Eventos cardiovasculares tempranos y tardíos en pacientes ingresados por neumonía adquirida en la comunidad

IntroductionCommunity-acquired pneumonia increases the risk of cardiovascular events (CVE). The objective of this study was to analyze host, severity, and etiology factors associated with the appearance of early and late events and their impact on mortality.MethodProspective multicenter cohort study in patients hospitalized for pneumonia. CVE and mortality rates were collected at admission, 30-day follow-up (early events), and one-year follow-up (late events).ResultsIn total, 202 of 1,967 (10.42%) patients presented early CVE and 122 (6.64%) late events; 16% of 1-year mortality was attributed to cardiovascular disease. The host risk factors related to cardiovascular complications were: age ≥ 65 years, smoking, and chronic heart disease. Alcohol abuse was a risk factor for early events, whereas obesity, hypertension, and chronic renal failure were related to late events. Severe sepsis and Pneumonia Severity Index (PSI) ≥ 3 were independent risk factors for early events, and only PSI ≥ 3 for late events. Streptococcus pneumoniae was the microorganism associated with most cardiovascular complications. Developing CVE was an independent factor related to early (OR 2.37) and late mortality (OR 4.05).ConclusionsAge, smoking, chronic heart disease, initial severity, and S. pneumoniae infection are risk factors for early and late events, complications that have been related with an increase of the mortality risk during and after the pneumonia episode. Awareness of these factors can help us make active and early diagnoses of CVE in hospitalized CAP patients and design future interventional studies to reduce cardiovascular risk.     

Increased winter mortality: The effect of season,temperature and deprivation in the acutely ill medical patient

BackgroundStudies examining seasonal mortality have found excess winter mortality, particularly in the elderly. We examined the seasonal mortality variations for all emergency medical admissions to St James' Hospital, Dublin, over 10 years (2002–2011). We explored the effects of ambient temperature, deprivation markers, case-mix, co-morbidity and illness severity on seasonal mortality.MethodsAll emergency admissions to an acute hospital were categorised by season. We examined season as a predictor of 30-day hospital mortality.Results30-day in-hospital mortality was lowest in autumn (7.5%) and highest in winter (9.6%). Winter admission had 17% (p = 0.009) increased unadjusted risk of a death by day 30 (OR 1.17: 95% CI 1.07, 1.28). A clinical classification system identified that chronic obstructive disease, pneumonia, epilepsy/seizures and congestive heart failure had more presentations in the winter. Multivariate analysis found that winter was not an independent predictor (OR 1.08: 95% CI 0.97, 1.19). Predictors including illness severity and the Charlson Index accounted for the increased risk of winter admission. The minimum daily temperature independently predicted outcome; there was a 20% increased in-hospital death rate when it was colder (OR 1.20: 95% CI 1.09, 1.33; p < 0.001). Deprivation was a univariate and multivariate (OR 1.22 95%CI 1.07, 1.39; p = 0.002) predictor of mortality, but did not show marked seasonal variation.ConclusionPatients admitted in the winter have an approximate 17% increased risk of an in-hospital death by 30 days; this is related to cold along with increased illness severity and co-morbidity burden. The disease profile is different with winter admissions.     

Predictors of Timely Antibiotic Administration for Patients Hospitalized With Community-Acquired Pneumonia From the Cluster-Randomized EDCAP Trial

IntroductionTo identify factors associated with timely initiation of antibiotic therapy for patients hospitalized with pneumonia.DesignSecondary analysis of a cluster-randomized, controlled trial.SettingThirty- two emergency departments (EDs) in Pennsylvania and Connecticut.SubjectsPatients with a clinical and radiographic diagnosis of community-acquired pneumonia.InterventionsFrom January to December 2001, EDs were randomly allocated to guideline implementation strategies of low (n = 8), moderate (n = 12), and high intensity (n = 12) to improve the initial site of treatment and the performance of evidence-based processes of care. Our primary outcome was antibiotic initiation within 4 hours of presentation, which at that time was the recommended process of care for inpatients.ResultsOf the 2076 inpatients enrolled, 1632 (78.6%) received antibiotic therapy within 4 hours of presentation. Antibiotic timeliness ranged from 55.6% to 100% (P < 0.001) by ED and from 77.0% to 79.7% (P = 0.2) across the 3 guideline implementation arms. In multivariable analysis, heart rate ≥ 125 per minute (OR = 1.6, 95% CI 1.1-2.3), respiratory rate ≥ 30 per minute (OR = 2.3, 95% CI 1.6-3.4), and aspiration pneumonia (OR = 3.7, 95% CI 1.1-12.7) were positively associated with timely initiation of antibiotic therapy, whereas a hematocrit < 30% (OR = 0.6, 95% CI 0.4-1.0) was negatively associated with this outcome.ConclusionsTimely initiation of antibiotic therapy is associated primarily with patient-related factors that reflect severity of illness at presentation. Although this study demonstrates an opportunity to improve performance on this quality measure in nearly one quarter of inpatients with pneumonia, we failed to identify any modifiable patient, provider, or hospital level factors to target in such quality improvement efforts.     

Complicaciones y mortalidad a 30 días y al año en pacientes con primer IAMCEST tratados en la red Codi IAM en 2010-2016: análisis del efecto del género

Introduction and objectivesST-segment elevation myocardial infarction (STEMI) emergency care networks aim to increase reperfusion rates and reduce ischemic times. The influence of sex on prognosis is still being debated. Our objective was to analyze prognosis according to sex after a first STEMI.MethodsThis multicenter cohort study enrolled first STEMI patients from 2010 to 2016 to determine the influence of sex after adjustment for revascularization delays, age, and comorbidities. End points were 30-day mortality, the 30-day composite of mortality, ventricular fibrillation, pulmonary edema, or cardiogenic shock, and 1-year all-cause mortality.ResultsFrom 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74-124] in 2016, both P = .001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P = .001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95).ConclusionsCompared with men, women with a first STEMI had similar 30-day mortality and complication rates but significantly lower 1-year mortality after adjustment for age and severity.     

Association entre l’hypertension artérielle,les traitements inhibiteurs du système rénine angiotensine et les formes graves de COVID-19. Étude prospective monocentrique française

Background and aimAngiotensin converting enzyme (ACE) type 2 is the receptor of SARSCoV-2 for cell entry into lung cells. Because ACE-2 may be modulated by ACE inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), there are concern that patients treated with ACEIs and ARBs are at higher risk for COVID-19 infection or severity. This study sought to analyse the association of severe forms of COVID-19 and mortality with hypertension and a previous treatment with ACEI and ARB.MethodsProspective follow-up of 433 consecutive patients hospitalised for COVID-19 pneumonia confirmed by PCR or highly probable on clinical, biological, and radiological findings, and included in the COVHYP study. Mortality and severe COVID-19 (criteria: death, intensive care unit, or hospitalisation > 30 days) were compared in patients receiving or not ACEIs and ARBs. Follow-up was 100% at hospital discharge, and 96.5% at > 1 month.ResultsAge was 63.6 ± 18.7 years, and 40%) were female. At follow-up (mean 78 ± 50 days), 136 (31%) patients had severity criteria (death, 64 ; intensive care unit, 73; hospital stay > 30 days, 49). Hypertension (55.1% vs 36.7%, P < 0.001) and antihypertensive treatment were associated with severe COVID-19 and mortality. The association between ACEI/ARB treatment and COVID-19 severity criteria found in univariate analysis (Odds Ratio 1.74, 95%CI [1.14–2.64], P = 0.01) was not confirmed when adjusted on age, gender, and hypertension (adjusted OR1.13 [0.59–2.15], P = 0.72). Diabetes and hypothyroidism were associated with severe COVID-19, whereas history of asthma was not.ConclusionThis study suggests that previous treatment with ACEI and ARB is not associated with hospital mortality, 1- and 2-month mortality, and severity criteria in patients hospitalised for COVID-19. No protective effect of ACEIs and ARBs on severe pneumonia related to COVID-19 was demonstrated.     

Serum albumin as an outcome predictor in hospital emergency medical admissions

BackgroundTo examine the relationship between admission serum albumin and 30-day mortality during an emergency medical admission.MethodsAn analysis was performed of all emergency medical patients admitted to St. James's Hospital (SJH), Dublin between 1st January 2002 and 31st December 2008, using the hospital in-patient enquiry (HIPE) system, linked to the patient administration system, and laboratory datasets. Mortality was defined as an in-hospital death within 30 days. Logistic regression was used to calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals for defined albumin subsets.FindingsUnivariate analysis using predefined criteria based on distribution, identified the groups of < 10% and between 10 and 25% of the serum albumin frequency distribution as at increased mortality risk. Their mortality rates were 31.7% and 15.4% respectively; their unadjusted odds rates were 6.35 (5.68, 7.09) and 2.11 (1.90, 2.34). Patients in the lowest 25% of the distribution had a 30-day mortality of 19.9% and this significantly increased risk persisted, after adjustment for other outcome predictors including co-morbidity and illness severity (OR 2.95 (2.49, 3.48): p < 0.0001).InterpretationSerum albumin is predictive of 30-day mortality in emergency medical patients; mortality is non-linearly related to baseline albumin. The disproportionate increased death risk for patients in the lowest 25% of the frequency distribution (< 36 g/L) is not due to co-morbidity factors or acute illness severity.     

Effect of the Early Combination of Continuous Positive Airway Pressure and High-Flow Nasal Cannula on Mortality and Intubation Rates in Patients With COVID-19 and Acute Respiratory Distress Syndrome. The DUOCOVID Study

IntroductionNon invasive respiratory support (NIRS) is useful for treating acute respiratory distress syndrome (ARDS) secondary to COVID-19, mainly in mild–moderate stages. Although continuous positive airway pressure (CPAP) seems superior to other NIRS, prolonged periods of use and poor adaptation may contribute to its failure. The combination of CPAP sessions and high-flow nasal cannula (HFNC) breaks could improve comfort and keep respiratory mechanics stable without reducing the benefits of positive airway pressure (PAP). Our study aimed to determine if HFNC + CPAP initiates early lower mortality and endotracheal intubation (ETI) rates.MethodsSubjects were admitted to the intermediate respiratory care unit (IRCU) of a COVID-19 monographic hospital between January and September 2021. They were divided according to Early HFNC + CPAP (first 24 h, EHC group) and Delayed HFNC + CPAP (after 24 h, DHC group). Laboratory data, NIRS parameters, and the ETI and 30-day mortality rates were collected. A multivariate analysis was performed to identify the risk factors associated with these variables.ResultsThe median age of the 760 included patients was 57 (IQR 47–66), who were mostly male (66.1%). The median Charlson Comorbidity Index was 2 (IQR 1–3) and 46.8% were obese. The median PaO₂/FiO₂ upon IRCU admission was 95 (IQR 76–126). The ETI rate in the EHC group was 34.5%, with 41.8% for the DHC group (p = 0.045), while 30-day mortality was 8.2% and 15.5%, respectively (p = 0.002).ConclusionsParticularly in the first 24 h after IRCU admission, the HFNC + CPAP combination was associated with a reduction in the 30-day mortality and ETI rates in patients with ARDS secondary to COVID-19.     

Clinical Predictors and Risk Factors for Relapsing Clostridium difficile Infection

BackgroundClostridium difficile infection (CDI) is a common cause of morbidity among hospitalized patients. Multiple factors have been associated with primary CDI, but risk factors for CDI relapses are less well described.MethodsThis was a retrospective cohort study of patients with CDI over a 15-month period. We compared patients with relapsing and nonrelapsing CDI, including risk factors associated with primary CDI and other variables hypothesized to be associated with relapsing CDI and 90-day mortality. Multivariable logistic regression models were created to examine risk factors for relapse and 90-day mortality.ResultsOne hundred twenty-nine consecutive patients with CDI were included; 38 (29%) had relapsing CDI. Factors associated with relapsing CDI included fluoroquinolone use (71% versus 49%, P = 0.04) and incidence of stroke (29% versus 12%, P = 0.02). In a regression model, use of a fluoroquinolone was associated with relapsing CDI (OR = 2.52, 95% CI = 1.11-5.72). Factors associated with 90-day mortality included higher Charlson comorbidity index score (4.34 ± 1.71 versus 3.42 ± 2.08, P = 0.02), severe CDI (58% versus 32%, P = 0.01), and the use of piperacillin/ tazobactam (45% versus 23%, P = 0.03) or meropenem (10% versus 1%, P = 0.04). In the regression analysis, 90-day mortality was associated with severe CDI (OR = 1.76; 95% CI = 1.19-2.59).ConclusionsFluoroquinolone use and prior stroke are associated with an increased risk of relapsing CDI. Relapsing CDI and severe CDI are both associated with increased 90-day mortality.     

Influence of age on perioperative major adverse cardiovascular events and mortality risks in elective non-cardiac surgery

Background and aimsAdvanced age increases the risk of perioperative cardiovascular complications and may pose reluctance to subject elderly patients to surgery. We examined the impact of high age on perioperative major adverse cardiovascular events (MACE) and mortality in a nationwide cohort of patients undergoing elective surgery.MethodsAll Danish patients aged ≥ 20 years undergoing non-cardiac, elective surgery in 2005–2011 were identified from nationwide administrative registers. Risks of 30-day MACE (non-fatal ischemic stroke, non-fatal myocardial infarction, or cardiovascular death) and all-cause mortality were analyzed by multivariable logistic regression models (adjusted for comorbidities, revised cardiac risk index, cardiovascular pharmacotherapy, body mass index, and surgery type).ResultsA total of 386,818 procedures on 302,459 patients were included; mean age was 54.8 years (min–max 20–104), and 44% were men. A total of 1297 (0.34%) had perioperative MACE and 1449 (0.37%) died. Advanced age was associated with increased risks of MACE (odds ratio [OR], 1.87; 95% CI, 1.78–1.98 per 10-year high) and mortality (OR, 1.87; 95% CI, 1.78–1.96 per 10-year high). A total of 21,511 procedures were performed on patients > 80–90 years old, and 1662 on patients > 90 years. The numbers of MACE and crude mortality rates were 331 (1.7%) and 388 (2.0%) among > 80–90 years old, and 50 (3.0%) and 67 (4.0%) for those aged > 90 years.ConclusionThe risk of mortality and major adverse cardiovascular events within 30 days after surgery increased with advanced age. However, despite advanced age, the absolute event rates appeared to be relatively modest and around 4% for people aged above 90 years.     

Primary transcatheter closure of post-myocardial infarction ventricular septal rupture using amplatzer atrial septal occlusion device: A study from tertiary care in South India

ObjectiveThe study investigated effectiveness of transcatheter closure of post-myocardial infarction (MI) ventricular septal rupture (VSR) using atrial septal device (ASD) occluder in a cohort of patients admitted at our institute.MethodThis was a retrospective, observational and single center study, which included patients who were treated with transcatheter closure for post-MI VSR at our tertiary care center between May 2000 and August 2014 depending upon inclusion and exclusion criteria. Primary outcome was all-cause mortality at 30-days follow-up. The MELD-XI (Model for End Stage Liver Disease) score was used as a predictor for poor outcome in these patients.ResultsA total of 21 patients (mean age 66.4 ± 5.9 years) were included in the study. Study cohort predominantly included male patients (n = 15; 71.4%) and patients with single vessel disease (n = 15; 71.4%). Revascularization of the culprit lesion, before VSR closure, was attempted in 6 patients. Except one patient (treated with Cera^® occluder), all patients were treated with Amplatzer^® ASD occluders. Average diameter of VSR was 20.8 ± 6.9 mm. Diameter of the device used in the study ranged from 10 mm to 30 mm. Residual defect was detected in 13 patients (62%). All-cause mortality at 30-day follow-up was observed in 9 (42.9%) patients. Time to VSR closure, diameter of VSR, and serum creatinine levels were significantly related to the 30-day mortality. MELD-XI score was found to be strongly associated with increased risk of mortality.ConclusionPrimary transcatheter VSR closure using ASD occluders is a feasible approach which can provide reasonable survival outcomes along with equitable mortality rates.     

Predictors of 7- and 30-day mortality in pediatric intensive care unit patients with cancer and hematologic malignancy infected with Gram-negative bacteria

BackgroundInfection with Gram-negative bacteria is associated with increased morbidity and mortality. The aim of this study was to evaluate the predictors of 7- and 30-day mortality in pediatric patients in an intensive care unit with cancer and/or hematologic diseases and Gram-negative bacteria infection.MethodsData were collected relating to all episodes of Gram-negative bacteria infection that occurred in a pediatric intensive care unit between January 2009 and December 2012, and these cases were divided into two groups: those who were deceased seven and 30 days after the date of a positive culture and those who survived the same time frames. Variables of interest included age, gender, presence of solid tumor or hematologic disease, cancer status, central venous catheter use, previous Pseudomonas aeruginosa infection, infection by multidrug resistant-Gram-negative bacteria, colonization by multidrug resistant-Gram-negative bacteria, neutropenia in the preceding seven days, neutropenia duration ≥3 days, healthcare-associated infection, length of stay before intensive care unit admission, length of intensive care unit stay >3 days, appropriate empirical antimicrobial treatment, definitive inadequate antimicrobial treatment, time to initiate adequate antibiotic therapy, appropriate antibiotic duration ≤3 days, and shock. In addition, use of antimicrobial agents, corticosteroids, chemotherapy, or radiation therapy in the previous 30 days was noted.ResultsMultivariate logistic regression analysis resulted in significant relationship between shock and both 7-day mortality (odds ratio 12.397; 95% confidence interval 1.291–119.016; p = 0.029) and 30-day mortality (odds ratio 6.174; 95% confidence interval 1.760–21.664; p = 0.004), between antibiotic duration ≤3 days and 7-day mortality (odds ratio 21.328; 95% confidence interval 2.834-160.536; p = 0.003), and between colonization by multidrug resistant-Gram-negative bacteria and 30-day mortality (odds ratio 12.002; 95% confidence interval 1.578–91.286; p = 0.016).ConclusionsShock was a predictor of 7- and 30-day mortality, and colonization by multidrug resistant-Gram-negative bacteria was an important risk factor for 30-day mortality.     

Identification of Low-risk Patients With Acute Symptomatic Pulmonary Embolism

BackgroundIdentification of patients with acute symptomatic pulmonary embolism (PE) who are at low-risk for short-term complications to warrant outpatient care lacks clarity.MethodIn order to identify patients at low-risk for 30-day all-cause and PE-related mortality, we used a cohort of haemodynamically stable patients from the RIETE registry to compare the false-negative rate of four strategies: the simplified Pulmonary Embolism Severity Index (sPESI); a modified (i.e., heart rate cutoff of 100 beats/min) sPESI; and a combination of the original and the modified sPESI with computed tomography (CT)-assessed right ventricle (RV)/left ventricle (LV) ratio.ResultsOverall, 137 of 3117 patients with acute PE (4.4%) died during the first month. Of these, 41 (1.3%) died from PE, and 96 (3.1%) died from other causes. The proportion of patients categorized as having low-risk was highest with the sPESI and lowest with the combination of a modified sPESI and CT-assessed RV/LV ratio (32.5% versus 16.5%; P < 0.001). However, among patients identified as low-risk, the 30-day mortality rate was lowest with the combination of a modified sPESI and CT-assessed RV/LV ratio and highest with the sPESI (0.4% versus 1.0%; P = 0.03). The 30-day PE-related mortality rates for patients designated as low-risk by the sPESI, the modified sPESI, and the combination of the original and modified sPESI with CT-assessed RV/LV ratio were 0.7%, 0.4%, 0.7%, and 0.2%, respectively.ConclusionsThe combination of a negative modified sPESI with CT-assessed RV/LV ratio ≤1 identifies patients with acute PE who are at very low-risk for short-term mortality.     

Mortality risk score for Klebsiella pneumoniae bacteraemia

BackgroundKlebsiella pneumoniae bacteraemia (KPB) has been associated with multiple risk factors. However association of these risk factors with mortality secondary to KPB has been poorly documented.ObjectivesTo assess underlying co-morbidities in patients with KPB and any associated presentations. These findings were then used to devise a score to estimate the risk of in-hospital mortality in patients with underlying KPB.MethodsA retrospective analysis of all patients diagnosed with KPB between November 2007 and March 2012 at Mater Dei hospital in Malta was carried out. Using the odds ratios of risk factors for mortality associated with KPB, a mortality risk score was then prepared.Results186 patients (mean age 62 years; mean hospital stay 22.6 days) were included. 51 patients died as inpatients. Being admitted to intensive care (Overall risk (OR): 9, p < 0.0001), having a solid organ tumour (OR 3, p < 0.005), and having an underlying pneumonia (OR 3, p < 0.021) were statistically significant risk factors associated with mortality. There were 0% mortality in patients with a score of 0, and progressively increasing mortalities with increasing scores up to a 100% mortality in patients with scores of > 15. This translated into a validated risk score where an increasing score reflected an increasing mortality.ConclusionsKlebsiella pneumoniae bacteraemia is associated with high in-patient mortality. ICU admission, underlying solid tumours, and co-existent pneumonias are among the factors used in our mortality risk score. This needs to be further validated in larger populations.     

The impact of preoperative steroid use on short-term outcomes following surgery for inflammatory bowel disease

BackgroundInflammatory bowel disease (IBD) patients are frequently treated with steroids prior to surgery. We characterized the association between preoperative steroid use and postoperative complications in a large prospective cohort.MethodsWe identified patients who underwent major IBD-related abdominal surgery in the American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) between 2005 and 2012. We compared the risk of postoperative complications and 30-day mortality between preoperative steroid users and non-users.ResultsWe identified 8260 Crohn's disease (CD) and 7235 ulcerative colitis (UC) patients who underwent major abdominal surgery. Preoperative steroid use was associated with higher risk of postoperative complications, excluding death, in both CD (22.6% vs. 18.5%, P < 0.0001) and UC (30.1% vs. 22.5%, P < 0.0001). The adjusted odds ratio for any postoperative complication associated with steroids was 1.26 (95% CI: 1.12–1.41) for CD and 1.44 (95% CI: 1.28–1.61) for UC. Infectious complications were more frequent with steroid use in both CD (15.2% vs. 12.9%, P = 0.004) and UC (19.4% vs. 15.6%, P < 0.0001), specifically intra-abdominal infections and sepsis. Steroid use was associated with increased risk of venous thromboembolism (VTE) in both CD (OR, 1.66; 95% CI: 1.17–2.35) and UC (OR, 2.66; 95% CI: 2.01–3.53). 30-day mortality did not differ among steroid users and non-users (6.8/1000 vs. 5.8/1000, P = 0.58 for CD; 13.5/1000 vs. 15.2/1000, P = 0.55 for UC).ConclusionsPreoperative steroids are associated with higher risk of postoperative sepsis and VTE in IBD. Increased infectious control measures and VTE prophylaxis may reduce adverse events.     

Prognostic significance of a prolonged international normalized ratio in elderly patients in an internal medicine ward

PurposeTo investigate clinical characteristics and the prognostic significance of a prolonged international normalized ratio (INR) without obvious cause or anticoagulant treatment, in elderly inpatients.MethodsDemographic, clinical, and laboratory data, in-hospital death and 30 day-mortality were prospectively registered for 100 consecutive patients aged ≥75 years admitted to an internal medicine ward for a variety of acute medical disorders, and compared according to normal (≤1.15) and prolonged (>1.15) INR on admission. Exclusion criteria were: anticoagulant therapy, disseminated intravascular coagulopathy, acute bleeding, liver disease, active malignant disorder, and known coagulopathy.ResultsProlonged INR was found in 52% of patients. Patients with prolonged INR tended more likely to present with dementia and pressure sores than patients with normal INR. Moreover, patients with prolonged INR more often needed assisted feeding and presented lower mean levels of serum albumin on admission. In-hospital (21.2% vs. 6.2%) and 30-day (32.7% vs. 6.2%) mortality rates were significantly higher in patients with prolonged INR than those with normal INR. On stepwise logistic regression analysis, prolonged INR strongly predicted 30-day mortality (P = 0.004, relative risk 1.67, 95% confidence interval 1.07–2.60).ConclusionsProlonged INR without obvious cause or anticoagulant treatment is common among elderly patients admitted to an internal medicine ward, and is associated with a severe clinical profile. Prolonged INR is a powerful predictor of 30-day mortality. Assessment of INR my improve risk stratification for elderly inpatients.     

Impact of smoking status on early and late outcomes after isolated coronary artery bypass graft surgery

BackgroundThere are limited data on the impact of smoking status on outcomes after isolated coronary artery bypass graft (CABG) surgery.MethodsData obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program were retrospectively analyzed. Demographic and operative data were compared between patients who were non-smokers, previous smokers, and current smokers. The independent impact of smoking status on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively.ResultsIsolated CABG surgery was performed in 21 534 patients; smoking status was recorded in 21 486 (99.8%). Of these, 7023 (32.6%) had no previous smoking history, 11 183 (59.1%) were previous smokers, and 3290 (15.2%) were current smokers. The 30-day mortality rate was 1.8% in non-smokers, 1.5% in previous smokers, and 1.5% in current smokers (p = NS). The incidence of peri-operative complications was generally similar in the three groups, but current smokers were at an increased risk of pneumonia (p < 0.001), and multisystem failure (p = 0.003). The mean follow-up period for this study was 37 months (range, 0–106 months). After adjusting for differences in patient variables, the incidence of late mortality was higher in previous smokers [hazard ratio (HR), 1.73; 95% confidence interval (CI), 1.47–2.05; p < 0.001] or current smokers (HR, 1.41; 95% CI, 1.26–1.59; p < 0.001) compared to non-smokers.ConclusionSmoking status is not associated with early mortality after isolated CABG. It is, however, associated with an increased risk of pulmonary complications and reduced long-term survival.     

Estudio del deterioro psicofísico y funcional en pacientes ingresados con neumonía. Análisis por grupos de edad

IntroductionHospital admissions due to pneumonia range from 1.1 to 4 per 1,000 patients and this figure increases with age. Hospitalization causes a decline in functional status. Physical impairment impedes recovery and constitutes a higher risk of disability and mortality in elderly people.The objective of this study is to assess the impact of hospital stay in patients with pneumonia related with age.MethodA total of 116 patients with pneumonia were included in this study, and divided into two age groups: < 75 years (n = 68) and ≥ 75 years (n = 48). Respiratory function, physical function and psychological and emotional profile were evaluated. Pneumonia severity, nutritional status, independence and comorbidities were also assessed.ResultsStatistical analyses revealed significant differences between both age groups in pneumonia severity and comorbidities. Significant improvements between admission and discharge were found in lung function in both groups (p < 0.05), while a significant decrease (p < 0.05) in strength assessed by dynamometer was found in the ≥ 75 years group.ConclusionHospitalization leads to a significant physical impairment in patients admitted for pneumonia. This deterioration increases with age.     

Decreased IGF-1 levels potentiate association of inflammation with all-cause and cardiovascular mortality in prevalent hemodialysis patients

ObjectiveInsulin-like growth factor-1 (IGF-1) and inflammation have both been linked to high cardiovascular risk and mortality in the general population, as well as in hemodialysis (HD) patients. We hypothesized that the association of low IGF-1 with chronic inflammation may increase the mortality risk in HD patients.DesignWe investigated the interactions between inflammatory biomarkers (IL-6 and TNF-α) and IGF-1 as predictors of death over a 4 years of follow-up (median — 47 months, interquartile range — 17.5–75 months) in 96 prevalent HD patients (35% women, mean age of 64.9 ± 11.6 years).ResultsA significant interaction effect of low IGF-1 (defined as a level less than median) and high IL-6 (defined as a level higher than median) on all-cause and cardiovascular mortality was found: crude Cox hazard ratios (HR) for the product termed IGF-1 × IL-6 were 4.27, with a 95% confidence interval (CI): 2.10 to 8.68 (P < 0.001) and 7.49, with a 95% CI: 2.40–24.1 (P = 0.001), respectively. Across the four IGF-1–IL-6 categories, the group with low IGF-1 and high IL-6 exhibited the worse outcome in both all-cause and cardiovascular mortality (multivariable adjusted hazard ratios were 4.92, 95% CI 1.86 to 13.03, and 14.34, 95% CI 1.49 to 137.8, respectively). The main clinical characteristics of patients in the low-IGF-1-high IL-6 group didn't differ from other IGF-1–IL-6 categorized groups besides gender that consequently was inserted in all multivariable models together with the other potential confounders.ConclusionsAn increase in mortality risk was observed in HD patients with low IGF-1 and high IL-6 levels, especially cardiovascular causes.     

Risk stratification using D-dimers in patients presenting to the emergency department with nonspecific complaints

BackgroundPatients with nonspecific complaints (NSC) such as generalized weakness present frequently to acute care settings. These patients are at risk of adverse health outcomes. The aim of our study was to test the hypothesis whether D-dimers are predictive for 30-day mortality in patients with NSCs.MethodsDelayed type cross-sectional diagnostic study with a 30-day follow-up period, registered with ClinicalTrials.gov (NCT00920491). This study took place in 2 EDs in Northwestern Switzerland. Patients were enrolled in the study if they were over 18 years of age, gave informed consent, and if they presented with NSCs such as generalized weakness. D-dimer levels were determined at ED presentation.ResultsThe final study population consisted of 524 patients. Median age was 82 years (IQR = 75 to 87 years); 40.5% were men. There were 489 survivors and 35 non-survivors at 30-day follow-up. Twenty-one (60%) of the non-survivors were males. D-dimer levels were significantly higher in non-survivors than in survivors (p < 0.001). Univariate Cox regression models for D-dimer resulted in a C-index of 0.77 for prediction of mortality. A model including sex, age, Katz ADL and D-dimer in a multivariate Cox regression lead to a C-Index of 0.80.ConclusionD-dimer testing might be an effective risk stratification tool in patients with NSC by helping to identify patients at low risk of short-term mortality with a sensitivity of 0.97 and a negative likelihood ratio of 0.121. The use of D-dimers for risk stratification in patients with NSC should be confirmed with prospective studies.