Search

Objective: Polycystic ovary syndrome (PCOS) symptoms extend beyond reproductive issues, impacting mental health significantly, with noted correlations to anxiety, depression, and suicide attempts. The objective of this study was to quantify psychiatric comorbidities among adolescent females with PCOS., Methods: Utilizing the National Inpatient Sample dataset from January 2016 to December 2018, this study examined a cohort of female adolescents aged 14-17 years diagnosed with PCOS, identified via International Classification of Diseases, Tenth Revision, Clinical Modification code E28.2, and matched 1:2 with non-PCOS individuals on demographic variables using propensity score matching. The primary outcomes included the prevalence of psychiatric disorders and were analyzed through categorical and continuous variable comparisons, employing t tests and Rao-Scott adjusted χ 2 tests, with odds ratios calculated to assess associations., Results: The study encompassed 11,985 patients, highlighting a significantly higher prevalence of mood disorders, major depressive disorder, and anxiety disorders in the PCOS cohort compared to controls ( P < .001). Specifically, mood disorders were reported in 43.6% of the PCOS group. Attention-deficit/hyperactivity disorder/conduct disorders were also more prevalent in the PCOS population. However, rates of schizophrenia and suicidal ideation/attempts did not significantly differ between groups., Conclusion: Adolescents with PCOS exhibit increased psychiatric comorbidities, highlighting the urgent need for integrated care strategies. Future research should aim to elucidate the mechanisms underlying these associations and develop effective interventions to improve outcomes in this vulnerable population., Prim Care Companion CNS Disord 2024;26(6):24m03760 ., Author affiliations are listed at the end of this article., (© Copyright 2024 Physicians Postgraduate Press, Inc.)

Background: The opioid epidemic in the United States has devastated the lives of individuals and imposed decades-long opportunity costs on the community., Methods: We analyzed Emergency Medical Services (EMS) data from the Maryland Department of Health installation of the Electronic Surveillance System for Early Notification of Community-Based Epidemics (ESSENCE) to assess the impact of COVID-19 on EMS call volume and how COVID-19 impacted patients' decisions whether to accept transport to a hospital following an EMS call., Results: The rate of patients accepting transportation via EMS to a hospital emergency department (ED) declined for both opioid-related and non-opioid-related calls from prepandemic (before April 2020) to mid-pandemic (mid-March 2020 to mid-April 2020). The opioid-related call volume increased more from pre- to mid-pandemic for male patients than for female patients, and this "gender gap" had not returned to prepandemic levels by April 2021., Conclusion: Consistent with reports from other states, the pandemic worsened the opioid crisis in Maryland, impacting some populations more than others while also decreasing the likelihood that individuals experiencing an opioid-related overdose would seek further medical care following an EMS call., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The American Heart Association Life's Simple 7 (LS7) is a composite metric assessing cardiovascular health on a scale of 0-14 comprised of nutrition, physical activity, cigarette use, body mass index, blood pressure, cholesterol and glucose., Methods: Using data from the Healthy Aging in Neighborhoods of Diversity across the Life Span study [n = 1465, Age at visit 1 (v1: 2004-2009): 30-66 y, 41.7 % male, 60.6 % African American], we investigated associations of trajectories in depressive symptoms (2004-2017) with Life's simple 7 scores after ∼8.6 years follow-up (2013-2017). Analyses used group-based zero-inflated Poisson trajectory (GBTM) models and multiple linear or ordinal logistic regression. GBTM analyses generated two classes of depressive symptoms trajectories ("low declining" and "high declining"), based on intercept and slope direction and significance., Results: Overall, "high declining depressive symptoms" vs. the "low declining" group was associated with -0.67 ± 0.10 lower scores on LS7 total score (P < 0.001) in analyses adjusted for age, sex, race and the inverse mills ratio. This effect was markedly attenuated to -0.45 ± 0.10 score-points (P < 0.001) upon adjustment for socio-economic factors and to -0.27 ± 0.10 score-points (P < 0.010) in fully adjusted analyses, with a stronger association detected among women (β ± SE: -0.45 ± 0.14, P = 0.002). An association between elevated depressive symptoms over time ("high declining" vs "low declining") and LS7 total score was detected among African American adults (β ± SE: -0.281 ± 0.131, p = 0.031, full model). Moreover, the "high declining" vs. "low declining" depressive symptoms group was associated with a lower score on LS7 physical activity (β ± SE: -0.494 ± 0.130, P < 0.001)., Conclusions: Poorer cardiovascular health was linked to higher depressive symptoms over time., Competing Interests: Conflict of interest All authors declare no conflict of interest., (Published by Elsevier B.V.)

Background and Objectives: Serum antioxidant vitamins and carotenoids may protect against neurodegeneration with age. We examined associations of these nutritional biomarkers with incident all-cause and Alzheimer disease (AD) dementia among US middle-aged and older adults., Methods: Using data from the third National Health and Nutrition Examination Surveys (1988-1994), linked with Centers for Medicare & Medicaid follow-up data, we tested associations and interactions of serum vitamins A, C, and E and total and individual serum carotenoids and interactions with incident AD and all-cause dementia. Cox proportional hazards regression models were conducted., Results: After ≤26 years follow-up (mean 16-17 years, 7,283 participants aged 45-90 years at baseline), serum lutein+zeaxanthin was associated with reduced risk of all-cause dementia (65+ age group), even in the lifestyle-adjusted model (per SD: hazard ratio [HR] 0.93, 95% CI 0.87-0.99; p = 0.037), but attenuated in comparison with a socioeconomic status (SES)-adjusted model (HR 0.92, 95% CI 0.86-0.93; p = 0.013). An inverse relationship was detected between serum β-cryptoxanthin (per SD increase) and all-cause dementia (45+ and 65+) for age- and sex-adjusted models (HR 0.86, 95% CI 0.80-0.93; p < 0.001 for 45+; HR 0.86, 95% CI 0.80-0.93; p = 0.001 for 65+), a relationship remaining strong in SES-adjusted models (HR 0.89, 95% CI 0.82-0.96; p = 0.006 for 45+; HR 0.88, 95% CI 0.81-0.96; p = 0.007 for 65+), but attenuated in subsequent models. Antagonistic interactions indicate putative protective effects of 1 carotenoid may be observed at lower levels other carotenoids or antioxidant vitamin., Discussion: Incident all-cause dementia was inversely associated with serum lutein+zeaxanthin and β-cryptoxanthin levels. Further studies with time-dependent exposures and randomized trials are needed to test neuroprotective effects of supplementing the diet with select carotenoids., Classification of Evidence: This study provides Class II evidence that incident all-cause dementia was inversely associated with serum lutein+zeaxanthin and β-cryptoxanthin levels., (© 2022 American Academy of Neurology.)

Background: To identify key socio-demographic, lifestyle, and health predictors of self-reported coronavirus disease 2019 (Covid-19) history, examine cardiometabolic health characteristics as predictors of self-reported Covid-19 history and compare groups with and without a history of Covid-19 on trajectories in cardiometabolic health and blood pressure measurements over time, among United States (U.S.) older adults., Methods: Nationally representative longitudinal data on U.S. older adults from the 2006-2020 Health and Retirement Study were analyzed using logistic and mixed-effects logistic regression models., Results: Based on logistic regression, number of household members (OR=1.26, 95% CI: 1.05, 1.52), depressive symptoms score (OR = 1.21, 95% CI: 1.04, 1.42) and number of cardiometabolic risk factors or chronic conditions ("1-2" vs "0") (OR = 0.27, 95% CI: 0.11, 0.67) were significant predictors of self-reported Covid-19 history. Based on mixed-effects logistic regression, several statistically significant predictors of Covid-19 history were identified, including female sex (OR = 3.06, 95% CI: 1.57, 5.96), other race (OR = 5.85, 95% CI: 2.37, 14.43), Hispanic ethnicity (OR = 2.66, 95% CI: 1.15, 6.17), number of household members (OR = 1.25, 95% CI: 1.10, 1.42), moderate-to-vigorous physical activity (1-4 times per month vs never) (OR = 0.38, 95% CI: 0.18, 0.78) and number of cardiometabolic risk factors or chronic conditions ("1-2" vs "0") (OR = 0.34, 95% CI: 0.19, 0.60)., Conclusions: Number of household members, depressive symptoms and number of cardiometabolic risk factors or chronic conditions may be key predictors for self-reported Covid-19 history among U.S. older adults. In-depth analyses are needed to confirm preliminary findings., (Published by Elsevier Inc.)

Importance: Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited., Objective: To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment., Design, Setting, and Participants: This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020., Exposure: Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin., Main Outcomes and Measures: The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration., Results: Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.6%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%])., Conclusions and Relevance: The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally.

Abstract: Despite its public health significance, TBI management across US healthcare institutions and patient characteristics with an emphasis on utilization and outcomes of TBI-specific procedures have not been evaluated at the national level.We aimed to characterize top 10 procedure codes among hospitalized adults with TBI as primary diagnosis by injury severity.A Cross-sectional study was conducted using 546, 548 hospitalization records from the 2004 to 2014 Nationwide Inpatient Sample were analyzed.Data elements of interest included injury, patient, hospital characteristics, procedures, in-hospital death and length of stay.Ten top procedure codes were "Closure of skin and subcutaneous tissue of other sites", "Insertion of endotracheal tube", "Continuous invasive mechanical ventilation for less than 96 consecutive hours", "Venous catheterization (not elsewhere classified)", "Continuous invasive mechanical ventilation for 96 consecutive hours or more", "Transfusion of packed cells", "Incision of cerebral meninges", "Serum transfusion (not elsewhere classified)", "Temporary tracheostomy", and "Arterial catherization". Prevalence rates ranged between 3.1% and 15.5%, with variations according to injury severity and over time. Whereas "Closure of skin and subcutaneous tissue of other sites" was associated with fewer in-hospital deaths and shorter hospitalizations, "Temporary tracheostomy" was associated with fewer in-hospital deaths among moderate-to-severe TBI patients, and "Continuous invasive mechanical ventilation for less than 96 consecutive hours" was associated with shorter hospitalizations among severe TBI patients. Other procedures were associated with worse outcomes.Nationwide, the most frequently reported hospitalization procedure codes among TBI patients aimed at homeostatic stabilization and differed in prevalence, trends, and outcomes according to injury severity., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: We compared outcomes of therapeutic plasma exchange (TPE) vs intravenous immunoglobulin (IVIG) among hospitalized patients diagnosed with Guillain-Barré syndrome (GBS)., Methods: In a retrospective cohort study of 6642 records (2637 TPE and 4005 IVIG) from the 2002-2014 Nationwide Inpatient Sample, treatment type was examined as predictor of length of stay, total charges, and in-hospital death, with regression modeling using risk adjustment and propensity scoring to control for confounders., Results: Compared with those receiving IVIG, patients who underwent TPE experienced prolonged hospitalization by approximately 7.5 days, greater hospitalization costs by approximately $46,000, and increased in-hospital death with an odds ratio of 2.78. Results did not change after controlling for confounders through risk adjustment, propensity score adjustment, or matching., Conclusions: TPE may be associated with poorer healthcare utilization outcomes vs IVIG, although confounding by indication could not be ascertained., (© 2020 Wiley Periodicals, Inc.)

Background: To examine patterns and outcomes of bariatric surgeries, including Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB), among women diagnosed with polycystic ovarian syndrome (PCOS). Materials and Methods: Retrospective cohort study using 1998-2011 Nationwide Inpatient Sample data. A total of 52,668 hospital discharge records met eligibility criteria among PCOS women, 18-49 years. Of those, 17,759 had an obesity/overweight diagnosis and 4310 underwent bariatric surgery. Furthermore, 3086 underwent RYGB ( n  = 2411), LSG ( n  = 126), or LAGB ( n  = 549), and were compared to 78,931 non-PCOS controls. Multiple regression models were constructed to examine patient- and hospital-level predictors of obesity/overweight and bariatric surgery, as well as type of bariatric surgery (RYGB, LSG, or LAGB) as a predictor of in-hospital outcomes and PCOS status. Results: The prevalence of obesity/overweight (≈34%) among women diagnosed with PCOS, and of bariatric surgery (≈24%) among women diagnosed with PCOS and obese/overweight varied by patient- and hospital-level characteristics. Women having PCOS and overweight/obesity, who underwent LSG or LAGB, had shorter hospital stay, reduced hospital charges, and better disposition at discharge compared to those who underwent RYGB. PCOS cases and non-PCOS controls experienced similar treatment selection and in-hospital outcomes after bariatric surgery. Also, PCOS cases and non-PCOS controls experienced similar in-hospital outcomes after undergoing RYGB, LSG, or LAGB. Conclusions: Compared to RYGB, LSG and LAGB resulted in improved in-hospital outcomes among obese/overweight PCOS and non-PCOS patients. Further research is needed to examine health care disparities in the context of PCOS, obesity/overweight, and bariatric surgery.

Microbial agents including periodontal pathogens have recently appeared as important actors in Alzheimer's disease (AD) pathology. We examined associations of clinical periodontal and bacterial parameters with incident all-cause and AD dementia as well as AD mortality among US middle-aged and older adults. Clinical [Attachment Loss (AL); probing pocket depth (PPD)] and bacterial [pathogen immunoglobulin G (IgG)] periodontal markers were investigated in relation to AD and all-cause dementia incidence and to AD mortality, using data from the third National Health and Nutrition Examination Surveys (NHANES III, 1988-1994) linked longitudinally with National Death Index and Medicare data through January 1, 2014, with up to 26 years of follow-up. Sex- and age-specific multivariable-adjusted Cox proportional hazards models were conducted. Among those ≥65 years, AD incidence and mortality were consistently associated with PPD, two factors and one cluster comprised of IgG titers against Porphyromonas gingivalis (P. gingivalis), Prevotella melaninogenica (P. melaninogenica) and Campylobacter rectus (C. rectus) among others. Specifically, AD incidence was linked to a composite of C. rectus and P. gingivalis titers (per SD, aHR = 1.22; 95% CI, 1.04-1.43, p = 0.012), while AD mortality risk was increased with another composite (per SD, aHR = 1.46; 95% CI, 1.09-1.96, p = 0.017) loading highly on IgG for P. gingivalis, Prevotella intermedia, Prevotella nigrescens, Fusobacterium nucleatum, C. rectus, Streptococcus intermedius, Capnocylophaga Ochracea, and P. melaninogenica. This study provides evidence for an association between periodontal pathogens and AD, which was stronger for older adults. Effectiveness of periodontal pathogen treatment on reducing sequelae of neurodegeneration should be tested in randomized controlled trials.

Context: Breast cancer (BC) is the most common malignancy among women in the US. Vitamin D status and intakes are thought to be inversely associated with BC occurrence., Objectives: In our systematic review and meta-analysis, we evaluated evidence linking serum 25(OH)D (both in serum and diet) with breast cancer (BC) occurrence., Data Sources and Extraction: Only observational studies from databases such as PubMed and Cochrane (January 1st 2000 through March 15th, 2018) were included using PRISMA guidelines. Publication bias and consistency upon replication were assessed, while harmonizing risk ratios (RR, 95% CI) of BC, per fixed increment of 5 exposures [10 ng/mL of 25(OH)D; 100 IU/d for total/dietary vitamin D intakes; vitamin D deficiency; supplement use). RRs were pooled using random effect models., Data Analysis: Pooled findings from 22 studies suggested a net direct association between 25(OH)D deficiency and BC, with RR pooled  = 1.91, 95% CI: 1.51-2.41, P < 0.001). Total vitamin D intake (RR pooled  = 0.99, 95% CI: 0.97-1.00, P = 0.022, per 100 IU/d) and supplemental vitamin D (RR pooled  = 0.97, 95% CI:0.95-1.00, P = 0.026) were inversely associated with BC. No evidence of publication bias was found; all 5 exposures of interest were consistent upon replication., Conclusions: 25(OH)D deficiency was directly related to BC while total vitamin D and supplemental vitamin D intakes had an inverse relationship with this outcome. Randomized clinical trials are warranted pending further evidence from primary meta-analyses of observational studies., (Published by Elsevier Ltd.)

Aims: To assess whether nursing home (NH) residents with type 2 diabetes mellitus (T2D) preferentially received "T2D-friendly" (vs "T2D-unfriendly") β-blockers after acute myocardial infarction (AMI), and to evaluate the comparative effects of the two groups of β-blockers., Materials and Methods: This new-user retrospective cohort study of NH residents with AMI from May 2007 to March 2010 used national data from the Minimum Data Set and Medicare system. T2D-friendly β-blockers were those hypothesized to increase peripheral glucose uptake through vasodilation: carvedilol, nebivolol and labetalol. Primary outcomes were hospitalizations for hypoglycaemia and hyperglycaemia in the 90 days after AMI. Secondary outcomes were functional decline, death, all-cause re-hospitalization and fracture hospitalization. We compared outcomes using binomial and multinomial logistic regression models after propensity score matching., Results: Of 2855 NH residents with T2D, 29% initiated a T2D-friendly β-blocker vs 24% of 6098 without T2D (P < 0.001). For primary outcomes among residents with T2D, T2D-friendly vs T2D-unfriendly β-blockers were associated with a reduction in hospitalized hyperglycaemia (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.21-0.97), but unassociated with hypoglycaemia (OR 2.05, 95% CI 0.82-5.10). For secondary outcomes, T2D-friendly β-blockers were associated with a greater rate of re-hospitalization (OR 1.26, 95% CI 1.01-1.57), but not death (OR 1.06, 95% CI 0.85-1.32), functional decline (OR 0.91, 95% CI 0.70-1.19), or fracture (OR 1.69, 95% CI 0.40-7.08)., Conclusions: In older NH residents with T2D, T2D-friendly β-blocker use was associated with a lower rate of hospitalization for hyperglycaemia, but a higher rate of all-cause re-hospitalization., (© 2018 John Wiley & Sons Ltd.)

Background: It remains unclear how indigenous mortality varies between residential areas. We conducted a systematic review and meta-analysis on mortality patterns in urban, rural and very remote areas for the adult and infant indigenous populations of Australia, Canada, New Zealand and the USA., Methods: A literature search was performed using major online electronic publication repositories. Studies presenting indigenous mortality or disease incidence/prevalence in urban, rural or very remote areas were included. Indigenous mortality and disease incidence/prevalence in both urban and very remote areas were compared with those in rural areas. Studies that reported number of deaths or disease incidences along with population were included in the meta-analysis., Results: Thirty-one studies were included with data from Australia (n=19), Canada (n=3), New Zealand (n=1) and the USA (n=8). Indigenous adult all-cause mortality, cervical cancer mortality, trauma mortality and incidence of myocardial infarction were all significantly lower in urban areas compared with rural areas. Likewise, indigenous adult cardiovascular mortality and renal disease mortality were significantly lower in very remote areas compared with rural areas, while indigenous infant all-cause mortality showed no significant difference in urban, rural or very remote areas., Conclusions: Urban areas consistently experienced lower adult indigenous mortality compared with rural areas, as did some very remote areas. Indigenous infants, however, experience similar mortality rates across all residential areas.

Epidemiological studies have confirmed associations of the vitamin D receptor (VDR) and vitamin D-related gene polymorphisms with adiposity and other metabolic disturbances. Those associations may be sex-specific. We evaluated the cross-sectional and longitudinal relationships between metabolic disturbances and haplotypes constructed from single nucleotide polymorphisms of VDR (BsmI:G/A: rs1544410; ApaI:A/C: rs7975232; and TaqI:G/A: rs731236) and MEGALIN (rs3755166:G/A; rs2075252:C/T and rs2228171:C/T) genes, in a sample of African-American adults. From 1,024 African Americans participating in the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS, 2004-2013, Baltimore, MD), our analyses included 539 participants with complete genetic, baseline covariate and metabolic outcome data (at baseline and follow-up). Mean ± SD period of follow-up was 4.64 ± 0.93 y. Multivariable-adjusted Cox proportional hazards and logistic regression models were conducted. Among key findings, in men, incident hypertension was inversely related to MEGALIN 1 (GCC), [HR = 0.45, 95% CI: 0.23-0.90, p = 0.024]. Overall, there was a direct, linear dose-response association between VDR 2 (AAG: BAt) and MetS at baseline [OR = 1.60, 95% CI: 1.11-2.31, p = 0.012], while among men, VDR 3 (GAA: bAT) was inversely related to baseline MetS [OR = 0.40, 95% CI: 0.19-0.81, p = 0.011]. In conclusion, VDR and MEGALIN gene variations can affect prevalent MetS and the incidence rate of hypertension, respectively, among African-American urban adults.

Aim: Establish the frequency of abnormal vital signs in medical and surgical ward patients; study their association with "critical events," which for the purposes of this study, were mortality, cardiac arrests and unplanned ICU transfers., Design and Methods: Four-month prospective, observational cohort study; University-affiliated US Veteran's hospital. Vital signs from all regular ward medical and surgical inpatients were recorded over the study period and compared with records of cardiac arrests, mortality and ICU admissions., Results: Using the Hospital's Medical Emergency Team criteria to define normal/abnormal thresholds for vital signs, abnormal vital signs (VS(MET)) were found in 16% of patients; of these; 35% experienced a critical event vs. 2.5% in the patients with normal vital signs (OR 21, 95% CI 12-35, p<0.001). The sensitivity of VS(MET) to predict a critical event was 0.72 and the positive predictive value was 0.35; sensitivity decreased to 0.28 and positive predictive value increased to 0.78 for patients that had two different VS(MET). Survival was significantly lower in both medical and surgical patients with VS(MET) at both 30 days and at 1 year following discharge (p<0.02). Both medical and surgical patients with VS(MET) had twice the length of stay of patients with normal vitals (3 vs. 7 days; p<0.001)., Conclusions: Even single recordings of VS(MET) signaled increased risk for critical events in hospital ward patients. Use of vital signs as criteria for additional patient assessment and possible ICU admission appears justified. Development of abnormal vitals during hospitalization may signify impaired physiologic reserve that places a patient at higher risk for mortality after discharge.