A Population-Based Cohort Study on Peripheral Arterial Disease in Patients with Schizophrenia

Mortality and excess life-years lost in patients with schizophrenia under community care: a 5-year follow-up cohort study

OBJECTIVE

Mortality rate is a general indicator which can be used to measure care and management of schizophrenia. This cohort study evaluated the standardized mortality ratios (SMRs) of all-cause mortality and life-years lost (LYLs) in patients with schizophrenia under a community care program in China.

METHODS

Data were obtained from the National Community Care Program System for Severe Mental Disorders. A total of 99,214 patients diagnosed with schizophrenia were enrolled before December 2014 and followed between 2015 and 2019. A total of 9,483 patients died. Crude mortality rates (CMRs) and SMRs were then stratified by natural vs. unnatural causes, and major groups of death were standardized according to the 2010 National Population SMRs. The corresponding LYLs at birth were also calculated by gender and age.

RESULTS

The SMRs of patients with schizophrenia were significantly elevated during the study period, with an overall SMR of 4.98 (95%CI 2.67-7.32). Neoplasms, cardiovascular diseases, cerebrovascular diseases, external injuries, and poisonings were the most significant causes of death among patients with schizophrenia compared to the general population. The mean LYLs of patients with schizophrenia were 15.28 (95%CI 13.26-17.30). Males with schizophrenia lost 15.82 life-years (95%CI 13.48-18.16), and females lost 14.59 life-years (95%CI 13.12-16.06).

CONCLUSIONS

Patients with schizophrenia under community care had a high mortality rate in our study, even though mental health services have been integrated into the general healthcare system in China to narrow treatment gaps in mental health for > 10 years. In terms of mortality outcome indicators, effective and quality mental health services still have a long way to go. The current study demonstrates the potential for improved prevention and treatment of individuals with schizophrenia under community care.

Peripheral artery disease in patients with schizophrenia as compared to controls

BACKGROUND

Patients with schizophrenia have an increased prevalence of risk factors for peripheral artery disease (PAD) and is expected to have an increased prevalence of PAD. PAD can be detected utilizing toe-brachial index (TBI) which screens for vascular pathology proximal to the toes.

METHODS

Using a cross-sectional design, we defined the subpopulations: (1) Patients diagnosed with schizophrenia less than 2 years before inclusion (SCZ < 2), (2) Psychiatric healthy controls matched to subpopulation 1 on sex, age, and smoking status, and (3) Patients diagnosed with schizophrenia 10 or more years before inclusion (SCZ ≥ 10). TBI was calculated by dividing toe pressures by systolic brachial blood pressure, and PAD was defined by TBI < 0.70. Logistic regression analysis with PAD as outcome and sex, age, smoking status, BMI, skin temperature, diagnosis of schizophrenia, and comorbidities as explanatory variables was conducted.

RESULTS

PAD was present in 26.2% of patients diagnosed with SCZ < 2 (17 of 65) and in 18.5% of psychiatric healthy controls (12 of 65) with no statistically significant difference in prevalence rates (p = 0.29). PAD was present in 22.0% of patients diagnosed with SCZ ≥ 10 (31 of 141). In logistic regression, patients diagnosed with SCZ < 2 had an increased odds of PAD with psychiatric healthy controls as reference (Odds ratio = 2.80, 95% confidence interval 1.09-7.23, p = 0.03). The analysis was adjusted for age, sex, smoking status, BMI and comorbidities such as hypertension, diabetes and heart disease.

CONCLUSIONS

This study did not find statistically significant increased prevalence rates of PAD in patients with schizophrenia even though patients with SCZ were compared to psychiatric healthy controls using TBI. Utilizing logistic regression PAD was associated with schizophrenia diagnosis within the last 2 years, age and skin temperature. As PAD is initially asymptomatic, screening could be relevant in patients with schizophrenia if other risk factors are prevalent. Further large-scale multicenter studies are warranted to investigate schizophrenia as a potential risk factor for PAD.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02885792.

Factors Impacting Survival in Patients With Major Burn-Induced Acute Kidney Injury Postrenal Replacement Therapy: A Nationwide Study With 15 Years Follow-Up in Taiwan

BACKGROUND

Major burn-induced acute kidney injury (AKI) causes extremely high mortality, even though renal replacement therapy (RRT) was thought of as the most efficient treatment. There was scanty research for investigating the characteristic of burn-AKI-RRT patients during intensive care. This study aims to investigate the factors impacting the survival outcomes in those burn-AKI-RRT cases.

METHODS

Using the Taiwan National Health Insurance Research Database and its affiliated database, the Registry for Catastrophic Illness Patients, we defined a cohort composed of 171 patients encountering major burn-induced AKI and receiving RRT during burn care for a 15-year observation period. Demographic characteristic, comorbidities, total body surface area (TBSA), major procedures, and complications were analyzed to explore the factors affecting the survival outcomes during acute burn care and 1 year after discharge.

RESULTS

Patients who underwent tracheostomy and skin grafting had higher survival rates during acute burn care (tracheostomy: mortality vs survival, 15.7% vs 30.2%; P = 0.0257; skin grafting: mortality vs survival, 57.4% vs 76.2%; P = 0.0134). Multivariate regression analysis showed that tracheostomy group significantly presented with lower mortality risk by 65% (odds ratio [OR], 0.35; P = 0.0372), and subgroup analysis of delaminating follow-up duration showed that patients with tracheostomy had higher overall survival by 22% (90-day postburn mortality: nontracheostomy vs tracheostomy, 58.3% vs 36.3%; adjusted hazards ratio, 0.39; 95% confidence interval, 0.22-0.69; P = 0.0011), especially during postburn first 30 days (adjusted hazards ratio, 0.15; 95% confidence interval, 0.05-0.49; P = 0.0016). Total body surface area did not significantly affect survival; however, mortality risk was significantly higher in those with a larger TBSA (TBSA, ≥80%; OR, 6.48; P = 0.0022; TBSA, 60-79%; OR, 3.12; P = 0.0518; TBSA, 40-59%; OR, 1.88; P = 0.2402; TBSA, 30-39% as reference).

CONCLUSIONS

For patients with major burn-induced AKI receiving RRT, tracheostomy and skin grafting may improve survival in the cases living through acute burn stage.

Elevated Cardiopulmonary Complications after Revascularization in Patients with Severe Mental Health Disorders

INTRODUCTION

Mental health disorders (MHD) are prevalent within surgical patient populations and can be associated with poorer postoperative outcomes, particularly in those with more severe MHD (schizophrenia and bipolar disorder). However, these associations have not been examined in vascular surgery patients. This study investigated patients undergoing lower extremity revascularization, hypothesizing that those with severe MHD would experience worse health and postoperative outcomes.

METHODS

A retrospective chart review of patients from 2010-2015 with peripheral arterial disease (PAD) requiring revascularization was conducted, with subsequent narrowing to those with concurrent MHD diagnoses, including severe MHD (sMHD) defined as bipolar disorder or schizophrenia and non-severe MHD (nsMHD), defined as anxiety or depression. The primary endpoints were 30-day mortality; Major Adverse Limb Events (MALE) including amputation at the above or below knee level; and Major Adverse Cardiac Events (MACE) including myocardial infarction (MI), congestive heart failure (CHF) exacerbation, and arrhythmia. Secondary endpoints were readmission within 30 days, pulmonary complications, and wound infection. Statistical analyses included Fisher Exact Test and Student's T-test.

RESULTS

Eighteen patients with MHD (sMHD, n=10; nsMHD, n=8) were identified and stratified. Twenty-four limbs were revascularized (sMHD, n=13; nsMHD, n=11). Overall incidence of 30-day mortality, MALE, and MACE were 4.2%, 33.3%, and 50.0%, respectively. Readmission rate, pneumonia, and wound infection occurred in 41.7%, 20.8%, and 16.7% of the population. Stratifying by MHD severity, no significant differences were observed for medical comorbidities, MALE, intervention type (open vs. endovascular), or treatment indication (claudication vs. critical limb ischemia). Patients with sMHD had significantly higher rates of MACE compared to patients with nsMHD (30.8% vs. 18.2%, p<.05). Pneumonia was also more prevalent in this group (38.5% vs. 0.0%, p<.05).

CONCLUSION

While patients with concurrent diagnoses of MHD and PAD presented with similar comorbidities, comparable disease severity, and were equally treated by open versus endovascular techniques, those with severe MHD suffered significantly elevated rates of cardiopulmonary complications, specifically MACE and pneumonia. Further investigation is warranted to identify opportunities to optimize post-operative care for these complex patients.

Fasting plasma glucose variability and HbA1c are associated with peripheral artery disease risk in type 2 diabetes

BACKGROUND

This study investigated whether visit-to-visit fasting plasma glucose (FPG) variability, as measured by the coefficient of variation (CV), increased peripheral artery disease (PAD) risk.

METHODS

Individuals with type 2 diabetes from the National Diabetes Care Management Program during the period 2002-2004, ≥ 30 years of age, and free of PAD (n = 30,932) were included and monitored until 2011. Cox proportional hazards regression models were implemented to analyze related determinants of PAD.

RESULTS

A total of 894 incident cases of PAD were identified during an average 8.2 years of follow-up, resulting in a crude incidence rate of 3.53 per 1000 person-years. Both FPG-CV and HbA1c were significantly associated with PAD after multivariate adjustment, with corresponding hazard ratios of 1.24 [95% confidence interval (CI) 1.04-1.47] for FPG-CV in the third tertile and 1.50 (95% CI 1.10-2.04) for HbA1c ≥ 10%. The findings of the sensitivity analysis remained consistent after excluding potential confounders, demonstrating the consistency of the results.

CONCLUSIONS

The associations between HbA1c, variability in FPG-CV, and PAD suggest a linked pathophysiological mechanism, suggesting the crucial role of glycemic variability in clinical management and therapeutic goals in preventing PAD in type 2 diabetes.

Risk factors for early circulatory mortality in patients with schizophrenia

Patients with schizophrenia have higher mortality and shortened life expectancy than the general population, and cardiovascular disease (CVD) accounts for up to 50% cases of early mortality in schizophrenia. We determined risk factors, particularly pathophysiological changes, for early circulatory mortality in schizophrenia. In this multi-institutional, nested, case-control study, we enrolled consecutive inpatients with schizophrenia admitted to three psychiatric hospitals in the northern Taiwan. Seventy-nine patients who died of CVD before 65 years of age were identified as cases through record linkage, and 158 controls were randomly selected in a 2:1 ratio through risk-set density sampling, after matching for age (±2 years), sex, and index admission (±3 years). Data were obtained through medical record reviews. At the time of death, the mean age of the patients was 47.5 years (standard deviation = 10.3). Conditional logistic regression revealed that the duration of antipsychotic treatment was significantly associated with a lower risk of early circulatory mortality, and leukocyte counts at index hospitalization were significantly associated with a higher risk. Systemic inflammation may be a risk factor for early circulatory mortality in schizophrenia, but antipsychotic treatment, in particular typical antipsychotic treatment, could be a protective factor.