Risk Factor For Overall Mortality Research Articles

Outcome of Norwood operation for hypoplastic left heart syndrome.

The Norwood procedure, the first surgical step of staged palliation for hypoplastic left heart syndrome (HLHS), is also applied for other complex single ventricle lesions. This study aimed to evaluate the outcome of the Norwood operation in a single center over 4years and to identify clinical and anatomic risk factors for overall mortality. A retrospective review of the pediatric cardiovascular surgery database was performed to identify infants with HLHS who underwent NP (Norwood procedure) at our institution between January 2007 and December 2011. Our study population consisted of 85 patients with HLHS. Early mortality (30days postoperative period) between January 2007 and December 2011 for Norwood operation was 7 (8.2%) out of 85 patient, and overall mortality was 24 (28.2%). Our single-center experience shows that the Norwood operation can be performed for complex single ventricle lesions with similarly good early outcomes regardless of the underlying anatomy.

Long‐term outcomes among 2‐year survivors of autologous hematopoietic cell transplantation for Hodgkin and diffuse large b‐cell lymphoma

Autologous hematopoietic cell transplantation (auto-HCT) is a standard therapy for relapsed classic Hodgkin lymphoma (cHL) and diffuse large B-cell lymphoma (DLBCL); however, long-term outcomes are not well described. This study analyzed survival, nonrelapse mortality, late effects, and subsequent malignant neoplasms (SMNs) in 1617 patients who survived progression-free for ≥2 years after auto-HCT for cHL or DLBCL between 1990 and 2008. The median age at auto-HCT was 40 years; the median follow-up was 10.6 years. The 5-year overall survival rate was 90% (95% confidence interval [CI], 87%-92%) for patients with cHL and 89% (95% CI, 87%-91%) for patients with DLBCL. The risk of late mortality in comparison with the general population was 9.6-fold higher for patients with cHL (standardized mortality ratio [SMR], 9.6) and 3.4-fold higher for patients with DLBCL (SMR, 3.4). Relapse accounted for 44% of late deaths. At least 1 late effect was reported for 9% of the patients. A total of 105 SMNs were confirmed: 44 in the cHL group and 61 in the DLBCL group. According to a multivariate analysis, older age, male sex, a Karnofsky score < 90, total body irradiation (TBI) exposure, and a higher number of lines of chemotherapy before auto-HCT were risk factors for overall mortality in cHL. Risk factors in DLBCL were older age and TBI exposure. A subanalysis of 798 adolescent and young adult patients mirrored the outcomes of the overall study population. Despite generally favorable outcomes, 2-year survivors of auto-HCT for cHL or DLBCL have an excess late-mortality risk in comparison with the general population and experience an assortment of late complications. Cancer 2018;124:816-25. © 2017 American Cancer Society.

An unjustified benefit: immortal time bias in the analysis of time-dependent events

Immortal time bias is a problem arising from methodologically wrong analyses of time-dependent events in survival analyses. We illustrate the problem by analysis of a kidney transplantation study. Following patients from transplantation to death, groups defined by the occurrence or nonoccurrence of graft failure during follow-up seemingly had equal overall mortality. Such naive analysis assumes that patients were assigned to the two groups at time of transplantation, which actually are a consequence of occurrence of a time-dependent event later during follow-up. We introduce landmark analysis as the method of choice to avoid immortal time bias. Landmark analysis splits the follow-up time at a common, prespecified time point, the so-called landmark. Groups are then defined by time-dependent events having occurred before the landmark, and outcome events are only considered if occurring after the landmark. Landmark analysis can be easily implemented with common statistical software. In our kidney transplantation example, landmark analyses with landmarks set at 30 and 60months clearly identified graft failure as a risk factor for overall mortality. We give further typical examples from transplantation research and discuss strengths and limitations of landmark analysis and other methods to address immortal time bias such as Cox regression with time-dependent covariables.

This Month in Adult Urology

No AccessJournal of UrologyThis Month in Adult Urology1 Oct 2017This Month in Adult Urology Joseph A. Smith Joseph A. SmithJoseph A. Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.07.012AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "This Month in Adult Urology." The Journal of Urology, 198(4), pp. 715–716 References 1 : Surgical treatment of female stress urinary incontinence: AUA/SUFU guideline. J Urol2017; 198: 875. Link, Google Scholar 2 : AUA policy statement on use of multiparametric magnetic resonance imaging in the diagnosis, staging and management of prostate cancer. J Urol2017; 198: 832. Abstract, Google Scholar 3 : Predictive nomogram for recurrence following surgery for nonmetastatic renal cell cancer with tumor thrombus. J Urol2017; 198: 810. Abstract, Google Scholar 4 : Predicting complications following robot-assisted partial nephrectomy with the ACS NSQIP® universal surgical risk calculator. J Urol2017; 198: 803. Link, Google Scholar 5 : Effects of withdrawing α1-blocker from combination therapy with α1-blocker and 5α-reductase inhibitor in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: a prospective and comparative trial using urodynamics. J Urol2017; 198: 905. Abstract, Google Scholar 6 : Focal laser ablation of prostate cancer: feasibility of magnetic resonance imaging-ultrasound fusion for guidance. J Urol2017; 198: 839. Link, Google Scholar 7 : Dietary and lifestyle risk factors associated with incident kidney stones in men and women. J Urol2017; 198: 858. Link, Google Scholar 8 : Severity of preoperative proteinuria is a risk factor for overall mortality in patients undergoing nephrectomy. J Urol2017; 198: 795. Link, Google Scholar 9 : Characteristics associated with treatment response and satisfaction in women undergoing onabotulinumtoxinA and sacral neuromodulation for refractory urgency urinary incontinence. J Urol2017; 198: 890. Abstract, Google Scholar © 2017 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 198Issue 4October 2017Page: 715-716 Advertisement Copyright & Permissions© 2017 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph A. Smith More articles by this author Expand All Advertisement PDF downloadLoading ...

Experience With Pericardiectomy for Constrictive Pericarditis Over Eight Decades

The purpose of this study was to review the surgical outcomes of pericardiectomy for constrictive pericarditis and to examine risk factors for overall mortality in a contemporary period. We reviewed all patients who underwent pericardiectomy for constriction from 1936 through 2013. The investigation included constrictive pericarditis cases confirmed intraoperatively, all other types of pericarditis were excluded; 1,071 pericardiectomies were performed in 1,066 individual patients. Patients were divided into two intervals: a historical (pre-1990) group (n= 259) and a contemporary (1990-2013) group (n= 807). Patients in the contemporary group were older (61 versus 49 years; p < 0.001), more symptomatic (NYHA class III or IV in 79.6% versus 71.2%; p < 0.001), and more frequently underwent concomitant procedures (21.4% versus 5.4%; p < 0.001) compared with those in thehistorical group. In contrast to the historical cases inwhich the etiologies of constriction were mostly idiopathic (81.1%), nearly half of contemporary cases had a nonidiopathic etiology (postoperative 32.3%, radiation 11.4%). Although 30-day mortality decreased from 13.5% in the historical era to 5.2% in the contemporary era (p < 0.001), overall survival was similar after adjusting for patient characteristics. Risk factors of overall mortality in the contemporary group included NYHA class III or IV (HR 2.17, p < 0.001), etiology of radiation (HR 3.93, p < 0.001) or postcardiac surgery (HR 1.47, p < 0.001), and need for cardiopulmonary bypass (HR 1.35, p= 0.014). There was a significant change in disease etiology over the study period. Long-term survival after pericardiectomy is affected by patient characteristics including etiology of constriction and severity of symptoms.

Cause-specific death after surgical resection for early-stage non-small-cell lung cancer.

Surgical resection is the recommended treatment for patients with early-stage non-small-cell lung cancer. However, it is believed that causes other than lung cancer can lead to death following surgical resection. Investigating the risk factors for overall mortality and analysing the specific causes of death may indicate the degree of influence of other causes of death. We assessed individual risk factors affecting overall and cause-specific mortality in a Cox proportional hazards model in a cohort of patients with resected Stage I/II non-small-cell lung cancer (n = 756) from 2007 to 2015 in a tertiary university centre. The follow-up period ranged from 3 days to 9.3 years. Median survival time was 7.3 years (95% confidence interval 6.0-7.9). A few patients died of cardiovascular disease (n = 19) and were included in the group 'other cause'. In a competing risk model, we evaluated the risk factors for specific causes of death in patients dying of lung cancer and dying of non-lung cancer specific conditions. The overall survival was 94%, 62% and 50% at 1, 5 and 7 years, respectively. At the end of the follow-up period, the risk of having died of, respectively, lung cancer or other causes was 36% and 24%. The cumulative incidence of death of lung cancer increased continuously during the study. Risk factors predicting death of all causes and death of non-small-cell lung cancer were increasing age, severely reduced lung function, Eastern Cooperative Oncology Group Performance Status ≥2, preoperative examination without positron emission tomography/computed tomography, histological tumour diagnosis other than adenocarcinoma and squamous cell carcinoma and increasing disease stage. In patients dying of other causes, age, gender, body mass index, smoking and Eastern Cooperative Oncology Group Performance Status ≥2 affected the mortality rate. The probability of having died of lung cancer continued to increase beyond 5 years after the operation. Surveillance of risk factors associated with an increased mortality rate should be considered in the postoperative follow-up examination after lung cancer resection.

High molecular weight fibroblast growth factor-2 as a promising prognosticbiomarker to predict the occurrence of heart failure in atrial fibrillation patients.

Heart failure (HF) has a significant effect on the prognosis of the patients with atrial fibrillation (AF), and also it is an important risk factor for overall mortality. High molecular weight fibroblast growth factor-2 (Hi-FGF-2) is emerging as a prognostic marker with HF and AF. The aim of this study was to prove that Hi-FGF-2 would predict occurrence of HF in the patients with AF. Subjects diagnosed with paroxysmal AF (Group paAF), persistent AF (Group peAF) and sinus rhythm (Group SR) were enrolled in the study. Serum Hi-FGF-2 concentration was measured by ELISA at baseline. Multivariable logistic models and receiver operating characteristic (ROC) curve analysis were established to predict the prognosis of AF subjects. 260 patients were enrolled in the study: 104 (40.0%) admitted for sinus rhythm (Group SR) and 156 (60.0%) with AF (Group paAF and Group peAF). The Hi-FGF-2 levels were much lower in the Group SR (58.2±27.1ng/L) than in the Group AF. Furthermore, the Group peAF (84.3±34.1ng/L) had higher Hi-FGF-2 levels than the Group paAF (72.9±35.8ng/L). Serum Hi-FGF-2 levels were classified into trisection in the multivariable logistic model (T1<57.3ng/L, 57.3<T2<86.5ng/L, and T3>86.5ng/L). Hi-FGF-2 showed good predictive ability for new-onset HF in the patients with AF. The occurrence of HF was associated significantly with increased tertile of serum Hi-FGF-2 levels (T2: OR 5.922, 95% CI 1.109-31.626, P=0.037 and T3: OR 8.262, 95% CI 1.735-39.343, P=0.008). ROC curve analysis showed that the area under curves for Hi-FGF-2 were 0.720 (P<0.0001). Hi-FGF-2 has a significant meaning in AF subjects. Further to this, higher circulating Hi-FGF-2 was highly related to persistent AF, and Hi-FGF-2 may be an independent risk factor of occurrence HF in AF subjects.

Risk factors and clinical outcomes for carbapenem-resistant Gram-negative late-onset sepsis in a neonatal intensive care unit

Carbapenem-resistant (CR), Gram-negative (GN), late-onset sepsis (LOS) is a serious threat in the neonatal intensive care unit (NICU). To assess the prevalence of CR-GN-LOS in NICU patients and to identify the risk factors and outcomes associated with its acquisition. Neonates with carbapenem-susceptible (CS)-GN-LOS were compared with those with CR-GN-LOS in a two-year observational study. A total of 158 patients had GN-LOS; 100 infants had CS-GN-LOS and 58 infants had CR-GN-LOS. The incidence rate of CR-GN-LOS was 6.5 cases per 1000 patient-days. The most frequent bacterial strain in both groups was Klebsiella pneumoniae. The duration of total parenteral nutrition (TPN) (P=0.006) and prior carbapenem use (P=0.01) were independent risk factors for CR-GN-LOS acquisition. CR-GN-LOS was associated with higher mortality than CS-GN-LOS (P=0.04). Birth weight, small for gestational age, time to start enteral feeding, exclusive formula feeding, previous surgery, previous antifungal use, central venous device before onset, duration of central venous device, and infectious complications were identified as dependent risk factors for overall mortality. However, only male gender (P=0.04) and infectious complications (P < 0.001) were independent risk factors associated with mortality. Infectious complication rates, duration of mechanical ventilation, and length of hospital stay were significantly higher in infants with CR compared to CS-GN-LOS. The duration of TPN and carbapenem use were the independent predictors for CR-GN-LOS acquisition. CR-GN-LOS is associated with higher mortality, infectious complication rates, longer mechanical ventilation, and longer hospital stay. Male gender and infectious complications were the independent risk factors for mortality in neonates with GN-LOS.

Severity of Preoperative Proteinuria is a Risk Factor for Overall Mortality in Patients Undergoing Nephrectomy

Chronic kidney disease may adversely affect survival following nephrectomy. Proteinuria is increasingly used as a marker of kidney disease. However, the relationship between preoperative proteinuria and survival after nephrectomy remains incompletely characterized. We evaluated the association of preoperative proteinuria with overall and cancer specific survival using our institutional nephrectomy registry. We identified 1,846 patients with localized clear cell renal cell carcinoma treated with curative intent (radical or partial nephrectomy) between 1995 and 2010. Patients were categorized for analysis based on preoperative proteinuria severity (mild, moderate or severe). Overall and cancer specific survival was estimated by the Kaplan-Meier method. Cox proportional hazards regression models were used to assess for variables associated with overall and cancer specific mortality. Preoperative urine protein testing was available in 1,347 patients (73%). A total of 804 patients (60%) were classified with mild proteinuria (less than 150 mg per day), 332 (25%) were classified with moderate proteinuria (150 to 500 mg per day) and 211 (16%) were classified with severe proteinuria (greater than 500 mg per day). On multivariable analysis with mild proteinuria as the reference category the adjusted HR for all cause mortality was 1.18 (95% CI 0.95-1.48, p=0.14) for moderate proteinuria and 1.61 (95% CI 1.26-2.07, p <0.001) for severe proteinuria. However, the proteinuria level was not associated with cancer specific survival. Severe preoperative proteinuria is associated with worse overall survival following radical or partial nephrectomy for localized clear cell renal cell carcinoma. Preoperative proteinuria should be evaluated in patients undergoing nephrectomy and considered when estimating overall patient health status.

Tobacco use and outcome in radical prostatectomy patients.

Cigarette smoking has been consistently associated with increased risk of overall mortality, but the importance of smoking for patients with prostate cancer (CaP) who are candidates for curative radical prostatectomy (RP) has received less attention. This retrospectively designed cohort study investigated the association of smoking history at RP with subsequent CaP treatment outcomes and overall mortality. A total of 1981 patients who underwent RP at Roswell Park Cancer Institute (RPCI) between 1993 and 2014 were studied. Smoking history was considered as a risk factor for overall mortality as well as for currently accepted CaP treatment outcomes (biochemical failure, treatment failure, distant metastasis, and disease‐specific mortality). The associations of smoking status with these outcomes were tested by Cox proportional hazard analyses. A total of 153 (8%) patients died during follow‐up. Current smoking at diagnosis was a statistically significant predictor of overall mortality after RP (current smokers vs. former and never smokers, hazards ratio 2.07, 95% confidence interval [CI]: 1.36–3.14). This association persisted for overall mortality at 3, 5, and 10 years (odds ratios 2.07 [95% CI: 1.36–3.15], 2.05 [95% CI: 1.35–3.12], and 1.8 [95% CI: 1.18–2.74], respectively). Smoking was not associated with biochemical failure, treatment failure, distant metastasis, or CaP‐specific mortality, and the association of smoking with overall mortality did not appear to be functionally related to treatment or biochemical failure, or to distant metastasis. Smoking is a non‐negligible risk factor for death among CaP patients who undergo RP; patients who smoke are far more likely to die of causes other than CaP.

Atrial fibrillation in hypertrophic cardiomyopathy: A turning point towards increased morbidity and mortality

BackgroundAtrial fibrillation (AF) is the most common arrhythmic event in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to identify the clinical impact and prognostic significance of AF on a large cohort of patients with HCM. MethodsEchocardiographic and clinical correlates, risk factors for AF and thromboembolic stroke and the prognostic significance of AF were evaluated in 509 patients with an established diagnosis of HCM. ResultsA total of 119 patients (23.4%) were diagnosed with AF during the index evaluation visit. AF patients had a higher prevalence of stroke and presented with worse functional impairment. Left atrial diameter (LA size) was a common independent predictor of the arrhythmia (OR: 2.2, 95% CI 1.6-3.3) and thromboembolic stroke (OR: 1.6, 95% CI 1.01-2.40). AF was an important risk factor for overall mortality (HR=3.4, 95% CI: 1.7-6.5), HCM-related mortality (HR=3.9, 95% CI: 1.8-8.2) and heart failure-related mortality (HR=6.0, 95% CI: 2.0-17.9), even after adjusting for statistically significant clinical and demographic risk factors. However, AF did not affect the risk for sudden death. ConclusionsLA size is an independent predictor of both AF and thromboembolic stroke. Moreover, patients with AF, regardless of type, have significantly higher mortality rates than patients without AF.

Sudden death and its risk factors after atrioventricular junction ablation and pacemaker implantation in patients with atrial fibrillation

Although sudden death (SD) is a rare complication after atrioventricular junction (AVJ) ablation and permanent pacemaker implantation, the risk factors leading to this SD remain unknown. The purpose of this study was to investigate SD and its risk factors after ablate-and-pace strategy for rate control in atrial fibrillation (AF) patients during long-term follow-up. METHODS: From January 2005 to December 2009, we enrolled into this study 517 AF patients with AVJ ablation and right ventricular pacemaker implantation. Patients were divided into 2 groups, SD and non-SD. Cox proportional hazards models were used to assess potential risk factors for overall mortality and SD. During a mean follow-up of 25.8 ± 18.6 months (range, 3 days to 63.8 months), 53 patients died (15 with SD). Cox proportional hazards models showed that the presence of congestive heart failure, New York Heart Association functional class, chronic renal failure, and nonsustained ventricular tachycardia were risk factors that predicted overall mortality. For SD, the presence of dilated cardiomyopathy and mitral stenosis were associated risk factors. SD was exclusively seen in patients who had narrow QRS complex or right bundle branch block prior to AVJ ablation and pacemaker implantation; SD was not seen in any patient with preexisting complete left bundle branch block. Dilated cardiomyopathy, mitral stenosis, and baseline QRS morphology should be examined as potential risk factors for SD after AVJ ablation and pacemaker implantation.

Increasing physical activity through mobile device interventions: A systematic review.

Physical inactivity is a health problem that affects people worldwide and has been identified as the fourth largest risk factor for overall mortality (contributing to 6% of deaths globally). Many researchers have tried to increase physical activity levels through traditional methods without much success. Thus, many researchers are turning to mobile technology as an emerging method for changing health behaviours. This systematic review sought to summarise and update the existing scientific literature on increasing physical activity through mobile device interventions, taking into account the methodological quality of the studies. The articles were identified by searching the PubMed, SCOPUS and SPORTDiscus databases for studies published between January 2003 and December 2013. Studies investigating efforts to increase physical activity through mobile phone or even personal digital assistant interventions were included. The search results allowed the inclusion of 11 studies that gave rise to 12 publications. Six of the articles included in this review reported significant increases in physical activity levels. The number of studies using mobile devices for interventions has increased exponentially in the last few years, but future investigations with better methodological quality are needed to draw stronger conclusions regarding how to increase physical activity through mobile device interventions.

Survival benefit of additional surgery after noncurative endoscopic resection in patients with early gastric cancer

Excellent long-term outcome is expected for early gastric cancers (EGCs) after endoscopic submucosal dissection (ESD). However, if ESD is considered noncurative at the pathologic evaluation, additional surgery is recommended. We evaluated whether long-term outcome is compromised if additional surgery is not performed for EGCs that are out-of-indication. We retrospectively analyzed a cohort of patients with EGC not meeting ESD indications whose initial treatment was either ESD (n= 219) or surgery (n= 1799). Among them, 127 patients who underwent additional surgery after initial ESD and 67 patients who did not were matched using propensity scores to patients who initially underwent standard surgery, at a 1:1 ratio. Overall mortality and gastric cancer recurrence were compared. The overall mortality and gastric cancer recurrence rates were not significantly different between the 127patients who underwent initial ESD with additional surgery and the corresponding initial standard surgerypatients. However, the overall mortality of the 67 patients who underwent ESD without additional surgery (5-year mortality, 26.0%; 95% CI, 13.5%-49.9%) was higher than that of the matched initial standard surgery patients (5-year mortality, 14.5%; 95% CI, 6.3%-33.6%; P= .04). Gastric cancer recurrence was also higher in ESD patients without additional surgery (5-year recurrence, 17.0%; 95% CI, 7.6%-37.8%) than in the matched initial surgery group (0%; P= .002). In multivariate analyses, ESD without additional surgery was a significant risk factor for overall mortality and gastric cancer recurrence. Additional surgery should be encouraged after non-curative ESD to obtain long-term outcomes comparable with those of initial standard surgery. (Clinical trial registration number: NCC2015-0093.).

Tricuspid Valve Replacement Through Right Thoracotomy has Better Outcomes in Redo Cases

The tricuspid valve is usually ignored and tricuspid interventions are mostly done in the context of other planned cardiac surgery. Isolated tricuspid reoperative procedure, especially tricuspid valve replacement (TVR) is very rare and carries a very high mortality rate. In this prospective study, clinical results of isolated TVR either through a median re-sternotomy or an antero-lateral thoracotomy with conventional cardiopulmonary bypass (CPB) have been evaluated. Thirty patients with previous open heart surgery through median sternotomy had isolated TVR between 2004 and 2011. Operative approaches were through a median re-sternotomy in 13 patients and a right antero-lateral thoracotomy in 17 patients. Follow-up period is complete with a mean duration of 19.77±17.08 months. The hospital mortality rates were 46.2% (six patients) in the Median Re-sternotomy Group and 5.9% (one patient) in the Thoracotomy Group (p= 0.025). The surgical procedures lasted shorter and the postoperative drainage amounts were lower in the Thoracotomy Group (298.08±76.64min vs 246.76±47.40min, p= 0.032 and 1787.50±1399.53mL vs 903.33±692.43mL, p= 0.03 respectively). Presence of ascites in the preoperative period (p= 0.007), operative technique (median re-sternotomy) (p= 0.025), use of cross-clamp (p= 0.048), and need for inotropic support during the operation (p= 0.002) were statistically significant factors affecting the hospital mortality. The mean estimated life period was better for the Thoracotomy Group (16.7±5.03 versus 35.9±5.01 months, p= 0.044). Presence of ascites in the preoperative period was a significant risk factor for overall mortality according to Cox regression analysis. Thoracotomy for TVR in patients with previous median sternotomy is a practical and safe technique with lower mortality rates.

High mortality rates after nonelective colon cancer resection: results of a national audit.

Colon cancer resection in a nonelective setting is associated with high rates of morbidity and mortality. The aim of this retrospective study is to identify risk factors for overall mortality after colon cancer resection with a special focus on nonelective resection. Data were obtained from the Dutch Surgical Colorectal Audit. Patients undergoing colon cancer resection in the Netherlands between January 2009 and December 2013 were included. Patient, treatment and tumour factors were analysed in relation to the urgency of surgery. The primary outcome was 30-day postoperative mortality. The study included 30907 patients. A nonelective colon cancer resection was performed in 5934 (19.2%) patients. There was a 4.4% overall mortality rate, with significantly more deaths after nonelective surgery (8.5% vs 3.4%, P<0.001). Older patients, male patients and patients with high comorbidity, advanced tumours, perforated tumours, a tumour in the right or transverse colon and postoperative anastomotic leakage were at risk of postoperative death. In nonelective resections, a right-sided tumour and postoperative anastomotic leakage were associated with high mortality. Nonelective colon cancer resection is associated with high mortality. In particular, right-sided resections and patients with tumour perforation are at particularly high risk. The optimization of patients prior to surgery and expeditious operation after diagnosis might prevent the need for a nonelective resection.

Low serum intact parathyroid hormone level is an independent risk factor for overall mortality and major adverse cardiac and cerebrovascular events in incident dialysis patients.

Abnormal bone dynamics is a major risk factor for cardiovascular disease in patients with chronic kidney disease. The level of serum intact parathyroid hormone (iPTH) is widely used as a bone dynamic marker. We investigated the effect of the mean level of serum iPTH on overall mortality and cardiovascular outcomes in incident dialysis patients. Chronic kidney disease-mineral bone disorder (CKD-MBD) is a major risk factor for cardiovascular disease (CVD) in patients with end-stage renal disease (ESRD). CKD-MBD is classified as low- or high-turnover bone disease according to the bone dynamics; both are related to vascular calcification in ESRD. To evaluate the prognostic value of abnormal serum parathyroid hormone (PTH) levels on ESRD patients, we investigated the effects of time-averaged serum intact PTH (TA-iPTH) levels on overall mortality and major adverse cardiac and cerebrovascular events (MACCEs) in incident dialysis patients. Four hundred thirteen patients who started dialysis between January 2009 and September 2013 at Yonsei University Health System were enrolled. The patients were divided into three groups according to TA-iPTH levels during the 12months after the initiation of dialysis: group 1, <65pg/ml; group 2, 65-300pg/ml; and group 3, >300pg/ml. Cox regression analyses were performed to determine the prognostic value of TA-iPTH for overall mortality and MACCEs. The mean age of the patients was 57 ± 15years, and 222 patients (54%) were men. During the median follow-up of 40.8 ± 29.3months, 49 patients (12%) died, and MACCEs occurred in 55 patients (13%). The multivariate Cox regression analyses demonstrated that a low TA-iPTH level was an independent risk factor for both overall mortality (group 2 as reference; group 1: hazard ratio (HR) = 2.06, 95% confidence interval (CI) = 1.11-3.83, P = 0.023) and MACCEs (HR = 1.82, 95% CI = 1.04-3.20, P = 0.036) in incident dialysis patients after adjustment for confounding factors. Low serum TA-iPTH is a useful clinical marker of both overall mortality and MACCEs in patients undergoing incident dialysis, mediated by vascular calcification.

IP119. Correlates of Hypothermic Circulatory Arrest and Risk of Operative Mortality in Thoracoabdominal Aortic Repair

Use of hypothermic circulatory arrest (HCA) as a surgical adjunct in descending thoracic and thoracoabdominal repair (D/TAAA) is associated with variable results. We reviewed our experience using HCA during D/TAAA. Data were collected from medical records into an IRB-approved longitudinal clinical research database. Univariate and multivariable analyses were conducted by standard methods for frequency, continuous, and failure-time data. Preoperative characteristics and in-hospital and long-term outcomes were analyzed to identify correlates of HCA and determine risk factors for early and long-term mortality. Between 1999 and 2014, 1183 patients underwent 1251 thoracic or TAAA repair. HCA was required in 33 patients (2.6%; 23 men, 10 women). The median age was 60 (range, 50-68 years). A total of 29 patients (88%) had repair of the distal arch and descending thoracic and 4 (12%) for thoracoabdominal aorta. Median pump time and circulatory arrest time were 136 (IQR 111-153) and 18 (13-25), respectively. The perioperative stroke rate was 4 of 33 (12%). Three patients (9.1%) had spinal cord ischemia. Postoperative hemodialysis was required in 9.1% of patients. Overall, 30-day mortality was 8 (24%). Long-term survival over a median follow-up period of 1.4 (IQR .01-5.2) years was 47.4% at 5 years. Previous DTA repair, previous arch repair, prior TEVAR, history of coarctation, and emergency presentation had increased propensity for use of HCA (Table). Intraoperative coagulopathy commonly complicated the operative repair in those who required HCA (48.5% vs 13.9%; P < .001). HCA did not increase the risk for any postoperative major complications. Although long-term survival between D/TAAA repairs with and without HCA was not statistically different at 5 years (47.4% vs 58.5%; P = .069; Fig), HCA itself was a significant risk factor for overall mortality (hazard ratio, 1.8; 95% CI, 1.0-2.9; P = .034). HCA was significantly associated with intraoperative coagulopathy and mortality but did not increase the risk for postoperative morbidity or mortality. Careful surgical planning with judicious application of HCA may be associated with acceptable outcomes, especially in patients when proximal aortic control is not easily accessible.TableIndependent correlates determining propensity for hypothermic circulatory arrest in descending thoracic aneurysm (DTA) and descending thoracoabdominal (DTAAA) repairParameterParameter estimateOR95% CLP valueDTAA extent C1.18873.2831.440, 7.482.0047Previous DTA repair1.56744.7941.832, 12.546.0014Prior arch repair1.43204.1871.821, 9.628.0008Prior TEVAR2.30139.9872.694, 37.018.0006Prior coarctation2.07937.9991.701, 37.609.0085Emergency1.20263.3291.313, 8.437.0113CL, Confidence limits; OR, odds ratio; TEVAR, thoracic endovascular aortic repair. Open table in a new tab

Pediatric and adult trauma centers differ in evaluation, treatment, and outcomes for severely injured adolescents

Background/purposeThis study aims to investigate differences in imaging, procedure utilization, and clinical outcomes of severely injured adolescents treated at adult versus pediatric trauma centers. MethodsThe National Trauma Data Bank was queried retrospectively for adolescents, 15–19years old, with a length of stay (LOS) >1day and Injury Severity Score (ISS) >25 treated at adult (ATC) or pediatric (PTC) Level 1 trauma centers from 2007 to 2011. Patient demographics and utilization of imaging and procedures were analyzed. Univariate and multivariate regression analysis was used to compare outcomes. ResultsOf 12,861 adolescents, 51% were treated at ATC. Older age and more nonwhites were seen at ATC (p<0.01). Imaging and invasive procedures were more common at ATC (p<0.01). Shorter LOS (p=0.03) and higher home discharge rates (p<0.01) were seen at PTC. ISS and mortality did not differ. Age, race, ATC care (all p<0.01), and admission systolic blood pressure (SBP) (p=0.03) were predictors of CT utilization. ISS, SBP, and race (p<0.01) were risk factors for overall mortality; SBP (p=0.03) and ISS (p<0.01) predicted death from penetrating injury. ConclusionsSeverely injured adolescents experience improved outcomes and decreased imaging and invasive procedures without additional mortality risk when treated at PTC. PTC is an appropriate destination for severely injured adolescents.

The PPARγ2 P12A polymorphism is not associated with all-cause mortality in patients with type 2 diabetes mellitus.

The high mortality risk of patients with type 2 diabetes mellitus may well be explained by the several comorbidities and/or complications. Also the intrinsic genetic component predisposing to diabetes might have a role in shaping the risk of diabetes-related mortality. Among type 2 diabetes mellitus SNPs, rs1801282 is of particular interest because (i) it is harbored by peroxisome proliferator-activated receptor-γ2 (PPARγ2), which is the target for thiazolidinediones which are used as antidiabetic drugs, decreasing all-cause mortality in type 2 diabetes mellitus, and (ii) it is associated with insulin resistance and related traits, risk factors for overall mortality in type 2 diabetes mellitus. We investigated the role of PPARγ2 P12A, according to a dominant model (PA+AA vs. PP individuals) on incident all-cause mortality in three cohorts of type 2 diabetes mellitus, comprising a total of 1672 patients (462 deaths) and then performed a meta-analysis of ours and all available published data. In the three cohorts pooled and analyzed together, no association between PPARγ2 P12A and all-cause mortality was observed (HR 1.02, 95% CI 0.79-1.33). Similar results were observed after adjusting for age, sex, smoking habits, and BMI (HR 1.09, 95% CI 0.83-1.43). In a meta-analysis of ours and all studies previously published (n=3241 individuals; 666 events), no association was observed between PPARγ2 P12A and all-cause mortality (HR 1.07, 95% CI 0.85-1.33). Results from our individual samples as well as from our meta-analysis suggest that the PPARγ2 P12A does not significantly affect all-cause mortality in patients with type 2 diabetes mellitus.