

Mortality after total hip replacement surgery: A systematic review.

Total hip replacement causes a short-term increase in the risk of mortality. It is important to quantify this and to identify modifiable risk factors so that the risk of post-operative mortality can be minimised. We performed a systematic review and critical evaluation of the current literature on the topic. We identified 32 studies published over the last 10 years which provide either 30-day or 90-day mortality data. We estimate the pooled incidence of mortality during the first 30 and 90 days following hip replacement to be 0.30% (95% CI 0.22 to 0.38) and 0.65% (95% CI 0.50 to 0.81), respectively. We found strong evidence of a temporal trend towards reducing mortality rates despite increasingly co-morbid patients. The risk factors for early mortality most commonly identified are increasing age, male gender and co-morbid conditions, particularly cardiovascular disease. Cardiovascular complications appear to have overtaken fatal pulmonary emboli as the leading cause of death after hip replacement.Cite this article: Bone Joint Res 2014;3:175–82.

Mitral valve repair versus replacement in patients with ischaemic mitral regurgitation and depressed ejection fraction: risk factors for early and mid-term mortality

Mitral valve (MV) surgery for ischaemic mitral regurgitation (IMR) in patients with depressed left ventricular ejection fraction (LVEF) is associated with poor outcomes. The optimal surgical strategy for IMR in these patients remains controversial. The objective of this study was to compare the early mortality and mid-term survival of MV repair versus MV replacement in patients with IMR and depressed LVEF undergoing coronary artery bypass grafting (CABG). A retrospective, observational, cohort study was undertaken of prospectively collected data on 126 consecutive CABG patients with IMR and LVEF <40% undergoing either MV repair (n = 98, 78%) or MV replacement (n = 28, 22%) between July 2002 and February 2011. The overall mortality rate was 7.9% (n = 10). MV replacement was associated with a 4-fold increase in the risk of death compared with MV repair [17.9%, n = 5 vs 5.1%, n = 5; odds ratio (OR) 4.04, 95% confidence interval (CI) 1.08-15.1, P = 0.04]. However, after adjusting for preoperative risk factors, the type of surgical procedure was not an independent risk factor for early mortality (OR 0.1, 95% CI 0.01-31, P = 0.7). Multivariable analysis showed that preoperative LVEF (OR 0.8, 95% CI 0.6-0.9, P = 0.018), preoperative B-type natriuretic peptide (BNP) levels (OR 1.01, 95% CI 1-1.02, P = 0.025), preoperative left ventricle end-systolic diameter (OR 0.8, 95% CI 0.7-1.0, P = 0.05) and preoperative left atrial diameter (OR 1.3, 95% CI 1.0-1.6, P = 0.015) were independent risk factors of early mortality. At the median follow-up of 45 months (interquartile range 20-68 months), the mid-term survival rate was 74% in the MV repair group and 70% in the MV replacement group (P = 0.08). At follow-up, predictors of worse survival were BNP levels [hazard ratio (HR) 1.0, 95% CI 1.0-1.01, P = 0.047], preoperative renal failure (HR 4.6, 95% CI 1.1-20.3, P = 0.039) and preoperative atrial fibrillation (HR 3.3, 95% CI 1.1-10, P = 0.032). MV repair in CABG patients with IMR and depressed LVEF is not superior to MV replacement with regard to operative early mortality and mid-term survival.

(137) - Preoperative Risk Factors for Early Mortality in Patients Bridged to Transplant with a Continuous Flow Left Ventricular Assist Device

(137) - Preoperative Risk Factors for Early Mortality in Patients Bridged to Transplant with a Continuous Flow Left Ventricular Assist Device