Hemodiafiltration: a synergy yet to be convincing / Hemodiafiltração: uma sinergia ainda não convincente

ABSTRACT The desperate attempt to improve mortality, morbidity, quality of life and patient-reported outcomes in patients on hemodialysis has led to multiple attempts to improve the different modes, frequencies, and durations of dialysis sessions in the last few decades. Nothing has been more appealing than the combination of diffusion and convection in the form of hemodiafiltration. Despite the concrete evidence of better clearance of middle weight molecules and better hemodynamic stability, tangible evidence to support the universal adoption is still at a distance. Survival benefits seen in selected groups who are likely to tolerate hemodiafiltration with better vascular access and with lower comorbid burden, need to be extended to real life dialysis patients who are older than the population studied and have significantly higher comorbid burden. Technical demands of initiation hemodiafiltration, the associated costs, and the incremental benefits targeted, along with patient-reported outcomes, need to be explored further before recommending hemodiafiltration as the mode of choice.

RESUMO A tentativa desesperada de melhorar a mortalidade, morbidade, qualidade de vida e desfechos relatados pelos pacientes em indivíduos em hemodiálise levou a diversas tentativas de aprimorar os diferentes modos, frequências e durações das sessões de diálise nas últimas décadas. Nada foi mais atrativo do que a combinação de difusão e convecção na forma de hemodiafiltração. Apesar das evidências concretas de melhor depuração de moléculas de peso médio e melhor estabilidade hemodinâmica, evidências tangíveis para apoiar a adoção universal ainda estão distantes. Os benefícios de sobrevida observados em grupos selecionados que provavelmente toleram a hemodiafiltração com melhor acesso vascular e com menor carga de comorbidades precisam ser estendidos aos pacientes reais em diálise, que são mais velhos do que a população estudada e apresentam uma carga de comorbidades significativamente maior. As exigências técnicas do início da hemodiafiltração, os custos associados e os benefícios incrementais almejados, juntamente com os desfechos relatados pelos pacientes, precisam ser melhor explorados antes de se recomendar a hemodiafiltração como o modo de escolha.

Asociación entre Glucemia inestable, tiempo de estancia y mortalidad de pacientes en estado críticos: Estudio de cohorte / Associação Entre Glicemia Instável, Tempo de Permanência e Mortalidade de Pacientes Críticos: Estudo de Coorte / Relationships between unstable Glycemia, Hospital Length Of Stay, and mortality In Critically Ill patients: A cohort study

Resumen Introducción: El control y la evaluación de los niveles glucémicos de pacientes en estado críticos es un desafío y una competencia del equipo de enfermería. Por lo que, determinar las consecuencias de esta durante la hospitalización es clave para evidenciar la importancia del oportuno manejo. Objetivo: Determinar la asociación entre la glucemia inestable (hiperglucemia e hipoglucemia), el resultado de la hospitalización y la duración de la estancia de los pacientes en una unidad de cuidados intensivos. Metodología: Estudio de cohorte prospectivo realizado con 62 pacientes a conveniencia en estado crítico entre marzo y julio de 2017. Se recogieron muestras diarias de sangre para medir la glucemia. Se evaluó la asociación de la glucemia inestable con la duración de la estancia y el resultado de la hospitalización mediante ji al cuadrado de Pearson. El valor de p<0.05 fue considerado significativo. Resultados: De las 62 personas participantes, 50 % eran hombres y 50 % mujeres. La edad media fue de 63.3 años (±21.4 años). La incidencia de glucemia inestable fue del 45.2 % y se asoció con una mayor duración de la estancia en la UCI (p<0.001) y una progresión a la muerte como resultado de la hospitalización (p=0.03). Conclusión: Entre quienes participaron, la glucemia inestable se asoció con una mayor duración de la estancia más prolongada y con progresión hacia la muerte, lo que refuerza la importancia de la actuación de enfermería para prevenir su aparición.

Resumo Introdução: O controle e avaliação dos níveis glicêmicos em pacientes críticos é um desafio e uma competência da equipe de enfermagem. Portanto, determinar as consequências da glicemia instável durante a hospitalização é chave para evidenciar a importância da gestão oportuna. Objetivo: Determinar a associação entre glicemia instável (hiperglicemia e hipoglicemia), os desfechos hospitalares e o tempo de permanência dos pacientes em uma unidade de terapia intensiva. Métodos: Um estudo de coorte prospectivo realizado com 62 pacientes a conveniência em estado crítico entre março e julho de 2017. Foram coletadas amostras diariamente de sangue para medir a glicemia. A associação entre a glicemia instável com o tempo de permanência e o desfecho da hospitalização foi avaliada pelo teste qui-quadrado de Pearson. O valor de p <0,05 foi considerado significativo. Resultados: Das 62 pessoas participantes, 50% eram homens e 50% mulheres. A idade média foi de 63,3 anos (±21,4 anos). A incidência de glicemia instável foi de 45,2% e se associou a um tempo de permanência mais prolongado na UTI (p <0,001) e uma progressão para óbito como desfecho da hospitalização (p = 0,03). Conclusão: Entre os participantes, a glicemia instável se associou a um tempo mais longo de permanência e com progressão para óbito, enfatizando a importância da actuação da equipe de enfermagem para prevenir sua ocorrência.

Abstract Introduction: The control and evaluation of glycemic levels in critically ill patients is a challenge and a responsibility of the nursing team; therefore, determining the consequences of this during hospitalization is key to demonstrate the importance of timely management. Objective: To determine the relationship between unstable glycemia (hyperglycemia and hypoglycemia), hospital length of stay, and the hospitalization outcome of patients in an Intensive Care Unit (ICU). Methods: A prospective cohort study conducted with 62 critically ill patients by convenience sampling between March and July 2017. Daily blood samples were collected to measure glycemia. The correlation of unstable glycemia with the hospital length of stay and the hospitalization outcome was assessed using Pearson's chi-square. A p-value <0.05 was considered significant. Results: Among the 62 patients, 50% were male and 50% were female. The mean age was 63.3 years (±21.4 years). The incidence of unstable glycemia was 45.2% and was associated with a longer ICU stay (p<0.001) and a progression to death as a hospitalization outcome (p=0.03). Conclusion: Among critically ill patients, unstable glycemia was associated with an extended hospital length of stay and a progression to death, emphasizing the importance of nursing intervention to prevent its occurrence.

Mortality and its predictors in abdominal injury across sub-Saharan Africa: systematic review and meta-analysis.

BACKGROUND: Abdominal injuries exert a significant impact on global morbidity and mortality. The aggregation of mortality data and its determinants across different regions holds immense importance for designing informed healthcare strategies. Hence, this study assessed the pooled mortality rate and its predictors across sub-Saharan Africa. METHOD: This meta-analysis employed a comprehensive search across multiple electronic databases including PubMed, Africa Index Medicus, Science Direct, and Hinari, complemented by a search of Google Scholar. Subsequently, data were extracted into an Excel format. The compiled dataset was then exported to STATA 17 statistical software for analysis. Utilizing the Dersimonian-Laird method, a random-effect model was employed to estimate the pooled mortality rate and its associated predictors. Heterogeneity was evaluated via the I2 test, while publication bias was assessed using a funnel plot along with Egger's, and Begg's tests. RESULT: This meta-analysis, which includes 33 full-text studies, revealed a pooled mortality rate of 9.67% (95% CI; 7.81, 11.52) in patients with abdominal injuries across sub-Saharan Africa with substantial heterogeneity (I2 = 87.21%). This review also identified significant predictors of mortality. As a result, the presence of shock upon presentation demonstrated 6.19 times (95% CI; 3.70-10.38) higher odds of mortality, followed by ICU admission (AOR: 5.20, 95% CI; 2.38-11.38), blunt abdominal injury (AOR: 8.18, 95% CI; 4.97-13.45), post-operative complications (AOR: 8.17, 95% CI; 4.97-13.44), and the performance of damage control surgery (AOR: 4.62, 95% CI; 1.85-11.52). CONCLUSION: Abdominal injury mortality is notably high in sub-Saharan Africa. Shock at presentation, ICU admission, blunt abdominal injury, postoperative complications, and use of damage control surgery predict mortality. Tailored strategies to address these predictors could significantly reduce deaths in the region.

The effects of health risk behaviors to excess mortality in the population with depression: A cohort study based on NHANES data.

BACKGROUND: The population with depression had a considerable excess mortality risk. This increased mortality may be attributed to the biological consequences of depression or the substantial prevalence of health risk behaviors (HRBs). This study aimed to quantify the combined effects of four major HRBs - smoking, excessive alcohol use, physical inactivity, and an unhealthy diet - on excess mortality among depressed individuals. METHODS: This study included 35,738 adults from the National Health and Nutrition Examination Survey 2005-06 to 2017-18, with mortality follow-up data censored through 2019. The standardized prevalence of HRBs was calculated for populations with and without depression. Poisson regression models were used to calculate the mortality rate ratio (MRR). Based on model adjusting for socio-demographic factors, the attenuation of MRR was determined after further adjustment for HRBs. RESULTS: A total of 3147 participants were identified as having depression. All HRBs showed a significantly higher prevalence among the population with depression. After adjusting for socio-demographic factors, depression was associated with 1.7 and 1.8 times higher all-cause and cardiovascular disease mortality rate, respectively. Further adjustment for all current HRBs resulted in a 21.9 % reduction in all-cause mortality rate and a 15.4 % decrease in cardiovascular disease mortality rate. LIMITATION: HRBs were reported at a single time point, and we are unable to demonstrate a causal effect. CONCLUSION: At least 1/5 of excess mortality for population with depression was attributable to HRBs. Efforts should be made to address HRBs among population with depression.

Multi-center study on mortality in children, and adults with sickle cell anemia-risk factors and causes of death.

Sickle cell disease (SCD) is a major public health burden worldwide with increasing morbidity and mortality. The study evaluates the risk factors associated with mortality in SCD patients, between the years 2006 and 2020 at three hospitals in Oman. The analysis includes clinical manifestations, haematological, biochemical, and radiological parameters, use of antibiotics, and blood and exchange transfusions. Our cohort included 123 patients (82 males, 41 females), with a median age of 27 (Interquartile Range 21-35 years). SCD related complications included acute chest syndrome (ACS) in 52.8%, splenic sequestration in 21.1%, right upper quadrant syndrome in 19.5%, more than > 6 VOC/year in 17.9%, and stroke in 13.8%. At the terminal admission, patients had cough, reduced O2 saturation, crepitation and fever in 24.4%, 49.6%, 53.6% and 68.3% respectively. Abnormal chest X-ray and chest CT scan were seen in 57.7%, and 76.4% respectively. Laboratory parameters showed a significant drop in hemoglobin (Hb) and platelet counts from baseline, with a significant rise in WBC, LDH and CRP from baseline (p < 0.05, Wilcoxon Signed Ranks test). All patients received antibiotics, whereas, 95.9% and 93.5% received simple blood transfusions, and exchange transfusions respectively, and 66.6% required non-invasive ventilation. Among the causes of death, ACS is seen in 32 (26%), sepsis in 49 (40%), and miscellaneous in 42 (34%). Sudden death was seen in 32 (26%) of patients. Male gender, with low HbF, rapid drop in Hb and platelet, and increased in WBC, LDH, ferritin, and CRP, correlated significantly with mortality in this cohort.

New Perspectives in the Association between Anthropometry and Mortality: The Role of Calf Circumference.

AIMS: Considering the impact of sarcopenia on mortality, and the difficulty to assessment of body composition, the hypothesis of the study is that calf circumference (CC) is closely related to mortality in older patients. The aim of the study was to analyze the potential role of CC to predict mortality in old individuals at 3, 6 and 12 months after discharge from hospital. METHODS: Patients aged >65 years were recruited for this retrospective study from September 2021 to March 2022. Their physical and body composition characteristics (including Body Mass Index-BMI and Mini Nutritional Assessment-MNA) were measured; data on mortality at 3 (T3), 6 (T6) and 12 (T12) months after discharge were recorded. Sarcopenia was diagnosed according to the 2019 European Consensus criteria. RESULTS: Participants were 192 older adults (92 women), with a mean age of 82.8±7.0 years. Sarcopenic people were 41. The mortality rate was higher in sarcopenic people only at T3 and T6. CC had comparable validity in predicting mortality to that of MNA and ASMMI (Appendicular Skeletal Muscle Mass), and was better than BMI and serum albumin at each time point. Youden's index showed that the best cut-off for CC for predicting mortality was 30.6 cm both at T3 (sensitivity: 74%; specificity: 75%) and T6 (sensitivity: 75%; specificity: 67%). At the Cox regression model for mortality, high values of CC (HR 0.73, CI95% 0.60-0.89/p<0.001) and ADL scores (HR 0.72, CI95% 0.54-0.96/p=0.04) were protective factors at T6 and T12 respectively; at T12 high comorbidity rate was a risk factor (HR 1.28, IC95% 1.02-1.62/p=0.04). CONCLUSIONS: CC has a validity comparable to MNA and ASMMI in predicting mortality at 3, 6 and 12 months after hospital discharge. Moreover, it can be considered an independent predictor of medium-term mortality in the hospitalized older population. CC can be an effective method for the prognostic stratification of these patients, due to its simplicity and immediacy.

Co-Occurrence of Sarcopenia and Frailty in Acutely Admitted Older Medical Patients: Results from the Copenhagen PROTECT Study.

BACKGROUND: Sarcopenia and frailty are often used interchangeably in clinical practice yet represent two distinct conditions and require different therapeutic approaches. The literature regarding the co-occurrence of both conditions in older patients is scarce as most studies have investigated the prevalence of sarcopenia and frailty separately. OBJECTIVES: We aim to evaluate the prevalence and co-occurrence of sarcopenia and frailty in a large sample of acutely admitted older medical patients. DESIGN: Secondary analyses using cross-sectional data from the Copenhagen PROTECT study. SETTING: Patients were included from the acute medical ward at Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark, between November 2019 and November 2021. PARTICIPANTS: Acutely admitted older medical patients (≥65 years). MEASUREMENTS: Handgrip strength (HGS) was investigated using a handheld dynamometer. Lean mass (SMI) was investigated using direct-segmental multifrequency bioelectrical impedance analyses (DSM-BIA). Low HGS, low SMI, and sarcopenia were defined according to the recent definitions from the European Working Group on Sarcopenia in Older People (EWGSOP2). The Clinical Frailty Scale (CFS) was used to evaluate frailty, with a value > 5 indicating the presence of frailty. Patients were enrolled and tested within 24 hours of admission. RESULTS: This study included 638 patients (mean age: 78.2±7.6, 55% female) with complete records of SMI, HGS, and the CFS. The prevalence of low HGS, low SMI, sarcopenia, and frailty were 39.0%, 33.1%, 19.7%, and 39.0%, respectively. Sarcopenia and frailty co-occurred in 12.1% of the patients. CONCLUSIONS: It is well-known that sarcopenia and frailty represent clinical manifestations of ageing and overlap in terms of the impairment in physical function observed in both conditions. Our results demonstrate that sarcopenia and frailty do not necessarily co-occur within the older acutely admitted patient, highlighting the need for separate assessments of frailty and sarcopenia to ensure the accurate characterization of the health status of older patients.

No healthcare coverage, big problem: lack of insurance for older population associated with worse emergency general surgery outcomes.

Introduction: Older populations, being a unique subset of patients, have poor outcomes for emergency general surgery (EGS). In regions lacking specialized medical coverage for older patients, disparities in healthcare provision lead to poor clinical outcomes. We aimed to identify factors predicting index admission inpatient mortality from EGS among sexagenarians, septuagenarians, and octogenarians. Methods: Data of patients aged >60 years with EGS conditions defined by the American Association for the Surgery of Trauma at primary index admission from 2010 to 2019 operated and non-operated at a large South Asian tertiary care hospital were analyzed. The primary outcome was primary index admission inpatient 30-day mortality. Parametric survival regression using Weibull distribution was performed. Factors such as patients' insurance status and surgical intervention were assessed using adjusted HR and 95% CI with a p-value of <0.05 considered statistically significant. Results: We included 9551 primary index admissions of patients diagnosed with the nine most common primary EGS conditions. The mean patient age was 69.55±7.59 years. Overall mortality and complication rates were 3.94% and 42.29%, respectively. Primary index admission inpatient mortality was associated with complications including cardiac arrest and septic shock. Multivariable survival analysis showed that insurance status was not associated with mortality (HR 1.13; 95% CI 0.79, 1.61) after adjusting for other variables. The odds of developing complications among self-paid individuals were higher (adjusted OR 1.17; 95% CI 1.02, 1.35). Conclusion: Lack of healthcare coverage for older adults can result in delayed presentation, leading to increased morbidity. Close attention should be paid to such patients for timely provision of treatment. There is a need to expand primary care access and proper management of comorbidities for overall patient well-being. Government initiatives for expanding insurance coverage for older population can further enhance their healthcare access, mitigating the risk of essential treatments being withheld due to financial limitations. Level of evidence: III.

The potential of urban trees to reduce heat-related mortality in London.

Increasing temperatures and more frequent heatwave events pose threats to population health, particularly in urban environments due to the urban heat island (UHI) effect. Greening, in particular planting trees, is widely discussed as a means of reducing heat exposure and associated mortality in cities. This study aims to use data from personal weather stations (PWS) across the Greater London Authority to understand how urban temperatures vary according to tree canopy coverage and estimate the heat-health impacts of London's urban trees. Data from Netatmo PWS from 2015-2022 were cleaned, combined with official Met Office temperatures, and spatially linked to tree canopy coverage and built environment data. A generalized additive model was used to predict daily average urban temperatures under different tree canopy coverage scenarios for historical and projected future summers, and subsequent health impacts estimated. Results show areas of London with higher canopy coverage have lower urban temperatures, with average maximum daytime temperatures 0.8 °C and minimum temperatures 2.0 °C lower in the top decile versus bottom decile canopy coverage during the 2022 heatwaves. We estimate that London's urban forest helped avoid 153 heat attributable deaths from 2015-2022 (including 16 excess deaths during the 2022 heatwaves), representing around 16% of UHI-related mortality. Increasing tree coverage 10% in-line with the London strategy would have reduced UHI-related mortality by a further 10%, while a maximal tree coverage would have reduced it 55%. By 2061-2080, under RCP8.5, we estimate that London's current tree planting strategy can help avoid an additional 23 heat-attributable deaths a year, with maximal coverage increasing this to 131. Substantial benefits would also be seen for carbon storage and sequestration. Results of this study support increasing urban tree coverage as part of a wider public health effort to mitigate high urban temperatures.

Implementing Community-Based Strategies for Improved Pneumonia Care in Children: Insights From a Pilot Study.

INTRODUCTION: Respiratory ailments, encompassing a spectrum of disorders, are a leading cause of mortality and morbidity in children, with pneumonia being particularly significant, accounting for 16% of child mortality. To ensure timely engagement with healthcare services, it is imperative to instill awareness through Information, Education, and Communication (IEC) initiatives targeting mothers of children under five. The primary objective of this pilot study is to assess the feasibility of a community-based intervention on health-seeking behaviour, knowledge, and practice measures concerning the management and prevention of pneumonia in children. METHODOLOGY: The pilot study mirrored the main study's procedures in two villages, Bhuvanahalli and Gavanahalli, each randomly assigned as either an experimental or a control group. We selected 12 mothers with children under the age of five who had community-acquired pneumonia, employing a straightforward random technique, with six mothers from each group. These mothers were interviewed using a structured questionnaire focusing on health-seeking behaviour, knowledge, and practices related to the management and prevention of pneumonia. Mothers in the experimental group received a community-based intervention, specifically an educational set focusing on health-seeking behaviour, knowledge, and practice measures concerning the management and prevention of pneumonia in children, while those in the control group continued with their routine practices. We collected post-test data from the mothers in both groups at the 2nd, 4th, and 6th months of the intervention. The data analysis was conducted using the IBM SPSS Statistics for Windows, Version 28 (Released 2021; IBM Corp., Armonk, New York) software. The Mann-Whitney test and Kruskal-Wallis analyses indicated a notable and statistically significant shift in health-seeking behaviour, knowledge, and practices pertaining to the management and prevention of pneumonia in children as a result of the community-based educational intervention implemented in the experimental group (P<0.05). CONCLUSION: Community-based intervention is crucial to preventing mortality and morbidity in children. The findings of the pilot study affirm its feasibility and lay a strong foundation for further investigation and implementation.

An Upsurge of Measles Cases in Mali-a Consequence of Pandemic-associated Disruption in Routine Immunization.

Measles deaths highlight immunization program gaps. In the Child Health and Mortality Prevention Surveillance study in Mali, we observed a rise in under-5 measles-related deaths in 2022 that corresponded with increased measles cases at the same time and a decline in measles vaccine coverage in Mali in 2020.

Long Term Survival Benefits of Different Conduits Used in Coronary Artery Bypass Graft Surgery- A Single Institutional Practice Over 20 Years.

Objective: This study determined hazard factors and long-term survival rate of total arterial coronary artery bypass graft surgery over 20 years in an extensively large, population-based cohort. Methods: A total of 2979 patients who underwent isolated CABG from April 1999 to March 2020 were studied in 4 groups- Group-A (bilateral internal mammary artery ± radial artery), Group-B (single internal mammary artery + radial artery ± saphenous vein), Group-C (single internal mammary artery ± saphenous vein; no radial artery), and Group-D (radial artery ± saphenous vein; no internal mammary artery). The study endpoints analysed the correlation between the number and types of grafts with the survival time following isolated CABG surgery. Results: The total arterial revascularization (Group A) group had an admirable mean long-term survival of ~19 years, compared to 18.6 years (Group B), 15.86 years (Group C), and 10.99 years (Group D). A Kaplan-Meier curve demonstrated confidence interval (CI) for study groups- (95% CI 18.33-19.94), (95% CI 18.14-19.06), (95% CI 15.40-16.32), and (95% CI 9.61-12.38) in Group A, B, C, D respectively. In the Holm-Sidak method analysis, significant associations existed between the number of arterial grafts and the long-term outcome. A statistically significant (P≤0.05) long-term survival advantage for arterial grafting was demonstrated, especially total arterial revascularisation over all other combinations except single internal mammary artery + radial artery grafting. Conclusion: In this series, over 20 years, total arterial CABG use has excellent long-term survival, achieving complete myocardial revascularisation. There is no significant difference between the BIMA group and SIMA with radial artery. However, there is a reduced survival with decreased use of arterial conduits.

Ambient air pollution and mortality: The role of socioeconomic conditions.

Background: There is a vast body of literature covering the association between air pollution exposure and nonaccidental mortality. However, the role of socioeconomic status (SES) in this relationship is still not fully understood. Objectives: We investigated if individual and contextual SES modified the relationship between short-term exposure to ozone (O3), nitrogen dioxide (NO2), and particulate matter with aerodynamic diameter <10 µm (PM10) on cardiovascular, respiratory, and all nonaccidental mortality. Methods: We conducted a time-stratified case-crossover study. Analyses were based on information on 280,685 deaths from 2011 to 2015 in the city of São Paulo. Education was used as an individual SES, and information on the district of residence was used to build a contextual SES. Exposure to PM10, NO2, and O3 was accessed from monitoring stations and linked to each case based on the date of death. Conditional logistic regression models were used to estimate the effects of air pollutants, and interaction terms were added to access the effect modification of SES. Results: Individuals with lower education had an increased chance of dying for all nonaccidental outcomes (1.54% [0.91%, 2.14%]) associated with exposure to PM10. Individuals living in lower SES areas had an increased chance of dying for nonaccidental (0.52% [0.16%, 0.88%]), cardiovascular (1.17% [0.88%, 1.46%]), and respiratory (1.70% [0.47%, 2.93%]) causes owing to NO2 exposure. Conclusion: Exposure to air pollutants increases the chance of dying by nonaccidental, cardiovascular, and respiratory causes. Lower educational levels and living on lower contextual SES increased the risk of mortality associated with air pollution exposure.

Heat-related mortality and ambulance transport after a power outage in the Tokyo metropolitan area.

Background: Air conditioners can prevent heat-related illness and mortality, but the increased use of air conditioners may enhance susceptibility to heat-related illnesses during large-scale power failures. Here, we examined the risks of heat-related illness ambulance transport (HIAT) and mortality associated with typhoon-related electricity reduction (ER) in the summer months in the Tokyo metropolitan area. Methods: We conducted event study analyses to compare temperature-HIAT and mortality associations before and after the power outage (July to September 2019). To better understand the role of temperature during the power outage, we then examined whether the temperature-HIAT and mortality associations were modified by different power outage levels (0%, 10%, and 20% ER). We computed the ratios of relative risks to compare the risks associated with various ER values to the risks associated without ER. Results: We analyzed the data of 14,912 HIAT cases and 74,064 deaths. Overall, 93,200 power outage cases were observed when the typhoon hit. Event study results showed that the incidence rate ratio was 2.01 (95% confidence interval [CI] = 1.42, 2.84) with effects enduring up to 6 days, and 1.11 (95% CI = 1.02, 1.22) for mortality on the first 3 days after the typhoon hit. Comparing 20% to 0% ER, the ratios of relative risks of heat exposure were 2.32 (95% CI = 1.41, 3.82) for HIAT and 0.95 (95% CI = 0.75, 1.22) for mortality. Conclusions: A 20% ER was associated with a two-fold greater risk of HIAT because of summer heat during the power outage, but there was little evidence for the association with all-cause mortality.

Predictors of mortality in hospitalized African American COVID-19 patients with cancer.

Background: Coronavirus disease 2019 (COVID-19) manifest differently depending on patients' background and pre-existing conditions. It remains unclear how African Americans with cancer have been affected in comparison to those without. In this study, we aim to identify demographic, clinical, and laboratory markers associated with mortality in COVID-19 patients with cancer. Methods: We reviewed all COVID-19 hospitalized patients' records from Dec. 2019 to Oct. 2021 at Howard University Hospital. Patients having a history of, or active, cancer were reviewed. Clinical, treatment, lab test values, and pathological data were extracted. Univariable and multivariable analyses were conducted on the entire cohort as well as on cases and controls separately, using SPSS software. Results: Out of 512 COVID-19 infected patients, 49 had cancer, either active or history of cancer (cases) and 463 COVID-19 were cancer-free (controls), allowing for comparison. African American race was predominant in both cases and controls, 83.7% and 66.7% respectively. Cancer patients were older than non-cancer patients (mean age: 70.6 vs. 56.3 years) and had an increased length of hospital stay (mean 13.9 vs. 9.4 days). Mortality is significantly higher among cancer patients (n=10, 20.4%, P=0.03) compared to non-cancer COVID-19 patients (n=41, 8.9%). Among cancer patients, breast cancer was more prevalent in females and prostate cancer in males (54% and 52%, respectively). A comparison of patients with active vs. previous cancer showed no significant difference in the clinical outcome, death vs. discharge (P=0.34). A higher reduction in albumin level in cancer cases, from the time of admission to day 5, was significantly associated with death during the hospital stay compared to those discharged (n=24, 49.0%, P<0.001). In controls, lymphopenia (n=436, 94.2%, P=0.05), aspartate aminotransferase (AST) (n=59, 12.7%, P=0.008) and albumin (n=40, 8.6%, P=0.02) have shown an association with increased mortality. Conclusions: Albumin level has an inverse relationship with clinical outcomes among all COVID-19 infected cancer patients. Reduction in albumin level during the hospital stay, particularly in COVID-19 cancer patients should be considered as a predictor of mortality. Further research with a large cohort size is needed to verify and identify other predictors of outcomes in COVID-19 patients with cancer.

Mortality risk factors in the dependent population of Castilla-La Mancha (Spain) before and during the first COVID-19 wave.

The coronavirus disease pandemic has had an important impact worldwide. The population aged over 65 years and aged dependent persons are the population groups which have suffered in a highest level the consequences of the pandemic in terms of cases and death. In Spain, the situation is similar to other countries, but regional studies are needed because competencies on long-term care depend on regional public administration. Thus, the aim of this work is to analyse social and individual factors associated with the risk of mortality of legally recognised dependent people during the pandemic compared to a non-pandemic period. The data were extracted from the administrative database on individuals included in Castilla-La Mancha's long-term care system and it was merged with the information from the Spanish National Death Index administered by the Ministry of Health, Consumption and Social Welfare. The results show that the risk of mortality between March and June 2020 was positively associated with being male; being older than 65, with an especially high impact in the group aged over 90; having a higher level of dependency; living in a nursing home; and living in a place with more population density. Intraregional differences related to health areas also exists in both pandemic and non-pandemic periods. These findings are critical with a view to enhancing protocols for the care of the most vulnerable population groups.

Development of novel prognostic models based on dynamic changes in risk factors for hepatitis B associated acute-on-chronic liver failure:a 10-year retrospective study.

Background/Aims: Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality, and early prediction is critical to reduce the deaths of ACLF patients. To date, however, the prognostic accuracy of current models for ACLF is unsatisfactory, particularly, in patients with hepatitis B virus (HBV) infection. This study aims to develop novel prognostic models based on the dynamic changes in variables to predict the short-term mortality of HBV-associated ACLF (HBV-ACLF). Methods: A retrospective cohort study was conducted, with the population comprised in whom ACLF was confirmed.319 patients were enrolled and their clinical data were collected on Days 1 and 7 following hospital admission. Univariate and multivariate analyses were performed to identify risk factors for 28 and 90-day mortality. The dynamic alterations in the risk factors were further analyzed, and Days 1 and 7 prognostic models were constructed. Receiver operating characteristic (ROC) analysis were used to identify and compared the predictors of prognosis among our model. Results: Univariate and multivariate analyses revealed significant risk factors at Days 1 and 7, which when combined with the clinically important parameters, were used to establish the Days 1 and 7 prognostic models. For 28-day mortality, the predictive accuracy of the Day 1 prognostic model was significantly higher than that of the albumin-bilirubin (ALBI) model. For 90-day mortality, the predictive accuracy of the Days 1 and 7 prognostic models was significantly higher than that of the Model of End-Stage Liver Disease (MELD), MELD-sodium (MELD-Na), and ALBI prognostic models. Conclusions: The prognostic models established in this study were superior to the existing prognostic scoring systems to accurately predict short-term mortality, and therefore, could be potential novel prognostic tools for HBV-ACLF.

Child, maternal, and adult mortality in rural Ethiopia in 2019: a cross-sectional mortality survey using electronic verbal autopsies.

Background: Ethiopia, with about 10% of Africa's population, has little direct information on causes of death, particularly in rural areas where 80% of Ethiopians live. In 2019-2020, we conducted electronic verbal autopsies (e-VA) to examine causes of death and quantify cause-specific mortality rates in rural Ethiopia. Methods: We examined deaths under 70 years in the three years prior to the survey dates (November 25, 2019-February 29, 2020) among 2% of East Gojjam Zone (Amhara Region) using registered deaths and adding random sampling in this cross-sectional study. Trained surveyors interviewed relatives of the deceased with central dual-physician assignment of causes as the main outcome. We documented details on age, sex and location of death, and derived overall rural death rates using 2007 Census data and the United Nations national estimates for 2019. To these, we applied our sample-weighted causes to derive cause-specific mortality rates. We calculated death risks for the leading causes for major age groups. Findings: We studied 3516 deaths: 55% male, 97% rural, and 68% occurring at home. At ages 5 and older, injuries were notable, accounting for over a third of deaths at 5-14 years, half of the deaths at ages 15-29 years, and a quarter of deaths at ages 30-69 years. Neonatal mortality was high, mostly from prematurity/low birthweight and infections. Among children under 5 (excluding neonates), infections caused nearly two-thirds of deaths. Most maternal deaths (84%) arose from direct causes. After injuries, especially suicide, assaults, and road traffic accidents, vascular disease (15%) and cancer (13%) were the leading causes among adults at 30-69 years. HIV/AIDS and tuberculosis deaths were also important causes among adults. Interpretation: Rural Ethiopia has a high burden of avoidable mortality, particularly injury, including suicide, assaults, and road traffic accidents. Funding: International Development Research Centre, and the Canadian Institutes of Health Research.

Association between concurrence of multiple risk factors and under-5 mortality: a pooled analysis of data from Demographic and Health Survey in 61 low-and-middle-income countries.

Background: Exposure to multiple risk factors is prevalent in low-and middle-income countries (LMICs), challenging one-directional strategies to address preventable under-5 mortality (U5M). This study aims to assess the associations between concurrence of multiple risk factors and U5M in LMICs. Methods: We extracted data from the Demographic and Health Surveys conducted between 2010 and 2021 across 61 LMICs. Our primary outcome was U5M, defined as deaths from birth to 59 months. Binary logistic regression model was applied to ascertain the association between U5M and a total of 20 critical risk factors. Upon identifying the risk factors demonstrating the strongest associations, we investigated the simultaneous presence of multiple risk factors in each individual and assessed their combined effects on U5M with logistic regression models. Findings: Of the 604,372 under-5 children, 18,166 (3.0%) died at the time of the survey. Unsatisfied family planning needs was the strongest risk factor for U5M (odds ratio [OR]: 2.0, 95% confidence interval [CI]: 1.9-2.1), followed by short birth interval (<18 months; OR: 2.0, 95% CI: 1.9-2.1), small birth size (OR: 2.0, 95% CI: 1.8-2.1), never breastfed or delayed breastfeeding (OR: 2.0, 95% CI: 1.9-2.0), and low maternal education (OR: 1.6, 95% CI: 1.4-1.8). 66.7% (66.6%-66.8%) of the children had 2 or more leading risk factors simultaneously. Simultaneous presence of multiple leading risk factors was significantly associated with elevated risk of U5M and children presenting with all 5 leading risk factors exhibited an exceedingly high risk of U5M (OR: 5.2, 95% CI: 4.3-6.3); a dose-response relationship between the number of risk factors and U5M was also observed-with the increment of numbers of leading risk factors, the U5M showed an increasing trend (p-trend < 0.001). Interpretation: Exposure to multiple risk factors is very common in LMICs and underscores the necessity of developing multisectoral and integrated approaches to accelerate progress in reducing U5M in line with the SDG 3.2. Funding: This research is funded by Research Fund, Vanke School of Public Health, Tsinghua University.

The Value of Emergency Care Data Set (ECDS) Presentation Codes for Predicting Mortality and Inpatient Admission.

BACKGROUND:  Early identification of patients at higher risk of death and hospital admission is an important problem in Emergency Departments (ED). Most triage scales were developed before current electronic healthcare records were developed. The implementation of a national Emergency Care Data Set (ECDS) allows for the standardised recording of presenting complaints and the use of Electronic Patient Records (EPR) offers the potential for automated triage. The mortality risk and need for hospital admission associated with the different presenting complaints in a standardised national data set has not been previously reported. This study aimed to quantify the risks of death and hospitalisation from presenting complaints. This would be valuable in developing automated triage tools and decision support software. METHODS: We conducted an observational retrospective cohort study on patients who visited a single ED in 2021. The presenting complaints related to subsequent attendances were excluded. This patient list was then manually matched with a routinely collected list of deaths. All deaths that occurred within 30 days of attendance were included. RESULTS: Data was collected from 84,999 patients, of which 1,159 people died within 30 days of attendance. The mortality rate was the highest in cardiac arrest [32 (78.1%)], cardiac arrest due to trauma [2(50%)] and respiratory arrest [3(50%)]. Drowsy [17(12%)], hypothermia [3(13%)] and cyanosis [1(10%)] were also high-risk categories. Chest pain [34(0.6%)] was not a high-risk presenting complaint. CONCLUSION: The initial presenting complaint in ECDS may be useful to identify people at higher and lower risk of death. This information is useful for building automated triage models.