Reduced Risk Of Mortality Research Articles

Role of Cytoreductive Nephrectomy in Metastatic Clear Cell Renal cell Carcinoma in the Era of immunotherapy: An Analysis of the National Cancer Database

BackgroundThe effectiveness of the clinical outcome of CN (Cytoreductive Nephrectomy) in cases of mccRCC (Metastatic Clear Cell Renal cell Carcinoma) is still uncertain despite two trials, SURTIME and CARMENA. These trials, conducted with Sunitinib as the standard treatment, did not provide evidence supporting the use of CN. MethodsWe queried the NCDB for stage IV mccRCC patients between the years of 2004 to 2020, who received (immunotherapy) IO with or without nephrectomy. Overall survival (OS) was calculated among three groups of IO alone, IO followed by CN (IOCN), CN followed by IO (CNIO). Cox models compared OS by treatment group after adjusting for sociodemographic, health, and facility variables. ResultsFrom 1,549,101 renal cancer cases, 7983 clear and nonclear cell renal cell carcinoma cases were identified. After adjusting for sociodemographic and health covariates, patients who received IO followed by CN or CN followed by IO had a respective 64% (adjusted Hazard Ratio [aHR] = 0.36, 95% CI = 0.30-0.43, P = .006] and 47% (aHR = 0.53, 95% CI = 0.49-0.56, P = .001) mortality risk reduction respectively compared to patients who received IO alone. Compared to White adults, individuals who identified as Black exhibited 17% higher risk mortality (aHR = 1.17, 95% CI = 1.06-1.30, P = .002). Patients who received CN prior to IO had a 59% associated mortality risk compared to patients who received IO followed by CN who had a lower risk, 35.7% (P < .001). ConclusionsPatients receiving CN regardless of sequence with IO did better than IO alone in this national registry-based adjusted analysis for mccRCC. Presently available data indicates that the combination of CN and IO holds promise for enhancing clinical results in patients with mRCC.

Clinical utility of the neutrophil elastase inhibitor sivelestat for the treatment of ALI/ARDS patients with COVID-19

BackgroundSivelestat, a neutrophil elastase inhibitor, is postulated to mitigate acute lung injury in patients following emergency surgery. However, its efficacy in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) induced by coronavirus disease 2019 (COVID-19) remains uncertain. This study aims to evaluate the pulmonary protective effects of sivelestat in COVID-19 patients with ALI/ARDS. MethodsA retrospective study was conducted involving 2454 COVID-19 patients between October 5, 2022, and February 1, 2023. Of these, 102 patients received sivelestat (0.2 mg/kg/h), while 2352 age- and sex-matched controls were identified. Propensity score matching (PSM) analysis was used to match sivelestat and non-sivelestat subgroups in ratios of 1:1 and 1:3 for sensitivity analysis. The primary outcome was a composite of effective outcomes, including 30-day mortality. Secondary outcomes included changes in partial pressure of arterial oxygen (PaO2), the ratio of PaO2 to the fraction of inspired oxygen (PaO2/FiO2), and various cytokine levels. Safety evaluations included assessments of liver function, kidney function, and leukopenia. ResultsIn the propensity score-matched analysis, the sivelestat group had a higher proportion of severe/critical patients (87.26 % vs. 51.02 %, P < 0.001), more ARDS patients (4.9 % vs. 0.43 %, P < 0.001), and more patients with interstitial lung disease (4.9 % vs. 1.49 %, P = 0.023), but fewer patients with stroke (17.65 % vs. 19.86 %, P < 0.001). Oxygen therapy rates were similar between the groups (79.41 % vs. 80.95 %, P = 0.9). The relative risk reduction in 30-day mortality was 88.45 % (95 % confidence interval [CI] 81.23%–93.21 %) for severe/critical COVID-19 patients treated with sivelestat. Sivelestat significantly decreased cytokine levels of interferon alpha (IFNα), interleukin-1 beta (IL-1β), and interleukin-2 (IL-2).In the sivelestat group, the mortality rate was significantly reduced with standard oxygenation and HFNC therapy(P < 0.05). The treatment with sivelestat did not increase side effects. ConclusionThe administration of the neutrophil elastase inhibitor sivelestat may improve clinical outcomes in COVID-19 patients with ALI/ARDS. These findings suggest that sivelestat could be considered an effective treatment option to alleviate pulmonary inflammatory injury caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Serial gait speed measurements over time and dynamic survival prediction in older adults

BackgroundA one-time gait speed measurement predicts mortality risk. A framework for updating a clinician’s mortality risk perception with new information from each clinic visit is needed. We used joint modeling of longitudinal and survival data for dynamic prediction of mortality risk. MethodsWe fit sex-stratified joint models to 20-meter (bi)annual longitudinal gait speed measured every 6 months and 14-year survival data from the Health, Aging and Body Composition Study allowing for non-linear fluctuations of gait speed and controlling for important covariates such as age, recent hospitalization, blood pressure, obesity, and comorbidities. ResultsParticipants (N = 3048) were 74 years old with gait speed 1.18 m/s. They were 42% Black, and 52% died over 14 years. Higher gait speed of 0.1 m/s was associated with 23% (95% confidence interval or CI = 20–25%) and 25% (CI = 21–28%) reductions in mortality risk in men and women; and a 0.05 m/s annualized slowing (slope) with 31% (CI = 13–51%) increase in men (all p < 0.05), with findings persisting after covariate adjustment. Distant gait speed history over a year prior contributed little for mortality risk prediction with mean change of only 1–2% in 5-year risk. ConclusionThe two most recent gait speeds appear sufficient to consider for mortality risk in the present initial analysis. More frequent gait speeds need to be considered in mortality risk prediction before definitive conclusions supporting real-world application.

The Importance of Geographic Proximity of Convalescent Plasma Donors.

Donor-recipient proximity emerged as an important factor influencing the efficacy of COVID-19 convalescent plasma (CCP) treatment during the early stages of the COVID-19 pandemic. This relationship was uncovered while analyzing data collected in the collaborative Expanded Access Program (EAP) for CCP at Mayo Clinic, a project aimed to establish protocols for CCP use amid the uncertainty of the novel disease. Analysis of data from nearly 28,000 patients revealed a significant reduction in risk of 30-day mortality for those receiving near-sourced plasma when compared to those receiving distantly sourced plasma [pooled relative risk, 0.73 (95% CI 0.67-0.80)], prompting adjustments in treatment protocols at selected institutions, and highlighting the importance of proximity in optimizing CCP outcomes. Despite its significance, subsequent studies of CCP effectiveness in COVID-19 have often overlooked donor-recipient proximity. Our findings emphasize the importance of donor-recipient proximity in CCP treatment in the current pandemic, and we discuss potential methods for improving CCP efficacy in future pandemics. Our recommendations include prioritizing virus genotyping for vulnerable patients, establishing a robust testing infrastructure, and collecting additional donor data to enhance plasma selection. This chapter underscores the importance of comprehensive data collection and sharing to navigate the evolving landscape of newly emerging infectious diseases.

Causal Effects of Competing Obstetrical Interventions: Mediators of Placental Abruption and Perinatal Mortality.

Placental abruption, the premature placental separation, confers increased perinatal mortality risk with preterm delivery as an important pathway through which the risk appears mediated. While pregnancies complicated by abruption are often delivered through an obstetrical intervention, many deliver spontaneously. We examined the contributions of clinician-initiated (PTDIND) and spontaneous (PTDSPT) preterm delivery at <37 weeks as competing causal mediators of the abruption-perinatal mortality association. Using the Consortium for Safe Labor (2002-2008) data (n = 203,990; 1.6% with abruption), we applied a potential outcomes-based mediation analysis to decompose the total effect into direct and mediator-specific indirect effects through PTDIND and PTDSPT. Each mediated effect describes the reduction in the counterfactual mortality risk if that preterm delivery subtype was shifted from its distribution under abruption to without abruption. The total effect risk ratio (RR) of abruption on perinatal mortality was 5.4 (95% confidence interval [CI] 4.6, 6.3). The indirect effect RRs for PTDIND and PTDSPT were 1.5 (95% CI: 1.4, 1.6) and 1.5 (95% CI: 1.5, 1.6), respectively; these corresponded to mediated proportions of 25% each. These findings underscore that spontaneous and clinician-initiated preterm deliveries each play essential roles in shaping perinatal mortality risks associated with placental abruption.

Clinical real-world effectiveness of nirmatrelvir/ritonavir for the treatment of SARS-CoV-2 infection: A meta-analysis

Abstract Background: According to the Evaluation of Protease Inhibition for COVID-19 in High-Risk Patients (EPIC-HR) study, compared with a placebo, nirmatrelvir/ritonavir significantly reduced the risk of coronavirus disease 2019 (COVID-19)-related hospitalization or mortality in unvaccinated patients. The Delta variant was the most prevalent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant among all treatment recipients in the EPIC-HR study. The Omicron variant is less pathogenic than the Delta variant. The efficacy of nirmatrelvir/ritonavir in partially or fully immunized patients with Omicron variant-related infections must be further evaluated. Objectives: The current meta-analysis aimed to evaluate the therapeutic efficacy of nirmatrelvir/ritonavir based on factors including hospitalization, all-cause mortality, and COVID-19 rebound in patients who were partially or fully immunized against COVID-19. Methods: This meta-analysis aimed to evaluate the therapeutic efficacy of nirmatrelvir/ritonavir based on factors including hospitalization, all-cause mortality, and COVID-19 rebound in patients who were partially or fully immunized against COVID-19. It included 26 studies that directly examined the clinical efficacy of nirmatrelvir/ritonavir versus placebo in adult patients with SARS-CoV-2 infection caused by the Omicron variant. The search criteria comprised keywords such as hospitalization, all-cause mortality, and COVID-19 rebound. Results: The all-cause mortality risk was reduced by 59% in patients aged ≥65 years. However, their hospitalization risk decreased by only 36%. The reduction in all-cause mortality and hospitalization risk was similar between patients with low and high COVID-19 vaccination coverage. Patients receiving nirmatrelvir/ritonavir had a higher incidence of COVID-19 rebound than those receiving a placebo. However, the hospitalization risk and all-cause mortality of adult patients with COVID-19 treated with nirmatrelvir/ritonavir reduced by 53% and 57%, respectively. Conclusion: The current meta-analysis of 26 studies indicates that adult patients with COVID-19 treated with nirmatrelvir/ritonavir reduced the risk of hospitalization by 53% and all-cause mortality by 57% compared to a placebo.

Ambient fine particulate matter and Life's essential 8 and mortality in adults in China: A Nationwide retrospective cohort study

BackgroundEnhanced cardiovascular health (CVH) is linked to reduced mortality risks, whereas long-term exposure to fine particulate matter (PM2.5), elevates these risks. Whether long-term exposure to PM2.5 counteracts the health benefits of high CVH is unknown. The study aims to evaluate whether the association of CVH assessed by Life's Essential 8 (LE8) with death was consistent between participants with different PM2.5 exposures. MethodsWe included 134,727 participants in the field survey of China Chronic Disease and Risk Factor Surveillance which was conducted from August 2013 to June 2014. The deaths of participants were obtained by linking to the National Mortality Surveillance System (2013–2018). The environmental data is obtained by satellite inversion. The participants' CVH scores were calculated using the LE8 method. Hazard ratio (HR) and 95% confidence intervals (95%CI) for mortality were calculated using Cox regression models. ResultsA total of 2,936 all-cause deaths and 1,158 cardiovascular disease (CVD) deaths were recorded. Compared to those with low CVH, adults with high CVH demonstrated a reduced risk of all-cause mortality, irrespective of their PM2.5 exposure levels (P < 0.05, all P for interaction >0.05). Furthermore, in comparison to those with low CVH and highest PM2.5 exposure, adults with high CVH and lowest PM2.5 exposure exhibited HR of 0.18 (95%CI, 0.12–0.25) for all-cause mortality and 0.13 (95%CI, 0.08–0.22) for CVD mortality. ConclusionsHigh CVH is associated with reduced all-cause mortality risk, regardless of PM2.5 exposure levels. For Chinese adults, sustaining high CVH is advisable, irrespective of their residential location.

Associations of multiple carotenoid co-exposure with all-cause and cause-specific mortality in US adults: a prospective cohort study.

Epidemiological evidence regarding circulating carotenoids and mortality risk remains conflicting, and most studies focus on the impact of individual carotenoids. This study aimed to elucidate the effects of co-exposure to multiple serum carotenoids on mortality risk. We enrolled 22,472 participants aged ≥20 from the National Health and Nutrition Examination Survey (NHANES) III (1988-1994) and NHANES 2003-2006. Baseline serum levels of five major carotenoids (α-carotene, β-carotene, lycopene, β-cryptoxanthin, and lutein/zeaxanthin) were measured, and individuals were followed up until December 31, 2019. Carotenoid co-exposure patterns were identified using the K-means method. Cox proportional hazard models were used to investigate the associations between carotenoid exposure and mortality risk. During a median follow-up of 16.7 years, 7,901 deaths occurred. K-means clustered participants into low-level, low-lycopene, high-lycopene, and high-level exposure groups. In the fully adjusted model, low-lycopene, high-lycopene, and high-level exposure groups had significantly lower all-cause mortality risks compared to the low-level exposure group, with hazard ratios (HRs) and 95% confidence intervals (CIs) of 0.79 (0.72, 0.87), 0.75 (0.67, 0.84), and 0.67 (0.61, 0.74), respectively. For cardiovascular disease mortality, the high-lycopene exposure group had a 27% reduced risk (HR: 0.73, 95% CI: 0.61-0.86), and the high-level exposure group had a 21% reduced risk (HR: 0.79, 95% CI: 0.67-0.93). For cancer mortality, the high-lycopene and high-level exposure groups had 30% and 35% lower risks, with HRs (95% CIs) of 0.70 (0.57, 0.86) and 0.65 (0.54, 0.79), respectively. This study revealed that co-exposure to multiple serum carotenoids was associated with reduced mortality risk, highlighting the potential health benefits of increased carotenoid intake. Further investigation is warranted to elucidate the underlying mechanisms of interactions among different carotenoids.

Efficacy of COVID-19 Oral antivirals in hospitalised oldest-old with high morbidity burden: a target trial emulation study.

Molnupiravir and nirmatrelvir-ritonavir are orally administered pharmacotherapies for mild to moderate COVID-19. However, the effectiveness of these drugs among very old (≥80years), hospitalised patients remains unclear, limiting the risk-benefit assessment of these antivirals in this specific group. This study investigates the effectiveness of these antivirals in reducing mortality among this group of hospitalised patients with COVID-19. Using a territory-wide public healthcare database in Hong Kong, a target trial emulation study was conducted with data from 13 642 eligible participants for the molnupiravir trial and 9553 for the nirmatrelvir-ritonavir trial. The primary outcome was all-cause mortality. Immortal time and confounding bias was minimised using cloning-censoring-weighting approach. Mortality odds ratios were estimated by pooled logistic regression after adjusting confounding biases by stabilised inverse probability weights. Both molnupiravir (HR: 0.895, 95% CI: 0.826-0.970) and nirmatrelvir-ritonavir (HR: 0.804, 95% CI: 0.678-0.955) demonstrated moderate mortality risk reduction among oldest-old hospitalised patients. No significant interaction was observed between oral antiviral treatment and vaccination status. The 28-day risk of mortality was lower in initiators than non-initiators for both molnupiravir (risk difference: -1.09%, 95% CI: -2.29, 0.11) and nirmatrelvir-ritonavir (risk difference: -1.71%, 95% CI: -3.30, -0.16) trials. The effectiveness of these medications was observed regardless of the patients' prior vaccination status. Molnupiravir and nirmatrelvir-ritonavir are moderately effective in reducing mortality risk among hospitalised oldest-old patients with COVID-19, regardless of their vaccination status.

Introduction of Endovascular Thrombectomy to The Island Nation — The Maldives

Over the years multiple treatment trials were researched up on for acute management of ischemic stroke to reduce mortality risk and morbidity rate among adults who suffered. Here, we report a case of 63 years Muslim diabetic female with multiple co-morbidities of coronary heart disease, pulmonary disease, and internal carotid artery aneurysm presented with thrombotic occlusion of left middle cerebral artery who underwent Maldives first ever endovascular thrombectomy using combined technique.

Sex-difference of multifactorial intervention on cardiovascular and mortality risk in DKD: post-hoc analysis of a randomised clinical trial

ObjectiveWomen with type 2 diabetes experience higher cardiovascular and mortality risk than men possibly because of a sub-optimal cardio-protective treatment. We evaluated whether an intensive multifactorial therapy (MT) produces similar protective effect on development of adverse outcomes in women and men.Research design and methodsNephropathy in Diabetes type 2 study is an open-label cluster randomized trial comparing the effect of Usual Care (UC) or MT of main cardiovascular risk factors (blood pressure < 130/80 mmHg, HbA1c < 7%, LDL < 100 mg/dL, and total cholesterol < 175 mg/dL) on cardiovascular and mortality risk in patients with type 2 diabetes. In this post-hoc analysis, we stratified patients by sex to compare the occurrence of MACEs (primary endpoint) and all-cause death (secondary endpoint) between women (104 MT and 105 UC) and men (103 MT and 83 UC).ResultsAchievement of therapeutic goals was similar by sex, with 44% and 47% of women and men in MT achieving at least 3 targets vs. 16% and 20% of women and men in UC. During a median follow-up of 13.0 years, we recorded 262 MACE (48.5% in women) and 189 deaths (53.6% in women). Compared to the UC group, the risk of MACE in the MT group was reduced by 52% in women and by 44% in men (P = 0.11). Conversely, the reduction in mortality risk by MT was greater in women (44% versus 12%, P = 0.019).ConclusionsMT similarly reduces the risk of MACEs in either sex. This therapeutic approach is associated with a survival advantage in women as compared with men and it may represent an important rationale to motivate physicians in overcoming their therapeutic inertia often encountered in female patients as well as to encourage patients of both sexes at improving their adherence to multidrug therapy.

Revisiting the concept of bout: associations of moderate-to-vigorous physical activity sessions and non-sessions with mortality

IntroductionCurrent physical activity guidelines recommend 150 min of moderate-to-vigorous physical activity (MVPA) for health benefits, regardless of the pattern of MVPA. However, MVPA that occurs in sessions (MVPA-S) may have different health implications compared to MVPA that is not accumulated in sessions (MVPA-nonS). This study aimed to investigate the associations of MVPA-S and MVPA-nonS with mortality.MethodsWe conducted a cohort study of the National Health and Nutrition Examination Survey 2003–2006 (n = 5,658) with accelerometer-measured physical activity at baseline and mortality followed through December 31, 2019. A session was defined as a time window of 30 min or longer where the average intensity was at or above 2020 counts/minute. MVPA accumulated within such sessions was quantified as MVPA-S, while MVPA accumulated outside the sessions was quantified as MVPA-nonS. We examined the joint association of MVPA-S and MVPA-nonS by classifying the participants into four groups (both < 75 min/week [referent], MVPA-S ≥ 75 and MVPA-nonS < 75, MVPA-S < 75 and MVPA-nonS ≥ 75, and both ≥ 75). We used 75 min as the cut-point because it is half of the guideline-recommended MVPA volume where a strong MVPA-mortality association has been observed in previous studies, and because it was close to the median of MVPA-nonS (75 min/week was the 54th percentile), allowing a sufficient sample size in each group for testing statistical significance. The hazard ratios and 95% confidence intervals were estimated with adjustment for important confounders.ResultsDuring 13.9 years of follow-up (74,988 person-years), there were 1,424 deaths, out of which 472 were related to cardiovascular diseases (CVD). Compared to the referent combination (both < 75), the hazard ratios in the other three combinations were 0.48 (0.33–0.69), 0.85 (0.71–1.01), and 0.45 (0.30–0.67) for all-cause mortality; and were 0.34 (0.17–0.70), 0.96 (0.69–1.33), and 0.40 (0.17–0.90) for CVD mortality, respectively. Results were largely consistent in the spline-based models, age- and sex-stratified analyses, complete-case analysis, competing risk analysis, and the analysis excluding deaths within two years of follow-up.ConclusionIn conclusion, MVPA accumulated in sessions that lasted at least 30 min was associated with significant reductions in all-cause and CVD-specific mortality risks. The health implications of MVPA that were not accumulated in such sessions warrant further investigation.

Association between the use of statins and in-hospital mortality risk in patients with sepsis-induced coagulopathy during ICU stays: a study based on medical information mart for intensive care database

BackgroundThe objective of this study was to explore the correlation between statin administration in the intensive care unit (ICU) setting and the in-hospital mortality risk of patients suffering from sepsis-induced coagulopathy (SIC).MethodsUtilizing a retrospective cohort study design, this investigation collected data from the Medical Information Mart for Intensive Care (MIMIC)-IV spanning 2008 to 2019. The diagnosis of SIC was established based on a SIC score of 4 or above. Statin usage during the ICU period was extracted from the prescription records based on the keywords of statin medications. The primary endpoint analyzed was the in-hospital mortality within the ICU, characterized by any death occurring during the ICU admission.ResultsDuring the follow-up, which had a median duration of approximately 7.28 days, 18.19% of the 4,777 SIC patients died in the ICU. Statin was linked with a decrease in the risk of in-hospital mortality for SIC patients in the ICU [hazard ratio (HR): 0.73, 95% confidence interval (CI): 0.60–0.89, P = 0.002]. Relative to rosuvastatin, the use of atorvastatin (HR: 0.54, 95% CI: 0.34–0.85, P = 0.008) or simvastatin (HR: 0.55, 95% CI: 0.33–0.92, P = 0.024), as well as combinations of multiple statins (HR: 0.36, 95% CI: 0.15–0.86, P = 0.022), was associated with a reduction in ICU in-hospital mortality risk. Subgroup analysis also suggested that the use of atorvastatin, simvastatin, or a combination of statins had an advantage over rosuvastatin in reducing ICU in-hospital mortality in SIC patients older than 65 years of age or SIC patients with respiratory failure or cardiogenic shock (all P < 0.05).ConclusionThe present study supports the potential benefits of statin use in mortality in SIC patients during ICU stays. The study encourages clinicians to consider the benefits of statins and supports the ongoing exploration of statins for enhanced outcomes in critical care settings.

Vaccinome landscape in nearly 620,000 patients with diabetes.

Type 1 (T1D) and type 2 diabetes (T2D) are associated with an elevated incidence of infectious diseases and a higher risk of infections-related hospitalization and death. In this study, we delineated the "vaccinome" landscape obtained with a large immunization schedule offered by the Regional Government of Lombardy in a cohort of 618,396 patients with diabetes (T1D and T2D). Between September 2021 and September 2022, immunization coverage for influenza, meningococcus, pneumococcus, and herpes zoster was obtained from the public computerized registry of the healthcare system of Lombardy Region (Italy) in 618,396 patients with diabetes and in 9,534,087 subjects without diabetes. Type of diabetes, age, mortality, and hospitalizations were retrospectively analyzed in vaccinated and unvaccinated patients. Among patients with diabetes (T1D and T2D), 44.6% received the influenza vaccine, 10.9% the pneumococcal vaccine, 2.5% the anti-meningococcus vaccine and 0.7% the anti-zoster vaccine. Patients with diabetes immunized for influenza, zoster and meningococcus showed a 2-fold overall reduction in mortality risk and a decrease in hospitalizations. A 3-fold lower risk of mortality and a decrease in hospitalizations for both cardiac and pulmonary causes were also observed after influenza, zoster, and meningococcus immunization in older patients with diabetes. Immunization coverage is still far from the recommended targets in patients with diabetes. Despite this, influenza vaccination protected nearly 3,800 per 100,000 patients with diabetes from risk of death. The overall impressive decrease in mortality and hospitalizations observed in vaccinated patients strengthens the need for scaling up the "vaccinome" landscape in patients with diabetes.

Sepsis Alert Systems, Mortality, and Adherence in Emergency Departments

Early detection and management of sepsis are crucial for patient survival. Emergency departments (EDs) play a key role in sepsis management but face challenges in timely response due to high patient volumes. Sepsis alert systems are proposed to expedite diagnosis and treatment initiation per the Surviving Sepsis Campaign guidelines. To review and analyze the association of sepsis alert systems in EDs with patient outcomes. A thorough search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library from January 1, 2004, to November 19, 2023. Studies that evaluated sepsis alert systems specifically designed for adult ED patients were evaluated. Inclusion criteria focused on peer-reviewed, full-text articles in English that reported on mortality, ICU admissions, hospital stay duration, and sepsis management adherence. Exclusion criteria included studies that lacked a control group or quantitative reports. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Two independent reviewers conducted the data extraction using a standardized form. Any disagreements were resolved through discussion. The data were synthesized using a random-effects model due to the expected heterogeneity among the included studies. Key outcomes included mortality, intensive care unit admissions, hospital stay duration, and adherence to the sepsis bundle. Of 3281 initially identified studies, 22 (0.67%) met inclusion criteria, encompassing 19 580 patients. Sepsis alert systems were associated with reduced mortality risk (risk ratio [RR], 0.81; 95% CI, 0.71 to 0.91) and length of hospital stay (standardized mean difference [SMD], -0.15; 95% CI, -0.20 to -0.11). These systems were also associated with better adherence to sepsis bundle elements, notably in terms of shorter time to fluid administration (SMD, -0.42; 95% CI, -0.52 to -0.32), blood culture (SMD, -0.31; 95% CI, -0.40 to -0.21), antibiotic administration (SMD, -0.34; 95% CI, -0.39 to -0.29), and lactate measurement (SMD, -0.15; 95% CI, -0.22 to -0.08). Electronic alerts were particularly associated with reduced mortality (RR, 0.78; 95% CI, 0.67 to 0.92) and adherence with blood culture guidelines (RR, 1.14; 95% CI, 1.03 to 1.27). These findings suggest that sepsis alert systems in EDs were associated with better patient outcomes along with better adherence to sepsis management protocols. These systems hold promise for enhancing ED responses to sepsis, potentially leading to better patient outcomes.

Comparative analysis of the safety and effectiveness of Nirmatrelvir-Ritonavir and Azvudine in older patients with COVID-19: a retrospective study from a tertiary hospital in China.

Introduction: Numerous studies have explored the treatment outcomes of Nirmatrelvir-Ritonavir and Azvudine in older patients with COVID-19. However, direct comparisons between these two drugs are still relatively limited. This study aims to compare the safety and effectiveness of these two drugs in Chinese older patients with early infection to provide strategies for clinical treatment. Methods: Older COVID-19 patients (age ≥65) hospitalized during the winter 2022 epidemic in China were included and divided into Nirmatrelvir-Ritonavir and Azvudine. Demographics, medication information, laboratory parameters, and treatment outcomes were collected. All-cause 28-day mortality, delta cycle threshold (ΔCt), nucleic acid negative conversion time, and incidence of adverse events were defined as outcomes. Propensity score matching (PSM), Kaplan-Meier, Cox proportional hazards model, subgroup analysis, and nomograms were selected to evaluate the outcomes. Results: A total of 1,508 older COVID-19 patients were screened. Based on the inclusion and exclusion criteria, 1,075 patients were eligible for the study. After PSM, the final number of older COVID-19 patients included in the study was 375, and there were no significant differences in demographic characteristics between the two groups (p > 0.05). Compared to the Azvudine group, the Nirmatrelvir-Ritonavir group showed a higher incidence of multiple adverse events (12.8% vs 5.2%, p = 0.009). The incidence of adverse events related to abnormal renal function was higher in the Nirmatrelvir-Ritonavir group compared to the Azvudine group (13.6% vs 7.2%, p = 0.045). There were no significant differences between the two groups in terms of all-cause 28-day mortality (HR = 1.020, 95% CI: 0.542 - 1.921, p = 0.951), whereas there were significant differences in nucleic acid negative conversion time (HR = 1.659, 95% CI: 1.166 - 2.360, p = 0.005) and ΔCt values (HR = 1.442, 95% CI: 1.084 - 1.918, p = 0.012). Conclusion: Azvudine and Nirmatrelvir-Ritonavir have comparable effectiveness in reducing mortality risk. Azvudine may perform better in nucleic acid negative conversion time and virus clearance and shows slightly better safety in older patients. Further studies with a larger sample size were needed to validate the result.

Depression Is Associated with a Higher Risk of Mortality among Breast Cancer Survivors: Results from the National Health and Nutrition Examination Survey-National Death Index Linked Study.

Breast cancer (BC) and depression are globally prevalent problems. Numerous reviews have indicated the high prevalence of depression among BC survivors. However, the long-term impact of depression on survival among BC survivors has not been well explored. For this investigation, we aimed to explore the relationship between BC, depression, and mortality from a national random sample of adult American women. Data from the U.S. National Health and Nutrition Examination Survey (years 2005-2010) were linked with mortality data from the National Death Index up to December 31st, 2019. A total of 4719 adult women (ages 45 years and older) were included in the study sample with 5.1% having breast cancer and more than a tenth (12.7%) having depression. The adjusted hazard ratio (HR) for all-cause mortality risk among those with BC was 1.50 (95% CI = 1.05-2.13) compared to those without BC. In the adjusted analysis, the risk of all-cause mortality was highest among women with both depression and BC (HR = 3.04; 95% CI = 1.15-8.05) compared to those without BC or depression. The relationship between BC and mortality was moderated by cardiovascular diseases, anemia, smoking, age, PIR, and marital status. Our analysis provides vital information on factors that could be helpful for interventions to reduce mortality risk among those with BC and depression. In addition, given the higher risk of mortality with co-occurring BC and depression, collaborative healthcare practices should help with widespread screening for and treatment of depression among BC survivors.

Joint effect of atrial fibrillation and obesity on mortality in critically ill patients

BackgroundThe interplay between atrial fibrillation (AF) and obesity on mortality in critically ill patients warrants detailed exploration, given their individual impacts on patient prognosis. This study aimed to assess the associations between AF, obesity, and 1-year mortality in a critically ill population.MethodsUtilizing data from the Medical Information Mart for Intensive Care (MIMIC)-IV database, we conducted a retrospective analysis of adult patients admitted to the intensive care unit. The primary endpoint was 1-year mortality, analyzed through Cox regression with hazard ratio (HR) and Kaplan-Meier survival methods.ResultsThe study included 25,654 patients (median age 67.0 years, 40.6% female), with 39.0% having AF and 36.1% being obese. Multivariate COX regression analysis revealed that AF was associated with a 14.7% increase in the risk of 1-year mortality (p < 0.001), while obesity was linked to a 13.9% reduction in mortality risk (p < 0.001). The protective effect of obesity on mortality was similar in patients with (HR = 0.85) and without AF (HR = 0.86). AF led to a slightly higher risk of mortality in patients without obesity (HR = 1.16) compared to those with obesity (HR = 1.13). Kaplan-Meier survival curves highlighted that non-obese patients with AF had the lowest survival rate, whereas the highest survival was observed in obese patients without AF.ConclusionsAF significantly increased 1-year mortality risk in critically ill patients, whereas obesity was associated with a decreased mortality risk. The most adverse survival outcomes were identified in non-obese patients with AF.

The influence of the health status and functional capacity assessment of older people with heart failure on the participation in a cardiac rehabilitation program after myocardial infarction

Abstract Background Cardiac rehabilitation (CR) after myocardial infarction (MI), conducted by a multidisciplinary team, is considered to be the most effective secondary prevention strategy. CR might be particularly beneficial in older patients, who often suffer from heart failure (HF) and other comorbidities. Low enrolment in CR programs is observed in various age groups despite the proven effectiveness of CR in the reduction of subsequent ischemic episodes, hospitalization, and mortality risk. Purpose The study aimed to analyze the impact of the health status and functional capacity assessment of elderly patients with HF using the Vulnerable Elders Survey (VES-13) scale on the willingness to participate in the CR program as part of the national Comprehensive Care Program after Myocardial Infarction. Methods The analysis of the medical records of MI patients, who were hospitalized between 2017 and 2023 and met the inclusion criteria for CR was performed. People included in the study were ≥60 years of age and had previously been diagnosed with HF. The study included 350 people who underwent VES-13 assessment during hospitalization. The median age of the studied group was 74 (IQR 68-81), with the majority of males (59.1%). Results The willingness to participate in CR was declared by 26.3% of respondents. The median VES-13 score was 3 (IQR 2-7) points and was higher in patients who did not want to participate in CR [3 (IQR 2-7) vs 2 (IQR 1-3), p &amp;lt;0.0001]. In the group of patients who scored &amp;lt;3 points in the VES-13 scale, there was a significantly higher percentage of patients declaring their willingness to participate in CR compared to the group with ≥3 points (38.8% vs 18.5%, p=0.0001). Univariate analysis showed that all parameters assessed by the VES-13 scale had a significant impact on patients' willingness to participate in CR (Figure 1). Independent factors determining patients' declaration were age, difficulties in reaching or extending arms above the shoulder level, and limitations in shopping for personal items (like toilet items or medicines) (Figure 2). Conclusion The VES-13 scale can help to identify patients with HF after MI who require additional support and motivation in the decision process to participate in coordinated care and early CR. Limitations in the everyday functioning of elderly patients with HF determine the lack of willingness to participate in CR after MI. It is necessary to carry out intensive educational and motivational activities to improve the recruitment to the CR program.

Effect of Antifibrotic Use on Mortality in Patients with Idiopathic Pulmonary Fibrosis.

Rationale: Observational studies report a significant protective effect of antifibrotics on mortality among patients with idiopathic pulmonary fibrosis (IPF). Many of these studies, however, were subject to immortal time bias because of the mishandling of delayed antifibrotic initiation. Objectives: To evaluate the antifibrotic effect on mortality among patients with IPF using appropriate statistical methods that avoid immortal time bias. Methods: Using a large administrative database, we identified 10,289 patients with IPF, of whom 2,300 used antifibrotics. Treating delayed antifibrotic initiation as a time-dependent variable, three statistical methods were used to control baseline characteristics and avoid immortal time bias. Stratified analysis was performed for patients who initiated antifibrotics early and those who initiated treatment late. For comparison, methods that mishandle immortal time bias were performed. A simulation study was conducted to demonstrate the performance of these models in a wide range of scenarios. Results: All three statistical methods yielded nonsignificant results for the antifibrotic effect on mortality, with the stratified analysis for patients with early antifibrotic initiation suggesting evidence for reduced mortality risk (for all patients, hazard ratio, 0.89; 95% confidence interval, 0.79-1.01; P = 0.08; for patients who were 65 years or older, hazard ratio, 0.85; 95% confidence interval, 0.73-0.98; P = 0.03). Methods that mishandle immortal time bias demonstrated significantly lower mortality risk for antifibrotic users. Bias of these methods was evident in the simulation study, where appropriate methods performed well with little to no bias. Conclusions: Findings in this study did not confirm an association between antifibrotics and mortality, with a stratified analysis showing support for a potential treatment effect with early treatment initiation.