Significant Predictor Of 1-year Mortality Research Articles

Malnutrition and Mortality in Frail and Non-Frail Older Adults Undergoing Aortic Valve Replacement.

Older adults undergoing aortic valve replacement (AVR) are at risk for malnutrition. The association between preprocedural nutritional status and midterm mortality has yet to be determined. The FRAILTY-AVR (Frailty in Aortic Valve Replacement) prospective multicenter cohort study was conducted between 2012 and 2017 in 14 centers in 3 countries. Patients ≥70 years of age who underwent transcatheter or surgical AVR were eligible. The Mini Nutritional Assessment-Short Form was assessed by trained observers preprocedure, with scores ≤7 of 14 considered malnourished and 8 to 11 of 14 considered at risk for malnutrition. The Short Performance Physical Battery was simultaneously assessed to measure physical frailty, with scores ≤5 of 12 considered severely frail and 6 to 8 of 12 considered mildly frail. The primary outcome was 1-year all-cause mortality, and the secondary outcome was 30-day composite mortality or major morbidity. Multivariable regression models were used to adjust for potential confounders. There were 1158 patients (727 transcatheter AVR and 431 surgical AVR), with 41.5% females, a mean age of 81.3 years, a mean body mass index of 27.5 kg/m2, and a mean Society of Thoracic Surgeons-Predicted Risk of Mortality of 5.1%. Overall, 8.7% of patients were classified as malnourished and 32.8% were at risk for malnutrition. Mini Nutritional Assessment-Short Form scores were modestly correlated with Short Performance Physical Battery scores (Spearman R=0.31, P<0.001). There were 126 deaths in the transcatheter AVR group (19.1 per 100 patient-years) and 30 deaths in the surgical AVR group (7.5 per 100 patient-years). Malnourished patients had a nearly 3-fold higher crude risk of 1-year mortality compared with those with normal nutritional status (28% versus 10%, P<0.001). After adjustment for frailty, Society of Thoracic Surgeons-Predicted Risk of Mortality, and procedure type, preprocedural nutritional status was a significant predictor of 1-year mortality (odds ratio, 1.08 per Mini Nutritional Assessment-Short Form point; 95% CI, 1.01-1.16) and of the 30-day composite safety end point (odds ratio, 1.06 per Mini Nutritional Assessment-Short Form point; 95% CI, 1.001-1.12). Preprocedural nutritional status is associated with mortality in older adults undergoing AVR. Clinical trials are needed to determine whether pre- and postprocedural nutritional interventions can improve clinical outcomes in these vulnerable patients.

Long-term effects of iron deficiency in patients with heart failure with or without anemia: the RAID-HF follow-up study.

Iron deficiency (ID) has been recognized as a relevant comorbidity in heart failure with reduced ejection fraction (HFrEF); however, study data have shown that diagnostic and therapeutic efforts on ID are primarily performed in patients with anemia. The RAID-HF registry investigated consecutive patients with ID and HFrEF in 11 heart centers in Germany and Switzerland. The present analysis focuses on 1-year follow-up data in patients with versus without anemia. In 505 patients with HFrEF and ID and 418 patients with HFrEF without ID 1-year follow-up was performed. Patients with ID had a higher long-term mortality compared to those without ID (19.5% vs. 13.7%, p = 0.02) and reported a lower quality of life. Only a minority of patients with ID (9.3%) received iron supplementation during long-term course, just 4.7% intravenously. Anemia was associated with an elevated mortality whereas ID versus no ID did not predict mortality in anemic patients (log-rank p = 0.78). However, in patients without anemia ID versus no ID predicted mortality (log-rank p = 0.002). In the adjusted analysis a significant interaction remained, with ID being a significant predictor of 1-year mortality in patients without anemia (HR 2.15, 95% CI 1.12-3.78), but not in anemic patients (HR 0.99, 95% CI 0.65-1.49). RAID-HF demonstrates the impact of ID on long-term mortality and quality of life in patients with HFrEF and reveals an underuse of iron supplementation in current clinical practice. Particularly in patients without anemia the diagnosis of ID is of clinical relevance to identify patients at higher mortality risk.

Clinical Frailty as an Outcome Predictor After Transcatheter Aortic Valve Implantation

Society of Thoracic Surgeons (STS) score and frailty index are calculated routinely as part of transcatheter aortic valve implantation (TAVI) assessment to determine procedure risk. We aim to evaluate the incremental improvement of STS risk score using frailty status in predicting short- and long-term outcome after TAVI. Study population included 544 consecutive TAVI patients who completed full frailty assessment and STS score calculation before the procedure. Frailty is defined by the presence of any 3 of the following 5 criteria: algorithm-defined grip strength and 15-foot walking tests, body mass index < 20 kg/m2, Katz activity of daily living ≤ 4/6, serum albumin < 3.5 g/dl. Multivariable logistic analysis of 30-day and 1-year mortality was performed using a logistic regression model that comprised the STS risk score model as a single variable. Based on frailty definition, 242 patients were frail and 302 patients were not. STS score was higher in the frail group than in the nonfrail group. Compared with STS risk score alone, frailty status was a significant predictor of 1-year mortality after TAVI procedure (odds ratio 1.0, 95% confidence interval [CI] 1.0 to 1.1, p = 0.029 vs 2.75, 95% CI 1.55 to 4.87, p <0.001, respectively). Although the c-statistic of the 1-year STS risk prediction model only changed from 0.62 to 0.66 (p = 0.08), the net reclassification improvement increased significantly to 52.8% after adding frailty to the prediction model (95% CI 0.28 to 0.77, p <0.0001). Frailty status is associated with higher mortality in TAVI cohort and incrementally improves the well-validated STS risk prediction model. Frailty assessment should continue to be part of the preprocedural assessment to further improve patient outcomes after TAVI.

Comparison of Direct and Less Invasive Techniques for the Treatment of Severe Aorto-Iliac Occlusive Disease

Severe aorto-iliac occlusive disease (AIOD) is traditionally treated with aorto-bifemoral bypass (ABF) or aorto-unifemoral bypass (AUF). However, cross-femoral bypass(CFB) and hybrid femoral endarterectomy and patch angioplasty with iliac stenting (EPS) have gained popularity as less invasive options. We sought to compare 1-year survival, primary patency, and major amputation rates between open surgical (ABF and AUF) and 2 less invasive reconstruction techniques (CFB and EPS) using a large, multicenter cohort. This is a retrospective cohort study of patients who underwent either ABF/AUF or CFB/EPS for AIOD between 2006 and 2013 in the Society for Vascular Surgery Vascular Quality Initiative registry. Baseline patient and periprocedural variables were compared. Propensity score matching (PSM) was performed to predict the likelihood of more invasive repair. Kaplan-Meier analysis and Cox models were performed for 1-year survival, primary patency, and major amputation. 1872 patients underwent procedures for AIOD, including 1,133 ABF/AUF and 739 CFB/EPS, during the study period. Indication was critical limb ischemia in 47.3% (n=886). Median follow-up time was 305days (range, 10-406). After PSM, the matched cohort included 1,094 ABF/AUF and 711 CFB/EPS patients. Multivariate analysis revealed that patient factors and procedure indication were significant predictors of 1-year mortality and major amputation, but not procedure type. ABF/AUF was associated with improved primary patency over CFB/EPS at 1 year (94.1%±1.1% vs. 92.3%±1.5%, hazard ratio 0.65, 95% confidence interval 0.45-0.94; P=0.02). In a propensity-matched cohort from a multicenter vascular surgery registry, a direct approach to AIOD (ABF/AUF) demonstrated better 1-year primary patency than commonly used less invasive strategies. However, treatment approach was not a predictor of 1-year survival or limb salvage, suggesting that patient factors and procedure indication have a greater impact on outcome.

The Sernbo score predicts 1-year mortality after displaced femoral neck fractures treated with a hip arthroplasty

Background and purpose — Displaced femoral neck fractures (FNFs) are associated with high rates of mortality during the first postoperative year. The Sernbo score (based on age, habitat, mobility, and mental state) can be used to stratify patients into groups with different 1-year mortality. We assessed this predictive ability in patients with a displaced FNF treated with a hemiarthroplasty or a total hip arthroplasty.Patients and methods — 292 patients (median age 83 (65–99) years, 68% female) with a displaced FNF were included in this prospective cohort study. To predict 1-year mortality, we used a multivariate logistic regression analysis including comorbidities and perioperative management. A receiver operating characteristic (ROC) analysis was used to evaluate the predictive ability of the Sernbo score, which was subsequently divided in a new manner into a low, intermediate, or high risk of death during the first year.Results — At 1-year follow-up, the overall mortality rate was 24%, and in Sernbo’s low-, intermediate-, and high-risk groups it was 5%, 22%, and 51%, respectively. The Sernbo score was the only statistically significant predictor of 1-year mortality: odds ratio for the intermediate-risk group was 4.2 (95% Cl: 1.5–12) and for the high-risk group it was 15 (95% CI: 5–40). The ROC analysis showed a fair predictive ability of the Sernbo score, with an area under the curve (AUC) of 0.79 (95% CI: 0.73–0.83). Using a cutoff of less than 11 points on the score gave a sensitivity of 61% and a specificity of 83%.Interpretation — The Sernbo score identifies patients who are at high risk of dying in the first postoperative year. This scoring system could be used to better tailor perioperative care and treatment in patients with displaced FNF.

The Role of Red Blood Cell Distribution Width for Predicting 1-year Mortality in Patients Admitted to the Emergency Department with Severe Dyspnoea

SummaryBackgroundUniversally accepted and validated instruments for predicting the outcome of patients presenting to the emergency department (ED) with severe dyspnoea do not exist so far, nor are they regularly used by the emergency physicians. This study hence aimed to establish whether red blood cell distribution width (RDW) may be a predictive parameter of 1-year mortality in a population of patients admitted to the ED with severe dyspnoea attributable to different underlying disorders.MethodsWe retrospectively evaluated all the patients undergoing arterial blood gas analysis for severe dyspnoea (irrespective of the cause) during admission to ED of University Hospital of Verona from September 1, 2014 to November 31, 2014.ResultsThe final study population consisted of 287 patients for whom complete clinical and laboratory information was available. Overall, 36 patients (12.5%) died after a 1-year follow-up. The RDW value was found to be considerably increased in patients who deceased during the follow-up compared to those who survived (17.2% versus 14.8%; p<0.001). In both univariate and multivariate analyses, the RDW value was found to be a significant predictor of 1-year mortality. In particular, patients with RDW ≥ 15.0% displayed a 72% increased risk of 1-year mortality after multiple adjustments.ConclusionsThe measurement of RDW, a very simple and inexpensive laboratory parameter, may represent an important factor for predicting medium-term mortality in patients presenting to the ED with severe dyspnoea.

Predicting Mortality in Systemic Sclerosis-Associated Interstitial Lung Disease Using Risk Prediction Models Derived From Idiopathic Pulmonary Fibrosis

Mortality risk prediction tools have been developed in idiopathic pulmonary fibrosis, however, it is unknown whether these models accurately estimate mortality in systemic sclerosis-associated interstitial lung disease (SSc-ILD). Four baseline risk prediction models--the Composite Physiologic Index, the Interstitial Lung Disease-Gender, Age, Physiology Index, the du Bois index, and the modified du Bois index--were calculated for patients recruited from a specialized SSc-ILD clinic. Each baseline model was assessed using logistic regression analysis with 1-year mortality as the outcome variable. Discrimination was quantified using the area under the receiver operating characteristic curve. Calibration was assessed using the goodness-of-fit test. The incremental prognostic ability of additional predictor variables was determined by adding prespecified variables to each baseline model. The 156 patients with SSc-ILD completed 1,294 pulmonary function tests, 725 6-min walk tests, and 637 echocardiograms. Median survival was 15.0 years from the time of SSc-ILD diagnosis. All baseline models were significant predictors of 1-year mortality in SSc-ILD. The modified du Bois index had an area under the receiver operating characteristic curve of 0.84, compared with 0.77 to 0.81 in the other models. Calibration was acceptable for the modified du Bois index, but was poor for the other models. All baseline models include FVC and 6-min walk distance was identified as an additional independent predictor of 1-year mortality. The modified du Bois index has good discrimination and calibration for the prediction of 1-year mortality in SSc-ILD. FVC and 6-min walk distance are important independent predictors of 1-year mortality in SSc-ILD.

Obvious emphysema on computed tomography during an acute exacerbation of chronic obstructive pulmonary disease predicts a poor prognosis.

Emphysematous change on computed tomography (CT) during the stable phase of chronic obstructive pulmonary disease (COPD) is reported to correlate with COPD prognosis. Acute exacerbation of COPD (AECOPD) is associated with a high risk of mortality and a poor prognosis. This study aims to study the relationship between prognosis and emphysematous changes on CT during an AECOPD. Histories were recorded, and CT acquired for 106 patients who visited the emergency department for an AECOPD. Emphysematous change was quantified by measuring the percentage of low-attenuation areas (LAA%) in the entire lung on CT images with a threshold of -950 Hounsfield units. Other factors that could influence AECOPD prognosis were also recorded on admission and analysed. At follow ups conducted in 1 year, patient survival, the modified Medical Research Council (mMRC) Dyspnoea Scale, and performance status (PS) were evaluated, and a COPD Assessment Test (CAT) was completed. The 1-year follow up was completed by 103 of 106 patients. The median LAA% was significantly higher in non-survivors (11%, n = 16) than in survivors (5.69%, n = 87) (P = 0.006) at the 1-year follow up. LAA% was significantly correlated with mMRC grade (r = 0.285, P = 0.008), PS (r = 0.397, P < 0.001) and CAT score (r = 0.27, P = 0.017) at the 3-month follow up, and with mMRC grade (r = 0.405, P < 0.001) and PS (r = 0.377, P < 0.001) at the 1-year follow up. LAA% > 7.5% was a significant predictor of 1-year mortality, higher mMRC and PS at the 3-month and 1-year follow ups, after adjustment for other prognostic predictors. Obvious emphysematous changes on CT (LAA% > 7.5%) during an AECOPD predicts a poor prognosis independent of other known indicators.

Mortality and Financial Burden of Periprosthetic Fractures of the Femur.

Objective:This study examines patient factors to identify risks of 12-month mortality following periprosthetic femur fractures. Hospital charges were analyzed to quantify the financial burden for treatment modalities.Methods:Data were retrospectively analyzed from a prospective database at a university hospital setting. One-hundred and thirteen patients with a periprosthetic fracture of the proximal or distal femur were identified. Risk factors for 12-month mortality were analyzed, and financial data were compared between the various treatment modalities.Results:In all, 14% of patients died (16 of 113) within 3 months and the 1-year mortality was 17.7% (20 of 113). Patients who died within 1 year had higher hospital charges (US$33 880 ± 25 051 vs US$22 886 ± 16 841; P = .01) and were older (87.6 ± 8.5 vs 81.5 ± 8.6; P = .004). Logistic regression analysis revealed age was the only significant predictor of 1-year mortality (P = .029, odds ratio 1.1). Analysis of financial data revealed 4 distinct groups (P < .05 between groups). Distal femoral revision arthroplasty (RA-DF) generated the highest hospital charges of US$91 035 ± 25 579 (n = 3). The second most highly charged group included proximal femoral fractures treated with revision arthroplasty (US$34 078 ± 17 832; n = 20) and hemi/total hip arthroplasty (THA; US$41 556 ± 23 651; n = 8). The third most charged group underwent open reduction internal fixation of the proximal (US$18 706 ± 6829; n = 35) and distal (US$22 381 ± 10 835; n = 35) femur. Nonoperative treatment generated the lowest charges (US$6426 ± 2899; n = 11). On average, the hospital lost money treating patients with RA-DF (US$−19 080 ± 2022 per patient) and hemi/THA (US$−6594 ± 9305 per patient), while all other treatment groups were profitable.Conclusion:One-year mortality after periprosthetic femur fractures was 17.7%, is mostly influenced by age, and 80% of deaths occur within 3 months. Patients treated with primary/revision arthroplasty generate more hospital charges than internal fixation. The average patient treated with revision arthroplasty of the distal femur or hemi/THA for a periprosthetic femur fractures resulted in net financial losses for the hospital.

Predictors of 30-day and 1-year mortality after transvenous lead extraction: a single-centre experience

Owing to the increasing use of cardiac implantable electronic devices, there is a growing need for safe and effective techniques to manage device-related complications and lead dysfunction. Lead extraction remains a challenging procedure with inherent risks. We present the 30-day and long-term outcomes of lead extractions in the University Hospitals Leuven. We report a retrospective cohort study of 176 patients admitted to the University Hospitals Leuven between January 2005 and December 2011, for the transvenous extraction of 295 leads. Indications for extraction were lead dysfunction and device upgrade in 84 (47.7%), pocket infection in 61 (34.7%), and systemic infection in 31 patients (17.6%). Extraction was successful in 95.5% of patients with complete removal of the leads or only a minor fragment remaining. One fatal peri-procedural complication occurred. Thirty-day mortality was 3.4% (n = 6). Systemic infection was the only significant predictor of 30-day mortality [odds ratio (OR) 29.706; P = 0.029]. A lower level of haemoglobin prior to extraction also tended to be related with a higher mortality, but this was not significant (OR 2.024; P = 0.082). One-year mortality was 8.5% (n = 15). Systemic infection (OR 9.727; P = 0.009), a lower level of haemoglobin (OR 1.597; P = 0.05), and a higher level of ureum (OR 1.021; P = 0.017) prior to extraction were significant predictors of 1-year mortality. Systemic infection was associated with significantly higher 30-day (19%), 1-year (32%), and long-term (39%) mortality rates. Lead extraction can be safely and successfully performed in the majority of patients, with limited life-threatening complications. However, lead extraction because of systemic infection is associated with a significantly higher risk of short- and long-term mortality.

Feasibility of NOTES omental plug repair of perforated peptic ulcers: results from a clinical pilot trial

Ulcer perforation carries up to a 30 % 1-year mortality rate. Intervention-related adverse events are among statistically significant predictors of 1-year mortality. A natural orifice transluminal endoscopic surgical (NOTES) approach may be less invasive and may decrease procedure-related adverse events by diminishing the so-called second hit, thus leading to decreased morbidity and mortality. We sought to assess the feasibility of an endoscopic transluminal omental plug technique in patients with perforated gastroduodenal ulcers under laparoscopic guidance. Patients with suspected acute gastroduodenal ulcer perforations were offered participation in this prospective pilot study. Closure of the perforation was attempted using the NOTES omental plug technique. Demographic, clinical, endoscopic, and radiographic data were abstracted, as were data for morbidity, mortality, and pilot data regarding quality of life (QOL). From February 2010 through February 2012, a total of 17 patients presented to a tertiary care center with clinically suspected perforated ulcer. Of seven patients (mean age 79 years, range 64-89 years) who consented to the study, three underwent the study procedure. All patients had multiple comorbidities. Two patients presented with 4-6 mm perforated peptic ulcers and underwent successful laparoscopic-assisted NOTES omental and falciform ligament patch closure, respectively. Postoperative radiographic contrast studies showed no leak, and patients were discharged home on postoperative days 3 and 4. The third patient had undergone enterocutaneous fistula repair with herniorrhaphy 6 weeks before. Although a transluminal endoscopic approach was feasible, the omentum was under too much tension to be secured. This procedure was converted to an open omental patch repair. For all but one patient who provided consent, obtaining QOL data was feasible. Initial results from a laparoscopic-assisted NOTES approach for closure of perforated peptic ulcers appear promising and enable swift recovery in selected patients. This is especially important in elderly and/or immunocompromised patients. Technical details and patient selection criteria continue to evolve.

Impact of Comorbidities on the Outcomes of Older Patients Receiving Rectal Cancer Surgery

The decision to perform surgery on older patients often presents as an ethical dilemma. The purpose of this study is to investigate the impact of comorbidities on the clinical outcomes of older rectal cancer surgery patients, with the goal of enabling healthcare professionals to evaluate the risk of surgery for the treatment of cancer in older patients with comorbid chronic disease. This study included 320 patients >60 years of age who were treated from 2004–2009 at a medical center in northern Taiwan. Logistic regression and Cox proportional hazards regression were used to determine if various chronic diseases (e.g., hypertension, diabetes, cardiovascular disease, cerebrovascular disease) increase the risk of in-hospital complications and 1-year mortality. In the multivariate analysis, the risk of in-hospital complications for diabetic patients was 3.43 times that of nondiabetic patients (95% confidence interval [CI]: 1.13–10.37). For patients with cerebrovascular disease, the risk was 4.99 times that of those without cerebrovascular disease (95% CI: 1.30–19.07). In addition, patients ≥80 years of age demonstrated significantly higher 1-year mortality rates (HR = 3.49, 95% CI:1.18–10.30). However, a history of hypertension, diabetes, cardiovascular disease, or cerebrovascular disease was not a significant predictor of 1-year mortality. Older patients with comorbidities are at a higher risk of in-hospital complications following rectal cancer surgery, whereas the presence of comorbidities did not show a significant adverse effect on 1-year mortality in the present study. We suggest using population-based data to establish effective therapeutic strategies for treating each comorbidity.

Safety and efficacy of rescue angioplasty for ST-elevation myocardial infarction with high utilization rates of glycoprotein IIb/IIIa inhibitors

Fibrinolytic therapies remain widely used for ST-elevation myocardial infarction, and for "failed reperfusion," rescue percutaneous coronary intervention (PCI) is guideline recommended to improve outcomes. However, these recommendations are based on data from an earlier era of pharmacotherapy and procedural techniques. To determine factors affecting prognosis after rescue PCI, we studied 241 consecutive patients (median age 55 years, interquartile range [IQR] 48-65) undergoing procedures between 2001 and 2009 (53% anterior ST-elevation myocardial infarction and 78% transferred). The median treatment-related times were 1.2 hours (IQR 0.8-2.2) from symptom onset to door, 2 hours (IQR 1.3-3.2) from symptom onset to fibrinolysis (93% tenecteplase), and 3.9 hours (IQR 3.1-5.2) from fibrinolysis to balloon. Procedural characteristics were stent deployment in 95% (11.6% drug eluting) and 78% glycoprotein IIb/IIIa inhibitor use, and Thrombolysis In Myocardial Infarction (TIMI) 3 flow rates pre-PCI and post-PCI were 41% and 91%, respectively (P < .001). At 30 days, TIMI major bleeding occurred in 16 (6.6%) patients, and 23 (9.5%) patients received transfusions; nonfatal stroke occurred in 4 (1.7%) patients (2 hemorrhagic). Predictors of TIMI major bleeding were female gender (odds ratio 3.194, 95% CI 1.063-9.597; P = .039) and pre-PCI shock (odds ratio 3.619, 95% CI,1.073-12.207; P = .038). Mortality at 30 days was 6.2%, and 3.2% in patients without pre-PCI shock. One-year mortality was 8.2% (5.3% in patients without pre-PCI cardiogenic shock), 5.2% had reinfarction, and the target vessel revascularization rate was 6.4% (2.6% in arteries ≥ 3.5 mm in diameter). Pre-PCI shock, female gender, and post-PCI TIMI flow grades ≤ 2 were significant predictors of 1-year mortality on multivariable regression modeling, but TIMI major bleeding was not. Rescue PCI with contemporary treatments can achieve mortality rates similar to rates for contemporary primary PCI in patients without pre-PCI shock. Whether rates of bleeding can be reduced by different pharmacotherapies and interventional techniques needs clarification in future studies.

The influence of smoking status on malnutrition risk and 1-year mortality in outpatients with chronic obstructive pulmonary disease

Introduction: Smoking status in outpatients with chronic obstructive pulmonary disease (COPD) has been associated with a low body mass index (BMI) and reduced mid-arm muscle circumference (Cochrane & Afolabi, 2004). Individuals with COPD identified as malnourished have also been found to be twice as likely to die within 1 year compared to non-malnourished patients (Collins et al., 2010). Although malnutrition is both preventable and treatable, it is not clear what influence current smoking status, another modifiable risk factor, has on malnutrition risk. The current study aimed to establish the influence of smoking status on malnutrition risk and 1-year mortality in outpatients with COPD. Methods: A prospective nutritional screening survey was carried out between July 2008 and May 2009 at a large teaching hospital (Southampton General Hospital) and a smaller community hospital within Hampshire (Lymington New Forest Hospital). In total, 424 outpatients with a diagnosis of COPD were routinely screened using the ‘Malnutrition Universal Screening Tool’, ‘MUST’ (Elia, 2003); 222 males, 202 females; mean (SD) age 73 (9.9) years; mean (SD) BMI 25.9 (6.4) kg m−2. Smoking status on the date of screening was obtained for 401 of the outpatients. Severity of COPD was assessed using the GOLD criteria, and social deprivation determined using the Index of Multiple Deprivation (Nobel et al., 2008). Results: The overall prevalence of malnutrition (medium + high risk) was 22%, with 32% of current smokers at risk (who accounted for 19% of the total COPD population). In comparison, 19% of nonsmokers and ex-smokers were likely to be malnourished [odds ratio, 1.965; 95% confidence interval (CI), 1.133–3.394; P = 0.015]. Smoking status remained an independent risk factor for malnutrition even after adjustment for age, social deprivation and disease-severity (odds ratio, 2.048; 95% CI, 1.085–3.866; P = 0.027) using binary logistic regression. After adjusting for age, disease severity, social deprivation, smoking status, malnutrition remained a significant predictor of 1-year mortality [odds ratio (medium + high risk versus low risk), 2.161; 95% CI, 1.021–4.573; P = 0.044], whereas smoking status did not (odds ratio for smokers versus ex-smokers + nonsmokers was 1.968; 95% CI, 0.788–4.913; P = 0.147). Table 1. Mean (SD) and percentage weight loss at 6 months and 1 year post-gastric band and gastric bypass Mean (SD) initial weight on admission for surgery (kg) Mean (SD) weight loss at 6 months (kg) Mean (SD) percentage total weight loss at 6 months Mean (SD) weight loss at 1 year (kg) Mean (SD) percentage total weight loss at 1 year LAGB 103.1 (7.0) 10.3 (7.7) 9.7* (6.9) 9.6 (8.6) 8.8* (7.7) LRYGB 133.6 (22.6) 30.1 (9.6) 22.1 (5.3) 41.7 (17.1) 29.7 (9.6) *P < 0.005 compared with LRYGB. Discussion: This study highlights the potential importance of combined nutritional support and smoking cessation in order to treat malnutrition. The close association between smoking status and malnutrition risk in COPD suggests that smoking is an important consideration in the nutritional management of malnourished COPD outpatients. Conclusions: Smoking status in COPD outpatients is a significant independent risk factor for malnutrition and a weaker (nonsignificant) predictor of 1-year mortality. Malnutrition significantly predicted 1 year mortality.

Immediate and mid-term results of transfemoral aortic valve implantation using either the Edwards Sapien™ transcatheter heart valve or the Medtronic CoreValve ® System in high-risk patients with aortic stenosis

We sought to describe the results of transfemoral aortic valve implantation using either the Sapien prosthesis or the CoreValve System. Results of transfemoral aortic valve implantation using both commercially available prostheses have rarely been studied. Of 236 patients at high-risk or with contraindications to surgery, consecutively referred for transcatheter aortic valve implantation between October 2006 and June 2009, 83 were treated with transfemoral aortic valve implantation. The Sapien was the only prosthesis available until May 2008 and, since then, was used as the first option, while the CoreValve System was used when contraindications to the Sapien prosthesis were present. Patients were aged 81+/-9 years, 98% in New York Heart Association classes III/IV, with predicted surgical mortalities of 26+/-14% using the EuroSCORE and 15+/-8% using the Society of Thoracic Surgeons Predicted Risk of Mortality score. Seventy-two patients were treated with the Sapien prosthesis and 11 with the CoreValve System. The valve was implanted in 94% of the cases. Thirty-day mortality was 7%. Overall, 1- and 2-year survival rates were 78+/-5% and 71+/-7%, respectively. Among patients treated with the Sapien, the 1-year survival rate was 67+/-12% in the first 20% of patients versus 86+/-5% in the last 80% of patients (p=0.02). In univariate analysis, early experience was the only significant predictor of 1-year mortality. Combining the use of the Sapien and the CoreValve prostheses increases the number of patients who can be treated by transfemoral aortic valve implantation and provides satisfactory results at 2 years in this high-risk population. The results are strongly influenced by experience.

Clinical Utility of Malnutrition-Inflammation Score in Maintenance Hemodialysis Patients: Focus on Identifying the Best Cut-Off Point

Background: Malnutrition-inflammation score (MIS) is a comprehensive and quantitative system to assess malnutrition-inflammation complex syndrome, and a strong correlation between MIS and morbidity/mortality in maintenance hemodialysis (MHD) patients had been demonstrated. However, there is no cut-off value of MIS to categorize patients into high risk or low risk patients. Methods: A total of 257 chronic stable and ambulatory adult MHD patients from Far Eastern Memorial Hospital were enrolled for the study. The MIS of each patient was recorded at the initiation of study and the study population was followed up as a 12-month prospective cohort to evaluate mortality as the primary outcome. Results: Twelve patients died in the 12-month observational period. Both multiple logistic regression analyses and Cox proportional hazards model denoted MIS, alkaline phosphatase, transferrin saturation, ferritin, and total iron binding capacity as significant predictors of 1-year mortality. The conditional effect plot of MIS on 1-year mortality revealed that when fixing the alkaline phosphatase, transferrin saturation, ferritin, and total iron binding capacity at a mean value, the probability of death for an MHD patient whose MIS was 3, 4, and 5 is 10, 40, and 80%, respectively. Conclusions: Our study shows that MHD patients with MIS score of more than 4–5 had a significant risk of 1-year mortality. Additional risk factors associated with short-term mortality besides malnutrition-inflammation complex syndrome were anemia and renal osteodystrophy. This study proves that MIS is a useful tool to risk-stratify Asian MHD patients and to identify those at risk of short-term death. Nutritional interventions that can improve the MIS may also improve survival, but this hypothesis needs to be verified in interventional studies.

Statins are independently associated with reduced mortality in patients undergoing infrainguinal bypass graft surgery for critical limb ischemia

Evidence suggesting a beneficial effect of cardioprotective medications in patients with lower extremity atherosclerosis derives largely from secondary prevention studies of heterogeneous populations. Patients with critical limb ischemia (CLI) have a large atherosclerotic burden with related high mortality. The effect of such therapies in this population is largely inferred and unproven. The Project of Ex-Vivo vein graft Engineering via Transfection III (PREVENT III) cohort comprised 1404 patients with CLI who underwent lower extremity bypass grafting in a multicenter, randomized prospective trial testing the efficacy of edifoligide for the prevention of graft failure. Propensity scores were used to evaluate the influence of statins, beta-blockers, and antiplatelet agents on outcomes while adjusting for demographics, comorbidities, medications, and surgical variables that may influence drug use. Primary outcomes were major adverse cardiovascular events < or =30 days, vein graft patency, and 1-year survival assessed by Kaplan-Meier method. Potential determinants of 1-year survival were modeled using a multivariate Cox regression. In this cohort, 636 patients (45%) were taking statins, 835 (59%) were taking beta-blockers, and 1121 (80%) were taking antiplatelet drugs. Perioperative major adverse cardiovascular events (7.8%) and early mortality (2.7%) were not measurably affected by the use of any drug class. Statin use was associated with a significant survival advantage at 1 year of 86% vs 81% (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.52-0.98; P = .03) by analysis of both unweighted and propensity score-weighted data. Use of beta-blockers and antiplatelet drugs had no appreciable impact on survival. None of the drug classes were associated with graft patency measures at 1 year. Significant predictors of 1-year mortality by Cox regression modeling were statin use (HR, 0.67; 95% CI, 0.51-0.90; P = .001), age >75 (HR, 2.1; 95% CI, 1.60-2.82; P = .001), coronary artery disease (HR, 1.5; 95% CI, 1.15-2.01; P = .001), chronic kidney disease stages 4 (HR, 2.0; 95% CI, 1.17-3.55; P = .001) and 5 (HR, 3.4; 95% CI, 2.39-4.73; P < .001), and tissue loss (HR, 1.9; 95% CI, 1.23-2.80; P = .003). Statin use is associated with improved survival in CLI patients 1 year after surgical revascularization. Further studies are indicated to determine optimal dosing in this population and to definitively address the question of relationship to graft patency. These data add to the growing literature supporting statin use in patients with advanced peripheral arterial disease.

Registry of the International Society for Heart and Lung Transplantation: Twenty-second Official Adult Heart Transplant Report—2005

Registry of the International Society for Heart and Lung Transplantation: Twenty-second Official Adult Heart Transplant Report—2005

A direct comparison of the natriuretic peptides and their relationship to survival in chronic heart failure of a presumed non‐ischaemic origin

The natriuretic peptides have been validated as sensitive and specific markers of left ventricular dysfunction; brain natriuretic peptide (BNP), N-terminal atrial natriuretic peptide (NT-proANP) and N-terminal brain natriuretic peptide (NT-proBNP) elevations have been associated with New York Heart Association (NYHA) Class I-IV heart failure. We directly compared the association of each of these markers with 1-year survival in 173 patients with chronic heart failure of a presumed nonischaemic origin entering the PRAISE-2 Trial, a clinical study which assessed the therapeutic effect of Amlodipine in patients with NYHA Class III and IV heart failure and a left ventricular ejection fraction (LVEF) <30%. BNP, NT-proBNP, and NT-proANP levels were all correlated with 1-year mortality by univariate Cox proportional hazards analyses. With respect to multivariate Cox proportional hazards regression models containing variables deemed significant in univariate analyses, NT-proANP alone was identified as an independent predictor of 1-year mortality when log-transformed continuous covariates were utilized in the analysis. When the analysis was repeated using dichotomous covariates, NT-proANP remained the most significant predictor of 1-year mortality, followed by NT-proBNP, NYHA classification and BNP. We conclude that all three natriuretic peptides are significant predictors of short-term mortality in subjects with chronic congestive heart failure (CHF) of a presumed nonischaemic origin. Larger prospective studies are required to validate the clinical utility of NT-proANP as a discriminating marker of short-term survival, and to validate proposed cutoffs of approximately 2300 pmol/l for NT-proANP, 1500 pg/ml for NT-proBNP, and 50 pmol/l for BNP as prognostic indicators of adverse short-term outcome.