Times Higher Risk Of Death Research Articles

Insomnia predicts long-term all-cause mortality after acute myocardial infarction: A prospective cohort study

BackgroundSleep impairment such as insomnia is an established risk factor for the development of cardiovascular disease and acute myocardial infarction (AMI). The aim of the current study was to examine the association between insomnia and all-cause mortality among AMI patients. MethodsThis prospective cohort study used data on n=732 patients recruited from September 2006 to May 2011 as part of the Västmanland Myocardial Infarction Study (VaMIS), a prospective cohort study of AMI patients living in Västmanland County, Sweden. Participants were followed up for all-cause mortality until December 9, 2015. The outcome of interest was time-to-death (TTD), with the presence of insomnia being the risk factor of main interest. Data were analyzed using a piecewise Cox regression model with change point for insomnia at two years of follow-up, adjusted for socioeconomic, lifestyle and clinical risk factors. ResultsIn total, n=175 (23.9%) of the participants suffered from insomnia. During a mean (SD) follow-up time of 6.0 (2.5) years (4392person–years), a total of n=231 (31.6%) participants died, n=77 (44.0%) in the insomnia group and n=154 (27.6%) in the non-insomnia group (log-rank test p<0.001). In a multiple adjusted piecewise Cox regression model, insomnia did not imply a higher risk of death during the first two years after AMI (HR 0.849; 95% CI 0.508–1.421; p=0.534). During the period after the first two years, however, insomnia implied a 1.6 times higher risk of death (HR 1.597; 95% CI 1.090–2.341; p=0.016). ConclusionsInsomnia implies a higher risk of death among AMI patients in the long term.

Impact of diabetes mellitus on risk of cardiovascular disease and all-cause mortality: Evidence on health outcomes and antidiabetic treatment in United States adults.

AIMTo examine the epidemic of diabetes mellitus (DM) and its impact on mortality from all-cause and cardiovascular disease (CVD), and to test the effect of antidiabetic therapy on the mortality in United States adults.METHODSThe analysis included a randomized population sample of 272149 subjects ages ≥ 18 years who participated in the National Health Interview Surveys (NHIS) in 2000-2009. Chronic conditions (hypertension, DM and CVD) were classified by participants’ self-reports of physician diagnosis. NHIS-Mortality Linked Files, and NHIS-Medical Expenditure Panel Survey Linkage Files on prescribed medicines for patients with DM were used to test the research questions. χ2, Poisson and Cox’s regression models were applied in data analysis.RESULTSOf all participants, 22305 (8.2%) had DM. The prevalence of DM significantly increased from 2000 to 2009 in all age groups (P < 0.001). Within an average 7.39 (SD = 3) years of follow-up, male DM patients had 1.56 times higher risk of death from all-cause (HR = 1.56, 95%CI: 1.49-1.64), 1.72 times higher from heart disease [1.72 (1.53-1.93)], 1.48 times higher from cerebrovascular disease [1.48 (1.18-1.85)], and 1.67 times higher from CVD [1.67 (1.51-1.86)] than subjects without DM, respectively. Similar results were observed in females. In males, 10% of DM patients did not use any antidiabetic medications, 38.1% used antidiabetic monotherapy, and 51.9% used ≥ 2 antidiabetic medications. These corresponding values were 10.3%, 40.4% and 49.4% in females. A significant protective effect of metformin monotherapy or combination therapy (except for insulin) on all-cause mortality and a protective but non-significant effect on CVD mortality were observed.CONCLUSIONThis is the first study using data from multiple linkage files to confirm a significant increased prevalence of DM in the last decade in the United States. Patients with DM have significantly higher risk of death from all-cause and CVD than those without DM. Antidiabetic mediations, specifically for metformin use, show a protective effect against all-cause and CVD mortalities.

Cause-specific excess mortality in patients treated for cancer of the oral cavity and oropharynx: A population-based study

To assess cause-specific mortality in a large population-based cohort of 14,393 patients treated for squamous cell carcinoma of the oral cavity (OC) or oropharynx (OP) in The Netherlands between 1989 and 2006. Causes of death were obtained for 94.7% of 9620 patients who had died up to January 1, 2009. We assessed standardized mortality ratios (SMR) and absolute excess mortality (AEM), comparing observed cause-specific mortality with expected mortality for our cohort based on general population mortality rates. Median survival was 3.9 years. Overall, the study population experienced a 6-fold higher (95% Confidence Interval (95% CI) 5.9-6.1) mortality risk compared with the general population. After three years, 41% of OP and 29% of OC patients had died due to cancer of the oral cavity and pharynx. Additionally, OC and OP patients experienced high excess mortality from esophageal (SMR 10.6 and 17.9) and lung cancer (SMR 4.6 and 6.3). With regard to non-cancer deaths, the highest AEMs were due to diseases of the circulatory system, with OC patients experiencing an AEM of 11.3 per 10,000 person-years for ischemic heart disease. OP patients experienced excess mortality due to pneumonia (AEM 22.1 per 10,000 person-years). The risk of death due to diseases of the digestive system was for OP and OC patients where about equal (AEM 28.7 and 23.80, respectively). The SMR for death due to pneumonia was more than two times higher (4.4 vs. 1.7) for OP patients than for OC patients (P<0.001). From 15 years after diagnosis, second tumors located outside the head and neck region accounted for most of the excess mortality. Excess mortality in OC and OP patients appears to be dominated by effects of heavy tobacco and alcohol use with high AEM due to second tumors, respiratory, cardiovascular and gastrointestinal diseases. Patients with OP experienced more than two times higher risk of death due to pneumonia than OC patients. Therefore, awareness of this potential complication should be raised along with development of prevention strategies.

Alcohol Dependence and Mortality: Implications for Treatment

Alcohol use disorders are the most common mental disorder worldwide with an estimated 3.6% prevalence among adults aged 15–65 (Rehm et al., 2009). They are associated with significant morbidity as well as negative social consequences for both the sufferer and those around them. The categorization of alcohol use disorders is complicated and the subject of much debate. Within the current World Health Organisation International Classification of Disease (ICD 10) alcohol dependence syndrome is a separate diagnosis characterised by a cluster of behavioural, cognitive and physiological phenomena including a strong desire to drink alcohol, difficulty in controlling use, tolerance (need to consume greater amounts to get the same effect) and withdrawal symptoms on stopping alcohol use distinct from the diagnosis “harmful alcohol use” (World Health Organisation, 1997). Until recently this distinction was also reflected in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM IV) but within the DSM V updated in 2013 the previous diagnoses of “alcohol dependence” and “alcohol abuse” were merged to one diagnosis of “Alcohol Use Disorder” due to concern that these are not two distinct phenomena but represent a spectrum of severity of the same underlying disorder (National Institute on Alcohol Abuse and Alcoholism, 2015). In their systematic literature review and meta-analysis Laramee and colleagues have shown that those with alcohol dependence (using broad criteria not limited to clinical diagnoses by either ICD 10 or DSM IV criteria) are at approximately 3.5 times higher risk of death than the general population (Laramee et al., 2015). This finding is similar to a previous systematic review of the association between all alcohol use disorders and mortality which found that mortality risk was 3 times higher in men and over 4 times higher in women with alcohol use disorders (Roerecke and Rehm, 2013). Interestingly however Laramee et al. also showed an increase in mortality of 25% among those with alcohol dependence compared to those with criteria for the diagnosis alcohol abuse suggesting an increased severity of this diagnosis in terms of health risk, even if the two conditions represent an underlying continuum. Roerecke and Rehm have previously shown that this increased risk in those with alcohol use disorders is found for all causes of death with particularly high standardised mortality ratios for digestive disease, especially liver cirrhosis, and mental disorders (Roerecke and Rehm, 2014). Risk from unintentional injuries and suicides was also substantially higher. Cause-specific mortality from alcohol dependence has not been investigated in this way but similarities between findings for both alcohol use disorders and alcohol dependence and all-cause mortality suggest that this pattern is likely to be similar. In addition to showing the substantial increased mortality risk found in those with alcohol dependence Laramee et al. also consider whether mortality risk differed among those with alcohol dependence who continue to drink heavily versus those who are abstinent and those who have reduced their alcohol consumption. The results show a dose–response with lowest mortality in those who are abstinent but also reduced mortality in those who reduce their drinking. The authors use this finding to justify reducing drinking as a valid treatment outcome alongside total abstinence, but further than this these results add to body of evidence that effective treatment outcome which actually leads to decreases in drinking can save lives. If reducing alcohol consumption even among those in treatment, who are likely to have the most severe disease, results in lower mortality then it is clear that the health effects of heavy alcohol use are at least to some extent reversible and it is never too late to intervene. The findings from Laramee et al. are consistent with findings for alcohol use disorder that decreasing alcohol consumption substantially reduces the increased mortality risk associated with this illness (Roerecke et al., 2013). However despite the high prevalence of alcohol use disorders and the high cost associated with morbidity and mortality the treatment gap for alcohol use disorders is larger than for any other mental disorder (Kohn et al., 2004). The majority of people with alcohol use disorders receive no treatment at all (Kohn et al., 2004, Drummond et al., 2011). Reasons for this low level of treatment are multi-factorial and diverse but stigma (Schomerus et al., 2011), lack of recognition by medical professionals and low levels of funding (Kohn et al., 2004) are likely to be key factors. The paper from Laramee et al. showing the substantial increased mortality among those with alcohol dependence emphasises the need for both better prevention and treatment of this harmful disease.

Retrospective analysis of the impact of platinum dose reduction and chemotherapy delays on the outcomes of stage III ovarian cancer patients.

BackgroundOvarian cancer is a common gynaecological malignancy still remaining a challenge to treat. The objective of this study was to evaluate the impact of platinum dose reduction and chemotherapy delays on progression free survival and overall survival in patients with stage III ovarian cancer and to analyze reasons for such chemotherapy scheme modifications.MethodsMedical records of patients with FIGO stage III ovarian cancer were reviewed. Inclusion criteria involved FIGO stage III epithelial ovarian carcinoma; cytoreductive surgery performed and 6 courses of platinum-based chemotherapy completed; no neoadjuvant chemotherapy applied; and no history of previous malignancies. Progression free survival and overall survival were analyzed using Kaplan-Meier and Cox proportional hazards models.ResultsSignificant 3.3 times higher death risk in patients who experienced only chemotherapy delays compared with patients who did not experience any chemotherapy scheme modifications was established (HR = 3.3, 95% Cl: 1.2 – 8.5, p = 0.016). Increased death risk in patients who experienced only chemotherapy delays compared with patients who experienced both chemotherapy delays and platinum dose reduction was also established (HR = 2.3, 95% Cl: 1.1 – 4.8, p = 0.021). Main reasons for chemotherapy scheme modifications (in decreasing order) were the following: neutropenia, modifications with no objective medical reasons, renal disorders, anaemia, poor performance status, gastrointestinal symptoms and neuropathy. Overall survival in patients who experienced chemotherapy scheme modifications with no objective medical reasons was non-inferior than in patients who did not experience any chemotherapy scheme modifications.ConclusionsChemotherapy delays in patients with FIGO stage III ovarian cancer caused lower overall survival. The most common reason for chemotherapy scheme modifications was neutropenia.

Traffic accidents in Belo Horizonte: the view from three different sources, 2008 to 2010.

To analyze the contribution of three data sources in the description of traffic accidents in the city of Belo Horizonte, Brazil. Exploratory study of databases: BHTRANS (metropolitan traffic and transportation authority), Hospital Admissions and Mortality Information Systems, with estimation of proportions, coefficients and odds ratios. Incomplete data was observed in the three sources, especially regarding alcohol consumption by drivers and use of safety equipment. The victim profile among the sources was consistent: young adults, males, motorcycle riders and pedestrians. In addition to the high mortality rate (19.4 per 100.000 inhabitants), an increase in the number of non-fatal accidents was observed. An increase of 34% in hospital admissions and of 53% in hospital costs was evidenced. The motorcycle accident rate is higher than expected given the fleet composition. Male drivers have the highest risk of injury or death; relative to drivers, passengers or pedestrians have a 1,8 times higher risk of death. There was a 12% increase in the number of deaths at the site of the accident, 55% of which showed positive evidence of alcohol use and 50% higher risk of fatal accidents on weekends. Despite some incomplete record keeping and non-specific death registry codes, it was possible to characterize the main factors associated with accidents: elderly pedestrians, motorcycle riders, alcohol consumption and speeding. The study demonstrated the complementarity of the three data sources, with their different goals, and revealed important features of the traffic accident event-chain and victim profile, providing key data for the development of mitigation strategies.

Diagnostic and Long-Term Prognostic Value of Sensitive Troponin I in Symptomatic Patients Suspected of Acute Heart Failure.

To evaluate the diagnostic and prognostic value of sensitive troponin I (TnI) in patients with acute dyspnea and/or peripheral edema suspected of having acute heart failure (AHF). This single centre prospective clinical study evaluates 372 patients presenting with acute dyspnea and/or peripheral edema to the emergency department (ED). Measurements of TnI and NT-proBNP were performed at the initial presentation in the ED. All patients were followed up to 5 years. The diagnostic value of TnI compared to NT-proBNP for AHF diagnosis as well as long-term prognostic values for all cause mortality and AHF related rehospitalization were evaluated. TnI plus NT-proBNP improved the diagnosis of AHF (improvement of accuracy (75%, 95% CI 71% - 79%), specificity (68%, 95% CI 62% - 74%), PPV (54%, 95% CI 47% - 62%), and NRI +0.15) compared to NT-proBNP alone (p = 0.0001). TnI levels showed independent prognostic value for all-cause mortality and AHF related rehospitalization after 1 and 5 years (range of AUCs 0.64 - 0.72; p = 0.03 or lower). Highest TnI levels of the 4th quartile revealed an up to 5.5 times higher risk of death within 1 and 5 years (range of HRs: 2.5 - 5.5; p = 0.0001). TnI added significantly to multivariable Cox prediction models even after adjusting for NT-proBNP, particularly in AHF patients (range of HRs: 2.1 - 2.7; p ≤ 0.05). TnI improves AHF diagnosis when combined with NT-proBNP. TnI identifies patients with high 1- and 5-year all-cause mortality and AHF-related rehospitalization risk and adds prognostic value to NT-proBNP.

Poor Sleep May Increase Suicide Risk in Older Adults

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessPoor Sleep May Increase Suicide Risk in Older AdultsLynne LambergLynne LambergSearch for more papers by this authorPublished Online:15 Sep 2014https://doi.org/10.1176/appi.pn.2014.9b12AbstractTargeting disturbed sleep in older adults may be a novel way to reduce the risk of suicide in a population in whom such risk is elevated.Sleep disturbances confer an increased risk for suicidal behaviors in older adults, even when depressed mood is accounted for, a study of more than 14,000 people aged 66 to 90 suggests.Rebecca Bernert, Ph.D., says “Targeting disturbed sleep as a visible warning sign of suicide may constitute a novel opportunity for improved risk detection. . . “Norbert von der Groeben/Stanford School of MedicineOlder adults have more trouble sleeping than younger adults. Approximately 57 percent of people aged 65 and older report experiencing clinically significant sleep disruption, Rebecca Bernert, Ph.D., director of the Suicide Prevention Research Laboratory at Stanford University School of Medicine, and colleagues noted in a study published online August 13 in JAMA Psychiatry.Older adults also die by suicide more frequently than younger people, the researchers said. More than 33,000 Americans died by suicide in 2010, according to the Centers for Disease Control and Prevention. Among Americans of all ages, the rate was 12.4 per 100,000. In those aged 65 to 74, the rate was 13.7. In people aged 85 and older, the rate jumped to 17.6. To assess the contribution of poor sleep to suicide risk, Bernert and colleagues drew upon data from a longitudinal, multisite study of 14,456 community-dwelling adults aged 65 and older, the Established Populations for Epidemiologic Studies of the Elderly project.They compared self-reported sleep quality in 20 people who died by suicide over a 10-year observation period with sleep quality reported by 400 other participants randomly selected and matched for age, sex, study site, and duration in the study.People who reported poor sleep quality at baseline had a 1.4 times higher risk of death by suicide over the 10-year observation period than those who said they slept well, Bernert’s group found. Even after the researchers controlled for effects of depressed mood, they found that poor sleep quality at baseline was associated with a 1.2 times greater risk for suicide death.While people who died by suicide had higher rates of both sleep disturbances and depressive symptoms than controls did, sleep disturbances outperformed depressive symptoms in predicting risk of death by suicide 10 years later. Two sleep complaints—difficulty falling asleep and nonrestorative sleep, particularly in combination—specifically predicted increased risk for suicide.Older adults frequently visit their primary care physician in the weeks preceding their death by suicide, the researchers said. Friends and family often know when someone close to them is sleeping poorly. Thus, “Targeting disturbed sleep as a visible warning sign of suicide may constitute a novel opportunity for improved risk detection, particularly among those at elevated risk,” Bernert and colleagues suggested. Poor subjective sleep quality, they said, also may represent a novel therapeutic target for suicide prevention in late life. ■“Association of Poor Subjective Sleep Quality With Risk for Death by Suicide During a 10-Year Period: A Longitudinal, Population-Based Study of Late Life” can be accessed here. ISSUES NewArchived

THE INFLUENCE OF GLYCEMIA ON SHORT-TERM PROGNOSIS IN MYOCARDIAL INFARCTION WITHOUT ANAMNESIS OF 2ND TYPE DIABETES

Aim. To estimate the impact of glycemia recorded during myocardial infarction (MI) in-patient care on short-term prognosis of patients without 2nd type diabetes mellitus (2DM).Material and methods. Totally 296 patients were prospectively investigated. According to glucose levels patients were divided into three groups: 1st with ≤4,0 mM/l (7,4%); 2nd with 4,01–7,79 mM/l (69,9%); 3rd with ≥7,8 mM/l (22,6%). The rate of glucose metabolism disorders and complications during in-hospital care were studied.Results. In 2/3 of patients with glycemia ≥7,8 mM/l at hospitalization, later the changes of glucose metabolism were found by glucosetolerance test: prediabetes (36,9%), 2DM (32,3%). In the patients of 3rd group significantly higher was the rate of 3-vessel disease (41,8%) anf MI complications: congestive left-ventricular failure — 52,2% vs 27,3% in the 1st group and 34,1% in the second (p=0,017), cardiogenic shock — 26,9% vs 4,5% and 6,8% (p&lt;0,001), conduction disorders — 27,3% vs 9,1% and 11,7% (p=0,006), in-hospital mortality — 13,8% vs 4,5% and 4,4% (p=0,025). The risk of death in subjects with glycemia ≥7,8 mM/l was 3,48 (95% CI: 1,41–8,60) times higher than in normoglycemic (p=0,007). The glycemia was independently linked with complications of MI during in-hospital period: OR = 1,128; 95% CI: 1,005–1,266 (p=0,042), — as also with the age, severity of myocardial damage and systolic pressure at admittance.Conclusion. There was higher prevalence of MI complications and 3 times higher risk of death in patients without 2DM, but having ≥7,8 mM/l glucose (22,6% of patients) at admittance. The glycemia parameter was an independent predictor for unfavorable prognosis of MI without previous 2DM diagnosis and should be used as part of secondary prevention care.

Sarcopenia: An Independent Predictor of Mortality in Community-Dwelling Older Korean Men

The concept of sarcopenia has expanded recently to include muscle strength or physical performance. We investigated whether the Europe Working Group on Sarcopenia in Older People (EWGSOP) definition of sarcopenia predicts the risk of all-cause mortality in community-dwelling older adults. This study included 284 men and 272 women aged 65 and older. The outcome was all-cause mortality during the 6-year follow-up period. We defined sarcopenia based on the EWGSOP definitions of sarcopenia: height (ht)- or weight (wt)-adjusted appendicular skeletal muscle mass (ASM/ht(2) or ASM/wt) assessed by dual-energy x-ray absorptiometry, leg muscle strength, and short physical performance battery test score. During the 6-year follow-up, 40 men and 19 women died. The risk of death was 2.99 times and 3.22 times higher in men with sarcopenia identified by ASM/ht(2) and ASM/wt, respectively, compared with nonsarcopenic men. The hazard ratio for death was 5.37 for men with weak leg muscle strength. Men with a low short physical performance battery score had a 3.15 times higher risk of death compared with those with high short physical performance battery scores, even after adjusting for all covariates. The adjusted hazard ratios for EWGSOP-defined sarcopenia were 4.00 for ASM/ht(2) and 6.89 for ASM/wt in men. By contrast, sarcopenia defined by these criteria was not associated with a higher risk of death in women. Our data suggest that, in older men, EWGSOP-defined sarcopenia is related to higher mortality compared with nonsarcopenia regardless of the ASM/ht(2) or ASM/wt index. In older women, further studies with large sample sizes are needed to assess whether EWGSOP-defined sarcopenia increases the mortality risk.

Prevention of Surgical Site Infection: Beyond SCIP

Surgical site infections (SSIs) are a leading cause of patient morbidity and mortality. Each SSI that occurs is associated with approximately seven to 10 additional postoperative hospital days,1,2 and patients with SSIs have a two to 11 times higher risk of death compared to surgical patients without SSIs.3,4 Surgical site infections have now emerged as the most common and most costly cause of health care–associated infection.5,6 Thus, hospitals and health care providers must constantly pursue and improve adherence with evidence-based strategies for preventing these devastating infections. Several core SSI prevention strategies have been promoted by the Surgical Care Improvement Project (SCIP), including the appropriate choice and timing of antimicrobial prophylaxis, avoiding shaving surgical site hair, maintaining perioperative patient normothermia, and controlling perioperative blood glucose.7 During the past decade, many, if not most, providers associated with quality improvement and surgical improvement programs in the United States have become familiar with the SCIP recommendations. In fact, health care providers are placing great effort on improving staff member compliance with these recommendations because rates of performance on SCIP measures now affect hospital payment under the Centers for Medicare & Medicaid Services Value-Based Purchasing Program.8,9 Compliance with some of the SCIP recommendations is now close to 100%; thus, some of these quality measures have been retired (eg, avoiding surgical site hair shaving). If hospitals are near 100% compliance with some of the basic SCIP recommendations, yet SSIs still occur and harm patients, the question then becomes, “What else can be done?” This column will summarize several additional evidence-based strategies that go beyond SCIP recommendations to prevent SSIs: optimizing antimicrobial prophylaxis dosing, preparing the colon with mechanical bowel preparation and oral antibiotics, optimizing tissue oxygenation, and using a surgical safety checklist.

High-Dose Cytarabine Monotherapy Versus Intermediate Or High-Dose Cytarabine In Combination With Other Agents As Second-Line Salvage Therapy In Patients With Acute Myeloid Leukemia Who Did Not Respond To Initial Induction Therapy

IntroductionCurrently there is no standard for second-line salvage therapy in patients with acute myeloid leukemia (AML) who do not respond to initial induction therapy. The efficacy of current recommended second-line salvage regimens seems to be similar, but the tolerability can vary significantly. Anecdotally, high-dose cytarabine (HiDAC) monotherapy seems to be better tolerated than other recommended combination salvage regimens. Therefore, we conducted a retrospective analysis to evaluate the MSKCC experience with HiDAC monotherapy as compared to combination with other chemotherapeutic agents. MethodsWe included AML patients ≥ 18 years of age who did not respond to first induction therapy and received HiDAC (group 1; cytarabine 3g/m2 q12h for up to 12 doses) or intermediate- or high-dose cytarabine (1g/m2 or 3g/m2 at various numbers of doses) in combination with other agents (group 2) as second-line salvage, between the years 2003 and 2013. The combination group (group 2) consisted of regimens such as: MEC, CLAG, FLAG-I, and mitoxantrone or idarubicin with HiDAC. We evaluated the overall response rate (ORR), relapse free survival (RFS), and overall survival (OS). Univariate analysis was used to evaluate the potential association between outcomes and the following patient characteristics at the time of diagnosis: peripheral and marrow blast count, white blood cell count (WBC), platelet count, anthracycline agent used in first induction, cytogenetics risk, age, comorbidities (cardiac history, diabetes, hypertension, pulmonary, renal, and hepatic compromise), and AML subtype such as de novo (DN), antecedent (AHD), and treatment-related (t-AML). ResultsGroup 1 (monotherapy) had 30 patients and group 2 (combination) had 77 patients. Patient characteristics were similar between the two groups with the exception of age, anthracycline type (daunorubicin vs idarubicin) used in first induction, and transplant status. Group 1 had more patients younger than 58 years old (median), more daunorubicin use, and more patients who underwent allogeneic stem cell transplantation. The side effects in group 1 were notable for pneumonia, C. diff, and bacteremia. The most notable side effects in group 2 were pneumonia, C. diff, bacteremia, sepsis, and treatment-related deaths. No statistically significant difference was observed in ORR (36.7% vs 33.3%; p = 0.922), RFS (9.3 vs 5.9 months; p = 0.53), and OS (12.9 vs 6.8 months; p = 0.329) between group 1 and group 2 respectively.Univariate screening showed no difference in ORR with respect to patient characteristics in group 1. In group 2, ORRs with regard to AML subtype were 64%, 28%, 8% for DN, AHD, t-AML respectively (p = 0.014), and a higher ORR was observed in patients with WBC ≥ 10 K/mcL (58.3% vs 41.7%; p = 0.051) and patients with good or intermediate cytogenetic risks (64% vs 36%; p = 0.017). For RFS, patients in group 1 with WBC > 10 K/mcL were associated with 3 times higher risk of relapse or death (p = 0.029). For RFS in group 2, patients with AHD and t-AML were associated with higher risk of relapse (HR (95% CI): 1.3 and 3.7 respectively, p = 0.002) compared to DN. For OS, patients in group 1 with WBC > 10 K/mcL were at 2.7 times higher risk of death (p = 0.049), an association which was not present in group 2. For OS, patients in group 2 with t-AML and AHD were at 4.2 times and 1.7 times higher risk of death than DN (p = 0.001) and this difference was not present in group 1. Patients with poor cytogenetic risks or comorbidities of interest did worse in terms of overall RFS (p < 0.001, p = 0.02 respectively) and OS (p < 0.001, p = 0.009 respectively). Outcomes did not seem to be associated with type of anthracycline used in first induction or platelet count at diagnosis.▪▪ ConclusionsRecognizing the limitations of a retrospective study, our analysis showed no difference in ORR, RFS, and OS for HiDAC monotherapy compared to intermediate- or high-dose cytarabine combinations. Our univariate analysis suggests statistically significant differences in ORR, RFS, and OS with regard to AML subtype, WBC at time of diagnosis, comorbidities, and cytogenetics risk. We are subcategorizing the combination group into intermediate-dose and high-dose cytarabine combination and compare them to monotherapy. We are looking at additional molecular genetics information besides NPM1, CEBPA, and FLT3 that could also influence outcomes. Disclosures:No relevant conflicts of interest to declare.

Infant mortality in a very low birth weight cohort from a public hospital in Rio de Janeiro, RJ, Brazil

OBJECTIVES: to evaluate infant mortality in very low birth weight newborns from a public hospital in Rio de Janeiro, Brazil (2002-2006). METHODS: a retrospective cohort study was performed using the probabilistic linkage method to identify infant mortality. Mortality proportions were calculated according to birth weight intervals and period of death. The Kaplan-Meier method was used to estimate overall cumulative survival probability. The association between maternal schooling and survival of very low birth weight infants was evaluated by means of Cox proportional hazard models adjusted for: prenatal care, birth weight, and gestational age. RESULTS: the study included 782 very low birth weight newborns. Of these, (28.6%) died before one year of age. Neonatal mortality was 19.5%, and earlyneonatal mortality was 14.9%. Mortality was highest in the lowest weight group (71.6%). Newborns whose mothers had less than four years of schooling had 2.5 times higher risk of death than those whose mothers had eight years of schooling or more, even after adjusting for intermediate factors. CONCLUSIONS: the results showed higher mortality among very low birth weight infants. Low schooling was an independent predictor of infant death in this low-income population sample.

Personality and All-Cause Mortality: Individual-Participant Meta-Analysis of 3,947 Deaths in 76,150 Adults

Personality may influence the risk of death, but the evidence remains inconsistent. We examined associations between personality traits of the five-factor model (extraversion, neuroticism, agreeableness, conscientiousness, and openness to experience) and the risk of death from all causes through individual-participant meta-analysis of 76,150 participants from 7 cohorts (the British Household Panel Survey, 2006-2009; the German Socio-Economic Panel Study, 2005-2010; the Household, Income and Labour Dynamics in Australia Survey, 2006-2010; the US Health and Retirement Study, 2006-2010; the Midlife in the United States Study, 1995-2004; and the Wisconsin Longitudinal Study's graduate and sibling samples, 1993-2009). During 444,770 person-years at risk, 3,947 participants (54.4% women) died (mean age at baseline = 50.9 years; mean follow-up = 5.9 years). Only low conscientiousness-reflecting low persistence, poor self-control, and lack of long-term planning-was associated with elevated mortality risk when taking into account age, sex, ethnicity/nationality, and all 5 personality traits. Individuals in the lowest tertile of conscientiousness had a 1.4 times higher risk of death (hazard ratio = 1.37, 95% confidence interval: 1.18, 1.58) compared with individuals in the top 2 tertiles. This association remained after further adjustment for health behaviors, marital status, and education. In conclusion, of the higher-order personality traits measured by the five-factor model, only conscientiousness appears to be related to mortality risk across populations.

Survival Rate in Patients Affected by Dementia Followed by Memory Clinics (UVA) in Italy

People affected by dementia experienced decreased life expectancy with a 2-4 times higher risk of death at a given age compared to non-demented people. Dementia represents a major cost to health care and society in the Western world and, particularly in Italy, is projected to become a high-resource demanding chronic disease. The present study aimed to estimate the average survival rate of a group of community dwelling elderly affected by dementia in Italy, and to assess the predictive variables associated with survival length. This retrospective study collected the data of patients (n = 290) who died from 2008 to 2012. The data were extracted from a cohort of over 2,000 patients from three outpatient Dementia Clinics of Genoa (Italy). Demographic data and other clinical parameters listed in the patients' clinical records were collected. The mean survival rate after dementia diagnosis was 3.3 ± 0.1 years, lower compared to the age-matched healthy population. The survival rate of these patients showed a significant correlation with age (n = 290; r = -0.16: p < 0.006), with the cognitive status (n = 285; r = 0.16: p < 0.007), with education (n = 204; r = 0.23: p < 0.001), with comorbidity (n = 138; r = -0.41: p < 0.0001), with depressive mood (n = 74; r = 0.44: p < 0.0001), and with the functional status (ADL: n = 242, r = 0.29: p < 0.0001; IADL: n = 243; r = 0.25: p < 0.0001). Multivariate regression revealed age, gender, and functional status as the main determinants informing patient survival. The study provides interesting and reliable data on the pivotal value of early dementia diagnosis in predicting longer survival and addresses comprehensive geriatric assessment, which encompasses most of the predictive variables provided by the study, as a remarkable tool in estimating life expectancy of patients with dementia.

Factors Influencing Survival in Stage IV Colorectal Cancer: The Influence of DNA Ploidy

Objective. To evaluate the prognostic significance of microscopically assessed DNA ploidy and other clinical and laboratory parameters in stage IV colorectal cancer (CRC). Methods. 541 patients with histologically proven stage IV CRC treated with palliative chemotherapy at our institution were included in this retrospective analysis, and 9 variables (gender, age, performance status, carcinoembryonic antigen, cancer antigen 19-9, C-Reactive Protein (CRP), anaemia, hypoalbuminaemia, and ploidy (DNA Index)) were assessed for their potential relationship to survival. Results. Mean survival time was 12.8 months (95% confidence interval (CI) 12.0–13.5). Multivariate analysis revealed that DNA indexes of 2.2–3.6 and >3.6 were associated with 2.94 and 4.98 times higher probability of death, respectively, compared to DNA index <2.2. CRP levels of >15 mg/dL and 5–15 mg/dL were associated with 2.52 and 1.72 times higher risk of death, respectively. Hazard ratios ranged from 1.29 in patients mild anaemia (Hb 12–13.5 g/dL) to 1.88 in patients with severe anaemia (Hb < 8.5 g/dL). Similarly, the presence of hypoalbuminaemia (albumin < 5 g/dL) was found to confer 1.41 times inferior survival capability. Conclusions. Our findings suggest that patients with stage IV CRC with low ploidy score and CRP levels, absent or mild anaemia, and normal albumin levels might derive greatest benefit from palliative chemotherapy.

Intestinal perforation in gynecologic oncology: Do all patients benefit from surgical management?

ObjectiveTo identify those patients with gynecologic cancers and intestinal perforation in whom conservative management may be appropriate. MethodsA retrospective review was performed of all gynecologic oncology patients with intestinal perforation at our institution between 1995 and 2011. The Kaplan–Meier method and Cox proportional hazards models were used to analyze factors influencing survival. ResultsForty-three patients met the study criteria. The mean age was 59years (range: 38–82years). A large number of patients had peritoneal carcinomatosis and history of bowel obstruction. Surgery was performed in 28 patients, and 15 were managed conservatively. Overall mortality at 1, 3, 6, and 12months was 26%, 40%, 47%, and 59%, respectively. Only cancer burden at the time of perforation was independently predictive of mortality. Patients with peritoneal carcinomatosis, distant metastasis, or both were at 42 times higher risk of death than those with no evidence of disease (95% CI: 3.28–639.83), and at 7 times higher risk of death than those with microscopic/localized disease (95% CI: 1.77–29.94). When adjusted for the extent of disease spread, management approach (conservative vs. surgical) was not a significant predictor of survival (p≥0.05). The length of hospital stay (19days vs. 7days) and the complication rate (75% vs. 26.7%) were significantly higher in the surgical group than in the non-surgical group (p<0.05). ConclusionsPatients who develop intestinal perforation in the setting of widely metastatic disease have a particularly poor prognosis. Aggressive surgical management is unlikely to benefit such patients and further impairs their quality of life.

Iliac Conduits for Endovascular Repair of Aortic Pathologies

Challenging iliac access during thoracic endovascular aortic repair (TEVAR) is associated with a higher risk of access site complications such as injury or rupture of the iliac vessels. As a result, the use of iliac conduits is frequently used to facilitate access during TEVAR. This report evaluates the effect of iliac conduits on TEVAR outcomes. The 2005-2010 American College of Surgeons Surgical Quality Improvement Program database was queried to identify vascular patients undergoing elective TEVAR. Patients without conduit (Group A) were compared to patients who underwent TEVAR with conduit (Group B). We identified 1037 patients (90%) in Group A (69 ± 12.7 years, 42% female) and 117 patients (10%) in Group B (70 ± 12.6 years, 68% female). Women received conduits more often than men (Male:5.8%, Female:15.7%, p < 0.001). There was no significant difference in the rate of non-surgical (A:19%,B:25%,p = 0.121), pulmonary (A:11%,B:16%, p = 0.115), renal (A:3.1%, B:1.7%, p = 0.4) and cardiovascular complications (A:8%, B:12%, p = 0.143) between groups. However, any complication (A:24%, B:33%. p = 0.025), surgical complications (A:10%, B:16%, p = 0.035) and mortality (A:4.5%, B:12%. p = 0.001) were significantly higher in Group B. In multivariate analysis, use of conduit was associated with a 3.8 times higher risk of death compared with no conduit after controlling for confounders. Length of in-hospital stay was similar for both groups (A:6.6 ± 8.8, B:7.6 ± 8 days, p = 0.247). The use of conduits had a declining rate over time from 17.9% in 2006 down to 6.5% in 2010. Female patients more frequently require iliac conduits during TEVAR compared to men. Conduits were associated with a higher rate of surgical complications and mortality. The incidence of conduit use has decreased threefold in the last five years. Safer access for TEVAR by use of a conduit should not be abandoned based on these results, but there should be a heightened awareness for the higher rate of mortality in these patients.

Antidepressants do not improve event-free survival in patients with heart failure when depressive symptoms remain

ObjectiveThe purpose of this secondary data analysis was to compare event-free survival among four groups of patients with heart failure (HF) that were stratified by presence of depressive symptoms and antidepressants. MethodsWe analyzed data from 209 outpatients (30.6% female, 62 ± 12 years, 54% NYHA Class III/IV) enrolled in a multicenter HF registry who had data on depressive symptoms, antidepressant use, and cardiac rehospitalization and death outcomes during 1 year follow up. Depressive symptoms were assessed using the Patient Health Questionnaire-9. ResultsDepressive symptoms, not antidepressant therapy, predicted event-free survival (HR = 2.4, 95% CI = 1.2–4.6, p = .009). Depressed patients without antidepressants had 4.1 times higher risk of death and hospitalization than non-depressed patients on antidepressant (95% CI = 1.2–13.9, p = .022) after controlling for age, gender, NYHA class, body mass index, diabetes, medication of ACEI and beta-blockers. ConclusionAntidepressant use was not a predictor of event-free survival outcomes when patients still reported depressive symptoms. Ongoing assessment of patients on antidepressants is needed to assure adequate treatment.

Bone Markers in the Treatment of Cancer Related Bone Disease in Patients with Metastatic Breast Cancer

Bone metastases and treatment-induced osteoporosis are frequently the maincauses of morbidity in patients with malignancies. Monitoring the level of bone markers (markers of bone metabolism) has been fairly well mapped in osteoporosis, where medical procedures can be modified according to the kinetics of marker levels before an answer can be evaluated by densitometry and before the onset of fractures. In bone metastases the role of these levels is not clear. The metabolic markers of bone resorption under review in this set were s-Cross Laps (CTX) - a peptide that is a part of C - telopeptide, and N-terminal propeptide of collagen type 1 (P1NP). Material and methods: We monitored a group of 52 female patients with metastatic breastcancer. The patients received appropriate systemic treatment based on the immunohistochemistry of the tumor; the treatment consisted of hormone therapy or chemotherapy, and included parenteral bisphosphonates (ibandronate and zoledronic acid alternately). Routine biochemical tests and blood count done prior to the initiation of therapy also included taking laboratory markers of bone metabolism CTX and P1NP and measuring bone mineral density (according to T-score). These bone markers were then checked in three, six, nine and twelve months, and matched with the progress of the disease. Total monitoring time was fifteen months. Results: The patients in this set whose CTX value in the first sampling was less than 0.425 ran 8.5 times higher risk of death; the patients whose P1NP value reached more than 74 in the first collection ran 8.7 times higher risk of death. According to Cox proportional-hazards regression analysis for CTX, the significance level of p-value was 0.0452 and HR was 8.516 (95% CI 1.047 to 69.262), a difference which is not statistically significant. Regarding P1NP in Cox regression analysis, the significance level of p-value is 0.0433 and HR 8.673 (95% CI 1.067 to 70.520). Even this difference is therefore not statistically significant. When comparing the kinetics of marker levels, the difference is below statistical significance: p-value 0.6131 for P1NP and p-value 0.6357 for CTX. Conclusion: The results of this study confirm a correlation between the starting levels of CTX and P1NP with the overall survival rate, which corresponds to the other results presented in literature.