Dataset Information

Propensity-Adjusted Comparison of Mortality of Elderly Versus Very Elderly Ventilated Patients.

ABSTRACT:

Background

The growing proportion of elderly intensive care patients constitutes a public health challenge. The benefit of critical care in these patients remains unclear. We compared outcomes in elderly versus very elderly subjects receiving mechanical ventilation.

Methods

In total, 5,557 mechanically ventilated subjects were included in our post hoc retrospective analysis, a subgroup of the VENTILA study. We divided the cohort into 2 subgroups on the basis of age: very elderly subjects (age ≥ 80 y; n = 1,430), and elderly subjects (age 65-79 y; n = 4,127). A propensity score on being very elderly was calculated. Evaluation of associations with 28-d mortality was done with logistic regression analysis.

Results

Very elderly subjects were clinically sicker as expressed by higher SAPS II scores (53 ± 18 vs 50 ± 18, P < .001), and their rates of plateau pressure < 30 cm H₂O were higher, whereas other parameters did not differ. The 28-d mortality was higher in very elderly subjects (42% vs 34%, P < .001) and remained unchanged after propensity score adjustment (adjusted odds ratio 1.31 [95% CI 1.16-1.49], P < .001).

Conclusions

Age was an independent and unchangeable risk factor for death in mechanically ventilated subjects. However, survival rates of very elderly subjects were > 50%. Denial of critical care based solely on age is not justified. (ClinicalTrials.gov registration NCT02731898.).

SUBMITTER: Wernly B

PROVIDER: S-EPMC9994107 | biostudies-literature | 2021 May

REPOSITORIES: biostudies-literature

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Publications

Propensity-Adjusted Comparison of Mortality of Elderly Versus Very Elderly Ventilated Patients.

Wernly Bernhard B Bruno Raphael Romano RR Frutos-Vivar Fernando F Peñuelas Oscar O Rezar Richard R Raymondos Konstantinos K Muriel Alfonso A Du Bin B Thille Arnaud W AW Ríos Fernando F González Marco M Del-Sorbo Lorenzo L Marín Maria Del Carmen MDC Pinheiro Bruno Valle BV Soares Marco Antonio MA Nin Nicolas N Maggiore Salvatore M SM Bersten Andrew A Kelm Malte M Amin Pravin P Cakar Nahit N Young Suh Gee G Abroug Fekri F Jibaja Manuel M Matamis Dimitros D Zeggwagh Amine Ali AA Sutherasan Yuda Y Guidet Bertrand B De Lange Dylan W DW Beil Michael M Svri Sigal S van Heerden Vernon V Flaatten Hans H Anzueto Antonio A Osmani Venet V Esteban Andrés A Jung Christian C

Respiratory care 20210302 5

<h4>Background</h4>The growing proportion of elderly intensive care patients constitutes a public health challenge. The benefit of critical care in these patients remains unclear. We compared outcomes in elderly versus very elderly subjects receiving mechanical ventilation.<h4>Methods</h4>In total, 5,557 mechanically ventilated subjects were included in our post hoc retrospective analysis, a subgroup of the VENTILA study. We divided the cohort into 2 subgroups on the basis of age: very elderly s ...[more]

PMID: 33653910

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Project description:IntroductionElderly patients are at increased risk of developing sepsis and its adverse outcomes. Diagnosing and prognosing sepsis is particularly challenging in older patients, especially early at emergency department (ED) arrival. We aimed to study and compare the characteristics of elderly and very elderly ED patients with sepsis and determine baseline factors associated with in-hospital mortality. We also compared prognostic accuracy of the criteria for systemic inflammatory response syndrome, quick sequential organ failure assessment (qSOFA), and the National Early Warning Score in predicting mortality.MethodsWe conducted a retrospective study at the ED of Siriraj Hospital Mahidol University in Bangkok, Thailand. Patients over 18 years old who were diagnosed and treated for sepsis in the ED between August 2018-July 2019 were included. We categorized patients into non-elderly (aged <65 years), elderly (aged 65-79 years), and the very elderly (aged >80 years) groups. The primary outcome was in-hospital mortality. Baseline demographics, comorbidities, source and etiology of sepsis, including physiologic variables, were compared and analyzed to identify predictors of mortality. We calculated and compared the area under the receiver operator characteristics curves (AUROC) of early warning scores.ResultsOf 1616 ED patients with sepsis, 668 (41.3%) were very elderly, 512 (31.7%) were elderly, and 436 (27.0%) were non-elderly. The mortality rate was highest in the very elderly, followed by the elderly and the non-elderly groups (32.3%, 25.8%, and 24.8%, respectively). Factors associated with mortality in the very elderly included the following: age; do-not-resuscitate (DNR) status; history of recent admission <3 months; respiratory tract infection; systolic blood pressure <100 millimeters mercury (SBP<100); oxygen saturation; and Glasgow Coma Scale (GCS) score. Factors associated with mortality in the elderly were DNR status, body temperature, and GCS score. qSOFA had the highest AUROC in predicting in-hospital mortality in both very elderly and elderly patients (AUROC 0.60 [95% confidence interval {CI}, 0.55-0.65] and 0.55 [95% CI, 0.49-0.61, respectively]).ConclusionThe mortality rate in the very elderly was higher than in the younger populations. Age, DNR status, recent admission, respiratory tract infection, SBP<100, oxygen saturation. and GCS score independently predicted hospital mortality in very elderly patients. The qSOFA score had better but only moderate accuracy in predicting mortality in elderly and very elderly sepsis patients.

Project description:Elevated blood pressure (BP) is frequently diagnosed in very elderly hospitalized patients. Accurate diagnosis of hypertension is challenging in the hospital environment, due to the "white coat effect," and both overtreatment and undertreatment can adversely affect clinical outcome. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has the potential to avoid the "white coat effect" and accurately guide the management of hypertension. However, effects of the hospital environment on ABPM are unknown in the very elderly. We set out to enroll 45 patients, age ≥70 years, with elevated conventional BP during hospitalization in this observational study. It was prespecified by protocol to assess initially the difference between 24-hour BP during hospital-admission and home follow-up. Subsequent analysis should investigate the change in anxiety (Hospital Anxiety and Depression Scale-A [HADS-A]) after discharge, the correlation with change in 24-hour BP after discharge, and the prevalence of orthostatic hypertension. Thirty-one patients were included in the final analysis (age 83.5 ± 4.4 years; 71% female). Twenty-four-hour BP decreased significantly after hospital discharge (systolic from 133.5 ± 15.6 to 126.2 ± 14.4 mm Hg [millimeter of mercury], P = .008; diastolic from 71.0 ± 9.0 to 68.3 ± 8.6 mm Hg, P = .046). Anxiety level (HADS-A) decreased significantly after discharge, from 7.5 (interquartile range [IQR]: 4.0-13.8) to 5.0 (IQR: 4.0-8.0, P = .012). The change in anxiety was a predictor of change in systolic BP after discharge (F[1,20] = 5.9, P = .025). Sixty-one percent of the patients had significant orthostatic hypotension during hospital stay. In conclusion, 24-hour BP in very elderly patients is lower in the home environment than during hospitalization. This phenomenon seems to be directly linked to a lower anxiety-level at home. Reassessing hypertension at home may decrease the need for (intensified) antihypertensive medical therapy in a substantial number of patients. This is particularly important in the very elderly, who have a high prevalence of symptomatic and asymptomatic orthostatic hypotension, making them prone to hazardous effects of antihypertensive therapy.

Project description:AimsThe mortality in cardiogenic shock (CS) is high. The role of specific mechanical circulatory support (MCS) systems is unclear. We aimed to compare patients receiving Impella versus ECLS (extracorporal life support) with regard to baseline characteristics, feasibility, and outcomes in CS.Methods and resultsThis is a retrospective cohort study including CS patients over 18 years with a complete follow-up of the primary endpoint and available baseline lactate level, receiving haemodynamic support either by Impella 2.5 or ECLS from two European registries. The decision for device implementation was made at the discretion of the treating physician. The primary endpoint of this study was all-cause mortality at 30 days. A propensity score for the use of Impella was calculated, and multivariable logistic regression was used to obtain adjusted odds ratios (aOR). In total, 149 patients were included, receiving either Impella (n = 73) or ECLS (n = 76) for CS. The feasibility of device implantation was high (87%) and similar (aOR: 3.14; 95% CI: 0.18-56.50; P = 0.41) with both systems. The rates of vascular injuries (aOR: 0.95; 95% CI: 0.10-3.50; P = 0.56) and bleedings requiring transfusions (aOR: 0.44; 95% CI: 0.09-2.10; P = 0.29) were similar in ECLS patients and Impella patients. The use of Impella or ECLS was not associated with increased odds of mortality (aOR: 4.19; 95% CI: 0.53-33.25; P = 0.17), after correction for propensity score and baseline lactate level. Baseline lactate level was independently associated with increased odds of 30 day mortality (per mmol/L increase; OR: 1.29; 95% CI: 1.14-1.45; P < 0.001).ConclusionsIn CS patients, the adjusted mortality rates of both ECLS and Impella were high and similar. The baseline lactate level was a potent predictor of mortality and could play a role in patient selection for therapy in future studies. In patients with profound CS, the type of device is likely to be less important compared with other parameters including non-cardiac and neurological factors.

Project description:BackgroundRandomized trials support the use of transcatheter aortic valve replacement (TAVR) for the treatment of aortic stenosis in high- and intermediate-risk patients, but the generalizability of those results in clinical practice has been challenged.ObjectivesThe aim of this study was to determine the safety and effectiveness of TAVR versus surgical aortic valve replacement (SAVR), particularly in intermediate- and high-risk patients, in a nationally representative real-world cohort.MethodsUsing data from the Transcatheter Valve Therapy Registry and Society of Thoracic Surgeons National Database linked to Medicare administrative claims for follow-up, 9,464 propensity-matched intermediate- and high-risk (Society of Thoracic Surgeons Predicted Risk of Mortality score ≥3%) U.S. patients who underwent commercial TAVR or SAVR were examined. Death, stroke, and days alive and out of the hospital to 1 year were compared, as well as discharge home, with subgroup analyses by surgical risk, demographics, and comorbidities.ResultsIn a propensity-matched cohort (median age 82 years, 48% women, median Society of Thoracic Surgeons Predicted Risk of Mortality score 5.6%), TAVR and SAVR patients experienced no difference in 1-year rates of death (17.3% vs. 17.9%; hazard ratio: 0.93; 95% confidence interval [CI]: 0.83 to 1.04) and stroke (4.2% vs. 3.3%; hazard ratio: 1.18; 95% CI: 0.95 to 1.47), and no difference was observed in the proportion of days alive and out of the hospital to 1 year (rate ratio: 1.00; 95% CI: 0.98 to 1.02). However, TAVR patients were more likely to be discharged home after treatment (69.9% vs. 41.2%; odds ratio: 3.19; 95% CI: 2.84 to 3.58). Results were consistent across most subgroups, including among intermediate- and high-risk patients.ConclusionsAmong unselected intermediate- and high-risk patients, TAVR and SAVR resulted in similar rates of death, stroke, and DAOH to 1 year, but TAVR patients were more likely to be discharged home.

Dataset Information

Propensity-Adjusted Comparison of Mortality of Elderly Versus Very Elderly Ventilated Patients.

Background

Methods

Results

Conclusions

Publications

Propensity-Adjusted Comparison of Mortality of Elderly Versus Very Elderly Ventilated Patients.

Similar Datasets

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