Muscle loss contributes to higher morbidity and mortality in COPD: An analysis of national trends

BACKGROUND AND OBJECTIVE

COPD is the third most common cause of death worldwide and fourth most common in the United States. In hospitalized patients with COPD, mortality, morbidity and healthcare resource utilization are high. Skeletal muscle loss is frequent in patients with COPD. However, the impact of muscle loss on adverse outcomes has not been systematically evaluated. We tested the hypothesis that patients hospitalized for COPD exacerbation with, compared to those without, a secondary diagnosis of muscle loss phenotype (all ICD-9 codes associated with muscle loss including cachexia) will have higher mortality and cost of care.

METHODS

The NIS database of hospitalized patients in 2011 (1 January-31 December) in the United States was used. The impact of a muscle loss phenotype on in-hospital mortality, LOS and cost of care for each of the 174 808 hospitalizations for COPD exacerbations was analysed.

RESULTS

Of the subjects admitted for a COPD exacerbation, 12 977 (7.4%) had a secondary diagnosis of muscle loss phenotype. A diagnosis of muscle loss phenotype was associated with significantly higher in-hospital mortality (14.6% vs 5.7%, P < 0.001), LOS (13.3 + 17.1 vs 5.7 + 7.6, P < 0.001) and median hospital charge per patient ($13 947 vs $6610, P < 0.001). Multivariate regression analysis showed that muscle loss phenotype increased mortality by 111% (95% CI: 2.0-2.2, P < 0.001), LOS by 68.4% (P < 0.001) and the direct cost of care by 83.7% (P < 0.001) compared to those without muscle loss.

CONCLUSION

In-hospital mortality, LOS and healthcare costs are higher in patients with COPD exacerbations and a muscle loss phenotype.

Temporal changes in treatments and outcomes after acute myocardial infarction among cancer survivors and patients without cancer, 1995 to 2013

BACKGROUND

There is a paucity of information about treatment and mortality trends after acute myocardial infarction (AMI) for cancer survivors (CS).

METHODS

In this population-based study, the authors compared temporal trends of treatments and outcomes (mortality, nonfatal cardiovascular outcomes), among CS and patients without cancer (the noncancer patient [NCP] group) with AMI in Ontario (Canada) using inverse probability treatment weight (IPTW)-adjusted modeling.

RESULTS

Of 270,089 patients with AMI (22,907 CS, 247,182 NCP, 1995-2013; median follow-up, 10.1 and 11.0 years, respectively), the use of invasive coronary strategies and pharmacotherapies increased and mortality declined for CS and NCP (all Ptrend  < .001). At 30 days after AMI, there was no difference between CS and NCP in the receipt of coronary angiography (incidence risk ratio [IRR], 0.98; 95% confidence interval [CI], 0.96-1.01; P = .23), percutaneous coronary intervention (IRR, 0.98; 95% CI, 0.94-1.02; P = .29), or bypass (IRR, 0.93; 95% CI, 0.85-1.02; P = .11). At 90 days after AMI, there was no difference in the receipt of β-blockers, clopidogrel, or nitrates; but CS were less often prescribed angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and statins. CS had higher all-cause mortality at 30 days (adjusted hazard ratio [HR] 1.12; 95% CI, 1.07-1.17; P < .001), at 1 year (1.16; 95% CI, 1.12-1.20; P < .001), and long term (HR, 1.21; 95% CI, 1.17-1.25; P < .001) and had a greater risk of heart failure (HR, 1.08; 95% CI, 1.03-1.14; P = .001), but not myocardial re-infarction (HR, 0.98; 95% CI, 0.95-1.01; P = .22) or stroke (HR, 1.06; 95% CI, 0.97-1.16; P = .18).

CONCLUSIONS

Among CS and NCP with AMI in Ontario, similar improvements in mortality and receipt of treatments were observed between 1995 and 2013. However, compared with NCP, CS had a higher risk of mortality and heart failure. Cancer 2018;124:1269-78. © 2017 American Cancer Society.

Predictive factors of mortality after colectomy in ischemic colitis: an ACS-NSQIP database study

Background

Surgical intervention for ischemic colitis is associated with significant postoperative morbidity and mortality. Predictive factors of adverse outcomes have been reported in the literature, but are based on small sample populations. We sought to identify risk factors for mortality after emergent colectomy for ischemic colitis using a clinical outcomes database.

Methods

The American College of Surgeons National Surgical Quality Improvement Project database was queried from 2010 to 2015 to identify emergent colectomies performed for ischemic colitis using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. Univariate and multivariate logistic regression analysis was used to identify independent risk factors associated with increased risk of mortality.

Results

A total of 4548 patients undergoing emergent colectomies for ischemic colitis were identified. Overall, 30-day postoperative mortality was 25.3%. On univariate analysis, preoperative risk factors associated with a higher rate of mortality include dyspnea, functional status, ventilator dependency, history of chronic obstructive pulmonary disease, ascites, congestive heart failure exacerbation, hypertension, dialysis dependency, cancer, open wounds, chronic steroids, weight loss >10%, transfusions within 72 hours before surgery, septic shock and duration from hospital admission to surgery. Factors that were significant for mortality on logistic regression analysis include elderly age, poor functional status, multiple comorbidities, septic shock, blood transfusion, acute renal failure and the duration of time from hospital admission to surgery.

Conclusions

Postoperative morbidity and mortality rates for ischemic colitis remain significantly high. Identification of risk factors may help patient selection for surgical interventions, and make informed decisions with patients and family members. Although it is certainly challenging, early diagnosis and prompt surgical intervention for patients with ischemic colitis may improve outcomes.

Study type and level of evidence

Therapeutic/care management, level II

Subarachnoid versus Nonsubarachnoid Traumatic Brain Injuries: The Impact of Decision-Making on Patient Safety

Introduction

Traumatic intracranial hemorrhages (ICHs) are high priority injuries. Traumatic brain bleeds can be categorized as traumatic subarachnoid hemorrhage (SAH) versus non-SAH-ICH. Non-SAH-ICH includes subdural, epidural, and intraventricular hematomas and brain contusions. We hypothesize that awake patients with SAH will have lower mortality and needless interventions than awake patients with non-SAH-ICHs.

Study Design and Methods

A review of data collected from our Level I trauma center was conducted. Awake was defined as an initial Glasgow coma score (GCS) 13-15. Patients were divided into two cohorts: awake SAH and awake non-SAH-ICH. Chi-square and t-test analyses were used with statistical significance defined as P < 0.05.

Results

A total of 12,482 trauma patients were admitted during the study period, of which 225 had a SAH and GCS of 13-15 while 826 had a non-SAH-ICH with a GCS of 13-15. There was no significant difference in demographics between the two groups. Predicted survival between the two groups was similar (97.3 vs. 95.7%, P > 0.05). Mortality rates were, however, significantly lower in SAH patients compared to the non-SAH-ICH (4/225 [1.78%] vs. 22/826 [2.66%], P < 0.05). The need for neurosurgical intervention was significantly different comparing the SAH group versus non-SAH-ICH (2/225 [0.89%] vs. 100/826 [12.1%], P < 0.05).

Conclusion

Despite similar predicted mortality rates, awake patients with a SAH are associated with a significantly lower risk of death and need for neurosurgical intervention when compared to other types of awake patients with a traumatic brain bleed.

Mortality outcome and predictive risk factors for death in patients with heart failure and reduced ejection fraction who declined implantable cardioverter defibrillator implantation in Singapore

BACKGROUND

There have been conflicting data regarding the risk of sudden cardiac death (SCD) in Asian population with reduced left ventricular ejection fraction (LVEF). We aim to study mortality outcome and its risk predictors in patients with reduced LVEF who declined an implantable cardioverter defibrillator (ICD) implantation and assess whether current ICD guidelines for primary prevention are applicable to the population in Singapore.

METHODS

This prospective observational study involved 240 consecutive patients who fulfilled the ACC/AHA/HRS criteria for ICD implantation for primary prevention of SCD but declined ICD implantation. Baseline characteristics and mortality outcomes through May 2017 were collected via case-note review after a mean follow-up of 44.8 ± 16.6 months.

RESULTS

Majority of our patients were Chinese (71.3%), followed by Malays (16.2%) and Indians (10.8%). Mean age (±SD) was 61 ± 10 years, and 84% were male. Majority were in New York Heart Association (NYHA) functional classes I (46.7%) and II (46.3%). Over a mean follow-up of 44.8 ± 16.6 months, all-cause mortality rate was 34.6%. Diabetes mellitus (HR = 1.57; 95% CI, 1.01-2.44; P = 0.047) and chronic kidney disease (CKD; HR = 1.95; 95% CI, 1.17-3.23; P = 0.010) were independent predictors of mortality. Patients in NYHA classes II (HR = 2.15; 95% CI, 1.32-3.50; P = 0.002) and III (HR = 2.82; 95% CI, 1.34-5.96; P = 0.007) showed higher risk of death.

CONCLUSION

The mortality rate was comparable with major primary prevention trials. ICD guideline recommendations for primary prevention may thus be applicable to our local population. Patients with diabetes, CKD, and poorer NYHA status exhibited higher mortality rates.

Impact of immigration on outcomes following acute decompensated heart failure: A retrospective cohort study

AIMS

The study aims to investigate the impact of immigration status on short- and long-term outcomes in patients hospitalized with acute decompensated heart failure (ADHF).

METHODS

We conducted a retrospective cohort study at a single centre, analysing 7457 patients admitted for ADHF between 2007 and 2017, with follow-up until 2020 (mean 3.7 ± 3.5 years). Patients were categorized as immigrants (born abroad, 78.1%) or natives (born in Israel, 21.9%). Outcomes included in-hospital mortality, 30 day readmissions, 30 day mortality, 1 year mortality and 5 year all-cause mortality. Kaplan-Meier survival curves, a nonparametric analysis, were used to estimate survival probabilities across multiple timeframes while multivariable logistic and Cox regression analyses adjusted for key covariates such as age, sex and comorbidities. A stratified analysis compared outcomes between adulthood and early-life immigrants.

RESULTS

Immigrants were older than natives (79.0 ± 10.1 vs. 70.8 ± 13.8 years, P < 0.001) and more likely to be female (53.2% vs. 45.0%, P < 0.001). Adjusted analyses revealed that immigration status was independently associated with higher 30 day [odds ration (OR) 1.37, 95% CI 1.12-1.67, P = 0.002], 1 year [hazard ratio (HR) 1.35, 95% confidence interval (CI) 1.19-1.52, P < 0.001] and 5 year mortality (HR 1.20, 95% CI 1.12-1.29, P < 0.001). No significant associations were found for in-hospital mortality (OR 1.26, 95% CI 0.98-1.63, P = 0.07) or 30 day readmissions (OR 0.93, 95% CI 0.79-1.08, P = 0.31). Stratification by immigration age showed similar 5 year mortality between adulthood and early-life immigrants.

CONCLUSIONS

Immigration status independently predicts worse short- and long-term outcomes in ADHF patients. The findings highlight the need for tailored healthcare policies to address disparities and improve outcomes in immigrant populations.

Assessment of Microcirculatory Changes in Patients With Cervical Spinal Cord Injuries and Neurogenic Shock During the Acute Phase Using Near-Infrared Spectroscopy

Background Cervical spinal cord injury (SCI) is a severe condition that can lead to neurogenic shock, a life-threatening complication. Neurogenic shock is characterized by a sudden impairment of sympathetic tone, resulting in vasodilation, hypotension, and bradycardia. This disruption can significantly affect blood flow dynamics, particularly in the microcirculation. Near-infrared spectroscopy (NIRS) is a device that enables the monitoring of tissue oxygenation and the assessment of microcirculatory status. This study aimed to apply NIRS in conjunction with the vascular occlusion test (VOT) to evaluate microcirculatory function in SCI patients with neurogenic shock and analyze its association with in-hospital mortality. Methods This prospective study included cervical SCI patients with neurogenic shock on whom NIRS was performed along with VOT within 24 hours after admission in the ICU (T0). Follow-up measurements were taken at the time of the acute phase (D0), and on days 3, 5, and 7. The de-oxygenation (DeO2) slope, re-oxygenation (ReO2) slope, and the reperfusion area were recorded. The prevalence of microcirculatory dysfunction, and mortality rate were primary outcomes of this study. Results The prevalence of microcirculatory alterations was 239 (92%), with 122 (47%) of patients still exhibiting alterations at day 7 (D7). Survivors had higher NIRS parameters at D0 compared to non-survivors. The ReO2 slope at D0 was significantly decreased in patients who developed new-onset kidney injury and nosocomial infections. Conclusion The prevalence of microcirculatory disturbance was high in patients with an SCI and neurogenic shock, and it was linked to in-hospital mortality and complications.

Unveiling Factors Influencing Mortality in Irish Hip Fracture Patients: A Comprehensive Five-Year Analysis

BACKGROUND

Hip fractures impose a substantial healthcare burden, contributing to increased morbidity, disability, and mortality. The Irish Hip Fracture Standards (IHFS) were officially employed in 2017, providing specialized pathways for hip fracture care to improve patient outcomes. This study evaluated the performance of our unit regarding hip fracture care and analyzed individual outcome parameters.

METHODS

Data spanning 5 years (2015 to 2019) preceding the COVID-19 era were extracted from our hip fracture repository. Patients aged 60 years and more were included. The dataset integrated demographic information and outcomes, validating mortality events using the Irish death events registry. Mortality rates were measured cumulatively and at various time intervals. There were 1,685 hip fractures treated during the study timeframe; average patient age was 78 years, with women constituting 68% of the cohort.

RESULTS

The one-year mortality rate was 20.8% (n = 350). Adverse outcomes were observed in older patients, men, and those who had higher American Society of Anesthesiologists scores. Patients adhering to IHFS 1 (P ≤ 0.05) and IHFS 2 (P ≤ 0.05) exhibited improved outcomes. Our institution displayed lower compliance rates with IHFS 1 and 2 when compared to standards 3 to 6, with the latter standards showing no notable impact on mortality outcomes.

CONCLUSIONS

While our unit's hip fracture care outcomes align well with national averages, resource constraints hinder full compliance with IHFS 1 and 2, emphasizing the need for targeted resource allocation in areas with the greatest impact on outcomes.

Outcomes and factors influencing outcomes of critically ill HIV-positive patients in a tertiary care center in South India

The incidence of (Human immune deficiency) HIV in India has fallen by 58% since the onset of the HIV epidemic. As of 2016 there are 2.1 million people living in India with HIV and only 49% of the adults with HIV are on ART (1). The HIV infected individuals may require intensive care due to various reasons. This study attempts to look at the outcomes of these patients admitted in the intensive care unit and the predictors of these outcomes.

Determinant of 30-Day Mortality of Pulmonary Legionellosis: Do Coinfections Matter?

We retrospectively reviewed 64 cases of cancer with pulmonary legionellosis (Legionella pneumophila in 73%). Nearly all patients received Legionella-active antibiotics, yet 30-day mortality was 23%. Independent predictors of 30-day mortality were hyponatremia, bilateral lung involvement, and Sequential Organ Failure Assessment score ≥5. Lung coinfections were common (31%) but did not significantly increase mortality.