The studies carried out in Spain reveal substantial differences between regions and between hospitals in the management of patients with AMI. 33, 34, 35, 36, 37, 38, 39 and 40 The PRIAMHO I study found no significant differences in the mortality associated with access to a catheterization laboratory, 41 whereas the PRIAMHO II study demonstrated that the improvement in 1-year mortality was related to better access, a more widespread use of reperfusion, and better therapeutic management at discharge. 42 The IBERICA study reported a lower 28-day mortality rate among the AMI patients who were admitted to coronary care units, 43 and a lower mortality due to AMI 30 days after hospital admission has been associated with the opening of a catheterization laboratory. 44 The probability of an AMI patient dying during the hospital stay has been estimated to be 25% higher in hospitals that do not have an intensive care unit. 35 Studies carried out by the Spanish Agencia de Evaluación de Tecnologías Sanitarias (Agency for the Evaluation of Heath Care Technologies) found a higher in-hospitalmortality rate in AMI patients who did not undergo an interventional coronary procedure, 45 but they did not report differences in mortality related to the technological level of the centers. 16 The GYSCA study found that the treatment received by patients with non-ST elevation acute coronary syndrome admitted to hospitals with no catheterization laboratory differed more widely from that recommended by the guidelines; these investigators observed no significant differences in in-hospitalmortality, but the incidence of readmission was significantly higher. 38 The MASCARA study found no relationship between the performance of primary percutaneous coronary intervention in patients with ST-elevation acute coronary syndrome and survival at 6 months. 36
dysfunction, usually defined as creatinine > 1.5 mg/dL, was the most robust predictor of death among prog- nostic parameters for in-hospitalmortality in patients with SBP. That finding warrants the iden- tification of patients at high risk of death and the intravenous administration of albumin to reduce re- nal impairment and improve survival, as previously described. 17 Another study analyzing four data sets 18
Results. A total of 22,901 patient-years were included in the analysis, with 6917 hospital admissions, corresponding to 1937 subjects (75% male, mean age 36 ± 11 years, 37% HIV/HCV co-infected patients). The median length of hospital stay was 8 days (5–16), and the 30-day hospital re-admission rate was 20.1%. A significant decrease in hospital admissions related with infectious and psychiatric diseases was observed in the last period (2003–2013), but there was an increase in those related with malignancies, cardiovascular, gastrointestinal, and chronic respiratory diseases. In-hospitalmortality remained high (6.8% in the first period vs. 6.3% in the second one), with a progressive increase of non-AIDS-defining illness deaths (37.9% vs. 68.3%, P < .001). The admission rate significantly dropped after 1996 (4.9% yearly), but it was less pronounced in HCV co-infected patients (1.7% yearly).
jects with RF when compared to patients without RF (26 vs. 1%, p < 0.000001), particularly in res- pect to RF due to HRS type 1 and bacterial infections (Table 4). Overall, patients with RF, with exception of those with parenchymal kidney disease, had hig- her mortality, when compared to their counterparts without RF. In regard to the cause of RF, mortality in the group of patients with HRS type 1 was signi- ficantly higher, when compared to other groups with the exception of HRS type 2 (Table 4). On the other hand, subjects with RF due to hypovolemia and parenchymal kidney diseases had lower mortali- ty, when compared to their counterparts with HRS type 1 and with bacterial infections. In addition, subjects with parenchymal kidney diseases have lo- wer mortality even when compared to their counter- parts with HRS type 2 (Table 4).
All cirrhotic patients from a database with a diagno- sis of an acute EVB episode admitted to our hospital between 2003 and 2006 were studied. The inclusion criteria were: adult patients with diagnosis of hepatic cirrhosis of any etiology (diagnosed by liver biopsy, clinical manifestations and/or imaging studies) and acute EVB (hematemesis and/or melena occurred dur- ing a period of 24 hrs before admission due to endo- scopically confirmed esophageal varices). We exclud- ed non-cirrhotic patients with EVB or cirrhotic pa- tients with any other source of bleeding such as gastric varices, congestive gastropathy or ectopic varices and as well as patients with hepatocellular carcinoma. Vari- ables such as age, gender, comorbid entities, etiology of cirrhosis and type of haemostatic treatment were re- corded for each patient. The variceal size was defined by the Paquet classification. 18
Our overall cumulative survival was 88.2% at one year, 76.6% at five years, and 42.3% at 10 years. The low 10-year survival is attributed to the average patient age of almost 76 years at implantation in our series, and it is in line with the results obtained in other studies with similar populations. The fact that respiratory and cancer diseases were among the three most common causes of death after hospital discharge further identifies an aging population with a significant number of associated comorbidities. In fact, preoperative expected mortality rose to 10.4% ± 10.8% as estimated by logistic euroSCORE. Conversely, our in-hospitalmortality was 6.7% which is in line with that reported in other series with similar high-risk populations.[3, 21]
Study outcome and prognostic variables. The pri- mary outcome of the study was in-hospitalmortality, consistent with the APACHE-II methodology. All can- didate prognostic variables (risk factors) for in-hospitalmortality were chosen from the components of the APACHE-II model: (1) the Acute Physiology Score (APS) and (2) the Chronic Health (CH) status, classified as a binary variable according to whether or not the patient had any chronic health dysfunction; that is, a history of severe organ system insufficiency as defined in the original APACHE-II study 5 ; (3) operative urgency classified with
fore diagnostic endoscopy. However, there are no studies specifically addressing the benefits of vasoactive drugs in patients with ET depending on their baseline liver func- tion. Furthermore, current recommendations for manage- ment of AVB do not differ for patients with different functional hepatic reserve. The use of these vasoactive drugs carries a risk of side effects and increases the cost of medical care. These considerations suggest that patients might benefit from a stratified approach to treatment, tak- ing into account the baseline risk of the patient. Indeed, the Baveno VI workshop was entitled “Stratifying risk and individualizing care for portal hypertension”. Thus, the aims of this retrospective comparative study was to ana- lyze the failure to control bleeding, hospitalmortality and transfusion requirements among patients with AVB ac- cording to their functional hepatic reserve assessed by the CP score and the Model for End-stage Liver Disease (MELD).
In patients admitted to the intensive care unit (ICU), the extra mortality due to VAP remains a controversial issue in the literature. Previous studies have reached conflicting conclusions regarding the impact of VAP on mortality [1,8-17]. Although the gross mortality rate is high, there are doubts as to whether the higher mortality rate is due to VAP itself or to the seriousness of the underlying illness. Patients undergoing heart surgery are at a particularly high risk for the development of VAP due to the presence of multiple comorbidities, frequent postoperative use of invasive devices (eg, intraaortic balloon counterpulsation, pulmonary artery catheter), and the common use of cardiopulmonary bypass (CPB). At the same time, in- hospital patients are also at risk for multiple postoperative events (eg, myocardial infarction [MI], congestive heart failure, acute renal failure, strokes) [1-4,16,18,19]. These comorbidities complicate the evaluation of the impact of VAP on mortality . The repercussions of VAP on in- hospitalmortality have not been adequately studied in the area of cardiac surgery.
Composite. Table 7 summarizes the PIRO domains with each respective strat- ification level. The risk associated with each of the PIRO components was as- sessed in both of the datasets (Table 8). For the PROWESS placebo database, all individual components except R have a significant increase in odds ratio for mor- tality in logistic regression after adjust- ment for an earlier variable for PIRO, and as noted, because of the observed odds ratio and width of confidence interval, this may be due to underpowered sample sizes of PROWESS to detect “R” effects. The Hosmer-Lemeshow tests for PROWESS (p ⫽ 0.33) indicate that the model using P, I, R, and O has a good fit of the data across all patients, from high to low risk of death. In the PROGRESS dataset, all PIRO components were significant (p ⬍ 0.0001). Generally, all of the components were similar in their increase in risk of death for every one-point increase (odds ratios range from 1.3 to 1.5 for one level increases). A nonsignificant Hosmer- Lemeshow test (p ⫽ 0.45) indicated that the model had a good fit of the data across all patients, from high to low risk of death. Comparing odds ratios allows one to assess the relative contributions of changes in each component. Because, generally, all of the components were similar in their increase in risk of death for every one point increase, we per- formed an analysis of mortality by com- posite PIRO score with a minimum of 0 and a maximum of 13. Figure 1, A and B demonstrate the in-hospitalmortality by composite PIRO score from PROWESS and PROGRESS, respectively. In PROWESS, the correlation of the PIRO total score and in-hospitalmortality rates was 0.974 (p ⬍ 0.0001), and in PROGRESS, the correlation of the PIRO total score and hospitalmortality rates was 0.998 (p ⬍ 0.0001).
The main outcome measure was in-hospitalmortality from any cause, but we also assessed 90-day mortality. Sample size was calculated considering a difference of 10% in hospitalmortality between groups as relevant, the frequency of the alle- les in the population (control group), and a β error of 20% and an α error of 5%. An interim analysis was planned after 225 patients were enrolled. At that point, the absolute difference in mortality between AA individuals of TNF-β (the polymorphisms more consistently associated with mortality) and GG/GA indi- viduals was only 5%, and this was considered not clinically rel- evant in septic patients, whose outcome is influenced by many variables. With these data, it would be required to enroll 2,500 patients to achieve statistical significance. For these reasons, we elected to terminate the study.
Apparently, the reduction of in-hospitalmortality of patients with acute coronary syndromes has led to an increased number of cases with chronic coronary diseases that are likely to suffer new cardiovascular events. A 3-year follow-up of the REACH (Reduction of atherothrombosis for Continued Health) trial revealed that all cardiovascular events increase from 25.5 to 40.5%, and cardiovascular mortality increases from 4.7 to 8.8% if more than one vascular region is affected 32 .
non-cardiovascular deaths, and only 5.6% were secondary to PCI complications (Table III). In- hospitalmortality was 16.4% (12 patients). Four patients died during PCI (1 tamponade, 1 elec- tro-mechanic dissociation, and 2 had cardiogenic shock). At one year of follow-up there were 6 deaths (7.8%). Five-year follow-up was complet- ed in 35% of the patients; 3 deaths occurred during this period of time (1-5 years), and 2 had TVR due to acute coronary syndromes). Univariate analysis is showed in Table IV. Car- diogenic shock and heart failure were strongly associated with MACE and mortality (P < 0.001) and, the presence of complete A-V Block or atri- al fibrillation (AF) was also associated with both (p = 0.002 and p = 0.001, respectively). Follow-up survival time and free composite end point survival time are showed in Table IV and by Kaplan-Meier survival curves in figure 1. Among other previously known factors the presence of A-V block or AF and the presence of diabetes were significantly associated with MACE and mortality at 1-year follow-up (p < 0.05).
The study of compression of mortality and variability of age at death are very important and contribute to a better understanding of the changing health status of the elderly popula- tion, especially regarding the duration of active and disabled years of life around the age of death (Stallard, 2016; Edwards and Tuljapurkar, 2005). In fact, a reduction in the variability of age at death with an increase in the average age of death is of crucial importance for public health planners, since the diseases that affect these individuals are chronic, mostly requiring monitoring of conditions over a long period of time (Stallard, 2016). As noted by Canudas- Romo (2010), delayed mortality implies that a more heterogeneous group of the population is reaching older ages and we can expect that health differentials and disparities that are common in early life in lac, are now persisting in older age groups. In the near future, health systems in Latin America, and families, will have to deal with a larger and more diverse range of health issues, at older ages. This might imply larger costs and more complex interventions to mitigate the differences.
The wealth of scientific production found in the literature is focused on the negation or corroboration of the hypotheses of absolute income and income inequality. This problem was investigated by Wilkinson in a series of articles with income as a predictive variable of health conditions. He demonstrated that absolute income (mean income) and not income inequality is important in determining the health status of individuals in poor countries (Wilkinson, 1992; Braveman, 2002; Blakely et al., 2003). During the 1990s and the first years of this decade, various studies were published in different parts of the world, correlating income level and income inequality with mortality. The results, for the most part, corroborate the hypothesis of absolute income for poor countries and the hypothesis of income inequality for rich countries (Ghosh y Kulkarni, 2004; Rossi et al., 2000).
This study included data for all PLWH followed in an ambispective cohort in a reference HIV clinic (University Hospital of A Coruña, Spain) between 1993 and 2014. All hospital admissions and the causes of death were obtained from the hospital records encoded according to the International Classification of Diseases (ICD-9). Liver-related disease was considered to include the following codes: viral hepatitis (070, 573.3), alcoholic liver disease (571.0−571.3), nonalcoholic liver disease (570, 571.4−571.9, 572−573), primary liver cancer (155), and decompensated cirrhosis (789.5, 567.23, 456.0). Cholelithiasis and cholecystitis (574−575) were not included as liver-related conditions. Fatal infections occurring in PLWH with cirrhosis were classified as liver-related deaths/hospitalizations when the episode included a code for cirrhotic decompensation.
To date, only five cohort studies have been published exploring the relationship between the use of oral antibi- otics and mortality for IMD [7,12-15]. Except for the cohort analysed by Barquet et al., no other study has con- trolled for the relationship between use of antibiotics and death for any covariable. Although all the studies found benefits to be gained from oral antibiotics, some authors, such as Morant, advise against their use, on the grounds that this treatment reduces the possibility of obtaining an accurate microbiological diagnosis and that the benefit in terms of survival is not significant. Indication bias can be observed in the work of García et al., in which all the patients who received oral antibiotherapy presented men- ingitis as a clinical form on admission to hospital. Only the study by Barquet et al. found a significant association between oral antibiotics and mortality. This association was controlled for age, neurological focus and haemor- rhagic diathesis. Of these groups, two could be inferred by the use of antibiotics (neurological focus and haemor- rhagic diathesis). In other words, pre-hospital antibiotics could, theoretically, have influenced the appearance or otherwise of these two symptoms; thus, the use of clinical items present at admission to hospital is not a good way of controlling the previous use of antibiotherapy. As the use of antibiotics may well modify the progression and prognosis of IMD, it is preferable to control the relation- ship between antibiotics and mortality through a variable that is less affected by treatment. Accordingly, we built our propensity score using symptoms studied in the anamne- sis. This explains why the antibiotics prescribed and the
tients of compensated cirrhosis. At baseline HPS was present in 24% patients. They found a signifi- cant association between patient survival and HPS even after adjusting for Child-Pugh score. In sub- group analyses, HPS increased mortality in Child class C patients only. In their study patients with HPS had median survival 10.6 months as compared to patients without HPS who had median survival of 40.8 months. Besides HPS and Child-Pugh class, age and blood urea nitrogen were also independently associated with survival. Similar findings were ob- served in a study by Fallon, et al. 6 in which HPS
This study has a number of limitations. We must mention the lack of data and follow-up information from patients who were treated at our institution before the Orthogeriatric Program’s implementation. Therefore, performing any com- parisons between our patients and those treated before them is of extreme diffi- culty, which was one of the reasons we stratified according to year of admittance. Likewise, any analysis on the impact of this program in terms of survival or mortality rates at our institution cannot be completed. It is worth mentioning that there are multiple covariates associated with mortality and outcome that were not assessed, such as costs and health care system limitations, which can also influ- ence results. Thus, any conclusions made on our population must be carefully weighed when comparing other populations, especially in developed countries, as this model was based on the particular needs of our population and the institu- tion. Finally, because these programs imply different interventions on patients, we cannot directly assess the impact of any specific interventions on mortality.