Risk Factors For Short-term Mortality Research Articles

The short-term prognosis for hospitalized acute myocardial infarction patients: the impact of complication by community-acquired pneumonia

To analyze the correlation between the complication by community-acquired pneumonia (CAP) and the short-term prognosis in hospitalized acute myocardial infarction (AMI) patients. Five thousand five hundred and twenty-four AMI patients hospitalized in the PLA General Hospital from January 1993 to December 2009 were enrolled for clinical data, incidence of complications and 30-day mortality. The data from patients with and without CAP complications were compared. Multivariate logistic regression analysis was employed to assess the impact of CAP on the short-term prognosis of these patients. In all 5 524 AMI patients studied, 477 cases of CAP was found (8.6%) . In comparison with those without CAP complication, these patients had higher age (74.3 ± 6.5 vs. 67.8 ± 4.5). The incidence of comorbidities [including old myocardial infarction (20.8% vs. 11.5%), hypertension (54.3% vs. 48.9%), diabetic mellitus (32.7% vs. 22.6%), cerebral-vascular disease (8.2% vs. 3.5%), chronic renal dysfunction (10.5% vs. 3.0%)], and complications [including arrhythmia (8.8% vs. 4.6%), gastrointestinal bleeding (5.0% vs. 0.8%) and shock (8.6% vs. 3.1%)] were all significantly higher, and hyperlipidemia (18.9% vs. 30.6%) was significantly lower (P < 0.05 or P < 0.01) in CAP complicated patients. The 30-day mortality was also significantly higher (32.1% vs. 9.7%, P < 0.01). Multivariate logistic regression analysis identified CAP and chronic renal dysfunction as an independent predictor of short-term mortality [odds ratio (OR) of CAP 3.693, 95% confidence interval (95%CI) 2.340 ~ 5.829, P < 0.01; OR of chronic renal dysfunction 12.608, 95%CI 4.448 ~ 35.739, P < 0.01]. The incidence of CAP complication was higher in AMI patients with higher age.CAP complicated patients were more likely to develop comorbidities/complications, and had higher short-term mortality. CAP was an independent risk factor of short-term mortality.

Causes of Short-Term Mortality After Appendectomy

This case control study is a detailed analysis of the causes of death and the risk factors of short-term mortality after appendectomy. Although death is a rare event after appendectomy, we found a 7-fold excess mortality after appendectomy overall and a 9-fold excess mortality after negative appendectomy, compared to the background population in a previous study from Sweden, in accordance with others. All patients who died within 30 days after appendectomy, and controls matched to age, sex and period, were identified of 119,060 patients who were operated with appendectomy in 1987 to 1996 from the Swedish National Inpatient Registry. Causes of death and differences between the cases and controls in comorbidity and appendectomy diagnoses were analyzed on the basis of a review of hospital records. Only patients and controls with appendectomy as the only surgical intervention and without prevalent malignant diagnosis were included in the analysis to avoid bias. A total of 179 patients who died within 30 days and 400 matched controls remained for the analyses. Nonproductive and negative exploration was strongly associated with mortality [odds ratio (OR), 5.11; confidence interval (CI), 2.09-12.48; P < 0.001 and OR, 2.38; CI, 1.24-4.57; P = 0.009, respectively] in contrast to perforated appendicitis (OR, 1.60; CI, 0.95-2.70; P = 0.078) after adjustment for age, sex, and comorbidity. Chronic obstructive pulmonary disease (OR, 3.31; CI, 1.05-10.45, P = 0.041), renal insufficiency (OR, 2.32; CI, 1.26-4.27; P = 0.007), and diabetes mellitus were also independent risk factors (OR, 2.39; CI, 1.12-5.12; P = 0.025). Cardiovascular or thromboembolic disease was responsible for the death in more than 50% of the cases, whereas appendicitis was responsible in only 17.9%. Appendicitis is only responsible for a small portion of the deaths after appendectomy. Comorbidity and negative appendectomy are strongly associated with mortality, suggesting that comorbidity, diagnostic failure, and the anesthesiosurgical trauma may play an important role.

Clinical outcome and predictors for adverse events after transcatheter aortic valve implantation with the use of different devices and access routes

Transcatheter aortic valve implantation (TAVI) is a treatment option for high-risk patients with severe aortic stenosis. Previous reports focused on a single device or access site, whereas little is known of the combined use of different devices and access sites as selected by the heart team. The purpose of this study is to investigate clinical outcomes of TAVI using different devices and access sites. A consecutive cohort of 200 patients underwent TAVI with the Medtronic CoreValve Revalving system (Medtronic Core Valve LLC, Irvine, CA; n = 130) or the Edwards SAPIEN valve (Edwards Lifesciences LLC, Irvine, CA; n = 70) implanted by either the transfemoral or transapical access route. Device success and procedure success were 99% and 95%, respectively, without differences between devices and access site. All-cause mortality was 7.5% at 30 days, with no differences between valve types or access sites. Using multivariable analysis, low body mass index (<20 kg/m(2)) (odds ratio [OR] 6.6, 95% CI 1.5-29.5) and previous stroke (OR 4.4, 95% CI 1.2-16.8) were independent risk factors for short-term mortality. The VARC-defined combined safety end point occurred in 18% of patients and was driven by major access site complications (8.0%), life-threatening bleeding (8.5%) or severe renal failure (4.5%). Transapical access emerged as independent predictor of adverse outcome for the Valve Academic Research Consortium-combined safety end point (OR 3.3, 95% CI 1.5-7.1). A heart team-based selection of devices and access site among patients undergoing TAVI resulted in high device and procedural success. Low body mass index and history of previous stroke were independent predictors of mortality. Transapical access emerged as a risk factor for the Valve Academic Research Consortium-combined safety end point.

Risk factors for short-term mortality from carbon monoxide poisoning treated with hyperbaric oxygen*

Carbon monoxide (CO) poisoning is common in the United States, accounting for approximately 2,700 deaths annually. Few publications have described the mortality rate of CO-poisoned patients who survive to reach a hospital and die despite maximal medical care. Further, while risk factors for cognitive sequelae in survivors of CO poisoning have become clearer recently, factors associated with death are less well defined. This study was conducted to 1) determine the short-term mortality risk for patients treated with hyperbaric oxygen for CO poisoning, and 2) determine whether any factors related to the poisoning episode are predictive of mortality. A departmental database and medical records of 1,505 consecutive patients treated with hyperbaric oxygen at a single institution from 1978 to 2005 were reviewed. Demographic and clinical data were extracted for analysis. Mortality data, including cause of death, were obtained through a search of the National Death Index of the National Center for Health Statistics. A total of 38 patients experienced short-term mortality from their episode of CO poisoning, yielding a death rate of 2.6% in medically treated patients. Characteristics significantly associated with mortality included fire as a source of CO, loss of consciousness, carboxyhemoglobin level, arterial pH, and presence of endotracheal intubation during hyperbaric treatment. The mortality rate for medically treated CO-poisoned patients in this series was 2.6%, similar to the limited combined experience previously reported in the literature. Factors most strongly associated with mortality were severe metabolic acidosis and need for endotracheal intubation.

Risk factors for short-term mortality from carbon monoxide poisoning treated with hyperbaric oxygen*

Department of Physiology, Loma Linda University, Loma Linda, CA (Ostrowski) Department of Neurosurgery, Anesthesiology, and Physiology, Loma Linda University, Loma Linda, CA (Zhang) The authors have not disclosed any potential conflicts of interest.

Short-term clinical outcome after acute symptomatic pulmonary embolism

Though studies have identified clinical variables that predict adverse events in patients with acute pulmonary embolism (PE), they have typically not differentiated short-term from long-term predictors. This multicenter prospective cohort study included consecutive outpatients with objectively confirmed symptomatic acute PE. We analyzed the incidence and time course of death, venous thromboembolism (VTE) recurrence, and major bleeding, and we compared event rates during short-term (first week) and long-term (3 months) follow-up after the diagnosis of PE. We also assessed risk factors for short-term mortality. During the first three months after diagnosis of PE, 142 of 1,338 (10.6%) patients died. Thirty-six deaths (2.7%) occurred during the first week after diagnosis of PE, and 61.1% of these were due to PE. Thirty-eight patients (2.8%) had recurrent VTE during the three-month follow-up, though none of the recurrences occurred during the first week after diagnosis of PE. During the three-month follow-up, major bleeding occurred in 48 patients (3.6%). Twenty-one (1.6%) major bleeds occurred during the first week of follow-up, and nine of these were fatal. Short-term mortality was significantly increased in patients who initially presented with systolic arterial hypotension (odds ratio [OR] 3.35; 95% CI, 1.51-5.41) or immobilization due to a medical illness (OR 2.89; 95% confidence interval [CI], 1.31-6.39). In conclusion, during the first week after the diagnosis of PE, death and major bleeding occur more frequently than recurrent VTE. Patients with systolic arterial hypotension and immobilization at the time of PE diagnosis had an increased risk of short-term mortality.

Low complement C4B gene copy number predicts short-term mortality after acute myocardial infarction

Some recent data indicate that risk of death after acute coronary syndrome is under genetic control. Previously, we found that the C4B*Q0 genotype (low copy number of the C4B gene that encodes the fourth component of complement) is strongly associated with morbidity and mortality of cardiovascular diseases (CVD). The +252 G allele of the lymphotoxin-alpha (LTA) gene encoded close to the C4B gene was also reported to be related to CVD-related mortality in an Oriental population. The relationship between the copy number of the genes encoding the fourth component of complement (C4A and C4B) and LTA 252 single-nucleotide polymorphism (SNP) on the one hand and mortality after acute myocardial infarction (AMI) was studied in 142 Icelandic patients. The number of the C4A and C4B genes was determined in genomic DNA samples by a newly developed real-time PCR-based method; lymphotoxin-alpha (LTA) +252 A>G polymorphism was determined by PCR-restriction fragment length polymorphism analysis. The C4B*Q0 genotype was found to be strongly associated with 1-year mortality, with a hazard ratio of 3.50 (1.38-8.87) (P = 0.008) (adjusted Cox regression analysis). This association was, however, restricted to ever-smoking patients. By contrast, neither C4A gene copy numbers nor LTA 252 SNP did confer increased risk of mortality after AMI. This observation indicates that low C4B copy number is a strong risk factor for short-term mortality after AMI in smoking Icelandic patients, whereas LTA 252 G allele is not a risk factor in Caucasian population.

Risk Factors for Short-Term Mortality in Older Subjects with Acute Ischemic Stroke

Background: Stroke is the third cause of death in older individuals living in Western Countries. The identification of predictors for mortality after stroke has a major importance for clinicians in order to allow the implementation of therapeutic and preventive strategies. Objective: To evaluate the association between clinical and laboratory parameters and 30-days total mortality in a large sample of older patients with stroke. Methods: 469 older patients (median age: 80.0 years) consecutively hospitalized for acute ischemic stroke were enrolled. The data recorded included: (1) clinical features of stroke; (2) routine clinical chemistry analyses; (3) medical history, and (4) 12-lead ECG. All patients underwent computed tomography scan of the brain. Stroke type was classified by the Oxfordshire Community Stroke Project system. Results: 130 subjects died within 30 days after stroke, with an overall mortality of 27.7%. At univariate analysis, altered levels of consciousness (ALC), congestive heart failure, atrial fibrillation, previous stroke, high blood glucose, fibrinogen and blood sedimentation rate levels, higher white blood cell count, lower serum albumin and iron levels were associated with mortality. Multivariate logistic regression analysis indicated that short-term mortality was associated with ALC (OR: 11.80; CI 95%: 5.50–24.00), congestive heart failure (OR: 3.06; CI 95%: 1.04–8.80), and age (OR: 1.04; CI 95%: 1.002–1.09) independent of gender, previous stroke, AF, fasting blood glucose, serum albumin, serum iron, and white blood cell count. In patients with ALC (high-mortality rate: 63.6%), only hyperglycemia (III vs. I tertile, OR: 9.60; CI 95%: 1.65–52.50) was associated with mortality after multivariate adjustment. Conclusion: Our study highlights the role of ALC and congestive heart failure in the short-term prognostic stratification of older patients with acute ischemic stroke. Furthermore, our results support the value of post-stroke hyperglycemia as a marker for short-term mortality also in advanced age, and particularly in the presence of ALC and in nondiabetic individuals.

Anemia is an independent risk for mortality after acute myocardial infarction in patients with and without diabetes.

IntroductionAnemia and diabetes are risk factors for short-term mortality following an acute myocardial infarction(AMI). Anemia is more prevalent in patients with diabetes. We performed a retrospective study to assess the impact of the combination of diabetes and anemia on post-myocardial infarction outcomes.MethodsData relating to all consecutive patients hospitalized with AMI was obtained from a population-based disease-specific registry. Patients were divided into 4 groups: diabetes and anemia (group A, n = 716), diabetes and no anemia (group B, n = 1894), no diabetes and anemia (group C, n = 869), and no diabetes and no anemia (group D, n = 3987). Mortality at 30 days and 31 days to 36 months were the main outcome measures.Results30-day mortality was 32.3% in group A, 16.1% in group B, 21.5% in group C, 6.6% in group D (all p < 0.001). 31-day to 36-month mortality was 47.6% in group A, 20.8% in group B, 34.3% in group C, and 10.4% in group D (all p < 0.001). Diabetes and anemia remained independent risk factors for mortality with odds ratios of 1.61 (1.41–1.85, p < 0.001) and 1.59 (1.38–1.85, p < 0.001) respectively at 36 months. Cardiovascular death from 31-days to 36-months was 43.7% of deaths in group A, 54.1% in group B, 47.0% in group C, 50.8% group D (A vs B, p < 0.05).InterpretationPatients with both diabetes and anemia have a significantly higher mortality than those with either diabetes or anemia alone. Cardiovascular death remained the most likely cause of mortality in all groups.

MELD score and hepatocellular carcinoma identify patients at different risk of short-term mortality among cirrhotics bleeding from esophageal varices

The role of model for end stage liver disease (MELD) and the presence of hepatocellular carcinoma (HCC) as risk factors of short-term mortality in patients bleeding from oesophageal varices were evaluated. From February 2002 to August 2003, 172 cirrhotic patients admitted for the first episode of bleeding from oesophageal varices received vasoactive and endoscopic therapy. Patients' survival was evaluated at 6 weeks and 3 months. The role of MELD and HCC as independent risk factors of mortality was evaluated. In the 172 patients, the overall mortality was 21.5% at 6 weeks and 30.2% at 3 months. MELD score resulted a good predictor of mortality either at 6 weeks or 3 months. Fifty-four patients (31.3%) had HCC. The presence of advanced HCC was an independent risk factor of mortality at 3 months. Patients with MELD score>15 and advanced HCC had a significantly worse survival than patients with MELD<or=15 and without HCC or with early HCC either at 6 weeks or 3 months MELD score and the presence of HCC allow to identify patients at different risk of short-term mortality among cirrhotic patients at first episode of bleeding from oesophageal varices.

Comparison of short-term mortality risk factors for valve replacement versus coronary artery bypass graft surgery

Background Risk factors for 30-day operative (short-term) mortality following coronary artery bypass graft (CABG only) procedures are well established. However, little is known about how the risk factors for short-term mortality following valve replacement procedures (with or without a CABG procedure performed) compare with CABG only risk factors. Methods Department of Veterans Affairs (VA) records (65,585 records) were collected from October 1991 through March 2001 and analyzed. Risk factors for short-term mortality were compared across three subgroups of patients: CABG only surgery (n = 56,318), aortic valve replacement (AVR) with or without CABG (n = 7450), and mitral valve replacement (MVR) with or without CABG (n = 1817). Multivariable logistic regression analyses were used to compare the relative magnitude of risk for 19 candidate predictor variables across subgroups. Results Only three patient baseline characteristics differed significantly in magnitude of risk between the procedure groups. Partially or totally dependent functional status significantly increased the risk of short-term mortality for AVR patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.29–2.09) and MVR patients (OR 2.21, 95% CI 1.48–3.30), but not for CABG only patients (OR 1.04, 95% CI 0.93–1.16). Conversely, previous heart surgery and New York Heart Association functional class III or IV symptoms conferred greater magnitude of risk for CABG only patients compared with the valve subgroups. Conclusions Overall, the risk factors for short-term mortality following valve replacement and CABG surgery appear to be relatively consistent. However, clinicians should be aware of the importance of preoperative functional status as a unique predictor of mortality following valve surgery.

Evaluation of nutritional practice in hospitalized cirrhotic patients: Results of a prospective study

Objective We evaluated the impact of malnutrition and nutrition practice in 396 hospitalized cirrhotic patients (Child stages A, B, and C: 60, 169, and 167 patients) in a readaptative unit for liver diseases. Methods Triceps skinfold thickness and mid-arm muscle circumference were measured at admission, and spontaneous dietary intake was evaluated at admission and during hospital stay. Results Ascites was associated with impairment of nutrition status: 49% and 30.4% of non-ascitic patients, 49.1% and 40.5% of patients with mild ascites, and 65.5% and 48.3% of patients with tense ascites had mid-arm muscle circumferences and triceps skinfold thicknesses, respectively, below the fifth percentile of a reference population ( P < 0.05 and P = 0.02, respectively). Decrease in dietary intake paralleled worsening of liver failure: 48% and 34% of Child A patients, 51.7% and 35.8% of Child B patients, and 80.3% and 62.9% of Child C patients at admission had caloric intakes below 30 kcal/kg of body weight and protein intakes below 1 g/kg of body weight, respectively ( P < 0.001). Mortality rate was 15.4% during hospital stay; Child-Pugh score ( P = 0.0014), age ( P = 0.0029), severe septic complications ( P = 0.0050), and decrease in caloric intake during hospital stay ( P = 0.0072) were independently associated with mortality. Twenty-four patients received enteral feeding that was initiated before admission in four patients and after 12.4 ± 8.3 d of hospitalization in 20 patients because of low caloric intake (<25 kcal/kg) despite oral supplements. Patients receiving enteral feeding were older ( P < 0.01), had a higher Child-Pugh score ( P < 0.01), and a higher mortality rate ( P < 0.001) than other patients. Conclusions Hospitalized cirrhotic patients have a high prevalence rate of malnutrition, and most do not satisfy their nutritional requirements. Decrease in caloric intake is an independent risk factor of short-term mortality. Enteral nutrition after failure of oral supplementation has no clinical benefit. Tube feeding may be indicated earlier in the course of the disease.

Risk factors for intermediate-term survival after coronary artery bypass grafting

Background. Risk factors for short-term mortality after coronary artery bypass grafting are well established, but little is known about risk factors for intermediate-term mortality. Methods. We analyzed the outcomes of 11,815 patients undergoing coronary artery bypass grafting in one of the 43 cardiac surgery programs of the Department of Veteran Affairs. Risk factors for intermediate- and short-term mortality were determined using Cox proportional hazards regression models. Effects of risk factors during these two periods were explicitly compared. Results. We found important differences in mortality risk-factor sets between the intermediate- and short-term periods after coronary artery bypass grafting. The majority of predictors of intermediate-term mortality were noncardiac-related variables, whereas the majority of predictors of short-term mortality were cardiac-related variables. Impaired functional status, chronic obstructive pulmonary disease, and renal dysfunction had greater effects in the intermediate-term period. Previous heart operation, angina class III or IV, previous myocardial infarction, and preoperative use of an intraaortic balloon pump had greater effects in the short-term period. Conclusions. The risk factors for intermediate-term mortality identified in this study can augment preoperative risk assessment and counseling of patients. Clinicians should be aware of the importance of noncardiac-related variables as predictors of mortality in the intermediate-term period after coronary artery bypass grafting.

43. The value of the Cockcroft formula in obese diabetic patients

In hemodialysis patients extracellular fluid overload is a predictor of all-cause and cardiovascular mortality, and a relation with inflammation has been reported in previous studies. The magnitude and nature of this interaction and the effects of moderate fluid overload and extracellular fluid depletion on survival are still unclear. We present the results of an international cohort study in 8883 hemodialysis patients from the European MONDO initiative database where, during a three-month baseline period, fluid status was assessed using bioimpedance and inflammation by C-reactive protein. All-cause mortality was recorded during 12 months of follow up. In a second analysis a three-month baseline period was added to the first baseline period, and changes in fluid and inflammation status were related to all-cause mortality during six-month follow up. Both pre-dialysis estimated fluid overload and fluid depletion were associated with an increased mortality, already apparent at moderate levels of estimated pre-dialysis fluid overload (1.1–2.5L); hazard ratio 1.64 (95% confidence interval 1.35–1.98). In contrast, post-dialysis estimated fluid depletion was associated with a survival benefit (0.74 [0.62–0.90]). The concurrent presence of fluid overload and inflammation was associated with the highest risk of death. Thus, while pre-dialysis fluid overload was associated with inflammation, even in the absence of inflammation, fluid overload remained a significant risk factor for short-term mortality, even following improvement of fluid status.

Impaired pulmonary function as a risk factor for mortality.

Prospective follow-up information obtained between 1976 and 1981 on mortality among 2539 individuals showed that pulmonary function impairment is a risk factor for short-term mortality, even when risk factors such as age, sex, and smoking are considered. Predicted risk curves for impaired individuals (those with forced expiratory volume in one second less than 68% of forced vital capacity) are consistently higher among all race-sex categories over all ages. Survival analysis using the proportional hazards model shows a steeper decline in estimated survival among individuals with poor pulmonary function compared to those with good pulmonary function, adjusted for age, race, and smoking effects. These observations are consistent with the concept that impairment of pulmonary function is a risk factor for morbidity and mortality from several nonrespiratory as well as respiratory diseases and that it acts by contributing to various pathogenic mechanisms in different organ systems.