Social Security Death Index Research Articles

Abstract 17900: Medical Therapy Influences Outcome Of PCI Vs CABG Comparison Studies

Introduction: Multiple studies have compared coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) to determine the optimal strategy for coronary revascularization (CR). Very few have evaluated the impact of medication history on the relative outcomes. Hypothesis: Evidence-based medical therapy influences outcomes of CABG vs. PCI Methods: All non-STEMI patients (N=3871 PCI, 1181 CABG) undergoing isolated CR in eight community-based hospitals were enrolled. Follow-up (63.5±27.9, median 79.7 months) was obtained at 12, 18 and >60 months by patient/physician contact and Social Security Death Index. Kaplan-Meier curves were used to compare survival free of MACE (nonfatal myocardial infarction, PCI, CABG, mortality) between groups,. Results: Compliance with appropriate anti-platelet therapy improved long-term freedom from MACE in both PCI and CABG patients (Figure 1). Similarly, lipid-lowering therapy improved MACE-free survival in both PCI and CABG patients (Figure 2). Interestingly, treatment with beta blockers appeared to have either a negative (PCI) or marginal (CABG) impact.(Figure 3), most likely representing patient selection. Conclusion: Medication history has a dramatic impact on the long-term outcomes of both PCI and CABG patients and therefore must be included in the evaluation of comparative strategies for revascularization.

Abstract 15613: Change in Cardiorespiratory Fitness is Inversely Related to Mortality Among Men and Women: Data From the Henry Ford Exercise Testing (FIT) Project

Background: Cardiorespiratory fitness (CRF) is inversely related to all-cause mortality and cardiovascular-related morbidity and mortality. However, there is limited data describing whether change in CRF is associated with improved outcomes. Hypothesis: Change in CRF between two clinical exercise stress tests is related to risk of all-cause mortality. Methods: In this retrospective, observational study, we identified 14,305 patients (age = 55 ± 11 y; 39% women; 30% non-white) who completed two clinically-indicated exercise tests that were at least 12 mo apart between 1991 and 2009 within the Henry Ford Health System. CRF was quantified in metabolic equivalents of task (METs) estimated from peak treadmill speed and grade. All-cause mortality was identified through April 2013 using the Social Security Death Index. Cox regression analysis was used to evaluate the risk of mortality associated with change in CRF between tests 1 and 2. Change in CRF was analyzed as the change in categorization between Poor Fitness (<7 METs) and Fit (≥ 7 METs) and as an absolute change in peak METs. Based on data at test 1, covariates included age; sex; race; cardiovascular risk factors; medications; and history of coronary artery disease, heart failure, and atrial fibrillation; as well as year of test 1 and time between tests 1 and 2. Results: The mean time between test 1 and 2 was 4.3 ± 2.8 y. During 9.4 ± 3.9 y of follow-up after test 2, there were 1,980 (14%) deaths. Adjusted Cox regression results are shown in the Table. Among all patients, each 1 MET increase in CRF at test 2 was associated with a 5% lower risk of mortality (hazard ratio 95% confidence interval 0.94, 0.97; p < 0.001). Conclusions: Among men and women referred for a clinical exercise test, change in CRF from Poor Fitness to Fit is associated with a 38% lower risk of all-cause mortality relative to patients who remain Poor Fit. These data support the importance of improving CRF and the clinical utility of serial assessments of CRF in risk assessment.

Abstract 12773: Dose-dependence of Beta-blocker Therapy on Subsequent Mortality in One Year Survivors After Myocardial Infarction

Background: Beta-blocker (BB) therapy after acute myocardial infarction (MI) improves survival. The benefits of long term treatment remain debated. Methods: Of 7058 patients enrolled in the OBTAIN prospective multi-center registry of patients with acute MI, follow-up BB dosing information was available in 2822 patients who survived ≥1 year. BB dose was indexed to the target BB dose used in RCTs (when available), reported as %; only BBs studied in RCTs were included in this analysis. Dosage groups were No BB (n=302), ≤12.5% (n=557), 12.6-25% (n=848), 26-50% (n=687), and >50% (n=428) of target dose respectively. Vital status was obtained by chart review, Social Security Death Index, or direct contact. Adjustment for baseline differences among groups was achieved by propensity score analysis (predicted 1-year BB dose as control variable). Results: In the 5 groups, mean age was 62-64 years, with significant differences in gender, clinical, and MI characteristics. Mean ejection fractions were 47-50%. The figure shows Kaplan-Meier survival curves (unadjusted, p=0.06). Propensity score analysis showed an independent effect of BB dose on mortality (p=0.047). Compared to No BB, only the 12.6-25% dose group had a significant mortality reduction (HR 0.46, 95% CI 0.25-0.86, p=0.014). Conclusions: At one year after MI, continued BB therapy may be associated with lower mortality, but there appears to be a dose-dependence to this effect. Further studies are needed to optimize BB dosing strategies for long-term treatment after MI.

Abstract 16899: Change in Cardiorespiratory Fitness is Inversely Related to Mortality Among Black and White Patients: Data From the Henry Ford Exercise Testing (FIT) Project

Background: Cardiorespiratory fitness (CRF) is inversely related to all-cause mortality and cardiovascular-related morbidity and mortality. However, there is limited data describing whether change in CRF is associated with improved outcomes. Hypothesis: Change in CRF between two clinical exercise stress tests is related to risk of all-cause mortality. Methods: In this retrospective, observational study, we identified 14,305 patients (age = 55 ± 11 y; 39% women; 30% non-white) who completed two clinically-indicated exercise tests that were at least 12 mo apart between 1991 and 2009 within the Henry Ford Health System. CRF was quantified in metabolic equivalents of task (METs) estimated from peak treadmill speed and grade. All-cause mortality was identified through April 2013 using the Social Security Death Index. Cox regression analysis was used to evaluate the risk of mortality associated with change in CRF between tests 1 and 2. Change in CRF was analyzed as the change in categorization between Poor Fitness (<7 METs) and Fit (≥ 7 METs) and as an absolute change in peak METs. Based on data at test 1, covariates included age; sex; race; cardiovascular risk factors; medications; and history of coronary artery disease, heart failure, and atrial fibrillation; as well as year of test 1 and years between tests 1 and 2. Results: The mean time between test 1 and 2 was 4.3 ± 2.8 y. During 9.4 ± 3.9 y of follow-up after test 2, there were 1,980 (14%) deaths. Adjusted Cox regression results are shown in the Table. Among all patients, each 1 MET increase in CRF at test 2 was associated with a 5% lower risk of mortality (hazard ratio 95% confidence interval 0.94, 0.97; p < 0.001). Conclusions: Among men and women referred for a clinical exercise test, change in CRF from Poor Fitness to Fit is associated with a 38% lower risk of all-cause mortality relative to patients who remain Unfit. These data support the importance of improving CRF and the clinical utility of serial assessments of CRF in risk assessment.

Abstract 13468: The Interaction Between the Prognostic Value of Chronotropic Incompetence and Cardiorespiratory Fitness: The Henry Ford Exercise Testing (FIT) Project

Background: Cardiorespiratory fitness (CRF) and chronotropic incompetence (CI) have both been associated with increased all - cause mortality. We tested the hypothesis that the association of CI with all - cause mortality is modified by a CRF level above and below 10 metabolic equivalents of task (METs). Methods: We included 43,402 patients who completed a clinical exercise stress test between 1991 and 2009. Patients on AV nodal blocking agents, antiarrhythmics and with known coronary artery disease/heart failure were excluded. Patients were followed-up for a mean duration of 11.5±5.2 years for all-cause mortality ascertained by a search of the social security death index in April 2013. CRF was estimated in metabolic equivalents of task (METs). Cox proportional hazards regression models were used to assess the risk of all - cause mortality associated with CI with adjustments for confounders. Results: Compared to no CI, patients with CI were older (51±12 vs. 54±13 years), less often white (68% vs. 58%), dyslipidemic (41% vs. 37%) and more likely to be hypertensive (46% vs. 60%), diabetic (15% vs. 22%), and smoke (40% vs. 51%). On average, patients with CI had lower CRF (9.8±2.8 vs. 7.4±3.0, p <.001). In adjusted Cox regression model, CI was associated with higher risk of mortality [Hazard ratio (HR), 2.12; 95% confidence interval (2.00 -2.27); p<.001)]. The association of CI and mortality was attenuated when METs was included as a covariate in the regression model [HR, 1.49; 95% confidence interval (1.39-1.61); p<.001]. There was a significant interaction of CRF ≥ 10 METs with the association of CI and mortality (p interaction 0.004) which is shown in Figure 1. This was a subaditive and multiplicative interaction of CRF with CI. Conclusions: This study demonstrates that CRF attenuates the mortality risk associated with CI. In addition, patients with CI in the presence of CRF ≥ 10 METs have a much lower risk than patients with CI and lower CRF.

Long-Term Post-CABG Survival: Performance of Clinical Risk Models Versus Actuarial Predictions.

Background/aimClinical risk models are commonly used to predict short‐term coronary artery bypass grafting (CABG) mortality but are less commonly used to predict long‐term mortality. The added value of long‐term mortality clinical risk models over traditional actuarial models has not been evaluated. To address this, the predictive performance of a long‐term clinical risk model was compared with that of an actuarial model to identify the clinical variable(s) most responsible for any differences observed.MethodsLong‐term mortality for 1028 CABG patients was estimated using the Hannan New York State clinical risk model and an actuarial model (based on age, gender, and race/ethnicity). Vital status was assessed using the Social Security Death Index. Observed/expected (O/E) ratios were calculated, and the models' predictive performances were compared using a nested c‐index approach. Linear regression analyses identified the subgroup of risk factors driving the differences observed.ResultsMortality rates were 3%, 9%, and 17% at one‐, three‐, and five years, respectively (median follow‐up: five years). The clinical risk model provided more accurate predictions. Greater divergence between model estimates occurred with increasing long‐term mortality risk, with baseline renal dysfunction identified as a particularly important driver of these differences.ConclusionsLong‐term mortality clinical risk models provide enhanced predictive power compared to actuarial models. Using the Hannan risk model, a patient's long‐term mortality risk can be accurately assessed and subgroups of higher‐risk patients can be identified for enhanced follow‐up care. More research appears warranted to refine long‐term CABG clinical risk models. doi: 10.1111/jocs.12665 (J Card Surg 2016;31:23–30)

MNGO-19RETROSPECTIVE REVIEW OF OVERALL SURVIVAL IN MENINGIOMA PATIENTS TREATED WITH RADIOTHERAPY OR COMBINED RADIOTHERAPY AND SURGERY

INTRODUCTION: Meningiomas account for 15-20% of adult primary brain neoplasms with an incidence of approximately 2.6 per 100,000 persons. This is a retrospective review of all meningioma cases at our institution treated with radiotherapy alone versus combined radiotherapy and surgery to assess prognostic factors affecting overall survival. METHODS: Patient electronic medical records were used to obtain demographic data and details pertinent to the case including age at diagnosis, location of tumor, World Health Organization (WHO) grade and treatment rendered. Follow up data was obtained for all patients in whom this was available in our records; for the rest, the U.S. social security death index was accessed to determine if and when an individual had expired. The project was approved by the Institutional Review Board (IRB) at our institution. RESULTS: One hundred and forty-two (142) patients (92 women and 50 men) were treated at our institution between 1997 and 2014. The average age at diagnosis was 53.8 years. One hundred and three (103) patients were treated with surgery followed by radiotherapy. Thirty-three (33) patients received only radiation treatment. With overall survival (OS) defined as the survival time starting at the end of the first course of radiation treatment, the 10-year OS was 68.0% for all patients. Ten-year OS in patients treated with combination surgery and radiation was 75.0%; ten-year OS in patients treated with radiation alone was 40.0%. In fifty-five (55) patients with known grade I meningiomas, the 10-year OS was 84.0%. Twenty nine (29) patients had known grade II or III meningiomas and had a 10-year OS of 69.2%. CONCLUSIONS: We demonstrate that a combined treatment approach with surgery and radiotherapy improves overall survival compared to treatment with radiotherapy alone. Independent of treatment type, patients with grade I meningiomas have improved overall survival compared to patients with higher grade meningiomas.

Association Between Anemia, Bleeding, and Transfusion with Long-term Mortality Following Noncardiac Surgery

BackgroundPreoperative anemia is a well-established risk factor for short-term mortality in patients undergoing noncardiac surgery, but appropriate thresholds for transfusion remain uncertain. The objective of this study was to determine long-term outcomes associated with anemia, hemorrhage, and red blood cell transfusion in patients undergoing noncardiac surgery. MethodsWe performed a long-term follow-up study of consecutive subjects undergoing hip, knee, and spine surgery between November 1, 2008 and December 31, 2009. Clinical data were obtained from administrative and laboratory databases, and retrospective record review. Preoperative anemia was defined as baseline hemoglobin < 13 g/dL for men and < 12 g/dL for women. Hemorrhage was defined by International Classification of Diseases, Ninth Revision coding. Data on long-term survival were collected from the Social Security Death Index database. Logistic regression models were used to identify factors associated with long-term mortality. ResultsThere were 3050 subjects who underwent orthopedic surgery. Preoperative anemia was present in 17.6% (537) of subjects, hemorrhage occurred in 33 (1%), and 766 (25%) received at least one red blood cell transfusion. Over 9015 patient-years of follow-up, 111 deaths occurred. Anemia (hazard ratio [HR] 3.91; confidence interval [CI], 2.49-6.15) and hemorrhage (HR 5.28; 95% CI, 2.20-12.67) were independently associated with long-term mortality after multivariable adjustment. Red blood cell transfusion during the surgical hospitalization was associated with long-term mortality (HR 3.96; 95% CI, 2.47-6.34), which was attenuated by severity of anemia (no anemia [HR 4.39], mild anemia [HR 2.27], and moderate/severe anemia [HR 0.81]; P for trend .0015). ConclusionsPreoperative anemia, perioperative bleeding, and red blood cell transfusion are associated with increased mortality at long-term follow-up after noncardiac surgery. Strategies to minimize anemia and bleeding should be considered for all patients, and restrictive transfusion strategies may be advisable. Further investigation into mechanisms of these adverse events is warranted.

Clinical Characteristics and Outcomes for Solitary Fibrous Tumor (SFT): A Single Center Experience.

Solitary fibrous tumor (SFT) is a mesenchymal neoplasm of fibrous origin. The 2013 WHO classification of soft tissue tumors defines malignant forms as hypercellular, mitotically active (>4 mitosis/10 high-power fields), with cytological atypia, tumor necrosis, and/or infiltrative margins. With an IRB-approved protocol, we investigated patient records and clinicopathologic data from our Sarcoma Database to describe the clinical characteristics of both benign and malignant SFT. All pathology specimens were reviewed by two pathologists. Descriptive statistics and univariate/multivariate survival analysis were performed. Patient records and Social Security Death Index were used to evaluate vital status. Of 82 patients, 47 (57%) were women and 73 (89%) were Caucasian. Median age was 62 years (range, 20 to 89). Thirty-two (39%) patients succumbed to the disease. Primary tumor site was lung/pleura in 28 (34%), abdomen/pelvis in 23 (28%), extremity in 13 (16%), and head/neck in 9 (11%) patients. Pathology was described as benign in 42 (51%) and malignant in 40 (49%) patients. Compared to benign SFT, malignant histology is associated with larger tumor size, higher mitotic counts, metastatic disease at diagnosis, and greater use of chemotherapy and radiation therapy. Gender, age, and tumor site were not significantly different between benign and malignant subtypes. By univariate analysis, only benign vs. malignant variant and complete resection positively impacted overall survival (P = 0.02 and P<0.0001, respectively). In the multivariable analysis of overall survival, receiving chemotherapy or not receiving surgery were two variables significantly associated with higher failure rate in overall survival: patients with chemotherapy vs. no chemotherapy (P = 0.003, HR = 4.55, with 95% CI: 1.68–12.34) and patients without surgery vs. with surgery (P = 0.005, HR = 25.49, with 95% CI: 2.62–247.57). Clear survival differences exist between benign and malignant SFT. While surgery appears to be the best treatment option for benign and malignant SFT, better systemic therapies are needed to improve outcomes of patients with metastatic, malignant SFT.

Impact of hepatitis C status on 20-year mortality of patients with substance use disorders.

BackgroundThe magnitude of the effect of hepatitis C viral infection on survival is still not fully understood. The objective of this study was to determine whether the presence of hepatitis C viral antibodies in 1991 was associated with increased mortality 20 years later within a cohort of patients with substance use disorders. Secondary objectives were to determine other factors that were associated with increased mortality in the cohort.MethodsA subset of a 1991 study cohort of patients who had presented for detoxification was reexamined 20 years later. The Social Security Death Index was queried to identify which of the original patients had died. Attributes of survivors and non-survivors were compared, with special attention to their hepatitis C status in 1991. The original study and this analysis were conducted in the chemical detoxification unit at Johns Hopkins Bayview (previously Francis Scott Key Hospital), an academic urban hospital. All participants met the criteria for alcohol or opioid dependence at the time of admission in 1991. The primary study outcome was 20-year mortality after initial admission in 1991, with a planned analysis of hepatitis C status.ResultsTwenty years after admission, 362 patients survived and 82 had died. Of the 284 patients who were hepatitis C positive, 228 survived (80 %). Of the 160 patients who were hepatitis C negative, 134 survived (84 %). This absolute risk increase of 4 % was not statistically significant (p = 0.37). Factors associated with increased mortality included male sex, white race, older age, and reported use of alcohol, cocaine, and illicit methadone. Binary logistic regression including hepatitis C status and these other variables yielded an adjusted odds ratio of 0.87 (95 % CI 0.49–1.55); (p = 0.64) for hepatitis C positive 20-year survival.ConclusionsHepatitis C positivity was not associated with a statistically significant difference in 20-year survival. The effect of the virus on mortality, if present, is small, relative to the effect of substance use disorders alone.

Survival comparison of patients treated with one versus five fraction palliative radiotherapy.

200 Background: Choice of fractionation scheme for palliative radiotherapy has received greater attention in recent years, particularly in the current healthcare environment where issues of cost and quality of life have taken on increasing importance. The ASTRO Choosing Wisely campaign recommends against routine use of extended fractionation schemes ( &gt; 10 fractions) for palliation of bone metastases given equivalent pain relief between 30 Gy in 10 fractions and 8 Gy in 1 fraction, and strong consideration for use of 8 Gy in 1 fraction is urged for patients with a limited prognosis or transportation difficulties. We investigated whether there was a difference in survival between patients treated with an intermediate fractionation scheme (5 fractions) and patients who received single-fraction treatment. Methods: We identified 220 patients who received a total of 264 courses of palliative radiotherapy with either 8 Gy in 1 fraction (n = 91) or 20 Gy in 5 fractions (n = 173). Date of death was obtained from either the patient’s medical record, the Social Security Death Index, or publicly available obituaries. If none of these yielded a date of death, patients were censored at the date of their last clinical encounter. The majority of patients (n = 192) were treated for bone metastases. All primary sites were included, with the three most common histologies being lung, breast and prostate (n = 80, 31 and 16, respectively). Results: Overall, we found no significant survival difference between the two groups. Patients treated with 8 Gy in 1 fraction had a median survival of 146 days, whereas patients treated with 20 Gy in 5 fractions had a median survival of 183 days (p = 0.43). Conclusions: Given no difference in survival between fractionation schemes of 20 Gy in 5 fractions and 8 Gy in 1 fraction, delivery of palliative radiation in a single fraction should be strongly considered. Previous studies have identified a higher re-treatment rate in single-fraction treatments, although closer analysis of this data revealed no difference in absolute pain scores prior to re-treatment. Thus, re-treatment for single-fraction radiotherapy may be due instead to a greater clinical willingness to re-treat as opposed to a greater clinical need.

Fractionation of palliative radiotherapy in metastatic breast cancer: Selection and survival.

201 Background: Various schedules of palliative radiotherapy (pRT) are prescribed for metastatic breast cancer (MBC) patients. Length of treatment can vary from a single day to three weeks. Single fraction pRT provides similar pain relief vs. multi-fraction pRT for bone metastases, but retreatment rates are higher. In the era of targeted and hormonal therapy, patients with MBC can survive many years after their initial diagnosis. We investigated whether patients with MBC who were prescribed single fraction pRT had poorer prognoses and experienced shorter survival than patients who were prescribed multi-fraction pRT. Methods: Patients at a single institution with MBC underwent pRT, with fractionation schedules including 8 Gy in 1 fraction (fx), 20 Gy in 5 fx, 30 Gy in 10 fx, 37.5 Gy in 15 fx between 2001-2015. 392 treatments were prescribed (109/241/29/13 in each regimen as above). Date of death was obtained from medical records, Social Security Death Index, or published obituaries. Patients who were alive or whose date of death could not be determined were censored at the date of their last encounter. Survival was calculated from the start of treatment to the date of death or censorship. Results: Patients treated with 37.5 Gy in 15 fx (MS 20 months, p = 0.002) or 30 Gy in 10 fx (MS 22 months, p = 0.03) experienced longer survival than patients treated with 8 Gy in 1 fx (MS 8 months). There was no significant survival difference between patients treated with 20 Gy in 5 fx (MS 18 months, p = 0.49) and patients treated with 8 Gy in 1 fx. There was no significant survival difference between patients treated by the three multi-fractionation schedules. Conclusions: MBC patients who were prescribed 37.5 Gy and 30 Gy lived longer than patients who were prescribed 8 Gy of pRT. No statistically significant difference was found between patients who were prescribed 20 Gy compared to 8 Gy, possibly due to the lower number of patients who received these regimens. Single fraction pRT was more likely to be prescribed to patients who would ultimately have shorter survival. More research is needed, ideally across multiple institutions, to explore the correlation between physician estimation of patient survival and selection of pRT regimen for patients with MBC.

Short-term and longer-term survival after veno-arterial extracorporeal membrane oxygenation in an adult patient population: does older age matter?

Veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO) is increasingly being used for patients with refractory cardiopulmonary failure. This study evaluates the short-term (to discharge) and longer-term (1 year) survival among older (⩾65 years) versus younger (<65 years) adults, adjusted for comorbidities, in a diverse cohort of V-A ECMO patients. This was a retrospective cohort analysis of 131 adult patients (28% ⩾65 years old) who received V-A ECMO at an academic medical center from 2004-2013. Demographics, comorbidities and surgical characteristics were abstracted from the medical records and verified. Mortality status at discharge and at one year post-ECMO were determined by the hospital clinical information system, updated monthly with Social Security Death Index data. Cox proportional hazard analyses were conducted to evaluate associations between age strata and mortality at discharge and at one year post ECMO initiation, adjusted for covariates. The survival rate following V-A ECMO was 48% (n=68/131) to discharge and 44% (n=58/131) to one year. Age ⩾65 versus <65 was significantly associated with increased mortality during hospitalization (HR:2.03; 95%CI=1.23-3.33) and at one year (HR:1.81; 95% CI=1.12-2.93); these associations were attenuated and did not retain statistical significance after adjustment for comorbidities (HR:1.61; 95%CI=0.90-2.88 and HR:1.42; 95% CI=0.81-2.50, respectively). Statistically significant predictors of mortality at discharge and one year included history of coronary artery bypass graft, peripheral vascular disease and renal failure/dialysis (p<0.05). Older age was not independently associated with short-term or longer-term survival among V-A ECMO patients, but may reflect greater comorbidity, suggesting that age alone may not disqualify patients from V-A ECMO therapy.

Motivation and mortality in geriatric patients with early stage breast cancer.

105 Background: Evidence suggests that an older patient’s motivation and life outlook are associated with health outcomes. A measure of motivation called the Getting Out of Bed Scale (GOB) was previously validated in a cohort of geriatric patients with early stage breast cancer. The aim of our project was to assess the association between GOB and mortality, both all-cause and breast-cancer specific, using the same dataset. Methods: We evaluated 660 women ≥ 65-years old diagnosed with stage I-IIIA primary breast cancer in four geographic regions in the US. Data were collected over ten-years of follow-up from consenting women’s medical records, telephone interviews, National Death Index, and Social Security Death Index. To address attrition bias, a multiple imputation approach using two-fold fully conditional specification was used to generate a complete dataset and allow for sufficient power in our statistical testing. Results: Using this dataset, a cox regression survival analysis found no significant association between GOB and mortality, both all-cause [5 years HR (95% CI): 0.76 (0.50,1.15), 10 years: 0.77 (0.59, 1.01)] and breast-cancer-specific [5 years: 0.92 (0.48, 1.73), 10 years: 0.84 (0.53, 1.33)]. This observation held true even after adjustment for other validated health-related quality of life measures of mental health, physical functioning, and socioeconomic status. Notably, patients with high mental health scores as measured by the Mental Health Index Short Form had significantly lower mortality, both all-cause [5 years: 0.42 (0.27, 0.65), 10 years: 0.59 (0.44, 0.79)] and breast-cancer specific [5 years: 0.42 (0.20, 0.90), 10 years: 0.52 (0.31, 0.89)]. Conclusions: These results suggest that GOB does not predict mortality in geriatric patients with early stage breast cancer; however, more research is needed to assess hope and outcomes in geriatric cancer patients. This study would not have been possible without the multiple imputations approach, which allows for greater power in researching longitudinal datasets that would otherwise suffer from loss to follow up.

Predicting Long-Term Outcomes in Pleural Infections. RAPID Score for Risk Stratification.

Pleural infections are associated with significant morbidity and mortality. The recently developed RAPID (renal, age, purulence, infection source, and dietary factors) score consists of five clinical factors that can identify patients at risk for increased mortality. The objective of this study was to further validate the RAPID score in a diverse cohort, identify factors associated with mortality, and provide long-term outcomes. We evaluated a single-center retrospective cohort of 187 patients with culture-positive pleural infections. Patients were classified by RAPID scores into low-risk (0-2), medium-risk (3-4), and high-risk (5-7) groups. The Social Security Death Index was used to determine date of death. All-cause mortality was assessed at 3 months, 1 year, 3 years, and 5 years. Clinical factors and comorbid conditions were evaluated for association. Three-month mortality for low-, medium-, and high-risk groups was 1.5, 17.8, and 47.8%, respectively. Increased odds were observed among medium-risk (odds ratio, 14.3; 95% confidence interval, 1.8-112.6; P = 0.01) and high-risk groups (odds ratio, 53.3; 95% confidence interval, 6.8-416.8; P < 0.01). This trend continued at 1, 3, and 5 years. Factors associated with high-risk scores include gram-negative rod infections, heart disease, diabetes, cancer, lung disease, and increased length of stay. When applied to a diverse patient cohort, the RAPID score predicts outcomes in patients up to 5 years and may aid in long-term risk stratification on presentation.

Outcomes and Worsening Renal Function in Patients Hospitalized With Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) has been described as a disease of elderly subjects with female predominance and hypertension. Our clinical experience suggests patients with HFpEF from an urban population are far more heterogenous, with greater co-morbidities and significant inhospital morbidity. There are limited data on the hospitalization course and outcomes in acute decompensated HFpEF. Hospitalizations for acute heart failure at our institution from July 2011 to June 2012 were identified by International Classification of Diseases, Ninth Revision, codes and physician review for left ventricular ejection fraction ≥50% and were reviewed for patient characteristics and clinical outcomes. Worsening renal function (WRF) was defined as creatinine increase of ≥0.3mg/dl by 72hours after admission. Hospital readmission and mortality data were captured from electronic medical records and the Social Security Death Index. Of 434 heart failure admissions, 206 patients (47%) with HFpEF were identified. WRF developed in 40%, the highest reported in HFpEF to date, and was associated with higher blood pressure and lower volume of diuresis. Compared to previous reports, hospitalized patients with HFpEF were younger (mean age 63.2 ± 13.6years), predominantly black (74%), and had more frequent and severe co-morbidities: hypertension (89%), diabetes (56%), and chronic kidney disease (55%). There were no significant differences in 1- and 12-month outcomes by gender, race, or WRF. In conclusion, we found hospitalized patients with HFpEF from an urban population develop a high rate of WRF are younger than previous cohorts, often black, and have greater co-morbidities than previously described.

A Guide for a Cardiovascular Genomics Biorepository: the CATHGEN Experience.

The CATHeterization GENetics (CATHGEN) biorepository was assembled in four phases. First, project start-up began in 2000. Second, between 2001 and 2010, we collected clinical data and biological samples from 9334 individuals undergoing cardiac catheterization. Samples were matched at the individual level to clinical data collected at the time of catheterization and stored in the Duke Databank for Cardiovascular Diseases (DDCD). Clinical data included the following: subject demographics (birth date, race, gender, etc.); cardiometabolic history including symptoms; coronary anatomy and cardiac function at catheterization; and fasting chemistry data. Third, as part of the DDCD regular follow-up protocol, yearly evaluations included interim information: vital status (verified via National Death Index search and supplemented by Social Security Death Index search), myocardial infarction (MI), stroke, rehospitalization, coronary revascularization procedures, medication use, and lifestyle habits including smoking. Fourth, samples were used to generate molecular data. CATHGEN offers the opportunity to discover biomarkers and explore mechanisms of cardiovascular disease.

Long-term Risk of Melanoma-Related Mortality for Patients With Uveal Melanoma Treated With Proton Beam Therapy.

Little is known about the long-term risk of dying of uveal melanoma after treatment with radiotherapy. To determine the long-term risk of dying of this disease, we evaluated melanoma-related mortality rates up to 25 years after proton beam therapy in a large series of patients with uveal melanoma. In this analysis, we included 3088 patients with uveal melanoma, identified from a hospital-based cohort and treated with proton irradiation between January 1975 and December 2005. Vital status and cause of death were ascertained through active follow-up and searches of government databases (the Social Security Death Index and the National Death Index) through December 31, 2008. Cumulative rates of melanoma-related mortality were calculated using the Kaplan-Meier method. Patient and tumor characteristics of known prognostic significance for melanoma-associated death were evaluated, including patient age and tumor dimensions. The primary outcome measure was cumulative rates of melanoma-specific mortality, and secondary measures included annual melanoma-specific mortality hazard rates and cumulative all-cause mortality rates. Of 1490 deceased patients, 620 (41.6%) died of ocular melanoma. In addition, 19 patients were alive, but their melanoma metastasized, by the end of the observation period (mean follow-up after diagnosis of metastasis, 5.3 years). All-cause mortality rates in this cohort were 49.0% (95% CI, 47.0-51.1) at 15 years, 58.6% (95% CI, 56.4%-60.8%) at 20 years, and 66.8% (95% CI, 64.2%-69.4%) at 25 years. Melanoma-related mortality rates were 24.6% (95% CI, 22.8-26.4) at 15 years after treatment, 25.8% (95% CI, 24.0-27.8) at 20 years after treatment, and 26.4% (95% CI, 24.5-28.5) at 25 years after treatment. The 20-year mortality rate was 8.6% (95% CI, 6.2-11.9) for younger patients (≤ 60 years) with small tumors (≤ 11 mm) and 40.1% (95% CI, 36.1-44.3) for older patients (>60 years) with large tumors (>11 mm). In this large series of patients with ocular melanoma treated conservatively with proton beam irradiation, the cumulative melanoma-related mortality rates continued to increase up to 23 years after treatment. Annual rates decreased considerably (to <1%) 14 years after treatment. Information regarding the long-term risk of dying of uveal melanoma may be useful to clinicians when counseling patients.

Length of stay and long-term mortality following ST elevation myocardial infarction.

Over the last few decades, there has been a significant reduction in hospital length of stay (LOS) among patients undergoing percutaneous intervention (PCI) for ST elevation myocardial infarction (STEMI). Although studies have looked at predictors of long hospital stay after STEMI, the impact of LOS on long-term outcomes after PCI remains unknown. We aimed to evaluate the association between LOS at the time of index hospitalization for PCI and long-term mortality among patients presenting with STEMI. We examined all patients undergoing PCI for STEMI at the Cleveland Clinic Catheterization Laboratory between 2002 and 2011. Long-term all-cause mortality was assessed using the Social Security Death Index and electronic medical record review. LOS was extracted from the discharge summary of the index hospitalization. A total of 1,963 patients were included in the study. Of these 1,963 patients undergoing PCI for STEMI, 126 (6.4%) died during the index hospitalization. Among survivors of this hospitalization, we observed a significant increase in long-term mortality with an increase in LOS during index hospitalization (P < 0.001). Adjustment for demographic and clinical characteristics yielded statistically significant increased mortality among patients with LOS of 6-10 days [HR (95% CI): 2.2 (1.3-3.5)] and LOS > 10 days [HR (95% CI): 2.6 (1.6-4.3)], in comparison with patients with LOS of 1-2 days. Long hospital stay after PCI among patients with STEMI was associated with an increased long-term mortality. A long hospital stay may be used as a marker to identify patients at higher risk for long-term mortality.

Survival in systemic sclerosis–pulmonary arterial hypertension by serum autoantibody status in the Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma (PHAROS) Registry

ObjectiveTo determine the association between serum autoantibodies and survival in patients with incident systemic sclerosis (SSc)–pulmonary arterial hypertension (PAH) enrolled in the Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma (PHAROS) Registry. MethodsPatients with definite PAH diagnosed by right heart catheterization within 6 months of registry enrollment were studied. Serum autoantibodies were assayed at each participating institution’s clinical laboratory. Mortality data were collected from electronic medical records and/or the Social Security Death Index. Kaplan−Meier survival estimates were reported for five autoantibody groups (anticentromere/AC, nucleolar ANA/NUC, anti-topoisomerase/Scl-70, overlapping or non-specific autoantibodies/other, and a combined group with similar survival consisting of RNA polymerase III, U1RNP, and autoantibody-negative patients). Cox proportional hazards models permitted examination of the association between autoantibody groups and overall survival, controlling for age, sex, race, and SSc disease duration. ResultsIn all, 162 subjects had PAH, and serum autoantibody and survival information; 60 (37%) had AC, 39 (24%) NUC, 11 (7%) Scl-70, 28 (17%) had other, 9 (6%) RNA pol, 8 (5%) U1RNP autoantibodies, and 7 (4%) had negative antibodies; 32 (20%) subjects died over a median follow-up time of 2.1 years (range: 0.01–6.8); 1- and 3-year survival estimates were, respectively, 94% and 78% for AC, 94% and 72% for NUC, 89% and 63% for Scl-70, 92% and 79% for the other group, and 100% and 93% for the combined group. Unadjusted and adjusted hazard ratios revealed no statistically significant association between risk of death and autoantibodies. ConclusionAnticentromere and NUC autoantibodies are prevalent in SSc-PAH patients. An association between serum autoantibodies and survival in patients with SSc-PAH was not identified in the PHAROS cohort.