A matter of life and death: population mortality and football results

PubMed Central

Kirkup, W; Merrick, D

2003-01-01

Objectives: To determine whether football results are associated with mortality from circulatory disease. Design: Retrospective study, comparing mortality on days of football matches between 18 August 1994 and 28 December 1999 with the results of the football matches. Setting: Newcastle and North Tyneside, Sunderland, Tees, and Leeds Health Authority areas of England. Subjects: All persons resident in Newcastle and North Tyneside, Sunderland, Tees, and Leeds Health Authority areas of England. Main outcome measures: Mortality attributable to acute myocardial infarction and stroke. Results: On days when the local professional football team lost at home, mortality attributable to acute myocardial infarction and stroke increased significantly in men (relative risk 1.28, 95% confidence intervals 1.11 to 1.47). No increase was observed in women. Conclusions: Results achieved by the local professional football team are associated systematically with circulatory disease death rates over a five year period in men, but not women. PMID:12775788

Is patriarchy the source of men's higher mortality?

PubMed Central

Stanistreet, D; Bambra, C; Scott-Samuel, A

2005-01-01

Objective: To examine the relation between levels of patriarchy and male health by comparing female homicide rates with male mortality within countries. Hypothesis: High levels of patriarchy in a society are associated with increased mortality among men. Design: Cross sectional ecological study design. Setting: 51 countries from four continents were represented in the data—America, Europe, Australasia, and Asia. No data were available for Africa. Results: A multivariate stepwise linear regression model was used. Main outcome measure was age standardised male mortality rates for 51 countries for the year 1995. Age standardised female homicide rates and GDP per capita ranking were the explanatory variables in the model. Results were also adjusted for the effects of general rates of homicide. Age standardised female homicide rates and ranking of GDP were strongly correlated with age standardised male mortality rates (Pearson's r = 0.699 and Spearman's 0.744 respectively) and both correlations achieved significance (p<0.005). Both factors were subsequently included in the stepwise regression model. Female homicide rates explained 48.8% of the variance in male mortality, and GDP a further 13.6% showing that the higher the rate of female homicide, and hence the greater the indicator of patriarchy, the higher is the rate of mortality among men. Conclusion: These data suggest that oppression and exploitation harm the oppressors as well as those they oppress, and that men's higher mortality is a preventable social condition, which could be tackled through global social policy measures. PMID:16166362

Socioeconomic factors and mortality in urban settings: the case of Barcelona, Spain.

PubMed Central

Borrell, C; Arias, A

1995-01-01

STUDY OBJECTIVE--This study aimed to describe the relationship between health and socioeconomic indicators in the 38 neighbourhoods of the city of Barcelona, Spain. DESIGN--Mortality data for 1983-89 and socioeconomic data for each of the 38 neighbourhoods of Barcelona were used. Mortality indicators used were the comparative mortality figure, the ratio of potential years of life lost, and life expectancy at birth. Socioeconomic indicators were the percentage of unemployed, the percentage of illiteracy, monthly telephone usage, the average power and age of cars, and the average rateable value of buildings and of land. The statistical correlation between socioeconomic indicators and mortality indicators was studied by Spearman's rank correlation coefficient. SETTING--The 38 neighbourhoods of Barcelona, Spain. MEASUREMENTS AND MAIN RESULTS--The comparative mortality figure ranged from 87.41-152.43 and the ratio of potential years of life lost from 74.94-237.31 in both sexes. Both the absolute difference and the ratio of the value for the neighbourhood with lowest mortality and that with highest mortality were larger when premature mortality was examined. Life expectancy at birth ranged from 64.77-75.32 years in men and 75.04-81.51 in women. All correlations between mortality and socioeconomic indicators were high and statistically significant: the higher the unemployment and illiteracy levels and the older the cars, the greater the comparative mortality figure and ratio of potential years of life lost, and the lower the life expectancy (negative correlations). Conversely, the higher the telephone use, the more powerful the cars, and the greater the rateable value, the lower the mortality (negative correlations) and the greater the life expectancy. These correlations were greater in males than in females. The highest correlations were with illiteracy. CONCLUSIONS--This study has detected significant differences in mortality in a large town in the Mediterranean region of Europe. Images PMID:7499987

Development and validation of a risk model for long-term mortality after percutaneous coronary intervention: The IDEA-BIO Study.

PubMed

van Boven, Nick; van Domburg, Ron T; Kardys, Isabella; Umans, Victor A; Akkerhuis, K Martijn; Lenzen, Mattie J; Valgimigli, Marco; Daemen, Joost; Zijlstra, Felix; Boersma, Eric; van Geuns, Robert-Jan

2018-03-01

We aimed to develop a model to predict long-term mortality after percutaneous coronary intervention (PCI), to aid in selecting patients with sufficient life expectancy to benefit from bioabsorbable scaffolds. Clinical trials are currently designed to demonstrate superiority of bioabsorbable scaffolds over metal devices up to 5 years after implantation. From 2000 to 2011, 19.532 consecutive patients underwent PCI in a tertiary referral hospital. Patients were randomly (2:1) divided into a training (N = 13,090) and validation (N = 6,442) set. Cox regression was used to identify determinants of long-term mortality in the training set and used to develop a risk model. Model performance was studied in the training and validation dataset. Median age was 63 years (IQR 54-72) and 72% were men. Median follow-up was 3.6 years (interquartile range [IQR] 2.4-6.8). The ratio elective vs. non-elective PCIs was 42/58. During 88,620 patient-years of follow-up, 3,156 deaths occurred, implying an incidence rate of 35.6 per 1,000. Estimated 5-year mortality was 12.9%.Regression analysis revealed age, body mass index, diabetes mellitus, renal insufficiency, prior myocardial infarction, PCI indication, lesion location, number of diseased vessels and cardiogenic shock at presentation as determinants of mortality. The long-term risk model showed good discrimination in the training and validation sets (c-indices 0.76 and 0.74), whereas calibration was appropriate. A simple risk model, containing 9 baseline clinical and angiographic variables effectively predicts long-term mortality after PCI and may possibly be used to select suitable patients for bioabsorbable scaffolds. © 2017 Wiley Periodicals, Inc.

The effects of designation and volume of neonatal care on mortality and morbidity outcomes of very preterm infants in England: retrospective population-based cohort study.

PubMed

Watson, S I; Arulampalam, W; Petrou, S; Marlow, N; Morgan, A S; Draper, E S; Santhakumaran, S; Modi, N

2014-07-07

To examine the effects of designation and volume of neonatal care at the hospital of birth on mortality and morbidity outcomes in very preterm infants in a managed clinical network setting. A retrospective, population-based analysis of operational clinical data using adjusted logistic regression and instrumental variables (IV) analyses. 165 National Health Service neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit and participating in the Neonatal Economic, Staffing and Clinical Outcomes Project. 20 554 infants born at <33 weeks completed gestation (17 995 born at 27-32 weeks; 2559 born at <27 weeks), admitted to neonatal care and either discharged or died, over the period 1 January 2009-31 December 2011. Tertiary designation or high-volume neonatal care at the hospital of birth. Neonatal mortality, any in-hospital mortality, surgery for necrotising enterocolitis, surgery for retinopathy of prematurity, bronchopulmonary dysplasia and postmenstrual age at discharge. Infants born at <33 weeks gestation and admitted to a high-volume neonatal unit at the hospital of birth were at reduced odds of neonatal mortality (IV regression odds ratio (OR) 0.70, 95% CI 0.53 to 0.92) and any in-hospital mortality (IV regression OR 0.68, 95% CI 0.54 to 0.85). The effect of volume on any in-hospital mortality was most acute among infants born at <27 weeks gestation (IV regression OR 0.51, 95% CI 0.33 to 0.79). A negative association between tertiary-level unit designation and mortality was also observed with adjusted logistic regression for infants born at <27 weeks gestation. High-volume neonatal care provided at the hospital of birth may protect against in-hospital mortality in very preterm infants. Future developments of neonatal services should promote delivery of very preterm infants at hospitals with high-volume neonatal units. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Predicting ICU mortality: a comparison of stationary and nonstationary temporal models.

PubMed Central

Kayaalp, M.; Cooper, G. F.; Clermont, G.

2000-01-01

OBJECTIVE: This study evaluates the effectiveness of the stationarity assumption in predicting the mortality of intensive care unit (ICU) patients at the ICU discharge. DESIGN: This is a comparative study. A stationary temporal Bayesian network learned from data was compared to a set of (33) nonstationary temporal Bayesian networks learned from data. A process observed as a sequence of events is stationary if its stochastic properties stay the same when the sequence is shifted in a positive or negative direction by a constant time parameter. The temporal Bayesian networks forecast mortalities of patients, where each patient has one record per day. The predictive performance of the stationary model is compared with nonstationary models using the area under the receiver operating characteristics (ROC) curves. RESULTS: The stationary model usually performed best. However, one nonstationary model using large data sets performed significantly better than the stationary model. CONCLUSION: Results suggest that using a combination of stationary and nonstationary models may predict better than using either alone. PMID:11079917

Pediatric sepsis in the developing world: challenges in defining sepsis and issues in post-discharge mortality.

PubMed

Wiens, Matthew O; Kumbakumba, Elias; Kissoon, Niranjan; Ansermino, J Mark; Ndamira, Andrew; Larson, Charles P

2012-01-01

Sepsis represents the progressive underlying inflammatory pathway secondary to any infectious illness, and ultimately is responsible for most infectious disease-related deaths. Addressing issues related to sepsis has been recognized as an important step towards reducing morbidity and mortality in developing countries, where the majority of the 7.5 million annual deaths in children under 5 years of age are considered to be secondary to sepsis. However, despite its prevalence, sepsis is largely neglected. Application of sepsis definitions created for use in resource-rich countries are neither practical nor feasible in most developing country settings, and alternative definitions designed for use in these settings need to be established. It has also been recognized that the inflammatory state created by sepsis increases the risk of post-discharge morbidity and mortality in developed countries, but exploration of this issue in developing countries is lacking. Research is urgently required to characterize better this potentially important issue.

Religion, a social determinant of mortality? A 10-year follow-up of the Health and Retirement Study

PubMed Central

Blevins, John; Kiser, Mimi

2017-01-01

The social determinants of health framework has brought a recognition of the primary importance of social forces in determining population health. Research using this framework to understand the health and mortality impact of social, economic, and political conditions, however, has rarely included religious institutions and ties. We investigate a well-measured set of social and economic determinants along with several measures of religious participation as predictors of adult mortality. Respondents (N = 18,370) aged 50 and older to the Health and Retirement Study were interviewed in 2004 and followed for all-cause mortality to 2014. Exposure variables were religious attendance, importance, and affiliation. Other social determinants of health included gender, race/ethnicity, education, household income, and net worth measured at baseline. Confounders included physical and mental health. Health behaviors and social ties were included as potential explanatory variables. Cox proportional hazards regressions were adjusted for complex sample design. After adjustment for confounders, attendance at religious services had a dose-response relationship with mortality, such that respondents who attended frequently had a 40% lower hazard of mortality (HR = 0.60, 95% CI 0.53–0.68) compared with those who never attended. Those for whom religion was “very important” had a 4% higher hazard (HR = 1.04, 95% CI 1.01–1.07); religious affiliation was not associated with risk of mortality. Higher income and net worth were associated with a reduced hazard of mortality as were female gender, Latino ethnicity, and native birth. Religious participation is multi-faceted and shows both lower and higher hazards of mortality in an adult US sample in the context of a comprehensive set of other social and economic determinants of health. PMID:29261682

Religion, a social determinant of mortality? A 10-year follow-up of the Health and Retirement Study.

PubMed

Idler, Ellen; Blevins, John; Kiser, Mimi; Hogue, Carol

2017-01-01

The social determinants of health framework has brought a recognition of the primary importance of social forces in determining population health. Research using this framework to understand the health and mortality impact of social, economic, and political conditions, however, has rarely included religious institutions and ties. We investigate a well-measured set of social and economic determinants along with several measures of religious participation as predictors of adult mortality. Respondents (N = 18,370) aged 50 and older to the Health and Retirement Study were interviewed in 2004 and followed for all-cause mortality to 2014. Exposure variables were religious attendance, importance, and affiliation. Other social determinants of health included gender, race/ethnicity, education, household income, and net worth measured at baseline. Confounders included physical and mental health. Health behaviors and social ties were included as potential explanatory variables. Cox proportional hazards regressions were adjusted for complex sample design. After adjustment for confounders, attendance at religious services had a dose-response relationship with mortality, such that respondents who attended frequently had a 40% lower hazard of mortality (HR = 0.60, 95% CI 0.53-0.68) compared with those who never attended. Those for whom religion was "very important" had a 4% higher hazard (HR = 1.04, 95% CI 1.01-1.07); religious affiliation was not associated with risk of mortality. Higher income and net worth were associated with a reduced hazard of mortality as were female gender, Latino ethnicity, and native birth. Religious participation is multi-faceted and shows both lower and higher hazards of mortality in an adult US sample in the context of a comprehensive set of other social and economic determinants of health.

Key considerations in designing a patient navigation program for colorectal cancer screening.

PubMed

DeGroff, Amy; Coa, Kisha; Morrissey, Kerry Grace; Rohan, Elizabeth; Slotman, Beth

2014-07-01

Colorectal cancer is the second leading cause of cancer mortality among those cancers affecting both men and women. Screening is known to reduce mortality by detecting cancer early and through colonoscopy, removing precancerous polyps. Only 58.6% of adults are currently up-to-date with colorectal cancer screening by any method. Patient navigation shows promise in increasing adherence to colorectal cancer screening and reducing health disparities; however, it is a complex intervention that is operationalized differently across institutions. This article describes 10 key considerations in designing a patient navigation intervention for colorectal cancer screening based on a literature review and environmental scan. Factors include (1) identifying a theoretical framework and setting program goals, (2) specifying community characteristics, (3) establishing the point(s) of intervention within the cancer continuum, (4) determining the setting in which navigation services are provided, (5) identifying the range of services offered and patient navigator responsibilities, (6) determining the background and qualifications of navigators, (7) selecting the method of communications between patients and navigators, (8) designing the navigator training, (9) defining oversight and supervision for the navigators, and (10) evaluating patient navigation. Public health practitioners can benefit from the practical perspective offered here for designing patient navigation programs. © 2013 Society for Public Health Education.

Cardiovascular events in a physical activity intervention compared with a successful aging intervention: The LIFE Study randomized trial

USDA-ARS?s Scientific Manuscript database

IMPORTANCE: Whether sustained physical activity prevents cardiovascular disease (CVD) events in older adults is uncertain. OBJECTIVE: To test the hypothesis that cardiovascular morbidity and mortality would be reduced in participants in a long-term physical activity program. DESIGN, SETTING, AND PAR...

Simultaneous Prediction of New Morbidity, Mortality, and Survival without New Morbidity from Pediatric Intensive Care: A New Paradigm for Outcomes Assessment

PubMed Central

Pollack, Murray M.; Holubkov, Richard; Funai, Tomohiko; Berger, John T.; Clark, Amy E.; Meert, Kathleen; Berg, Robert A.; Carcillo, Joseph; Wessel, David L.; Moler, Frank; Dalton, Heidi; Newth, Christopher J. L.; Shanley, Thomas; Harrison, Rick E.; Doctor, Allan; Jenkins, Tammara L.; Tamburro, Robert; Dean, J. Michael

2015-01-01

Objective Assessments of care including quality assessments adjusted for physiological status should include the development of new morbidities as well as mortalities. We hypothesized that morbidity, like mortality, is associated with physiological dysfunction and could be predicted simultaneously with mortality. Design Prospective cohort study from December 4, 2011 to April 7, 2013. Setting and Patients General and cardiac/cardiovascular pediatric intensive care units at 7 sites. Measurements and Main Results Among 10,078 admissions, the unadjusted morbidity rates (measured with the Functional Status Scale (FSS), and defined as an increase of ≥ 3 from pre-illness to hospital discharge) were 4.6% (site range 2.6% to 7.7%) and unadjusted mortality rates were 2.7% (site range 1.3% – 5.0%). Morbidity and mortality were significantly (p<0.001) associated with physiological instability (measured with the PRISM III score) in dichotomous (survival, death) and trichotomous (survival without new morbidity, survival with new morbidity, death) models without covariate adjustments. Morbidity risk increased with increasing PRISM III scores and then decreased at the highest PRISM III values as potential morbidities became mortalities. The trichotomous model with covariate adjustments included age, admission source, diagnostic factors, baseline FSS and the PRISM III score. The three-level goodness of fit test indicated satisfactory performance for the derivation and validation sets (p>0.20). Predictive ability assessed with the volume under the surface (VUS) was 0.50 ± 0.019 (derivation) and 0.50 ± 0.034 (validation) (versus chance performance = 0.17). Site-level standardized morbidity ratios were more variable than standardized mortality ratios. Conclusions New morbidities were associated with physiological status and can be modeled simultaneously with mortality. Trichotomous outcome models including both morbidity and mortality based on physiological status are suitable for research studies, and quality and other outcome assessments. This approach may be applicable to other assessments presently based only on mortality. PMID:25985385

Effects of Hurricane Katrina on nursing facility resident mortality, hospitalization, and functional decline.

PubMed

Dosa, David; Feng, Zhanlian; Hyer, Kathy; Brown, Lisa M; Thomas, Kali; Mor, Vincent

2010-09-01

The study was designed to examine the 30- and 90-day mortality and hospitalization rates among nursing facility (NF) residents in the affected areas of Louisiana and Mississippi following Hurricane Katrina and to assess the rate of significant posthurricane functional decline. A secondary data analysis was conducted using Medicare claims merged with NF resident data from the Minimum Data Set. Thirty- and 90-day mortality and hospitalization rates for long-stay (>90 days) residents residing in 141 at-risk NFs during Hurricane Katrina were compared to rates for residents residing at the same facilities during the same time period in prior nonhurricane years (2003 and 2004). Functional decline was assessed as a 4+ drop in function using a 28-point Minimum Data Set Activities of Daily Living Scale. There were statistically significant differences (all P < .0001) in mortality, hospitalization, and functional decline among residents exposed to Hurricane Katrina. At 30 days, the mortality rate was 3.88% among the exposed cohort compared with 2.10% and 2.28% for residents in 2003 and 2004, respectively. The 90-day mortality rate was 9.27% compared with 6.71% and 6.31%, respectively. These mortality differences translated into an additional 148 deaths at 30 days and 230 deaths at 90 days. The 30-day hospitalization rate was 9.87% compared with 7.21% and 7.53%, respectively. The 90-day hospitalization rate was 20.39% compared with 18.61% and 17.82%, respectively. Finally, the rate of significant functional decline among survivors was 6.77% compared with 5.81% in 2003 and 5.10% in 2004. NF residents experienced a significant increase in mortality, hospitalization, and functional decline during Hurricane Katrina.

Mortality and Clostridium difficile infection in an Australian setting.

PubMed

Mitchell, Brett G; Gardner, Anne; Hiller, Janet E

2013-10-01

To quantify the risk of death associated with Clostridium difficile infection, in an Australian tertiary hospital. Two reviews examining Clostridium difficile infection and mortality indicate that Clostridium difficile infection is associated with increased mortality in hospitalized patients. Studies investigating the mortality of Clostridium difficile infection in settings outside of Europe and North America are required, so that the epidemiology of Clostridium difficile infection in these regions can be understood and appropriate prevention strategies made. An observational non-concurrent cohort study design was used. Data from all persons who had (exposed) and a matched sample of persons who did not have Clostridium difficile infection, for the calendar years 2007-2010, were analysed. The risk of dying within 30, 60, 90 and 180 days was compared using the two groups. Kaplan-Meier survival analysis and conditional logistic regression models were applied to the data to examine time to death and mortality risk adjusted for comorbidities using the Charlson Comorbidity Index. One hundred and fifty-eight cases of infection were identified. A statistically significant difference in all-cause mortality was identified between exposed and non-exposed groups at 60 and 180 days. In a conditional regression model, mortality in the exposed group was significantly higher at 180 days. In this Australian study, Clostridium difficile infection was associated with increased mortality. In doing so, it highlights the need for nurses to immediately instigate contact precautions for persons suspected of having Clostridium difficile infection and to facilitate a timely faecal collection for testing. Our findings support ongoing surveillance of Clostridium difficile infection and associated prevention and control activities. © 2013 Blackwell Publishing Ltd.

The volume-mortality relation for radical cystectomy in England: retrospective analysis of hospital episode statistics

PubMed Central

Bottle, Alex; Darzi, Ara W; Athanasiou, Thanos; Vale, Justin A

2010-01-01

Objectives To investigate the relation between volume and mortality after adjustment for case mix for radical cystectomy in the English healthcare setting using improved statistical methodology, taking into account the institutional and surgeon volume effects and institutional structural and process of care factors. Design Retrospective analysis of hospital episode statistics using multilevel modelling. Setting English hospitals carrying out radical cystectomy in the seven financial years 2000/1 to 2006/7. Participants Patients with a primary diagnosis of cancer undergoing an inpatient elective cystectomy. Main outcome measure Mortality within 30 days of cystectomy. Results Compared with low volume institutions, medium volume ones had a significantly higher odds of in-hospital and total mortality: odds ratio 1.72 (95% confidence interval 1.00 to 2.98, P=0.05) and 1.82 (1.08 to 3.06, P=0.02). This was only seen in the final model, which included adjustment for structural and processes of care factors. The surgeon volume-mortality relation showed weak evidence of reduced odds of in-hospital mortality (by 35%) for the high volume surgeons, although this did not reach statistical significance at the 5% level. Conclusions The relation between case volume and mortality after radical cystectomy for bladder cancer became evident only after adjustment for structural and process of care factors, including staffing levels of nurses and junior doctors, in addition to case mix. At least for this relatively uncommon procedure, adjusting for these confounders when examining the volume-outcome relation is critical before considering centralisation of care to a few specialist institutions. Outcomes other than mortality, such as functional morbidity and disease recurrence may ultimately influence towards centralising care. PMID:20305302

Seasonal Variations in Mortality, Clinical, and Laboratory Parameters in Hemodialysis Patients: A 5-Year Cohort Study

PubMed Central

Usvyat, Len A.; Carter, Mary; Thijssen, Stephan; Kooman, Jeroen P.; van der Sande, Frank M.; Zabetakis, Paul; Balter, Paul; Levin, Nathan W.; Kotanko, Peter

2012-01-01

Summary Background and objectives Mortality varies seasonally in the general population, but it is unknown whether this phenomenon is also present in hemodialysis patients with known higher background mortality and emphasis on cardiovascular causes of death. This study aimed to assess seasonal variations in mortality, in relation to clinical and laboratory variables in a large cohort of chronic hemodialysis patients over a 5-year period. Design, setting, participants, & measurements This study included 15,056 patients of 51 Renal Research Institute clinics from six states of varying climates in the United States. Seasonal differences were assessed by chi-squared tests and univariate and multivariate cosinor analyses. Results Mortality, both all-cause and cardiovascular, was significantly higher during winter compared with other seasons (14.2 deaths per 100 patient-years in winter, 13.1 in spring, 12.3 in autumn, and 11.9 in summer). The increase in mortality in winter was more pronounced in younger patients, as well as in whites and in men. Seasonal variations were similar across climatologically different regions. Seasonal variations were also observed in neutrophil/lymphocyte ratio and serum calcium, potassium, and platelet values. Differences in mortality disappeared when adjusted for seasonally variable clinical parameters. Conclusions In a large cohort of dialysis patients, significant seasonal variations in overall and cardiovascular mortality were observed, which were consistent over different climatic regions. Other physiologic and laboratory parameters were also seasonally different. Results showed that mortality differences were related to seasonality of physiologic and laboratory parameters. Seasonal variations should be taken into account when designing and interpreting longitudinal studies in dialysis patients. PMID:22096041

The SLUScore: A Novel Method for Detecting Hazardous Hypotension in Adult Patients Undergoing Noncardiac Surgical Procedures

PubMed Central

Yuan, Hui; Dryden, Jefferson K.; Strehl, Kristen E.; Cywinski, Jacek B.; Ehrenfeld, Jesse M.; Bromley, Pamela

2017-01-01

BACKGROUND: It has been suggested that longer-term postsurgical outcome may be adversely affected by less than severe hypotension under anesthesia. However, evidence-based guidelines are unavailable. The present study was designed to develop a method for identifying patients at increased risk of death within 30 days in association with the severity and duration of intraoperative hypotension. METHODS: Intraoperative mean arterial blood pressure recordings of 152,445 adult patients undergoing noncardiac surgery were analyzed for periods of time accumulated below each one of the 31 thresholds between 75 and 45 mm Hg (hypotensive exposure times). In a development cohort of 35,904 patients, the associations were sought between each of these 31 cumulative hypotensive exposure times and 30-day postsurgical mortality. On the basis of covariable-adjusted percentage increases in the odds of mortality per minute elapsed of hypotensive exposure time, certain sets of exposure time limits were calculated that portended certain percentage increases in the odds of mortality. A novel risk-scoring method was conceived by counting the number of exposure time limits that had been exceeded within each respective set, one of them being called the SLUScore. The validity of this new method in identifying patients at increased risk was tested in a multicenter validation cohort consisting of 116,541 patients from Cleveland Clinic, Vanderbilt and Saint Louis Universities. Data were expressed as 95% confidence interval, P < .05 considered significant. RESULTS: Progressively greater hypotensive exposures were associated with greater 30-day mortality. In the development cohort, covariable-adjusted (age, Charlson score, case duration, history of hypertension) exposure limits were identified for time accumulated below each of the thresholds that portended certain identical (5%–50%) percentage expected increases in the odds of mortality. These exposure time limit sets were shorter in patients with a history of hypertension. A novel risk score, the SLUScore (range 0–31), was conceived as the number of exposure limits exceeded for one of these sets (20% set). A SLUScore > 0 (average 13.8) was found in 40% of patients who had twice the mortality, adjusted odds increasing by 5% per limit exceeded. When tested in the validation cohort, a SLUScore > 0 (average 14.1) identified 35% of patients who had twice the mortality, each incremental limit exceeded portending a 5% compounding increase in adjusted odds of mortality, independent of age and Charlson score (C = 0.73, 0.72–0.74, P < .05). CONCLUSIONS: The SLUScore represents a novel method for identifying nearly 1 in every 3 patients experiencing greater 30-day mortality portended by more severe intraoperative hypotensive exposures. PMID:28107274

Design of a multi-arm randomized clinical trial with no control arm.

PubMed

Magaret, Amalia; Angus, Derek C; Adhikari, Neill K J; Banura, Patrick; Kissoon, Niranjan; Lawler, James V; Jacob, Shevin T

2016-01-01

Clinical trial designs that include multiple treatments are currently limited to those that perform pairwise comparisons of each investigational treatment to a single control. However, there are settings, such as the recent Ebola outbreak, in which no treatment has been demonstrated to be effective; and therefore, no standard of care exists which would serve as an appropriate control. For illustrative purposes, we focused on the care of patients presenting in austere settings with critically ill 'sepsis-like' syndromes. Our approach involves a novel algorithm for comparing mortality among arms without requiring a single fixed control. The algorithm allows poorly-performing arms to be dropped during interim analyses. Consequently, the study may be completed earlier than planned. We used simulation to determine operating characteristics for the trial and to estimate the required sample size. We present a potential study design targeting a minimal effect size of a 23% relative reduction in mortality between any pair of arms. Using estimated power and spurious significance rates from the simulated scenarios, we show that such a trial would require 2550 participants. Over a range of scenarios, our study has 80 to 99% power to select the optimal treatment. Using a fixed control design, if the control arm is least efficacious, 640 subjects would be enrolled into the least efficacious arm, while our algorithm would enroll between 170 and 430. This simulation method can be easily extended to other settings or other binary outcomes. Early dropping of arms is efficient and ethical when conducting clinical trials with multiple arms. Copyright © 2015 Elsevier Inc. All rights reserved.

Simulation of Population Processes with a Programmable Pocket Calculator.

ERIC Educational Resources Information Center

Kidd, N. A. C.

1979-01-01

Presents a set of simulation models for use in teaching population dynamics. These models are designed specifically for use with a programmable pocket calculator, and can be used to demonstrate growth of populations with discrete or overlapping generations and also to explore effects of density-dependent and -independent mortality. (Author/CS)

Unemployment and HIV mortality in the countries of the Organisation for Economic Co-operation and Development: 1981–2009

PubMed Central

Maruthappu, Mahiben; Williams, Callum; Zeltner, Thomas; Atun, Rifat

2017-01-01

Objectives To determine an association between unemployment rates and human immunodeficiency virus (HIV) mortality in the Organisation for Economic Co-operation and Development (OECD). Design Multivariate regression analysis. Participants OECD member states. Setting OECD. Main outcome measures World Health Organization HIV mortality. Results Between 1981 and 2009, a 1% increase in unemployment was associated with an increase in HIV mortality in the OECD (coefficient for men 0.711, 0.334–1.089, p = 0.0003; coefficient for women 0.166, 0.071–0.260, p = 0.0007). Time lag analysis showed a significant increase in HIV mortality for up to two years after rises in unemployment: p = 0.0008 for men and p = 0.0030 for women in year 1, p = 0.0067 for men and p = 0.0403 for women in year 2. Conclusions Rises in unemployment are associated with increased HIV mortality. Economic fiscal policy may impact upon population health. Policy discussions should take into consideration potential health outcomes. PMID:28748096

Surgeon and Hospital Volume as Quality Indicators for CABG in Taiwan: Examining Hazard to Mortality and Accounting for Unobserved Heterogeneity

PubMed Central

Hockenberry, Jason M; Lien, Hsien-Ming; Chou, Shin-Yi

2010-01-01

Objective To investigate whether provider volume has an impact on the hazard of mortality for coronary artery bypass grafting (CABG) patients in Taiwan. Data Sources/Study Setting Multiple sources of linked data from the National Health Insurance Program in Taiwan. Study Design The linked data were used to identify 27,463 patients who underwent CABG without concomitant angioplasty or valve procedures and the surgeon and hospital volumes. Generalized estimating equations and hazard models were estimated to assess the impact of volume on mortality. The hazard modeling technique used accounts for bias stemming from unobserved heterogeneity. Principal Findings Both surgeon and hospital volume quartiles are inversely related to the hazard of mortality after CABG. Patients whose surgeon is in the three higher volume quartiles have lower 1-, 3-, 6-, and 12-month mortality after CABG, while only those having their procedure performed at the highest quartile of volume hospitals have lower mortality outcomes. Conclusions Mortality outcomes are related to provider CABG volume in Taiwan. Unobserved heterogeneity is a concern in the volume–outcome relationship; after accounting for it, surgeon volume effects on short-term mortality are large. Using models controlling for unobserved heterogeneity and examining longer term mortality may still differentiate provider quality by volume. PMID:20662948

Deprivation and mortality in non-metropolitan areas of England and Wales.

PubMed Central

Jessop, E G

1996-01-01

OBJECTIVE: To test the hypothesis that the relationship between deprivation and mortality is weaker among residents of non-metropolitan areas of England and Wales than among residents of metropolitan areas. DESIGN: This study compared mortality, expressed as standardised mortality ratios (SMRs), in residents of metropolitan and non-metropolitan districts at three levels of deprivation classified by an electoral ward deprivation score and by home and car ownership. SMRs were computed for all causes of death, for bronchitis and asthma (ICD9 codes 490-493), and for accident, violence, and poisoning (ICD9 codes 800-999). SETTING: England and Wales. PARTICIPANTS: Members of the longitudinal study of the Office of Population Censuses and Surveys, a quasi-random 1% sample of the population of England and Wales. MAIN RESULTS: There was an association between deprivation and mortality which was clear for all cause mortality, more noticeable for respiratory disease, and less clear for deaths from accident, violence, and poison. In general, the results showed a remarkable similarity between metropolitan and non-metropolitan areas. CONCLUSIONS: This study does not support the hypothesis that the relationship between mortality and deprivation differs between residents of metropolitan and non-metropolitan areas of England and Wales. PMID:8944858

Sulfonylureas and the Risks of Cardiovascular Events and Death: A Methodological Meta-Regression Analysis of the Observational Studies.

PubMed

Azoulay, Laurent; Suissa, Samy

2017-05-01

Recent randomized trials have compared the newer antidiabetic agents to treatments involving sulfonylureas, drugs associated with increased cardiovascular risks and mortality in some observational studies with conflicting results. We reviewed the methodology of these observational studies by searching MEDLINE from inception to December 2015 for all studies of the association between sulfonylureas and cardiovascular events or mortality. Each study was appraised with respect to the comparator, the outcome, and study design-related sources of bias. A meta-regression analysis was used to evaluate heterogeneity. A total of 19 studies were identified, of which six had no major design-related biases. Sulfonylureas were associated with an increased risk of cardiovascular events and mortality in five of these studies (relative risks 1.16-1.55). Overall, the 19 studies resulted in 36 relative risks as some studies assessed multiple outcomes or comparators. Of the 36 analyses, metformin was the comparator in 27 (75%) and death was the outcome in 24 (67%). The relative risk was higher by 13% when the comparator was metformin, by 20% when death was the outcome, and by 7% when the studies had design-related biases. The lowest predicted relative risk was for studies with no major bias, comparator other than metformin, and cardiovascular outcome (1.06 [95% CI 0.92-1.23]), whereas the highest was for studies with bias, metformin comparator, and mortality outcome (1.53 [95% CI 1.43-1.65]). In summary, sulfonylureas were associated with an increased risk of cardiovascular events and mortality in the majority of studies with no major design-related biases. Among studies with important biases, the association varied significantly with respect to the comparator, the outcome, and the type of bias. With the introduction of new antidiabetic drugs, the use of appropriate design and analytical tools will provide their more accurate cardiovascular safety assessment in the real-world setting. © 2017 by the American Diabetes Association.

Modeled Urea Distribution Volume and Mortality in the HEMO Study

PubMed Central

Greene, Tom; Depner, Thomas A.; Levin, Nathan W.; Chertow, Glenn M.

2011-01-01

Summary Background and objectives In the Hemodialysis (HEMO) Study, observed small decreases in achieved equilibrated Kt/Vurea were noncausally associated with markedly increased mortality. Here we examine the association of mortality with modeled volume (Vm), the denominator of equilibrated Kt/Vurea. Design, setting, participants, & measurements Parameters derived from modeled urea kinetics (including Vm) and blood pressure (BP) were obtained monthly in 1846 patients. Case mix–adjusted time-dependent Cox regressions were used to relate the relative mortality hazard at each time point to Vm and to the change in Vm over the preceding 6 months. Mixed effects models were used to relate Vm to changes in intradialytic systolic BP and to other factors at each follow-up visit. Results Mortality was associated with Vm and change in Vm over the preceding 6 months. The association between change in Vm and mortality was independent of vascular access complications. In contrast, mortality was inversely associated with V calculated from anthropometric measurements (Vant). In case mix–adjusted analysis using Vm as a time-dependent covariate, the association of mortality with Vm strengthened after statistical adjustment for Vant. After adjustment for Vant, higher Vm was associated with slightly smaller reductions in intradialytic systolic BP and with risk factors for mortality including recent hospitalization and reductions in serum albumin concentration and body weight. Conclusions An increase in Vm is a marker for illness and mortality risk in hemodialysis patients. PMID:21511841

Does increased emergency medical services prehospital time affect patient mortality in rural motor vehicle crashes? A statewide analysis.

PubMed

Gonzalez, Richard P; Cummings, Glenn R; Phelan, Herbert A; Mulekar, Madhuri S; Rodning, Charles B

2009-01-01

Fatality rates from rural vehicular trauma are almost double those found in urban settings. It has been suggested that increased prehospital time is a factor that adversely affects fatality rates in rural vehicular trauma. By linking and analyzing Alabama's statewide prehospital data, emergency medical services (EMS) prehospital time was assessed for rural and urban vehicular crashes. An imputational methodology permitted linkage of data from police motor vehicle crash (MVC) and EMS records. MVCs were defined as rural or urban by crash location using the United States Census Bureau criteria. Areas within Alabama that fell outside the Census Bureau definition of urban were defined as rural. Prehospital data were analyzed to determine EMS response time, scene time, and transport time in rural and urban settings. Over a 2-year period from January 2001 through December 2002, data were collected from EMS Patient Care Reports and police crash reports for the entire state of Alabama. By using an imputational methodology and join specifications, 45,763 police crash reports were linked to EMS Patient Care Reports. Of these, 34,341 (75%) were injured in rural settings and 11,422 (25%) were injured in urban settings. A total of 714 mortalities were identified, of which 611 (1.78%) occurred in rural settings and 103 (.90%) occurred in urban settings (P < .0001). When mortalities occurred, the mean EMS response time in rural settings was 10.67 minutes and 6.50 minutes in urban settings (P < .0001). When mortalities occurred, the mean EMS scene time in rural settings was 18.87 minutes and 10.83 minutes in urban settings (patients who were dead on scene and extrication patients were excluded from both settings) (P < .0001). When mortalities occurred, the mean EMS transport time in rural settings was 12.45 minutes and 7.43 minutes in urban settings (P < .0001). When mortalities occurred, the overall mean prehospital time in rural settings was 42.0 minutes and 24.8 minutes in urban settings (P < .0001). The mean EMS response time for rural MVCs with survivors was 8.54 minutes versus a mean of 10.67 minutes with mortalities (P < .0001). The mean EMS scene time for rural MVCs with survivors was 14.81 minutes versus 18.87 minutes with mortalities (patients who were dead on scene and extrication patients were excluded) (P = .0014). Based on this statewide analysis of MVCs, increased EMS prehospital time appears to be associated with higher mortality rates in rural settings.

First do no harm: the impact of recent armed conflict on maternal and child health in Sub-Saharan Africa

PubMed Central

O'Hare, Bernadette A M; Southall, David P

2007-01-01

Objectives To compare the rates of under-5 mortality, malnutrition, maternal mortality and other factors which influence health in countries with and without recent conflict. To compare central government expenditure on defence, education and health in countries with and without recent conflict. To summarize the amount spent on SALW and the main legal suppliers to countries in Sub-Saharan African countries (SSA), and to summarize licensed production of Small Arms and Light Weapons (SALW) in these countries. Design We compared the under-5 mortality rate in 2004 and the adjusted maternal mortality ratio in SSA which have and have not experienced recent armed conflict (post-1990). We also compared the percentage of children who are underweight in both sets of countries, and expenditure on defence, health and education. Setting Demographic data and central government expenditure details (1994-2004) were taken from UNICEF's The State of the World's Children 2006 report. Main outcome measures Under-5 mortality, adjusted maternal mortality, and government expenditure. Results 21 countries have and 21 countries have not experienced recent conflict in this dataset of 42 countries in SSA. Median under-5 mortality in countries with recent conflict is 197/1000 live births, versus 137/1000 live births in countries without recent conflict. In countries which have experienced recent conflict, a median of 27% of under-5s were moderately underweight, versus 22% in countries without recent conflict. The median adjusted maternal mortality in countries with recent conflict was 1000/100,000 births versus 690/100,000 births in countries without recent conflict. Median reported maternal mortality ratio is also significantly higher in countries with recent conflict. Expenditure on health and education is significantly lower and expenditure on defence significantly higher if there has been recent conflict. Conclusions There appears to be an association between recent conflict and higher rates of under-5 mortality, malnutrition and maternal mortality. Governments spend more on defence and less on health and education if there has been a recent conflict. SALW are the main weapon used and France and the UK appear to be the two main suppliers of SALW to SSA. PMID:18065709

Type 2 Diabetes Genetic Predisposition, Obesity, and All-Cause Mortality Risk in the U.S.: A Multiethnic Analysis

PubMed Central

Leong, Aaron; Porneala, Bianca; Dupuis, Josée; Florez, Jose C.

2016-01-01

OBJECTIVE Type 2 diabetes (T2D) is associated with increased mortality in ethnically diverse populations, although the extent to which this association is genetically determined is unknown. We sought to determine whether T2D-related genetic variants predicted all-cause mortality, even after accounting for BMI, in the Third National Health and Nutrition Examination Survey. RESEARCH DESIGN AND METHODS We modeled mortality risk using a genetic risk score (GRS) from a weighted sum of risk alleles at 38 T2D-related single nucleotide polymorphisms. In age-, sex-, and BMI-adjusted logistic regression models, accounting for the complex survey design, we tested the association with mortality in 6,501 participants. We repeated the analysis within ethnicities (2,528 non-Hispanic white [NHW], 1,979 non-Hispanic black [NHB], and 1,994 Mexican American [MA]) and within BMI categories (<25, 25–30, and ≥30 kg/m2). Significance was set at P < 0.05. RESULTS Over 17 years, 1,556 participants died. GRS was associated with mortality risk (OR 1.04 [95% CI 1.00–1.07] per T2D-associated risk allele, P = 0.05). Within ethnicities, GRS was positively associated with mortality risk in NHW and NHB, but not in MA (0.95 [0.90–1.01], P = 0.07). The negative trend in MA was largely driven by those with BMI <25 kg/m2 (0.91 [0.82–1.00]). In NHW, the positive association was strongest among those with BMI ≥30 kg/m2 (1.07 [1.02–1.12]). CONCLUSIONS In the U.S., a higher T2D genetic risk was associated with increased mortality risk, especially among obese NHW. The underlying genetic basis for mortality likely involves complex interactions with factors related to ethnicity, T2D, and body weight. PMID:26884474

Rationale, study design and analysis plan of the lung imaging morphology for ventilator settings in acute respiratory distress syndrome study (LIVE study): Study protocol for a randomised controlled trial.

PubMed

Jabaudon, Matthieu; Godet, Thomas; Futier, Emmanuel; Bazin, Jean-Étienne; Sapin, Vincent; Roszyk, Laurence; Pereira, Bruno; Constantin, Jean-Michel

2017-10-01

Different acute respiratory distress syndrome (ARDS) phenotypes may explain controversial results in clinical trials. Lung-morphology is one of the ARDS-phenotypes and physiological studies suggest different responses in terms of positive-end-expiratory-pressure (PEEP) and recruitment-manoeuvres (RM) according to loss of aeration. To evaluate whether tailored ventilator regimens may impact ARDS outcomes, our group has designed a randomised-clinical-trial of ventilator settings according to lung morphology in moderate-to-severe ARDS (LIVE study). Patients will be enrolled within the first 12hours of ARDS onset. In both groups, volume-controlled ventilation with low tidal-volumes (Vt) will be used to target a plateau pressure≤30 cmH 2 O. In the control group, the PEEP level and inspired fraction of oxygen (FiO 2 ) will be set using the ARDSNet table; a Vt of 6 mL/kg of predicted body weight (PBW) will be set and prone position (PP) will be applied. In the intervention arm, the ventilator will be set according to lung morphology (focal/non-focal) that will be assessed according to CT-scan±chest x-ray+lung echography. For focal ARDS patients, a Vt of 8 mL/kg PBW will be used along with low PEEP and PP. For non-focal ARDS patients, a Vt of 6 mL/kg PBW will be used with RM and PEEP to reach a plateau pressure≤30 cmH 2 O. The primary outcome is all-cause 90-day mortality and the secondary outcomes are: in-hospital mortality, mortality at day 28, 60, 180 and 365; ventilator-free days at day 30, quality of life at one year; ventilator-associated pneumonia rate; barotrauma; ICU and hospital length of stay. This RCT is registered on Clinicaltrials.gov under identifier NCT02149589. Copyright © 2017 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

Aspirin Is Associated With Reduced Cardiovascular and All-Cause Mortality in Type 2 Diabetes in a Primary Prevention Setting

PubMed Central

Ong, Greg; Davis, Timothy M.E.; Davis, Wendy A.

2010-01-01

OBJECTIVE To determine whether regular aspirin use (≥75 mg/day) is independently associated with cardiovascular disease (CVD) and all-cause mortality in community-based patients with type 2 diabetes and no history of CVD. RESEARCH DESIGN AND METHODS Of the type 2 diabetic patients recruited to the longitudinal observational Fremantle Diabetes Study, 651 (50.3%) with no prior CVD history at entry between 1993 and 1996 were followed until death or the end of June 2007, representing a total of 7,537 patient-years (mean ± SD 11.6 ± 2.9 years). Cox proportional hazards modeling was used to determine independent baseline predictors of CVD and all-cause mortality including regular aspirin use. RESULTS There were 160 deaths (24.6%) during follow-up, with 70 (43.8%) due to CVD. In Kaplan-Meier survival analysis, there was no difference in either CVD or all-cause mortality in aspirin users versus nonusers (P = 0.52 and 0.94, respectively, by log-rank test). After adjustment for significant variables in the most parsimonious Cox models, regular aspirin use at baseline independently predicted reduced CVD and all-cause mortality (hazard ratio [HR] 0.30 [95% CI 0.09–0.95] and 0.53 [0.28–0.98[, respectively; P ≤ 0.044). In subgroup analyses, aspirin use was independently associated with reduced all-cause mortality in those aged ≥65 years and men. CONCLUSIONS Regular low-dose aspirin may reduce all-cause and CVD mortality in a primary prevention setting in type 2 diabetes. All-cause mortality reductions are greatest in men and in those aged ≥65 years. The present observational data support recommendations that aspirin should be used in primary CVD prevention in all but the lowest risk patients. PMID:19918016

Educating Normal Breast Mucosa to Prevent Breast Cancer

DTIC Science & Technology

2016-12-01

prevention of breast cancer and the feasibility of translating this approach into preventive breast cancer vaccine setting. 15. SUBJECT TERMS...immunity. Our overall goal is to develop a preventative vaccination strategy to reduce the incidence and mortality from breast cancer based on...thorough understanding of the immunity in breast mucosa will enable the design of appropriate vaccination strategies aimed at generating persistent

The Effect of Dialysis Chains on Mortality among Patients Receiving Hemodialysis

PubMed Central

Zhang, Yi; Cotter, Dennis J; Thamer, Mae

2011-01-01

Objective To examine the association between dialysis facility chain affiliation and patient mortality. Study Setting Medicare dialysis population. Study Design Data from the United States Renal Data System (USRDS) were used to identify 3,601 free-standing dialysis facilities and 34,914 Medicare patients' incidence to end-stage renal disease (ESRD) in 2004. Mixed-effect regression models were used to estimate patient mortality by dialysis facility chain and profit status during the 2-year follow-up. Data Collection USRDS data were matched with facility, cost, and census data. Principle Findings Of the five largest dialysis chains, the lowest mortality risk was observed among patients dialyzed at nonprofit (NP) Chain 5 facilities. Compared with Chain 5, hazard ratios were 19 percent higher (95 percent CI 1.06–1.34) and 24 percent higher (95 percent CI 1.10–1.40) for patients dialyzed at for-profit (FP) Chain 1 and Chain 2 facilities, respectively. In addition, patients at FP facilities had a 13 percent higher risk of mortality than those in NP facilities (95 percent CI 1.06–1.22). Conclusions Large chain affiliation is an independent risk factor for ESRD mortality in the United States. Given the movement toward further consolidation of large FP chains, reasons behind the increase in mortality require scrutiny. PMID:21143480

Mortality Associated With Seasonal and Pandemic Influenza Among Pregnant and Nonpregnant Women of Childbearing Age in a High-HIV-Prevalence Setting-South Africa, 1999-2009.

PubMed

Tempia, Stefano; Walaza, Sibongile; Cohen, Adam L; von Mollendorf, Claire; Moyes, Jocelyn; McAnerney, Johanna M; Cohen, Cheryl

2015-10-01

Information on the mortality burden associated with seasonal and pandemic influenza virus infection among pregnant women is scarce in most settings, particularly in sub-Saharan Africa where pregnancy and maternal mortality rates as well as human immunodeficiency virus (HIV) prevalence are elevated. We used an ecological study design to estimate the seasonal and A(H1N1)pdm09 influenza-associated mortality among pregnant and nonpregnant women of childbearing age (15-49 years) by HIV serostatus during 1999-2009 in South Africa. Mortality rates were expressed per 100 000 person-years. During 1999-2009, the estimated mean annual seasonal influenza-associated mortality rates were 12.6 (123 deaths) and 7.3 (914 deaths) among pregnant and nonpregnant women, respectively. Among pregnant women, the estimated mean annual seasonal influenza-associated mortality rates were 74.9 (109 deaths) among HIV-infected and 1.5 (14 deaths) among HIV-uninfected individuals. Among nonpregnant women, the estimated mean annual seasonal influenza-associated mortality rate was 41.2 (824 deaths) among HIV-infected and 0.9 (90 deaths) among HIV-uninfected individuals. Pregnant women experienced an increased risk of seasonal influenza-associated mortality compared with nonpregnant women (relative risk [RR], 2.8; 95% confidence interval [CI], 1.7-3.9). In 2009, the estimated influenza A(H1N1)pdm09-associated mortality rates were 19.3 (181 deaths) and 9.4 (1189 deaths) among pregnant and nonpregnant women, respectively (RR, 3.2; 95% CI, 2.3-4.1). Among women of childbearing age, the majority of estimated seasonal influenza-associated deaths occurred in HIV-infected individuals. Pregnant women experienced an increased risk of death associated with seasonal and A(H1N1)pdm09 influenza infection compared with nonpregnant women. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Nutritional status and mortality of refugee and resident children in a non-camp setting during conflict: follow up study in Guinea-Bissau

PubMed Central

Aaby, Peter; Gomes, Joaquim; Fernandes, Manuel; Djana, Queba; Lisse, Ida; Jensen, Henrik

1999-01-01

Objective To study the effects on children of humanitarian aid agencies restricting help to refugee families (internally displaced people). Design Follow up study of 3 months. Setting Prabis peninsular outside Bissau, the capital of Guinea-Bissau, which has functioned as a refugee area for internally displaced people in the ongoing war, and the study area of the Bandim health project in Bissau. Participants 422 children aged 9-23 months in 30 clusters. Main outcome measures Mid-upper arm circumference and survival in relation to residence status. Results During the refugee situation all children deteriorated nutritionally, and mortality was high (3.0% in a 6 week period). Rice consumption was higher in families resident in Prabis than in refugees from Bissau but there was no difference in food expenditure. Nutritional status, measured by mid- upper arm circumference, was not associated with rice consumption levels in the family, and the decline in circumference was significantly worse for resident than for refugee children; the mid-upper arm circumference of refugee children increased faster than that of resident children. For resident children, mortality was 4.5 times higher (95% confidence interval 1.1 to 30.0) than for refugee children. Mortality for both resident and refugee children was 7.2 times higher (1.3 to 133.9) during the refugee’s stay in Prabis compared with the period after the departure of the refugees. Conclusion In a non-camp setting, residents may be more malnourished and have higher mortality than refugees. Major improvements in nutritional status and a reduction in mortality occurred in resident and refugee children as soon as refugees returned home despite the fact that there was no improvement in food availability. Key messagesDuring the war in Guinea-Bissau, most of the population fled from the capital and moved in with relatives, friends, or strangersInternational agencies insisted on only providing help to refugees (internally displaced people)During the first month of conflict, there were already profound effects on the nutritional status and mortality of young childrenFood consumption was higher in resident families, but resident children were more malnourished and had higher mortality than refugee childrenNutritional status and survival improved for both refugee and resident children once the refugees returned to Bissau PMID:10506040

MORBIDITY AND SURVIVAL PROBABILITY IN BURN PATIENTS IN MODERN BURN CARE

PubMed Central

Jeschke, Marc G.; Pinto, Ruxandra; Kraft, Robert; Nathens, Avery B.; Finnerty, Celeste C.; Gamelli, Richard L.; Gibran, Nicole S.; Klein, Matthew B.; Arnoldo, Brett D.; Tompkins, Ronald G.; Herndon, David N.

2014-01-01

Objective Characterizing burn sizes that are associated with an increased risk of mortality and morbidity is critical because it would allow identifying patients who might derive the greatest benefit from individualized, experimental, or innovative therapies. Although scores have been established to predict mortality, few data addressing other outcomes exist. The objective of this study was to determine burn sizes that are associated with increased mortality and morbidity after burn. Design and Patients Burn patients were prospectively enrolled as part of the multicenter prospective cohort study, Inflammation and the Host Response to Injury Glue Grant, with the following inclusion criteria: 0–99 years of age, admission within 96 hours after injury, and >20% total body surface area burns requiring at least one surgical intervention. Setting Six major burn centers in North America. Measurements and Main Results Burn size cutoff values were determined for mortality, burn wound infection (at least two infections), sepsis (as defined by ABA sepsis criteria), pneumonia, acute respiratory distress syndrome, and multiple organ failure (DENVER2 score >3) for both children (<16 years) and adults (16–65 years). Five-hundred seventy-three patients were enrolled, of which 226 patients were children. Twenty-three patients were older than 65 years and were excluded from the cutoff analysis. In children, the cutoff burn size for mortality, sepsis, infection, and multiple organ failure was approximately 60% total body surface area burned. In adults, the cutoff for these outcomes was lower, at approximately 40% total body surface area burned. Conclusions In the modern burn care setting, adults with over 40% total body surface area burned and children with over 60% total body surface area burned are at high risk for morbidity and mortality, even in highly specialized centers. PMID:25559438

No evidence of temperature-dependent sex determination or sex-biased embryo mortality in the chicken.

PubMed

Collins, K E; Jordan, B J; McLendon, B L; Navara, K J; Beckstead, R B; Wilson, J L

2013-12-01

Skewing the sex ratio at hatch in commercial poultry would be economically beneficial to the poultry industry. The existence of temperature-dependent sex determination is uncertain in birds. This experiment investigated if incubation temperatures skew sex ratios of commercial broilers. Three incubators were each set at a hot (38.3°C), standard (37.5°C), or cool (36.7°C) single-stage incubation temperature one time over 3 trials to eliminate incubator effect as a Latin square design. Sex ratios of hatched chicks and dead embryos were monitored. In one trial, embryo weights were evaluated. The percentages of male hatched chicks did not differ based on incubation temperature (P = 0.4486; 49.5% in the hot treatment, 51.4% at standard temperature, and 49.8% in the cool treatment). The percent hatch of eggs set was lower in the hot treatment (83.6%) than the standard (93.5%) and cool (91.6%) treatments (P < 0.0001) with greater late embryonic mortality in the hot treatment (P < 0.0001); however, the sex ratio of dead embryos did not differ among treatments (P = 0.9863). Pooled data of embryo mortality found no sex-biased embryo mortality with a female/male sex ratio of 1.22:1 (χ(2) = 1.27; P = 0.2596). Embryos from the hot treatment were heavier than those from the standard treatment by d 14 of incubation and were heavier than the embryos from the cool treatment by d 9 of incubation (P < 0.0001). These data indicate that incubation temperature affects embryonic mortality and embryonic growth rate, but it does not affect the sex ratio of broiler chickens. Additionally, no evidence was found for sex-biased embryo mortality in commercial broilers even at the incubation temperatures of this study.

Immigration, Wealth and the ‘Mortality Plateau’ in Emergent Urban-Industrial Towns of Nineteenth-Century Massachusetts

PubMed Central

Beemer, Jeffrey K.; Anderton, Douglas L.

2013-01-01

The mortality transition in Western Europe and the U.S. encompassed a much more complex set of conditions and experiences than earlier thought. Our research addresses the complex set of relationships among growing urban communities, family wealth, immigration and mortality in New England by examining individual-level, socio-demographic mortality correlates during the nineteenth-century mortality plateau and its early twentieth-century decline. In contrast to earlier theories that proposed a more uniform mortality transition, we offer an alternative hypothesis that focuses on the impact of family wealth and immigration on individual-level mortality during the early stages of the mortality transition in Northampton and Holyoke, Massachusetts. PMID:23667286

Has NHS reorganisation saved lives? A CuSum study using 65 years of data

PubMed Central

Lale, Alice S

2016-01-01

Objectives To determine if NHS reforms affect population mortality. Design Retrospective study using routinely published data. Setting & participants Resident population of England and Wales 1948 to 2012 Main outcome measure All cause age sex directly standardised mortality England and Wales 1948 to 2012. Methods Using the CuSum technique and Change-Point Analysis to identify sustained changes in the improving age-standardised mortality rates for the period 1948-2012, and comparing the time of these changes with periods of NHS reform. Where observed changes did not fit with NHS reform, changes external to the NHS were sought as a possible explanation of changes observed. Results CuSum plotting and CPA showed no significant changes in female mortality trend between 1948 and 2012. However, this analysis identified a sustained improvement in the male mortality trend, occurring in the mid-1970s. A further change in the rate of male mortality decline was found around the Millennium. Conclusion The 1974 NHS reorganisation, changing service arrangements predominantly for women and children, is considered an unlikely explanation of the improved rate of male mortality decline. Thus, centrally led NHS reorganisation has never had any detectable effect on either male or female mortality and must be considered ineffective for this purpose. But some evidence supporting the view that increased funding improves outcomes is found. PMID:26432817

Utilizing tenets of inoculation theory to develop and evaluate a preventive alcohol education intervention.

PubMed

Duryea, E J

1983-04-01

With the advent of the Surgeon General's Report, Healthy People, a renewed interest in and concern for the health-risky practices of the school aged has emerged. Moreover, because the mortality rates for the 15 to 24 year age group continues to increase while the mortality rates for every other age group continues to decline, a school health education imperative has become prevention-based interventions. The experimental, prevention-based alcohol education program reported here describes one such intervention directed at 9th grade students. The program was grounded on the principles of Inoculation Theory and evaluated using a Solomon Four-Group Design. Results indicate that the formulation of preventive alcohol education programs utilizing Inoculation Theory in a school setting is both feasible and productive in achieving designated objectives. Longitudinal assessment of the subjects with regard to their alcohol-related behavior is continuing throughout their high school careers.

Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study.

PubMed

Gill, Christopher J; Phiri-Mazala, Grace; Guerina, Nicholas G; Kasimba, Joshua; Mulenga, Charity; MacLeod, William B; Waitolo, Nelson; Knapp, Anna B; Mirochnick, Mark; Mazimba, Arthur; Fox, Matthew P; Sabin, Lora; Seidenberg, Philip; Simon, Jonathon L; Hamer, Davidson H

2011-02-03

To determine whether training traditional birth attendants to manage several common perinatal conditions could reduce neonatal mortality in the setting of a resource poor country with limited access to healthcare. Prospective, cluster randomised and controlled effectiveness study. Lufwanyama, an agrarian, poorly developed district located in the Copperbelt province, Zambia. All births carried out by study birth attendants occurred at mothers' homes, in rural village settings. 127 traditional birth attendants and mothers and their newborns (3559 infants delivered regardless of vital status) from Lufwanyama district. Using an unblinded design, birth attendants were cluster randomised to intervention or control groups. The intervention had two components: training in a modified version of the neonatal resuscitation protocol, and single dose amoxicillin coupled with facilitated referral of infants to a health centre. Control birth attendants continued their existing standard of care (basic obstetric skills and use of clean delivery kits). The primary outcome was the proportion of liveborn infants who died by day 28 after birth, with rate ratios statistically adjusted for clustering. Secondary outcomes were mortality at different time points; and comparison of causes of death based on verbal autopsy data. Among 3497 deliveries with reliable information, mortality at day 28 after birth was 45% lower among liveborn infants delivered by intervention birth attendants than control birth attendants (rate ratio 0.55, 95% confidence interval 0.33 to 0.90). The greatest reductions in mortality were in the first 24 hours after birth: 7.8 deaths per 1000 live births for infants delivered by intervention birth attendants compared with 19.9 per 1000 for infants delivered by control birth attendants (0.40, 0.19 to 0.83). Deaths due to birth asphyxia were reduced by 63% among infants delivered by intervention birth attendants (0.37, 0.17 to 0.81) and by 81% within the first two days after birth (0.19, 0.07 to 0.52). Stillbirths and deaths from serious infection occurred at similar rates in both groups. Training traditional birth attendants to manage common perinatal conditions significantly reduced neonatal mortality in a rural African setting. This approach has high potential to be applied to similar settings with dispersed rural populations. Trial registration Clinicaltrials.gov NCT00518856.

Application of sepsis definitions to pediatric patients admitted with suspected infections in Uganda

PubMed Central

Wiens, Matthew O.; Larson, Charles P.; Kumbakumba, Elias; Kissoon, Niranjan; Ansermino, J. Mark; Singer, Joel; Wong, Hubert; Ndamira, Andrew; Kabakyenga, Jerome; Moschovis, Peter; Kiwanuka, Julius

2017-01-01

Objectives Acute infectious diseases are the most common cause of under-5 mortality. However, the hospital burden of non-neonatal pediatric sepsis has not previously been described in the resource poor setting. The objective of this study was to determine the prevalence of sepsis among children 6 months to 5 years of age admitted with proven or suspected infection and to evaluate the presence of sepsis as a predictive tool for mortality during admission. Design In this Prospective cohort study we used the pediatric International Consensus Conference definition of sepsis to determine the prevalence of sepsis among children admitted to the pediatric ward with a proven or suspected infection. The diagnosis of sepsis, as well as each individual component of the sepsis definition, were evaluated for capturing in-hospital mortality. Setting The pediatric ward of two hospitals in Mbarara, Uganda Patients Admitted children between 6 months and 5 years with a confirmed or suspected infection. Interventions None Measurements and Main Results One thousand three hundred and seven (1307) subjects with a confirmed or suspected infection were enrolled and 65 children died (5.0%) during their admission. One thousand one hundred and twenty-one (85.9%) met the systemic inflammatory response syndrome criteria, and therefore were defined as having sepsis. The sepsis criteria captured 61 deaths, demonstrating a sensitivity and specificity of 95% (95% CI 90% – 100%) and 15% (95% CI 13% – 17%), respectively. The most discriminatory individual component of the SIRS criteria was the leukocyte count which alone had a sensitivity of 72% and a specificity of 56% for the identification of mortality in hospital. Conclusions This study is among the first to quantify the burden of non-neonatal pediatric sepsis in children with suspected infection, using the international consensus sepsis definition, in a typical resource constrained setting in Africa. This definition was found to be highly sensitive in identifying those who died, but had very low specificity as most children who were admitted with infections had sepsis. The SIRS-based sepsis definition offers little value in identification of children at high risk of in-hospital mortality in this setting. PMID:27043996

Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study

PubMed Central

Colantuoni, Elizabeth; Mendez-Tellez, Pedro A; Dinglas, Victor D; Sevransky, Jonathan E; Dennison Himmelfarb, Cheryl R; Desai, Sanjay V; Shanholtz, Carl; Brower, Roy G; Pronovost, Peter J

2012-01-01

Objective To evaluate the association of volume limited and pressure limited (lung protective) mechanical ventilation with two year survival in patients with acute lung injury. Design Prospective cohort study. Setting 13 intensive care units at four hospitals in Baltimore, Maryland, USA. Participants 485 consecutive mechanically ventilated patients with acute lung injury. Main outcome measure Two year survival after onset of acute lung injury. Results 485 patients contributed data for 6240 eligible ventilator settings, as measured twice daily (median of eight eligible ventilator settings per patient; 41% of which adhered to lung protective ventilation). Of these patients, 311 (64%) died within two years. After adjusting for the total duration of ventilation and other relevant covariates, each additional ventilator setting adherent to lung protective ventilation was associated with a 3% decrease in the risk of mortality over two years (hazard ratio 0.97, 95% confidence interval 0.95 to 0.99, P=0.002). Compared with no adherence, the estimated absolute risk reduction in two year mortality for a prototypical patient with 50% adherence to lung protective ventilation was 4.0% (0.8% to 7.2%, P=0.012) and with 100% adherence was 7.8% (1.6% to 14.0%, P=0.011). Conclusions Lung protective mechanical ventilation was associated with a substantial long term survival benefit for patients with acute lung injury. Greater use of lung protective ventilation in routine clinical practice could reduce long term mortality in patients with acute lung injury. Trial registration Clinicaltrials.gov NCT00300248. PMID:22491953

Widening social inequalities in mortality: the case of Barcelona, a southern European city.

PubMed Central

Borrell, C; Plasència, A; Pasarin, I; Ortún, V

1997-01-01

OBJECTIVE: To analyse trends in mortality inequalities in Barcelona between 1983 and 1994 by comparing rates in those electoral wards with a low socioeconomic level and rates in the remaining wards. DESIGN: Mortality trends study. SETTING: The city of Barcelona (Spain). SUBJECTS: The study included all deaths among residents of the two groups of city wards. Details were obtained from death certificates. MAIN OUTCOME MEASURES: Age standardised mortality rates, age standardised rates of years of potential life lost, and age specific mortality rates in relation to cause of death, sex, and year were computed as well as the comparative mortality figure and the ratio of standardised rates of years of potential life lost. RESULTS: Rates of premature mortality increased from 5691.2 years of potential life lost per 100,000 inhabitants aged 1 to 70 years in 1983 to 7606.2 in 1994 in the low socioeconomic level wards, and from 3731.2 to 4236.9 in the other wards, showing an increase in inequalities over the 12 years, mostly due to AIDS and drug overdose as causes of death. Conversely, cerebrovascular disease showed a reduction in inequality over the same period. Overall mortality in the 15-44 age group widened the gap between both groups of wards. CONCLUSION: AIDS and drug overdose are emerging as the causes of death that are contributing to a substantial increase in social inequality in terms of premature mortality, an unreported observation in European urban areas. PMID:9519129

Implementing Community Baby Showers to Address Infant Mortality in Oklahoma.

PubMed

Thornberry, Timothy; Han, Jennifer; Thomas, Linda

2017-03-01

IMPORTANCE: Oklahoma has one of the highest rates of infant mortality and poor birth outcomes in the U.S., particularly among minority populations. OBJECTIVES: To describe the formation and implementation of a state-led infant mortality prevention program which sought to: educate minorities about their disproportionate risk for infant mortality; improve pregnancy, infancy, and early childhood outcomes; and prevent infant mortality. DESIGN, SETTING, AND PARTICIPANTS: Participants completed one of many community baby shower events and were evaluated pre- and post-shower on infant mortality and well-baby knowledge. INTERVENTION: The "A Healthy Baby Begins with You" program. Main outcomes and measures. Pre- and post-intervention questionnaires assessing participant knowledge about infant mortality and willingness to share learned knowledge with others in the community. RESULTS: Preliminary results suggest that community baby showers were well-received. Respondents tended to be American Indians, non-Hispanic Whites, or Blacks/African Americans, young adults (aged 20 to 29 years), pregnant women, and mothers of grandparents of young children. Showers were successful in increasing participant knowledge of infant mortality, although these results varied by respondent race and age. Most respondents reported intent to share knowledge acquired during community baby showers with others. CONCLUSIONS AND RELEVANCE: Preliminary findings suggest community baby showers may increase participant knowledge, although future studies are needed to ensure effectiveness across all participant subgroups. This study documents the feasibility and acceptability of a community-based educational program targeting dissemination of infant mortality and well-child information. Barriers and future directions for research and prevention are discussed.

Prognostic indicators of 6-month mortality in elderly people with advanced dementia: A systematic review

PubMed Central

Brown, Meghan A; Sampson, Elizabeth L; Jones, Louise

2013-01-01

Background: For end-of-life dementia patients, palliative care offers a better quality of life than continued aggressive or burdensome medical interventions. To provide the best care options to dementia sufferers, validated, reliable, sensitive, and accurate prognostic tools to identify end-of-life dementia stages are necessary. Aim: To identify accurate prognosticators of mortality in elderly advanced dementia patients consistently reported in the literature. Design: Systematic literature review. Data sources: PubMed, Embase, and PsycINFO databases were searched up to September 2012. Reference lists of included studies were also searched. Inclusion criteria were studies measuring factors specifically related to 6-month outcome in patients diagnosed with dementia in any residential or health-care setting. Results: Seven studies met the inclusion criteria, five of which were set in the United States and two in Israel. Methodology and prognostic outcomes varied greatly between the studies. All but one study found that Functional Assessment Staging phase 7c, currently widely used to assess hospice admission eligibility in the United States, was not a reliable predictor of 6-month mortality. The most common prognostic variables identified related to nutrition/nourishment, or eating habits, followed by increased risk on dementia severity scales and comorbidities. Conclusions: Although the majority of studies agreed that the Functional Assessment Staging 7c criterion was not a reliable predictor of 6-month mortality, we found a lack of prognosticator concordance across the literature. Further studies are essential to identify reliable, sensitive, and specific prognosticators, which can be applied to the clinical setting and allow increased availability of palliative care to dementia patients. PMID:23175514

Two denominators for one numerator: the example of neonatal mortality.

PubMed

Harmon, Quaker E; Basso, Olga; Weinberg, Clarice R; Wilcox, Allen J

2018-06-01

Preterm delivery is one of the strongest predictors of neonatal mortality. A given exposure may increase neonatal mortality directly, or indirectly by increasing the risk of preterm birth. Efforts to assess these direct and indirect effects are complicated by the fact that neonatal mortality arises from two distinct denominators (i.e. two risk sets). One risk set comprises fetuses, susceptible to intrauterine pathologies (such as malformations or infection), which can result in neonatal death. The other risk set comprises live births, who (unlike fetuses) are susceptible to problems of immaturity and complications of delivery. In practice, fetal and neonatal sources of neonatal mortality cannot be separated-not only because of incomplete information, but because risks from both sources can act on the same newborn. We use simulations to assess the repercussions of this structural problem. We first construct a scenario in which fetal and neonatal factors contribute separately to neonatal mortality. We introduce an exposure that increases risk of preterm birth (and thus neonatal mortality) without affecting the two baseline sets of neonatal mortality risk. We then calculate the apparent gestational-age-specific mortality for exposed and unexposed newborns, using as the denominator either fetuses or live births at a given gestational age. If conditioning on gestational age successfully blocked the mediating effect of preterm delivery, then exposure would have no effect on gestational-age-specific risk. Instead, we find apparent exposure effects with either denominator. Except for prediction, neither denominator provides a meaningful way to define gestational-age-specific neonatal mortality.

The global problem of childhood diarrhoeal diseases: emerging strategies in prevention and management

PubMed Central

Mokomane, Margaret; Kasvosve, Ishmael; de Melo, Emilia; Pernica, Jeffrey M.; Goldfarb, David M.

2017-01-01

Acute diarrhoeal diseases remain a leading cause of global morbidity and mortality particularly among young children in resource-limited countries. Recent large studies utilizing case–control design, prospective sampling and more sensitive and broad diagnostic techniques have shed light on particular pathogens of importance and highlighted the previously under recognized impact of these infections on post-acute illness mortality and growth. Vaccination, particularly against rotavirus, has emerged as a key effective means of preventing significant morbidity and mortality from childhood diarrhoeal disease. Other candidate vaccines against leading diarrhoeal pathogens, such as enterotoxigenic Escherichia coli and Shigella spp., also hold significant promise in further ameliorating the burden of enteric infections in children. Large studies are also currently underway evaluating novel and potential easy-to-implement water, sanitation and hygiene (WASH) preventive strategies. Given the ongoing global burden of this illness, the paucity of new advances in case management over the last several decades remains a challenge. The increasing recognition of post-acute illness mortality and growth impairment has highlighted the need for interventions that go beyond management of dehydration and electrolyte disturbances. The few trials of novel promising interventions such as probiotics have mainly been conducted in high-income settings. Trials of antimicrobials have also been primarily conducted in high-income settings or in travellers from high-income settings. Bloody diarrhoea has been shown to be a poor marker of potentially treatable bacterial enteritis, and rising antimicrobial resistance has also made empiric antimicrobial therapy more challenging in many settings. Novel effective and sustainable interventions and diagnostic strategies are clearly needed to help improve case management. Diarrhoeal disease and other enteric infections remain an unmet challenge in global child health. Most promising recent developments have been focused around preventive measures, in particular vaccination. Further advances in prevention and case management including the possible use of targeted antimicrobial treatment are also required to fully address this critical burden on child health and human potential. PMID:29344358

Mortality Differences Between Traditional Medicare and Medicare Advantage: A Risk-Adjusted Assessment Using Claims Data

PubMed Central

Beveridge, Roy A.; Mendes, Sean M.; Caplan, Arial; Rogstad, Teresa L.; Olson, Vanessa; Williams, Meredith C.; McRae, Jacquelyn M.; Vargas, Stefan

2017-01-01

Medicare Advantage (MA) has grown rapidly since the Affordable Care Act; nearly one-third of Medicare beneficiaries now choose MA. An assessment of the comparative value of the 2 options is confounded by an apparent selection bias favoring MA, as reflected in mortality differences. Previous assessments have been hampered by lack of access to claims diagnosis data for the MA population. An indirect comparison of mortality as an outcome variable was conducted by modeling mortality on a traditional fee-for-service (FFS) Medicare data set, applying the model to an MA data set, and then evaluating the ratio of actual-to-predicted mortality in the MA data set. The mortality model adjusted for clinical conditions and demographic factors. Model development considered the effect of potentially greater coding intensity in the MA population. Further analysis calculated ratios for subpopulations. Predicted, risk-adjusted mortality was lower in the MA population than in FFS Medicare. However, the ratio of actual-to-predicted mortality (0.80) suggested that the individuals in the MA data set were less likely to die than would be predicted had those individuals been enrolled in FFS Medicare. Differences between actual and predicted mortality were particularly pronounced in low income (dual eligibility), nonwhite race, high morbidity, and Health Maintenance Organization (HMO) subgroups. After controlling for baseline clinical risk as represented by claims diagnosis data, mortality differences favoring MA over FFS Medicare persisted, particularly in vulnerable subgroups and HMO plans. These findings suggest that differences in morbidity do not fully explain differences in mortality between the 2 programs. PMID:28578605

Rationale and design of PRIMA II: A multicenter, randomized clinical trial to study the impact of in-hospital guidance for acute decompensated heart failure treatment by a predefined NT-PRoBNP target on the reduction of readmIssion and Mortality rAtes.

PubMed

Stienen, Susan; Salah, Khibar; Moons, Andreas H M; Bakx, Adrianus L M; van Pol, Petra E; Schroeder-Tanka, Jutta M; Voogel, Albertus J; Keijer, Jan T; Kortz, R A Mikael; Dickhoff, Cathelijne; Meregalli, Paola G; Tijssen, Jan G; Pinto, Yigal M; Kok, Wouter E

2014-07-01

Hospital admissions for acute decompensated heart failure (ADHF) are frequent and are accompanied by high percentages of mortality and readmissions. Brain natriuretic peptide (BNP) and the inactive N-terminal fragment of its precursor proBNP (NT-proBNP) are currently the best predictors of prognosis in heart failure (HF) patients. In the setting of chronic HF, studies that performed guidance of therapy by NT-proBNP have had only limited success. For patients with ADHF, retrospective studies have shown that a reduction in NT-proBNP of ≤30% during admission is a significant predictor of HF readmissions and mortality. These data suggest a role for NT-proBNP guidance in the setting of ADHF admissions. The PRIMA II is an investigator-initiated, multicenter, randomized, controlled, prospective 2-arm trial that investigates the impact of inhospital guidance for ADHF treatment by a predefined NT-proBNP target (>30% reduction during admission) on the reduction of readmission and mortality rates within 180 days. Consenting ADHF patients with NT-proBNP levels of >1,700 ng/L are eligible. After achieving clinical stability, a total of 340 patients are randomized to either NT-proBNP-guided or conventional treatment (1:1). The primary end point is dual, that is, a composite of all-cause mortality and readmission for HF in 180 days and the number of days alive out of hospital in 180 days. Secondary end points are readmissions and/or mortality in 180 days, cost effectiveness of hospitalization days in 180 days, readmissions and mortality in 90 days, and quality of life. The PRIMA II trial aims at providing scientific evidence for the use of NT-proBNP-guided therapy compared with conventional treatment in patients admitted for ADHF. Copyright © 2014 Mosby, Inc. All rights reserved.

Association of blood pressure in late adolescence with subsequent mortality: cohort study of Swedish male conscripts

PubMed Central

Neovius, Martin; Tynelius, Per; Rasmussen, Finn

2011-01-01

Objective To investigate the nature and magnitude of relations of systolic and diastolic blood pressures in late adolescence to mortality. Design Nationwide cohort study. Setting General community in Sweden. Participants Swedish men (n=1 207 141) who had military conscription examinations between 1969 and 1995 at a mean age of 18.4 years, followed up for a median of 24 (range 0-37) years. Main outcome measures Total mortality, cardiovascular mortality, and non-cardiovascular mortality. Results During follow-up, 28 934 (2.4%) men died. The relation of systolic blood pressure to total mortality was U shaped, with the lowest risk at a systolic blood pressure of about 130 mm Hg. This pattern was driven by the relation to non-cardiovascular mortality, whereas the relation to cardiovascular mortality was monotonically increasing (higher risk with higher blood pressure). The relation of diastolic blood pressure to mortality risk was monotonically increasing and stronger than that of systolic blood pressure, in terms of both relative risk and population attributable fraction (deaths that could be avoided if blood pressure was in the optimal range). Relations to cardiovascular and non-cardiovascular mortality were similar, with an apparent risk threshold at a diastolic blood pressure of about 90 mm Hg, below which diastolic blood pressure and mortality were unrelated, and above which risk increased steeply with higher diastolic blood pressures. Conclusions In adolescent men, the relation of diastolic blood pressure to mortality was more consistent than that of systolic blood pressure. Considering current efforts for earlier detection and prevention of risk, these observations emphasise the risk associated with high diastolic blood pressure in young adulthood. PMID:21343202

Urbanisation and coronary heart disease mortality among African Americans in the US South.

PubMed Central

Barnett, E; Strogatz, D; Armstrong, D; Wing, S

1996-01-01

STUDY OBJECTIVE: Despite significant declines since the late 1960s, coronary mortality remains the leading cause of death for African Americans. African Americans in the US South suffer higher rates of cardiovascular disease than African Americans in other regions; yet the mortality experiences of rural-dwelling African Americans, most of whom live in the South, have not been described in detail. This study examined urban-rural differentials in coronary mortality trends among African Americans for the period 1968-86. SETTING: The United States South, comprising 16 states and the District of Columbia. STUDY POPULATION: African American men and women aged 35-74 years. DESIGN: Analysis of urban-rural differentials in temporal trends in coronary mortality for a 19 year study period. All counties in the US South were grouped into five categories: greater metropolitan, lesser metropolitan, adjacent to metropolitan, semirural, and isolated rural. Annual age adjusted mortality rates were calculated for each urban status group. In 1968, observed excesses in coronary mortality were 29% for men and 45% for women, compared with isolated rural areas. Metropolitan areas experienced greater declines in mortality than rural areas, so by 1986 the urban-rural differentials in coronary mortality were 3% for men and 11% for women. CONCLUSIONS: Harsh living conditions in rural areas of the South precluded important coronary risk factors and contributed to lower mortality rates compared with urban areas during the 1960s. The dramatic transformation from an agriculturally based economy to manufacturing and services employment over the course of the study period contributed to improved living conditions which promoted coronary mortality declines in all areas of the South; however, the most favourable economic and mortality trends occurred in metropolitan areas. Images PMID:8935454

Changes in government spending on healthcare and population mortality in the European union, 1995–2010: a cross-sectional ecological study

PubMed Central

Watkins, Johnathan; Atun, Rifat; Williams, Callum; Zeltner, Thomas; Maruthappu, Mahiben

2015-01-01

Objective Economic measures such as unemployment and gross domestic product are correlated with changes in health outcomes. We aimed to examine the effects of changes in government healthcare spending, an increasingly important measure given constrained government budgets in several European Union countries. Design Multivariate regression analysis was used to assess the effect of changes in healthcare spending as a proportion of total government expenditure, government healthcare spending as a proportion of gross domestic product and government healthcare spending measured in purchasing power parity per capita, on five mortality indicators. Additional variables were controlled for to ensure robustness of data. One to five year lag analyses were conducted. Setting and Participants European Union countries 1995–2010. Main outcome measures Neonatal mortality, postneonatal mortality, one to five years of age mortality, under five years of age mortality, adult male mortality, adult female mortality. Results A 1% decrease in government healthcare spending was associated with significant increase in all mortality metrics: neonatal mortality (coefficient −0.1217, p = 0.0001), postneonatal mortality (coefficient −0.0499, p = 0.0018), one to five years of age mortality (coefficient −0.0185, p = 0.0002), under five years of age mortality (coefficient −0.1897, p = 0.0003), adult male mortality (coefficient −2.5398, p = 0.0000) and adult female mortality (coefficient −1.4492, p = 0.0000). One per cent decrease in healthcare spending, measured as a proportion of gross domestic product and in purchasing power parity, was both associated with significant increases (p < 0.05) in all metrics. Five years after the 1% decrease in healthcare spending, significant increases (p < 0.05) continued to be observed in all mortality metrics. Conclusions Decreased government healthcare spending is associated with increased population mortality in the short and long term. Policy interventions implemented in response to the financial crisis may be associated with worsening population health. PMID:26510733

Cancer incidence and mortality in workers employed at a transformer manufacturing plant: update to a cohort study.

PubMed

Yassi, Annalee; Tate, Robert B; Routledge, Michael

2003-07-01

This study is an extension of a previously published analysis of cancer mortality in a transformer manufacturing plant where there had been extensive use of mineral oil transformer fluid. The objectives of the present study were to update the mortality analysis and include deaths for the past 6 years as well as to do an analysis of cancer incidence of the cohort. A cohort of 2,222 males working at a transformer manufacturing plant between 1946 and 1975 was constructed. Using a classical historical cohort study design, cancer incidence and mortality were determined through record linkage with Canadian provincial and national registries. The rates of cancer incidence and mortality experienced by this cohort were compared to that of the Canadian male population. A statistically significant increased risk of developing and dying of pancreatic cancer was found but not an increase in overall cancer mortality. This was consistent with the previous report from this group. Interestingly, the cohort demonstrated a statistically significant risk of overall cancer incidence and specific increased incidence of gallbladder cancer. This study contributes further evidence to the growing body of literature indicating the carcinogenic properties of mineral oils used in occupational settings, in particular those used prior to 1970s. Copyright 2003 Wiley-Liss, Inc.

Mortality from breast carcinoma among US women: the role and implications of socio-economics, heterogeneous insurance, screening mammography, and geography.

PubMed

Okunade, Albert A; Karakus, Mustafa C

2003-11-01

Despite rapid advances in medicine and beneficial lifestyle changes, the incidence and mortality rate of gynecologic carcinoma remains high worldwide. This paper presents the econometric model findings of the major drivers of breast cancer mortality among US women. The results have implications for public health policy formulation on disease incidence and the drivers of mortality risks. The research methodology is a fixed-effects GLS regression model of breast cancer mortality in US females age 25 and above, using 1990-1997 time-series data pooled across 50 US states and DC. The covariates are age, years schooled, family income, 'screening' mammography, insurance coverage types, race, and US census region. The regressions have strong explanatory powers. Finding education and income to be significantly and positively correlated with mortality supports the 'life in the fast lanes' hypothesis of Phelps. The policy of raising a woman's education at a given income appears more beneficial than raising her income at a given education level. The relatively higher mortality rate for Blacks suggests implementing culturally appropriate set of disease prevention and health promotion programs and policies. Mortality differs across insurance types with Medicaid the worst suggesting need for program reform. Mortality is greater for women ages 25-44 years, females 40-49 years who have had screening mammography, smokers, and residents of some US states. These findings suggest imposing more effective tobacco use control policies (e.g., imposing a special tobacco tax on adult smokers), creating a more tractable screening mammography surveillance system, and designing region-specific programs to cut breast cancer mortality risks.

A critical review and meta-analysis of the association between overt hyperthyroidism and mortality.

PubMed

Brandt, Frans; Green, Anders; Hegedüs, Laszlo; Brix, Thomas H

2011-10-01

Overt hyperthyroidism has been associated with cardiac arrhythmias, hypercoagulopathy, stroke, and pulmonary embolism, all of which may increase mortality. Some, but not all, studies show an increased mortality in patients with hyperthyroidism. This inconsistency may be due to differences in study design, characteristics of participants, or confounders. In order to test whether hyperthyroidism influences mortality, we performed a critical review and statistical meta-analysis. Based on an electronic PubMed search, using the Medical Subject Heading words such as hyperthyroidism, thyrotoxicosis, and mortality or survival, case-control and cohort studies were selected and reviewed. Using meta-analysis, an overall relative risk (RR) of mortality was calculated. Eight studies fulfilled the inclusion criteria, six of which showed an increased all-cause mortality; seven studies, including 31,138 patients and 400,000 person years at risk, allowed calculation of mortality in a meta-analysis. Based on this, the RR of overall mortality was 1.21 (95% confidence interval: 1.05-1.38). Analyses including studies considering setting, treatment, and control for co-morbidity did not significantly alter this finding. As the measured heterogeneity (I(2)) ranges from 89.1 to 98.3%, which is much higher than the 50% generally viewed on as a threshold, the statistical heterogeneity is very pronounced in the included studies. In patients diagnosed with hyperthyroidism, mortality is increased by ∼ 20%. Future studies need to address the cause of hyperthyroidism, impact of type of therapy, time dependency, as well as the potential influence of confounding or genetic susceptibility before the question of causality can be answered.

The Thule episode epidemiological follow up after the crash of a B-52 bomber in Greenland: registry linkage, mortality, hospital admissions.

PubMed Central

Juel, K

1992-01-01

STUDY OBJECTIVES--The aim was to explore the pattern of disease in staff associated with a bomber that crashed in 1968 when carrying nuclear bombs. DESIGN--The database was constructed from staff files of Danish workers employed from 1 April 1963 to 1 July 1971. Comparison was made between subsequent mortality and hospital admissions of workers employed during the clean up of the crashed bomber, and those employed outside this period. SETTING--The study involved workers employed at Thule US air base in Greenland. MAIN RESULTS--During 1963-1971, 4322 staff were employed at the air base. Of these, 4265 (98.7%) were identified in 1987, among whom 1202 workers were employed during the clean up period. No differences were found in total mortality, or mortality from cancer, heart disease, or accidents, after allowing for differences in age, marital status, or length of employment, between those employed during the clean up period and those employed at other times. Similarly, no difference in hospital admissions between the two groups was found. CONCLUSIONS--No harmful effects on health due to the crash were found, as measured by mortality and hospital admissions. PMID:1431702

Effects of microwave radiation on house dust mites, Dermatophagoides pteronyssinus and Dermatophagoides farinae (Astigmata: Pyroglyphidae).

PubMed

Ernieenor, F C L; Ho, T M

2010-11-01

Dermatophagoides pteronyssinus and Dermatophagoides farinae mites are commonly found in house dust, and are important sources of allergens affecting humans. Various approaches to killing the mites have been examined. This study investigated the mortalities of adult mites exposed to 2,450 MHz microwave radiation produced by 3 ovens at various exposure times and power settings. The ovens all had 3 power settings. The average maximum water temperatures generated at high, medium and low power settings were 99.4 +/- 0.2, 84.1 +/- 0.4 and 44.8 +/- 0.9 degrees C, respectively. At high and medium settings, there was 100.0% mortality in both species when exposed for 300 seconds. The mean mortality rates at low power were 10.8 +/- 0.7% for D. pteronyssinus and 9.7 +/- 2.6% for D. farinae. When mites were exposed in the presence of culture media, the mortality rates decreased with increasing weight of media. The mean mortality with the largest amount of media tested at high power setting was 61.4%.

The effectiveness of health systems in influencing avoidable mortality: a study in Valencia, Spain, 1975-90.

PubMed Central

Albert, X; Bayo, A; Alfonso, J L; Cortina, P; Corella, D

1996-01-01

OBJECTIVES: To measure variations in the Holland and Charlton classifications of avoidable death causes and to estimate the effect of the Spanish national health system on avoidable mortality. DESIGN: Mortality in the Valencian Community was assessed between 1975 and 1990. The classifications of Holland and Charlton, used to assess avoidable causes of death, were compared. Holland's classification was then used to divide avoidable mortality into two groups--medical care indicators (MCI), which show the effectiveness of health care, and national health policy indicators (NHPI), which show the status of primary prevention. Comparisons were made with rates, group rates, and population rates. Trends and indices were also studied. SETTING: Valencia, Spain, 1975-90. RESULTS: During the study period, avoidable morality (only assessed by MCI) fell 63%, whereas the remainder of the mortality (non-MCI causes, that is all the non-avoidable causes together with the NHPI group) fell by 17%. If it is assumed that the mortality due to non-MCI causes indicates the overall effect of the environmental, social, nutritional, and genetic influences, then the difference between this and the MCI group would take us nearer the actual effect of the intervention of the health system. CONCLUSIONS: It is concluded that in this community, the health system has been responsible for approximately 47% of the total reduction in mortality from avoidable causes in the period studied. PMID:8935465

Outcome of severely injured trauma patients at a designated trauma centre in the Hong Kong Special Administrative Region.

PubMed

Leung, Ka Kit Gilberto; Ho, Wendy; Tong, King Hung Daniel; Yuen, Wai Key

2010-05-20

The Hong Kong Special Administrative Region (HKSAR) of the People's Republic of China (PRC) has seen significant changes in its trauma service over the last ten years including the implementation of a regional trauma system. The author's institution is one of the five trauma centres designated in 2003. This article reports our initial clinical experience. A prospective single-centre trauma registry from January 2004 to December 2008 was reviewed. The primary clinical outcome measure was hospital mortality. The Trauma and Injury Severity Score (TRISS) methodology was used for bench-marking with the North America Major Trauma Outcome Study (MTOS) database. There were 1451 patients. The majority (83.9%) suffered from blunt injury. The overall mortality rate was 7.8%. Severe injury, defined as the Injury Severity Score > 15, occurred in 22.5% of patients, and was associated with a mortality rate of 31.6%. A trend of progressive improvement was noted. The M-statistic was 0.99, indicating comparable case-mix with the MTOS. The Z- and W-statistics of each individual year revealed fewer, but not significantly so, number of survivors than expected. Trauma centre designation was feasible in the HKSAR and was associated with a gradual improvement in patient care. Trauma system implementation may be considered in regions equipped with the necessary socio-economic and organizational set-up.

Impact of 4.0% chlorhexidine cleansing of the umbilical cord on mortality and omphalitis among newborns of Sylhet, Bangladesh: design of a community-based cluster randomized trial.

PubMed

Mullany, Luke C; El Arifeen, Shams; Winch, Peter J; Shah, Rasheduzzaman; Mannan, Ishtiaq; Rahman, Syed M; Rahman, Mohammad R; Darmstadt, Gary L; Ahmed, Saifuddin; Santosham, Mathuram; Black, Robert E; Baqui, Abdullah H

2009-10-21

The World Health Organization recommends dry cord care for newborns but this recommendation may not be optimal in low resource settings where most births take place in an unclean environment and infections account for up to half of neonatal deaths. A previous trial in Nepal indicated that umbilical cord cleansing with 4.0% chlorhexidine could substantially reduce mortality and omphalitis risk, but policy changes await additional community-based data. The Projahnmo Chlorhexidine study was a three-year, cluster-randomized, community-based trial to assess the impact of three cord care regimens on neonatal mortality and omphalitis. Women were recruited mid-pregnancy, received a basic package of maternal and neonatal health promotion messages, and were followed to pregnancy outcome. Newborns were visited at home by local village-based workers whose areas were randomized to either 1) single- or 2) 7-day cord cleansing with 4.0% chlorhexidine, or 3) promotion of dry cord care as recommended by WHO. All mothers received basic messages regarding hand-washing, clean cord cutting, and avoidance of harmful home-base applications to the cord. Death within 28 days and omphalitis were the primary outcomes; these were monitored directly through home visits by community health workers on days 1, 3, 6, 9, 15, and 28 after birth. Due to report in early 2010, the Projahnmo Chlorhexidine Study examines the impact of multiple or single chlorhexidine cleansing of the cord on neonatal mortality and omphalitis among newborns of rural Sylhet District, Bangladesh. The results of this trial will be interpreted in conjunction with a similarly designed trial previously conducted in Nepal, and will have implications for policy guidelines for optimal cord care of newborns in low resource settings in Asia. ClinicalTrials.gov (NCT00434408).

Use of the interRAI CHESS scale to predict mortality among persons with neurological conditions in three care settings.

PubMed

Hirdes, John P; Poss, Jeffrey W; Mitchell, Lori; Korngut, Lawrence; Heckman, George

2014-01-01

Persons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions. Survival analyses were done with interRAI assessments linked to mortality data among persons in home care (n = 359,940), complex continuing care hospitals/units (n = 88,721), and nursing homes (n = 185,309) in seven Canadian provinces/territories. CHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings. CHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada) that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.

[Maternal mortality rate in the Aurelio Valdivieso General Hospital: a ten years follow up].

PubMed

Noguera-Sánchez, Marcelo Fidias; Arenas-Gómez, Susana; Rabadán-Martínez, Cesar Esli; Antonio-Sánchez, Pedro

2013-01-01

In México, the maternal mortality rate has been diminishing in the country in the last decades, except in the state of Oaxaca. Oaxaca is located amongst the entities with the highest ratios of maternal mortality. To analyze the behavior and epidemiological tendencies of maternal mortality over 10 years at the Dr. Aurelio Valdivieso General Hospital. In a retrospective, descriptive, and transverse analysis, we reviewed the maternal mortality files from the gynecology and obstetrics division. Three sets of variables were designed: social, obstetrical and circumstantial. We used general and descriptive statistical tools. From January first to December 31th of 2009 there were registered 109 maternal deaths. Excluding 2 non-obstetrical deaths, ths results in 107 maternal deaths. Divided into 75 direct maternal deaths and 32 indirect maternal deaths, the maternal mortality rate was 172.14 × 100,000 livebirths. Eighty-nine maternal deaths were foreseeable (83%) and 18 were not foreseeable (17%) as was stated by the Ad Hoc Committee within the Dr. Aurelio Valdivieso General Hospital. Pregnancy-related hypertension accounts for the highest pathology in relation to maternal deaths, the low literacy and puerperium correlated to a higher risk. Low human development index and low literacy were the variables that accounted for higher mortality risk. Also, we found that the higher occurrence of maternal deaths appeared during the puerperium and within hospital wards. The maternal mortality rate founded was the higher amongst the various areas of the country.

Where technology does not go: specialised neonatal care in resource-poor and conflict-affected contexts

PubMed Central

van den Boogaard, W.; Van den Bergh, R.; Takarinda, K. C.; Martinez, P.; Bekouanebandi, J. G.; Javed, I.; Ndelema, B.; Lefèvre, A.; Khalid, G. G.; Zuniga, I.

2017-01-01

Setting: Although neonatal mortality is gradually decreasing worldwide, 98% of neonatal deaths occur in low- and middle-income countries, where hospital care for sick and premature neonates is often unavailable. Médecins Sans Frontières Operational Centre Brussels (MSF-OCB) managed eight specialised neonatal care units (SNCUs) at district level in low-resource and conflict-affected settings in seven countries. Objective: To assess the performance of the MSF SNCU model across different settings in Africa and Southern Asia, and to describe the set-up of eight SNCUs, neonate characteristics and clinical outcomes among neonates from 2012 to 2015. Design: Multicentric descriptive study. Results: The MSF SNCU model was characterised by an absence of high-tech equipment and an emphasis on dedicated nursing and medical care. Focus was on the management of hypothermia, hypoglycaemia, feeding support and early identification/treatment of infection. Overall, 11 970 neonates were admitted, 41% of whom had low birthweight (<2500 g). The main diagnoses were low birthweight, asphyxia and neonatal infections. Overall mortality was 17%, with consistency across the sites. Chances of survival increased with higher birthweight. Conclusion: The standardised SNCU model was implemented across different contexts and showed in-patient outcomes within acceptable limits. Low-tech medical care for sick and premature neonates can and should be implemented at district hospital level in low-resource settings. PMID:28695092

Neonatal hypothermia in low-resource settings.

PubMed

Mullany, Luke C

2010-12-01

Hypothermia among newborns is considered an important contributor to neonatal morbidity and mortality in low-resource settings. However, in these settings only limited progress has been made towards understanding the risk of mortality after hypothermia, describing how this relationship is dependent on both the degree or severity of exposure and the gestational age and weight status of the baby, and implementing interventions to mitigate both exposure and the associated risk of poor outcomes. Given the centrality of averting neonatal mortality to achieving global milestones towards reductions in child mortality by 2015, recent years have seen substantial resources and efforts implemented to improve understanding of global epidemiology of neonatal health. In this article, a summary of the burden, consequences, and risk factors of neonatal hypothermia in low-resources settings is presented, with a particular focus on community-based data. Context-appropriate interventions for reducing hypothermia exposure and the role of these interventions in reducing global neonatal mortality burden are explored. Copyright © 2010 Elsevier Inc. All rights reserved.

Sarcopenic Obesity and Risk of Cardiovascular Disease and Mortality: A Population-Based Cohort Study of Older Men

PubMed Central

Atkins, Janice L; Whincup, Peter H; Morris, Richard W; Lennon, Lucy T; Papacosta, Olia; Wannamethee, S Goya

2014-01-01

Objectives To examine associations between sarcopenia, obesity, and sarcopenic obesity and risk of cardiovascular disease (CVD) and all-cause mortality in older men. Design Prospective cohort study. Setting British Regional Heart Study. Participants Men aged 60–79 years (n = 4,252). Measurements Baseline waist circumference (WC) and midarm muscle circumference (MAMC) measurements were used to classify participants into four groups: sarcopenic, obese, sarcopenic obese, or optimal WC and MAMC. The cohort was followed for a mean of 11.3 years for CVD and all-cause mortality. Cox regression analyses assessed associations between sarcopenic obesity groups and all-cause mortality, CVD mortality, CVD events, and coronary heart disease (CHD) events. Results There were 1,314 deaths, 518 CVD deaths, 852 CVD events, and 458 CHD events during follow-up. All-cause mortality risk was significantly greater in sarcopenic (HR = 1.41, 95% CI = 1.22–1.63) and obese (HR = 1.21, 95% CI = 1.03–1.42) men than in the optimal reference group, with the highest risk in sarcopenic obese (HR = 1.72, 95% CI = 1.35–2.18), after adjustment for lifestyle characteristics. Risk of CVD mortality was significantly greater in sarcopenic and obese but not sarcopenic obese men. No association was seen between sarcopenic obesity groups and CHD or CVD events. Conclusion Sarcopenia and central adiposity were associated with greater cardiovascular mortality and all-cause mortality. Sarcopenic obese men had the highest risk of all-cause mortality but not CVD mortality. Efforts to promote healthy aging should focus on preventing obesity and maintaining muscle mass. PMID:24428349

Age and sex of surgeons and mortality of older surgical patients: observational study

PubMed Central

Jena, Anupam B; Orav, E John; Blumenthal, Daniel M; Tsai, Thomas C; Mehtsun, Winta T; Jha, Ashish K

2018-01-01

Abstract Objective To investigate whether patients’ mortality differs according to the age and sex of surgeons. Design Observational study. Setting US acute care hospitals. Participants 100% of Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 20 major non-elective surgeries between 2011 and 2014. Main outcome measure Operative mortality rate of patients, defined as death during hospital admission or within 30 days of the operative procedure, after adjustment for patients’ and surgeons’ characteristics and indicator variables for hospitals. Results 892 187 patients who were treated by 45 826 surgeons were included. Patients’ mortality was lower for older surgeons than for younger surgeons: the adjusted operative mortality rates were 6.6% (95% confidence interval 6.5% to 6.7%), 6.5% (6.4% to 6.6%), 6.4% (6.3% to 6.5%), and 6.3% (6.2% to 6.5%) for surgeons aged under 40 years, 40-49 years, 50-59 years, and 60 years or over, respectively (P for trend=0.001). There was no evidence that adjusted operative mortality differed between patients treated by female versus male surgeons (adjusted mortality 6.3% for female surgeons versus 6.5% for male surgeons; adjusted odds ratio 0.97, 95% confidence interval 0.93 to 1.01). After stratification by sex of surgeon, patients’ mortality declined with age of surgeon for both male and female surgeons (except for female surgeons aged 60 or older); female surgeons in their 50s had the lowest operative mortality. Conclusion Using national data on Medicare beneficiaries in the US, this study found that patients treated by older surgeons had lower mortality than patients treated by younger surgeons. There was no evidence that operative mortality differed between male and female surgeons. PMID:29695473

Users' guides to the medical literature: how to use an article about mortality in a humanitarian emergency

PubMed Central

Mills, Edward J; Checchi, Francesco; Orbinski, James J; Schull, Michael J; Burkle, Frederick M; Beyrer, Chris; Cooper, Curtis; Hardy, Colleen; Singh, Sonal; Garfield, Richard; Woodruff, Bradley A; Guyatt, Gordon H

2008-01-01

The accurate interpretation of mortality surveys in humanitarian crises is useful for both public health responses and security responses. Recent examples suggest that few medical personnel and researchers can accurately interpret the validity of a mortality survey in these settings. Using an example of a mortality survey from the Democratic Republic of Congo (DRC), we demonstrate important methodological considerations that readers should keep in mind when reading a mortality survey to determine the validity of the study and the applicability of the findings to their settings. PMID:18826636

Using Claims Data to Examine Mortality Trends Following Hospitalization for Heart Attack in Medicare

PubMed Central

Ash, Arlene S; Posner, Michael A; Speckman, Jeanne; Franco, Shakira; Yacht, Andrew C; Bramwell, Lindsey

2003-01-01

Objective To see if changes in the demographics and illness burden of Medicare patients hospitalized for acute myocardial infarction (AMI) from 1995 through 1999 can explain an observed rise (from 32 percent to 34 percent) in one-year mortality over that period. Data Sources Utilization data from the Centers for Medicare and Medicaid Services (CMS) fee-for-service claims (MedPAR, Outpatient, and Carrier Standard Analytic Files); patient demographics and date of death from CMS Denominator and Vital Status files. For over 1.5 million AMI discharges in 1995–1999 we retain diagnoses from one year prior, and during, the case-defining admission. Study Design We fit logistic regression models to predict one-year mortality for the 1995 cases and apply them to 1996–1999 files. The CORE model uses age, sex, and original reason for Medicare entitlement to predict mortality. Three other models use the CORE variables plus morbidity indicators from well-known morbidity classification methods (Charlson, DCG, and AHRQ's CCS). Regressions were used as is—without pruning to eliminate clinical or statistical anomalies. Each model references the same diagnoses—those recorded during the pre- and index admission periods. We compare each model's ability to predict mortality and use each to calculate risk-adjusted mortality in 1996–1999. Principal Findings The comprehensive morbidity classifications (DCG and CCS) led to more accurate predictions than the Charlson, which dominated the CORE model (validated C-statistics: 0.81, 0.82, 0.74, and 0.66, respectively). Using the CORE model for risk adjustment reduced, but did not eliminate, the mortality increase. In contrast, adjustment using any of the morbidity models produced essentially flat graphs. Conclusions Prediction models based on claims-derived demographics and morbidity profiles can be extremely accurate. While one-year post-AMI mortality in Medicare may not be worsening, outcomes appear not to have continued to improve as they had in the prior decade. Rich morbidity information is available in claims data, especially when longitudinally tracked across multiple settings of care, and is important in setting performance targets and evaluating trends. PMID:14596389

Evaluating the validity of multiple imputation for missing physiological data in the national trauma data bank.

PubMed

Moore, Lynne; Hanley, James A; Lavoie, André; Turgeon, Alexis

2009-05-01

The National Trauma Data Bank (NTDB) is plagued by the problem of missing physiological data. The Glasgow Coma Scale score, Respiratory Rate and Systolic Blood Pressure are an essential part of risk adjustment strategies for trauma system evaluation and clinical research. Missing data on these variables may compromise the feasibility and the validity of trauma group comparisons. To evaluate the validity of Multiple Imputation (MI) for completing missing physiological data in the National Trauma Data Bank (NTDB), by assessing the impact of MI on 1) frequency distributions, 2) associations with mortality, and 3) risk adjustment. Analyses were based on 170,956 NTDB observations with complete physiological data (observed data set). Missing physiological data were artificially imposed on this data set and then imputed using MI (MI data set). To assess the impact of MI on risk adjustment, 100 pairs of hospitals were randomly selected with replacement and compared using adjusted Odds Ratios (OR) of mortality. OR generated by the observed data set were then compared to those generated by the MI data set. Frequency distributions and associations with mortality were preserved following MI. The median absolute difference between adjusted OR of mortality generated by the observed data set and by the MI data set was 3.6% (inter-quartile range: 2.4%-6.1%). This study suggests that, provided it is implemented with care, MI of missing physiological data in the NTDB leads to valid frequency distributions, preserves associations with mortality, and does not compromise risk adjustment in inter-hospital comparisons of mortality.

Exploring the Association between Macroeconomic Indicators and Dialysis Mortality

PubMed Central

Stel, Vianda S.; Caskey, Fergus J.; Stengel, Benedicte; Elliott, Robert F.; Covic, Adrian; Geue, Claudia; Cusumano, Ana; MacLeod, Alison M.; Jager, Kitty J.

2012-01-01

Summary Background and objectives Mortality on dialysis varies greatly worldwide, with patient-level factors explaining only a small part of this variation. The aim of this study was to examine the association of national-level macroeconomic indicators with the mortality of incident dialysis populations and explore potential explanations through renal service indicators, incidence of dialysis, and characteristics of the dialysis population. Design, setting, participants, & measurements Aggregated unadjusted survival probabilities were obtained from 22 renal registries worldwide for patients starting dialysis in 2003–2005. General population age and health, macroeconomic indices, and renal service organization data were collected from secondary sources and questionnaires. Linear modeling with log–log transformation of the outcome variable was applied to establish factors associated with survival on dialysis. Results Two-year survival on dialysis ranged from 62.3% in Iceland to 89.8% in Romania. A higher gross domestic product per capita (hazard ratio=1.02 per 1000 US dollar increase), a higher percentage of gross domestic product spent on healthcare (1.10 per percent increase), and a higher intrinsic mortality of the dialysis population (i.e., general population-derived mortality risk of the dialysis population in that country standardized for age and sex; hazard ratio=1.04 per death per 10,000 person years) were associated with a higher mortality of the dialysis population. The incidence of dialysis and renal service indicators were not associated with mortality on dialysis. Conclusions Macroeconomic factors and the intrinsic mortality of the dialysis population are associated with international differences in the mortality on dialysis. Renal service organizational factors and incidence of dialysis seem less important. PMID:22837275

Performance measures for a dialysis setting.

PubMed

Gu, Xiuzhu; Itoh, Kenji

2018-03-01

This study from Japan extracted performance measures for dialysis unit management and investigated their characteristics from professional views. Two surveys were conducted using self-administered questionnaires, in which dialysis managers/staff were asked to rate the usefulness of 44 performance indicators. A total of 255 managers and 2,097 staff responded. Eight performance measures were elicited from dialysis manager and staff responses: these were safety, operational efficiency, quality of working life, financial effectiveness, employee development, mortality, patient/employee satisfaction and patient-centred health care. These performance measures were almost compatible with those extracted in overall healthcare settings in a previous study. Internal reliability, content and construct validity of the performance measures for the dialysis setting were ensured to some extent. As a general trend, both dialysis managers and staff perceived performance measures as highly useful, especially for safety, mortality, operational efficiency and patient/employee satisfaction, but showed relatively low concerns for patient-centred health care and employee development. However, dialysis managers' usefulness perceptions were significantly higher than staff. Important guidelines for designing a holistic hospital/clinic management system were yielded. Performance measures must be balanced for outcomes and performance shaping factors (PSF); a common set of performance measures could be applied to all the healthcare settings, although performance indicators of each measure should be composed based on the application field and setting; in addition, sound causal relationships between PSF and outcome measures/indicators should be explored for further improvement. © 2017 European Dialysis and Transplant Nurses Association/European Renal Care Association.

The business cycle and mortality: Urban versus rural counties.

PubMed

Sameem, Sediq; Sylwester, Kevin

2017-02-01

Many studies have found that mortality declines during recessions, but do such results remain consistent in both urban and rural settings? To help uncover explanations for such a pro-cyclical nature of mortality, the present study revisits this topic but allows for associations between unemployment and mortality to differ between urban and rural areas. Using a total of 66 863 observations across 3066 counties of the U.S. from 1990 to 2013, we allow the coefficient on unemployment to differ between urban and rural counties. With an exception of deaths due to external accidents being pro-cyclical in rural settings, we find that the negative association between unemployment and mortality more generally holds for urban areas, particularly for females and the elderly. Moreover, we find death due to circulatory disease or influenza/pneumonia to be especially more prevalent in urban areas. Given that the negative associations between unemployment and mortality are generally stronger in cities, views attempting to explain pro-cyclical mortality should focus on characteristics in urban settings. Copyright © 2016 Elsevier Ltd. All rights reserved.

Comparison of Pediatric Severe Sepsis Managed in U.S. and European ICUs

PubMed Central

Giuliano, John S.; Markovitz, Barry P.; Brierley, Joe; Levin, Richard; Williams, Gary; Lum, Lucy Chai See; Dorofaeff, Tavey; Cruces, Pablo; Bush, Jenny L.; Keele, Luke; Nadkarni, Vinay M.; Thomas, Neal J.; Fitzgerald, Julie C.; Weiss, Scott L.

2017-01-01

Objectives Pediatric severe sepsis remains a significant global health problem without new therapies despite many multicenter clinical trials. We compared children managed with severe sepsis in European and U.S. PICUs to identify geographic variation, which may improve the design of future international studies. Design We conducted a secondary analysis of the Sepsis PRevalence, OUtcomes, and Therapies study. Data about PICU characteristics, patient demographics, therapies, and outcomes were compared. Multivariable regression models were used to determine adjusted differences in morbidity and mortality. Setting European and U.S. PICUs. Patients Children with severe sepsis managed in European and U.S. PICUs enrolled in the Sepsis PRevalence, OUtcomes, and Therapies study. Interventions None. Measurements and Main Results European PICUs had fewer beds (median, 11 vs 24; p < 0.001). European patients were younger (median, 1 vs 6 yr; p < 0.001), had higher severity of illness (median Pediatric Index of Mortality −3, 5.0 vs 3.8; p = 0.02), and were more often admitted from the ward (37% vs 24%). Invasive mechanical ventilation, central venous access, and vasoactive infusions were used more frequently in European patients (85% vs 68%, p = 0.002; 91% vs 82%, p = 0.05; and 71% vs 50%; p < 0.001, respectively). Raw morbidity and mortality outcomes were worse for European compared with U.S. patients, but after adjusting for patient characteristics, there were no significant differences in mortality, multiple organ dysfunction, disability at discharge, length of stay, or ventilator/vasoactive-free days. Conclusions Children with severe sepsis admitted to European PICUs have higher severity of illness, are more likely to be admitted from hospital wards, and receive more intensive care therapies than in the United States. The lack of significant differences in morbidity and mortality after adjusting for patient characteristics suggests that the approach to care between regions, perhaps related to PICU bed availability, needs to be considered in the design of future international clinical trials in pediatric severe sepsis. PMID:27124566

Trade-offs in experimental designs for estimating post-release mortality in containment studies

USGS Publications Warehouse

Rogers, Mark W.; Barbour, Andrew B; Wilson, Kyle L

2014-01-01

Estimates of post-release mortality (PRM) facilitate accounting for unintended deaths from fishery activities and contribute to development of fishery regulations and harvest quotas. The most popular method for estimating PRM employs containers for comparing control and treatment fish, yet guidance for experimental design of PRM studies with containers is lacking. We used simulations to evaluate trade-offs in the number of containers (replicates) employed versus the number of fish-per container when estimating tagging mortality. We also investigated effects of control fish survival and how among container variation in survival affects the ability to detect additive mortality. Simulations revealed that high experimental effort was required when: (1) additive treatment mortality was small, (2) control fish mortality was non-negligible, and (3) among container variability in control fish mortality exceeded 10% of the mean. We provided programming code to allow investigators to compare alternative designs for their individual scenarios and expose trade-offs among experimental design options. Results from our simulations and simulation code will help investigators develop efficient PRM experimental designs for precise mortality assessment.

A Nine-Year Follow-up Study of Sleep Patterns and Mortality in Community-Dwelling Older Adults in Taiwan

PubMed Central

Chen, Hsi-Chung; Su, Tung-Ping; Chou, Pesus

2013-01-01

Study Objectives: To simultaneously explore the associations between mortality and insomnia, sleep duration, and the use of hypnotics in older adults. Design: A fixed cohort study. Setting: A community in Shih-Pai area, Taipei, Taiwan. Participants: A total of 4,064 participants over the age of 65 completed the study. Intervention: N/A. Measurements and Results: Insomnia was classified using an exclusionary hierarchical algorithm, which categorized insomnia as “no insomnia,” “subjective poor sleep quality,” “Pittsburgh Sleep Quality Index > 5 insomnia,” “1-month insomnia disorder,” and “6-month insomnia disorder.” The main outcome variables were 9-year all-cause mortality rates. In the all-cause mortality analyses, when hypnotic use, depressive symptoms and total sleep time were excluded from a proportional hazards regression model, subjects with “Pittsburgh Sleep Quality Index > 5 insomnia” had a higher mortality risk (HR: 1.21, 95% CI: 1.01-1.45). In the full model, frequent hypnotic use and long sleep duration predicted higher mortality rates. However, the increased mortality risk for subjects with “Pittsburgh Sleep Quality Index > 5 insomnia” was not observed in the full model. On the contrary, individuals with a 6-month DSM-IV insomnia disorder had a lower risk for premature death (HR: 0.64, 95% CI: 0.43-0.96). Conclusions: Long sleep duration and frequent hypnotics use predicted an increased mortality risk within a community-dwelling sample of older adults. The association between insomnia and mortality was affected by insomnia definition and other parameters related to sleep patterns. Citation: Chen HC; Su TP; Chou P. A nine-year follow-up study of sleep patterns and mortality in community-dwelling older adults in Taiwan. SLEEP 2013;36(8):1187-1198. PMID:23904679

Relationship Between Circulating Concentrations of Thyrotropin, Free Thyroxine, and Free Triiodothyronine and 9-Year Mortality in Euthyroid Elderly Subjects

PubMed Central

Ceresini, Graziano; Marina, Michela; Lauretani, Fulvio; Maggio, Marcello; Bandinelli, Stefania; Ceda, Gian Paolo; Ferrucci, Luigi

2015-01-01

Objectives Thyroid dysfunction in the elderly is associated with adverse clinical outcomes, with mortality being associated with low TSH. However, it is still unknown whether variability of thyroid function test within the reference range is associated with mortality in older adults. We studied the association between plasma levels of TSH, free T3 (FT3), and free T4 (FT4), and all-cause mortality in older adults who had all three hormones within the normal range. Design Longitudinal study Setting Community-based Participants Total of 815 euthyroid participants of the InCHIANTI study, aged 65 years or older Measurements All subjects had TSH, FT3, and FT4 within the reference range at baseline. Plasma TSH, FT3 and FT4 were predictors and 9-year all-cause mortality was the outcome. Cox proportional hazards models adjusted for confounders were used to examine the relationship between quartiles of TSH, FT3, and FT4 and all-cause mortality over 9 years of follow-up. Results During the follow-up (mean persons-years 8643.74 [min-max, 35.36-16985.00]), 181 deaths occurred (22.2%). Participants with TSH in the lower quartile had higher mortality than the rest of the population. After adjusting for multiple confounders, participants with TSH in the lowest quartile (Hazard Ratio: 2.22; 95% Confidence Interval: 1.19–4.22) had significantly higher all-cause mortality than those with TSH in the highest quartile. Neither FT3 nor FT4 were associated with mortality. Conclusions In euthyroid elderly subjects, normal-low TSH represents an independent risk factor for all-cause mortality. PMID:27000328

Comparing Self-Reported Health Status and Diagnosis-Based Risk Adjustment to Predict 1- and 2 to 5-Year Mortality

PubMed Central

Pietz, Kenneth; Petersen, Laura A

2007-01-01

Objectives To compare the ability of two diagnosis-based risk adjustment systems and health self-report to predict short- and long-term mortality. Data Sources/Study Setting Data were obtained from the Department of Veterans Affairs (VA) administrative databases. The study population was 78,164 VA beneficiaries at eight medical centers during fiscal year (FY) 1998, 35,337 of whom completed an 36-Item Short Form Health Survey for veterans (SF-36V) survey. Study Design We tested the ability of Diagnostic Cost Groups (DCGs), Adjusted Clinical Groups (ACGs), SF-36V Physical Component score (PCS) and Mental Component Score (MCS), and eight SF-36V scales to predict 1- and 2–5 year all-cause mortality. The additional predictive value of adding PCS and MCS to ACGs and DCGs was also evaluated. Logistic regression models were compared using Akaike's information criterion, the c-statistic, and the Hosmer–Lemeshow test. Principal Findings The c-statistics for the eight scales combined with age and gender were 0.766 for 1-year mortality and 0.771 for 2–5-year mortality. For DCGs with age and gender the c-statistics for 1- and 2–5-year mortality were 0.778 and 0.771, respectively. Adding PCS and MCS to the DCG model increased the c-statistics to 0.798 for 1-year and 0.784 for 2–5-year mortality. Conclusions The DCG model showed slightly better performance than the eight-scale model in predicting 1-year mortality, but the two models showed similar performance for 2–5-year mortality. Health self-report may add health risk information in addition to age, gender, and diagnosis for predicting longer-term mortality. PMID:17362210

Role of allostatic load and health behaviours in explaining socioeconomic disparities in mortality: a structural equation modelling approach.

PubMed

Kim, Gyu Ri; Jee, Sun Ha; Pikhart, Hynek

2018-06-01

The relationship between socioeconomic status and mortality has been well established; however, the extent to which biological factors mediate this relationship is less clear, and empirical evidence from non-Western settings is limited. Allostasis, a cumulative measure of physiological dysregulation, has been proposed as the underlying mechanism linking socioeconomic status to adverse health outcomes. The current study aimed to ascertain the contribution of allostatic load (AL) and health behaviours to socioeconomic inequalities in mortality among Korean adults. The sample comprised 70 713 middle-aged and older-aged adults, aged 40-79 years from the Korean Metabolic Syndrome Mortality Study. Using structural equation modelling (SEM), mediation analyses were performed to estimate the effects of socioeconomic position (SEP) on mortality over the follow-up and the extent to which AL, physical exercise and non-smoking status mediate the association between SEP and mortality. A total of 5618 deaths (7.9%) occurred during the mean follow-up of 15.2 years (SD 2.9). SEM confirmed a direct significant effect of SEP on mortality, as well as significant indirect paths through AL, physical exercise and non-smoking status. Our findings provide support for the mediating role of AL and health behaviours in the link between SEP and mortality. Policies designed to reduce social disparities in mortality in the long term should primarily focus on reducing stress and promoting healthy lifestyles among the socially disadvantaged groups. Future studies should further assess the role of other mediators such as psychosocial factors, which may contribute to socioeconomic inequalities in mortality. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Association of rule of law and health outcomes: an ecological study

PubMed Central

Pinzon-Rondon, Angela Maria; Attaran, Amir; Botero, Juan Carlos; Ruiz-Sternberg, Angela Maria

2015-01-01

Objectives To explore whether the rule of law is a foundational determinant of health that underlies other socioeconomic, political and cultural factors that have been associated with health outcomes. Setting Global project. Participants Data set of 96 countries, comprising 91% of the global population. Primary and secondary outcome measures The following health indicators, infant mortality rate, maternal mortality rate, life expectancy, and cardiovascular disease and diabetes mortality rate, were included to explore their association with the rule of law. We used a novel Rule of Law Index, gathered from survey sources, in a cross-sectional and ecological design. The Index is based on eight subindices: (1) Constraints on Government Powers; (2) Absence of Corruption; (3) Order and Security; (4) Fundamental Rights; (5) Open Government; (6) Regulatory Enforcement, (7) Civil Justice; and (8) Criminal Justice. Results The rule of law showed an independent association with infant mortality rate, maternal mortality rate, life expectancy, and cardiovascular disease and diabetes mortality rate, after adjusting for the countries’ level of per capita income, their expenditures in health, their level of political and civil freedom, their Gini measure of inequality and women's status (p<0.05). Rule of law remained significant in all the multivariate models, and the following adjustment for potential confounders remained robust for at least one or more of the health outcomes across all eight subindices of the rule of law. Findings show that the higher the country's level of adherence to the rule of law, the better the health of the population. Conclusions It is necessary to start considering the country's adherence to the rule of law as a foundational determinant of health. Health advocates should consider the improvement of rule of law as a tool to improve population health. Conversely, lack of progress in rule of law may constitute a structural barrier to health improvement. PMID:26515684

Anion gap as a prognostic tool for risk stratification in critically ill patients - a systematic review and meta-analysis.

PubMed

Glasmacher, Stella Andrea; Stones, William

2016-08-30

Lactate concentration is a robust predictor of mortality but in many low resource settings facilities for its analysis are not available. Anion gap (AG), calculated from clinical chemistry results, is a marker of metabolic acidosis and may be more easily obtained in such settings. In this systematic review and meta-analysis we investigated whether the AG predicts mortality in adult patients admitted to critical care settings. We searched Medline, Embase, Web of Science, Scopus, The Cochrane Library and regional electronic databases from inception until May 2016. Studies conducted in any clinical setting that related AG to in-hospital mortality, in-intensive care unit mortality, 31-day mortality or comparable outcome measures were eligible for inclusion. Methodological quality of included studies was assessed using the Quality in Prognostic Studies tool. Descriptive meta-analysis was performed and the I(2) test was used to quantify heterogeneity. Subgroup analysis was undertaken to identify potential sources of heterogeneity between studies. Nineteen studies reporting findings in 12,497 patients were included. Overall, quality of studies was poor and most studies were rated as being at moderate or high risk of attrition bias and confounding. There was substantial diversity between studies with regards to clinical setting, age and mortality rates of patient cohorts. High statistical heterogeneity was found in the meta-analyses of area under the ROC curve (I(2) = 99 %) and mean difference (I(2) = 97 %) for the observed AG. Three studies reported good discriminatory power of the AG to predict mortality and were responsible for a large proportion of statistical heterogeneity. The remaining 16 studies reported poor to moderate ability of the AG to predict mortality. Subgroup analysis suggested that intravenous fluids affect the ability of the AG to predict mortality. Based on the limited quality of available evidence, a single AG measurement cannot be recommended for risk stratification in critically ill patients. The probable influence of intravenous fluids on AG levels renders the AG an impractical tool in clinical practice. Future research should focus on increasing the availability of lactate monitoring in low resource settings. CRD42015015249 . Registered on 4th February 2015.

Hypoalbuminemia, Low Base Excess Values, and Tachypnea Predict 28-Day Mortality in Severe Sepsis and Septic Shock Patients in the Emergency Department.

PubMed

Seo, Min Ho; Choa, Minhong; You, Je Sung; Lee, Hye Sun; Hong, Jung Hwa; Park, Yoo Seok; Chung, Sung Phil; Park, Incheol

2016-11-01

The objective of this study was to develop a new nomogram that can predict 28-day mortality in severe sepsis and/or septic shock patients using a combination of several biomarkers that are inexpensive and readily available in most emergency departments, with and without scoring systems. We enrolled 561 patients who were admitted to an emergency department (ED) and received early goal-directed therapy for severe sepsis or septic shock. We collected demographic data, initial vital signs, and laboratory data sampled at the time of ED admission. Patients were randomly assigned to a training set or validation set. For the training set, we generated models using independent variables associated with 28-day mortality by multivariate analysis, and developed a new nomogram for the prediction of 28-day mortality. Thereafter, the diagnostic accuracy of the nomogram was tested using the validation set. The prediction model that included albumin, base excess, and respiratory rate demonstrated the largest area under the receiver operating characteristic curve (AUC) value of 0.8173 [95% confidence interval (CI), 0.7605-0.8741]. The logistic analysis revealed that a conventional scoring system was not associated with 28-day mortality. In the validation set, the discrimination of a newly developed nomogram was also good, with an AUC value of 0.7537 (95% CI, 0.6563-0.8512). Our new nomogram is valuable in predicting the 28-day mortality of patients with severe sepsis and/or septic shock in the emergency department. Moreover, our readily available nomogram is superior to conventional scoring systems in predicting mortality.

Evaluating the long-term consequences of air pollution in early life: geographical correlations between coal consumption in 1951/1952 and current mortality in England and Wales

PubMed Central

Phillips, David I W; Osmond, Clive; Southall, Humphrey; Aucott, Paula; Jones, Alexander; Holgate, Stephen T

2018-01-01

Objective To evaluate associations between early life air pollution and subsequent mortality. Design Geographical study. Setting Local government districts within England and Wales. Exposure Routinely collected geographical data on the use of coal and related solid fuels in 1951–1952 were used as an index of air pollution. Main outcome measures We evaluated the relationship between these data and both all-cause and disease-specific mortality among men and women aged 35–74 years in local government districts between 1993 and 2012. Results Domestic (household) coal consumption had the most powerful associations with mortality. There were strong correlations between domestic coal use and all-cause mortality (relative risk per SD increase in fuel use 1.124, 95% CI 1.123 to 1.126), and respiratory (1.238, 95% CI 1.234 to 1.242), cardiovascular (1.138, 95% CI 1.136 to 1.140) and cancer mortality (1.073, 95% CI 1.071 to 1.075). These effects persisted after adjustment for socioeconomic indicators in 1951, current socioeconomic indicators and current pollution levels. Conclusion Coal was the major cause of pollution in the UK until the Clean Air Act of 1956 led to a rapid decline in consumption. These data suggest that coal-based pollution, experienced over 60 years ago in early life, affects human health now by increasing mortality from a wide variety of diseases. PMID:29703847

Fluid Balance, Diuretic Use, and Mortality in Acute Kidney Injury

PubMed Central

Estrella, Michelle M.; Coresh, Josef; Brower, Roy G.; Liu, Kathleen D.

2011-01-01

Summary Background and objectives Management of volume status in patients with acute kidney injury (AKI) is complex, and the role of diuretics is controversial. The primary objective was to elucidate the association between fluid balance, diuretic use, and short-term mortality after AKI in critically ill patients. Design, setting, participants, & measurements Using data from the Fluid and Catheter Treatment Trial (FACTT), a multicenter, randomized controlled trial evaluating a conservative versus liberal fluid-management strategy in 1000 patients with acute lung injury (ALI), we evaluated the association of post-renal injury fluid balance and diuretic use with 60-day mortality in patients who developed AKI, as defined by the AKI Network criteria. Results 306 patients developed AKI in the first 2 study days and were included in our analysis. There were 137 in the fluid-liberal arm and 169 in the fluid-conservative arm (P = 0.04). Baseline characteristics were similar between groups. Post-AKI fluid balance was significantly associated with mortality in both crude and adjusted analysis. Higher post-AKI furosemide doses had a protective effect on mortality but no significant effect after adjustment for post-AKI fluid balance. There was no threshold dose of furosemide above which mortality increased. Conclusions A positive fluid balance after AKI was strongly associated with mortality. Post-AKI diuretic therapy was associated with 60-day patient survival in FACTT patients with ALI; this effect may be mediated by fluid balance. PMID:21393482

The Effect of Hospital Volume on Mortality in Patients Admitted with Severe Sepsis

PubMed Central

Shahul, Sajid; Hacker, Michele R.; Novack, Victor; Mueller, Ariel; Shaefi, Shahzad; Mahmood, Bilal; Ali, Syed Haider; Talmor, Daniel

2014-01-01

Importance The association between hospital volume and inpatient mortality for severe sepsis is unclear. Objective To assess the effect of severe sepsis case volume and inpatient mortality. Design Setting and Participants Retrospective cohort study from 646,988 patient discharges with severe sepsis from 3,487 hospitals in the Nationwide Inpatient Sample from 2002 to 2011. Exposures The exposure of interest was the mean yearly sepsis case volume per hospital divided into tertiles. Main Outcomes and Measures Inpatient mortality. Results Compared with the highest tertile of severe sepsis volume (>60 cases per year), the odds ratio for inpatient mortality among persons admitted to hospitals in the lowest tertile (≤10 severe sepsis cases per year) was 1.188 (95% CI: 1.074–1.315), while the odds ratio was 1.090 (95% CI: 1.031–1.152) for patients admitted to hospitals in the middle tertile. Similarly, improved survival was seen across the tertiles with an adjusted inpatient mortality incidence of 35.81 (95% CI: 33.64–38.03) for hospitals with the lowest volume of severe sepsis cases and a drop to 32.07 (95% CI: 31.51–32.64) for hospitals with the highest volume. Conclusions and Relevance We demonstrate an association between a higher severe sepsis case volume and decreased mortality. The need for a systems-based approach for improved outcomes may require a high volume of severely septic patients. PMID:25264788

Bladder cancer mortality and private well use in New England: An ecological study

USGS Publications Warehouse

Ayotte, J.D.; Baris, D.; Cantor, K.P.; Colt, J.; Robinson, G.R.; Lubin, J.H.; Karagas, M.; Hoover, R.N.; Fraumeni, J.F.; Silverman, D.T.

2006-01-01

Study objective: To investigate the possible relation between bladder cancer mortality among white men and women and private water use in New England, USA, where rates have been persistently raised and use of private water supplies (wells) common. Design: Ecological study relating age adjusted cancer mortality rates for white men and women during 1985-1999 and proportion of persons using private water supplies in 1970. After regressing mortality rates on population density, Pearson correlation coefficients were computed between residual rates and the proportion of the population using private water supplies, using the state economic area as the unit of calculation. Calculations were conducted within each of 10 US regions. Setting: The 504 state economic areas of the contiguous United States. Participants: Mortality analysis of 11 cancer sites, with the focus on bladder cancer. Main results: After adjusting for the effect of population density, there was a statistically significant positive correlation between residual bladder cancer mortality rates and private water supply use among both men and women in New England (men, r=0.42; women, r=0.48) and New York/New Jersey (men, r=0.49; women, r=0.62). Conclusions: Use of well water from private sources, or a close correlate, may be an explanatory variable for the excess bladder cancer mortality in New England. Analytical studies are underway to clarify the relation between suspected water contaminants, particularly arsenic, and raised bladder cancer rates in northern New England.

Social determinants for infant mortality in the Nordic countries, 1980-2001.

PubMed

Arntzen, Annett; Nybo Andersen, Anne Marie

2004-01-01

Social equity in health is an important goal of public health policies in the Nordic countries. Infant mortality is often used as an indicator of the health of societies, and has decreased substantially in the Nordic welfare states over the past 20 years. To identify social patterns in infant mortality in this context the authors set out to review the existing epidemiological literature on associations between social indicators and infant mortality in Denmark, Finland, Norway, and Sweden during the period 1980-2000. Nordic epidemiological studies in the databases ISI Web of Science, PubMed, and OVID, published between 1980 and 2000 focusing on social indicators of infant, neonatal, and postneonatal mortality, were identified. The selected keywords on social indicators were: education, income, occupation, social factors, socioeconomic status, social position, and social class. Social inequality in infant mortality was reported from Denmark, Finland, Norway, and Sweden, and it was found that these increased during the study period. Post-neonatal mortality showed a stronger association with social indicators than neonatal mortality. Some studies showed that neonatal mortality was associated with social indicators in a non-linear fashion, with high rates of mortality in both the lowest and highest social strata. The pattern differed, however, between countries with Finland and Sweden showing consistently less social inequalities than Denmark and Norway. While the increased inequality shown in most studies was an increase in relative risk, a single study from Denmark demonstrated an absolute increase in infant mortality among children born to less educated women. Social inequalities in infant mortality are observed in all four countries, irrespective of social indicators used in the studies. It is, however, difficult to draw inferences from the comparisons between countries, since different measures of social position and different inclusion criteria are used in the studies. Nordic collaborative analyses of social gradients in infant death are needed, taking advantage of the population-covering registers in longitudinal designs, to explore the mechanisms behind the social patterns in infant mortality.

Associations of Posthemodialysis Weights above and below Target Weight with All-Cause and Cardiovascular Mortality

PubMed Central

Kshirsagar, Abhijit V.; Falk, Ronald J.; Brunelli, Steven M.

2015-01-01

Background and objectives Fluid removal via ultrafiltration is a primary function of hemodialysis, and inadequate volume control is associated with significant morbidity and mortality among chronic dialysis patients. Treatment-to-treatment fluid removal goals are typically calculated on the basis of interdialytic weight gain and prescribed target weight. The clinical effect of frequent missed target weights is unclear. This study was designed to evaluate the associations of postdialysis weights above and below the prescribed target weight (separately) and outcomes. Design, setting, participants, & measurements Data were taken from a national cohort of 10,785 prevalent, thrice-weekly, in-center hemodialysis patients dialyzing from 2005 to 2008 (median time at risk, 2.1 [25th percentile, 75th percentile] years) at a single dialysis organization. Patients were characterized as having an above target weight miss if their postdialysis weight was >2 kg above target weight in at least 30% of baseline treatments (14.6% of cohort), or they were characterized as control otherwise. Below target weight miss characterization was analogous for patients with postdialysis weight >2 kg below target weight (6.6% of cohort). Coprimary endpoints were all-cause and cardiovascular mortality. Results Above target weight miss in at least 30% of treatments (versus not) was associated with greater all-cause mortality (adjusted hazard ratio, 1.28; 95% confidence interval, 1.15 to 1.43); and below target weight miss in at least 30% of treatments (versus not) was associated with greater all-cause mortality (adjusted hazard ratio, 1.22; 95% confidence interval, 1.05 to 1.40). Both above and below target weight misses were also significantly associated with greater cardiovascular mortality. Secondary analyses demonstrated dose-response relationships between target weight misses and mortality. Results from sensitivity analyses considering the difference in postdialysis and target weights as a proportion of body weight were analogous to the primary results. Conclusions Postdialysis weights >2 kg above and below target weight are associated with higher all-cause and cardiovascular mortality. Consistent target weight achievement is a viable target for improving fluid management. PMID:25862779

Changing mortality risk associated with CD4 cell response to antiretroviral therapy in South Africa

PubMed Central

Lawn, Stephen D.; Little, Francesca; Bekker, Linda-Gail; Kaplan, Richard; Campbel, Elizabeth; Orrell, Catherine; Wood, Robin

2013-01-01

Objective To determine the relationship between mortality risk and the CD4 cell response to antiretroviral therapy (ART). Design Observational community-based ART cohort in South Africa. Methods CD4 cell counts were measured 4 monthly, and deaths were prospectively ascertained. Cumulative person-time accrued within a range of updated CD4 cell count strata (CD4 cell-strata) was calculated and used to derive CD4 cell-stratified mortality rates. Results Patients (2423) (median baseline CD4 cell count of 105 cells/ml) were observed for up to 5 years of ART. One hundred and ninety-seven patients died during 3155 person years of observation. In multivariate analysis, mortality rate ratios associated with 0–49, 50–99, 100–199, 200–299, 300– 399, 400–499 and at least 500 cells/ml updated CD4 cell-strata were 11.6, 4.9, 2.6, 1.7, 1.5, 1.4 and 1.0, respectively. Analysis of CD4 cell count recovery permitted calculations of person-time accrued within these CD4 cell strata. Despite rapid immune recovery, high mortality in the first year of ART was related to the large proportion of person-time accrued within CD4 cell-strata less than 200 cells/ml. Moreover, patients with baseline CD4 cell counts less than 100 cells/ml had much higher cumulative mortality estimates at 1 and 4 years (11.6 and 16.7%) compared with those of patients with baseline counts of at least 100 cells/ml (5.2 and 9.5%) largely because of greater cumulative person-time at CD4 cell counts less than 200 cells/ml. Conclusion: Updated CD4 cell counts are the variable most strongly associated with mortality risk during ART. High cumulative mortality risk is associated with person-time accrued at low CD4 cell counts. National HIV programmes in resource-limited settings should be designed to minimize the time patients spend with CD4 cell counts less than 200 cells/ml both before and during ART. PMID:19114870

Serum Bicarbonate and Mortality in Stage 3 and Stage 4 Chronic Kidney Disease

PubMed Central

Schold, Jesse D.; Arrigain, Susana; Jolly, Stacey E.; Wehbe, Edgard; Raina, Rupesh; Simon, James F.; Srinivas, Titte R.; Jain, Anil; Schreiber, Martin J.; Nally, Joseph V.

2011-01-01

Summary Background and objectives The incidence and prevalence of metabolic acidosis increase with declining kidney function. We studied the associations of both low and high serum bicarbonate levels with all-cause mortality among stage 3 and 4 chronic kidney disease (CKD) patients. Design, setting, participants, & measurements We examined factors associated with low (<23 mmol/L) and high (>32 mmol/L) serum bicarbonate levels using logistic regression models and associations between bicarbonate and all-cause mortality using Cox-proportional hazard models, Kaplan–Meier survival curves, and time-dependent analysis. Results Out of 41,749 patients, 13.9% (n = 5796) had low and 1.6% (n = 652) had high serum bicarbonate levels. After adjusting for relevant covariates, there was a significant association between low serum bicarbonate and all-cause mortality (hazard ratio [HR] 1.23, 95% CI 1.16, 1.31). This association was not statistically significant among patients with stage 4 CKD and diabetes. The time-dependent analysis demonstrated a significant mortality risk associated with a decline from normal to low bicarbonate level (HR 1.59, 95% CI 1.49, 1.69). High serum bicarbonate levels were associated with death irrespective of the level of kidney function (HR 1.74, 95% CI 1.52, 2.00). When serum bicarbonate was examined as a continuous variable, a J-shaped relationship was noted between serum bicarbonate and mortality. Conclusions Low serum bicarbonate levels are associated with increased mortality among stage 3 CKD patients and patients without diabetes. High serum bicarbonate levels are associated with mortality in both stage 3 and stage 4 CKD patients. PMID:21885787

The Use of Bloodstream Infection Mortality to Measure the Impact of Antimicrobial Stewardship Interventions: Assessing the Evidence.

PubMed

Coulter, Sonali; Roberts, Jason A; Hajkowicz, Krispin; Halton, Kate

2017-03-30

This review sets out to evaluate the current evidence on the impact of inappropriate therapy on bloodstream infections (BSI) and associated mortality. Based on the premise that better prescribing practices should result in better patient outcomes, BSI mortality may be a useful metric to evaluate antimicrobial stewardship (AMS) interventions. A systematic search was performed in key medical databases to identify papers published in English between 2005 and 2015 that examined the association between inappropriate prescribing and BSI mortality in adult patients. Only studies that included BSIs caused by ESKAPE ( Enterococcus faecium/faecalis , Staphylococcus aureus , Klebsiella pneumoniae , Acinetobacter baumannii , Pseudomonas aeruginosa and Enterobacter species ) organisms were included. Study quality was assessed using the GRADE criteria and results combined using a narrative synthesis. We included 46 studies. Inappropriate prescribing was associated with an overall increase in mortality in BSI. In BSI caused by resistant gram positive organisms, such as methicillin resistant S. aureus , inappropriate therapy resulted in up to a 3-fold increase in mortality. In BSI caused by gram negative (GN) resistant organisms a much greater impact ranging from 3 to 25 fold increase in the risk of mortality was observed. While the overall quality of the studies is limited by design and the variation in the definition of appropriate prescribing, there appears to be some evidence to suggest that inappropriate prescribing leads to increased mortality in patients due to GN BSI. The highest impact of inappropriate prescribing was seen in patients with GN BSI, which may be a useful metric to monitor the impact of AMS interventions.

The Use of Bloodstream Infection Mortality to Measure the Impact of Antimicrobial Stewardship Interventions: Assessing the Evidence

PubMed Central

Coulter, Sonali; Roberts, Jason A.; Hajkowicz, Krispin; Halton, Kate

2017-01-01

This review sets out to evaluate the current evidence on the impact of inappropriate therapy on bloodstream infections (BSI) and associated mortality. Based on the premise that better prescribing practices should result in better patient outcomes, BSI mortality may be a useful metric to evaluate antimicrobial stewardship (AMS) interventions. A systematic search was performed in key medical databases to identify papers published in English between 2005 and 2015 that examined the association between inappropriate prescribing and BSI mortality in adult patients. Only studies that included BSIs caused by ESKAPE (Enterococcus faecium/faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species) organisms were included. Study quality was assessed using the GRADE criteria and results combined using a narrative synthesis. We included 46 studies. Inappropriate prescribing was associated with an overall increase in mortality in BSI. In BSI caused by resistant gram positive organisms, such as methicillin resistant S. aureus, inappropriate therapy resulted in up to a 3-fold increase in mortality. In BSI caused by gram negative (GN) resistant organisms a much greater impact ranging from 3 to 25 fold increase in the risk of mortality was observed. While the overall quality of the studies is limited by design and the variation in the definition of appropriate prescribing, there appears to be some evidence to suggest that inappropriate prescribing leads to increased mortality in patients due to GN BSI. The highest impact of inappropriate prescribing was seen in patients with GN BSI, which may be a useful metric to monitor the impact of AMS interventions. PMID:28458799

Average volume of alcohol consumption and all-cause mortality in African Americans: the NHEFS cohort.

PubMed

Sempos, Christopher T; Rehm, Jürgen; Wu, Tiejian; Crespo, Carlos J; Trevisan, Maurizio

2003-01-01

To analyze the relationship between average volume of alcohol consumption and all-cause mortality in African Americans. Prospective cohort study--the NHANES Epidemiologic Follow-Up Study (NHEFS)--with baseline data collected 1971 through 1975 as part of the first National Health and Nutrition Examination Survey (NHANES I) and follow-up through 1992. The analytic data set consisted of 2054 African American men (n = 768) and women (n = 1,286), 25 to 75 years of age, who were followed for approximately 19 years. Alcohol was measured with a quantity-frequency measure at baseline. All-cause mortality. No J-shaped curve was found in the relationship between average volume of alcohol consumption and mortality for male or female African Americans. Instead, no beneficial effect appeared and mortality increased with increasing average consumption for more than one drink a day. The reason for not finding the J-shape in African Americans may be the result of the more detrimental drinking patterns in this ethnicity and consequently the lack of protective effects of alcohol on coronary heart disease. Taking into account sampling design did not substantially change the results from the models, which assumed a simple random sample. If this result can be confirmed in other samples, alcohol policy, especially prevention, should better incorporate patterns of drinking into programs.

Behavior change for newborn survival in resource-poor community settings: bridging the gap between evidence and impact.

PubMed

Kumar, Vishwajeet; Kumar, Aarti; Darmstadt, Gary L

2010-12-01

Despite an established evidence base of simple, affordable, and low-cost interventions to avert neonatal deaths, global progress in reducing neonatal mortality has stagnated in recent years. Under-recognition of the critical role played by behavior change in ensuring adoption and dissemination of innovations is a major reason for this gap between evidence and impact. A general lack of understanding of the mechanisms underlying behavior change at a population level coupled with an under-appreciation of the sociocultural context of newborn care behaviors has underscored ill-informed approaches towards behavior change that have met with limited success. This article draws upon available evidence from prevention-oriented, community-based newborn survival trials to derive insights into the role of behavior change in neonatal mortality reduction. We propose a simple model, the intervention-causation pathway, to explain the pathway through which behavior change interventions may lead to reductions in mortality. Further, we explore the unique nature of newborn care behaviors and their underlying sociocultural context, along with state-of-the-art advances in social, behavioral, and management sciences. These principles form the basis of the behavior change management framework that has successfully guided intervention design and implementation, leading to high impact on neonatal mortality reduction, in Uttar Pradesh, India. We describe how the behavior change management framework can be applied to inform the design of theoretically and empirically sound behavior change interventions with greater precision, predictability and pace towards reduction in neonatal mortality. We finally touch upon key overarching principles that should guide intervention execution for maximal impact. Copyright © 2010 Elsevier Inc. All rights reserved.

Acid-base disorders in critically ill neonates

PubMed Central

Lekhwani, S.; Shanker, V.; Gathwala, G.; Vaswani, N. D.

2010-01-01

Objective: To study acid–base imbalance in common pediatric diseases (such as sepsis, bronchopneumonia, diarrhea, birth-asphyxia etc.) in neonates. Design and Setting: An observational study was conducted in an emergency room of a tertiary teaching care hospital in Haryana, India. Patients and Methods: Fifty neonates (from first hour to one month) attending pediatric emergency services with various ailments. Blood gas analysis, electrolytes, plasma lactate, and plasma albumin were estimated in neonates. Results: Metabolic acidosis was the most common acid–base disorder. Hyperlactatemia was observed in more than half of such cases. Birth asphyxia was another common disorder with the highest mortality in neonates followed by bronchopneumonia and sepsis. Significant correlation between mortality and critical values of lactate was observed. Conclusion: Birth asphyxia with high-lactate levels in neonates constituted major alterations in acid–base disorders seen in an emergency room of a tertiary teaching care hospital. Plasma lactate concentration measurement provides an invaluable tool to assess type of metabolic acidosis in addition to predicting mortality in these neonates. PMID:20859489

Using audit to enhance quality of maternity care in resource limited countries: lessons learnt from rural Tanzania.

PubMed

Nyamtema, Angelo S; de Jong, Alise Bartsch; Urassa, David P; van Roosmalen, Jos

2011-11-16

Although clinical audit is an important instrument for quality care improvement, the concept has not yet been adequately taken on board in rural settings in most resource limited countries where the problem of maternal mortality is immense. Maternal mortality and morbidity audit was established at Saint Francis Designated District Hospital (SFDDH) in rural Tanzania in order to generate information upon which to base interventions. Methods are informed by the principles of operations research. An audit system was established, all patients fulfilling the inclusion criteria for maternal mortality and severe morbidity were reviewed and selected cases were audited from October 2008 to July 2010. The causes and underlying factors were identified and strategic action plans for improvement were developed and implemented. There were 6572 deliveries and 363 severe maternal morbidities of which 36 women died making institutional case fatality rate of 10%. Of all morbidities 341 (94%) had at least one area of substandard care. Patients, health workers and administration related substandard care factors were identified in 50% - 61% of women with severe morbidities. Improving responsiveness to obstetric emergencies, capacity building of the workforce for health care, referral system improvement and upgrading of health centres located in hard to reach areas to provide comprehensive emergency obstetric care (CEmOC) were proposed and implemented as a result of audit. Our findings indicate that audit can be implemented in rural resource limited settings and suggest that the vast majority of maternal mortalities and severe morbidities can be averted even where resources are limited if strategic interventions are implemented.

Hypothyroidism and Mortality among Dialysis Patients

PubMed Central

Rhee, Connie M.; Alexander, Erik K.; Bhan, Ishir

2013-01-01

Summary Background and objectives Hypothyroidism is highly prevalent among ESRD patients, but its clinical significance and the benefits of thyroid hormone replacement in this context remain unclear. Design, setting, participants, & measurements This study examined the association between hypothyroidism and all-cause mortality among 2715 adult dialysis patients with baseline thyrotropin levels measured between April of 2005 and April of 2011. Mortality was ascertained from Social Security Death Master Index and local registration systems. The association between hypothyroidism (thyrotropin greater than assay upper limit normal) and mortality was estimated using Cox proportional hazards models. To reduce the risk of observing reverse-causal associations, models included a 30-day lag between thyrotropin measurement and at-risk time. Results Among 350 (12.9%) hypothyroid and 2365 (87.1%) euthyroid (assay within referent range) patients, 917 deaths were observed during 5352 patient-years of at-risk time. Hypothyroidism was associated with higher mortality. Compared with thyrotropin in the low-normal range (0.4–2.9 mIU/L), subclinical hypothyroidism (thyrotropin >upper limit normal and ≤10.0 mIU/L) was associated with higher mortality; high-normal thyrotropin (≥3.0 mIU/L and ≤upper limit normal) and overt hypothyroidism (thyrotropin >10.0 mIU/L) were associated with numerically greater risk, but estimates were not statistically significant. Compared with spontaneously euthyroid controls, patients who were euthyroid while on exogenous thyroid replacement were not at higher mortality risk, whereas patients who were hypothyroid were at higher mortality risk. Sensitivity analyses indicated that effects on cardiovascular risk factors may mediate the observed association between hypothyroidism and death. Conclusions These data suggest that hypothyroidism is associated with higher mortality in dialysis patients, which may be ameliorated by thyroid hormone replacement therapy. PMID:23258793

Total and cause-specific mortality of Finnish military personnel following service in international peacekeeping operations 1990–2010: a comprehensive register-based cohort study

PubMed Central

Laukkala, T; Parkkola, K; Henriksson, M; Pirkola, S; Kaikkonen, N; Pukkala, E; Jousilahti, P

2016-01-01

Objectives To estimate total and cause-specific mortality after international peacekeeping deployments among the Finnish military peacekeeping personnel in comparison to the general population of similar age and sex. Design A register-based study of a cohort of military peacekeeping personnel in 1990–2010 followed for mortality until the end of 2013. Causes of death were obtained from the national Causes of Death Register. The standardised mortality ratio (SMR) for total and cause-specific mortality was calculated as the ratio of observed and expected number of deaths. Setting Finland (peacekeeping operations in different countries in Africa, Asia and in an area of former Yugoslavia in Europe). Participants 14 584 men and 418 women who had participated in international military peacekeeping operations ending between 1990 and 2010. Interventions Participation in military peacekeeping operations. Main outcome Total and cause-specific mortality. Results 209 men and 3 women died after their peacekeeping service. The SMR for all-cause mortality was 0.55 (95% CI 0.48 to 0.62). For the male peacekeeping personnel, the SMR for all diseases was 0.44 (95% CI 0.35 to 0.53) and for accidental and violent deaths 0.69 (95% CI 0.57 to 0.82). The SMR for suicides was 0.71 (95% CI 0.53 to 0.92). Conclusions Even though military peacekeeping personnel are working in unique and often stressful conditions, their mortality after their service is lower compared with the general population. Military peacekeeping personnel appear to be a selected population group with low general mortality and no excess risk of any cause of death after peacekeeping service. PMID:27799241

Effects of economic downturns on child mortality: a global economic analysis, 1981–2010

PubMed Central

Maruthappu, Mahiben; Watson, Robert A; Watkins, Johnathan; Zeltner, Thomas; Raine, Rosalind; Atun, Rifat

2017-01-01

Objectives To analyse how economic downturns affect child mortality both globally and among subgroups of countries of variable income levels. Design Retrospective observational study using economic data from the World Bank's Development Indicators and Global Development Finance (2013 edition). Child mortality data were sourced from the Institute for Health Metrics and Evaluation. Setting Global. Participants 204 countries between 1981 and 2010. Main outcome measures Child mortality, controlling for country-specific differences in political, healthcare, cultural, structural, educational and economic factors. Results 197 countries experienced at least 1 economic downturn between 1981 and 2010, with a mean of 7.97 downturns per country (range 0–21; SD 0.45). At the global level, downturns were associated with significant (p<0.0001) deteriorations in each child mortality measure, in comparison with non-downturn years: neonatal (coefficient: 1.11, 95% CI 0.855 to 1.37), postneonatal (2.00, 95% CI 1.61 to 2.38), child (2.93, 95% CI 2.26 to 3.60) and under 5 years of age (5.44, 95% CI 4.31 to 6.58) mortality rates. Stronger (larger falls in the growth rate of gross domestic product/capita) and longer (lasting 2 years rather than 1) downturns were associated with larger significant deteriorations (p<0.001). During economic downturns, countries in the poorest quartile experienced ∼1½ times greater deterioration in neonatal mortality, compared with their own baseline; a 3-fold deterioration in postneonatal mortality; a 9-fold deterioration in child mortality and a 3-fold deterioration in under-5 mortality, than countries in the wealthiest quartile (p<0.0005). For 1–5 years after downturns ended, each mortality measure continued to display significant deteriorations (p<0.0001). Conclusions Economic downturns occur frequently and are associated with significant deteriorations in child mortality, with worse declines in lower income countries. PMID:28589010

The impact of place of enrollment and delay to reperfusion on 90-day post-infarction mortality in the ASSENT-4 PCI trial: assessment of the safety and efficacy of a new treatment strategy with percutaneous coronary intervention.

PubMed

Ross, Allan M; Huber, Kurt; Zeymer, Uwe; Armstrong, Paul W; Granger, Christopher B; Goldstein, Patrick; Bogaerts, Kris; Van de Werf, Frans

2009-10-01

We have performed a retrospective analysis of the data stratified by time to treatment and by enrollment site: percutaneous coronary intervention hospitals (PCIH), nonpercutaneous coronary intervention hospitals (NoPCIH), or in a pre-hospital setting (PreH). The ASSENT-4 PCI (Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention) trial intended to test the hypothesis that in ST-segment elevation myocardial infarction (STEMI) patients an upfront fibrinolytic bolus before PCI ("facilitated PCI") compared with primary PCI would benefit STEMI patients facing a long pre-PCI delay. Seven hundred forty-nine patients (45%) presented directly to PCIH, 578 (34%) presented to NoPCIH, and 334 (20%) were randomized and initially treated in the PreH setting. Patients in the PreH-facilitated group had the shortest delays (pain-to-fibrinolytic treatment 125 min) and the lowest 90-day mortality (3.1%). Among patients randomized to primary PCI, the shortest time from pain to first balloon was similarly in the PreH group (223 min). They had the lowest mortality of the primary PCI patient groups (4.1%). The highest mortality (8.4%) was in patients presenting to a PCIH and assigned to the facilitated strategy. Their pain-to-lysis time was 174 min and pain-to-PCI time 266 min (or 92 min after lysis). Few patients fit the target population, long delays to PCI for whom facilitated PCI was designed. Patients treated early after pain onset in the PreH setting do well after a facilitated approach. Despite limitations of post hoc subgroup analysis, these observations suggest caution in extrapolating the results of the ASSENT-4 trial to the "real world" where many patients might have potentially short pain-to-fibrinolysis time but are facing a long transport time to primary PCI.

Mortality associated with use of weapons in armed conflicts, wartime atrocities, and civilian mass shootings: literature review

PubMed Central

Coupland, Robin M; Meddings, David R

1999-01-01

Objective To determine the implications of variation in mortality associated with use of weapons in different contexts. Design Literature review. Settings Armed conflicts and civilian mass shootings, 1929-96. Main outcome measure Mortality from wounds. Results During the fighting of war the number of people wounded is at least twice the number killed and may be 13 times as high; this ratio of the number wounded to the number killed results from the impact of a weapon system on human beings in the particular context of war. When firearms are used against people who are immobilised, in a confined space, or unable to defend themselves the wounded to killed ratio has been lower than 1 or even 0. Conclusions Mortality from firearms depends not only on the technology of the weapon or its ammunition but also on the context in which it is used. The increased mortality resulting from the use of firearms in situations other than war requires a complex interaction of factors explicable in terms of wound ballistics and the psychology of the user. Understanding these factors has implications for recognition of war crimes. In addition, the lethality of conventional weapons may be increased if combatants are disabled by the new non-lethal weapons beforehand; this possibility requires careful legal examination within the framework of the Geneva Conventions. Key messagesMortality from firearms varies according to the context in which they are usedIn war the number of people wounded is at least twice the number killedThe number killed may be greater than the number wounded when firearms are used against people who are immobilised, in a confined space, or unable to defend themselvesRecognising how the wounded to killed ratio varies has implications for recognising war crimesCombining use of weapons that are designed to incapacitate with use of conventional weapons requires examination under the law of war PMID:10445920

Influence of alcohol use on mortality and expenditure during hospital admission: a cross-sectional study

PubMed Central

Peng, Shu-Hui; Hsu, Shiun-Yuan; Kuo, Pao-Jen; Rau, Cheng-Shyuan; Cheng, Ya-Ai; Hsieh, Ching-Hua

2016-01-01

Objectives This study was designed to investigate the effect of alcohol intoxication on clinical presentation of hospitalised adult trauma patients at a Level I trauma centre using propensity score matching. Design Cross-sectional study. Setting Taiwan. Participants Detailed data of 929 hospitalised adult trauma patients with alcohol intoxication, aged 20–65 years, and 10 104 corresponding patients without alcohol intoxication were retrieved from the Trauma Registry System between 1 January 2009 and 31 December 2014. Alcohol intoxication was defined as a blood alcohol concentration (BAC) ≥50 mg/dL. Main outcome measures In-hospital mortality and expenditure. Results Patients with alcohol intoxication presented with significantly higher short-term mortality (OR: 3.0, 95% CI 2.0 to 4.4; p<0.001) than patients without alcohol intoxication. However, on comparison with propensity score-matched patients with respect to sex, age, comorbidity, Glasgow Coma Scale (GCS), injury region based on Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS), alcohol intoxication did not significantly influence mortality (OR: 0.8, 95% CI 0.5 to 1.4; p=0.563). This implied that the higher mortality of alcohol-intoxicated patients was attributable to patient characteristics such as a higher injury severity rather than alcohol intoxication. Even on comparison with sex-matched, age-matched and comorbidity-matched patients without alcohol intoxication, patients with alcohol intoxication still had significantly higher total expenditure (17.4% higher), cost of operation (40.3% higher), cost of examination (52.8% higher) and cost of pharmaceuticals (38.3% higher). Conclusions The associated higher mortality of adult trauma patients with alcohol intoxication was completely attributable to other patient characteristics and associated injury severity rather than the effects of alcohol. However, patients with alcohol intoxication incurred significantly higher expenditure than patients without alcohol intoxication, even on comparison with sex-matched, age-matched and comorbidity-matched patients without alcohol intoxication. PMID:27803110

Clinical Presentation, Management and Outcome of Acute Coronary Syndrome in Yemen: Data from GULF RACE - 2 Registry

PubMed Central

Ahmed, Al-Motarreb; Abdulwahab, Al-Matry; Hesham, Al-Fakih; Nawar, Wather

2013-01-01

Background: Acute Coronary Syndrome (ACS) is increasing in Yemen in recent years and there are no data available on its short and long-term outcome. We evaluated the clinical pictures, management, in-hospital, and long-term outcomes of the ACS patients in Yemen. Design and Setting: A 9-month prospective, multi-center study conducted in 26 hospitals from 9 governorates. The study included 30-day and 1-year mortality follow-up. Patients and Methods: One thousand seven hundred and sixty one patients with ACS were collected prospectively during the 9-month period. Patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTEACS), including non-ST-elevation myocardial infarction and unstable angina were included. Conclusions: ACS patients in Yemen present at a relatively young age with high prevalence of Smoking, khat chewing and hypertension. STEMI patients present late, and their acute management is poor. In-hospital evidence-based medication rates are high, but coronary revascularization procedures were very low. In-hospital mortality was high and long-term mortality rates increased two folds compared with the in-hospital mortality. PMID:24695681

Stability of Predictors of Mortality after Spinal Cord Injury

PubMed Central

Krause, James S.; Saunders, Lee L.; Zhai, Yusheng

2011-01-01

Objective To identify the stability of socio-environmental, behavioral, and health predictors of mortality over an eight year time frame. Study Design Cohort study. Setting Data were analyzed at a large medical university in the Southeast United States of America (USA). Methods Adults with residual impairment from a spinal cord injury (SCI) who were at least one year post-injury at assessment were recruited through a large specialty hospital in the Southeast USA. 1209 participants were included in the final analysis. A piecewise exponential model with 2 equal time intervals (eight years total) was used to assess the stability of the hazard and the predictors over time. Results The hazard did significantly change over time, where the hazard in the first time interval was significantly lower than the second. There were no interactions between the socio-environmental, behavior, or health factors and time, although there was a significant interaction between age at injury (a demographic variable) and time. Conclusion These results suggest there is stability in the association between the predictors and mortality, even over an eight year time period. Results reinforce the use of historic variables for prediction of mortality in persons with SCI. PMID:22231541

The Empirical Foundations of Telemedicine Interventions for Chronic Disease Management

PubMed Central

Shannon, Gary W.; Smith, Brian R.; Alverson, Dale C.; Antoniotti, Nina; Barsan, William G.; Bashshur, Noura; Brown, Edward M.; Coye, Molly J.; Doarn, Charles R.; Ferguson, Stewart; Grigsby, Jim; Krupinski, Elizabeth A.; Kvedar, Joseph C.; Linkous, Jonathan; Merrell, Ronald C.; Nesbitt, Thomas; Poropatich, Ronald; Rheuban, Karen S.; Sanders, Jay H.; Watson, Andrew R.; Weinstein, Ronald S.; Yellowlees, Peter

2014-01-01

Abstract The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/re-admissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings. PMID:24968105

26 CFR 1.430(h)(3)-1 - Mortality tables used to determine present value.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 26 Internal Revenue 5 2011-04-01 2011-04-01 false Mortality tables used to determine present value... Mortality tables used to determine present value. (a) Basis for mortality tables—(1) In general. This section sets forth rules for the mortality tables to be used in determining present value or making any...

26 CFR 1.430(h)(3)-1 - Mortality tables used to determine present value.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 26 Internal Revenue 5 2013-04-01 2013-04-01 false Mortality tables used to determine present value... Mortality tables used to determine present value. (a) Basis for mortality tables—(1) In general. This section sets forth rules for the mortality tables to be used in determining present value or making any...

26 CFR 1.430(h)(3)-1 - Mortality tables used to determine present value.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 26 Internal Revenue 5 2012-04-01 2011-04-01 true Mortality tables used to determine present value... Mortality tables used to determine present value. (a) Basis for mortality tables—(1) In general. This section sets forth rules for the mortality tables to be used in determining present value or making any...

26 CFR 1.430(h)(3)-1 - Mortality tables used to determine present value.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 26 Internal Revenue 5 2014-04-01 2014-04-01 false Mortality tables used to determine present value... Mortality tables used to determine present value. (a) Basis for mortality tables—(1) In general. This section sets forth rules for the mortality tables to be used in determining present value or making any...

Hospital Spending and Inpatient Mortality: Evidence from California

PubMed Central

Romley, John A.; Jena, Anupam B.; Goldman, Dana P.

2013-01-01

Background Evidence shows that high Medicare spending is not associated with better health outcomes at a regional level, and that high spending in hospitals is not associated with better process quality. But the relationship between hospital spending and inpatient mortality is less well understood. Objective To determine the association between hospital spending and risk-adjusted inpatient mortality. Design Retrospective cohort study. Setting Database of discharge records from 1999–2008 for 208 California hospitals included in the Dartmouth Atlas of Health Care Patients 2,545,352 patients hospitalized during 1999–2008 with one of six major medical conditions. Measurements Inpatient mortality rates among patients admitted to hospitals with varying levels of end-of-life hospital spending. Results For each of six admitting diagnoses – acute myocardial infarction, congestive heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and pneumonia – patient admission to higher-spending hospitals was associated with lower risk-adjusted inpatient mortality. During 1999–2003, for example, patients admitted with acute myocardial infarction to California hospitals in the highest quintile of hospital spending had lower inpatient mortality than those admitted to hospitals in the lowest quintile (odds ratio of mortality 0.862, 95% confidence interval 0.742–0.983). Predicted inpatient deaths would increase by 1,831 if all patients admitted with acute myocardial infarction were cared for in hospitals in the lowest quintile of spending rather than the highest. The association between hospital spending and inpatient mortality did not vary by geographic region or hospital size. Limitations Unobserved predictors of mortality create uncertainty about whether greater inpatient hospital spending leads to lower inpatient mortality. Conclusion Hospitals that spend more at the end of life have lower inpatient mortality for a variety of major admitting medical conditions. Primary funding source National Institute on Aging, RAND Bing Center for Health Economics PMID:21282695

Unemployment and mortality among Finnish men, 1981-5.

PubMed Central

Martikainen, P T

1990-01-01

OBJECTIVE--To ascertain whether, after controlling for several relevant background variables simultaneously, unemployment is related to mortality and to assess whether this relation is causal or whether unhealthy people are more likely to become unemployed. DESIGN--Prospective study of mortality in Finland during 1981-5 based on 1980 census data on 30-54 year old wage earner men and with particular attention to unemployment in the year before the census. SETTING--Research project at the University of Helsinki. SUBJECTS--All wage earner men in Finland aged 30-54 at the 1980 census. MAIN OUTCOME MEASURES--Causes of death during 1981-5 and duration of unemployment in the year before the census. Background variables controlled for were age, socioeconomic state, marital state, and health. The data were analysed by log linear regression models. RESULTS--During the study period 1981-5, which covered almost 2.7 million person years, there were 9810 deaths. After controlling for all background variables relative total mortality among unemployed versus employed men was 1.93 (95% confidence interval 1.82 to 2.05). The excess mortality was highest in accidental and violent causes of death (relative mortality 2.51; 95% confidence interval 2.28 to 2.76). For circulatory diseases the relative death rate was 1.54 (95% confidence interval 1.40 to 1.70), but among neoplasms only lung cancer was associated with excess mortality. Selection for unemployment based on age, socioeconomic state, and marital state was evident but no such selection was detected based on health. Effects of unemployment on mortality were more pronounced with increasing duration of unemployment. CONCLUSIONS--The relative excess mortality of unemployed men in Finland cannot fully be explained by demographic, social, and health variables preceding unemployment. Unemployment therefore seems to have an independent causal effect on male mortality. Further studies are needed to elucidate the mechanisms between unemployment and mortality. PMID:2282395

The use of audit to identify maternal mortality in different settings: is it just a difference between the rich and the poor?

PubMed

van Dillen, Jeroen; Stekelenburg, Jelle; Schutte, Joke; Walraven, Gijs; van Roosmalen, Jos

2007-01-01

To illustrate how maternal mortality audit identifies different causes of and contributing factors to maternal deaths in different settings in low- and high-income countries and how this can lead to local solutions in reducing maternal deaths. Descriptive study of maternal mortality from different settings and review of data on the history of reducing maternal mortality in what are now high-income countries. Kalabo district in Zambia, Farafenni division in The Gambia, Onandjokwe district in Namibia, and the Netherlands. Population of rural areas in Zambia and The Gambia, peri-urban population in Namibia and nationwide data from the Netherlands. Data from facility-based maternal mortality audits from three African hospitals and data from the latest confidential enquiry in the Netherlands. Maternal mortality ratio (MMR), causes (direct and indirect) and characteristics. MMR ranged from 10 per 100,000 (the Netherlands) to 1,540 per 100,000 (The Gambia). Differences in causes of deaths were characterized by HIV/AIDS in Namibia, sepsis and HIV/AIDS in Zambia, (pre-)eclampsia in The Netherlands and obstructed labour in The Gambia. Differences in maternal mortality are more than just differences between the rich and poor. Acknowledging the magnitude of maternal mortality and harnessing a strong political will to tackle the issues are important factors. However, there is no single, general solution to reduce maternal mortality, and identification of problems needs to be promoted through audit, both national and local.

The outcome of trauma patients with do-not-resuscitate orders.

PubMed

Matsushima, Kazuhide; Schaefer, Eric W; Won, Eugene J; Armen, Scott B

2016-02-01

Institutional variation in outcome of patients with do-not-resuscitate (DNR) orders has not been well described in the setting of trauma. The purpose of this study was to assess the impact of trauma center designation on outcome of patients with DNR orders. A statewide trauma database (Pennsylvania Trauma Outcome Study) was used for the analysis. Characteristics of patients with DNR orders were compared between state-designated level 1 and 2 trauma centers. Inhospital mortality and major complication rates were compared using hierarchical logistic regression models that included a random effect for trauma centers. We adjusted for a number of potential confounders and allowed for nonlinearity in injury severity score and age in these models. A total of 106,291 patients (14 level 1 and 11 level 2 trauma centers) were identified in the Pennsylvania Trauma Outcome Study database between 2007 and 2011. We included 5953 patients with DNR orders (5.6%). Although more severely injured patients with comorbid disease were made DNR in level 1 trauma centers, trauma center designation level was not a significant factor for inhospital mortality of patients with DNR orders (odds ratio, 1.33; 95% confidence interval, 0.81-2.18; P = 0.26). Level 1 trauma centers were significantly associated with a higher rate of major complications (odds ratio, 1.75; 95% confidence interval, 1.11-2.75; P = 0.016). Inhospital mortality of patients with DNR orders was not significantly associated with trauma designation level after adjusting for case mix. More aggressive treatment or other unknown factors may have resulted in a significantly higher complication rate at level 1 trauma centers. Copyright © 2016 Elsevier Inc. All rights reserved.

Estimating Global Burden of Disease due to congenital anomaly: an analysis of European data

PubMed Central

Boyle, Breidge; Addor, Marie-Claude; Arriola, Larraitz; Barisic, Ingeborg; Bianchi, Fabrizio; Csáky-Szunyogh, Melinda; de Walle, Hermien E K; Dias, Carlos Matias; Draper, Elizabeth; Gatt, Miriam; Garne, Ester; Haeusler, Martin; Källén, Karin; Latos-Bielenska, Anna; McDonnell, Bob; Mullaney, Carmel; Nelen, Vera; Neville, Amanda J; O’Mahony, Mary; Queisser-Wahrendorf, Annette; Randrianaivo, Hanitra; Rankin, Judith; Rissmann, Anke; Ritvanen, Annukka; Rounding, Catherine; Tucker, David; Verellen-Dumoulin, Christine; Wellesley, Diana; Wreyford, Ben; Zymak-Zakutnia, Natalia; Dolk, Helen

2018-01-01

Objective To validate the estimates of Global Burden of Disease (GBD) due to congenital anomaly for Europe by comparing infant mortality data collected by EUROCAT registries with the WHO Mortality Database, and by assessing the significance of stillbirths and terminations of pregnancy for fetal anomaly (TOPFA) in the interpretation of infant mortality statistics. Design, setting and outcome measures EUROCAT is a network of congenital anomaly registries collecting data on live births, fetal deaths from 20 weeks’ gestation and TOPFA. Data from 29 registries in 19 countries were analysed for 2005–2009, and infant mortality (deaths of live births at age <1 year) compared with the WHO Mortality Database. Eight EUROCAT countries were excluded from further analysis on the basis that this comparison showed poor ascertainment of survival status. Results According to WHO, 17%–42% of infant mortality was attributed to congenital anomaly. In 11 EUROCAT countries, average infant mortality with congenital anomaly was 1.1 per 1000 births, with higher rates where TOPFA is illegal (Malta 3.0, Ireland 2.1). The rate of stillbirths with congenital anomaly was 0.6 per 1000. The average TOPFA prevalence was 4.6 per 1000, nearly three times more prevalent than stillbirths and infant deaths combined. TOPFA also impacted on the prevalence of postneonatal survivors with non-lethal congenital anomaly. Conclusions By excluding TOPFA and stillbirths from GBD years of life lost (YLL) estimates, GBD underestimates the burden of disease due to congenital anomaly, and thus declining YLL over time may obscure lack of progress in primary, secondary and tertiary prevention. PMID:28667189

Global determinants of mortality in under 5s: 10 year worldwide longitudinal study.

PubMed

Hanf, Matthieu; Nacher, Mathieu; Guihenneuc, Chantal; Tubert-Bitter, Pascale; Chavance, Michel

2013-11-08

To assess at country level the association of mortality in under 5s with a large set of determinants. Longitudinal study. 193 United Nations member countries, 2000-09. Yearly data between 2000 and 2009 based on 12 world development indicators were used in a multivariable general additive mixed model allowing for non-linear relations and lag effects. National rate of deaths in under 5s per 1000 live births The model retained the variables: gross domestic product per capita; percentage of the population having access to improved water sources, having access to improved sanitation facilities, and living in urban areas; adolescent fertility rate; public health expenditure per capita; prevalence of HIV; perceived level of corruption and of violence; and mean number of years in school for women of reproductive age. Most of these variables exhibited non-linear behaviours and lag effects. By providing a unified framework for mortality in under 5s, encompassing both high and low income countries this study showed non-linear behaviours and lag effects of known or suspected determinants of mortality in this age group. Although some of the determinants presented a linear action on log mortality indicating that whatever the context, acting on them would be a pertinent strategy to effectively reduce mortality, others had a threshold based relation potentially mediated by lag effects. These findings could help designing efficient strategies to achieve maximum progress towards millennium development goal 4, which aims to reduce mortality in under 5s by two thirds between 1990 and 2015.

Austerity and old-age mortality in England: a longitudinal cross-local area analysis, 2007–2013

PubMed Central

McKee, Martin; Katikireddi, Srinivasa Vittal; Taylor-Robinson, David; Barr, Ben; Stuckler, David

2016-01-01

Objective There has been significant concern that austerity measures have negatively impacted health in the UK. We examined whether budgetary reductions in Pension Credit and social care have been associated with recent rises in mortality rates among pensioners aged 85 years and over. Design Cross-local authority longitudinal study. Setting Three hundred and twenty-four lower tier local authorities in England. Main outcome measure Annual percentage changes in mortality rates among pensioners aged 85 years or over. Results Between 2007 and 2013, each 1% decline in Pension Credit spending (support for low income pensioners) per beneficiary was associated with an increase in 0.68% in old-age mortality (95% CI: 0.41 to 0.95). Each reduction in the number of beneficiaries per 1000 pensioners was associated with an increase in 0.20% (95% CI: 0.15 to 0.24). Each 1% decline in social care spending was associated with a significant rise in old-age mortality (0.08%, 95% CI: 0.0006–0.12) but not after adjusting for Pension Credit spending. Similar patterns were seen in both men and women. Weaker associations observed for those aged 75 to 84 years, and none among those 65 to 74 years. Categories of service expenditure not expected to affect old-age mortality, such as transportation, showed no association. Conclusions Rising mortality rates among pensioners aged 85 years and over were linked to reductions in spending on income support for poor pensioners and social care. Findings suggest austerity measures in England have affected vulnerable old-age adults. PMID:26980412

The northern population development; colonization and mortality in Swedish Sápmi, 1776-1895.

PubMed

Sköld, Peter; Axelsson, Per

2008-02-01

The aim of the Consequence of Colonization project is to study population development and mortality in Swedish Sápmi. This article, the first to be drawn from our research, compares these changes between Sami and non-Sami, South and North Sami. Study design. Longitudinal individual based data from computerized records ofthe Glillivare, Undersåker and Frostviken parishes, divided into 2 40-year periods: 1776-1815 and 1856-1895. The main source material used for the present study was a set of data files from the Demographic Data Base (DDB) at Umeå University, the largest historical database in Europe. A Sami cohort was created by indicators of ethnicity in the parish registers, and was later extended with automatic linkages to children and parents. Sami mortality rates show great fluctuations during the period 1776-1815, almost always peaking at a higher rate than in the rest of Sweden. The non-Sami group had lower mortality rates compared with both Sweden as a whole and the Sami in the parish. Between 1856 and 1895, the non-Sami experienced a very small reduction in their mortality rates and the Sami experienced overall improvement in their health status. Significant differences in age-specific mortality appear when the South and North Sami are compared, showing that the South Sami had far lower child mortality rates. The Sami population's health status improved during the nineteenth century. This indicates that they had advanced in the epidemiologic transition model. A corresponding change is not found for the non-Sami group.

Forecasting the mortality rates of Malaysian population using Heligman-Pollard model

NASA Astrophysics Data System (ADS)

Ibrahim, Rose Irnawaty; Mohd, Razak; Ngataman, Nuraini; Abrisam, Wan Nur Azifah Wan Mohd

2017-08-01

Actuaries, demographers and other professionals have always been aware of the critical importance of mortality forecasting due to declining trend of mortality and continuous increases in life expectancy. Heligman-Pollard model was introduced in 1980 and has been widely used by researchers in modelling and forecasting future mortality. This paper aims to estimate an eight-parameter model based on Heligman and Pollard's law of mortality. Since the model involves nonlinear equations that are explicitly difficult to solve, the Matrix Laboratory Version 7.0 (MATLAB 7.0) software will be used in order to estimate the parameters. Statistical Package for the Social Sciences (SPSS) will be applied to forecast all the parameters according to Autoregressive Integrated Moving Average (ARIMA). The empirical data sets of Malaysian population for period of 1981 to 2015 for both genders will be considered, which the period of 1981 to 2010 will be used as "training set" and the period of 2011 to 2015 as "testing set". In order to investigate the accuracy of the estimation, the forecast results will be compared against actual data of mortality rates. The result shows that Heligman-Pollard model fit well for male population at all ages while the model seems to underestimate the mortality rates for female population at the older ages.

Emergency thoracic surgery in elderly patients

PubMed Central

Limmer, Stefan; Unger, Lena; Czymek, Ralf; Kujath, Peter; Hoffmann, Martin

2011-01-01

Objectives Emergency thoracic surgery in the elderly represents an extreme situation for both the surgeon and patient. The lack of an adequate patient history as well as the inability to optimize any co-morbidities, which are the result of the emergent situation, are the cause of increased morbidity and mortality. We evaluated the outcome and prognostic factors for this selected group of patients. Design Retrospective chart review. Setting Academic tertiary care referral center. Participants Emergency patients treated at the Department of Thoracic Surgery, University Hospital of Luebeck, Germany. Main outcome measures Co-morbidities, mortality, risk factors and hospital length of stay. Results A total of 124 thoracic procedures were performed on 114 patients. There were 79 men and 36 women (average age 72.5 ±6.4 years, range 65–94). The overall operative mortality was 25.4%. The most frequent indication was thoracic/mediastinal infection, followed by peri- or postoperative thoracic complications. Risk factors for hospital mortality were a high ASA score, pre-existing diabetes mellitus and renal insufficiency. Conclusions Our study documents a perioperative mortality rate of 25% in patients over 65 who required emergency thoracic surgery. The main indication for a surgical intervention was sepsis with a thoracic/mediastinal focus. Co-morbidities and the resulting perioperative complications were found to have a significant effect on both inpatient length of stay and outcome. Long-term systemic co-morbidities such as diabetes mellitus are difficult to equalize with respect to certain organ dysfunctions and significantly increase mortality. PMID:21369531

Quality of diet and mortality among Japanese men and women: Japan Public Health Center based prospective study

PubMed Central

Akter, Shamima; Kashino, Ikuko; Goto, Atsushi; Mizoue, Tetsuya; Noda, Mitsuhiko; Sasazuki, Shizuka; Sawada, Norie; Tsugane, Shoichiro

2016-01-01

Objective To examine the association between adherence to the Japanese Food Guide Spinning Top and total and cause specific mortality. Design Large scale population based prospective cohort study in Japan with follow-up for a median of 15 years. Setting 11 public health centre areas across Japan. Participants 36 624 men and 42 970 women aged 45-75 who had no history of cancer, stroke, ischaemic heart disease, or chronic liver disease. Main outcome measures Deaths and causes of death identified with the residential registry and death certificates. Results Higher scores on the food guide (better adherence) were associated with lower total mortality; the multivariable adjusted hazard ratios (95% confidence interval) of total mortality for the lowest through highest scores were 1.00, 0.92 (0.87 to 0.97), 0.88 (0.83 to 0.93), and 0.85 (0.79 to 0.91) (P<0.001 for trend) and the multivariable adjusted hazard ratio associated with a 10 point increase in food guide scores was 0.93 (0.91 to 0.95; P<0.001 for trend). This score was inversely associated with mortality from cardiovascular disease (hazard ratio associated with a 10 point increase 0.93, 0.89 to 0.98; P=0.005 for trend) and particularly from cerebrovascular disease (0.89, 0.82 to 0.95; P=0.002 for trend). There was some evidence, though not significant, of an inverse association for cancer mortality (0.96, 0.93 to 1.00; P=0.053 for trend). Conclusion Closer adherence to Japanese dietary guidelines was associated with a lower risk of total mortality and mortality from cardiovascular disease, particularly from cerebrovascular disease, in Japanese adults. PMID:27005903

The Hispanic Paradox and Predictors of Mortality in an Aging Bi-ethnic Cohort of Mexican Americans and European Americans: The San Antonio Longitudinal Study of Aging

PubMed Central

Espinoza, Sara E.; Jung, Inkyung; Hazuda, Helen

2013-01-01

OBJECTIVES To examine predictors of mortality in aging Mexican Americans (MAs) and European Americans (EAs). DESIGN Longitudinal, observational cohort study. SETTING Socioeconomically diverse neighborhoods in San Antonio, Texas. PARTICIPANTS Three hundred and ninety-four MA and 355 EA community-dwelling older adults (65+) who completed the baseline examination (1992–96) of the San Antonio Longitudinal Study of Aging (SALSA) and for whom vital status was ascertained over an average 8.2 years of follow-up. MEASUREMENTS Ethnic group was classified using a validated algorithm. Hazards ratios (HR) for mortality were estimated using Cox proportional hazards models with age, sex, ethnic group, education, income, frailty, diabetes with and without complications, comorbidity, cognition, depressive symptoms, and body mass index included as predictors in sequential models. RESULTS At baseline, MAs had higher prevalence of diabetes and frailty and lower socioeconomic status (SES) compared to EAs. The age- and sex-adjusted ethnic HR (MA vs. EA) for mortality was 1.54 (95% CI: 1.17–2.03). After adjusting for SES, the ethnic HR was no longer significant (HR = 1.16, 95% CI: 0.83–1.61). In the final model, comorbidity, diabetes with complications, depressive symptoms, and cognitive impairment were significant independent risk factors for mortality. CONCLUSION Contrary to the Hispanic paradox, MAs were at increased risk of mortality. Moreover, this ethnic disparity was largely explained by SES differences. Significant independent predictors of mortality, regardless of ethnic group, included diabetes with complications, comorbidity, depressive symptoms and cognitive impairment. Mortality reduction in older MAs requires attention to both socioeconomic disparities and disease factors. PMID:24000922

Heat-related mortality in the Florentine area (Italy) before and after the exceptional 2003 heat wave in Europe: an improved public health response?

PubMed

Morabito, Marco; Profili, Francesco; Crisci, Alfonso; Francesconi, Paolo; Gensini, Gian Franco; Orlandini, Simone

2012-09-01

High ambient temperatures have been associated with increased mortality across the world. Several studies suggest that timely preventive measures may reduce heat-related excess mortality. The main aim of this study was to detect the temporal modification of heat-related mortality, in older adults (aged 65-74) and in elderly ≥75 years old, in the Florentine area by comparing previous (1999-2002) and subsequent (2004-2007) periods to the summer of 2003, when a regional Heat-Health Warning System (HHWS) was set up. Mortality data from 1999 to 2007 (May-September) were provided by the Mortality Registry of the Tuscany Region (n = 21,092). Weather data were used to assess daily apparent temperatures (AT). Case-crossover time-stratified designs and constrained segmented distributed lag models were applied. No significant heat-related mortality odds ratio (OR) variations were observed among the sub-periods. Nevertheless, a general OR decrease dating from 1999-2002 (OR 1.23; lack of HHWS) to 2004-2005 (OR 1.21; experimental HHWS running only for Florence) and to 2006-2007 (OR 1.12; official HHWS extended to the whole Florentine area) was observed when the maximum AT was considered. This modification was only evident in subjects ≥75 years old. The heat effect was higher and sustained for more days (until lag 9) during the period 1999-2002 than 2004-2007. The decrease of the excessive heat effect on mortality between periods with the absence and existence of a HHWS is also probably due to the mitigation of preventive measures and the implementation of a HHWS with specific interventions for safeguarding the health of the "frail elderly".

Mortality from treatable illnesses in marginally housed adults: a prospective cohort study

PubMed Central

Jones, Andrea A; Vila-Rodriguez, Fidel; Leonova, Olga; Langheimer, Verena; Lang, Donna J; Barr, Alasdair M; Procyshyn, Ric M; Smith, Geoffrey N; Schultz, Krista; Buchanan, Tari; Krausz, Michael; Montaner, Julio S; MacEwan, G William; Rauscher, Alexander; Panenka, William J; Thornton, Allen E; Honer, William G

2015-01-01

Objectives Socially disadvantaged people experience greater risk for illnesses that may contribute to premature death. This study aimed to evaluate the impact of treatable illnesses on mortality among adults living in precarious housing. Design A prospective cohort based in a community sample. Setting A socially disadvantaged neighbourhood in Vancouver, Canada. Participants Adults (N=371) living in single room occupancy hotels or recruited from the Downtown Community Court and followed for median 3.8 years. Main outcome measures Participants were assessed for physical and mental illnesses for which treatment is currently available. We compared cohort mortality rates with 2009 Canadian rates. Left-truncated Cox proportional hazards modelling with age as the time scale was used to assess risk factors for earlier mortality. Results During 1269 person-years of observation, 31/371 (8%) of participants died. Compared with age-matched and sex-matched Canadians, the standardised mortality ratio was 8.29 (95% CI 5.83 to 11.79). Compared with those that had cleared the virus, active hepatitis C infection was a significant predictor for hepatic fibrosis adjusting for alcohol dependence and age (OR=2.96, CI 1.37 to 7.08). Among participants <55 years of age, psychosis (HR=8.12, CI 1.55 to 42.47) and hepatic fibrosis (HR=13.01, CI 3.56 to 47.57) were associated with earlier mortality. Treatment rates for these illnesses were low (psychosis: 32%, hepatitis C virus: 0%) compared with other common disorders (HIV: 57%, opioid dependence: 61%) in this population. Conclusions Hepatic fibrosis and psychosis are associated with increased mortality in people living in marginal conditions. Timely diagnosis and intervention could reduce the high mortality in marginalised inner city populations. PMID:26297373

Breast cancer mortality and associated factors in São Paulo State, Brazil: an ecological analysis

PubMed Central

Diniz, Carmen Simone Grilo; Pellini, Alessandra Cristina Guedes; Ribeiro, Adeylson Guimarães; Tedardi, Marcello Vannucci; de Miranda, Marina Jorge; Touso, Michelle Mosna; Baquero, Oswaldo Santos; dos Santos, Patrícia Carlos

2017-01-01

Objective Identify the factors associated with the age-standardised breast cancer mortality rate in the municipalities of State of São Paulo (SSP), Brazil, in the period from 2006 to 2012. Design Ecological study of the breast cancer mortality rate standardised by age, as the dependent variable, having each of the 645 municipalities in the SSP as the unit of analysis. Settings The female resident population aged 15 years or older, by age group and municipality, in 2009 (mid-term), obtained from public dataset (Informatics Department of the Unified Health System). Participants Women 15 years or older who died of breast cancer in the SSP were selected for the calculation of the breast cancer mortality rate, according to the municipality and age group, from 2006 to 2012. Main outcome measures Mortality rates for each municipality calculated by the direct standardisation method, using the age structure of the population of SSP in 2009 as the standard. Results In the final linear regression model, breast cancer mortality, in the municipal level, was directly associated with rates of nulliparity (p<0.0001), mammography (p<0.0001) and private healthcare (p=0.006). Conclusions The findings that mammography ratio was associated, in the municipal level, with increased mortality add to the evidence of a probable overestimation of benefits and underestimation of risks associated with this form of screening. The same paradoxical trend of increased mortality with screening was found in recent individual-level studies, indicating the need to expand informed choice for patients, primary prevention actions and individualised screening. Additional studies should be conducted to explore if there is a causality link in this association. PMID:28838894

C-Reactive Protein and Prediction of 1-Year Mortality in Prevalent Hemodialysis Patients

PubMed Central

Bazeley, Jonathan; Bieber, Brian; Li, Yun; Morgenstern, Hal; de Sequera, Patricia; Combe, Christian; Yamamoto, Hiroyasu; Gallagher, Martin; Port, Friedrich K.

2011-01-01

Summary Background and objectives Measurement of C-reactive protein (CRP) levels remains uncommon in North America, although it is now routine in many countries. Using Dialysis Outcomes and Practice Patterns Study data, our primary aim was to evaluate the value of CRP for predicting mortality when measured along with other common inflammatory biomarkers. Design, setting, participants, & measurements We studied 5061 prevalent hemodialysis patients from 2005 to 2008 in 140 facilities routinely measuring CRP in 10 countries. The association of CRP with mortality was evaluated using Cox regression. Prediction of 1-year mortality was assessed in logistic regression models with differing adjustment variables. Results Median baseline CRP was lower in Japan (1.0 mg/L) than other countries (6.0 mg/L). CRP was positively, monotonically associated with mortality. No threshold below which mortality rate leveled off was identified. In prediction models, CRP performance was comparable with albumin and exceeded ferritin and white blood cell (WBC) count based on measures of model discrimination (c-statistics, net reclassification improvement [NRI]) and global model fit (generalized R2). The primary analysis included age, gender, diabetes, catheter use, and the four inflammatory markers (omitting one at a time). Specifying NRI ≥5% as appropriate reclassification of predicted mortality risk, NRI for CRP was 12.8% compared with 10.3% for albumin, 0.8% for ferritin, and <0.1% for WBC. Conclusions These findings demonstrate the value of measuring CRP in addition to standard inflammatory biomarkers to improve mortality prediction in hemodialysis patients. Future studies are indicated to identify interventions that lower CRP and to identify whether they improve clinical outcomes. PMID:21868617

Weight History, All-Cause and Cause-Specific Mortality in Three Prospective Cohort Studies

PubMed Central

Yu, Edward; Stokes, Andrew C.; Ley, Sylvia H.; Manson, JoAnn E.; Willett, Walter; Satija, Ambika; Hu, Frank B.

2017-01-01

BACKGROUND The relationship between body mass index (BMI) and mortality remains controversial. OBJECTIVE To investigate the relationship between maximum BMI over 16 years and subsequent mortality. DESIGN Three prospective cohort studies. SETTING Nurses’ Health Study I and II, Health Professionals Follow-up Study. PARTICIPANTS 225,072 men and women accruing 32,571 deaths over a mean of 12.3 years of follow-up. MEASUREMENTS Maximum BMI over 16 years of weight history and all-cause and cause-specific mortality. RESULTS Maximum BMIs in the overweight (25.0 to 29.9 kg/m2) (multivariate hazard ratio (HR), 1.06; 95% confidence interval (CI), 1.03 – 1.08), obese I (30.0 to 34.9 kg/m2), (HR, 1.24; 95% CI, 1.20 – 1.29), and obese II (≥ 35.0 kg/m2) (HR, 1.73; 95% CI, 1.66 – 1.80) categories were associated with increases in risk of all-cause mortality. The pattern of excess risk with a maximum BMI above normal weight was maintained across strata defined by smoking status, sex, and age, but the excess was greatest among those <70 years old and never smokers. In contrast, a significant inverse association between overweight and mortality (HR, 0.96; 95% CI, 0.94 – 0.99) was observed when BMI was defined using a single baseline measurement. Maximum overweight was also associated with increased cause-specific mortality, including deaths from cardiovascular diseases and coronary heart disease. LIMITATIONS Residual confounding and misclassification. CONCLUSIONS The paradoxical association between overweight and mortality is reversed in analyses incorporating weight history. Maximum BMI may be a useful metric to minimize reverse causation bias associated with a single baseline BMI assessment. PMID:28384755

Serum Fractalkine (CX3CL1) and Cardiovascular Outcomes and Diabetes: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

PubMed Central

Shah, Rachana; Matthews, Gregory J.; Shah, Rhia Y.; McLaughlin, Catherine; Chen, Jing; Wolman, Melanie; Master, Stephen R.; Chai, Boyang; Xie, Dawei; Rader, Daniel J; Raj, Dominic S.; Mehta, Nehal N.; Budoff, Matthew; Fischer, Michael J.; Go, Alan S.; Townsend, Raymond R.; He, Jiang; Kusek, John W.; Feldman, Harold I.; Foulkes, Andrea S.; Reilly, Muredach P.

2015-01-01

Background Cardiometabolic disease is a major cause of morbidity and mortality in persons with chronic kidney disease (CKD). Fractalkine (CX3CL1) is a potential mediator of both atherosclerosis and metabolic disease. Studies on the relationship of CX3CL1 with risk of CVD events and metabolic traits are lacking, particularly in the high-risk setting of CKD. Study Design Cross-sectional and longitudinal observational analysis. Setting & Participants Adults with CKD from 7 US sites participating in the Chronic Renal Insufficiency Cohort (CRIC) Study. Predictor Quartiles of plasma CX3CL1 levels at baseline. Outcomes Baseline estimated glomerular filtration rate (eGFR) from a creatinine- and cystatin C–based equation, prevalent and incident CVD, diabetes, metabolic syndrome and its criteria, homeostatic model assessment of insulin resistance, hemoglobin A1C, myocardial infarction, all-cause mortality, and the composite outcome of myocardial infarction/all-cause mortality. Results Among 3687 participants, baseline CX3CL1 levels were positively associated with several CVD risk factors and metabolic traits, lower eGFR, and higher levels of inflammatory cytokines as well as prevalent CVD (OR, 1.09; 95% CI, 1.01–1.19; p=0.03). Higher CX3CL1 was also associated with prevalent diabetes (OR, 1.26; 95% CI, 1.16–1.38; p<0.001) in adjusted models. During a mean follow up of 6 years, there were 352 deaths, 176 myocardial infarctions, and 484 with composite outcomes. In fully-adjusted models, 1-SD higher CX3CL1 increased the hazard for all-cause mortality (1.11; 95% CI, 1.00–1.22; p=0.02) and the composite outcome (1.09; 95% CI, 1.00–1.19; p=0.04). Limitations Study design did not allow evaluation of changes over time, correlation with progression of phenotypes, or determination of causality of effect. Conclusions Circulating CX3CL1 may contribute to both atherosclerotic CVD and diabetes in a CKD cohort. Further studies are required to establish mechanisms through which CX3CL1 affects pathogenesis of atherosclerosis and diabetes. PMID:25795074

Vegetarian Dietary Patterns and Mortality in Adventist Health Study 2

PubMed Central

Orlich, Michael J.; Singh, Pramil N; Sabaté, Joan; Jaceldo-Siegl, Karen; Fan, Jing; Knutsen, Synnove; Beeson, W. Lawrence; Fraser, Gary E.

2014-01-01

Importance Some evidence suggests vegetarian dietary patterns may be associated with reduced mortality, but the relationship is not well established. Objective To evaluate the association between vegetarian dietary patterns and mortality. Design Prospective cohort study; mortality analysis by Cox proportional hazards regression, controlling for important demographic and lifestyle confounders. Setting Adventist Health Study 2 (AHS-2), a large North American cohort. Participants A total of 96 469 Seventh-day Adventist men and women recruited between 2002 and 2007, from which an analytic sample of 73 308 participants remained after exclusions. Exposures Diet was assessed at baseline by a quantitative food frequency questionnaire and categorized into 5 dietary patterns: nonvegetarian, semi-vegetarian, pesco-vegetarian, lacto-ovo–vegetarian, and vegan. Main Outcome and Measure The relationship between vegetarian dietary patterns and all-cause and cause-specific mortality; deaths through 2009 were identified from the National Death Index. Results There were 2570 deaths among 73 308 participants during a mean follow-up time of 5.79 years. The mortality rate was 6.05 (95% CI, 5.82–6.29) deaths per 1000 person-years. The adjusted hazard ratio (HR) for all-cause mortality in all vegetarians combined vs non-vegetarians was 0.88 (95% CI, 0.80–0.97). The adjusted HR for all-cause mortality in vegans was 0.85 (95% CI, 0.73–1.01); in lacto-ovo–vegetarians, 0.91 (95% CI, 0.82–1.00); in pesco-vegetarians, 0.81 (95% CI, 0.69–0.94); and in semi-vegetarians, 0.92 (95% CI, 0.75–1.13) compared with nonvegetarians. Significant associations with vegetarian diets were detected for cardiovascular mortality, noncardiovascular noncancer mortality, renal mortality, and endocrine mortality. Associations in men were larger and more often significant than were those in women. Conclusions and Relevance Vegetarian diets are associated with lower all-cause mortality and with some reductions in cause-specific mortality. Results appeared to be more robust in males. These favorable associations should be considered carefully by those offering dietary guidance. PMID:23836264

Adult non-communicable disease mortality in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System sites

PubMed Central

Streatfield, P. Kim; Khan, Wasif A.; Bhuiya, Abbas; Hanifi, Syed M.A.; Alam, Nurul; Bagagnan, Cheik H.; Sié, Ali; Zabré, Pascal; Lankoandé, Bruno; Rossier, Clementine; Soura, Abdramane B.; Bonfoh, Bassirou; Kone, Siaka; Ngoran, Eliezer K.; Utzinger, Juerg; Haile, Fisaha; Melaku, Yohannes A.; Weldearegawi, Berhe; Gomez, Pierre; Jasseh, Momodou; Ansah, Patrick; Debpuur, Cornelius; Oduro, Abraham; Wak, George; Adjei, Alexander; Gyapong, Margaret; Sarpong, Doris; Kant, Shashi; Misra, Puneet; Rai, Sanjay K.; Juvekar, Sanjay; Lele, Pallavi; Bauni, Evasius; Mochamah, George; Ndila, Carolyne; Williams, Thomas N.; Laserson, Kayla F.; Nyaguara, Amek; Odhiambo, Frank O.; Phillips-Howard, Penelope; Ezeh, Alex; Kyobutungi, Catherine; Oti, Samuel; Crampin, Amelia; Nyirenda, Moffat; Price, Alison; Delaunay, Valérie; Diallo, Aldiouma; Douillot, Laetitia; Sokhna, Cheikh; Gómez-Olivé, F. Xavier; Kahn, Kathleen; Tollman, Stephen M.; Herbst, Kobus; Mossong, Joël; Chuc, Nguyen T.K.; Bangha, Martin; Sankoh, Osman A.; Byass, Peter

2014-01-01

Background Mortality from non-communicable diseases (NCDs) is a major global issue, as other categories of mortality have diminished and life expectancy has increased. The World Health Organization's Member States have called for a 25% reduction in premature NCD mortality by 2025, which can only be achieved by substantial reductions in risk factors and improvements in the management of chronic conditions. A high burden of NCD mortality among much older people, who have survived other hazards, is inevitable. The INDEPTH Network collects detailed individual data within defined Health and Demographic Surveillance sites. By registering deaths and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available. Objective To describe patterns of adult NCD mortality from INDEPTH Network sites across Africa and Asia, according to the WHO 2012 verbal autopsy (VA) cause categories, with separate consideration of premature (15–64 years) and older (65+ years) NCD mortality. Design All adult deaths at INDEPTH sites are routinely registered and followed up with VA interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provide person-time denominators for mortality rates. Results A total of 80,726 adult (over 15 years) deaths were documented over 7,423,497 person-years of observation. NCDs were attributed as the cause for 35.6% of these deaths. Slightly less than half of adult NCD deaths occurred in the 15–64 age group. Detailed results are presented by age and sex for leading causes of NCD mortality. Per-site rates of NCD mortality were significantly correlated with rates of HIV/AIDS-related mortality. Conclusions These findings present important evidence on the distribution of NCD mortality across a wide range of African and Asian settings. This comes against a background of global concern about the burden of NCD mortality, especially among adults aged under 70, and provides an important baseline for future work. PMID:25377326

Positive and negative volume-outcome relationships in the geriatric trauma population.

PubMed

Matsushima, Kazuhide; Schaefer, Eric W; Won, Eugene J; Armen, Scott B; Indeck, Matthew C; Soybel, David I

2014-04-01

In trauma populations, improvements in outcome are documented in institutions with higher case volumes. However, it is not known whether improved outcomes are attributable to the case volume within specific higher-risk groups, such as the elderly, or to the case volume among all trauma patients treated by an institution. To test the hypothesis that outcomes of trauma care for geriatric patients are affected differently by the volume of geriatric cases and nongeriatric cases of an institution. This retrospective cohort study using a statewide trauma registry was set in state-designated levels 1 and 2 trauma centers in Pennsylvania. It included 39 431 eligible geriatric trauma patients (aged >65 years) in the Pennsylvania Trauma Outcomes Study. In-hospital mortality, major complications, and mortality after major complications (failure to rescue). Between 2001 and 2010, 39 431 geriatric trauma patients and 105 046 nongeriatric patients were captured in a review of outcomes in 20 state-designated levels 1 and 2 trauma centers. Larger volumes of geriatric trauma patients were significantly associated with lower odds of in-hospital mortality, major complications, and failure to rescue. In contrast, larger nongeriatric trauma volumes were significantly associated with higher odds of major complications in geriatric patients. Higher rates of in-hospital mortality, major complications, and failure to rescue were associated with lower volumes of geriatric trauma care and paradoxically with higher volumes of trauma care for younger patients. These findings offer the possibility that outcomes might be improved with differentiated pathways of care for geriatric trauma patients.

Impact of multisectoral health determinants on child mortality 1980-2010: An analysis by country baseline mortality.

PubMed

Cohen, Robert L; Murray, John; Jack, Susan; Arscott-Mills, Sharon; Verardi, Vincenzo

2017-01-01

Some health determinants require relatively stronger health system capacity and socioeconomic development than others to impact child mortality. Few quantitative analyses have analyzed how the impact of health determinants varies by mortality level. 149 low- and middle-income countries were stratified into high, moderate, low, and very low baseline levels of child mortality in 1990. Data for 52 health determinants were collected for these countries for 1980-2010. To quantify how changes in health determinants were associated with mortality decline, univariable and multivariable regression models were constructed. An advanced statistical technique that is new for child mortality analyses-MM-estimation with first differences and country clustering-controlled for outliers, fixed effects, and variation across decades. Some health determinants (immunizations, education) were consistently associated with child mortality reduction across all mortality levels. Others (staff availability, skilled birth attendance, fertility, water and sanitation) were associated with child mortality reduction mainly in low or very low mortality settings. The findings indicate that the impact of some health determinants on child mortality was only apparent with stronger health systems, public infrastructure and levels of socioeconomic development, whereas the impact of other determinants was apparent at all stages of development. Multisectoral progress was essential to mortality reduction at all baseline mortality levels. Policy-makers can use such analyses to direct investments in health and non-health sectors and to set five-year child mortality targets appropriate for their baseline mortality levels and local context.

Pediatric trauma BIG score: predicting mortality in children after military and civilian trauma.

PubMed

Borgman, Matthew A; Maegele, Marc; Wade, Charles E; Blackbourne, Lorne H; Spinella, Philip C

2011-04-01

To develop a validated mortality prediction score for children with traumatic injuries. We identified all children (<18 years of age) in the US military established Joint Theater Trauma Registry from 2002 to 2009 who were admitted to combat-support hospitals with traumatic injuries in Iraq and Afghanistan. We identified factors associated with mortality using univariate and then multivariate regression modeling. The developed mortality prediction score was then validated on a data set of pediatric patients (≤ 18 years of age) from the German Trauma Registry, 2002-2007. Admission base deficit, international normalized ratio, and Glasgow Coma Scale were independently associated with mortality in 707 patients from the derivation set and 1101 patients in the validation set. These variables were combined into the pediatric "BIG" score (base deficit + [2.5 × international normalized ratio] + [15 - Glasgow Coma Scale), which were each calculated to have an area under the curve of 0.89 (95% confidence interval: 0.83-0.95) and 0.89 (95% confidence interval: 0.87-0.92) on the derivation and validation sets, respectively. The pediatric trauma BIG score is a simple method that can be performed rapidly on admission to evaluate severity of illness and predict mortality in children with traumatic injuries. The score has been shown to be accurate in both penetrating-injury and blunt-injury populations and may have significant utility in comparing severity of injury in future pediatric trauma research and quality-assurance studies. In addition, this score may be used to determine inclusion criteria on admission for prospective studies when accurately estimating the mortality for sample size calculation is required.

Childhood mortality after a high dose of vitamin A in a high risk population.

PubMed Central

Daulaire, N. M.; Starbuck, E. S.; Houston, R. M.; Church, M. S.; Stukel, T. A.; Pandey, M. R.

1992-01-01

OBJECTIVES--To determine whether a single high dose of vitamin A given to all children in communities with high mortality and malnutrition could affect mortality and to assess whether periodic community wide supplementation could be readily incorporated into an ongoing primary health programme. DESIGN--Opportunistic controlled trial. SETTING--Jumla district, Nepal. SUBJECTS--All children aged under 5 years; 3786 in eight subdistricts given single dose of vitamin A and 3411 in remaining eight subdistricts given no supplementation. MAIN OUTCOME MEASURES--Mortality and cause of death in the five months after supplementation. RESULTS--Risk of death for children aged 1-59 months in supplemented communities was 26% lower (relative risk 0.74, 95% confidence interval 0.55 to 0.99) than in unsupplemented communities. The reduction in mortality was greatest among children aged 6-11 months: death rate (deaths/1000 child years at risk) was 133.8 in supplemented children and 260.8 in unsupplemented children (relative risk 0.51, 0.30 to 0.89). The death rate from diarrhoea was also reduced (63.5 supplemented v 97.5 unsupplemented; relative risk 0.65, 0.44 to 0.95). The extra cost per death averted was about $11. CONCLUSION--The results support a role for Vitamin A in increasing child survival. The supplementation programme was readily integrated with the ongoing community health programme at little extra cost. PMID:1739794

A statin a day keeps the doctor away: comparative proverb assessment modelling study

PubMed Central

Mizdrak, Anja; Scarborough, Peter

2013-01-01

Objective To model the effect on UK vascular mortality of all adults over 50 years old being prescribed either a statin or an apple a day. Design Comparative proverb assessment modelling study. Setting United Kingdom. Population Adults aged over 50 years. Intervention Either a statin a day for people not already taking a statin or an apple a day for everyone, assuming 70% compliance and no change in calorie consumption. The modelling used routinely available UK population datasets; parameters describing the relations between statins, apples, and health were derived from meta-analyses. Main outcome measure Mortality due to vascular disease. Results The estimated annual reduction in deaths from vascular disease of a statin a day, assuming 70% compliance and a reduction in vascular mortality of 12% (95% confidence interval 9% to 16%) per 1.0 mmol/L reduction in low density lipoprotein cholesterol, is 9400 (7000 to 12 500). The equivalent reduction from an apple a day, modelled using the PRIME model (assuming an apple weighs 100 g and that overall calorie consumption remains constant) is 8500 (95% credible interval 6200 to 10 800). Conclusions Both nutritional and pharmaceutical approaches to the prevention of vascular disease may have the potential to reduce UK mortality significantly. With similar reductions in mortality, a 150 year old health promotion message is able to match modern medicine and is likely to have fewer side effects.

Electrofishing for crappies: Electrical settings influence immobilization efficiency, injury, and mortality

USGS Publications Warehouse

Dolan, C.R.; Miranda, L.E.; Henry, T.B.

2002-01-01

Continuous direct current (DC) and pulsed DC (PDC) of varying frequency and pulse period are commonly used to immobilize and collect crappies Pomoxis spp. in freshwater. However, little information is available about the minimum electrical-setting thresholds required for immobilization or how the settings relate to incidence of injury. We investigated the effect of increasing power densities on the immobilization and injury of black crappies P. nigromaculatus (average total length = 154 mm) treated with DC and various PDC settings. Forced swimming toward the electrodes was observed in black crappies exposed to DC, but that was less apparent for PDC. The minimum peak power densities required to immobilize black crappies ranged from 0.10 to 6.5 mW/cm3 and depended on pulse frequency and period. The incidence of hemorrhaging ranged from 0% to 50% and that of spinal damage from 9% to 45%. However, the severity of injury also depended on pulse frequency and period. No fish suffered mortality at or below the immobilization thresholds, but mortality ranged from 0% to 15% at settings above the thresholds. Mortality was observed with PDC settings of 15 Hz only. Fish that were tetanized following electrical treatment were more prone to injury than those that exhibited narcosis.

[Estimation of the excess of lung cancer mortality risk associated to environmental tobacco smoke exposure of hospitality workers].

PubMed

López, M José; Nebot, Manel; Juárez, Olga; Ariza, Carles; Salles, Joan; Serrahima, Eulàlia

2006-01-14

To estimate the excess lung cancer mortality risk associated with environmental tobacco (ETS) smoke exposure among hospitality workers. The estimation was done using objective measures in several hospitality settings in Barcelona. Vapour phase nicotine was measured in several hospitality settings. These measurements were used to estimate the excess lung cancer mortality risk associated with ETS exposure for a 40 year working life, using the formula developed by Repace and Lowrey. Excess lung cancer mortality risk associated with ETS exposure was higher than 145 deaths per 100,000 workers in all places studied, except for cafeterias in hospitals, where excess lung cancer mortality risk was 22 per 100,000. In discoteques, for comparison, excess lung cancer mortality risk is 1,733 deaths per 100,000 workers. Hospitality workers are exposed to ETS levels related to a very high excess lung cancer mortality risk. These data confirm that ETS control measures are needed to protect hospital workers.

Values in breast cancer screening: an empirical study with Australian experts

PubMed Central

Parker, Lisa; Rychetnik, Lucie; Carter, Stacy

2015-01-01

Objective To explore what Australian experts value in breast screening, how these values are conceptualised and prioritised, and how they inform experts’ reasoning and judgement about the Australian breast-screening programme. Design Qualitative study based on interviews with experts. Participants 33 experts, including clinicians, programme managers, policymakers, advocates and researchers selected for their recognisable influence in the Australian breast-screening setting. Setting Australian breast-screening policy, practice and research settings. Results Experts expressed 2 types of values: ethical values (about what was good, important or right) and epistemological values (about how evidence should be created and used). Ethical values included delivering benefit, avoiding harm, promoting autonomy, fairness, cost effectiveness, accountability, professionalism and transparency. Epistemological values informed experts’ arguments about prioritising and evaluating evidence methodology, source population and professional interests. Some values were conceptualised differently by experts: for example, delivering benefit could mean reducing breast cancer mortality, reducing all-cause mortality, reducing mortality in younger women, reducing need for aggressive treatment, and/or reassuring women they were cancer free. When values came into conflict, experts prioritised them differently: for example, when experts perceived a conflict between delivering benefits and promoting autonomy, there were differences in which value was prioritised. We explain the complexity of the relationship between held values and experts’ overall views on breast cancer screening. Conclusions Experts’ positions in breast screening are influenced by evidence and a wide range of ethical and epistemological values. We conclude that discussions about values should be a regular part of breast-screening review in order to build understanding between those who hold different positions, and provide a mechanism for responding to these differences. PMID:25995235

Clinical risk factors for death after release from prison in Washington State: A nested case control study

PubMed Central

Binswanger, Ingrid A.; Stern, Marc F.; Yamashita, Traci E.; Mueller, Shane R.; Baggett, Travis P.; Blatchford, Patrick J.

2015-01-01

Background and aims While mortality rates after prison release are high, little is known about clinical risk factors for death. We sought to identify risk and protective factors for all-cause and accidental poisoning (overdose) death. Design Nested case control study of people released from prison. Setting Washington State Department of Corrections, Washington, USA. Participants Cases (699 all-cause deaths, of which 88 were among women, and 206 additional overdose deaths, of which 76 were among women) between 1999 and 2009 matched 1:1 to controls on sex, age and year of release using risk set sampling. Measurements Prison medical charts were abstracted for clinical information. Independent associations between clinical characteristics and all-cause and overdose mortality were assessed using conditional logistic regression. Findings Key independent risk factors for all-cause mortality included homelessness (Odds Ratio [OR] 1.53, 95% Confidence Interval [CI] 1.06, 2.23), injection drug use (OR 1.54, 95% CI 1.15, 2.05), tobacco use (OR 1.50, 95% CI 1.06, 2.12), cirrhosis (OR 4.42, 95% CI 1.63, 11.98), and psychiatric medications before release (OR 2.37, 95% CI 1.71, 3.29). Independent risk factors for overdose mortality included substance dependence (OR 2.33, 95% CI 1.32, 4.11), injection drug use (OR 2.43, 95% CI 1.53, 3.86), panic disorder (OR 3.87, 95% CI 1.62, 9.21), psychiatric prescriptions before release (OR 2.44, 95% CI 1.55, 3.85), and problems with opiates/sedatives (OR 2.81, 95% CI 1.40, 5.63). Substance use disorder treatment during the index incarceration was protective for all-cause (OR 0.67, 95% CI 0.49, 0.91) and overdose (OR 0.57, 95% CI 0.35, 0.90) mortality. Conclusions Injection drug use and substance use disorders are risk factors for death after release from prison. In-prison substance use treatment services may reduce the risk. PMID:26476210

Onset seasons and clinical outcomes in patients with Stanford type A acute aortic dissection: an observational retrospective study

PubMed Central

Chen, Zhaoran; Huang, Bi; Yang, Yanmin; Hui, Rutai; Lu, Haisong; Zhao, Zhenhua; Lu, Zhinan; Zhang, Shu; Fan, Xiaohan

2017-01-01

Objectives To evaluate the association of onset season with clinical outcome in type A acute aortic dissection (AAD). Design A single-centre, observational retrospective study. Setting The study was conducted in Fuwai Hospital, the National Centre for Cardiovascular Disease, Beijing, China. Participants From 2008 to 2010, a set of consecutive patients with type A AAD, confirmed by CT scanning, were enrolled and divided into four groups according to onset season: winter (December, January and February), spring (March, April and May), summer (June, July and August) and autumn (September, October and November). The primary end points were in-hospital death and all-cause mortality during follow-up. Results Of the 492 cases in this study, 129 occurred in winter (26.2%), 147 in spring (29.9%), 92 in summer (18.7%), and 124 in autumn (25.2%). After a median follow-up of 20.4 months (IQR 9.7–38.9), the in-hospital mortality in cases occurring in autumn was higher than in the other three seasons (23.4% vs 8.4%, p<0.01). Long-term mortality was comparable among the four seasonal groups (p=0.63). After adjustment for age, gender and other risk factors, onset in autumn was still an independent factor associated with increased risk of in-hospital mortality (HR 2.05; 95% CI 1.15 to 3.64, p=0.02) in addition to surgical treatment. Further analysis showed that the seasonal effect on in-hospital mortality (autumn vs other seasons: 57.4% vs 27.3%, p<0.01) was only significant in patients who did not receive surgical treatment. No seasonal effect on long-term clinical outcomes was found in this cohort. Conclusions Onset in autumn may be a factor that increases the risk of in-hospital death from type A AAD, especially in patients who receive conservative treatment. Immediate surgery improves the short-term and long-term outcomes regardless of onset season. PMID:28242769

Obstetric hemorrhage and shock management: using the low technology Non-pneumatic Anti-Shock Garment in Nigerian and Egyptian tertiary care facilities.

PubMed

Miller, Suellen; Fathalla, Mohamed M F; Ojengbede, Oladosu A; Camlin, Carol; Mourad-Youssif, Mohammed; Morhason-Bello, Imran O; Galadanci, Hadiza; Nsima, David; Butrick, Elizabeth; Al Hussaini, Tarek; Turan, Janet; Meyer, Carinne; Martin, Hilarie; Mohammed, Aminu I

2010-10-18

Obstetric hemorrhage is the leading cause of maternal mortality globally. The Non-pneumatic Anti-Shock Garment (NASG) is a low-technology, first-aid compression device which, when added to standard hypovolemic shock protocols, may improve outcomes for women with hypovolemic shock secondary to obstetric hemorrhage in tertiary facilities in low-resource settings. This study employed a pre-intervention/intervention design in four facilities in Nigeria and two in Egypt. Primary outcomes were measured mean and median blood loss, severe end-organ failure morbidity (renal failure, pulmonary failure, cardiac failure, or CNS dysfunctions), mortality, and emergency hysterectomy for 1442 women with ≥750 mL blood loss and at least one sign of hemodynamic instability. Comparisons of outcomes by study phase were assessed with rank sum tests, relative risks (RR), number needed to treat for benefit (NNTb), and multiple logistic regression. Women in the NASG phase (n = 835) were in worse condition on study entry, 38.5% with mean arterial pressure <60 mmHg vs. 29.9% in the pre-intervention phase (p = 0.001). Despite this, negative outcomes were significantly reduced in the NASG phase: mean measured blood loss decreased from 444 mL to 240 mL (p < 0.001), maternal mortality decreased from 6.3% to 3.5% (RR 0.56, 95% CI 0.35-0.89), severe morbidities from 3.7% to 0.7% (RR 0.20, 95% CI 0.08-0.50), and emergency hysterectomy from 8.9% to 4.0% (RR 0.44, 0.23-0.86). In multiple logistic regression, there was a 55% reduced odds of mortality during the NASG phase (aOR 0.45, 0.27-0.77). The NNTb to prevent either mortality or severe morbidity was 18 (12-36). Adding the NASG to standard shock and hemorrhage management may significantly improve maternal outcomes from hypovolemic shock secondary to obstetric hemorrhage at tertiary care facilities in low-resource settings.

Baseline renal insufficiency and risk of death among HIV-infected adults on antiretroviral therapy in Lusaka, Zambia

PubMed Central

Mulenga, Lloyd B.; Kruse, Gina; Lakhi, Shabir; Cantrell, Ronald A.; Reid, Stewart E.; Zulu, Isaac; Stringer, Elizabeth M.; Krishnasami, Zipporah; Mwinga, Alwyn; Saag, Michael S.; Stringer, Jeffrey S. A.; Chi, Benjamin H.

2009-01-01

Objective To examine the association between baseline renal insufficiency and mortality among adults initiating antiretroviral therapy (ART) in urban African setting. Design Open cohort evaluation Methods We examined mortality according to baseline renal function among adults initiating ART in Lusaka, Zambia. Renal function was assessed by the Cockcroft-Gault method, the Modification of Diet in Renal Disease (MDRD) equation, and serum creatinine. Results From April 2004 to September 2007, 25,779 individuals started ART with an available creatinine measurement at baseline. When creatinine clearance was calculated by the Cockcroft-Gault method, 8,456 (33.5%) had renal insufficiency: 73.5% were mild (60-89 mL/min), 23.4% moderate (30-59 mL/min), and 3.1% severe (<30 mL/min). Risk for mortality at or before 90 days was elevated for those with mildly (adjusted hazard ratio [AHR]=1.7; 95%CI=1.5-1.9), moderately (AHR=2.3; 95%CI=2.0-2.7), and severely (AHR=4.1; 95%CI=3.1-5.5) reduced creatinine clearance. Mild (AHR=1.4; 95%CI=1.2-1.6), moderate (AHR=1.9; 95%CI=1.5-2.3), and severe (AHR=3.6; 95%CI=2.4-5.5) insufficiency were also associated with increased mortality after 90 days, when compared to those with normal renal function. Trends were similar when renal function was estimated with MDRD or serum creatinine. Conclusions Renal insufficiency at time of ART initiation was prevalent and associated with increased mortality risk among adults in this population. These results have particular relevance for settings like Zambia, where tenofovir - a drug with known nephrotoxicity - has been adopted as part of first-line therapy. This emphasizes the need for resource-appropriate screening algorithms for renal disease, both as part of ART eligibility and pre-treatment assessment. PMID:18753939

Variation in the magnitude of black-white differences in stroke mortality by community occupational structure.

PubMed Central

Casper, M; Wing, S; Strogatz, D

1991-01-01

STUDY OBJECTIVE--The aim was to examine the patterns of black-white differences in stroke mortality across communities with varying levels of occupational structure in the southern region of the United States DESIGN--Annual age adjusted race-sex specific rates for stroke mortality were calculated for the years 1979-1981 and related to socioeconomic conditions. SETTING--The study involved 211 state economic areas comprising the southern region of the USA. STUDY POPULATION--Data on stroke mortality for black and white men and women between the ages of 35 and 74 years living in the study area were acquired from the National Center for Health Statistics. MEASUREMENTS AND MAIN RESULTS--Occupational structure was measured as the proportion of white collar workers in each state economic area, and is an indicator of the employment opportunities and related social and economic resources of a community. Stratified analyses and linear regression modelling indicate that communities of lower occupational structure have (a) higher levels of stroke mortality for all four race-sex groups (p less than 0.05) and (b) larger racial inequalities in stroke mortality (p less than 0.01). For men and women, the excess stroke mortality among blacks compared to whites is larger in communities of lower occupational structure. CONCLUSIONS--Consideration of occupational structure and related patterns of economic development is crucial for understanding the distribution of stroke mortality within and between racial groups, as well as for planning effective public health interventions. The larger racial inequalities in communities of lower occupational structure in the south suggest that aspects of the black experience which are conducive to high rates of stroke mortality are exacerbated in those communities. Public health interventions to reduce the racial and social inequalities in stroke mortality should recognise the social context within which nutritional, occupational, medical care, and environmental determinants of stroke are distributed. PMID:1795152

Reconciling the effects of screening on prostate cancer mortality in the ERSPC and PLCO trials

PubMed Central

Tsodikov, Alex; Gulati, Roman; Heijnsdijk, Eveline AM; Pinsky, Paul F; Moss, Sue M; Qiu, Sheng; de Carvalho, Tiago M; Hugosson, Jonas; Berg, Christine D; Auvinen, Anssi; Andriole, Gerald L; Roobol, Monique J; Crawford, E David; Nelen, Vera; Kwiatkowski, Maciej; Zappa, Marco; Luján, Marcos; Villers, Arnauld; Feuer, Eric J; de Koning, Harry J; Mariotto, Angela B; Etzioni, Ruth

2017-01-01

Background The European Randomized Study of Screening for Prostate Cancer (ERSPC) found screening reduced prostate cancer (PC) mortality, but the Prostate, Lung, Colorectal, and Ovarian trial (PLCO) found no reduction. Objective To evaluate whether effects of screening on PC mortality relative to no screening differed between the ERSPC and PLCO. Design Cox regression of PC death in each trial arm adjusted for age and trial, and extended analyses that accounted for increased incidence due to screening and diagnostic workup on each arm via mean lead times (MLTs). MLTs were estimated empirically and using analytic or microsimulation models. Setting Randomized controlled trials in Europe and the US. Participants Men aged 55–69 (ERSPC) or 55–74 (PLCO) at randomization. Intervention Prostate cancer screening. Measurements PC incidence and survival from randomization; PC incidence in the US before screening began. Results Estimated MLTs were similar in the ERSPC and PLCO intervention arms but were longer in the PLCO control arm than the ERSPC control arm. Extended analyses found no evidence that effects of screening differed between trials (P=0.37–0.47, range across MLT estimation approaches) but strong evidence that benefit increased with MLT (P=0.0027–0.0032). Screening was estimated to confer a 7–9% reduction in PC death per year of MLT. This translated into an estimated 25–31% and 27–32% lower risk of PC death under screening as performed in the ERSPC and PLCO intervention arms, respectively, relative to no screening. Limitations MLT is a simple metric of screening and diagnostic workup. Conclusion After accounting for differences in implementation and settings, the ERSPC and PLCO provide compatible evidence that screening reduces PC mortality. PMID:28869989

Race versus place of service in mortality among medicare beneficiaries with cancer.

PubMed

Onega, Tracy; Duell, Eric J; Shi, Xun; Demidenko, Eugene; Goodman, David C

2010-06-01

Evidence suggests that excess mortality among African-American cancer patients is explained in part by the healthcare setting. The objective of this study was to compare mortality among African-American and Caucasian cancer patients and to evaluate the influence of attendance at a National Cancer Institute (NCI)-designated comprehensive or clinical cancer center. The authors conducted a retrospective cohort analysis of Medicare beneficiaries with an incident diagnosis of lung, breast, colorectal, or prostate cancer between 1998 and 2002 who were identified from Surveillance, Epidemiology, and End Results data. Multivariate logistic regression models were used to assess the impact of NCI cancer center attendance and race on all-cause and cancer-specific mortality at 1 year and 3 years after diagnosis. The likelihood of 1-year and 3-year all-cause and cancer-specific mortality was higher for African Americans than for Caucasians in crude and adjusted models (cancer-specific adjusted: Caucasian referent, 1-year odds ratio [OR], 1.13; 95% confidence interval [CI], 1.07-1.19; 3-year OR, 1.23; 95% CI, 1.17-1.30). By cancer site, cancer-specific mortality was higher among African Americans at 1 year for breast and colorectal cancers and for all cancers at 3 years. NCI cancer center attendance was associated with significantly lower odds of mortality for African Americans (1-year OR, 0.63; 95% CI, 0.56-0.76; 3-year OR, 0.71; 95% CI, 0.62-0.81). With Caucasians as the referent group, the excess mortality risk among African Americans no longer was observed for all-cause or cancer-specific mortality risk among patients who attended NCI cancer centers (cancer-specific mortality:1-year OR, 0.95; 95% CI, 0.76-1.19; 3-year OR, 1.00; 95% CI, 0.82-1.21). African-American Medicare beneficiaries with lung, breast, colorectal, and prostate cancers had higher mortality compared with their Caucasian counterparts; however, there were no significant differences in mortality by race among those who attended NCI cancer centers. The results of this study suggested that place of service may explain some of the cancer mortality excess observed in African Americans. (c) 2010 American Cancer Society.

Using human rights in maternal mortality programs: from analysis to strategy.

PubMed

Freedman, L P

2001-10-01

This article describes an approach to maternal mortality reduction that uses human rights not simply to denounce the injustice of death in pregnancy and childbirth, but also to guide the design and implementation of maternal mortality policies and programs. As a first principle, programs and policies need to prioritize measures that promote universal access to high quality emergency obstetric care services, which we know from health research are essential to saving women's lives. With that priority, human rights principles can be integrated into programs at the clinical, facility management, and national policy levels. For example, a human rights 'audit' can help identify ways to encourage respectful, non-discriminatory treatment of patients, providers and staff in the clinical setting. Human rights principles of entitlement and accountability can inform mechanisms of community participation designed to improve responsiveness and functioning of health facilities. Human rights principles can inform analysis of health sector reform and its impact on access to emergency obstetric care. Whether applied to the intricacies of human relationships within a facility or to the impact of international financial institutions on health systems, the ultimate role of human rights is to identify the workings of power that keep unacceptable levels of maternal morality as they are and to use the human rights vision of dignity and social justice to work for the re-arrangements of power necessary for change.

AIDS-related and non-AIDS-related mortality in the Asia-Pacific region in the era of combination antiretroviral treatment.

PubMed

Falster, Kathleen; Choi, Jun Yong; Donovan, Basil; Duncombe, Chris; Mulhall, Brian; Sowden, David; Zhou, Jialun; Law, Matthew G

2009-11-13

Although studies have shown reductions in mortality from AIDS after the introduction of combination antiretroviral treatment (cART), little is known about cause-specific mortality in low-income settings in the cART era. We explored predictors of AIDS and non-AIDS mortality and compared cause-specific mortality across high-income and low-income settings in the Asia-Pacific region. We followed patients in the Asia Pacific HIV Observational Database from the date they started cART (or cohort enrolment if cART initiation was identified retrospectively), until the date of death or last follow-up visit. Competing risks methods were used to estimate the cumulative incidence, and to investigate predictors, of AIDS and non-AIDS mortality. Of 4252 patients, 215 died; 89 from AIDS, 97 from non-AIDS causes and 29 from unknown causes. Age more than 50 years [hazard ratio 4.29; 95% confidence interval (CI) 2.10-8.79] and CD4 cell counts less than or equal to 100 cells/microl (hazard ratio 8.59; 95% CI 5.66-13.03) were associated with an increased risk of non-AIDS mortality. Risk factors for AIDS mortality included CD4 cell counts less than or equal to 100 cells/microl (hazard ratio 34.97; 95% CI 18.01-67.90) and HIV RNA 10 001 or more (hazard ratio 4.21; 95% CI 2.07-8.55). There was some indication of a lower risk of non-AIDS mortality in Asian high-income, and possibly low-income, countries compared to Australia. Immune deficiency is associated with an increased risk of AIDS and non-AIDS mortality. Older age predicts non-AIDS mortality in the cART era. Less conclusive was the association between country-income level and cause-specific mortality because of the relatively high proportion of unknown causes of death in low-income settings.

Aldosterone, mortality, and acute ischaemic events in coronary artery disease patients outside the setting of acute myocardial infarction or heart failure.

PubMed

Ivanes, Fabrice; Susen, Sophie; Mouquet, Frédéric; Pigny, Pascal; Cuilleret, François; Sautière, Karine; Collet, Jean-Philippe; Beygui, Farzin; Hennache, Bernadette; Ennezat, Pierre Vladimir; Juthier, Françis; Richard, Florence; Dallongeville, Jean; Hillaert, Marieke A; Doevendans, Pieter A; Jude, Brigitte; Bertrand, Michel; Montalescot, Gilles; Van Belle, Eric

2012-01-01

Recent studies have demonstrated that aldosterone levels measured in patients with heart failure or acute myocardial infarction (MI) are associated with long-term mortality, but the association with aldosterone levels in patients with coronary artery disease (CAD) outside these specific settings remains unknown. In addition, no clear mechanism has been elucidated to explain these observations. The present study was designed to evaluate the relationship between the level of aldosterone and the risk of death and acute ischaemic events in CAD patients with a preserved left ventricular (LV) function and no acute MI. In 799 consecutive CAD patients referred for elective coronary angioplasty measurements were obtained before the procedure for: aldosterone (median = 25 pg/mL), brain natriuretic peptide (BNP) (median = 35 pg/mL), hsC-reactive protein (median = 4.17 mg/L), and left ventricular ejection fraction (mean = 58%). Patients with acute MI or coronary syndrome (ACS) who required urgent revascularization were not included in the study. The primary endpoint, cardiovascular death, occurred in 41 patients during a median follow-up period of 14.9 months. Secondary endpoints-total mortality, acute ischaemic events (acute MI or ischaemic stroke), and the composite of death and acute ischaemic events-were observed in 52, 54, and 94 patients, respectively. Plasma aldosterone was found to be related to BMI, hypertension and NYHA class, and inversely related to age, creatinine clearance, and use of beta-blockers. Multivariate Cox model analysis demonstrated that aldosterone was independently associated with cardiovascular mortality (P = 0.001), total mortality (P = 0.001), acute ischaemic events (P = 0.01), and the composite of death and acute ischaemic events (P = 0.004). Reclassification analysis, using integrated discrimination improvement (IDI) and net reclassification improvement (NRI), demonstrated incremental predictive value of aldosterone (P < 0.0001). Our results demonstrate that, in patients with CAD but without heart failure or acute MI, the level of aldosterone is strongly and independently associated with mortality and the occurrence of acute ischaemic events.

A new casemix adjustment index for hospital mortality among patients with congestive heart failure.

PubMed

Polanczyk, C A; Rohde, L E; Philbin, E A; Di Salvo, T G

1998-10-01

Comparative analysis of hospital outcomes requires reliable adjustment for casemix. Although congestive heart failure is one of the most common indications for hospitalization, congestive heart failure casemix adjustment has not been widely studied. The purposes of this study were (1) to describe and validate a new congestive heart failure-specific casemix adjustment index to predict in-hospital mortality and (2) to compare its performance to the Charlson comorbidity index. Data from all 4,608 admissions to the Massachusetts General Hospital from January 1990 to July 1996 with a principal ICD-9-CM discharge diagnosis of congestive heart failure were evaluated. Massachusetts General Hospital patients were randomly divided in a derivation and a validation set. By logistic regression, odds ratios for in-hospital death were computed and weights were assigned to construct a new predictive index in the derivation set. The performance of the index was tested in an internal Massachusetts General Hospital validation set and in a non-Massachusetts General Hospital external validation set incorporating data from all 1995 New York state hospital discharges with a primary discharge diagnosis of congestive heart failure. Overall in-hospital mortality was 6.4%. Based on the new index, patients were assigned to six categories with incrementally increasing hospital mortality rates ranging from 0.5% to 31%. By logistic regression, "c" statistics of the congestive heart failure-specific index (0.83 and 0.78, derivation and validation set) were significantly superior to the Charlson index (0.66). Similar incrementally increasing hospital mortality rates were observed in the New York database with the congestive heart failure-specific index ("c" statistics 0.75). In an administrative database, this congestive heart failure-specific index may be a more adequate casemix adjustment tool to predict hospital mortality in patients hospitalized for congestive heart failure.

mPneumonia: Development of an Innovative mHealth Application for Diagnosing and Treating Childhood Pneumonia and Other Childhood Illnesses in Low-Resource Settings

PubMed Central

Ginsburg, Amy Sarah; Delarosa, Jaclyn; Brunette, Waylon; Levari, Shahar; Sundt, Mitch; Larson, Clarice; Tawiah Agyemang, Charlotte; Newton, Sam; Borriello, Gaetano; Anderson, Richard

2015-01-01

Pneumonia is the leading infectious cause of death in children worldwide. Each year, pneumonia kills an estimated 935,000 children under five years of age, with most of these deaths occurring in developing countries. The current approach for pneumonia diagnosis in low-resource settings—using the World Health Organization Integrated Management of Childhood Illness (IMCI) paper-based protocols and relying on a health care provider’s ability to manually count respiratory rate—has proven inadequate. Furthermore, hypoxemia—a diagnostic indicator of the presence and severity of pneumonia often associated with an increased risk of death—is not assessed because pulse oximetry is frequently not available in low-resource settings. In an effort to address childhood pneumonia mortality and improve frontline health care providers’ ability to diagnose, classify, and manage pneumonia and other childhood illnesses, PATH collaborated with the University of Washington to develop “mPneumonia,” an innovative mobile health application using an Android tablet. mPneumonia integrates a digital version of the IMCI algorithm with a software-based breath counter and a pediatric pulse oximeter. We conducted a design-stage usability field test of mPneumonia in Ghana, with the goal of creating a user-friendly diagnostic and management tool for childhood pneumonia and other childhood illnesses that would improve diagnostic accuracy and facilitate adherence by health care providers to established guidelines in low-resource settings. The results of the field test provided valuable information for understanding the usability and acceptability of mPneumonia among health care providers, and identifying approaches to iterate and improve. This critical feedback helped ascertain the common failure modes related to the user interface design, navigation, and accessibility of mPneumonia and the modifications required to improve user experience and create a tool aimed at decreasing mortality from pneumonia and other childhood illnesses in low-resource settings. PMID:26474321

Application of artificial neural networks to establish a predictive mortality risk model in children admitted to a paediatric intensive care unit.

PubMed

Chan, C H; Chan, E Y; Ng, D K; Chow, P Y; Kwok, K L

2006-11-01

Paediatric risk of mortality and paediatric index of mortality (PIM) are the commonly-used mortality prediction models (MPM) in children admitted to paediatric intensive care unit (PICU). The current study was undertaken to develop a better MPM using artificial neural network, a domain of artificial intelligence. The purpose of this retrospective case series was to compare an artificial neural network (ANN) model and PIM with the observed mortality in a cohort of patients admitted to a five-bed PICU in a Hong Kong non-teaching general hospital. The patients were under the age of 17 years and admitted to our PICU from April 2001 to December 2004. Data were collected from each patient admitted to our PICU. All data were randomly allocated to either the training or validation set. The data from the training set were used to construct a series of ANN models. The data from the validation set were used to validate the ANN and PIM models. The accuracy of ANN models and PIM was assessed by area under the receiver operator characteristics (ROC) curve and calibration. All data were randomly allocated to either the training (n=274) or validation set (n=273). Three ANN models were developed using the data from the training set, namely ANN8 (trained with variables required for PIM), ANN9 (trained with variables required for PIM and pre-ICU intubation) and ANN23 (trained with variables required for ANN9 and 14 principal ICU diagnoses). Three ANN models and PIM were used to predict mortality in the validation set. We found that PIM and ANN9 had a high ROC curve (PIM: 0.808, 95 percent confidence interval 0.552 to 1.000, ANN9: 0.957, 95 percent confidence interval 0.915 to 1.000), whereas ANN8 and ANN23 gave a suboptimal area under the ROC curve. ANN8 required only five variables for the calculation of risk, compared with eight for PIM. The current study demonstrated the process of predictive mortality risk model development using ANN. Further multicentre studies are required to produce a representative ANN-based mortality prediction model for use in different PICUs.

Endotoxemia and mortality prediction in ICU and other settings: underlying risk and co-detection of gram negative bacteremia are confounders

PubMed Central

2012-01-01

Introduction The interdependence between endotoxemia, gram negative (GN) bacteremia and mortality has been extensively studied. Underlying patient risk and GN bacteremia types are possible confounders of the relationship. Methods Published studies with ≥10 patients in either ICU or non-ICU settings, endotoxemia detection by limulus assay, reporting mortality proportions and ≥1 GN bacteremia were included. Summary odds ratios (OR) for mortality were derived across all studies by meta-analysis for the following contrasts: sub-groups with either endotoxemia (group three), GN bacteremia (group two) or both (group one) each versus the group with neither detected (group four; reference group). The mortality proportion for group four is the proxy measure of study level risk within L'Abbé plots. Results Thirty-five studies were found. Among nine studies in an ICU setting, the OR for mortality was borderline (OR <2) or non-significantly increased for groups two (GN bacteremia alone) and three (endotoxemia alone) and patient group one (GN bacteremia and endotoxemia co-detected) each versus patient group four (neither endotoxemia nor GN bacteremia detected). The ORs were markedly higher for group one versus group four (OR 6.9; 95% confidence interval (CI), 4.4 -to 11.0 when derived from non-ICU studies. The distributions of Pseudomonas aeruginosa and Escherichia coli bacteremias among groups one versus two are significantly unequal. Conclusions The co-detection of GN bacteremia and endotoxemia is predictive of increased mortality risk versus the detection of neither but only in studies undertaken in a non-ICU setting. Variation in GN bacteremia species types and underlying risk are likely unrecognized confounders in the individual studies. PMID:22871090

The role of the Data and Safety Monitoring Board in a clinical trial: The CRISIS Study

PubMed Central

Holubkov, Richard; Casper, T. Charles; Dean, J. Michael; Anand, K. J. S.; Zimmerman, Jerry; Meert, Kathleen L.; Newth, Christopher J. L.; Berger, John; Harrison, Rick; Willson, Douglas F.; Nicholson, Carol

2012-01-01

Objective Randomized clinical trials are commonly overseen by a data and safety monitoring board (DSMB) comprised of experts in medicine, ethics, and biostatistics. DSMB responsibilities include protocol approval, interim review of study enrollment, protocol compliance, safety, and efficacy data. DSMB decisions can affect study design and conduct, as well as reported findings. Researchers must incorporate DSMB oversight into the design, monitoring, and reporting of randomized trials. Design Case study, narrative review. Methods The DSMB’s role during the comparative pediatric Critical Illness Stress-Induced Immune Suppression (CRISIS) Prevention Trial is described. Findings The NIH-appointed CRISIS DSMB was charged with monitoring sample size adequacy and feasibility, safety with respect to adverse events and 28-day mortality, and efficacy with respect to the primary nosocomial infection/sepsis outcome. The Federal Drug Administration also requested DSMB interim review before opening CRISIS to children below one year of age. The first interim analysis found higher 28-day mortality in one treatment arm. The DSMB maintained trial closure to younger children, and requested a second interim data review six months later. At this second meeting, mortality was no longer of concern, while a weak efficacy trend of lower infection/sepsis rates in one study arm emerged. As over 40% of total patients had been enrolled, the DSMB elected to examine conditional power, and unmask treatment arm identities. Upon finding somewhat greater efficacy in the placebo arm, the DSMB recommended stopping CRISIS due to futility. Conclusions The design and operating procedures of a multicenter randomized trial must consider a pivotal DSMB role. Maximum study design flexibility must be allowed, and investigators must be prepared for protocol modifications due to interim findings. The DSMB must have sufficient clinical and statistical expertise to assess potential importance of interim treatment differences in the setting of multiple looks at accumulating data with numerous outcomes and subgroups. PMID:23392377

Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis.

PubMed

Schuetz, Philipp; Wirz, Yannick; Sager, Ramon; Christ-Crain, Mirjam; Stolz, Daiana; Tamm, Michael; Bouadma, Lila; Luyt, Charles E; Wolff, Michel; Chastre, Jean; Tubach, Florence; Kristoffersen, Kristina B; Burkhardt, Olaf; Welte, Tobias; Schroeder, Stefan; Nobre, Vandack; Wei, Long; Bucher, Heiner C; Annane, Djillali; Reinhart, Konrad; Falsey, Ann R; Branche, Angela; Damas, Pierre; Nijsten, Maarten; de Lange, Dylan W; Deliberato, Rodrigo O; Oliveira, Carolina F; Maravić-Stojković, Vera; Verduri, Alessia; Beghé, Bianca; Cao, Bin; Shehabi, Yahya; Jensen, Jens-Ulrik S; Corti, Caspar; van Oers, Jos A H; Beishuizen, Albertus; Girbes, Armand R J; de Jong, Evelien; Briel, Matthias; Mueller, Beat

2018-01-01

In February, 2017, the US Food and Drug Administration approved the blood infection marker procalcitonin for guiding antibiotic therapy in patients with acute respiratory infections. This meta-analysis of patient data from 26 randomised controlled trials was designed to assess safety of procalcitonin-guided treatment in patients with acute respiratory infections from different clinical settings. Based on a prespecified Cochrane protocol, we did a systematic literature search on the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase, and pooled individual patient data from trials in which patients with respiratory infections were randomly assigned to receive antibiotics based on procalcitonin concentrations (procalcitonin-guided group) or control. The coprimary endpoints were 30-day mortality and setting-specific treatment failure. Secondary endpoints were antibiotic use, length of stay, and antibiotic side-effects. We identified 990 records from the literature search, of which 71 articles were assessed for eligibility after exclusion of 919 records. We collected data on 6708 patients from 26 eligible trials in 12 countries. Mortality at 30 days was significantly lower in procalcitonin-guided patients than in control patients (286 [9%] deaths in 3336 procalcitonin-guided patients vs 336 [10%] in 3372 controls; adjusted odds ratio [OR] 0·83 [95% CI 0·70 to 0·99], p=0·037). This mortality benefit was similar across subgroups by setting and type of infection (p interactions >0·05), although mortality was very low in primary care and in patients with acute bronchitis. Procalcitonin guidance was also associated with a 2·4-day reduction in antibiotic exposure (5·7 vs 8·1 days [95% CI -2·71 to -2·15], p<0·0001) and a reduction in antibiotic-related side-effects (16% vs 22%, adjusted OR 0·68 [95% CI 0·57 to 0·82], p<0·0001). Use of procalcitonin to guide antibiotic treatment in patients with acute respiratory infections reduces antibiotic exposure and side-effects, and improves survival. Widespread implementation of procalcitonin protocols in patients with acute respiratory infections thus has the potential to improve antibiotic management with positive effects on clinical outcomes and on the current threat of increasing antibiotic multiresistance. National Institute for Health Research. Copyright © 2018 Elsevier Ltd. All rights reserved.

Epidemiology and Mortality of Liver Abscess in End-Stage Renal Disease Dialysis Patients: Taiwan National Cohort Study

PubMed Central

Huang, Po-Chang; Wang, Jhi-Joung; Yang, Chun-Ming; Chu, Chin-Chen; Chio, Chung-Ching; Chang, Fu-Lin; Chien, Chih-Chiang

2014-01-01

Background and Objectives To determine the incidence rates and mortality of liver abscess in ESRD patients on dialysis. Design, Setting, Participants, & Measurements Using Taiwan’s National Health Insurance Research Database, we collected data from all ESRD patients who initiated dialysis between 2000 and 2006. Patients were followed until death, end of dialysis, or December 31, 2008. Predictors of liver abscess and mortality were identified using Cox models. Results Of the 53,249 incident dialysis patients identified, 447 were diagnosed as having liver abscesses during the follow-up period (224/100,000 person-years). The cumulative incidence rate of liver abscess was 0.3%, 1.1%, and 1.5% at 1 year, 5 years, and 7 years, respectively. Elderly patients and patients on peritoneal dialysis had higher incidence rates. The baseline comorbidities of diabetes mellitus, polycystic kidney disease, malignancy, chronic liver disease, biliary tract disease, or alcoholism predicted development of liver abscess. Overall in-hospital mortality was 10.1%. Conclusions The incidence of liver abscess is high among ESRD dialysis patients. In addition to the well known risk factors of liver abscess, two other important risk factors, peritoneal dialysis and polycystic kidney disease, were found to predict liver abscess in ESRD dialysis patients. PMID:24551077

Volunteering, Driving Status and Mortality in US Retirees

PubMed Central

Lee, Sei J.; Steinman, Michael A.; Tan, Erwin J.

2011-01-01

OBJECTIVES: Volunteering is associated with lower mortality in the elderly. Driving is associated with health and well-being and driving cessation has been associated with decreased out-of-home activity levels including volunteering. We evaluated how accounting for driving status altered the relationship between volunteering and mortality in US retirees. DESIGN: Observational prospective cohort SETTING and PARTICIPANTS: Nationally representative sample of retirees over age 65 from the Health and Retirement Study in 2000 and 2002, followed to 2006 (n=6408). MEASUREMENTS: Participants self-reported their volunteering, driving status, age, gender and race/ethnicity, presence of chronic conditions, geriatrics syndromes, socioeconomic factors, functional limitations and psychosocial factors. Death by December 31, 2006 was the outcome. RESULTS: For drivers, the mortality rates between volunteers (9%) and non-volunteers (12%) were similar; for limited or non-drivers, the mortality rate for volunteers (15%) was markedly lower compared to non-volunteers (32%). Our adjusted results showed that for drivers, the volunteering-mortality Odds Ratio (OR) was 0.90 (95%CI: 0.66–1.22), whereas for limited or non-drivers, the OR was 0.62 (95%CI: 0.49–0.78), (interaction p=0.05). The impact of driving status was greater for rural participants, with greater differences between rural drivers versus rural limited or non-drivers (interaction p=0.02) compared to urban drivers versus urban limited or non-drivers (interaction p=0.81). CONCLUSION: The influence of volunteering in decreasing mortality seems to be stronger among rural retirees who are limited or non-drivers. This may be because rural or non-driving retirees are more likely to be socially isolated and thus receive more benefit from the increased social integration from volunteering. PMID:21314648

Relation between increased numbers of safe playing areas and decreased vehicle related child mortality rates in Japan from 1970 to 1985: a trend analysis

PubMed Central

Nakahara, S.; Nakamura, Y.; Ichikawa, M.; Wakai, S.

2004-01-01

Objectives: To examine vehicle related mortality trends of children in Japan; and to investigate how environmental modifications such as the installation of public parks and pavements are associated with these trends. Design: Poisson regression was used for trend analysis, and multiple regression modelling was used to investigate the associations between trends in environmental modifications and trends in motor vehicle related child mortality rates. Setting: Mortality data of Japan from 1970 to 1994, defined as E-code 810–23 from 1970 to 1978 and E810–25 from 1979 to 1994, were obtained from vital statistics. Multiple regression modelling was confined to the 1970–1985 data. Data concerning public parks and other facilities were obtained from the Ministry of Land, Infrastructure, and Transport. Subjects: Children aged 0–14 years old were examined in this study and divided into two groups: 0–4 and 5–14 years. Main results: An increased number of public parks was associated with decreased vehicle related mortality rates among children aged 0–4 years, but not among children aged 5–14. In contrast, there was no association between trends in pavements and mortality rates. Conclusions: An increased number of public parks might reduce vehicle related preschooler deaths, in particular those involving pedestrians. Safe play areas in residential areas might reduce the risk of vehicle related child death by lessening the journey both to and from such areas as well as reducing the number of children playing on the street. However, such measures might not be effective in reducing the vehicle related mortalities of school age children who have an expanded range of activities and walk longer distances. PMID:15547055

Mortality in former Olympic athletes: retrospective cohort analysis

PubMed Central

Zwiers, R; Zantvoord, F W A; van Bodegom, D; van der Ouderaa, F J G; Westendorp, R G J

2012-01-01

Objective To assess the mortality risk in subsequent years (adjusted for year of birth, nationality, and sex) of former Olympic athletes from disciplines with different levels of exercise intensity. Design Retrospective cohort study. Setting Former Olympic athletes. Participants 9889 athletes (with a known age at death) who participated in the Olympic Games between 1896 and 1936, representing 43 types of disciplines with different levels of cardiovascular, static, and dynamic intensity exercise; high or low risk of bodily collision; and different levels of physical contact. Main outcome measure All cause mortality. Results Hazard ratios for mortality among athletes from disciplines with moderate cardiovascular intensity (1.01, 95% confidence interval 0.96 to 1.07) or high cardiovascular intensity (0.98, 0.92 to 1.04) were similar to those in athletes from disciplines with low cardiovascular intensity. The underlying static and dynamic components in exercise intensity showed similar non-significant results. Increased mortality was seen among athletes from disciplines with a high risk of bodily collision (hazard ratio 1.11, 1.06 to 1.15) and with high levels of physical contact (1.16, 1.11 to 1.22). In a multivariate analysis, the effect of high cardiovascular intensity remained similar (hazard ratio 1.05, 0.89 to 1.25); the increased mortality associated with high physical contact persisted (hazard ratio 1.13, 1.06 to 1.21), but that for bodily collision became non-significant (1.03, 0.98 to 1.09) as a consequence of its close relation with physical contact. Conclusions Among former Olympic athletes, engagement in disciplines with high intensity exercise did not bring a survival benefit compared with disciplines with low intensity exercise. Those who engaged in disciplines with high levels of physical contact had higher mortality than other Olympians later in life. PMID:23241269

Mortality and causes of death after traumatic spinal cord injury in Estonia

PubMed Central

Sabre, Liis; Rekand, Tiina; Asser, Toomas; Kõrv, Janika

2013-01-01

Study design Retrospective population-based study with mortality follow-up. Objective To study mortality, causes and risk factors for death in Estonian patients with traumatic spinal cord injury (TSCI). Setting All Estonian hospitals. Methods Medical records of patients with TSCI from all regional, central, general, and rehabilitation hospitals in Estonia from 1997 to 2007, were retrospectively reviewed. Mortality status was ascertained as of 31 December 2011. Causes of death were collected from the Estonian Causes of Death Registry. Standardized mortality ratios (SMRs) were calculated for the entire sample and for causes of death. A Cox proportional hazards modeling was used to identify the risk indicators for death. Results During the observation period (1997–2011) 162 patients of 595 died. Nearly half of the patients (n = 76) died during the first year after TSCI. The main causes of death were external causes (30%), cardiovascular disease (29%). and suicide (8%). The overall SMR was 2.81 (95% confidence interval 2.40–3.28) and SMR was higher for women than for men (3.80 vs. 2.70). Cause-specific SMRs were markedly elevated for sepsis and suicide. Mortality was significantly affected by the age at the time of injury, neurological level, and extent of the injury as well as the year of TSCI and complications. Conclusion Life expectancy is significantly decreased in patients with TSCI in Estonia compared with the general population. Deaths during the first year after the injury have an important impact on statistics. Treatment of cardiovascular diseases, infections, and prevention of suicide are useful for reducing mortality in patients with TSCI. PMID:24090049

Protective Effect of Dual-Strain Probiotics in Preterm Infants: A Multi-Center Time Series Analysis

PubMed Central

Schwab, Frank; Garten, Lars; Geffers, Christine; Gastmeier, Petra; Piening, Brar

2016-01-01

Objective To determine the effect of dual-strain probiotics on the development of necrotizing enterocolitis (NEC), mortality and nosocomial bloodstream infections (BSI) in preterm infants in German neonatal intensive care units (NICUs). Design A multi-center interrupted time series analysis. Setting 44 German NICUs with routine use of dual-strain probiotics on neonatal ward level. Patients Preterm infants documented by NEO-KISS, the German surveillance system for nosocomial infections in preterm infants with birth weights below 1,500 g, between 2004 and 2014. Intervention Routine use of dual-strain probiotics containing Lactobacillus acidophilus and Bifidobacterium spp. (Infloran) on the neonatal ward level. Main outcome measures Incidences of NEC, overall mortality, mortality following NEC and nosocomial BSI. Results Data from 10,890 preterm infants in 44 neonatal wards was included in this study. Incidences of NEC and BSI were 2.5% (n = 274) and 15.0%, (n = 1631), respectively. Mortality rate was 6.1% (n = 665). The use of dual-strain probiotics significantly reduced the risk of NEC (HR = 0.48; 95% CI = 0.38–0.62), overall mortality (HR = 0.60, 95% CI = 0.44–0.83), mortality after NEC (HR = 0.51, 95% CI = 0.26–0.999) and nosocomial BSI (HR = 0.89, 95% CI = 0.81–0.98). These effects were even more pronounced in the subgroup analysis of preterm infants with birth weights below 1,000 g. Conclusion In order to reduce NEC and mortality in preterm infants, it is advisable to add routine prophylaxis with dual-strain probiotics to clinical practice in neonatal wards. PMID:27332554

Education, income, and occupational class cannot be used interchangeably in social epidemiology. Empirical evidence against a common practice

PubMed Central

Geyer, Siegfried; Hemström, Örjan; Peter, Richard; Vågerö, Denny

2006-01-01

Study objective Education, income, and occupational class are often used interchangeably in studies showing social inequalities in health. This procedure implies that all three characteristics measure the same underlying phenomena. This paper questions this practice. The study looked for any independent effects of education, income, and occupational class on four health outcomes: diabetes prevalence, myocardial infarction incidence and mortality, and finally all cause mortality in populations from Sweden and Germany. Design Sweden: follow up of myocardial infarction mortality and all cause mortality in the entire population, based on census linkage to the Cause of Death Registry. Germany: follow up of myocardial infarction morbidity and all cause mortality in statutory health insurance data, plus analysis of prevalence data on diabetes. Multiple regression analyses were performed to calculate the effects of education, income, and occupational class before and after mutual adjustments. Setting and participants Sweden (all residents aged 25–64) and Germany (Mettman district, Nordrhein‐Westfalen, all insured persons aged 25–64). Main results Correlations between education, income, and occupational class were low to moderate. Which of these yielded the strongest effects on health depended on type of health outcome in question. For diabetes, education was the strongest predictor and for all cause mortality it was income. Myocardial infarction morbidity and mortality showed a more mixed picture. In mutually adjusted analyses each social dimension had an independent effect on each health outcome in both countries. Conclusions Education, income, and occupational class cannot be used interchangeably as indicators of a hypothetical latent social dimension. Although correlated, they measure different phenomena and tap into different causal mechanisms. PMID:16905727

Dietary factors in relation to daily activity energy expenditure and mortality among older adults

PubMed Central

Shahar, Danit R.; Harris, Tamara B.; Houston, Denise K.; Kritchevsky, Stephen B.; Lee, Jung-Sun; Rubin, Susan M.; Sellmeyer, Deborah E.; Tylavsky, Frances A.; Yu, Binbing

2009-01-01

Objective To examine the association between dietary factors to daily activity energy expenditure (DAEE) and mortality among older adults. Design and setting A sub-study of Health, Aging, and Body Composition study. Participants 298 older participants (aged 70–82 years) in the Health, Aging, and Body Composition Energy Expenditure sub-study. Measurements Dietary factors, DAEE, and all-cause mortality were measured in 298 older participants. Dietary factors include dietary intake assessed by the Block Food Frequency Questionnaire (FFQ), Healthy Eating Index (HEI), and self-reported appetite and enjoyment of eating. DAEE was assessed using doubly labeled water. All-cause mortality was evaluated over a 9 year period. Results Participants in the highest tertile of DAEE were more likely to be men and to report having a ‘good’ appetite; BMI among men, proportion married, IL-6 and CRP levels and energy intake were also higher. Fewer black participants were in the ‘good’ HEI category. Participants in the ‘good’ HEI category had higher cognitive scores and a higher education level. Participants who reported improvement in their appetite as well as participants who reported a ‘good’ appetite were at lower risk for mortality (HR (95% CI): 0.42 (0.24–0.74) and 0.50 (0.26–0.88), respectively) even after adjusting for DAEE, demographic, nutritional and health indices. Conclusions We showed an association between DAEE and appetite and mortality among well-functioning, community-dwelling older adults. These findings may have some practical use for the health providers. Inclusion of a question regarding appetite of an elderly patient may provide important information regarding risk for health deterioration and mortality. PMID:19390747

Influence of Body Mass Index on the Association of Weight Changes with Mortality in Hemodialysis Patients

PubMed Central

Cabezas-Rodriguez, Iván; Carrero, Juan Jesús; Zoccali, Carmine; Qureshi, Abdul Rashid; Ketteler, Markus; Floege, Jürgen; London, Gérard; Locatelli, Francesco; Gorriz, José Luis; Rutkowski, Boleslaw; Memmos, Dimitrios; Ferreira, Anibal; Covic, Adrian; Teplan, Vladimir; Bos, Willem-Jan; Kramar, Reinhard; Pavlovic, Drasko; Goldsmith, David; Nagy, Judit; Benedik, Miha; Verbeelen, Dierik; Tielemans, Christian; Wüthrich, Rudolf P.; Martin, Pierre-Yves; Martínez-Salgado, Carlos; Fernández-Martín, José Luis; Cannata-Andia, Jorge B.

2013-01-01

Summary Background and Objectives A high body mass index (BMI) is associated with lower mortality in patients undergoing hemodialysis. Short-term weight gains and losses are also related to lower and higher mortality risk, respectively. The implications of weight gain or loss may, however, differ between obese individuals and their nonobese counterparts. Design, Setting, Participants, & Measurements The Current Management of Secondary Hyperparathyroidism: A Multicenter Observational Study (COSMOS) is an observational study including 6797 European hemodialysis patients recruited between February 2005 and July 2007, with prospective data collection every 6 months for 3 years. Time-dependent Cox proportional hazard regressions assessed the effect of BMI and weight changes on mortality. Analyses were performed after patient stratification according to their starting BMI. Results Among 6296 patients with complete data, 1643 died. At study entry, 42% of patients had a normal weight (BMI, 20–25 kg/m2), 11% were underweight, 31% were overweight, and 16% were obese (BMI ≥30 kg/m2). Weight loss or gain (<1% or >1% of body weight) was strongly associated with higher rates of mortality or survival, respectively. After stratification by BMI categories, this was true in nonobese categories and especially in underweight patients. In obese patients, however, the association between weight loss and mortality was attenuated (hazard ratio, 1.28 [95% confidence interval (CI), 0.74 to 2.14]), and no survival benefit of gaining weight was seen (hazard ratio, 0.98 [95% CI, 0.59 to 1.62]). Conclusions Assuming that these weight changes were unintentional, our study brings attention to rapid weight variations as a clinical sign of health monitoring in hemodialysis patients. In addition, a patient’s BMI modifies the strength of the association between weight changes with mortality. PMID:24009217

The effect of increased coverage of participatory women's groups on neonatal mortality in Bangladesh: A cluster randomized trial.

PubMed

Fottrell, Edward; Azad, Kishwar; Kuddus, Abdul; Younes, Layla; Shaha, Sanjit; Nahar, Tasmin; Aumon, Bedowra Haq; Hossen, Munir; Beard, James; Hossain, Tanvir; Pulkki-Brannstrom, Anni-Maria; Skordis-Worrall, Jolene; Prost, Audrey; Costello, Anthony; Houweling, Tanja A J

2013-09-01

Community-based interventions can reduce neonatal mortality when health systems are weak. Population coverage of target groups may be an important determinant of their effect on behavior and mortality. A women's group trial at coverage of 1 group per 1414 population in rural Bangladesh showed no effect on neonatal mortality, despite a similar intervention having a significant effect on neonatal and maternal death in comparable settings. To assess the effect of a participatory women's group intervention with higher population coverage on neonatal mortality in Bangladesh. A cluster randomized controlled trial in 9 intervention and 9 control clusters. Rural Bangladesh. Women permanently residing in 18 unions in 3 districts and accounting for 19 301 births during the final 24 months of the intervention. Women's groups at a coverage of 1 per 309 population that proceed through a participatory learning and action cycle in which they prioritize issues that affected maternal and neonatal health and design and implement strategies to address these issues. Neonatal mortality rate. Analysis included 19 301 births during the final 24 months of the intervention. More than one-third of newly pregnant women joined the groups. The neonatal mortality rate was significantly lower in the intervention arm (21.3 neonatal deaths per 1000 live births vs 30.1 per 1000 in control areas), a reduction in neonatal mortality of 38% (risk ratio, 0.62 [95% CI, 0.43-0.89]) when adjusted for socioeconomic factors. The cost-effectiveness was US $220 to $393 per year of life lost averted. Cause-specific mortality rates suggest reduced deaths due to infections and those associated with prematurity/low birth weight. Improvements were seen in hygienic home delivery practices, newborn thermal care, and breastfeeding practices. Women's group community mobilization, delivered at adequate population coverage, is a highly cost-effective approach to improve newborn survival and health behavior indicators in rural Bangladesh. isrctn.org Identifier: ISRCTN01805825.

Long-term mortality after community-acquired pneumonia—impacts of diabetes and newly discovered hyperglycaemia: a prospective, observational cohort study

PubMed Central

Koskela, Heikki O; Salonen, Päivi H; Romppanen, Jarkko; Niskanen, Leo

2014-01-01

Objectives Community-acquired pneumonia is associated with a significant long-term mortality after initial recovery. It has been acknowledged that additional research is urgently needed to examine the contributors to this long-term mortality. The objective of the present study was to assess whether diabetes or newly discovered hyperglycaemia during pneumonia affects long-term mortality. Design A prospective, observational cohort study. Setting A single secondary centre in eastern Finland. Participants 153 consecutive hospitalised patients who survived at least 30 days after mild-to-moderate community-acquired pneumonia. Interventions Plasma glucose levels were recorded seven times during the first day on the ward. Several possible confounders were also recorded. The surveillance status and causes of death were recorded after median of 5 years and 11 months. Results In multivariate Cox regression analysis, a previous diagnosis of diabetes among the whole population (adjusted HR 2.84 (1.35–5.99)) and new postprandial hyperglycaemia among the non-diabetic population (adjusted HR 2.56 (1.04–6.32)) showed independent associations with late mortality. New fasting hyperglycaemia was not an independent predictor. The mortality rates at the end of follow-up were 54%, 37% and 10% among patients with diabetes, patients without diabetes with new postprandial hyperglycaemia and patients without diabetes without postprandial hyperglycaemia, respectively (p<0.001). The underlying causes of death roughly mirrored those in the Finnish general population with a slight excess in mortality due to chronic respiratory diseases. Pneumonia was the immediate cause of death in just 8% of all late deaths. Conclusions A previous diagnosis of diabetes and newly discovered postprandial hyperglycaemia increase the risk of death for several years after community-acquired pneumonia. As the knowledge about patient subgroups with an increased late mortality risk is gradually gathering, more studies are needed to evaluate the possible postpneumonia interventions to reduce late mortality. PMID:25146717

Inter-arm blood pressure difference and mortality: a cohort study in an asymptomatic primary care population at elevated cardiovascular risk

PubMed Central

Clark, Christopher E; Taylor, Rod S; Butcher, Isabella; Stewart, Marlene CW; Price, Jackie; Fowkes, F Gerald R; Shore, Angela C; Campbell, John L

2016-01-01

Background Differences in blood pressure between arms are associated with increased cardiovascular mortality in cohorts with established vascular disease or substantially elevated cardiovascular risk. Aim To explore the association of inter-arm difference (IAD) with mortality in a community-dwelling cohort that is free of cardiovascular disease. Design and setting Cohort analysis of a randomised controlled trial in central Scotland, from April 1998 to October 2008. Method Volunteers from Lanarkshire, Glasgow, and Edinburgh, free of pre-existing vascular disease and with an ankle-brachial index ≤0.95, had systolic blood pressure measured in both arms at recruitment. Inter-arm blood pressure differences were calculated and examined for cross-sectional associations and differences in prospective survival. Outcome measures were cardiovascular events and all-cause mortality during mean follow-up of 8.2 years. Results Based on a single pair of measurements, 60% of 3350 participants had a systolic IAD ≥5 mmHg and 38% ≥10 mmHg. An IAD ≥5 mmHg was associated with increased cardiovascular mortality (adjusted hazard ratio [HR] 1.91, 95% confidence interval [CI] = 1.19 to 3.07) and all-cause mortality (adjusted HR 1.44, 95% CI = 1.15 to 1.79). Within the subgroup of 764 participants who had hypertension, IADs of ≥5 mmHg or ≥10 mmHg were associated with both cardiovascular mortality (adjusted HR 2.63, 95% CI = 0.97 to 7.02, and adjusted HR 2.96, 95% CI = 1.27 to 6.88, respectively) and all-cause mortality (adjusted HR 1.67, 95% CI = 1.05 to 2.66, and adjusted HR 1.63, 95% CI = 1.06 to 2.50, respectively). IADs ≥15 mmHg were not associated with survival differences in this population. Conclusion Systolic IADs in blood pressure are associated with increased risk of cardiovascular events, including mortality, in a large cohort of people free of pre-existing vascular disease. PMID:27080315

Dying to be famous: retrospective cohort study of rock and pop star mortality and its association with adverse childhood experiences

PubMed Central

Bellis, Mark A; Hughes, Karen; Sharples, Olivia; Hennell, Tom; Hardcastle, Katherine A

2012-01-01

Objectives Rock and pop fame is associated with risk taking, substance use and premature mortality. We examine relationships between fame and premature mortality and test how such relationships vary with type of performer (eg, solo or band member) and nationality and whether cause of death is linked with prefame (adverse childhood) experiences. Design A retrospective cohort analysis based on biographical data. An actuarial methodology compares postfame mortality to matched general populations. Cox survival and logistic regression techniques examine risk and protective factors for survival and links between adverse childhood experiences and cause of death, respectively. Setting North America and Europe. Participants 1489 rock and pop stars reaching fame between 1956 and 2006. Outcomes Stars’ postfame mortality relative to age-, sex- and ethnicity-matched populations (USA and UK); variations in survival with performer type, and in cause of mortality with exposure to adverse childhood experiences. Results Rock/pop star mortality increases relative to the general population with time since fame. Increases are greater in North American stars and those with solo careers. Relative mortality begins to recover 25 years after fame in European but not North American stars. Those reaching fame from 1980 onwards have better survival rates. For deceased stars, cause of death was more likely to be substance use or risk-related in those with more adverse childhood experiences. Conclusions Relationships between fame and mortality vary with performers’ characteristics. Adverse experiences in early life may leave some predisposed to health-damaging behaviours, with fame and extreme wealth providing greater opportunities to engage in risk-taking. Millions of youths wish to emulate their icons. It is important they recognise that substance use and risk-taking may be rooted in childhood adversity rather than seeing them as symbols of success. PMID:23253869

Serum high density lipoprotein cholesterol, alcohol, and coronary mortality in male smokers.

PubMed Central

Paunio, M.; Virtamo, J.; Gref, C. G.; Heinonen, O. P.

1996-01-01

OBJECTIVE--To determine whether the increase in mortality from coronary heart disease with high concentration (> 1.75 mmol/l) of high density lipoprotein cholesterol could be due to alcohol intake. DESIGN--Cohort study. SETTING--Placebo group of the alpha tocopherol, beta carotene cancer prevention (ATBC) study of south western population in Finland. PARTICIPANTS--7052 male smokers aged 50-69 years enrolled to the ATBC study in the 1980s. MAIN OUTCOME MEASURES--The relative and absolute rates adjusted for risk factors for clinically or pathologically verified deaths from coronary heart disease for different concentrations of high density lipoprotein cholesterol with and without stratification for alcohol intake. Similar rates were also calculated for different alcohol consumption groups. RESULTS--During the average follow up period of 6.7 years 258 men died from verified coronary heart disease. Coronary death rate steadily decreased with increasing concentration of high density lipoprotein cholesterol until a high concentration. An increase in the rate was observed above 1.75 mmol/l. This increase occurred among those who reported alcohol intake. Mortality was associated with alcohol intake in a J shaped dose response, and those who reported consuming more than five drinks a day (heavy drinkers) had the highest death rate. Mortality was higher in heavy drinkers than in non-drinkers or light or moderate drinkers in all high density lipoprotein categories from 0.91 mmol/l upward. CONCLUSIONS--Mortality from coronary heart disease increases at concentrations of high density lipoprotein cholesterol over 1.75 mmol/l. The mortality was highest among heavy drinkers, but an increase was found among light drinkers also. PMID:8634563

Relative associations between depression and anxiety on adverse cardiovascular events: does a history of coronary artery disease matter? A prospective observational study

PubMed Central

Pelletier, Roxanne; Arsenault, André; Dupuis, Jocelyn; Laurin, Catherine; Blais, Lucie; Lavoie, Kim L

2015-01-01

Objectives To assess whether depression and anxiety increase the risk of mortality and major adverse cardiovascular events (MACE), among patients with and without coronary artery disease (CAD). Design and setting, and patients DECADE (Depression Effects on Coronary Artery Disease Events) is a prospective observational study of 2390 patients referred at the Montreal Heart Institute. Patients were followed for 8.8 years, between 1998 and 2009. Depression and anxiety were assessed using a psychiatric interview (Primary Care Evaluation of Mental Disorders, PRIME-MD). Outcomes data were obtained from Quebec provincial databases. Main outcome measures All-cause mortality and MACE. Results After adjustment for covariates, patients with depression were at increased risks of all-cause mortality (relative risk (RR)=2.84; 95% CI 1.25 to 6.49) compared with patients without depression. Anxiety was not associated with increased mortality risks (RR=0.86; 95% CI 0.31 to 2.36). When patients were stratified according to CAD status, depression increased the risk of mortality among patients with no CAD (RR=4.39; 95% CI 1.12 to 17.21), but not among patients with CAD (RR=2.32; 95% CI 0.78 to 6.88). Neither depression nor anxiety was associated with MACE among patients with or without CAD. Conclusions and relevance Depression, but not anxiety, was an independent risk factor for all-cause mortality in patients without CAD. The present study contributes to a better understanding of the relative and unique role of depression versus anxiety among patients with versus without CAD. PMID:26671946

Ambient air pollution and suicide in Tokyo, 2001-2011.

PubMed

Ng, Chris Fook Sheng; Stickley, Andrew; Konishi, Shoko; Watanabe, Chiho

2016-09-01

Some evidence suggests an association may exist between the level of air pollution and suicide mortality. However, this relation has been little studied to date. The current study examined the association in Tokyo, Japan. Suicide mortality data for Tokyo for the 11-year period 2001-2011 were obtained together with data on four air pollutants: fine particulate matter (PM2.5), suspended particulate matter (SPM), sulphur dioxide (SO2) and nitrogen dioxide (NO2). A time-stratified case-crossover study design was used to examine the daily association between the level of air pollution and suicide mortality. During the study period there were 29,939 suicide deaths. In stratified analyses an interquartile range (IQR) increase in the same-day concentration of NO2 was linked to increased suicide mortality among those aged under 30 (percentage change: 6.73%, 95% CI: 0.69-13.12%). An IQR increase in PM2.5 and SO2 was associated with a 10.55% (95% CI: 2.05-19.75%) and 11.47% (95% CI: 3.60-19.93%) increase, respectively, in suicide mortality among widowed individuals for mean exposure on the first four days (average lags 0-3). Positive associations were observed for the air pollutants in the summer although associations were reversed in autumn. We relied on monitoring data to approximate individual exposure to air pollutants. Higher levels of air pollution are associated with increased suicide mortality in some population subgroups in Tokyo. Further research is needed to elucidate the mechanisms linking air pollutants and suicide in this setting. Copyright © 2016 Elsevier B.V. All rights reserved.

Mortality and cancer morbidity among cement workers.

PubMed Central

Jakobsson, K; Horstmann, V; Welinder, H

1993-01-01

OBJECTIVE--To explore associations between exposure to cement dust and cause specific mortality and tumour morbidity, especially gastrointestinal tumours. DESIGN--A retrospective cohort study. SUBJECTS AND SETTING--2400 men, employed for at least 12 months in two Swedish cement factories. MAIN OUTCOME MEASURES--Cause specific morality from death certificates (1952-86). Cancer morbidity from tumour registry information (1958-86). Standardised mortality rates (SMRs; national reference rates) and standardised morbidity incidence rates (SIRs; regional reference rates) were calculated. RESULTS--An increased risk of colorectal cancer was found > or = 15 years since the start of employment (SIR 1.6, 95% confidence interval (95% CI) 1.1-2.3), mainly due to an increased risk for tumours in the right part of the colon (SIR 2.7, 95% CI 1.4-4.8), but not in the left part (SIR 1.0, 95% CI 0.3-2.5). There was a numerical increase of rectal cancer (SIR 1.5, 95% CI 0.8-2.5). Exposure (duration of blue collar employment)-response relations were found for right sided colon cancer. After > or = 25 years of cement work, the risk was fourfold (SIR 4.3, 95% CI 1.7-8.9). There was no excess of stomach cancer or respiratory cancer. Neither total mortality nor cause specific mortality were significantly increased. CONCLUSIONS--Diverging risk patterns for tumours with different localisations within the large bowel were found in the morbidity study. Long term exposure to cement dust was a risk factor for right sided colon cancer. The mortality study did not show this risk. PMID:8457494

Learning from death: a hospital mortality reduction programme

PubMed Central

Wright, John; Dugdale, Bob; Hammond, Ian; Jarman, Brian; Neary, Maria; Newton, Duncan; Patterson, Chris; Russon, Lynne; Stanley, Philip; Stephens, Rose; Warren, Erica

2006-01-01

Problem: There are wide variations in hospital mortality. Much of this variation remains unexplained and may reflect quality of care. Setting: A large acute hospital in an urban district in the North of England. Design: Before and after evaluation of a hospital mortality reduction programme. Strategies for change: Audit of hospital deaths to inform an evidence-based approach to identify processes of care to target for the hospital strategy. Establishment of a hospital mortality reduction group with senior leadership and support to ensure the alignment of the hospital departments to achieve a common goal. Robust measurement and regular feedback of hospital deaths using statistical process control charts and summaries of death certificates and routine hospital data. Whole system working across a health community to provide appropriate end of life care. Training and awareness in processes of high quality care such as clinical observation, medication safety and infection control. Effects: Hospital standardized mortality ratios fell significantly in the 3 years following the start of the programme from 94.6 (95% confidence interval 89.4, 99.9) in 2001 to 77.5 (95% CI 73.1, 82.1) in 2005. This translates as 905 fewer hospital deaths than expected during the period 2002-2005. Lessons learnt: Improving the safety of hospital care and reducing hospital deaths provides a clear and well supported goal from clinicians, managers and patients. Good leadership, good information, a quality improvement strategy based on good local evidence and a community-wide approach may be effective in improving the quality of processes of care sufficiently to reduce hospital mortality. PMID:16738373

Respiratory Syncytial Virus–Associated Mortality in Hospitalized Infants and Young Children

PubMed Central

Wilkes, Jacob; Korgenski, Kent; Sheng, Xiaoming

2015-01-01

BACKGROUND AND OBJECTIVE: Respiratory syncytial virus (RSV) is a common cause of pediatric hospitalization, but the mortality rate and estimated annual deaths are based on decades-old data. Our objective was to describe contemporary RSV-associated mortality in hospitalized infants and children aged <2 years. METHODS: We queried the Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID) for 2000, 2003, 2006, and 2009 and the Pediatric Health Information System (PHIS) administrative data from 2000 to 2011 for hospitalizations with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for RSV infection and mortality. RESULTS: The KID data sets identified 607 937 RSV-associated admissions and 550 deaths (9.0 deaths/10 000 admissions). The PHIS data set identified 264 721 RSV-associated admissions and 671 deaths (25.4 deaths/10 000 admissions) (P < .001 compared with the KID data set). The 2009 KID data set estimated 42.0 annual deaths (3.0 deaths/10 000 admissions) for those with a primary diagnosis of RSV. The PHIS data set identified 259 deaths with a primary diagnosis of RSV, with mortality rates peaking at 14.0/10 000 admissions in 2002 and 2003 and decreasing to 4.0/10 000 patients by 2011 (odds ratio: 0.27 [95% confidence interval: 0.14–0.52]). The majority of deaths in both the KID and PHIS data sets occurred in infants with complex chronic conditions and in those with other acute conditions such as sepsis that could have contributed to their deaths. CONCLUSIONS: Deaths associated with RSV are uncommon in the 21st century. Children with complex chronic conditions account for the majority of deaths, and the relative contribution of RSV infection to their deaths is unclear. PMID:25489019

A Review of Pediatric Critical Care in Resource-Limited Settings: A Look at Past, Present, and Future Directions

PubMed Central

Turner, Erin L.; Nielsen, Katie R.; Jamal, Shelina M.; von Saint André-von Arnim, Amelie; Musa, Ndidiamaka L.

2016-01-01

Fifteen years ago, United Nations world leaders defined millenium development goal 4 (MDG 4): to reduce under-5-year mortality rates by two-thirds by the year 2015. Unfortunately, only 27 of 138 developing countries are expected to achieve MDG 4. The majority of childhood deaths in these settings result from reversible causes, and developing effective pediatric emergency and critical care services could substantially reduce this mortality. The Ebola outbreak highlighted the fragility of health care systems in resource-limited settings and emphasized the urgent need for a paradigm shift in the global approach to healthcare delivery related to critical illness. This review provides an overview of pediatric critical care in resource-limited settings and outlines strategies to address challenges specific to these areas. Implementation of these tools has the potential to move us toward delivery of an adequate standard of critical care for all children globally, and ultimately decrease global child mortality in resource-limited settings. PMID:26925393

Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned.

PubMed

Slusher, Tina M; Kiragu, Andrew W; Day, Louise T; Bjorklund, Ashley R; Shirk, Arianna; Johannsen, Colleen; Hagen, Scott A

2018-01-01

Pediatric critical care is an important component of reducing morbidity and mortality globally. Currently, pediatric critical care in low middle-income countries (LMICs) remains in its infancy in most hospitals. The majority of hospitals lack designated intensive care units, healthcare staff trained to care for critically ill children, adequate numbers of staff, and rapid access to necessary medications, supplies and equipment. In addition, most LMICs lack pediatric critical care training programs for healthcare providers or certification procedures to accredit healthcare providers working in their pediatric intensive care units (PICU) and high dependency areas. PICU can improve the quality of pediatric care in general and, if properly organized, can effectively treat the severe complications of high burden diseases, such as diarrhea, severe malaria, and respiratory distress using low-cost interventions. Setting up a PICU in a LMIC setting requires planning, specific resources, and most importantly investment in the nursing and permanent medical staff. A thoughtful approach to developing pediatric critical care services in LMICs starts with fundamental building blocks: training healthcare professionals in skills and knowledge, selecting resource appropriate effective equipment, and having supportive leadership to provide an enabling environment for appropriate care. If these fundamentals can be built on in a sustainable manner, an appropriate critical care service will be established with the potential to significantly decrease pediatric morbidity and mortality in the context of public health goals as we reach toward the sustainable development goals.

Socioeconomic inequalities in suicide mortality before and after the economic recession in Spain.

PubMed

Borrell, Carme; Marí-Dell'Olmo, Marc; Gotsens, Mercè; Calvo, Montse; Rodríguez-Sanz, Maica; Bartoll, Xavier; Esnaola, Santiago

2017-10-04

An increase in suicide mortality is often observed in economic recessions. The objective of this study was to analyse trends in socioeconomic inequalities in suicide mortality before and during the economic recession in two geographical settings in Spain. This study analyses inequalities in mortality according to educational level during 3 different time periods based on individual data from the Basque Country and Barcelona city. We analysed suicide mortality data for all residents over 25 years of age from 2001 to 2012. Two periods before the crisis (2001-2004 and 2005-2008) and another during the crisis (2009-2012) were studied. We performed independent analyses for sex, age group, and for the two geographical settings. We fit Poisson regression models to study the relationship between educational level and mortality, and calculated the relative index of inequality (RII) and the slope index of inequality (SII) as comparative measures. For men in the Basque Country, all RII values for the three time periods were similar and almost all were greater than 2; in Barcelona the RII values were generally lower. The SII values for Barcelona tended to decrease over time, whereas in the Basque Country they showed a U-shaped pattern. Among women aged 25-44 years we found an association between educational level and suicide mortality during the first time period; however, we found no clear association for other age groups or time periods. This study within two geographical settings in Spain shows that trends in inequalities in suicide mortality according to educational level remained stable among men before and during the economic recession.

Acute care surgery: defining mortality in emergency general surgery in the state of Maryland.

PubMed

Narayan, Mayur; Tesoriero, Ronald; Bruns, Brandon R; Klyushnenkova, Elena N; Chen, Hegang; Diaz, Jose J

2015-04-01

Emergency general surgery (EGS) is a major component of acute care surgery, however, limited data exist on mortality with respect to trauma center (TC) designation. We hypothesized that mortality would be lower for EGS patients treated at a TC vs non-TC (NTC). A retrospective review of the Maryland Health Services Cost Review Commission database from 2009 to 2013 was performed. The American Association for the Surgery of Trauma EGS ICD-9 codes were used to identify EGS patients. Data collected included demographics, TC designation, emergency department admissions, and All Patients Refined Severity of Illness (APR_SOI). Trauma center designation was used as a marker of a formal acute care surgery program. Primary outcomes included in-hospital mortality. Multivariable logistic regression analysis was performed controlling for age. There were 817,942 EGS encounters. Mean ± SD age of patients was 60.1 ± 18.7 years, 46.5% were males; 71.1% of encounters were at NTCs; and 75.8% were emergency department admissions. Overall mortality was 4.05%. Mortality was calculated based on TC designation controlling for age across APR_SOI strata. Multivariable logistic regression analysis did not show statistically significant differences in mortality between hospital levels for minor APR_SOI. For moderate APR_SOI, mortality was significantly lower for TCs compared with NTCs (p < 0.001). Among TCs, the effect was strongest for Level I TC (odds ratio = 0.34). For extreme APR_SOI, mortality was higher at TCs vs NTCs (p < 0.001). Emergency general surgery patients treated at TCs had lower mortality for moderate APR_SOI, but increased mortality for extreme APR_SOI when compared with NTCs. Additional investigation is required to better evaluate this unexpected finding. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

A multicenter mortality prediction model for patients receiving prolonged mechanical ventilation

PubMed Central

Carson, Shannon S.; Kahn, Jeremy M.; Hough, Catherine L.; Seeley, Eric J.; White, Douglas B.; Douglas, Ivor S.; Cox, Christopher E.; Caldwell, Ellen; Bangdiwala, Shrikant I.; Garrett, Joanne M.; Rubenfeld, Gordon D.

2012-01-01

Objective Significant deficiencies exist in the communication of prognosis for patients requiring prolonged mechanical ventilation after acute illness, in part because of clinician uncertainty about long-term outcomes. We sought to refine a mortality prediction model for patients requiring prolonged ventilation using a multicentered study design. Design Cohort study. Setting Five geographically diverse tertiary care medical centers in the United States (California, Colorado, North Carolina, Pennsylvania, Washington). Patients Two hundred sixty adult patients who received at least 21 days of mechanical ventilation after acute illness. Interventions None. Measurements and Main Results For the probability model, we included age, platelet count, and requirement for vasopressors and/or hemodialysis, each measured on day 21 of mechanical ventilation, in a logistic regression model with 1-yr mortality as the outcome variable. We subsequently modified a simplified prognostic scoring rule (ProVent score) by categorizing the risk variables (age 18–49, 50–64, and >65 yrs; platelet count 0–150 and >150; vasopressors; hemodialysis) in another logistic regression model and assigning points to variables according to β coefficient values. Overall mortality at 1 yr was 48%. The area under the curve of the receiver operator characteristic curve for the primary ProVent probability model was 0.79 (95% confidence interval, 0.75–0.81), and the p value for the Hosmer-Lemeshow goodness-of-fit statistic was .89. The area under the curve for the categorical model was 0.77, and the p value for the goodness-of-fit statistic was .34. The area under the curve for the ProVent score was 0.76, and the p value for the Hosmer-Lemeshow goodness-of-fit statistic was .60. For the 50 patients with a ProVent score >2, only one patient was able to be discharged directly home, and 1-yr mortality was 86%. Conclusion The ProVent probability model is a simple and reproducible model that can accurately identify patients requiring prolonged mechanical ventilation who are at high risk of 1-yr mortality. PMID:22080643

Enduring health effects of asbestos use in Belgian industries: a record-linked cohort study of cause-specific mortality (2001–2009)

PubMed Central

Van den Borre, Laura; Deboosere, Patrick

2015-01-01

Objective To investigate cause-specific mortality among asbestos workers and potentially exposed workers in Belgium and evaluate potential excess in mortality due to established and suspected asbestos-related diseases. Design This cohort study is based on an individual record linkage between the 1991 Belgian census and cause-specific mortality information for Flanders and Brussels (2001–2009). Setting Belgium (Flanders and Brussels region). Participants The study population consists of 1 397 699 male workers (18–65 years) with 72 074 deaths between 1 October 2001 and 31 December 2009. Using a classification of high-risk industries, mortality patterns between 2056 asbestos workers, 385 046 potentially exposed workers and the working population have been compared. Outcome measures Standardised mortality ratios (SMRs) and 95% CIs are calculated for manual and non-manual workers. Results Our findings show clear excess in asbestos-related mortality in the asbestos industry with SMRs for mesothelioma of 4071 (CI 2327 to 6611) among manual workers and of 4489 (CI 1458 to 10 476) among non-manual workers. Excess risks in asbestos-related mortality are also found in the chemical industry, the construction industry, the electrical generation and distribution industry, the basic metals manufacturing industry, the metal products manufacturing industry, the railroad industry, and the shipping industry. Oral cancer mortality is significantly higher for asbestos workers (SMR 383; CI 124 to 894), railroad workers (SMR 192; CI 112 to 308), shipping workers (SMR 172; CI 102 to 271) and construction workers (SMR 125; CI 100 to 153), indicating a possible association with occupational asbestos exposure. Workers in all four industries have elevated mortality rates for cancer of the mouth. Only construction workers experience significantly higher pharyngeal cancer mortality (SMR 151; CI 104 to 212). Conclusions The study identifies vulnerable groups of Belgian asbestos workers, demonstrating the current-day health repercussions of historical asbestos use. Results support the hypothesis of a possible association between the development of oral cancer and occupational asbestos exposure. PMID:26109114

Independent and joint effects of sedentary time and cardiorespiratory fitness on all-cause mortality: the Cooper Center Longitudinal Study

PubMed Central

Shuval, Kerem; Finley, Carrie E; Barlow, Carolyn E; Nguyen, Binh T; Njike, Valentine Y; Pettee Gabriel, Kelley

2015-01-01

Objectives To examine the independent and joint effects of sedentary time and cardiorespiratory fitness (fitness) on all-cause mortality. Design, setting, participants A prospective study of 3141 Cooper Center Longitudinal Study participants. Participants provided information on television (TV) viewing and car time in 1982 and completed a maximal exercise test during a 1-year time frame; they were then followed until mortality or through 2010. TV viewing, car time, total sedentary time and fitness were the primary exposures and all-cause mortality was the outcome. The relationship between the exposures and outcome was examined utilising Cox proportional hazard models. Results A total of 581 deaths occurred over a median follow-up period of 28.7 years (SD=4.4). At baseline, participants’ mean age was 45.0 years (SD=9.6), 86.5% were men and their mean body mass index was 24.6 (SD=3.0). Multivariable analyses revealed a significant linear relationship between increased fitness and lower mortality risk, even while adjusting for total sedentary time and covariates (p=0.02). The effects of total sedentary time on increased mortality risk did not quite reach statistical significance once fitness and covariates were adjusted for (p=0.05). When examining this relationship categorically, in comparison to the reference category (≤10 h/week), being sedentary for ≥23 h weekly increased mortality risk by 29% without controlling for fitness (HR=1.29, 95% CI 1.03 to 1.63); however, once fitness and covariates were taken into account this relationship did not reach statistical significance (HR=1.20, 95% CI 0.95 to 1.51). Moreover, spending >10 h in the car weekly significantly increased mortality risk by 27% in the fully adjusted model. The association between TV viewing and mortality was not significant. Conclusions The relationship between total sedentary time and higher mortality risk is less pronounced when fitness is taken into account. Increased car time, but not TV viewing, is significantly related to higher mortality risk, even when taking fitness into account, in this cohort. PMID:26525421

Sex Differences in Mortality Following Acute Coronary Syndromes

PubMed Central

Berger, Jeffrey S.; Elliott, Laine; Gallup, Dianne; Roe, Matthew; Granger, Christopher B.; Armstrong, Paul W.; Simes, R. John; White, Harvey D.; Van de Werf, Frans; Topol, Eric J.; Hochman, Judith S.; Newby, L. Kristin; Harrington, Robert A.; Califf, Robert M; Becker, Richard C.; Douglas, Pamela S.

2009-01-01

Context There is conflicting information about whether sex-differences modulate short-term mortality following acute coronary syndromes (ACS). Objective To investigate the relationship between sex and 30-day mortality in ACS, and determine whether this relationship is modified by clinical syndrome or coronary anatomy using a large database across the spectrum of ACS and adjusting for potentially confounding clinical covariates. Design Setting and Participants Data from 11 ACS trials from 1993 to 2006 were pooled. Of 136,247 patients, 38,048 (28%) were women; 102,004 (26% women) STEMI, 14,466 (29% women) NSTEMI and 19,777 (40% women) unstable angina (UA). Main Outcome Measure Thirty-day mortality following ACS. Results Mortality at 30 days was 9.6% in women and 5.3% in men (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.83–2.00). After multivariable adjustment, mortality was not significantly different between women and men (adjusted OR 1.06, 95% CI 0.99–1.15). Importantly, a significant sex by type of ACS interaction was demonstrated (P<0.001). In STEMI, 30-day mortality was higher among women (adjusted OR 1.15, 95% CI 1.06–1.24), whereas NSTEMI (adjusted OR 0.77, 95% CI 0.63–0.95), and UA mortality was lower among women (adjusted OR 0.55, 95% CI 0.43–0.70). In a cohort of 35,128 patients with angiographic data, women more often had non-obstructive (15% vs. 8%,) and less often had 2-vessel (25% vs. 28%) and 3-vessel (23% vs. 26%) coronary disease regardless of ACS type. After additional adjustment for angiographic disease severity, 30-day mortality among women was not significantly different than men, regardless of ACS type. The relationship between sex and 30-day mortality was similar across the levels of angiographic disease severity (p-value for interaction =0.70), Conclusions Sex-based differences exist in 30-day mortality among ACS patients and vary depending on clinical presentation. However, these differences are markedly attenuated following adjustment for clinical differences and angiographic data. PMID:19706861

Weight-elimination neural networks applied to coronary surgery mortality prediction.

PubMed

Ennett, Colleen M; Frize, Monique

2003-06-01

The objective was to assess the effectiveness of the weight-elimination cost function in improving classification performance of artificial neural networks (ANNs) and to observe how changing the a priori distribution of the training set affects network performance. Backpropagation feedforward ANNs with and without weight-elimination estimated mortality for coronary artery surgery patients. The ANNs were trained and tested on cases with 32 input variables describing the patient's medical history; the output variable was in-hospital mortality (mortality rates: training 3.7%, test 3.8%). Artificial training sets with mortality rates of 20%, 50%, and 80% were created to observe the impact of training with a higher-than-normal prevalence. When the results were averaged, weight-elimination networks achieved higher sensitivity rates than those without weight-elimination. Networks trained on higher-than-normal prevalence achieved higher sensitivity rates at the cost of lower specificity and correct classification. The weight-elimination cost function can improve the classification performance when the network is trained with a higher-than-normal prevalence. A network trained with a moderately high artificial mortality rate (artificial mortality rate of 20%) can improve the sensitivity of the model without significantly affecting other aspects of the model's performance. The ANN mortality model achieved comparable performance as additive and statistical models for coronary surgery mortality estimation in the literature.

Modern modeling techniques had limited external validity in predicting mortality from traumatic brain injury.

PubMed

van der Ploeg, Tjeerd; Nieboer, Daan; Steyerberg, Ewout W

2016-10-01

Prediction of medical outcomes may potentially benefit from using modern statistical modeling techniques. We aimed to externally validate modeling strategies for prediction of 6-month mortality of patients suffering from traumatic brain injury (TBI) with predictor sets of increasing complexity. We analyzed individual patient data from 15 different studies including 11,026 TBI patients. We consecutively considered a core set of predictors (age, motor score, and pupillary reactivity), an extended set with computed tomography scan characteristics, and a further extension with two laboratory measurements (glucose and hemoglobin). With each of these sets, we predicted 6-month mortality using default settings with five statistical modeling techniques: logistic regression (LR), classification and regression trees, random forests (RFs), support vector machines (SVM) and neural nets. For external validation, a model developed on one of the 15 data sets was applied to each of the 14 remaining sets. This process was repeated 15 times for a total of 630 validations. The area under the receiver operating characteristic curve (AUC) was used to assess the discriminative ability of the models. For the most complex predictor set, the LR models performed best (median validated AUC value, 0.757), followed by RF and support vector machine models (median validated AUC value, 0.735 and 0.732, respectively). With each predictor set, the classification and regression trees models showed poor performance (median validated AUC value, <0.7). The variability in performance across the studies was smallest for the RF- and LR-based models (inter quartile range for validated AUC values from 0.07 to 0.10). In the area of predicting mortality from TBI, nonlinear and nonadditive effects are not pronounced enough to make modern prediction methods beneficial. Copyright © 2016 Elsevier Inc. All rights reserved.

World Federation of Pediatric Intensive Care and Critical Care Societies: Global Sepsis Initiative.

PubMed

Kissoon, Niranjan; Carcillo, Joseph A; Espinosa, Victor; Argent, Andrew; Devictor, Denis; Madden, Maureen; Singhi, Sunit; van der Voort, Edwin; Latour, Jos

2011-09-01

According to World Health Organization estimates, sepsis accounts for 60%-80% of lost lives per year in childhood. Measures appropriate for resource-scarce and resource-abundant settings alike can reduce sepsis deaths. In this regard, the World Federation of Pediatric Intensive Care and Critical Care Societies Board of Directors announces the Global Pediatric Sepsis Initiative, a quality improvement program designed to improve quality of care for children with sepsis. To announce the global sepsis initiative; to justify some of the bundles that are included; and to show some preliminary data and encourage participation. The Global Pediatric Sepsis Initiative is developed as a Web-based education, demonstration, and pyramid bundles/checklist tool (http://www.pediatricsepsis.org or http://www.wfpiccs.org). Four health resource categories are included. Category A involves a nonindustrialized setting with mortality rate <5 yrs and >30 of 1,000 children. Category B involves a nonindustrialized setting with mortality rate <5 yrs and <30 of 1,000 children. Category C involves a developing industrialized nation. In category D, developed industrialized nation are determined and separate accompanying administrative and clinical parameters bundles or checklist quality improvement recommendations are provided, requiring greater resources and tasks as resource allocation increased from groups A to D, respectively. In the vanguard phase, data for 361 children (category A, n = 34; category B, n = 12; category C, n = 84; category D, n = 231) were successfully entered, and quality-assurance reports were sent to the 23 participating international centers. Analysis of bundles for categories C and D showed that reduction in mortality was associated with compliance with the resuscitation (odds ratio, 0.369; 95% confidence interval, 0.188-0.724; p < .0004) and intensive care unit management (odds ratio, 0.277; 95% confidence interval, 0.096-0.80) bundles. The World Federation of Pediatric Intensive Care and Critical Care Societies Global Pediatric Sepsis Initiative is online. Success in reducing pediatric mortality and morbidity, evaluated yearly as a measure of global child health care quality improvement, requires ongoing active recruitment of international participant centers. Please join us at http://www.pediatricsepsis.org or http://www.wfpiccs.org.

Association of Nondisease-Specific Problems with Mortality, Long-Term Care, and Functional Impairment among Older Adults Who Require Skilled Nursing Care after Dialysis Initiation

PubMed Central

Plantinga, Laura; Hall, Rasheeda K.; Mirk, Anna; Zhang, Rebecca; Kutner, Nancy

2016-01-01

Background and objectives The majority of older adults who initiate dialysis do so during a hospitalization, and these patients may require post-acute skilled nursing facility (SNF) care. For these patients, a focus on nondisease-specific problems, including cognitive impairment, depressive symptoms, exhaustion, falls, impaired mobility, and polypharmacy, may be more relevant to outcomes than the traditional disease-oriented approach. However, the association of the burden of nondisease-specific problems with mortality, transition to long-term care (LTC), and functional impairment among older adults receiving SNF care after dialysis initiation has not been studied. Design, setting, participants, & measurements We identified 40,615 Medicare beneficiaries ≥65 years old who received SNF care after dialysis initiation between 2000 and 2006 by linking renal disease registry data with the Minimum Data Set. Nondisease-specific problems were ascertained from the Minimum Data Set. We defined LTC as ≥100 SNF days and functional impairment as dependence in all four essential activities of daily living at SNF discharge. Associations of the number of nondisease-specific problems (≤1, 2, 3, and 4–6) with 6-month mortality, LTC, and functional impairment were examined. Results Overall, 39.2% of patients who received SNF care after dialysis initiation died within 6 months. Compared with those with ≤1 nondisease-specific problems, multivariable adjusted hazard ratios (95% confidence interval) for mortality were 1.26 (1.19 to 1.32), 1.40 (1.33 to 1.48), and 1.66 (1.57 to 1.76) for 2, 3, and 4–6 nondisease-specific problems, respectively. Among those who survived, 37.1% required LTC; of those remaining who did not require LTC, 74.7% had functional impairment. A higher likelihood of transition to LTC (among those who survived 6 months) and functional impairment (among those who survived and did not require LTC) was seen with a higher number of problems. Conclusions Identifying nondisease-specific problems may help patients and families anticipate LTC needs and functional impairment after dialysis initiation. PMID:27733436

Pre-Stroke Weight Loss is Associated with Post-Stroke Mortality among Men in the Honolulu-Asia Aging Study

PubMed Central

Bell, Christina L.; Rantanen, Taina; Chen, Randi; Davis, James; Petrovitch, Helen; Ross, G. Webster; Masaki, Kamal

2013-01-01

Objective To examine baseline pre-stroke weight loss and post-stroke mortality among men. Design Longitudinal study of late-life pre-stroke body mass index (BMI), weight loss and BMI change (midlife to late-life), with up to 8-year incident stroke and mortality follow-up. Setting Honolulu Heart Program/Honolulu-Asia Aging Study. Participants 3,581 Japanese-American men aged 71–93 years and stroke-free at baseline. Main Outcome Measure Post-stroke Mortality: 30-day post-stroke, analyzed with stepwise multivariable logistic regression and long-term post-stroke (up to 8-year), analyzed with stepwise multivariable Cox regression. Results Weight loss (10-pound decrements) was associated with increased 30-day post-stroke mortality (aOR=1.48, 95%CI 1.14–1.92), long-term mortality after incident stroke (all types n=225, aHR=1.25, 95%CI=1.09–1.44) and long-term mortality after incident thromboembolic stroke (n=153, aHR 1.19, 95%CI-1.01–1.40). Men with overweight/obese late-life BMI (≥25kg/m2, compared to normal/underweight BMI) had increased long-term mortality after incident hemorrhagic stroke (n=54, aHR=2.27, 95%CI=1.07–4.82). Neither desirable nor excessive BMI reductions (vs. no change/increased BMI) were associated with post-stroke mortality. In the overall sample (n=3,581), nutrition factors associated with increased long-term mortality included 1) weight loss (10-pound decrements, aHR=1.15, 1.09–1.21); 2) underweight BMI (vs. normal BMI, aHR=1.76, 1.40–2.20); and 3) both desirable and excessive BMI reductions (vs. no change or gain, separate model from weight loss and BMI, aHRs=1.36–1.97, p<0.001). Conclusions Although obesity is a risk factor for stroke incidence, pre-stroke weight loss was associated with increased post-stroke (all types and thromboembolic) mortality. Overweight/obese late-life BMI was associated with increased post-hemorrhagic stroke mortality. Desirable and excessive BMI reductions were not associated with post-stroke mortality. Weight loss, underweight late-life BMI and any BMI reduction were all associated with increased long-term mortality in the overall sample. PMID:24113337

Critical care of tropical disease in low income countries: Report from the Task Force on Tropical Diseases by the World Federation of Societies of Intensive and Critical Care Medicine.

PubMed

Baker, Tim; Khalid, Karima; Acicbe, Ozlem; McGloughlin, Steve; Amin, Pravin

2017-12-01

Tropical disease results in a great burden of critical illness. The same life-saving and supportive therapies to maintain vital organ functions that comprise critical care are required by these patients as for all other diseases. In low income countries, the little available data points towards high mortality rates and big challenges in the provision of critical care. Improving critical care in low income countries requires a focus on hospital design, training, triage, monitoring & treatment modifications, the basic principles of critical care, hygiene and the involvement of multi-disciplinary teams. As a large proportion of critical illness from tropical disease is in low income countries, the impact and reductions in mortality rates of improved critical care in such settings could be substantial. Copyright © 2017. Published by Elsevier Inc.

Glucocorticoid exposure alters the pathogenesis of Theiler’s murine encephalomyelitis virus during acute infection

PubMed Central

Young, Erin E.; Prentice, Thomas W.; Satterlee, Danielle; McCullough, Heath; Sieve, Amy N.; Johnson, Robin R.; Welsh, Thomas H.; Welsh, C. Jane R.; Meagher, Mary W.

2008-01-01

Previous research has shown that chronic restraint stress exacerbates Theiler’s virus infection, a murine model for CNS inflammation and multiple sclerosis. The current set of experiments was designed to evaluate the potential role of glucocorticoids in the deleterious effects of restraint stress on acute CNS inflammatory disease. Exposure to chronic restraint stress resulted in elevated levels of corticosterone as well as increased clinical scores and weight loss (Experiment 1). In addition, corticosterone administration alone exacerbated behavioral signs of TMEV-induced sickness (i.e. decreased body weight, increased symptoms of encephalitis, and increased mortality) and reduced inflammation in the CNS (Experiment 2). Infected subjects receiving exogenous corticosterone showed exacerbation of acute phase measures of sickness and severe mortality as well as decreased viral clearance from CNS (Experiment 3). These findings indicate that corticosterone exposure alone is sufficient to exacerbate acute CNS inflammatory disease. PMID:18538803

Community-based measles mortality surveillance in two districts of Katanga Province, Democratic Republic of Congo.

PubMed

N'goran, Alexandra A; Ilunga, Ngoie; Coldiron, Matthew E; Grais, Rebecca F; Porten, Klaudia

2013-12-17

Mortality due to measles is often under-reported. Traditional methods of measuring mortality can be time and resource-intensive. We describe the implementation of a community-based method to monitor measles mortality. Using standardized questionnaires in the midst of a measles outbreak, a community-based network of volunteers recorded a much larger number of deaths (376) than deaths recorded in health centres (27). Deaths were predominantly (93.5%) among children aged less than 5 years; 54.5% of measles deaths reported antecedent measles vaccination. In this setting, the number of deaths due to measles reported in community-based surveillance was much higher than deaths reported in health centres. Lack of reliable population data and incomplete coverage of the surveillance system make it impossible to calculate overall attack rates and cause-specific mortality rates. Similar systems could be rapidly implemented in other difficult outbreak settings.

Relative Bradycardia in Patients with Septic Shock Requiring Vasopressor Therapy

PubMed Central

Beesley, Sarah J.; Wilson, Emily L.; Lanspa, Michael J.; Grissom, Colin K.; Shahul, Sajid; Talmor, Daniel; Brown, Samuel M.

2017-01-01

Importance Tachycardia is common in septic shock, but many patients with septic shock are relatively bradycardic. The incidence, determinants, and implications of relative bradycardia (heart rate <80 beats/min) in septic shock are unknown. Objective To determine mortality associated with patients who are relatively bradycardic while in septic shock. Design Retrospective study of patients admitted for septic shock to study ICUs during 2005-2013. Setting One large academic referral hospital and two community hospitals. Participants Adult patients with septic shock requiring vasopressors. Intervention None. Measurements Primary outcome was 28-day mortality. We used multivariate logistic regression to evaluate the association between relative bradycardia and mortality, controlling for confounding with inverse probability treatment weighting using a propensity score. Results We identified 1,554 patients with septic shock, of whom 686 (44%) met criteria for relative bradycardia at some time. Twenty-eight day mortality in this group was 21% compared to 34% in the never-bradycardic group (p<0.001). Relatively bradycardic patients were older (65 vs. 60 years, p<0.001) and had slightly lower illness severity (SOFA 10 vs 11, p = 0.004, and APACHE II 27 vs. 28, p=0.008). After inverse probability treatment weighting, covariates were balanced, and the association between relative bradycardia and survival persisted (p<0.001). Conclusions Relative bradycardia in patients with septic shock is associated with lower mortality, even after adjustment for confounding. Our data support expanded investigation into whether inducing relative bradycardia will benefit patients with septic shock. PMID:27618277

Tea Consumption and Mortality Among Oldest-Old Chinese

PubMed Central

Ruan, Rongping; Feng, Lei; Li, Jialiang; Ng, Tze-Pin; Zeng, Yi

2013-01-01

Objectives To investigate the association between tea consumption and mortality among oldest-old Chinese. Design Population-based longitudinal data from The Chinese Longitudinal Healthy Longevity Survey (CLHLS) was analyzed using Cox semi-parametric proportional hazard model. Setting 631 randomly selected counties and cities of China’s 22 provinces. Participants 9,093 old adults aged 80 and above who provided complete data at baseline survey (year 1998). Measurements Self-reported current frequency of tea drinking and past frequency around age 60 were ascertained at baseline survey, and follow-up survey was conducted respectively in years 2000, 2002 and 2005. Results Among oldest-old Chinese, tea consumption was associated with reduced risk of mortality after adjusting for demographic characteristics, socioeconomic status, health practices, and health status. Compared with non-tea drinkers, the adjusted hazard ratio (HR) was 0.90 (95% CI 0.84–0.96) for daily tea drinkers (at the baseline survey, 1998) and 1.00 (95% CI 1.01–1.07) for occasional tea drinkers respectively (P for linear trend=0.003). Similar results were found when tea drinking status around age 60 was used in analysis. Further analysis showed that compared to consistently infrequent tea drinkers, subjects who reported frequent tea drinking at both age 60 and at baseline survey had a 10% reduction in mortality (HR=0.90, 95%CI 0.84–0.97). Conclusion Tea consumption is associated reduced risk of mortality among oldest-old Chinese. PMID:24117374

Evaluation of mortality rate and predictors of outcome in dogs receiving outpatient treatment for parvoviral enteritis.

PubMed

Sarpong, Kathryn J; Lukowski, Jennifer M; Knapp, Cassandra G

2017-11-01

OBJECTIVE To determine mortality rates and prognostic factors for dogs with parvoviral enteritis receiving outpatient treatment. DESIGN Retrospective case series and case-control study. ANIMALS 130 client-owned dogs with a diagnosis of parvoviral enteritis between August 1, 2012, and January 31, 2015, that were treated with outpatient care. PROCEDURES Medical records were reviewed and data extracted regarding dog age, body weight, breed, and vaccination history; treatments administered; and short-term (≥ 3 day) outcome (determined via telephone call with owner). Treatments were administered according to clinician preference. Mortality rates were calculated overall and for various signalment and treatment groupings and compared. RESULTS 97 (75%) dogs survived and 33 (25%) dogs failed to survive for ≥ 3 days after initial diagnosis of parvoviral enteritis. Compared with distributions in the general hospital population, Chihuahuas, German Shepherd Dogs, pit bull-type dogs, and males were overrepresented. No significant difference was identified between survivors and nonsurvivors regarding age, body weight, or sex. Dogs prescribed a caloric supplement fed every 2 to 4 hours had a mortality rate of 19% (16/85). Most of these dogs had also received fluids administered SC, an antiemetic, and antimicrobials. CONCLUSIONS AND CLINICAL RELEVANCE Clinicians should note the 25% mortality rate of the dogs with parvoviral enteritis that received outpatient care in this study setting when discussing treatment options with owners of affected dogs who are financially unable to pursue hospitalization.

Direct and maternal additive effects are not the main determinants of Iberian piglet perinatal mortality.

PubMed

Muñoz, M; Rodríguez, M C; García-Cortes, L A; González, A; García-Casco, J M; Silió, L

2017-12-01

Data of 127,800 Iberian piglets were used to study genetic parameters of mortality at birth at the piglet level. These records proceed from three data sets: 4,987 litter of 2,156 sows of a dam line, 2,768 litter of 817 sows of a complete diallel cross between four Iberian strains and 7,153 litter of 2,113 sows of the Torbiscal composite line. Perinatal mortality was considered as a binary trait, and Bayesian threshold animal models were fitted to separately analyse the three data sets. The posterior means of direct heritability were 0.010, 0.004 and 0.003, and those of maternal heritability were 0.034, 0.011 and 0.014 for dam line, diallel cross and Torbiscal line, respectively. Important effects of litter size and parity order were inferred in the three data sets, of within-breed cross-breeding parameters in the diallel cross and of sex and sow handling in the Torbiscal line Therefore, the inclusion of perinatal mortality in the objective of selection is questionable in this breed and strategies for reducing piglet mortality successful in other breeds should be considered. © 2017 Blackwell Verlag GmbH.

Sample size calculations for cluster randomised crossover trials in Australian and New Zealand intensive care research.

PubMed

Arnup, Sarah J; McKenzie, Joanne E; Pilcher, David; Bellomo, Rinaldo; Forbes, Andrew B

2018-06-01

The cluster randomised crossover (CRXO) design provides an opportunity to conduct randomised controlled trials to evaluate low risk interventions in the intensive care setting. Our aim is to provide a tutorial on how to perform a sample size calculation for a CRXO trial, focusing on the meaning of the elements required for the calculations, with application to intensive care trials. We use all-cause in-hospital mortality from the Australian and New Zealand Intensive Care Society Adult Patient Database clinical registry to illustrate the sample size calculations. We show sample size calculations for a two-intervention, two 12-month period, cross-sectional CRXO trial. We provide the formulae, and examples of their use, to determine the number of intensive care units required to detect a risk ratio (RR) with a designated level of power between two interventions for trials in which the elements required for sample size calculations remain constant across all ICUs (unstratified design); and in which there are distinct groups (strata) of ICUs that differ importantly in the elements required for sample size calculations (stratified design). The CRXO design markedly reduces the sample size requirement compared with the parallel-group, cluster randomised design for the example cases. The stratified design further reduces the sample size requirement compared with the unstratified design. The CRXO design enables the evaluation of routinely used interventions that can bring about small, but important, improvements in patient care in the intensive care setting.

Self-Rated Health and Mortality: Does the Relationship Extend to a Low Income Setting?

ERIC Educational Resources Information Center

Frankenberg, Elizabeth; Jones, Nathan R.

2004-01-01

Although a relationship between poor self-reported health status and excess mortality risk has been well-established for industrialized countries, almost no research considers developing countries. We use data from Indonesia to show that in a low-income setting, as in more advantaged parts of the world, individuals who perceive their health to be…

Impact of grouping complications on mortality in traumatic brain injury: A nationwide population-based study.

PubMed

Ho, Chung-Han; Liang, Fu-Wen; Wang, Jhi-Joung; Chio, Chung-Ching; Kuo, Jinn-Rung

2018-01-01

Traumatic brain injury (TBI) is an important health issue with high mortality. Various complications of physiological and cognitive impairment may result in disability or death after TBI. Grouping of these complications could be treated as integrated post-TBI syndromes. To improve risk estimation, grouping TBI complications should be investigated, to better predict TBI mortality. This study aimed to estimate mortality risk based on grouping of complications among TBI patients. Taiwan's National Health Insurance Research Database was used in this study. TBI was defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes: 801-804 and 850-854. The association rule data mining method was used to analyze coexisting complications after TBI. The mortality risk of post-TBI complication sets with the potential risk factors was estimated using Cox regression. A total 139,254 TBI patients were enrolled in this study. Intracerebral hemorrhage was the most common complication among TBI patients. After frequent item set mining, the most common post-TBI grouping of complications comprised pneumonia caused by acute respiratory failure (ARF) and urinary tract infection, with mortality risk 1.55 (95% C.I.: 1.51-1.60), compared with those without the selected combinations. TBI patients with the combined combinations have high mortality risk, especially those aged <20 years with septicemia, pneumonia, and ARF (HR: 4.95, 95% C.I.: 3.55-6.88). We used post-TBI complication sets to estimate mortality risk among TBI patients. According to the combinations determined by mining, especially the combination of septicemia with pneumonia and ARF, TBI patients have a 1.73-fold increased mortality risk, after controlling for potential demographic and clinical confounders. TBI patients aged<20 years with each combination of complications also have increased mortality risk. These results could provide physicians and caregivers with important information to increase their awareness about sequences of clinical syndromes among TBI patients, to prevent possible deaths among these patients.

Understanding the contribution of common childhood illnesses and opportunistic infections to morbidity and mortality in children living with HIV in resource-limited settings.

PubMed

Modi, Surbhi; Chiu, Alex; Ng'eno, Bernadette; Kellerman, Scott E; Sugandhi, Nandita; Muhe, Lulu

2013-11-01

Although antiretroviral treatment (ART) has reduced the incidence of HIV-related opportunistic infections among children living with HIV, access to ART remains limited for children, especially in resource-limited settings. This paper reviews current knowledge on the contribution of opportunistic infections and common childhood illnesses to morbidity and mortality in children living with HIV, highlights interventions known to improve the health of children, and identifies research gaps for further exploration. Literature review of peer-reviewed articles and abstracts combined with expert opinion and operational experience. Morbidity and mortality due to opportunistic infections has decreased in both developed and resource-limited countries. However, the burden of HIV-related infections remains high, especially in sub-Saharan Africa, where the majority of HIV-infected children live. Limitations in diagnostic capacity in resource-limited settings have resulted in a relative paucity of data on opportunistic infections in children. Additionally, the reliance on clinical diagnosis means that opportunistic infections are often confused with common childhood illnesseswhich also contribute to excess morbidity and mortality in these children. Although several preventive interventions have been shown to decrease opportunistic infection-related mortality, implementation of many of these interventions remains inconsistent. In order to reduce opportunistic infection-related mortality, early ART must be expanded, training for front-line clinicians must be improved, and additional research is needed to improve screening and diagnostic algorithms.

Comparative analysis of premature mortality among urban immigrants in Bremen, Germany: a retrospective register-based linkage study

PubMed Central

Makarova, Nataliya; Brand, Tilman; Brünings-Kuppe, Claudia; Pohlabeln, Hermann; Luttmann, Sabine

2016-01-01

Objectives The main objective of this study was to explore differences in mortality patterns among two large immigrant groups in Germany: one from Turkey and the other from the former Soviet Union (FSU). To this end, we investigated indicators of premature mortality. Design This study was conducted as a retrospective population-based study based on mortality register linkage. Using mortality data for the period 2004–2010, we calculated age-standardised death rates (SDR) and standardised mortality ratios (SMR) for premature deaths (

Occupational and leisure time physical activity: risk of all-cause mortality and myocardial infarction in the Copenhagen City Heart Study. A prospective cohort study

PubMed Central

Marott, Jacob Louis; Gyntelberg, Finn; Søgaard, Karen; Suadicani, Poul; Mortensen, Ole S; Prescott, Eva; Schnohr, Peter

2012-01-01

Objectives Men with low physical fitness and high occupational physical activity are recently shown to have an increased risk of cardiovascular disease and all-cause mortality. The association between occupational physical activity with cardiovascular disease and all-cause mortality may also depend on leisure time physical activity. Design A prospective cohort study. Setting The Copenhagen City Heart Study. Participants 7819 men and women aged 25–66 years without a history of cardiovascular disease who attended an initial examination in the Copenhagen City Heart Study in 1976–1978. Outcome measures Myocardial infarction and all-cause mortality. Occupational physical activity was defined by combining information from baseline (1976–1978) with reassessment in 1981–1983. Conventional risk factors were controlled for in Cox analyses. Results During the follow-up from 1976 to 1978 until 2010, 2888 subjects died of all-cause mortality and 787 had a first event of myocardial infarction. Overall, occupational physical activity predicted all-cause mortality and myocardial infarction in men but not in women (test for interaction p=0.02). High occupational physical activity was associated with an increased risk of all-cause mortality among men with low (HR 1.56; 95% CI 1.11 to 2.18) and moderate (HR 1.31; 95% CI 1.05 to 1.63) leisure time physical activity but not among men with high leisure time physical activity (HR 1.00; 95% CI 0.78 to 1.26) (test for interaction p=0.04). Similar but weaker tendencies were found for myocardial infarction. Among women, occupational physical activity was not associated with subsequent all-cause mortality or myocardial infarction. Conclusions The findings suggest that high occupational physical activity imposes harmful effects particularly among men with low levels of leisure time physical activity. PMID:22331387

Thyroid STAtus and 6-Year Mortality in Elderly People Living in a Mildly Iodine-Deficient Area: The Aging in the Chianti Area (InCHIANTI) Study

PubMed Central

Ceresini, Graziano; Ceda, Gian Paolo; Lauretani, Fulvio; Maggio, Marcello; Usberti, Elisa; Marina, Michela; Bandinelli, Stefania; Guralnik, Jack M.; Valenti, Giorgio; Ferrucci, Luigi

2013-01-01

Objectives The relationship between thyroid dysfunction and mortality in elderly subjects is still undefined. In this population study we tested the hypothesis that in older subjects, living in a mildly iodine-deficient area, thyroid dysfunction may be associated with increased mortality independent of potential confounders. Design Longitudinal study Setting Community-based Participants Total of 951 subjects aged 65 years and older Measurements Plasma thyrotropin (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) concentrations and demographic features were evaluated in participants of the Aging in the Chianti Area (InCHIANTI) study, aged 65 years or older. Participants were classified according to thyroid function test. Kaplan-Meier survival and Cox proportional hazards models adjusted for confounders were used in the analysis. Results A total of 819 participants were euthyroid, 83 had Subclinical hyperthyroidism (SHyper), and 29 had Subclinical hypothyroidism (SHypo). Overt Hypo- and Hyperthyroidism were found in 5 and 15 subjects, respectively. During a median of six-years of follow-up, N 210 deaths occurred (22.1 %) of which 98 (46.6%) due to cardiovascular causes. Kaplan–Meier analysis revealed higher overall mortality for SHyper (P<0.04) as compared to euthyroid subjects. After adjusting for multiple confounders, participants with SHyper (Hazard Ratio[HR]:1.65; 95% Confidence Interval [CI]: 1.02–2.69) had significantly higher all-cause mortality than those with normal thyroid function. No significant association was found between SHyper and cardiovascular mortality. In euthyroid subjects, TSH was found to be predictive of a reduced risk of all-cause mortality (HR: 0.76; 95% CI, 0.57–0.99) Conclusion SHyper is an independent risk factor for all-cause mortality in the older population. Low-normal circulating TSH should be carefully monitored in euthyroid elderly individuals. PMID:23647402

Has the difference in mortality between percutaneous coronary intervention and coronary artery bypass grafting in people with heart disease and diabetes changed over the years? A systematic review and meta-regression

PubMed Central

Herbison, Peter; Wong, Cheuk-Kit

2015-01-01

Objectives To examine the difference in outcome between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), to see if it has changed over the years in diabetics deemed eligible for both treatments; and to contrast the long-term mortality findings with those in non-diabetics. Design Meta-analyses using data from randomised controlled trials found by searches on MEDLINE, EMBASE and the Cochrane Controlled Trials Register, from their inception until March 2015. Setting Studies had to be randomised controlled trials comparing PCI with CABG. Participants Those taking part in the studies had to have multivessel cardiac or left main artery cardiac disease and be deemed eligible for both treatments. Interventions PCI or CABG. Primary and secondary outcomes The primary outcome was all cause mortality. Secondary outcomes were a composite of mortality, stroke and myocardial infarction; cardiovascular death; and MACCE (Major Adverse Cardiac or Cerebrovascular Event). The longest follow-up was used in the analysis. Results Among 14 studies (4868 diabetics) reported over three decades, meta-regression shows no relationship between the year of publication and the difference in long term all cause mortality between PCI and CABG. CABG has maintained an approximately 30% mortality advantage compared to PCI. The other outcomes used showed the same lack of change over the years. These findings held true among insulin-requiring and non-insulin-requiring diabetics. However, among non-diabetics included in the 14 studies, there was no difference in mortality outcome between PCI and CABG. Conclusions The difference in outcome between PCI and CABG in diabetics has not narrowed from the beginning—with balloon angioplasty to current PCI—with the second generation of drug eluting stents. In contrast to the non-diabetics, there is a persistent 30% benefit in all cause mortality favouring CABG in diabetics, and this should be a major factor in treatment recommendation. PMID:26719324

Translating the WHO 25×25 goals into a UK context: the PROMISE modelling study

PubMed Central

Cobiac, Linda J; Scarborough, Peter

2017-01-01

Objective Model the impact of targets for obesity, diabetes, raised blood pressure, tobacco use, salt intake, physical inactivity and harmful alcohol use, as outlined in the Global Non-Communicable Disease Action Plan 2013–2020, on mortality and morbidity in the UK population. Design Dynamic population modelling study. Setting UK population. Participants Not available. Main outcome measures Mortality and morbidity (years lived with disability) from non-communicable diseases (NCDs) that are averted or delayed. Probability of achieving a 25% reduction in premature mortality from NCDs by 2025 (current WHO target) and a 33% reduction by 2030 (proposed target). Results The largest improvements in mortality would be achieved by meeting the obesity target and the largest improvements in morbidity would be achieved by meeting the diabetes target. The UK could achieve the 2025 and 2030 targets for reducing premature mortality with only a little additional preventive effort compared with current practice. Achieving all 7 risk targets could avert a total of 300 000 deaths (95% uncertainty interval 250 000 to 350 000) and 1.3 million years lived with disability (1.2–1.4 million) from NCDs by 2025, with the majority of health gains due to reduced mortality and morbidity from heart disease and stroke, and reduced morbidity from diabetes. Potential reductions in morbidity from depression and in morbidity and mortality from dementia at older ages are also substantial. Conclusions The global premature mortality targets are a potentially achievable goal for countries such as the UK that can capitalise on many decades of effort in prevention and treatment. High morbidity diseases and diseases in later life are not addressed in the Global NCD Action Plan and targets, but must also be considered a priority for prevention in the UK where the population is ageing and the costs of health and social care are rising. PMID:28377390

Delayed Antimicrobial Therapy Increases Mortality and Organ Dysfunction Duration in Pediatric Sepsis

PubMed Central

Weiss, Scott L.; Fitzgerald, Julie C.; Balamuth, Fran; Alpern, Elizabeth R.; Lavelle, Jane; Chilutti, Marianne; Grundmeier, Robert; Nadkarni, Vinay M.; Thomas, Neal J.

2014-01-01

Objectives Delayed antimicrobials are associated with poor outcomes in adult sepsis, but data relating antimicrobial timing to mortality and organ dysfunction in pediatric sepsis are limited. We sought to determine the impact of antimicrobial timing on mortality and organ dysfunction in pediatric patients with severe sepsis or septic shock. Design Retrospective observational study. Setting PICU at an academic medical center. Patients One hundred thirty patients treated for severe sepsis or septic shock. Interventions None. Measurements and Main Results We determined if hourly delays from sepsis recognition to initial and first appropriate antimicrobial administration were associated with PICU mortality (primary outcome); ventilator-free, vasoactive-free, and organ failure–free days; and length of stay. Median time from sepsis recognition to initial antimicrobial administration was 140 minutes (interquartile range, 74–277 min) and to first appropriate antimicrobial was 177 minutes (90–550 min). An escalating risk of mortality was observed with each hour delay from sepsis recognition to antimicrobial administration, although this did not achieve significance until 3 hours. For patients with more than 3-hour delay to initial and first appropriate antimicrobials, the odds ratio for PICU mortality was 3.92 (95% CI, 1.27–12.06) and 3.59 (95% CI, 1.09–11.76), respectively. These associations persisted after adjustment for individual confounders and a propensity score analysis. After controlling for severity of illness, the odds ratio for PICU mortality increased to 4.84 (95% CI, 1.45–16.2) and 4.92 (95% CI, 1.30–18.58) for more than 3-hour delay to initial and first appropriate antimicrobials, respectively. Initial antimicrobial administration more than 3 hours was also associated with fewer organ failure–free days (16 [interquartile range, 1–23] vs 20 [interquartile range, 6–26]; p = 0.04). Conclusions Delayed antimicrobial therapy was an independent risk factor for mortality and prolonged organ dysfunction in pediatric sepsis. PMID:25148597

A cancer survival model that takes sociodemographic variations in "normal" mortality into account: comparison with other models

PubMed Central

Kravdal, O

2002-01-01

Study objectives: Sociodemographic differentials in cancer survival have occasionally been studied by using a relative survival approach, where all cause mortality among persons with a cancer diagnosis is compared with that among similar persons without such a diagnosis ("normal" mortality). One should ideally take into account that this "normal" mortality not only depends on age, sex, and period, but also various other sociodemographic variables. However, this has very rarely been done. A method that permits such variations to be considered is presented here, as an alternative to an existing technique, and is compared with a relative survival model where these variations are disregarded and two other methods that have often been used. Design, setting, and participants: The focus is on how education and marital status affect the survival from 12 common cancer types among men and women aged 40–80. Four different types of hazard models are estimated, and differences between effects are compared. The data are from registers and censuses and cover the entire Norwegian population for the years 1960–1991. There are more than 100 000 deaths to cancer patients in this material. Main results and conclusions: A model for registered cancer mortality among cancer patients gives results that for most, but not all, sites are very similar to those from a relative survival approach where educational or marital variations in "normal" mortality are taken into account. A relative survival approach without consideration of these sociodemographic variations in "normal" mortality gives more different results, the most extreme example being the doubling of the marital differentials in survival from prostate cancer. When neither sufficient data on cause of death nor on variations in "normal" mortality are available, one may well choose the simplest method, which is to model all cause mortality among cancer patients. There is little reason to bother with the estimation of a relative-survival model that does not allow sociodemographic variations in "normal" mortality beyond those related to age, sex, and period. Fortunately, both these less data demanding models perform well for the most aggressive cancers. PMID:11896140

Sleep Apnea and 20-Year Follow-Up for All-Cause Mortality, Stroke, and Cancer Incidence and Mortality in the Busselton Health Study Cohort

PubMed Central

Marshall, Nathaniel S.; Wong, Keith K.H.; Cullen, Stewart R.J.; Knuiman, Matthew W.; Grunstein, Ronald R.

2014-01-01

Objective: To ascertain whether objectively measured obstructive sleep apnea (OSA) independently increases the risk of all cause death, cardiovascular disease (CVD), coronary heart disease (CHD), stroke or cancer Design: Community-based cohort Setting and Participants: 400 residents of the Western Australian town of Busselton Measures: OSA severity was quantified via the respiratory disturbance index (RDI) as measured by a single night recording in November-December 1990 using the MESAM IV device, along with a range of other risk factors. Follow-up for deaths and hospitalizations was ascertained via record linkage to the end of 2010. Results: We had follow-up data in 397 people and then removed those with a previous stroke (n = 4) from the mortality/ CVD/CHD/stroke analyses and those with cancer history from the cancer analyses (n = 7). There were 77 deaths, 103 cardiovascular events (31 strokes, 59 CHD) and 125 incident cases of cancer (39 cancer fatalities) during 20 years follow-up. In fully adjusted models, moderate-severe OSA was significantly associated with all-cause mortality (HR = 4.2; 95% CI 1.9, 9.2), cancer mortality (3.4; 1.1, 10.2), incident cancer (2.5; 1.2, 5.0), and stroke (3.7; 1.2, 11.8), but not significantly with CVD (1.9; 0.75, 4.6) or CHD incidence (1.1; 0.24, 4.6). Mild sleep apnea was associated with a halving in mortality (0.5; 0.27, 0.99), but no other outcome, after control for leading risk factors. Conclusions: Moderate-to-severe sleep apnea is independently associated with a large increased risk of all-cause mortality, incident stroke, and cancer incidence and mortality in this community-based sample. Commentary: A commentary on this article appears in this issue on page 363. Citation: Marshall NS; Wong KK; Cullen SR; Knuiman MW; Grunstein RR. Sleep apnea and 20-year follow-up for all-cause mortality, stroke, and cancer incidence and mortality in the Busselton health study cohort. J Clin Sleep Med 2014;10(4):355-362. PMID:24733978

Newborn Care in the Home and Health Facility: Formative Findings for Intervention Research in Cambodia

PubMed Central

Bazzano, Alessandra N.; Taub, Leah; Oberhelman, Richard A.; Var, Chivorn

2016-01-01

Global coverage and scale up of interventions to reduce newborn mortality remains low, though progress has been achieved in improving newborn survival in many low-income settings. An important factor in the success of newborn health interventions, and moving to scale, is appropriate design of community-based programs and strategies for local implementation. We report the results of formative research undertaken to inform the design of a newborn health intervention in Cambodia. Information was gathered on newborn care practices over a period of three months using multiple qualitative methods of data collection in the primary health facility and home setting. Analysis of the data indicated important gaps, both at home and facility level, between recommended newborn care practices and those typical in the study area. The results of this formative research have informed strategies for behavior change and improving referral of sick infants in the subsequent implementation study. Collection and dissemination of data on newborn care practices from settings such as these can contribute to efforts to advance survival, growth and development of newborns for intervention research, and for future newborn health programming. PMID:28009812

Predicting Honeybee Colony Failure: Using the BEEHAVE Model to Simulate Colony Responses to Pesticides

PubMed Central

2015-01-01

To simulate effects of pesticides on different honeybee (Apis mellifera L.) life stages, we used the BEEHAVE model to explore how increased mortalities of larvae, in-hive workers, and foragers, as well as reduced egg-laying rate, could impact colony dynamics over multiple years. Stresses were applied for 30 days, both as multiples of the modeled control mortality and as set percentage daily mortalities to assess the sensitivity of the modeled colony both to small fluctuations in mortality and periods of low to very high daily mortality. These stresses simulate stylized exposure of the different life stages to nectar and pollen contaminated with pesticide for 30 days. Increasing adult bee mortality had a much greater impact on colony survival than mortality of bee larvae or reduction in egg laying rate. Importantly, the seasonal timing of the imposed mortality affected the magnitude of the impact at colony level. In line with the LD50, we propose a new index of “lethal imposed stress”: the LIS50 which indicates the level of stress on individuals that results in 50% colony mortality. This (or any LISx) is a comparative index for exploring the effects of different stressors at colony level in model simulations. While colony failure is not an acceptable protection goal, this index could be used to inform the setting of future regulatory protection goals. PMID:26444386

Impact of active screening for methicillin-resistant Staphylococcus aureus (MRSA) and decolonization on MRSA infections, mortality and medical cost: a quasi-experimental study in surgical intensive care unit.

PubMed

Lee, Yuarn-Jang; Chen, Jen-Zon; Lin, Hsiu-Chen; Liu, Hsin-Yi; Lin, Shyr-Yi; Lin, Hsien-Ho; Fang, Chi-Tai; Hsueh, Po-Ren

2015-04-08

Methicillin-resistant Staphylococcus aureus (MRSA) is a leading pathogen of healthcare-associated infections in intensive care units (ICUs). Prior studies have shown that decolonization of MRSA carriers is an effective method to reduce MRSA infections in ICU patients. However, there is currently a lack of data on its effect on mortality and medical cost. Using a quasi-experimental, interrupted time-series design with re-introduction of intervention, we evaluated the impact of active screening and decolonization on MRSA infections, mortality and medical costs in the surgical ICU of a university hospital in Taiwan. Regression models were used to adjust for effects of confounding variables. MRSA infection rate decreased from 3.58 (baseline) to 0.42‰ (intervention period) (P <0.05), re-surged to 2.21‰ (interruption period) and decreased to 0.18‰ (re-introduction of intervention period) (P <0.05). Patients admitted to the surgical ICU during the intervention periods had a lower in-hospital mortality (13.5% (155 out of 1,147) versus 16.6% (203 out of 1,226), P = 0.038). After adjusting for effects of confounding variables, the active screening and decolonization program was independently associated with a decrease in in-hospital MRSA infections (adjusted odds ratio: 0.3; 95% CI: 0.1 to 0.8) and 90-day mortality (adjusted hazard ratio: 0.8; 95% CI: 0.7 to 0.99). Cost analysis showed that $22 medical costs can be saved for every $1 spent on the intervention. Active screening for MRSA and decolonization in ICU settings is associated with a decrease in MRSA infections, mortality and medical cost.

A Severe Sepsis Mortality Prediction Model and Score for Use with Administrative Data

PubMed Central

Ford, Dee W.; Goodwin, Andrew J.; Simpson, Annie N.; Johnson, Emily; Nadig, Nandita; Simpson, Kit N.

2016-01-01

Objective Administrative data is used for research, quality improvement, and health policy in severe sepsis. However, there is not a sepsis-specific tool applicable to administrative data with which to adjust for illness severity. Our objective was to develop, internally validate, and externally validate a severe sepsis mortality prediction model and associated mortality prediction score. Design Retrospective cohort study using 2012 administrative data from five US states. Three cohorts of patients with severe sepsis were created: 1) ICD-9-CM codes for severe sepsis/septic shock, 2) ‘Martin’ approach, and 3) ‘Angus’ approach. The model was developed and internally validated in ICD-9-CM cohort and externally validated in other cohorts. Integer point values for each predictor variable were generated to create a sepsis severity score. Setting Acute care, non-federal hospitals in NY, MD, FL, MI, and WA Subjects Patients in one of three severe sepsis cohorts: 1) explicitly coded (n=108,448), 2) Martin cohort (n=139,094), and 3) Angus cohort (n=523,637) Interventions None Measurements and Main Results Maximum likelihood estimation logistic regression to develop a predictive model for in-hospital mortality. Model calibration and discrimination assessed via Hosmer-Lemeshow goodness-of-fit (GOF) and C-statistics respectively. Primary cohort subset into risk deciles and observed versus predicted mortality plotted. GOF demonstrated p>0.05 for each cohort demonstrating sound calibration. C-statistic ranged from low of 0.709 (sepsis severity score) to high of 0.838 (Angus cohort) suggesting good to excellent model discrimination. Comparison of observed versus expected mortality was robust although accuracy decreased in highest risk decile. Conclusions Our sepsis severity model and score is a tool that provides reliable risk adjustment for administrative data. PMID:26496452

Association of Modality with Mortality among Canadian Aboriginals

PubMed Central

Hemmelgarn, Brenda; Rigatto, Claudio; Komenda, Paul; Yeates, Karen; Promislow, Steven; Mojica, Julie; Tangri, Navdeep

2012-01-01

Summary Background and objectives Previous studies have shown that Aboriginals and Caucasians experience similar outcome on dialysis in Canada. Using the Canadian Organ Replacement Registry, this study examined whether dialysis modality (peritoneal or hemodialysis) impacted mortality in Aboriginal patients. Design, setting, participants, & measurements This study identified 31,576 adult patients (hemodialysis: Aboriginal=1839, Caucasian=21,430; peritoneal dialysis: Aboriginal=554, Caucasian=6769) who initiated dialysis between January of 2000 and December of 2009. Aboriginal status was identified by self-report. Dialysis modality was determined 90 days after dialysis initiation. Multivariate Cox proportional hazards and competing risk models were constructed to determine the association between race and mortality by dialysis modality. Results During the study period, 939 (51.1%) Aboriginals and 12,798 (53.3%) Caucasians initiating hemodialysis died, whereas 166 (30.0%) and 2037 (30.1%), respectively, initiating peritoneal dialysis died. Compared with Caucasians, Aboriginals on hemodialysis had a comparable risk of mortality (adjusted hazards ratio=1.04, 95% confidence interval=0.96–1.11, P=0.37). However, on peritoneal dialysis, Aboriginals experienced a higher risk of mortality (adjusted hazards ratio=1.36, 95% confidence interval=1.13–1.62, P=0.001) and technique failure (adjusted hazards ratio=1.29, 95% confidence interval=1.03–1.60, P=0.03) than Caucasians. The risk of technique failure varied by patient age, with younger Aboriginals (<50 years old) more likely to develop technique failure than Caucasians (adjusted hazards ratio=1.76, 95% confidence interval=1.23–2.52, P=0.002). Conclusions Aboriginals on peritoneal dialysis experience higher mortality and technique failure relative to Caucasians. Reasons for this race disparity in peritoneal dialysis outcomes are unclear. PMID:22997343

The effect of maternal child marriage on morbidity and mortality of children under 5 in India: cross sectional study of a nationally representative sample

PubMed Central

Saggurti, Niranjan; Winter, Michael; Labonte, Alan; Decker, Michele R; Balaiah, Donta; Silverman, Jay G

2010-01-01

Objective To assess associations between maternal child marriage (marriage before age 18) and morbidity and mortality of infants and children under 5 in India. Design Cross-sectional analyses of nationally representative household sample. Generalised estimating equation models constructed to assess associations. Adjusted models included maternal and child demographics and maternal body mass index as covariates. Setting India. Population Women aged 15-49 years (n=124 385); data collected in 2005-6 through National Family Health Survey-3. Data about child morbidity and mortality reported by participants. Analyses restricted to births in past five years reported by ever married women aged 15-24 years (n=19 302 births to 13 396 mothers). Main outcome measures In under 5s: mortality related infectious diseases in the past two weeks (acute respiratory infection, diarrhoea); malnutrition (stunting, wasting, underweight); infant (age <1 year) and child (1-5 years) mortality; low birth weight (<2500 kg). Results The majority of births (73%; 13 042/19 302) were to mothers married as minors. Although bivariate analyses showed significant associations between maternal child marriage and infant and child diarrhoea, malnutrition (stunted, wasted, underweight), low birth weight, and mortality, only stunting (adjusted odds ratio 1.22, 95% CI 1.12 to 1.33) and underweight (1.24, 1.14 to 1.36) remained significant in adjusted analyses. We noted no effect of maternal child marriage on health of boys versus girls. Conclusions The risk of malnutrition is higher in young children born to mothers married as minors than in those born to women married at a majority age. Further research should examine how early marriage affects food distribution and access for children in India. PMID:20093277

Functional Status in ICU Survivors and out of hospital outcomes: a cohort study

PubMed Central

Rydingsward, Jessica E.; Horkan, Clare M.; Mogensen, Kris M.; Quraishi, Sadeq A.; Amrein, Karin; Christopher, Kenneth B.

2016-01-01

Objective Functional status at hospital discharge may be a risk factor for adverse events among survivors of critical illness. We sought to examine the association between functional status at hospital discharge in survivors of critical care and risk of 90-day all-cause mortality after hospital discharge. Design Single center retrospective cohort study Setting Academic Medical Center Patients 10,343 adults who received critical care from 1997 to 2011 and survived hospitalization. Interventions None Measurements and Main Results The exposure of interest was functional status determined at hospital discharge by a licensed physical therapist and rated based on qualitative categories adapted from the Functional Independence Measure. The main outcome was 90-day post hospital discharge all-cause mortality. A categorical risk prediction score was derived and validated based on a logistic regression model of the function grades for each assessment. In an adjusted logistic regression model, the lowest quartile of functional status at hospital discharge was associated with an increased odds of 90-day post-discharge mortality compared to patients with independent functional status [OR=7.63 (95%CI 3.83, 15.22; P<0.001)]. In patients who had at least seven days of physical therapy treatment prior to hospital discharge (N=2,293), the adjusted odds of 90-day post-discharge mortality in patients with marked improvement in functional status at discharge was 64% less than patients with no change in functional status [OR 0.36 (95%CI 0.24–0.53); P<0.001]. Conclusions Lower functional status at hospital discharge in survivors of critical illness is associated with increased post-discharge mortality. Further, patients whose functional status improves before discharge have decreased odds of post-discharge mortality. PMID:26929191

Neighbourhoods and homicide mortality: an analysis of race/ethnic differences

PubMed Central

Krueger, P; Bond, H; Rogers, R; Hummer, R

2004-01-01

Objective: To examine whether measures of neighbourhood economic deprivation, social disorganisation, and acculturation explain homicide mortality differentials between Mexican Americans, non-Hispanic black Americans, and non-Hispanic white Americans, net of individual factors. Design: Prospective study, National Health Interview Survey (1986–1994) linked to subsequent mortality in the National Death Index (1986–1997). Setting: United States of America. Participants: A nationally representative sample of non-institutionalised Mexican Americans, non-Hispanic black Amricans, and non-Hispanic white Americans, aged 18–50 at the point of interview. Analysis: Cox proportional hazard models estimate the risk of death associated with various neighbourhood and individual factors. Main results: Both individual and neighbourhood risk factors partially account for race/ethnic disparities in homicide. Homicide mortality risks are between 20% and 50% higher for residents of areas that have economic inequality of 0.50 or greater based on the coefficient of variation, or where 4% or more of the residents are Mexican American, 10% or more of the residents are non-Hispanic black, or 20% or more of the households are headed by single parents (p⩽.05). But residents of areas where 10% or more of their neighbours are foreign born have 35% lower mortality risks than people living in areas with fewer foreign born people (p⩽0.05). These differences persist even after controlling for individual level risk factors. Conclusions: The findings support economic deprivation, social disorganisation, and acculturation theories, and suggest that both neighbourhood and individual risk factors affect race/ethnic differences in homicide mortality. Public health policies must focus on both individual and neighbourhood factors to reduce homicide risks in vulnerable populations. PMID:14966236

Pre-ESRD Changes in Body Weight and Survival in Nursing Home Residents Starting Dialysis

PubMed Central

Stack, Shobha; Chertow, Glenn M.; Johansen, Kirsten L.; Si, Yan

2013-01-01

Summary Background and objectives Among patients receiving maintenance dialysis, weight loss at any body mass index is associated with mortality. However, it is not known whether weight changes before dialysis initiation are associated with mortality and if so, what risks are associated with weight gain or loss. Design, setting, participants, and measurements Linking data from the US Renal Data System to a national registry of nursing home residents, this study identified 11,090 patients who started dialysis between January of 2000 and December of 2006. Patients were categorized according to weight measured between 3 and 6 months before dialysis initiation and the percentage change in body weight before dialysis initiation (divided into quintiles). The outcome was mortality within 1 year of starting dialysis. Results There were 361 patients (3.3%) who were underweight (Quételet’s [body mass] index<18.5 kg/m2) and 4046 patients (36.5%) who were obese (body mass index≥30 kg/m2) before dialysis initiation. The median percentage change in body weight before dialysis initiation was −6% (interquartile range=−13% to 1%). There were 6063 deaths (54.7%) over 1 year of follow-up. Compared with patients with minimal weight changes (−3% to 3%, quintile 4), patients with weight loss ≥15% (quintile 1) had 35% higher risk for mortality (95% confidence interval, 1.25 to 1.47), whereas those patients with weight gain≥4% (quintile 5) had a 24% higher risk for mortality (95% confidence interval, 1.14 to 1.35) adjusted for baseline body mass index and other confounders. Conclusions Among nursing home residents, changes in body weight in advance of dialysis initiation are associated with significantly higher 1-year mortality. PMID:24009221

Dietary pattern and 20 year mortality in elderly men in Finland, Italy, and The Netherlands: longitudinal cohort study.

PubMed Central

Huijbregts, P.; Feskens, E.; Räsänen, L.; Fidanza, F.; Nissinen, A.; Menotti, A.; Kromhout, D.

1997-01-01

OBJECTIVE: To investigate the association of dietary pattern and mortality in international data. DESIGN: Cohort study with 20 years' follow up of mortality. SETTING: Five cohorts in Finland, the Netherlands, and Italy. SUBJECTS: Population based random sample of 3045 men aged 50-70 years in 1970. MAIN OUTCOME MEASURES: Food intake was estimated using a cross check dietary history. In this dietary survey method, the usual food consumption pattern in the 6-12 months is estimated. A healthy diet indicator was calculated for the dietary pattern, using the World Health Organisation's guidelines for the prevention of chronic diseases. Vital status was verified after 20 years of follow up, and death rates were calculated. RESULTS: Dietary intake varied greatly in 1970 between the three countries. In Finland and the Netherlands the intake of saturated fatty acids and cholesterol was high and the intake of alcohol was low; in Italy the opposite was observed. In total 1796 men (59%) died during 20 years of follow up. The healthy diet indicator was inversely associated with mortality (P for trend < 0.05). After adjustment for age, smoking, and alcohol consumption, the relative risk in the group with the healthiest diet indicator compared with the group with the least healthy was 0.87 (95% confidence interval 0.77 to 0.98). Estimated relative risks were essentially similar within each country. CONCLUSIONS: Dietary intake of men aged 50-70 is associated with a 20 year, all cause mortality in different cultures. The healthy diet indicator is useful in evaluating the relation of mortality to dietary patterns. PMID:9233319

Dialysate Sodium Concentration and the Association with Interdialytic Weight Gain, Hospitalization, and Mortality

PubMed Central

Hecking, Manfred; Karaboyas, Angelo; Saran, Rajiv; Sen, Ananda; Inaba, Masaaki; Rayner, Hugh; Hörl, Walter H.; Pisoni, Ronald L.; Robinson, Bruce M.; Sunder-Plassmann, Gere; Port, Friedrich K.

2012-01-01

Summary Background and objectives Recommendations to decrease the dialysate sodium (DNa) prescription demand analyses of patient outcomes. We analyzed morbidity and mortality at various levels of DNa, simultaneously accounting for interdialytic weight gain (IDWG) and for the mortality risk associated with lower predialysis serum sodium (SNa) levels. Design, setting, participants, & measurements We used multiply-adjusted linear mixed models to evaluate the magnitude of IDWG and Cox proportional hazards models to assess hospitalizations and deaths in 29,593 patients from the Dialysis Outcomes and Practice Patterns Study with baseline DNa and SNa as predictors, categorized according to lowest to highest levels. Results IDWG increased with higher DNa across all SNa categories, by 0.17% of body weight per 2 mEq/L higher DNa; however, higher DNa was not associated with higher mortality in a fully adjusted model (also adjusted for SNa; hazard ratio [HR]=0.98 per 2 mEq/L higher DNa, 95% confidence interval [CI] 0.95–1.02). Instead, higher DNa was associated with lower hospitalization risk (HR=0.97 per 2 mEq/L higher DNa, 95% CI 0.95–1.00, P=0.04). Additional adjustments for IDWG did not change these results. In sensitivity analyses restricted to study facilities, in which 90%–100% of patients have the same DNa (56%), the adjusted HR for mortality was 0.88 per 2 mEq/L higher DNa (95% CI 0.83–0.94). These analyses represented a pseudo-randomized experiment in which the association between DNa and mortality is unlikely to have been confounded by indication. Conclusions In the absence of randomized prospective studies, the benefit of reducing IDWG by decreasing DNa prescriptions should be carefully weighed against an increased risk for adverse outcomes. PMID:22052942

Fibroblast Growth Factor 23 and Cause-Specific Mortality in the General Population: The Northern Manhattan Study

PubMed Central

Souma, Nao; Isakova, Tamara; Lipiszko, David; Sacco, Ralph L.; Elkind, Mitchell S. V.; DeRosa, Janet T.; Silverberg, Shonni J.; Mendez, Armando J.; Dong, Chuanhui

2016-01-01

Context: An elevated fibroblast growth factor (FGF) 23 is an independent risk factor for cardiovascular disease and mortality in patients with kidney disease. The relationship between FGF23 and cause-specific mortality in the general population is unknown. Objective: To investigate the association of elevated FGF23 with the risk of cause-specific mortality in a racially and ethnically diverse urban general population. Design, Setting, Participants: The Northern Manhattan Study is a population-based prospective cohort study. Residents who were > 39 years old and had no history of stroke were enrolled between 1993 and 2001. Participants with available blood samples for baseline FGF23 testing were included in the current study (n = 2525). Main Outcome Measures: Cause-specific death events. Results: A total of 1198 deaths (474 vascular, 612 nonvascular, 112 unknown cause) occurred during a median follow-up of 14 years. Compared to participants in the lowest FGF23 quintile, those in the highest quintile had a 2.07-fold higher risk (95% confidence interval [CI], 1.45, 2.94) of vascular death and a 1.64-fold higher risk (95% CI, 1.22, 2.20) of nonvascular death in fully adjusted models. Higher FGF23 was independently associated with increased risk of mortality due to cancer, but only in Hispanic participants (hazard ratio per 1 unit increase in ln FGF23 of 1.87; 95% CI, 1.40, 2.50; P for interaction = .01). Conclusions: Elevated FGF23 was independently associated with increased risk of vascular and nonvascular mortality in a diverse general population and with increased risk of cancer death specifically in Hispanic individuals. PMID:27501282

Survival Advantage in Black Versus White Men With CKD: Effect of Estimated GFR and Case Mix

PubMed Central

Kovesdy, Csaba P.; Quarles, L. Darryl; Lott, Evan H.; Lu, Jun Ling; Ma, Jennie Z.; Molnar, Miklos Z.; Kalantar-Zadeh, Kamyar

2013-01-01

Background Black dialysis patients have significantly lower mortality compared to white patients, in contradistinction to the higher mortality seen in blacks in the general population. It is unclear if a similar paradox exists in non–dialysis-dependent CKD, and if it does, what its underlying reasons are. Study Design Historical cohort. Setting & Participants 518,406 white and 52,402 black male US veterans with non-dialysis dependent CKD stages 3–5. Predictor Black race. Outcomes & Measurements We examined overall and CKD stage-specific all-cause mortality using parametric survival models. The effect of sociodemographic characteristics, comorbidities and laboratory characteristics on the observed differences was explored in multivariable models. Results Over a median follow-up of 4.7 years 172,093 patients died (mortality rate, 71.0 [95% CI, 70.6–71.3] per 1000 patient-years). Black race was associated with significantly lower crude mortality (HR, 0.95; 95% CI, 0.94–0.97; p<0.001). The survival advantage was attenuated after adjustment for age (HR, 1.14; 95% CI, 1.12–1.16), but was even magnified after full multivariable adjustment (HR, 0.72; 95% CI, 0.70–0.73; p<0.001). The unadjusted survival advantage of blacks was more prominent in those with more advanced stages of CKD, but CKD stage-specific differences were attenuated by multivariable adjustment. Limitations Exclusively male patients. Conclusions Black patients with CKD have lower mortality compared to white patients. The survival advantage seen in blacks is accentuated in patients with more advanced stages of CKD, which may be explained by changes in case mix and laboratory characteristics occurring during the course of kidney disease. PMID:23369826

Effects of education and other socioeconomic factors on middle age mortality in rural Bangladesh

PubMed Central

Hurt, L; Ronsmans, C; Saha, S

2004-01-01

Study objective: To examine socioeconomic gradients in mortality in adult women and their husbands in Bangladesh, paying particular attention to the independent effects of the educational status of each spouse. Design: Historical cohort study. Setting: Matlab, a rural area 60 km south east of Dhaka, the capital of Bangladesh. Participants: 14 803 married women aged 45 or over and their husbands who were resident in the Matlab Demographic Surveillance area between 30 June 1982 and 31 December 1998. Main results: Mortality was lower in women with formal or Koranic education compared with those with none (adjusted rate ratio for formal education = 0.68, 95% CI 0.53 to 0.86; adjusted rate ratio for Koranic schooling = 0.82, 95% CI 0.66 to 1.00). After adjusting for her own education, the husband's level of education or occupation did not have an independent effect on a woman's survival. Men who had attended formal education had lower mortality than those without any education (adjusted rate ratio = 0.84, 95% CI 0.75 to 0.93), but men whose wives had been educated had an additional survival advantage independent of their own education and occupation (adjusted rate ratio = 0.76, 95% CI 0.67 to 0.87). Mortality in both sexes was also significantly associated with marital status and the percentage of surviving children, and in men was associated with the man's occupation, religion, area of residence. Conclusions: The data suggest that socioeconomic status has a strong influence on mortality in adults in Bangladesh. They also illustrate how important the continued promotion of education, particularly for women, may be for the survival of both women and men in rural Bangladesh. PMID:15026446

Association of Subdural Hematoma With Increased Mortality in Lobar Intracerebral Hemorrhage

PubMed Central

Patel, Pratik V.; FitzMaurice, Emilie; Kaveer Nandigam, R. N.; Auluck, Pavan; Viswanathan, Anand; Goldstein, Joshua N.; Rosand, Jonathan; Greenberg, Steven M.; Smith, Eric E.

2011-01-01

Objective To determine the prevalence of subdural hematoma (SDH) in patients presenting with primary non-traumatic lobar intracerebral hemorrhage (ICH) and characteristics associated with the presence of SDH. Design Retrospective analysis of data collected in a prospective cohort study. Setting Hospital. Patients Consecutive sample of 200 patients with primary lobar ICH and 75 patients with deep hemispheric ICH. Main Outcome Measures Presence of SDH and mortality. Results Subdural hematoma was present in 40 of 200 patients (20%) with primary lobar ICH. By contrast, SDH was not present in any of 75 consecutive patients with deep hemispheric ICH (P<.001 for comparison with lobar ICH). Intracerebral hemorrhage volume higher than 60 cm3 was the only independent predictor of SDH (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.14–6.34; P=.02). Subdural hematoma thickness more than 5 mm was an independent predictor of increased 30-day mortality (OR, 7.60; 95% CI, 1.86–30.99; P=.005) after controlling for other factors including ICH volume. Further analysis showed that the effect of SDH on mortality depended on ICH volume, with larger odds for mortality in those with low ICH volume (OR, 12.85; 95% CI, 2.42–68.23; P=.003 for those with ICH volume <30 cm3). Cerebral amyloid angiopathy was present in 8 of 9 patients with pathological specimens. Conclusions Nontraumatic SDH frequently accompanies primary lobar ICH and is associated with higher 30-day mortality, particularly when the ICH volume is relatively low. Rupture of an amyloid-laden leptomeningeal vessel, with extravasation into the brain parenchyma and subdural space, may be the pathogenic mechanism. PMID:19139303

What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe

PubMed Central

Bouvier-Colle, M-H; Mohangoo, AD; Gissler, M; Novak-Antolic, Z; Vutuc, C; Szamotulska, K; Zeitlin, J

2012-01-01

Objective To assess capacity to develop routine monitoring of maternal health in the European Union using indicators of maternal mortality and severe morbidity. Design Analysis of aggregate data from routine statistical systems compiled by the EURO-PERISTAT project and comparison with data from national enquiries. Setting Twenty-five countries in the European Union and Norway. Population Women giving birth in participating countries in 2003 and 2004. Methods Application of a common collection of data by selecting specific International Classification of Disease codes from the ‘Pregnancy, childbirth and the puerperium’ chapter. External validity was assessed by reviewing the results of national confidential enquiries and linkage studies. Main outcome measures Maternal mortality ratio, with distribution of specific obstetric causes, and severe acute maternal morbidity, which included: eclampsia, surgery and blood transfusion for obstetric haemorrhage, and intensive-care unit admission. Results In 22 countries that provided data, the maternal mortality ratio was 6.3 per 100 000 live births overall and ranged from 0 to 29.6. Under-ascertainment was evident from comparisons with studies that use enhanced identification of deaths. Furthermore, routine cause of death registration systems in countries with specific systems for audit reported higher maternal mortality ratio than those in countries without audits. For severe acute maternal morbidity, 16 countries provided data about at least one category of morbidity, and only three provided data for all categories. Reported values ranged widely (from 0.2 to 1.6 women with eclampsia per 1000 women giving birth and from 0.2 to 1.0 hysterectomies per 1000 women). Conclusions Currently available data on maternal mortality and morbidity are insufficient for monitoring trends over time in Europe and for comparison between countries. Confidential enquiries into maternal deaths are recommended. PMID:22571748

Residential and occupational exposure to sunlight and mortality from non-Hodgkin's lymphoma: composite (threefold) case-control study.

PubMed Central

Freedman, D. M.; Zahm, S. H.; Dosemeci, M.

1997-01-01

OBJECTIVE: To determine whether non-Hodgkin's lymphoma mortality is associated with sunlight exposure. DESIGN: Three case-control studies based on death certificates of non-Hodgkin's lymphoma, melanoma, and skin cancer mortality examining associations with potential sunlight exposure from residence and occupation. SETTING: 24 states in the United States. SUBJECTS: All cases were deaths from non-Hodgkin's lymphoma, melanoma, and non-melanotic skin cancer between 1984 and 1991. Two age, sex, and race frequency matched controls per case were selected from non-cancer deaths. MAIN OUTCOME MEASURES: Odds ratios for non-Hodgkin's lymphoma, melanoma, and skin cancer from residential and occupational sunlight exposure adjusted for age, sex, race, socioeconomic status, and farming occupation. RESULTS: Non-Hodgkin's lymphoma mortality was not positively associated with sunlight exposure based on residence. Both melanoma and skin cancer were positively associated with residential sunlight exposure. Adjusted odds ratios for residing in states with the highest sunlight exposure were 0.83 (95% confidence interval 0.81 to 0.86) for non-Hodgkin's lymphoma, 1.12 (1.06 to 1.19) for melanoma, and 1.30 (1.18 to 1.43) for skin cancer. In addition, non-Hodgkin's lymphoma mortality was not positively associated with occupational sunlight exposure (odds ratio 0.88; 0.81 to 0.96). Skin cancer was slightly positively associated with occupational sunlight exposure (1.14; 0.96 to 1.36). CONCLUSIONS: Unlike skin cancer and to some extent melanoma, non-Hodgkin's lymphoma mortality was not positively associated with exposure to sunlight. The findings do not therefore support the hypothesis that sunlight exposure contributes to the rising rates of non-Hodgkin's lymphoma. PMID:9167561

Best predictors for postfire mortality of ponderosa pine trees in the Intermountain West

Treesearch

Carolyn Hull Sieg; Joel D. McMillin; James F. Fowler; Kurt K. Allen; Jose F. Negron; Linda L. Wadleigh; John A. Anhold; Ken E. Gibson

2006-01-01

Numerous wildfires in recent years have highlighted managers' needs for reliable tools to predict postfire mortality of ponderosa pine (Pinus ponderosa Dougl. ex Laws.) trees. General applicability of existing mortality models is uncertain, as researchers have used different sets of variables. We quantified tree attributes, crown and bole fire...

A cluster randomized trial of routine HIV-1 viral load monitoring in Zambia: study design, implementation, and baseline cohort characteristics.

PubMed

Koethe, John R; Westfall, Andrew O; Luhanga, Dora K; Clark, Gina M; Goldman, Jason D; Mulenga, Priscilla L; Cantrell, Ronald A; Chi, Benjamin H; Zulu, Isaac; Saag, Michael S; Stringer, Jeffrey S A

2010-03-12

The benefit of routine HIV-1 viral load (VL) monitoring of patients on antiretroviral therapy (ART) in resource-constrained settings is uncertain because of the high costs associated with the test and the limited treatment options. We designed a cluster randomized controlled trial to compare the use of routine VL testing at ART-initiation and at 3, 6, 12, and 18 months, versus our local standard of care (which uses immunological and clinical criteria to diagnose treatment failure, with discretionary VL testing when the two do not agree). Dedicated study personnel were integrated into public-sector ART clinics. We collected participant information in a dedicated research database. Twelve ART clinics in Lusaka, Zambia constituted the units of randomization. Study clinics were stratified into pairs according to matching criteria (historical mortality rate, size, and duration of operation) to limit the effect of clustering, and independently randomized to the intervention and control arms. The study was powered to detect a 36% reduction in mortality at 18 months. From December 2006 to May 2008, we completed enrollment of 1973 participants. Measured baseline characteristics did not differ significantly between the study arms. Enrollment was staggered by clinic pair and truncated at two matched sites. A large clinical trial of routing VL monitoring was successfully implemented in a dynamic and rapidly growing national ART program. Close collaboration with local health authorities and adequate reserve staff were critical to success. Randomized controlled trials such as this will likely prove valuable in determining long-term outcomes in resource-constrained settings. Clinicaltrials.gov NCT00929604.

Viral Infection in Adults with Severe Acute Respiratory Infection in Colombia

PubMed Central

Remolina, Yuly Andrea; Ulloa, María Mercedes; Vargas, Hernán; Díaz, Liliana; Gómez, Sandra Liliana; Saavedra, Alfredo; Sánchez, Edgar; Cortés, Jorge Alberto

2015-01-01

Objectives To identify the viral aetiology in adult patients with severe acute respiratory infection (SARI) admitted to sentinel surveillance institutions in Bogotá in 2012. Design A cross-sectional study was conducted in which microarray molecular techniques for viral identification were used on nasopharyngeal samples of adult patients submitted to the surveillance system, and further descriptions of clinical features and relevant clinical outcomes, such as mortality, need for critical care, use of mechanical ventilation and hospital stay, were obtained. Setting Respiratory infections requiring hospital admission in surveillance centres in Bogotá, Colombia. Participants Ninety-one adult patients with acute respiratory infection (55% were female). Measurements Viral identification, intensive care unit admission, hospital stay, and mortality. Results Viral identification was achieved for 63 patients (69.2%). Comorbidity was frequently identified and mainly involved chronic pulmonary disease or pregnancy. Influenza, Bocavirus and Adenovirus were identified in 30.8%, 28.6% and 18.7% of the cases, respectively. Admission to the intensive care unit occurred in 42.9% of the cases, while mechanical ventilation was required for 36.3%. The average hospital stay was 9.9 days, and mortality was 15.4%. Antibiotics were empirically used in 90.1% of patients. Conclusions The prevalence of viral aetiology of SARI in this study was high, with adverse clinical outcomes, intensive care requirements and high mortality. PMID:26576054

Health Literacy and Outcomes among Patients with Heart Failure

PubMed Central

Peterson, Pamela N; Shetterly, Susan M; Clarke, Christina L; Bekelman, David B; Chan, Paul S; Allen, Larry A; Matlock, Daniel D; Magid, David J; Masoudi, Frederick A

2015-01-01

Context Little is known about the impact of low health literacy among patients with heart failure (HF), a condition that requires self-management and frequent interactions with the healthcare system. Objective Evaluate the association between low health literacy and all-cause rehospitalization and mortality among outpatients with HF. Design and Setting Retrospective cohort study performed at Kaiser Permanente Colorado, an integrated managed care organization. Patients with HF were identified between Jan, 2001 and May, 2008 and followed for a mean of 1.2 years. Patients were surveyed. Health literacy was assessed using three established screening questions and categorized as adequate or low. Patients Outpatients with HF. Main Outcomes All-cause mortality and hospitalization. Results The survey response rate was 72%. Of 1494 patients, 262 (17.5%) had low health literacy. Patients with low health literacy were older, of lower socioeconomic status, less likely to have at least a high school education and had higher rates of coexisting illnesses. In multivariable Cox regression, low health literacy was independently associated with higher mortality (unadjusted 17.6% vs. 6.3%; adjusted hazard ratio [HR]: 1.61; 95% CI 1.06–2.43; p=0.026), but not hospitalization (30.5% vs. 23.2%; HR:1.04; 95% CI 0.79–1.37; p=0.760). Conclusions Among patients with HF in an integrated managed care organization, low health literacy was significantly associated with higher all-cause mortality. PMID:21521851

Longevity of men capable of prolonged vigorous physical exercise: a 32 year follow up of 2259 participants in the Dutch eleven cities ice skating tour.

PubMed Central

van Saase, J L; Noteboom, W M; Vandenbroucke, J P

1990-01-01

OBJECTIVE--To compare the long term survival of a group of athletes taking prolonged vigorous physical exercise to that of the general population. DESIGN--Follow up of a cohort of participants in the Dutch eleven cities ice skating tour (a race and recreational tour) over a distance of 200 kilometers. SETTING--Data on participation from the organising committee and data on mortality from all municipalities in The Netherlands. SUBJECTS--2259 Male athletes. MAIN OUTCOME MEASURES--Comparison of all cause mortality in male participants in the tour with that in the general population of The Netherlands. RESULTS--The standardised mortality ratio for all participants during 32 years of follow up was 0.76 (95% confidence interval 0.68 to 0.85), and 0.90 (0.48 to 1.44) for participants in the race, and 0.72 (0.60 to 0.86) for participants in the recreational tour who finished within the time limit. CONCLUSIONS--The capacity for prolonged and vigorous physical exercise, particularly if the exercise is recreational, is a strong indicator of longevity. Images p1409-a p1411-a PMID:2279154

Effectiveness of Computerized Decision Support Systems Linked to Electronic Health Records: A Systematic Review and Meta-Analysis

PubMed Central

Kwag, Koren H.; Lytras, Theodore; Bertizzolo, Lorenzo; Brandt, Linn; Pecoraro, Valentina; Rigon, Giulio; Vaona, Alberto; Ruggiero, Francesca; Mangia, Massimo; Iorio, Alfonso; Kunnamo, Ilkka; Bonovas, Stefanos

2014-01-01

We systematically reviewed randomized controlled trials (RCTs) assessing the effectiveness of computerized decision support systems (CDSSs) featuring rule- or algorithm-based software integrated with electronic health records (EHRs) and evidence-based knowledge. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Abstracts of Reviews of Effects. Information on system design, capabilities, acquisition, implementation context, and effects on mortality, morbidity, and economic outcomes were extracted. Twenty-eight RCTs were included. CDSS use did not affect mortality (16 trials, 37395 patients; 2282 deaths; risk ratio [RR] = 0.96; 95% confidence interval [CI] = 0.85, 1.08; I2 = 41%). A statistically significant effect was evident in the prevention of morbidity, any disease (9 RCTs; 13868 patients; RR = 0.82; 95% CI = 0.68, 0.99; I2 = 64%), but selective outcome reporting or publication bias cannot be excluded. We observed differences for costs and health service utilization, although these were often small in magnitude. Across clinical settings, new generation CDSSs integrated with EHRs do not affect mortality and might moderately improve morbidity outcomes. PMID:25322302

Illness perceptions predict survival in haemodialysis patients.

PubMed

Chilcot, Joseph; Wellsted, David; Farrington, Ken

2011-01-01

Illness perceptions have been shown to be important determinants of functional and psychosocial outcomes, including quality of life and treatment adherence in end-stage renal disease patients. The aim of this prospective study was to determine whether haemodialysis patients' illness perceptions impact upon survival. Haemodialysis patients from a UK renal service completed the Revised Illness Perception Questionnaire. Over the study period (May 2007 to December 2010), all-cause mortality was recorded as the endpoint. 223 patients were followed up for a median of 15.9 months (min. 10 days, max. 42.7 months). The median dialysis vintage was 17.6 months (min. 4 days, max. 391.3 months). Treatment control perceptions demonstrated a significant association with mortality (HR = 0.91, 95% CI: 0.83-0.99, p = 0.03). After controlling for covariates, including age, albumin, extra renal comorbidity and depression scores, perception of treatment control remained a significant predictor of mortality (HR = 0.89, 95% CI: 0.80-0.99, p = 0.03). Patients' perceptions of treatment control (dialysis therapy) predict survival independently of survival risk factors, including comorbidity. Studies are required to test whether psychological interventions designed to modify maladaptive illness perceptions influence clinical outcomes in this patient setting. Copyright © 2011 S. Karger AG, Basel.

Revisiting the association of blood pressure with mortality in oldest old people in China: community based, longitudinal prospective study

PubMed Central

Lv, Yue-Bin; Gao, Xiang; Yin, Zhao-Xue; Chen, Hua-Shuai; Luo, Jie-Si; Brasher, Melanie Sereny; Kraus, Virginia Byers; Li, Tian-Tian; Zeng, Yi

2018-01-01

Abstract Objective To examine the associations of blood pressure with all cause mortality and cause specific mortality at three years among oldest old people in China. Design Community based, longitudinal prospective study. Setting 2011 and 2014 waves of the Chinese Longitudinal Healthy Longevity Survey, conducted in 22 Chinese provinces. Participants 4658 oldest old individuals (mean age 92.1 years). Main outcome measures All cause mortality and cause specific mortality assessed at three year follow-up. Results 1997 deaths were recorded at three year follow-up. U shaped associations of mortality with systolic blood pressure, mean arterial pressure, and pulse pressure were identified; values of 143.5 mm Hg, 101 mm Hg, and 66 mm Hg conferred the minimum mortality risk, respectively. After adjustment for covariates, the U shaped association remained only for systolic blood pressure (minimum mortality risk at 129 mm Hg). Compared with a systolic blood pressure value of 129 mm Hg, risk of all cause mortality decreased for values lower than 107 mm Hg (from 1.47 (95% confidence interval 1.01 to 2.17) to 1.08 (1.01 to 1.17)), and increased for values greater than 154 mm Hg (from 1.08 (1.01 to 1.17) to 1.27 (1.02 to 1.58)). In the cause specific analysis, compared with a middle range of systolic blood pressure (107-154 mm Hg), higher values (>154 mm Hg) were associated with a higher risk of cardiovascular mortality (adjusted hazard ratio 1.51 (95% confidence interval 1.12 to 2.02)); lower values (<107 mm Hg) were associated with a higher risk of non-cardiovascular mortality (1.58 (1.26 to 1.98)). The U shaped associations remained in sensitivity and subgroup analyses. Conclusions This study indicates a U shaped association between systolic blood pressure and all cause mortality at three years among oldest old people in China. This association could be explained by the finding that higher systolic blood pressure predicted a higher risk of death from cardiovascular disease, and that lower systolic blood pressure predicted a higher risk of death from non-cardiovascular causes. These results emphasise the importance of revisiting blood pressure management or establishing specific guidelines for management among oldest old individuals. PMID:29871897

Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK General Practice Research Database

PubMed Central

Cornish, Rosie; Macleod, John; Strang, John; Vickerman, Peter

2010-01-01

Objective To investigate the effect of opiate substitution treatment at the beginning and end of treatment and according to duration of treatment. Design Prospective cohort study. Setting UK General Practice Research Database Participants Primary care patients with a diagnosis of substance misuse prescribed methadone or buprenorphine during 1990-2005. 5577 patients with 267 003 prescriptions for opiate substitution treatment followed-up (17 732 years) until one year after the expiry of their last prescription, the date of death before this time had elapsed, or the date of transfer away from the practice. Main outcome measures Mortality rates and rate ratios comparing periods in and out of treatment adjusted for sex, age, calendar year, and comorbidity; standardised mortality ratios comparing opiate users’ mortality with general population mortality rates. Results Crude mortality rates were 0.7 per 100 person years on opiate substitution treatment and 1.3 per 100 person years off treatment; standardised mortality ratios were 5.3 (95% confidence interval 4.0 to 6.8) on treatment and 10.9 (9.0 to 13.1) off treatment. Men using opiates had approximately twice the risk of death of women (morality rate ratio 2.0, 1.4 to 2.9). In the first two weeks of opiate substitution treatment the crude mortality rate was 1.7 per 100 person years: 3.1 (1.5 to 6.6) times higher (after adjustment for sex, age group, calendar period, and comorbidity) than the rate during the rest of time on treatment. The crude mortality rate was 4.8 per 100 person years in weeks 1-2 after treatment stopped, 4.3 in weeks 3-4, and 0.95 during the rest of time off treatment: 9 (5.4 to 14.9), 8 (4.7 to 13.7), and 1.9 (1.3 to 2.8) times higher than the baseline risk of mortality during treatment. Opiate substitution treatment has a greater than 85% chance of reducing overall mortality among opiate users if the average duration approaches or exceeds 12 months. Conclusions Clinicians and patients should be aware of the increased mortality risk at the start of opiate substitution treatment and immediately after stopping treatment. Further research is needed to investigate the effect of average duration of opiate substitution treatment on drug related mortality. PMID:20978062

Associations of estimated glomerular filtration rate and albuminuria with mortality and renal failure by sex: a meta-analysis

PubMed Central

Nitsch, Dorothea; Grams, Morgan; Sang, Yingying; Black, Corri; Cirillo, Massimo; Djurdjev, Ognjenka; Iseki, Kunitoshi; Jassal, Simerjot K; Kimm, Heejin; Kronenberg, Florian; Øien, Cecilia M; Levin, Adeera; Woodward, Mark; Hemmelgarn, Brenda R

2013-01-01

Objective To assess for the presence of a sex interaction in the associations of estimated glomerular filtration rate and albuminuria with all-cause mortality, cardiovascular mortality, and end stage renal disease. Design Random effects meta-analysis using pooled individual participant data. Setting 46 cohorts from Europe, North and South America, Asia, and Australasia. Participants 2 051 158 participants (54% women) from general population cohorts (n=1 861 052), high risk cohorts (n=151 494), and chronic kidney disease cohorts (n=38 612). Eligible cohorts (except chronic kidney disease cohorts) had at least 1000 participants, outcomes of either mortality or end stage renal disease of ≥50 events, and baseline measurements of estimated glomerular filtration rate according to the Chronic Kidney Disease Epidemiology Collaboration equation (mL/min/1.73 m2) and urinary albumin-creatinine ratio (mg/g). Results Risks of all-cause mortality and cardiovascular mortality were higher in men at all levels of estimated glomerular filtration rate and albumin-creatinine ratio. While higher risk was associated with lower estimated glomerular filtration rate and higher albumin-creatinine ratio in both sexes, the slope of the risk relationship for all-cause mortality and for cardiovascular mortality were steeper in women than in men. Compared with an estimated glomerular filtration rate of 95, the adjusted hazard ratio for all-cause mortality at estimated glomerular filtration rate 45 was 1.32 (95% CI 1.08 to 1.61) in women and 1.22 (1.00 to 1.48) in men (Pinteraction<0.01). Compared with a urinary albumin-creatinine ratio of 5, the adjusted hazard ratio for all-cause mortality at urinary albumin-creatinine ratio 30 was 1.69 (1.54 to 1.84) in women and 1.43 (1.31 to 1.57) in men (Pinteraction<0.01). Conversely, there was no evidence of a sex difference in associations of estimated glomerular filtration rate and urinary albumin-creatinine ratio with end stage renal disease risk. Conclusions Both sexes face increased risk of all-cause mortality, cardiovascular mortality, and end stage renal disease with lower estimated glomerular filtration rates and higher albuminuria. These findings were robust across a large global consortium. PMID:23360717

Prognostic durability of liver fibrosis tests and improvement in predictive performance for mortality by combining tests.

PubMed

Bertrais, Sandrine; Boursier, Jérôme; Ducancelle, Alexandra; Oberti, Frédéric; Fouchard-Hubert, Isabelle; Moal, Valérie; Calès, Paul

2017-06-01

There is currently no recommended time interval between noninvasive fibrosis measurements for monitoring chronic liver diseases. We determined how long a single liver fibrosis evaluation may accurately predict mortality, and assessed whether combining tests improves prognostic performance. We included 1559 patients with chronic liver disease and available baseline liver stiffness measurement (LSM) by Fibroscan, aspartate aminotransferase to platelet ratio index (APRI), FIB-4, Hepascore, and FibroMeter V2G . Median follow-up was 2.8 years during which 262 (16.8%) patients died, with 115 liver-related deaths. All fibrosis tests were able to predict mortality, although APRI (and FIB-4 for liver-related mortality) showed lower overall discriminative ability than the other tests (differences in Harrell's C-index: P < 0.050). According to time-dependent AUROCs, the time period with optimal predictive performance was 2-3 years in patients with no/mild fibrosis, 1 year in patients with significant fibrosis, and <6 months in cirrhotic patients even in those with a model of end-stage liver disease (MELD) score <15. Patients were then randomly split in training/testing sets. In the training set, blood tests and LSM were independent predictors of all-cause mortality. The best-fit multivariate model included age, sex, LSM, and FibroMeter V2G with C-index = 0.834 (95% confidence interval, 0.803-0.862). The prognostic model for liver-related mortality included the same covariates with C-index = 0.868 (0.831-0.902). In the testing set, the multivariate models had higher prognostic accuracy than FibroMeter V2G or LSM alone for all-cause mortality and FibroMeter V2G alone for liver-related mortality. The prognostic durability of a single baseline fibrosis evaluation depends on the liver fibrosis level. Combining LSM with a blood fibrosis test improves mortality risk assessment. © 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Mortality rates at 10 years after metal-on-metal hip resurfacing compared with total hip replacement in England: retrospective cohort analysis of hospital episode statistics

PubMed Central

Kendal, Adrian R; Prieto-Alhambra, Daniel; Arden, Nigel K; Judge, Andrew

2013-01-01

Objectives To compare 10 year mortality rates among patients undergoing metal-on-metal hip resurfacing and total hip replacement in England. Design Retrospective cohort study. Setting English hospital episode statistics database linked to mortality records from the Office for National Statistics. Population All adults who underwent primary elective hip replacement for osteoarthritis from April 1999 to March 2012. The exposure of interest was prosthesis type: cemented total hip replacement, uncemented total hip replacement, and metal-on-metal hip resurfacing. Confounding variables included age, sex, Charlson comorbidity index, rurality, area deprivation, surgical volume, and year of operation. Main outcome measures All cause mortality. Propensity score matching was used to minimise confounding by indication. Kaplan-Meier plots estimated the probability of survival up to 10 years after surgery. Multilevel Cox regression modelling, stratified on matched sets, described the association between prosthesis type and time to death, accounting for variation across hospital trusts. Results 7437 patients undergoing metal-on-metal hip resurfacing were matched to 22 311 undergoing cemented total hip replacement; 8101 patients undergoing metal-on-metal hip resurfacing were matched to 24 303 undergoing uncemented total hip replacement. 10 year rates of cumulative mortality were 271 (3.6%) for metal-on-metal hip resurfacing versus 1363 (6.1%) for cemented total hip replacement, and 239 (3.0%) for metal-on-metal hip resurfacing versus 999 (4.1%) for uncemented total hip replacement. Patients undergoing metal-on-metal hip resurfacing had an increased survival probability (hazard ratio 0.51 (95% confidence interval 0.45 to 0.59) for cemented hip replacement; 0.55 (0.47 to 0.65) for uncemented hip replacement). There was no evidence for an interaction with age or sex. Conclusions Patients with hip osteoarthritis undergoing metal-on-metal hip resurfacing have reduced mortality in the long term compared with those undergoing cemented or uncemented total hip replacement. This difference persisted after extensive adjustment for confounding factors available in our data. The study results can be applied to matched populations, which exclude patients who are very old and have had complex total hip replacements. Although residual confounding is possible, the observed effect size is large. These findings require validation in external cohorts and randomised clinical trials. PMID:24284336

Daily mortality and air pollutants: findings from Köln, Germany.

PubMed Central

Spix, C; Wichmann, H E

1996-01-01

STUDY OBJECTIVE AND DESIGN: For the APHEA study, the short term effects of air pollutants on human health were investigated in a comparable way in various European cities. Daily mortality was used as one of the health effects indicators. This report aims to demonstrate the steps in epidemiological model building in this type of time series analysis aimed at detecting short term effects under a poisson distribution assumption and shows the tools for decision making. In addition, it assesses the impact of these steps on the pollution effect estimates. SETTING: Köln, Germany, is a city of one million inhabitants. It is densely populated with a warm, humid, unfavourable climate and a high traffic density. In previous studies, smog episodes were found to increase mortality and higher sulphur dioxide (SO2) levels were connected with increases in the number of episodes of croup. PARTICIPANTS, MATERIALS AND METHODS: Daily total mortality was obtained for 1975-85. SO2, total suspended particulates, and nitrogen dioxide (NO2) data were available from two to five stations for the city area, and size fractionated PM7 data from a neighbouring city. The main tools were time series plots of the raw data, predicted and residual data, the partial autocorrelation function and periodogram of the residuals, cross correlations of prefiltered series, plots of categorised influences, chi 2 statistics of influences and sensitivity analyses taking overdispersion and autocorrelation into account. RESULTS AND CONCLUSIONS: With regard to model building, it is concluded that seasonal and epidemic correction are the most important steps. The actual model chosen depends very much on the properties of the data set. For the pollution effect estimates, trend, season, and epidemic corrections are important to avoid overestimation of the effect, while an appropriate short term meterology influence correction model may actually prevent underestimation. When the model leaves very little over-dispersion and autocorrelation in the residuals, which indicates a good fit, correction for them has consequently little impact. Given the model, most of the range of SO2 values (5th centile to 95th centile) led to a 3-4% increase in mortality (significant), particulates led to a 2% increase (borderline significant, less data than for SO2), and NO2 had no relationship with mortality (measurements possibly not representative of actual exposure). Effects were usually delayed by a day. PMID:8758225

Perinatal and maternal outcomes in planned home and obstetric unit births in women at ‘higher risk’ of complications: secondary analysis of the Birthplace national prospective cohort study

PubMed Central

Li, Y; Townend, J; Rowe, R; Brocklehurst, P; Knight, M; Linsell, L; Macfarlane, A; McCourt, C; Newburn, M; Marlow, N; Pasupathy, D; Redshaw, M; Sandall, J; Silverton, L; Hollowell, J

2015-01-01

Objective To explore and compare perinatal and maternal outcomes in women at ‘higher risk’ of complications planning home versus obstetric unit (OU) birth. Design Prospective cohort study. Setting OUs and planned home births in England. Population 8180 ‘higher risk’ women in the Birthplace cohort. Methods We used Poisson regression to calculate relative risks adjusted for maternal characteristics. Sensitivity analyses explored possible effects of differences in risk between groups and alternative outcome measures. Main outcome measures Composite perinatal outcome measure encompassing ‘intrapartum related mortality and morbidity’ (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus or clavicle) and neonatal admission within 48 hours for more than 48 hours. Two composite maternal outcome measures capturing intrapartum interventions/adverse maternal outcomes and straightforward birth. Results The risk of ‘intrapartum related mortality and morbidity’ or neonatal admission for more than 48 hours was lower in planned home births than planned OU births [adjusted relative risks (RR) 0.50, 95% CI 0.31–0.81]. Adjustment for clinical risk factors did not materially affect this finding. The direction of effect was reversed for the more restricted outcome measure ‘intrapartum related mortality and morbidity’ (RR adjusted for parity 1.92, 95% CI 0.97–3.80). Maternal interventions were lower in planned home births. Conclusions The babies of ‘higher risk’ women who plan birth in an OU appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity. Rates of intrapartum related morbidity and mortality did not differ statistically significantly between settings at the 5% level but a larger study would be required to rule out a clinically important difference between the groups. PMID:25603762

Association Between Noninvasive Ventilation and Mortality Among Older Patients With Pneumonia

PubMed Central

Valley, Thomas S.; Walkey, Allan J.; Lindenauer, Peter K.; Wiener, Renda Soylemez; Cooke, Colin R.

2016-01-01

Objective Despite increasing use, evidence is mixed as to the appropriate use of noninvasive ventilation in patients with pneumonia. We aimed to determine the relationship between receipt of noninvasive ventilation and outcomes for patients with pneumonia in a real-world setting. Design, Setting, Patients We performed a retrospective cohort study of Medicare beneficiaries (aged > 64 yr) admitted to 2,757 acute-care hospitals in the United States with pneumonia, who received mechanical ventilation from 2010 to 2011. Exposures Noninvasive ventilation versus invasive mechanical ventilation. Measurement and Main Results The primary outcome was 30-day mortality with Medicare reimbursement as a secondary outcome. To account for unmeasured confounding associated with noninvasive ventilation use, an instrumental variable was used—the differential distance to a high noninvasive ventilation use hospital. All models were adjusted for patient and hospital characteristics to account for measured differences between groups. Among 65,747 Medicare beneficiaries with pneumonia who required mechanical ventilation, 12,480 (19%) received noninvasive ventilation. Patients receiving noninvasive ventilation were more likely to be older, male, white, rural-dwelling, have fewer comorbidities, and were less likely to be acutely ill as measured by organ failures. Results of the instrumental variable analysis suggested that, among marginal patients, receipt of noninvasive ventilation was not significantly associated with differences in 30-day mortality when compared with invasive mechanical ventilation (54% vs 55%; p = 0.92; 95% CI of absolute difference, –13.8 to 12.4) but was associated with significantly lower Medicare spending ($18,433 vs $27,051; p = 0.02). Conclusions Among Medicare beneficiaries hospitalized with pneumonia who received mechanical ventilation, noninvasive ventilation use was not associated with a real-world mortality benefit. Given the wide CIs, however, substantial harm associated with noninvasive ventilation could not be excluded. The use of noninvasive ventilation for patients with pneumonia should be cautioned, but targeted enrollment of marginal patients with pneumonia could enrich future randomized trials. PMID:27749319

Association between Oral Nutritional Supplementation and Clinical Outcomes among Patients with ESRD

PubMed Central

Cheu, Christine; Pearson, Jeffrey; Dahlerus, Claudia; Lantz, Brett; Chowdhury, Tania; Sauer, Peter F.; Farrell, Robert E.; Port, Friedrich K.

2013-01-01

Summary Background and objectives Oral nutritional supplementation (ONS) was provided to ESRD patients with hypoalbuminemia as part of Fresenius Medical Care Health Plan’s (FMCHP) disease management. This study evaluated the association between FMCHP’s ONS program and clinical outcomes. Design, setting, participants, & measurements Analyses included FMCHP patients with ONS indication (n=470) defined as 2-month mean albumin <3.8 g/dl until reaching a 3-month mean ≥3.8 g/dl from February 1, 2006 to December 31, 2008. Patients did not receive ONS if deemed inappropriate or refused. Patients on ONS were compared with patients who were not, despite meeting ONS indication. Patients with ONS indication regardless of use were compared with Medicare patients with similar serum albumin levels from the 2007 Centers for Medicare and Medicaid Services Clinical Performance Measures Project (CPM). Cox models calculated adjusted hospitalization and mortality risks at 1 year. Results Among patients with indication for ONS, 276 received supplements and 194 did not. ONS use was associated with 0.058 g/dl higher serum albumin overall (P=0.02); this difference decreased by 0.001 g/dl each month (P=0.05) such that the difference was 0.052 g/dl (P=0.04) in month 6 and the difference was no longer significant in month 12 . In analyses based on ONS use, ONS patients had lower hospitalization at 1 year (68.4%; P<0.01) versus patients without ONS (88.7%), but there was no significant reduction in mortality risk (P=0.29). In analyses based on ONS indication, patients with indication had lower mortality at 1 year (16.2%) compared with CPM patients (23.4%; P<0.01). Conclusions These findings suggest that ONS use was associated with significantly lower hospitalization rates but had no significant effect on mortality in a disease management setting. PMID:23085729

Tree mortality from drought, insects, and their interactions in a changing climate

Treesearch

William R. L. Anderegg; Jeffrey A. Hicke; Rosie A. Fisher; Craig D. Allen; Juliann Aukema; Barbara Bentz; Sharon Hood; Jeremy W. Lichstein; Alison K. Macalady; Nate McDowell; Yude Pan; Kenneth Raffa; Anna Sala; John D. Shaw; Nathan L. Stephenson; Christina Tague; Melanie Zeppel

2015-01-01

Climate change is expected to drive increased tree mortality through drought, heat stress, and insect attacks, with manifold impacts on forest ecosystems. Yet, climate-induced tree mortality and biotic disturbance agents are largely absent from process-based ecosystem models. Using data sets from the western USA and associated studies, we present a framework for...

Child Mortality in the School Setting. Position Statement. Revised

ERIC Educational Resources Information Center

Bergren, Martha Dewey

2017-01-01

It is the position of the National Association of School Nurses (NASN) that data on children's deaths in school should be recorded, analyzed and reported at the local, state and national levels. The systematic review of data on child mortality is necessary to drive interventions and policies that will decrease mortality from injuries, violence,…

Periodontitis and early mortality among adults treated with hemodialysis: a multinational propensity-matched cohort study.

PubMed

Ruospo, Marinella; Palmer, Suetonia C; Wong, Germaine; Craig, Jonathan C; Petruzzi, Massimo; De Benedittis, Michele; Ford, Pauline; Johnson, David W; Tonelli, Marcello; Natale, Patrizia; Saglimbene, Valeria; Pellegrini, Fabio; Celia, Eduardo; Gelfman, Ruben; Leal, Miguel R; Torok, Marietta; Stroumza, Paul; Bednarek-Skublewska, Anna; Dulawa, Jan; Frantzen, Luc; Del Castillo, Domingo; Schon, Staffan; Bernat, Amparo G; Hegbrant, Jorgen; Wollheim, Charlotta; Gargano, Letizia; Bots, Casper P; Strippoli, Giovanni Fm

2017-05-22

Periodontitis is associated with cardiovascular mortality in the general population and adults with chronic diseases. However, it is unclear whether periodontitis predicts survival in the setting of kidney failure. ORAL-D was a propensity matched analysis in 3338 dentate adults with end-stage kidney disease treated in a hemodialysis network in Europe and South America designed to examine the association between periodontitis and all-cause and cardiovascular-related mortality in people on long-term hemodialysis. Participants were matched 1:1 on their propensity score for moderate to severe periodontitis assessed using the World Health Organization Community Periodontal Index. A random-effects Cox proportional hazards model was fitted with shared frailty to account for clustering of mortality risk within countries. Among the 3338 dentate participants, 1355 (40.6%) had moderate to severe periodontitis at baseline. After using propensity score methods to generate a matched cohort of participants with periodontitis similar to those with none or mild periodontal disease, moderate to severe periodontitis was associated with a lower risk of all-cause (9.1 versus 13.0 per 100 person years, hazard ratio 0.74, 95% confidence interval 0.61 to 0.90) and cardiovascular (4.3 versus 6.9 per 100 person years, hazard ratio 0.67, 0.51 to 0.88) mortality. These associations were not changed substantially when participants were limited to those with 12 or more natural teeth and when accounting for competing causes of cardiovascular death. In contrast to the general population, periodontitis does not appear to be associated with an increased risk of early death in adults treated with hemodialysis.

Effect of conjugal bereavement on mortality of the bereaved spouse in participants of the Renfrew/Paisley Study

PubMed Central

Hart, Carole L; Hole, David J; Lawlor, Debbie A; Smith, George Davey; Lever, Tony F

2007-01-01

Objectives To investigate how loss of a spouse affects mortality risk in the bereaved partner. Design and setting Prospective cohort study in Renfrew and Paisley in Scotland. Participants 4395 married couples aged 45–64 years when the study was carried out between 1972 and 1976. Methods The date of bereavement for the bereaved spouse was the date of death of his or her spouse. Bereavement could occur at any time during the follow‐up period, so it was considered as a time‐dependent exposure variable and the Cox proportional hazards model for time‐dependent variables was used. The relative rate (RR) of mortality was calculated for bereaved versus non‐bereaved spouses and adjusted for confounding variables. Main outcome measures Causes of death to 31 March 2004. Results Bereaved participants were at higher risk than non‐bereaved participants of dying from any cause (RR 1.27; 95% CI 1.2 to 1.35). These risks remained but were attenuated after adjustment for confounding variables. There were raised RRs for bereaved participants dying of cardiovascular disease, coronary heart disease, stroke, all cancer, lung cancer, smoking‐related cancer, and accidents or violence. After adjustment for confounding variables, RRs remained higher for bereaved participants for all these causes except for mortality from lung cancer. There was no strong statistical evidence that the increased risks of death associated with bereavement changed with time after bereavement. Conclusions Conjugal bereavement, in addition to existing risk factors, is related to mortality risk for major causes of death. PMID:17435215

Precision, time, and cost: a comparison of three sampling designs in an emergency setting.

PubMed

Deitchler, Megan; Deconinck, Hedwig; Bergeron, Gilles

2008-05-02

The conventional method to collect data on the health, nutrition, and food security status of a population affected by an emergency is a 30 x 30 cluster survey. This sampling method can be time and resource intensive and, accordingly, may not be the most appropriate one when data are needed rapidly for decision making. In this study, we compare the precision, time and cost of the 30 x 30 cluster survey with two alternative sampling designs: a 33 x 6 cluster design (33 clusters, 6 observations per cluster) and a 67 x 3 cluster design (67 clusters, 3 observations per cluster). Data for each sampling design were collected concurrently in West Darfur, Sudan in September-October 2005 in an emergency setting. Results of the study show the 30 x 30 design to provide more precise results (i.e. narrower 95% confidence intervals) than the 33 x 6 and 67 x 3 design for most child-level indicators. Exceptions are indicators of immunization and vitamin A capsule supplementation coverage which show a high intra-cluster correlation. Although the 33 x 6 and 67 x 3 designs provide wider confidence intervals than the 30 x 30 design for child anthropometric indicators, the 33 x 6 and 67 x 3 designs provide the opportunity to conduct a LQAS hypothesis test to detect whether or not a critical threshold of global acute malnutrition prevalence has been exceeded, whereas the 30 x 30 design does not. For the household-level indicators tested in this study, the 67 x 3 design provides the most precise results. However, our results show that neither the 33 x 6 nor the 67 x 3 design are appropriate for assessing indicators of mortality. In this field application, data collection for the 33 x 6 and 67 x 3 designs required substantially less time and cost than that required for the 30 x 30 design. The findings of this study suggest the 33 x 6 and 67 x 3 designs can provide useful time- and resource-saving alternatives to the 30 x 30 method of data collection in emergency settings.

Precision, time, and cost: a comparison of three sampling designs in an emergency setting

PubMed Central

Deitchler, Megan; Deconinck, Hedwig; Bergeron, Gilles

2008-01-01

The conventional method to collect data on the health, nutrition, and food security status of a population affected by an emergency is a 30 × 30 cluster survey. This sampling method can be time and resource intensive and, accordingly, may not be the most appropriate one when data are needed rapidly for decision making. In this study, we compare the precision, time and cost of the 30 × 30 cluster survey with two alternative sampling designs: a 33 × 6 cluster design (33 clusters, 6 observations per cluster) and a 67 × 3 cluster design (67 clusters, 3 observations per cluster). Data for each sampling design were collected concurrently in West Darfur, Sudan in September-October 2005 in an emergency setting. Results of the study show the 30 × 30 design to provide more precise results (i.e. narrower 95% confidence intervals) than the 33 × 6 and 67 × 3 design for most child-level indicators. Exceptions are indicators of immunization and vitamin A capsule supplementation coverage which show a high intra-cluster correlation. Although the 33 × 6 and 67 × 3 designs provide wider confidence intervals than the 30 × 30 design for child anthropometric indicators, the 33 × 6 and 67 × 3 designs provide the opportunity to conduct a LQAS hypothesis test to detect whether or not a critical threshold of global acute malnutrition prevalence has been exceeded, whereas the 30 × 30 design does not. For the household-level indicators tested in this study, the 67 × 3 design provides the most precise results. However, our results show that neither the 33 × 6 nor the 67 × 3 design are appropriate for assessing indicators of mortality. In this field application, data collection for the 33 × 6 and 67 × 3 designs required substantially less time and cost than that required for the 30 × 30 design. The findings of this study suggest the 33 × 6 and 67 × 3 designs can provide useful time- and resource-saving alternatives to the 30 × 30 method of data collection in emergency settings. PMID:18454866

Interventions to reduce neonatal mortality from neonatal tetanus in low and middle income countries--a systematic review.

PubMed

Khan, Adeel Ahmed; Zahidie, Aysha; Rabbani, Fauziah

2013-04-09

In 1988, WHO estimated around 787,000 newborns deaths due to neonatal tetanus. Despite few success stories majority of the Low and Middle Income Countries (LMICs) are still struggling to reduce neonatal mortality due to neonatal tetanus. We conducted a systematic review to understand the interventions that have had a substantial effect on reducing neonatal mortality rate due to neonatal tetanus in LMICs and come up with feasible recommendations for decreasing neonatal tetanus in the Pakistani setting. We systemically reviewed the published literature (Pubmed and Pubget databases) to identify appropriate interventions for reducing tetanus related neonatal mortality. A total of 26 out of 30 studies were shortlisted for preliminary screening after removing overlapping information. Key words used were "neonatal tetanus, neonatal mortality, tetanus toxoid women". Of these twenty-six studies, 20 were excluded. The pre-defined exclusion criteria was (i) strategies and interventions to reduce mortality among neonates not described (ii) no abstract/author (4 studies) (iii) not freely accessible online (1 study) (iv) conducted in high income countries (2 studies) and (v) not directly related to neonatal tetanus mortality and tetanus toxoid immunization (5). Finally six studies which met the eligibility criteria were entered in the pre-designed data extraction form and five were selected for commentary as they were directly linked with neonatal tetanus reduction. Interventions that were identified to reduce neonatal mortality in LMICs were: a) vaccination of women of child bearing age (married and unmarried both) with tetanus toxoid b) community based interventions i.e. tetanus toxoid immunization for all mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; umbilical cord care and management of infections in newborns c) supplementary immunization (in addition to regular EPI program) d) safer delivery practices. The key intervention to reduce neonatal mortality from neonatal tetanus was found to be vaccination of pregnant women with tetanus toxoid. In the resource poor countries like Pakistan, this single intervention coupled with regular effective antenatal checkups, clean delivery practices and compliance with the "high- risk" approach can be effective in reducing neonatal tetanus.

Interventions to reduce neonatal mortality from neonatal tetanus in low and middle income countries - a systematic review

PubMed Central

2013-01-01

Background In 1988, WHO estimated around 787,000 newborns deaths due to neonatal tetanus. Despite few success stories majority of the Low and Middle Income Countries (LMICs) are still struggling to reduce neonatal mortality due to neonatal tetanus. We conducted a systematic review to understand the interventions that have had a substantial effect on reducing neonatal mortality rate due to neonatal tetanus in LMICs and come up with feasible recommendations for decreasing neonatal tetanus in the Pakistani setting. Methods We systemically reviewed the published literature (Pubmed and Pubget databases) to identify appropriate interventions for reducing tetanus related neonatal mortality. A total of 26 out of 30 studies were shortlisted for preliminary screening after removing overlapping information. Key words used were “neonatal tetanus, neonatal mortality, tetanus toxoid women”. Of these twenty-six studies, 20 were excluded. The pre-defined exclusion criteria was (i) strategies and interventions to reduce mortality among neonates not described (ii) no abstract/author (4 studies) (iii) not freely accessible online (1 study) (iv) conducted in high income countries (2 studies) and (v) not directly related to neonatal tetanus mortality and tetanus toxoid immunization (5). Finally six studies which met the eligibility criteria were entered in the pre-designed data extraction form and five were selected for commentary as they were directly linked with neonatal tetanus reduction. Results Interventions that were identified to reduce neonatal mortality in LMICs were: a) vaccination of women of child bearing age (married and unmarried both) with tetanus toxoid b) community based interventions i.e. tetanus toxoid immunization for all mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; umbilical cord care and management of infections in newborns c) supplementary immunization (in addition to regular EPI program) d) safer delivery practices. Conclusion The key intervention to reduce neonatal mortality from neonatal tetanus was found to be vaccination of pregnant women with tetanus toxoid. In the resource poor countries like Pakistan, this single intervention coupled with regular effective antenatal checkups, clean delivery practices and compliance with the “high- risk” approach can be effective in reducing neonatal tetanus. PMID:23570611

Mortality from different causes associated with meat, heme iron, nitrates, and nitrites in the NIH-AARP Diet and Health Study: population based cohort study

PubMed Central

Sinha, Rashmi; Ward, Mary H; Graubard, Barry I; Inoue-Choi, Maki; Dawsey, Sanford M; Abnet, Christian C

2017-01-01

Objective To determine the association of different types of meat intake and meat associated compounds with overall and cause specific mortality. Design Population based cohort study. Setting Baseline dietary data of the NIH-AARP Diet and Health Study (prospective cohort of the general population from six states and two metropolitan areas in the US) and 16 year follow-up data until 31 December 2011. Participants 536 969 AARP members aged 50-71 at baseline. Exposures Intake of total meat, processed and unprocessed red meat (beef, lamb, and pork) and white meat (poultry and fish), heme iron, and nitrate/nitrite from processed meat based on dietary questionnaire. Adjusted Cox proportional hazards regression models were used with the lowest fifth of calorie adjusted intakes as reference categories. Main outcome measure Mortality from any cause during follow-up. Results An increased risk of all cause mortality (hazard ratio for highest versus lowest fifth 1.26, 95% confidence interval 1.23 to 1.29) and death due to nine different causes associated with red meat intake was observed. Both processed and unprocessed red meat intakes were associated with all cause and cause specific mortality. Heme iron and processed meat nitrate/nitrite were independently associated with increased risk of all cause and cause specific mortality. Mediation models estimated that the increased mortality associated with processed red meat was influenced by nitrate intake (37.0-72.0%) and to a lesser degree by heme iron (20.9-24.1%). When the total meat intake was constant, the highest fifth of white meat intake was associated with a 25% reduction in risk of all cause mortality compared with the lowest intake level. Almost all causes of death showed an inverse association with white meat intake. Conclusions The results show increased risks of all cause mortality and death due to nine different causes associated with both processed and unprocessed red meat, accounted for, in part, by heme iron and nitrate/nitrite from processed meat. They also show reduced risks associated with substituting white meat, particularly unprocessed white meat. PMID:28487287

A population-based study of premature mortality in relation to neighbourhood density of alcohol sales and cheque cashing outlets in Toronto, Canada

PubMed Central

Matheson, Flora I; Creatore, Maria Isabella; Gozdyra, Piotr; Park, Alison L; Ray, Joel G

2014-01-01

Objective Alcohol overuse and poverty, each associated with premature death, often exist within disadvantaged neighbourhoods. Cheque cashing places (CCPs) may be opportunistically placed in disadvantaged neighbourhoods, where customers abound. We explored whether neighbourhood density of CCPs and alcohol outlets are each related to premature mortality among adults. Design Retrospective population-based study. Setting 140 neighbourhoods in Toronto, Ontario, 2005–2009. Participants Adults aged 20–59 years. Measures Our primary outcome was premature all-cause mortality among adults aged 20–59 years. Across neighbourhoods we explored neighbourhood density, in km2, of CCPs and alcohol outlets, and the relation of each to premature mortality. Poisson regression provided adjusted relative risks (aRRs) and 95% CIs, adjusting for material deprivation quintile (Q), crime Q and number of banks. Results Intentional self-harm, accidental poisoning and liver disease were among the top five causes of premature death among males aged 20–59 years. The overall premature mortality rate was 96.3/10 000 males and 55.9/10 000 females. Comparing the highest versus lowest CCP density Q, the aRR for death was 1.25 (95% CI 1.15 to 1.36) among males and 1.11 (95% CI 0.99 to 1.24) among females. The corresponding aRR comparing the highest Q versus lowest Q alcohol outlet density in relation to premature mortality was 1.36 (95% CI 1.25 to 1.48) for males and 1.11 (95% CI 1.00 to 1.24) for females. The pattern of the relation between either CCPs or alcohol outlet density and premature mortality was typically J shaped. Conclusions There is a J-shaped relation between CCP or alcohol outlet density and premature mortality, even on controlling for conventional measures of poverty. Formal banking and alcohol reduction strategies might be added to health promotion policies aimed at reducing premature mortality in highly affected neighbourhoods. PMID:25518874

Effect of depression on mortality and cardiovascular morbidity in type 2 diabetes mellitus after 3 years follow up. The DIADEMA study protocol

PubMed Central

2012-01-01

Background Type 2 diabetes mellitus and depression are highly prevalent diseases that are associated with an increased risk of cardiovascular disease and mortality. There is evidence about a bidirectional association between depressive symptoms and type 2 diabetes mellitus. However, prognostic implications of the joint effects of these two diseases on cardiovascular morbidity and mortality are not well-known. Method/design A three-year, observational, prospective, cohort study, carried out in Primary Health Care Centres in Madrid (Spain). The project aims to analyze the effect of depression on cardiovascular events, all-cause and cardiovascular mortality in patients with type 2 diabetes mellitus, and to estimate a clinical predictive model of depression in these patients. The number of patients required is 3255, all them with type 2 diabetes mellitus, older than 18 years, who regularly visit their Primary Health Care Centres and agree to participate. They are chosen by simple random sampling from the list of patients with type 2 diabetes mellitus of each general practitioner. The main outcome measures are all-cause and cardiovascular mortality and cardiovascular morbidity; and exposure variable is the major depressive disorder. There will be a comparison between depressed and not depressed patients in all-cause mortality, cardiovascular mortality, coronary artery disease and stroke using the Chi-squared test. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors that might alter the effect recorded will be taken into account in this analysis. To assess the effect of depression on the mortality, a survival analysis will be used comparing the two groups using the log-rank test. The control of potential confounding variables will be performed by the construction of a Cox regression model. Discussion Our study’s main contribution is to evaluate the increase in the risk of cardiovascular morbidity and mortality, in depressed Spanish adults with type 2 diabetes mellitus attended in Primary Health Care Setting. It would also be useful to identify subgroups of patients for which the interventions could be more beneficial. PMID:22846516

The impact of dietary habits and metabolic risk factors on cardiovascular and diabetes mortality in countries of the Middle East and North Africa in 2010: a comparative risk assessment analysis

PubMed Central

Afshin, Ashkan; Micha, Renata; Khatibzadeh, Shahab; Fahimi, Saman; Shi, Peilin; Powles, John; Singh, Gitanjali; Yakoob, Mohammad Yawar; Abdollahi, Morteza; Al-Hooti, Suad; Farzadfar, Farshad; Houshiar-rad, Anahita; Hwalla, Nahla; Koksal, Eda; Musaiger, Abdulrahman; Pekcan, Gulden; Sibai, Abla Mehio; Zaghloul, Sahar; Danaei, Goodarz; Ezzati, Majid; Mozaffarian, Dariush

2015-01-01

Objective/design We conducted a comparative risk assessment analysis to estimate the cardiometabolic disease (CMD) mortality attributable to 11 dietary and 4 metabolic risk factors in 20 countries of the Middle East by age, sex and time. The national exposure distributions were obtained from a systematic search of multiple databases. Missing exposure data were estimated using a multilevel Bayesian hierarchical model. The aetiological effect of each risk factor on disease-specific mortality was obtained from clinical trials and observational studies. The number of disease-specific deaths was obtained from the 2010 Global Burden of Disease mortality database. Mortality due to each risk factor was determined using the population attributable fraction and total number of disease-specific deaths. Setting/population Adult population in the Middle East by age, sex, country and time. Results Suboptimal diet was the leading risk factor for CMD mortality in 11 countries accounting for 48% (in Morocco) to 72% (in the United Arab Emirates) of CMD deaths. Non-optimal systolic blood pressure was the leading risk factor for CMD deaths in eight countries causing 45% (in Bahrain) to 68% (in Libya) of CMD deaths. Non-optimal body mass index and fasting plasma glucose were the third and fourth leading risk factors for CMD mortality in most countries. Among individual dietary factors, low intake of fruits accounted for 8% (in Jordan) to 21% (in Palestine) of CMD deaths and low intake of whole grains was responsible for 7% (in Palestine) to 22% (in the United Arab Emirates) of CMD deaths. Between 1990 and 2010, the CMD mortality attributable to most risk factors had decreased except for body mass index and trans-fatty acids. Conclusions Our findings highlight key similarities and differences in the impact of the dietary and metabolic risk factors on CMD mortality in the countries of the Middle East and inform priorities for policy measures to prevent CMD. PMID:25995236

Impact of Newborn Skin-Cleansing With Chlorhexidine on Neonatal Mortality in Southern Nepal: A Community-Based, Cluster-Randomized Trial

PubMed Central

Tielsch, James M.; Darmstadt, Gary L.; Mullany, Luke C.; Khatry, Subarna K.; Katz, Joanne; LeClerq, Steven C.; Shrestha, Shardaram; Adhikari, Ramesh

2008-01-01

OBJECTIVE Hospital-based data from Africa suggest that newborn skin-cleansing with chlorhexidine may reduce neonatal mortality. Evaluation of this intervention in the communities where most births occur in the home has not been done. Our objective was to assess the efficacy of a 1-time skin-cleansing of newborn infants with 0.25% chlorhexidine on neonatal mortality. METHODS The design was a community-based, placebo-controlled, cluster-randomized trial in Sarlahi District in southern Nepal. Newborn infants were cleansed with infant wipes that contained 0.25% chlorhexidine or placebo solution as soon as possible after delivery in the home (median: 5.8 hours). The primary outcome was all-cause mortality by 28 days. After the completion of the randomized phase, all newborns in study clusters were converted to chlorhexidine treatment for the subsequent 9 months. RESULTS A total of 17 530 live births occurred in the enrolled sectors, 8650 and 8880 in the chlorhexidine and placebo groups, respectively. Baseline characteristics were similar in the treatment groups. Intention-to-treat analysis among all live births showed no impact of the intervention on neonatal mortality. Among live-born infants who actually received their assigned treatment (98.7%), there was a nonsignificant 11% lower neonatal mortality rate among those who were treated with chlorhexidine compared with placebo. Low birth weight infants had a statistically significant 28% reduction in neonatal mortality; there was no significant difference among infants who were born weighing ≥2500 g. After conversion to active treatment in the placebo clusters, there was a 37% reduction in mortality among low birth weight infants in the placebo clusters versus no change in the chlorhexidine clusters. CONCLUSIONS Newborn skin-wiping with chlorhexidine solution once, soon after birth, reduced neonatal mortality only among low birth weight infants. Evidence from additional trials is needed to determine whether this inexpensive and simple intervention could improve survival significantly among low birth weight infants in settings where home delivery is common and hygiene practices are poor. PMID:17210728

Association of Serum Triglyceride to HDL Cholesterol Ratio with All-Cause and Cardiovascular Mortality in Incident Hemodialysis Patients

PubMed Central

Chang, Tae Ik; Streja, Elani; Soohoo, Melissa; Kim, Tae Woo; Rhee, Connie M.; Kovesdy, Csaba P.; Kashyap, Moti L.; Vaziri, Nosratola D.; Kalantar-Zadeh, Kamyar

2017-01-01

Background and objectives Elevated serum triglyceride/HDL cholesterol (TG/HDL-C) ratio has been identified as a risk factor for cardiovascular (CV) disease and mortality in the general population. However, the association of this important clinical index with mortality has not been fully evaluated in patients with ESRD on maintenance hemodialysis (MHD). We hypothesized that the association of serum TG/HDL-C ratio with all-cause and CV mortality in patients with ESRD on MHD is different from the general population. Design, setting, participants, & measurements We studied the association of serum TG/HDL-C ratio with all-cause and CV mortality in a nationally representative cohort of 50,673 patients on incident hemodialysis between January 1, 2007 and December 31, 2011. Association of baseline and time-varying TG/HDL-C ratios with mortality was assessed using Cox proportional hazard regression models, with adjustment for multiple variables, including statin therapy. Results During the median follow-up of 19 months (interquartile range, 11–32 months), 12,778 all-cause deaths and 4541 CV deaths occurred, respectively. We found that the 10th decile group (reference: sixth deciles of TG/HDL-C ratios) had significantly lower risk of all-cause mortality (hazard ratio, 0.91 [95% confidence interval, 0.83 to 0.99] in baseline and 0.86 [95% confidence interval, 0.79 to 0.94] in time-varying models) and CV mortality (hazard ratio, 0.83 [95% confidence interval, 0.72 to 0.96] in baseline and 0.77 [95% confidence interval, 0.66 to 0.90] in time-varying models). These associations remained consistent and significant across various subgroups. Conclusions Contrary to the general population, elevated TG/HDL-C ratio was associated with better CV and overall survival in patients on hemodialysis. Our findings provide further support that the nature of CV disease and mortality in patients with ESRD is unique and distinct from other patient populations. Hence, it is vital that future studies focus on identifying risk factors unique to patients on MHD and decipher the underlying mechanisms responsible for poor outcomes in patients with ESRD. PMID:28193609

Seasonal Influenza Infections and Cardiovascular Disease Mortality

PubMed Central

Nguyen, Jennifer L.; Yang, Wan; Ito, Kazuhiko; Matte, Thomas D.; Shaman, Jeffrey; Kinney, Patrick L.

2016-01-01

IMPORTANCE Cardiovascular deaths and influenza epidemics peak during winter in temperate regions. OBJECTIVES To quantify the temporal association between population increases in seasonal influenza infections and mortality due to cardiovascular causes and to test if influenza incidence indicators are predictive of cardiovascular mortality during the influenza season. DESIGN, SETTING, AND PARTICIPANTS Time-series analysis of vital statistics records and emergency department visits in New York City, among cardiovascular deaths that occurred during influenza seasons between January 1, 2006, and December 31, 2012. The 2009 novel influenza A(H1N1) pandemic period was excluded from temporal analyses. EXPOSURES Emergency department visits for influenza-like illness, grouped by age (≥0 years and ≥65 years) and scaled by laboratory surveillance data for viral types and subtypes, in the previous 28 days. MAIN OUTCOMES AND MEASURES Mortality due to cardiovascular disease, ischemic heart disease, and myocardial infarction. RESULTS Among adults 65 years and older, who accounted for 83.0% (73 363 deaths) of nonpandemic cardiovascular mortality during influenza seasons, seasonal average influenza incidence was correlated year to year with excess cardiovascular mortality (Pearson correlation coefficients ≥0.75, P≤.05 for 4 different influenza indicators). In daily time-series analyses using 4 different influenza metrics, interquartile range increases in influenza incidence during the previous 21 days were associated with an increase between 2.3% (95% CI, 0.7%–3.9%) and 6.3% (95% CI, 3.7%–8.9%) for cardiovascular disease mortality and between 2.4% (95% CI, 1.1%–3.6%) and 6.9% (95% CI, 4.0%–9.9%) for ischemic heart disease mortality among adults 65 years and older. The associations were most acute and strongest for myocardial infarction mortality, with each interquartile range increase in influenza incidence during the previous 14 days associated with mortality increases between 5.8% (95% CI, 2.5%–9.1%) and 13.1% (95% CI, 5.3%–20.9%). Out-of-sample prediction of cardiovascular mortality among adults 65 years and older during the 2009–2010 influenza season yielded average estimates with 94.0% accuracy using 4 different influenza metrics. CONCLUSIONS AND RELEVANCE Emergency department visits for influenza-like illness were associated with and predictive of cardiovascular disease mortality. Retrospective estimation of influenza-attributable cardiovascular mortality burden combined with accurate and reliable influenza forecasts could predict the timing and burden of seasonal increases in cardiovascular mortality. PMID:27438105

Risk factors for hospital-acquired hypernatremia among critically ill medical patients in a setting utilizing a preventive free water protocol: Do we need to do more?

PubMed Central

Varun, Sundar; Bhaskar, Emmanuel; Abraham, Georgi; Arunkumar, Anandabhavan Sukumaramenon; Renuka, Muthiah Kothandaramanujam

2013-01-01

Context: Hospital-acquired hypernatremia (HAH) is a frequent concern in critical care, which carries high mortality. Aims: To study the risk factors for HAH in settings that practice a preventive protocol. Settings and Design: Two tertiary-care hospitals. Prospective observational study design. Materials and Methods: Patients aged >18 years admitted for an acute medical illness with normal serum sodium and need for intensive care >48 h formed the study population. Details of the basic panel of investigations on admission, daily electrolytes and renal function test, sodium content of all intake, free water intake (oral, enteral and intravenous) and fluid balance every 24 h were recorded. Individuals with serum Na 140-142 meq/l received 500 ml of free water every 24 h, and those with 143-145 meq/l received 1000 ml free water every 24 h. Statistical Analysis Used: Risk factors associated with HAH was analysed by multiple logistic regression. Results: Among 670 study participants, 64 (9.5%) developed HAH. The median duration of hypernatremia was 3 days. A total 60 of 64 participants with HAH had features of renal concentrating defect during hypernatremia. Age >60 years (P = 0.02), acute kidney injury (AKI) on admission (P = 0.01), mechanical ventilation (P = 0.01), need for ionotropes (P = 0.03), worsening Sequential Organ Failure Assessment (SOFA) score after admission (P < 0.001), enteral tube feeds (P = 0.002), negative fluid balance (P = 0.02) and mannitol use (P < 0.001) were the risk factors for HAH. Mortality rate was 34.3% among hypernatremic patients. Conclusions: The study suggests that administration of free water to prevent HAH should be more meticulously complied with in patients who are elderly, present with AKI, suffer multi-organ dysfunction, require mechanical ventilation, receive enteral feeds and drugs like mannitol or ionotropes. PMID:23833473

The effect of illicit financial flows on time to reach the fourth Millennium Development Goal in Sub-Saharan Africa: a quantitative analysis

PubMed Central

Makuta, Innocent; Bar-Zeev, Naor; Chiwaula, Levison; Cobham, Alex

2014-01-01

Objectives This paper sets out to estimate the cost of illicit financial flows (IFF) in terms of the amount of time it could take to reach the fourth Millennium Development Goal (MDG) in 34 African countries. Design We have calculated the percentage increase in gross domestic product (GDP) if IFFs were curtailed using IFF/GDP ratios. We applied the income (GDP) elasticity of child mortality to the increase in GDP to estimate the reduction in time to reach the fourth MDG in 34 African countries. Participants children aged under five years. Settings 34 countries in SSA. Main outcome measures Reduction in time to reach the first indicator of the fourth MDG, under-five mortality rate in the absence of IFF. Results We found that in the 34 SSA countries, six countries will achieve their fourth MDG target at the current rates of decline. In the absence of IFF, 16 countries would reach their fourth MDG target by 2015 and there would be large reductions for all other countries. Conclusions This drain on development is facilitated by financial secrecy in other jurisdictions. Rich and poor countries alike must stem the haemorrhage of IFF by taking decisive steps towards improving financial transparency. PMID:24334911

Bait type influences on catch and bycatch in tandem hoop nets set in reservoirs

USGS Publications Warehouse

Long, James M.; Stewart, David R.; Shiflet, Jeremy; Balsman, Dane; Shoup, Daniel E.

2017-01-01

Tandem hoop nets have become the primary gear for sampling channel catfish Ictalurus punctatus, but suffer from high incidences of bycatch, particularly aquatic turtles that usually drown as a result. We sought to determine if bait type, ZOTE© soap and ground cheese logs, would influence catch of channel catfish (CPUE and mean TL) and bycatch of fishes and aquatic turtles. We sampled with tandem hoop nets in 13 Kentucky reservoirs (5–73 ha) using a crossover design and two sampling events. We found no difference in channel catfish catch rates between bait types, but mean sizes of fish caught using ZOTE© soap were approximately 24 mm longer compared to cheese. Fish bycatch was similar between bait types, but tandem hoop nets baited with ZOTE© soap caught up to 61% fewer turtles and mortality of turtles that were captured was up to 12% lower than those baited with cheese. Depth of net set, water temperature, and Secchi depth were environmental factors measured that affected catch and bycatch, but varied among species. Using ZOTE© soap as bait in tandem hoop nets appears to be a fairly simple and straightforward method for maintaining high catch rates of channel catfish while minimizing turtle mortality.

Number of organ dysfunctions predicts mortality in emergency department patients with suspected infection: a multicenter validation study.

PubMed

Jessen, Marie K; Skibsted, Simon; Shapiro, Nathan I

2017-06-01

The aim of this study was to validate the association between number of organ dysfunctions and mortality in emergency department (ED) patients with suspected infection. This study was conducted at two medical care center EDs. The internal validation set was a prospective cohort study conducted in Boston, USA. The external validation set was a retrospective case-control study conducted in Aarhus, Denmark. The study included adult patients (>18 years) with clinically suspected infection. Laboratory results and clinical data were used to assess organ dysfunctions. Inhospital mortality was the outcome measure. Multivariate logistic regression was used to determine the independent mortality odds for number and types of organ dysfunctions. We enrolled 4952 (internal) and 483 (external) patients. The mortality rate significantly increased with increasing number of organ dysfunctions: internal validation: 0 organ dysfunctions: 0.5% mortality, 1: 3.6%, 2: 9.5%, 3: 17%, and 4 or more: 37%; external validation: 2.2, 6.7, 17, 41, and 57% mortality (both P<0.001 for trend). Age-adjusted and comorbidity-adjusted number of organ dysfunctions remained an independent predictor. The effect of specific types of organ dysfunction on mortality was most pronounced for hematologic [odds ratio (OR) 3.3 (95% confidence interval (CI) 2.0-5.4)], metabolic [OR 3.3 (95% CI 2.4-4.6); internal validation], and cardiovascular dysfunctions [OR 14 (95% CI 3.7-50); external validation]. The number of organ dysfunctions predicts sepsis mortality.

Heat stress related dairy cow mortality during heat waves and control periods in rural Southern Ontario from 2010-2012.

PubMed

Bishop-Williams, Katherine E; Berke, Olaf; Pearl, David L; Hand, Karen; Kelton, David F

2015-11-27

Heat stress is a physiological response to extreme environmental heat such as heat waves. Heat stress can result in mortality in dairy cows when extreme heat is both rapidly changing and has a long duration. As a result of climate change, heat waves, which are defined as 3 days of temperatures of 32 °C or above, are an increasingly frequent extreme weather phenomenon in Southern Ontario. Heat waves are increasing the risk for on-farm dairy cow mortality in Southern Ontario. Heat stress indices (HSIs) are generally based on temperature and humidity and provide a relative measure of discomfort which can be used to predict increased risk of on-farm dairy cow mortality. In what follows, the heat stress distribution was described over space and presented with maps. Similarly, on-farm mortality was described and mapped. The goal of this study was to demonstrate that heat waves and related HSI increases during 2010-2012 were associated with increased on-farm dairy cow mortality in Southern Ontario. Mortality records and farm locations for all farms registered in the CanWest Dairy Herd Improvement Program in Southern Ontario were retrieved for 3 heat waves and 6 three-day control periods from 2010 to 2012. A random sample of controls (2:1) was taken from the data set to create a risk-based hybrid design. On-farm heat stress was estimated using data from 37 weather stations and subsequently interpolated across Southern Ontario by geostatistical kriging. A Poisson regression model was applied to assess the on-farm mortality in relation to varying levels of the HSI. For every one unit increase in HSI the on-farm mortality rate across Southern Ontario increases by 1.03 times (CI95% (IRR) = (1.025,1.035); p = ≤ 0.001). With a typical 8.6 unit increase in HSI from a control period to a heat wave, mortality rates are predicted to increase by 1.27 times. Southern Ontario was affected by heat waves, as demonstrated by high levels of heat stress and increased on-farm mortality. Farmers should be aware of these risks, and informed of appropriate methods to mitigate such risks.

Prediction of One-Year Survival in High-Risk Patients with Acute Coronary Syndromes: Results from the SYNERGY Trial

PubMed Central

Yang, Qinghong; Pieper, Karen S.; Antman, Elliott M.; White, Harvey D.; Goodman, Shaun G.; Cohen, Marc; Kleiman, Neal S.; Langer, Anatoly; Aylward, Philip E.; Col, Jacques J.; Reist, Craig; Ferguson, James J.; Califf, Robert M.

2008-01-01

BACKGROUND Despite advances in pharmacologic therapy and invasive management strategies for patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS), these patients still suffer substantial morbidity and mortality. OBJECTIVE The objective of this study was to analyze independent predictors of 1-year mortality in patients with high-risk NSTE ACS. DESIGN AND PARTICIPANTS A total of 9,978 patients were assigned to receive enoxaparin or unfractionated heparin (UFH) in this prospective, randomized, open-label, international trial. MEASUREMENTS Vital status at 1 year was collected. Univariable and multivariable predictors of 1-year mortality were identified. Three different multivariable regression models were constructed to identify: (1) predictors of 30-day mortality; (2) predictors of 1-year mortality; (3) predictors of 1-year mortality in 30-day survivors. The last model is the focus of this paper. RESULTS Overall, 9,922 (99.4%) of patients had 1-year follow-up. Of the 56 patients (37 UFH-assigned and 19 enoxaparin-assigned) without 1-year data, 11 patients were excluded because of withdrawal of consent, and 45 could not be located. One-year mortality was 7.5% (7.7% enoxaparin-assigned patients; 7.3% UFH-assigned patients; P = 0.4). In patients surviving 30 days after enrollment, independent predictors of 1-year mortality included factors known at baseline such as increased age, male sex, decreased weight, having ever smoked, decreased creatinine clearance, ST-segment depression, history of diabetes, history of angina, congestive heart failure, coronary artery bypass grafting, increased heart rate, rales, increased hematocrit, lowered hemoglobin, and higher platelet count. Factors predictive of mortality during the hospitalization and 30-day follow-up period were decreased weight at 30 days from baseline, atrial fibrillation, decreased nadir platelet, no use of beta-blockers and statins up to 30 days, and not receiving an intervention (c-index = 0.82). CONCLUSIONS Easily determined baseline clinical characteristics can be used to predict 1-year mortality with reasonable discriminative power. These models corroborate prior work in a contemporary aggressively managed population. A model to predict 1-year mortality in patients surviving at least 30 days may be quite helpful to healthcare providers in setting expectations and goals with patients after ACS. PMID:18196350

Development and Validation of a Deep Neural Network Model for Prediction of Postoperative In-hospital Mortality.

PubMed

Lee, Christine K; Hofer, Ira; Gabel, Eilon; Baldi, Pierre; Cannesson, Maxime

2018-04-17

The authors tested the hypothesis that deep neural networks trained on intraoperative features can predict postoperative in-hospital mortality. The data used to train and validate the algorithm consists of 59,985 patients with 87 features extracted at the end of surgery. Feed-forward networks with a logistic output were trained using stochastic gradient descent with momentum. The deep neural networks were trained on 80% of the data, with 20% reserved for testing. The authors assessed improvement of the deep neural network by adding American Society of Anesthesiologists (ASA) Physical Status Classification and robustness of the deep neural network to a reduced feature set. The networks were then compared to ASA Physical Status, logistic regression, and other published clinical scores including the Surgical Apgar, Preoperative Score to Predict Postoperative Mortality, Risk Quantification Index, and the Risk Stratification Index. In-hospital mortality in the training and test sets were 0.81% and 0.73%. The deep neural network with a reduced feature set and ASA Physical Status classification had the highest area under the receiver operating characteristics curve, 0.91 (95% CI, 0.88 to 0.93). The highest logistic regression area under the curve was found with a reduced feature set and ASA Physical Status (0.90, 95% CI, 0.87 to 0.93). The Risk Stratification Index had the highest area under the receiver operating characteristics curve, at 0.97 (95% CI, 0.94 to 0.99). Deep neural networks can predict in-hospital mortality based on automatically extractable intraoperative data, but are not (yet) superior to existing methods.

Job strain among blue-collar and white-collar employees as a determinant of total mortality: a 28-year population-based follow-up

PubMed Central

Seitsamo, Jorma; von Bonsdorff, Monika E; Ilmarinen, Juhani; Nygård, Clas-Håkan; Rantanen, Taina

2012-01-01

Objectives To investigate the effect of job demand, job control and job strain on total mortality among white-collar and blue-collar employees working in the public sector. Design 28-year prospective population-based follow-up. Setting Several municipals in Finland. Participants 5731 public sector employees from the Finnish Longitudinal Study on Municipal Employees Study aged 44–58 years at baseline. Outcomes Total mortality from 1981 to 2009 among individuals with complete data on job strain in midlife, categorised according to job demand and job control: high job strain (high job demands and low job control), active job (high job demand and high job control), passive job (low job demand and low job control) and low job strain (low job demand and high job control). Results 1836 persons died during the follow-up. Low job control among men increased (age-adjusted HR 1.26, 95% CI 1.12 to 1.42) and high job demand among women decreased the risk for total mortality HR 0.82 (95% CI 0.71 to 0.95). Adjustment for occupational group, lifestyle and health factors attenuated the association for men. In the analyses stratified by occupational group, high job strain increased the risk of mortality among white-collar men (HR 1.52, 95% CI 1.09 to 2.13) and passive job among blue-collar men (HR 1.28, 95% CI 1.05 to 1.47) compared with men with low job strain. Adjustment for lifestyle and health factors attenuated the risks. Among white-collar women having an active job decreased the risk for mortality (HR 0.78, 95% CI 0.60 to 1.00). Conclusion The impact of job strain on mortality was different according to gender and occupational group among middle-aged public sector employees. PMID:22422919

Opiates or cocaine: mortality from acute reactions in six major Spanish cities. State Information System on Drug Abuse (SEIT) Working Group.

PubMed Central

Sánchez, J; Rodríguez, B; de la Fuente, L; Barrio, G; Vicente, J; Roca, J; Royuela, L

1995-01-01

STUDY OBJECTIVE--To describe temporal and geographical variations in mortality from acute reactions to opiates or cocaine and the demographic and toxicological characteristics of persons who died from these in major Spanish cities between 1983 and 1991. DESIGN--Descriptive study. Data were obtained retrospectively from pathologists' reports. SETTING--Cities of Madrid, Barcelona, Valencia, Seville, Zaragoza, and Bilbao. SUBJECTS--Deaths from acute reactions to opiates or cocaine were defined as those in which pathologists' reports did not indicate any other cause of death and in which evidence was found of recent consumption of these drugs. MAIN RESULTS--The mortality rate from acute reactions to opiate/cocaine per 100,000 population in the six cities as a whole rose from 1.2 in 1983 to 8.2 in 1991. Average annual rates for the whole period ranged from 1.7 in Seville to 4.9 in Barcelona. The male/female rates ratio was 5.9:1. The mean age of persons who died rose from 25.1 years in 1983 to 28 years in 1991. In more than 90% of the cases in whom toxicological tests were undertaken opiates were detected, and the proportion in which benzodiazepines or cocaine were detected increased during the period studied. CONCLUSIONS--Between 1983 and 1991 mortality from acute reactions to opiates/cocaine rose dramatically in major Spanish cities and significant differences in mortality between cities were found. Deaths were concentrated among men and young people. Acute drug reactions became one of the leading causes of death in persons 15-39 years of age, representing 11.1% of mortality from all causes in 1988 for this age group. Future studies should examine the relationship between the temporal and geographical variations in this type of mortality and various personal, environmental and social factors. PMID:7707007

Cause of death and potentially avoidable deaths in Australian adults with intellectual disability using retrospective linked data

PubMed Central

Srasuebkul, Preeyaporn; Xu, Han; Howlett, Sophie

2017-01-01

Objectives To investigate mortality and its causes in adults over the age of 20 years with intellectual disability (ID). Design, setting and participants Retrospective population-based standardised mortality of the ID and Comparison cohorts. The ID cohort comprised 42 204 individuals who registered for disability services with ID as a primary or secondary diagnosis from 2005 to 2011 in New South Wales (NSW). The Comparison cohort was obtained from published deaths in NSW from the Australian Bureau of Statistics (ABS) from 2005 to 2011. Main outcome measures We measured and compared Age Standardised Mortality Rate (ASMR), Comparative Mortality Figure (CMF), years of productive life lost (YPLL) and proportion of deaths with potentially avoidable causes in an ID cohort with an NSW general population cohort. Results There were 19 362 adults in the ID cohort which experienced 732 (4%) deaths at a median age of 54 years. Age Standardised Mortality Rates increased with age for both cohorts. Overall comparative mortality figure was 1.3, but was substantially higher for the 20–44 (4.0) and 45–64 (2.3) age groups. YPLL was 137/1000 people in the ID cohort and 49 in the comparison cohort. Cause of death in ID cohort was dominated by respiratory, circulatory, neoplasm and nervous system. After recoding deaths previously attributed to the aetiology of the disability, 38% of deaths in the ID cohort and 17% in the comparison cohort were potentially avoidable. Conclusions Adults with ID experience premature mortality and over-representation of potentially avoidable deaths. A national system of reporting of deaths in adults with ID is required. Inclusion in health policy and services development and in health promotion programmes is urgently required to address premature deaths and health inequalities for adults with ID. PMID:28179413

Long-Term Renal and Cardiovascular Outcomes in Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) Participants by Baseline Estimated GFR

PubMed Central

Rahman, Mahboob; Cutler, Jeffrey A.; Davis, Barry R.; Piller, Linda B.; Whelton, Paul K.; Wright, Jackson T.; Barzilay, Joshua I.; Brown, Clinton D.; Colon, Pedro J.; Fine, Lawrence J.; Grimm, Richard H.; Gupta, Alok K.; Baimbridge, Charles; Haywood, L. Julian; Henriquez, Mario A.; Ilamaythi, Ekambaram; Oparil, Suzanne; Preston, Richard

2012-01-01

Summary Background and objectives CKD is common among older patients. This article assesses long-term renal and cardiovascular outcomes in older high-risk hypertensive patients, stratified by baseline estimated GFR (eGFR), and long-term outcome efficacy of 5-year first-step treatment with amlodipine or lisinopril, each compared with chlorthalidone. Design, setting, participants, & measurements This was a long-term post-trial follow-up of hypertensive participants (n=31,350), aged ≥55 years, randomized to receive chlorthalidone, amlodipine, or lisinopril for 4–8 years at 593 centers. Participants were stratified by baseline eGFR (ml/min per 1.73 m2) as follows: normal/increased (≥90; n=8027), mild reduction (60–89; n=17,778), and moderate/severe reduction (<60; n=5545). Outcomes were cardiovascular mortality (primary outcome), total mortality, coronary heart disease, cardiovascular disease, stroke, heart failure, and ESRD. Results After an average 8.8-year follow-up, total mortality was significantly higher in participants with moderate/severe eGFR reduction compared with those with normal and mildly reduced eGFR (P<0.001). In participants with an eGFR <60, there was no significant difference in cardiovascular mortality between chlorthalidone and amlodipine (P=0.64), or chlorthalidone and lisinopril (P=0.56). Likewise, no significant differences were observed for total mortality, coronary heart disease, cardiovascular disease, stroke, or ESRD. Conclusions CKD is associated with significantly higher long-term risk of cardiovascular events and mortality in older hypertensive patients. By eGFR stratum, 5-year treatment with amlodipine or lisinopril was not superior to chlorthalidone in preventing cardiovascular events, mortality, or ESRD during 9-year follow-up. Because data on proteinuria were not available, these findings may not be extrapolated to proteinuric CKD. PMID:22490878

Age-specific excess mortality patterns and transmissibility during the 1889-1890 influenza pandemic in Madrid, Spain.

PubMed

Ramiro, Diego; Garcia, Sara; Casado, Yolanda; Cilek, Laura; Chowell, Gerardo

2018-05-01

Although the 1889-1890 influenza pandemic was one of the most important epidemic events of the 19th century, little is known about the mortality impact of this pandemic based on detailed respiratory mortality data sets. We estimated excess mortality rates for the 1889-1890 pandemic in Madrid from high-resolution respiratory and all-cause individual-level mortality data retrieved from the Gazeta de Madrid, the Official Bulletin of the Spanish government. We also generated estimates of the reproduction number from the early growth phase of the pandemic. The main pandemic wave in Madrid was evident from respiratory and all-cause mortality rates during the winter of 1889-1890. Our estimates of excess mortality for this pandemic were 58.3 per 10,000 for all-cause mortality and 44.5 per 10,000 for respiratory mortality. Age-specific excess mortality rates displayed a J-shape pattern, with school children aged 5-14 years experiencing the lowest respiratory excess death rates (8.8 excess respiratory deaths per 10,000), whereas older populations aged greater than or equal to 70 years had the highest rates (367.9 per 10,000). Although seniors experienced the highest absolute excess death rates, the standardized mortality ratio was highest among young adults aged 15-24 years. The early growth phase of the pandemic displayed dynamics consistent with an exponentially growing transmission process. Using the generalized-growth method, we estimated the reproduction number in the range of 1.2-1.3 assuming a 3-day mean generation interval and of 1.3-1.5 assuming a 4-day mean generation interval. Our study adds to our understanding of the mortality impact and transmissibility of the 1889-1890 influenza pandemic using detailed individual-level mortality data sets. More quantitative studies are needed to quantify the variability of the mortality impact of this understudied pandemic at regional and global scales. Copyright © 2017 Elsevier Inc. All rights reserved.

On the Analysis of Case-Control Studies in Cluster-correlated Data Settings.

PubMed

Haneuse, Sebastien; Rivera-Rodriguez, Claudia

2018-01-01

In resource-limited settings, long-term evaluation of national antiretroviral treatment (ART) programs often relies on aggregated data, the analysis of which may be subject to ecological bias. As researchers and policy makers consider evaluating individual-level outcomes such as treatment adherence or mortality, the well-known case-control design is appealing in that it provides efficiency gains over random sampling. In the context that motivates this article, valid estimation and inference requires acknowledging any clustering, although, to our knowledge, no statistical methods have been published for the analysis of case-control data for which the underlying population exhibits clustering. Furthermore, in the specific context of an ongoing collaboration in Malawi, rather than performing case-control sampling across all clinics, case-control sampling within clinics has been suggested as a more practical strategy. To our knowledge, although similar outcome-dependent sampling schemes have been described in the literature, a case-control design specific to correlated data settings is new. In this article, we describe this design, discuss balanced versus unbalanced sampling techniques, and provide a general approach to analyzing case-control studies in cluster-correlated settings based on inverse probability-weighted generalized estimating equations. Inference is based on a robust sandwich estimator with correlation parameters estimated to ensure appropriate accounting of the outcome-dependent sampling scheme. We conduct comprehensive simulations, based in part on real data on a sample of N = 78,155 program registrants in Malawi between 2005 and 2007, to evaluate small-sample operating characteristics and potential trade-offs associated with standard case-control sampling or when case-control sampling is performed within clusters.

The Problem of Controlling for Imperfectly Measured Confounders on Dissimilar Populations: A Database Simulation Study

PubMed Central

Schonberger, Robert B; Gilbertsen, Todd; Dai, Feng

2013-01-01

Objective(s) Observational database research frequently relies on imperfect administrative markers to determine comorbid status, and it is difficult to infer to what extent the associated misclassification impacts validity in multivariable analyses. The effect that imperfect markers of disease will have on validity in situations where researchers attempt to match populations that have strong baseline health differences is underemphasized as a limitation in some otherwise high-quality observational studies. The present simulations were designed as a quantitative demonstration of the importance of this common and underappreciated issue. Design Two groups of Monte Carlo simulations were performed. The first demonstrated the degree to which controlling for a series of imperfect markers of disease between different populations taking 2 hypothetically harmless drugs would lead to spurious associations between drug assignment and mortality. The second Monte Carlo simulation applied this principle to a recent study in the field of anesthesiology that purported to show increased perioperative mortality in patients taking metoprolol versus atenolol. Setting/Participants/Interventions None. Measurements and Main Results Simulation 1: High type 1 error (ie, false positive findings of an independent association between drug assignment and mortality) was observed as sensitivity and specificity declined and as systematic differences in disease prevalence increased. Simulation 2: Propensity score matching across several imperfect markers was unlikely to eliminate important baseline health disparities in the referenced study. Conclusions In situations where large baseline health disparities exist between populations, matching on imperfect markers of disease may result in strong bias away from the null hypothesis. PMID:23962461

OFF! Clip-on Repellent Device With Metofluthrin Tested on Aedes aegypti (Diptera: Culicidae) for Mortality at Different Time Intervals and Distances.

PubMed

Bibbs, Christopher S; Xue, Rui-De

2016-03-01

The OFF! Clip-on mosquito-repellent device was tested outdoors against Aedes aegypti (L.). A single treatment device was used against batches of caged adult, nonblood fed Ae. aegypti at multiple locations 0.3m from treatment center. Another set of cages was stationed 0.6m from treatment. A final set of cages was placed 0.9m away. Trials ran for durations of 5, 15, 30, and 60 min. Initial knockdown and mortality after 24 h was recorded. The devices had effective knockdown and mortality. This was not sustained at distances greater than 0.3m from the device.

Observational methods to assess the effectiveness of screening colonoscopy in reducing right colon cancer mortality risk: SCOLAR.

PubMed

Goodman, Michael; Fletcher, Robert H; Doria-Rose, V Paul; Jensen, Christopher D; Zebrowski, Alexis M; Becerra, Tracy A; Quinn, Virginia P; Zauber, Ann G; Corley, Douglas A; Doubeni, Chyke A

2015-11-01

Screening colonoscopy's effectiveness in reducing risk of death from right colon cancers remains unclear. Methodological challenges of existing observational studies addressing this issue motivated the design of 'Effectiveness of Screening for Colorectal Cancer in Average-Risk Adults (SCOLAR)'. SCOLAR is a nested case-control study based on two large integrated health systems. This affords access to a large, well-defined historical cohort linked to integrated data on cancer outcomes, patient eligibility, test indications and important confounders. We found electronic data adequate for excluding ineligible patients (except family history), but not the detailed information needed for test indication assignment. The lessons of SCOLAR's design and implementation may be useful for future studies seeking to evaluate the effectiveness of screening tests in community settings.

Impact of the Garrett Lee Smith youth suicide prevention program on suicide mortality.

PubMed

Walrath, Christine; Garraza, Lucas Godoy; Reid, Hailey; Goldston, David B; McKeon, Richard

2015-05-01

We examined whether a reduction in youth suicide mortality occurred between 2007 and 2010 that could reasonably be attributed to Garrett Lee Smith (GLS) program efforts. We compared youth mortality rates across time between counties that implemented GLS-funded gatekeeper training sessions (the most frequently implemented suicide prevention strategy among grantees) and a set of matched counties in which no GLS-funded training occurred. A rich set of background characteristics, including preintervention mortality rates, was accounted for with a combination of propensity score-based techniques. We also analyzed closely related outcomes that we did not expect to be affected by GLS as control outcomes. Counties implementing GLS training had significantly lower suicide rates among the population aged 10 to 24 years the year after GLS training than similar counties that did not implement GLS training (1.33 fewer deaths per 100 000; P = .02). Simultaneously, we found no significant difference in terms of adult suicide mortality rates or nonsuicide youth mortality the year after the implementation. These results support the existence of an important reduction in youth suicide rates resulting from the implementation of GLS suicide prevention programming.

PHOSPHATE BINDER USE AND MORTALITY AMONG HEMODIALYSIS PATIENTS IN THE DOPPS: EVALUATION OF POSSIBLE CONFOUNDING BY NUTRITIONAL STATUS

PubMed Central

Lopes, Antonio Alberto; Tong, Lin; Thumma, Jyothi; Li, Yun; Fuller, Douglas S.; Morgenstern, Hal; Bommer, Jürgen; Kerr, Peter G; Tentori, Francesca; Akiba, Takashi; Gillespie, Brenda; Robinson, Bruce M.; Port, Friedrich K; Pisoni, Ronald L.

2014-01-01

Background Poor nutritional status and both hyperphosphatemia and hypophosphatemia are associated with increased mortality in maintenance hemodialysis (MHD) patients. We assessed associations of PB prescription with survival and indicators of nutritional status among (MHD) patients. Study Design Prospective cohort study (DOPPS) 1996 to 2008. Setting and Participants 23,898 MHD patients at 923 facilities in 12 countries. Predictors Patient-level PB prescription; and case-mix-adjusted facility percentage PB prescription using an instrumental-variable analysis. Outcome All-cause mortality. Results Overall, 88% of patients were prescribed PBs. The distributions of age, comorbidities and other characteristics showed small differences between facilities with higher and lower percentage PB prescription. Patient-level PB prescription was strongly associated at baseline with indicators of better nutrition, i.e., higher serum creatinine, albumin, normalized protein-catabolic rate, BMI and absence of cachectic appearance. Overall, patients prescribed PBs displayed 25% lower mortality (hazard ratio [HR] = 0.75, 95% confidence interval [CI] = 0.68–0.83) when adjusted for serum phosphorus and other covariates; further adjustment for nutritional indicators attenuated this association (HR = 0.88, 95% CI = 0.80–0.97). This inverse association, however, was observed only for patients with serum phosphorus ≥3.5mg/dL. In the instrumental-variable analysis, case-mix-adjusted facility percentage PB prescription (range: 23–100%) was positively associated with better nutritional status and inversely associated with mortality (HR for 10% more PB = 0.93, 95% CI = 0.89–0.96). Further adjustment for nutritional indicators reduced this association to HR = 0.95 (95% CI = 0.92–0.99). Limitations Results were based on PB prescription; PB and nutritional data were cross-sectional; dietary restriction was not assessed; observational design limits causal inference due to possible residual confounding. Conclusions Longer survival and better nutritional status were observed for MHD patients prescribed PBs and in facilities with greater percentage PB prescription. Understanding the mechanisms for explaining this effect and ruling out possible residual confounding require additional research. PMID:22385781

Long-term prognosis after acute kidney injury (AKI): what is the role of baseline kidney function and recovery? A systematic review.

PubMed

Sawhney, Simon; Mitchell, Mhairi; Marks, Angharad; Fluck, Nick; Black, Corrinda

2015-01-06

To summarise the evidence from studies of acute kidney injury (AKI) with regard to the effect of pre-AKI renal function and post-AKI renal function recovery on long-term mortality and renal outcomes, and to assess whether these factors should be taken into account in future prognostic studies. A systematic review of observational studies listed in Medline and EMBASE from 1990 to October 2012. All AKI studies in adults with data on baseline kidney function to identify AKI; with outcomes either stratified by pre-AKI and/or post-AKI kidney function, or described by the timing of the outcomes. Long-term mortality and worsening chronic kidney disease (CKD). Of 7385 citations, few studies met inclusion criteria, reported baseline kidney function and stratified by pre-AKI or post-AKI function. For mortality outcomes, three studies compared patients by pre-AKI renal function and six by post-AKI function. For CKD outcomes, two studies compared patients by pre-AKI function and two by post-AKI function. The presence of CKD pre-AKI (compared with AKI alone) was associated with doubling of mortality and a fourfold to fivefold increase in CKD outcomes. Non-recovery of kidney function was associated with greater mortality and CKD outcomes in some studies, but findings were inconsistent varying with study design. Two studies also reported that risk of poor outcome reduced over time post-AKI. Meta-analysis was precluded by variations in definitions for AKI, CKD and recovery. The long-term prognosis after AKI varies depending on cause and clinical setting, but it may also, in part, be explained by underlying pre-AKI and post-AKI renal function rather than the AKI episode itself. While carefully considered in clinical practice, few studies address these factors and with inconsistent study design. Future AKI studies should report pre-AKI and post-AKI function consistently as additional factors that may modify AKI prognosis. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

The Importance of Rockall Scoring System for Upper Gastrointestinal Bleeding in Long-Term Follow-Up.

PubMed

Bozkurt, Mehmet Abdussamet; Peker, Kıvanç Derya; Unsal, Mustafa Gökhan; Yırgın, Hakan; Kahraman, İzzettin; Alış, Halil

2017-06-01

The aim of the study is to examine the importance of Rockall scoring system in long-term setting to estimate re-bleeding and mortality rate due to upper gastrointestinal bleeding. A total of 321 patients who had been treated for upper gastrointestinal bleeding were recruited to the study. Patients' demographic and clinical data, the amount of blood transfusion, endoscopy results, and Rockall scores were retrieved from patients' charts. The re-bleeding, morbidity, and mortality rates were noted after 3 years of follow-up with telephone. Re-bleeding rate was statistically significantly higher in Rockall 4 group compared to Rockall 0 group. Mortality rate was also statistically significantly higher in Rockall 4 group. Rockall risk scoring system is a valuable tool to predict re-bleeding and mortality rates for patients with upper gastrointestinal bleeding in long-term setting.

Association Between Medicare Hospital Readmission Penalties and 30-Day Combined Excess Readmission and Mortality

PubMed Central

Abdul-Aziz, Ahmad A.; Hayward, Rodney A.; Aaronson, Keith D.; Hummel, Scott L.

2017-01-01

IMPORTANCE US hospitals receive financial penalties for excess risk–standardized 30-day readmissions and mortality in Medicare patients. Under current policy, readmission prevention is incentivized over 10-fold more than mortality reduction. OBJECTIVE To determine how penalties for US hospitals would change if policy equally weighted 30-day readmissions and mortality. DESIGN, SETTING, AND PARTICIPANTS Publicly available hospital-level data for fiscal year 2014 was obtained, including excess readmission ratio (ERR; risk-standardized predicted over expected 30-day readmissions) and 30-day mortality rates for heart failure, pneumonia, and acute myocardial infarction, as well as readmission penalties (as percent of Medicare Diagnosis Group payments). An excess mortality ratio (EMR) was calculated by dividing the risk-standardized predicted mortality by the national average mortality. Case-weighted aggregate ERR (ERRAGG) and EMR (EMRAGG) were calculated, and an excess combined outcome ratio (ECORAGG) was created by averaging ERRAGG and EMRAGG. We examined associations between readmission penalties, ERRAGG, EMRAGG, and ECORAGG. Analysis of variance was used to compare readmission penalties in hospitals with concordant (both ratios >1 or <1) and discordant performance by ERRAGG and ECORAGG. MAIN OUTCOMES AND MEASURES The primary outcome investigated was the association between readmission penalties and the calculated excess combined outcome ratio (ECORAGG). RESULTS In 1963 US hospitals with complete data, readmission penalties closely tracked excess readmissions (r = 0.81; P < .001), but were minimally and inversely related with excess mortality (r = −0.12; P < .001) and only modestly correlated with excess combined readmission and mortality (r = 0.36; P < .001). Using hospitals with concordant ERRAGG and ECORAGG as the reference group, 17%of hospitals had an ECORAGG ratio less than 1 (ie, superior combined mortality/readmission outcome) with an ERRAGG ratio greater than 1, and received higher mean (SD) readmission penalties (0.41% [0.28%] vs 0.29% [0.37%]; P < .001); 16%of US hospitals had an ECORAGG ratio of greater than 1 (ie, inferior combined mortality/readmission outcome) with an ERRAGG ratio less than 1, and received minimal mean (SD) readmission penalties (0.08%[0.12%]; P < .001 for comparison with reference). CONCLUSIONS AND RELEVANCE In fiscal year 2014, financial penalties for one-third of US hospitals would have been substantially altered if 30-day readmission and mortality were considered equally important. Under most circumstances, patients would rather avoid death than rehospitalization. Current Medicare financial penalties do not meet the goals of aligning incentives and fairly reimbursing hospitals for patient-centered outcomes. PMID:27784054

Community-based interventions to promote increased physical activity: a primer.

PubMed

Bopp, Melissa; Fallon, Elizabeth

2008-01-01

Current recommendations, based on an abundance of empirical data documenting the impact of physical activity (PA) on preventing morbidity and mortality associated with common chronic diseases, indicate that adults should accumulate 30 minutes of moderate-intensity PA > or =5 days per week. However, worldwide rates of PA remain low, indicating a great need for large-scale implementation of evidence-based PA interventions. We briefly present practical aspects of intervention planning, implementation and evaluation within common community settings. The first stage of intervention planning is formative research, which allows for a better understanding of the elements needed for a successful intervention. Partnering with community settings (schools, worksites, faith-based organizations and healthcare organizations) offers many benefits and the opportunity to reach specific populations. Setting-based approaches allow for multilevel strategies, ranging from individual-based programmes and educational initiatives to physical and social environmental changes. Various settings such as healthcare, worksite, and school- and community-based settings are discussed. Intervention delivery methods and strategies can range, depending on the population and setting targeted, from small-group approaches to mediated methods (e.g. print, telephone, electronic). The final phase of intervention planning and implementation is evaluation. Several objective and subjective methods of PA assessment are available to determine the effectiveness of the intervention. We have highlighted the need for process evaluation of intervention implementation to provide valuable information for the dissemination and sustainability of successful interventions. Although there are numerous considerations for the design, implementation, assessment and evaluation of PA interventions, the potential for positive impact on the overall health of the public indicates the necessity for programmes designed to increase PA.

The association of 83 plasma proteins with CHD mortality, BMI, HDL-, and total-cholesterol in men: applying multivariate statistics to identify proteins with prognostic value and biological relevance.

PubMed

Heidema, A Geert; Thissen, Uwe; Boer, Jolanda M A; Bouwman, Freek G; Feskens, Edith J M; Mariman, Edwin C M

2009-06-01

In this study, we applied the multivariate statistical tool Partial Least Squares (PLS) to analyze the relative importance of 83 plasma proteins in relation to coronary heart disease (CHD) mortality and the intermediate end points body mass index, HDL-cholesterol and total cholesterol. From a Dutch monitoring project for cardiovascular disease risk factors, men who died of CHD between initial participation (1987-1991) and end of follow-up (January 1, 2000) (N = 44) and matched controls (N = 44) were selected. Baseline plasma concentrations of proteins were measured by a multiplex immunoassay. With the use of PLS, we identified 15 proteins with prognostic value for CHD mortality and sets of proteins associated with the intermediate end points. Subsequently, sets of proteins and intermediate end points were analyzed together by Principal Components Analysis, indicating that proteins involved in inflammation explained most of the variance, followed by proteins involved in metabolism and proteins associated with total-C. This study is one of the first in which the association of a large number of plasma proteins with CHD mortality and intermediate end points is investigated by applying multivariate statistics, providing insight in the relationships among proteins, intermediate end points and CHD mortality, and a set of proteins with prognostic value.

The use of chlorhexidine to reduce maternal and neonatal mortality and morbidity in low-resource settings

PubMed Central

McClure, Elizabeth M; Goldenberg, Robert L; Brandes, Neal; Darmstadt, Gary L; Wright, Linda L

2009-01-01

Of the 4 million neonatal deaths and 500,000 maternal deaths that occur annually worldwide, almost 99% are in developing countries and one-third are associated with infections. Implementation of proven interventions and targeted research on a select number of promising high-impact preventative and curative interventions are essential to achieve Millennium Development Goals for reduction of child and maternal mortality. Feasible, simple, low-cost interventions have the potential to significantly reduce the mortality and severe morbidity associated with infection in these settings. Studies of chlorhexidine in developing countries have focused on three primary uses: 1) intrapartum vaginal and neonatal wiping, 2) neonatal wiping alone, and 3) umbilical cord cleansing. A study of vaginal wiping and neonatal skin cleansing with chlorhexidine, conducted in Malawi in the 1990s suggested that chlorhexidine has potential to reduce neonatal infectious morbidity and mortality. A recent trial of cord cleansing conducted in Nepal also demonstrated benefit. Although studies have shown promise, widespread acceptance and implementation of chlorhexidine use has not yet occurred. This paper is derived in part from data presented at a conference on the use of chlorhexidine in developing countries and reviews the available evidence related to chlorhexidine use to reduce mortality and severe morbidity due to infections in mothers and neonates in low-resource settings. It also summarizes issues related to programmatic implementation. PMID:17399714

Strategies to sustain a quality improvement initiative in neonatal resuscitation

PubMed Central

van Heerden, Carlien; Janse van Rensburg, Elsie S.

2016-01-01

Background Many neonatal deaths can be prevented globally through effective resuscitation. South Africa (SA) committed towards attaining the Millennium Development Goal 4 (MDG4) set by the World Health Organization (WHO). However, SA’s district hospitals have the highest early neonatal mortality rates. Modifiable and avoidable causes associated with patient-related, administrative and health care provider factors contribute to neonatal mortality. A quality improvement initiative in neonatal resuscitation could contribute towards decreasing neonatal mortality, thereby contributing towards the attainment of the MDG4. Aim The aim of this study was, (1) to explore and describe the existing situation regarding neonatal resuscitation in a district hospital, (2) to develop strategies to sustain a neonatal resuscitation quality improvement initiative and (3) to decrease neonatal mortality. Changes that occurred and the sustainability of strategies were evaluated. Setting A maternity section of a district hospital in South Africa. Methods The National Health Service (NHS) Sustainability Model formed the theoretical framework for the study. The Problem Resolving Action Research model was applied and the study was conducted in three cycles. Purposive sampling was used for the quantitative and qualitative aspects of data collection. Data was analysed accordingly. Results The findings indicated that the strategies formulated and implemented to address factors related to neonatal resuscitation (training, equipment and stock, staff shortages, staff attitude, neonatal transport and protocols) had probable sustainability and contributed towards a reduction in neonatal mortality in the setting. Conclusion These strategies had the probability of sustainability and could potentially improve neonatal outcomes and reduce neonatal mortality to contribute toward South Africa’s’ drive to attain the MDG4. PMID:27380840

The development of a VBHOM-based outcome model for lower limb amputation performed for critical ischaemia.

PubMed

Tang, T Y; Prytherch, D R; Walsh, S R; Athanassoglou, V; Seppi, V; Sadat, U; Lees, T A; Varty, K; Boyle, J R

2009-01-01

VBHOM (Vascular Biochemistry and Haematology Outcome Models) adopts the approach of using a minimum data set to model outcome and has been previously shown to be feasible after index arterial operations. This study attempts to model mortality following lower limb amputation for critical limb ischaemia using the VBHOM concept. A binary logistic regression model of risk of mortality was built using National Vascular Database items that contained the complete data required by the model from 269 admissions for lower limb amputation. The subset of NVD data items used were urea, creatinine, sodium, potassium, haemoglobin, white cell count, age on and mode of admission. This model was applied prospectively to a test set of data (n=269), which were not part of the original training set to develop the predictor equation. Outcome following lower limb amputation could be described accurately using the same model. The overall mean predicted risk of mortality was 32%, predicting 86 deaths. Actual number of deaths was 86 (chi(2)=8.05, 8 d.f., p=0.429; no evidence of lack of fit). The model demonstrated adequate discrimination (c-index=0.704). VBHOM provides a single unified model that allows good prediction of surgical mortality in this high risk group of individuals. It uses a small, simple and objective clinical data set that may also simplify comparative audit within vascular surgery.

Children’s Oxygen Administration Strategies Trial (COAST):  A randomised controlled trial of high flow versus oxygen versus control in African children with severe pneumonia

PubMed Central

Maitland, Kathryn; Kiguli, Sarah; Opoka, Robert O.; Olupot-Olupot, Peter; Engoru, Charles; Njuguna, Patricia; Bandika, Victor; Mpoya, Ayub; Bush, Andrew; Williams, Thomas N.; Grieve, Richard; Sadique, Zia; Fraser, John; Harrison, David; Rowan, Kathy

2018-01-01

Background: In Africa, the clinical syndrome of pneumonia remains the leading cause of morbidity and mortality in children in the post-neonatal period. This represents a significant burden on in-patient services. The targeted use of oxygen and simple, non-invasive methods of respiratory support may be a highly cost-effective means of improving outcome, but the optimal oxygen saturation threshold that results in benefit and the best strategy for delivery are yet to be tested in adequately powered randomised controlled trials. There is, however, an accumulating literature about the harms of oxygen therapy across a range of acute and emergency situations that have stimulated a number of trials investigating permissive hypoxia. Methods: In 4200 African children, aged 2 months to 12 years, presenting to 5 hospitals in East Africa with respiratory distress and hypoxia (oxygen saturation < 92%), the COAST trial will simultaneously evaluate two related interventions (targeted use of oxygen with respect to the optimal oxygen saturation threshold for treatment and mode of delivery) to reduce shorter-term mortality at 48-hours (primary endpoint), and longer-term morbidity and mortality to 28 days in a fractional factorial design, that compares: Liberal oxygenation (recommended care) compared with a strategy that permits hypoxia to SpO 2 > or = 80% (permissive hypoxia); andHigh flow using AIrVO 2 TM compared with low flow delivery (routine care). Discussion: The overarching objective is to address the key research gaps in the therapeutic use of oxygen in resource-limited setting in order to provide a better evidence base for future management guidelines. The trial has been designed to address the poor outcomes of children in sub-Saharan Africa, which are associated with high rates of in-hospital mortality, 9-10% (for those with oxygen saturations of 80-92%) and 26-30% case fatality for those with oxygen saturations <80%. Clinical trial registration: ISRCTN15622505 Trial status: Recruiting PMID:29383331

Family type, domestic violence and under-five mortality in Nigeria.

PubMed

Titilayo, Ayotunde; Anuodo, Oludare O; Palamuleni, Martin E

2017-06-01

Nigeria still showcases unacceptably high under-five mortality despite all efforts to reduce the menace. Investigating the significant predictors of this occurrence is paramount. To examine the interplay between family setting, domestic violence and under-five death in Nigeria. Cross-sectional secondary data, the 2013 Nigeria Demographic and Health Survey, (NDHS) women dataset was utilized. Subset of 26,997 ever married and ever had childbirth experience respondents were extracted from the nationally representative women dataset. Dependent and Independent variables were recoded to suit the statistical analysis for the study. The study revealed that 33.7% of the respondents were in polygyny family setting; one-quarter of the ever married women reported ever experiencing one form of domestic violence or the other. The results of the logistic regressions indicate that family type and domestic violence were significant predictors of under-five children mortality in Nigeria. The study concludes that women who belong to polygyny family setting and who ever experienced sexual domestic violence are highly susceptible to experience under-five children mortality than their counterparts. The study recommends that strategies and policies aimed at improving child survival should strengthen women empowerment initiatives, discourage multiple wives and campaign against domestic violence in Nigeria.

Do childhood vaccines have non-specific effects on mortality?

PubMed Central

Cooper, William O.; Boyce, Thomas G.; Wright, Peter F.; Griffin, Marie R.

2003-01-01

A recent article by Kristensen et al. suggested that measles vaccine and bacille Calmette-Gu rin (BCG) vaccine might reduce mortality beyond what is expected simply from protection against measles and tuberculosis. Previous reviews of the potential effects of childhood vaccines on mortality have not considered methodological features of reviewed studies. Methodological considerations play an especially important role in observational assessments, in which selection factors for vaccination may be difficult to ascertain. We reviewed 782 English language articles on vaccines and childhood mortality and found only a few whose design met the criteria for methodological rigor. The data reviewed suggest that measles vaccine delivers its promised reduction in mortality, but there is insufficient evidence to suggest a mortality benefit above that caused by its effect on measles disease and its sequelae. Our review of the available data in the literature reinforces how difficult answering these considerations has been and how important study design will be in determining the effect of specific vaccines on all-cause mortality. PMID:14758409

Dysthymia and Depression Increase Risk of Dementia and Mortality among Older Veterans

PubMed Central

Byers, Amy L.; Covinsky, Kenneth E.; Barnes, Deborah E.; Yaffe, Kristine

2011-01-01

Objective To determine if less severe depression spectrum diagnoses such as dysthymia, as well as depression, are associated with risk of developing dementia and mortality in a “real world” setting. Design Retrospective cohort study conducted using the Department of Veterans Affairs (VA) National Patient Care Database (1997-2007). Setting VA medical centers in the United States. Participants A total of 281,540 veterans 55 years and older without dementia at study baseline (1997-2000). Measurements Depression status and incident dementia were ascertained from ICD-9 codes during study baseline (1997-2000) and follow-up (2001-2007), respectively. Mortality was ascertained by time of death dates in the VA Vital Status File. Results Ten percent of veterans had baseline diagnosis of depression and nearly 1% had dysthymia. The unadjusted incidence of dementia was 11.2% in veterans with depression, 10.2% with dysthymia and 6.4% with neither. After adjusting for demographics and comorbidities, patients diagnosed with dysthymia or depression were twice as likely to develop incident dementia compared to those with no dysthymia/depression (adjusted dysthymia hazard ratio [HR]: 1.96, 95% confidence interval [CI]: 1.71-2.25; and depression HR: 2.18, 95% CI: 2.08-2.28). Dysthymia and depression also were associated with increased risk of death (31.6% dysthymia and 32.9% depression vs 28.5% neither; adjusted dysthymia HR: 1.41, 95% CI: 1.31-1.53; and depression HR: 1.47, 95% CI: 1.43-1.51). Conclusions Findings suggest that older adults with dysthymia or depression need to be monitored closely for adverse outcomes. Future studies should determine whether treatment of depression spectrum disorders may reduce risk of these outcomes. PMID:21597358

Italian Survey on Prevalence and Disease Management of Chronic Heart Failure and Chronic Obstructive Pulmonary Disease comorbidity in ambulatory patients. SUSPIRIUM study rationale and design.

PubMed

Griffo, Raffaele; Spanevello, Antonio; Temporelli, Pier Luigi; Faggiano, Pompilio; Carones, Mauro; Magni, Giovanna; Ambrosino, Nicolino; Tavazzi, Luigi

2014-03-01

Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are leading causes of morbidity and mortality worldwide. Through shared risk factors and pathophysiological mechanisms, CHF and COPD frequently coexist. The concurrent disease has important therapeutic implications and independently predicts worsened mortality, impaired functional status, and health service use. However, assessment of the comorbidity varies widely according to the population studied, diagnostic criteria and measurement tools applied. Both syndromes have been studied extensively but largely separately, mostly in the domain of the pulmonologist for COPD and in the domain of the cardiologist for CHF. The aim of the study is to evaluate in an Italian outpatients setting (10 cardiology and 10 pulmonology centers from the same institution) the prevalence, clinical profile and the routine diagnostic, functional and therapeutic work-up applied by cardiologists and pulmonologists in the presence/suspicion of concurrent disease in patients in a stable phase of their disease. For this purpose, CHF and COPU outpatients will be enrolled in a multicenter, nationwide, prospective observational study. Risk estimation of comorbidity will be based on suspected, documented or patient-reported diagnosis of COPD/CHF. In the absence of documented concurrent diagnosis, each specialist will describe the diagnostic, functional and therapeutic work-up applied. The design of the study focused on the diagnostic validation of the CHF-COPD comorbidity aims to provide relevant new information on the assessment of the coexistent condition in the cardiac and pulmonary outpatients setting and on specialty-related different diagnostic and therapeutic strategies of comorbidity utilized in real life clinical practice. The symptomatic and prognostic benefits resulting from a combined approach to CHF/COPD could outweigh those attainable by treating either condition alone.

Association Between Valvular Surgery and Mortality Among Patients With Infective Endocarditis Complicated by Heart Failure

PubMed Central

Kiefer, Todd; Park, Lawrence; Tribouilloy, Christophe; Cortes, Claudia; Casillo, Roberta; Chu, Vivian; Delahaye, Francois; Durante-Mangoni, Emanuele; Edathodu, Jameela; Falces, Carlos; Logar, Mateja; Miró, José M.; Naber, Christophe; Tripodi, Marie Françoise; Murdoch, David R.; Moreillon, Philippe; Utili, Riccardo; Wang, Andrew

2016-01-01

Context Heart failure (HF) is the most common complication of infective endocarditis. However, clinical characteristics of HF in patients with infective endocarditis, use of surgical therapy, and their associations with patient outcome are not well described. Objectives To determine the clinical, echocardiographic, and microbiological variables associated with HF in patients with definite infective endocarditis and to examine variables independently associated with in-hospital and 1-year mortality for patients with infective endocarditis and HF, including the use and association of surgery with outcome. Design, Setting, and Patients The International Collaboration on Endocarditis–Prospective Cohort Study, a prospective, multicenter study enrolling 4166 patients with definite native- or prosthetic-valve infective endocarditis from 61 centers in 28 countries between June 2000 and December 2006. Main Outcome Measures In-hospital and 1-year mortality. Results Of 4075 patients with infective endocarditis and known HF status enrolled, 1359 (33.4% [95% CI, 31.9%–34.8%]) had HF, and 906 (66.7% [95% CI, 64.2%–69.2%]) were classified as having New York Heart Association class III or IV symptom status. Within the subset with HF, 839 (61.7% [95% CI, 59.2%–64.3%]) underwent valvular surgery during the index hospitalization. In-hospital mortality was 29.7% (95% CI, 27.2%–32.1%) for the entire HF cohort, with lower mortality observed in patients undergoing valvular surgery compared with medical therapy alone (20.6% [95% CI, 17.9%–23.4%] vs 44.8% [95% CI, 40.4%–49.0%], respectively; P<.001). One-year mortality was 29.1% (95% CI, 26.0%–32.2%) in patients undergoing valvular surgery vs 58.4% (95% CI, 54.1%–62.6%) in those not undergoing surgery (P<.001). Cox proportional hazards modeling with propensity score adjustment for surgery showed that advanced age, diabetes mellitus, health care–associated infection, causative microorganism (Staphylococcus aureus or fungi), severe HF (New York Heart Association class III or IV), stroke, and paravalvular complications were independently associated with 1-year mortality, whereas valvular surgery during the initial hospitalization was associated with lower mortality. Conclusion In this cohort of patients with infective endocarditis complicated by HF, severity of HF was strongly associated with surgical therapy and subsequent mortality, whereas valvular surgery was associated with lower in-hospital and 1-year mortality. PMID:22110106

Specific Dietary Fats in Relation to Total and Cause-Specific Mortality

PubMed Central

Wang, Dong D.; Li, Yanping; Chiuve, Stephanie E.; Stampfer, Meir J.; Manson, JoAnn E.; Rimm, Eric B.; Willett, Walter C.; Hu, Frank B.

2016-01-01

Importance Previous studies have shown distinct associations between specific dietary fat and cardiovascular disease. However, evidence on specific dietary fats and mortality remains limited and inconsistent. Objective To examine the associations of specific dietary fats with total and cause-specific mortality in two large ongoing prospective cohort studies. Design, setting, and participants We investigated 83,349 women from the Nurses’ Health Study (1980-2012) and 42,884 men from the Health Professionals Follow-up Study (1986-2012) who were free from cardiovascular disease, cancer and diabetes at baseline. Dietary fat intake was assessed at baseline and updated every 2 to 4 years. Main outcomes and measures We performed systematic searches of the vital records of states and of the National Death Index, supplemented by reports from family members or postal authorities. Results We documented 33,304 deaths during 3,439,954 person-years of follow-up. After adjustment for known and suspected risk factors, dietary total fat, compared to total carbohydrate, was inversely associated with total mortality (P for trend <0.001). The hazard ratios (HRs) of total mortality comparing extreme quintiles of specific dietary fats was 1.08, (95% confidence interval (CI), 1.03-1.14) for saturated fat, 0.81 (95% CI, 0.78-0.84) for polyunsaturated fat, 0.89 (95% CI, 0.84-0.94) for monounsaturated fat and 1.13 (95% CI, 1.07-1.18) for trans fat (P for trend <0.001 for all). Replacing 5% of energy from saturated fats with equivalent energy from polyunsaturated fats and monounsaturated fats was associated with 27% (HR =0.73, 95% CI, 0.70-0.77) and 13% (HR =0.87, 95% CI, 0.82-0.93) estimated reductions in total mortality, respectively. HR of total mortality comparing extreme quintiles of n-6 polyunsaturated fat intake was 0.85 (95% CI, 0.81-0.89). Intake of n-6 polyunsaturated fat, especially linoleic acid, was inversely associated with mortality due to most major causes, while marine n-3 polyunsaturated fat intake was associated with a modestly lower total mortality (HR comparing extreme quintiles =0.96, 95% CI, 0.93-1.00). Conclusions and relevance Different types of dietary fats have divergent associations with total and cause-specific mortality. These findings support current dietary recommendations to replace saturated and trans fat with unsaturated fats. PMID:27379574

Increased mortality risk in women with depression and diabetes mellitus

PubMed Central

Pan, An; Lucas, Michel; Sun, Qi; van Dam, Rob M.; Franco, Oscar H.; Willett, Walter C.; Manson, JoAnn E.; Rexrode, Kathryn M.; Ascherio, Alberto; Hu, Frank B.

2011-01-01

Context Both depression and diabetes have been associated with an increased risk of all-cause and cardiovascular diseases (CVD) mortality. However, data evaluating the joint effects of these two conditions on mortality are sparse. Objectives To evaluate the individual and joint effects of depression and diabetes on all-cause and CVD mortality in a prospective cohort study. Design, Settings and Participants A total of 78282 female participants in the Nurses' Health Study aged 54-79 years at baseline in 2000 were followed until 2006. Depression was defined as having self-reported diagnosed depression, treatment with antidepressant medications, or a score indicating severe depressive symptomatology, i.e., a five-item Mental Health Index score ≤52. Self-reported type 2 diabetes was confirmed using a supplementary questionnaire. Main outcome measures All-cause and CVD-specific mortality. Results During 6 years of follow-up (433066 person-years), 4654 deaths were documented, including 979 deaths from CVD. Compared to participants without either condition, the age-adjusted relative risks (95% confidence interval, CI) for all-cause mortality were 1.76 (1.64-1.89) for women with depression only, 1.71 (1.54-1.89) for individuals with diabetes only, and 3.11 (2.70-3.58) for those with both conditions. The corresponding age-adjusted relative risks of CVD mortality were 1.81 (1.54-2.13), 2.67 (2.20-3.23), and 5.38 (4.19-6.91), respectively. These associations were attenuated after multivariate adjustment for other demographic variables, body mass index, smoking status, alcohol intake, physical activity, and major comorbidities (including hypertension, hypercholesterolemia, heart diseases, stroke and cancer) but remained significant, with the highest relative risks for all-cause and CVD mortality found in those with both conditions (2.07 [95% CI, 1.79-2.40] and 2.72 [95% CI, 2.09-3.54], respectively). Furthermore, the combination of depression with a long duration of diabetes (i.e., >10 years) or insulin therapy was associated with particularly higher risk of CVD mortality after multivariate adjustment (relative risk=3.22 and 4.90, respectively). Conclusions Depression and diabetes are associated with significantly increased risk of all-cause and CVD mortality. The coexistence of both conditions identifies particularly high-risk women. PMID:21199964

GFR at Initiation of Dialysis and Mortality in CKD: A Meta-analysis

PubMed Central

Susantitaphong, Paweena; Altamimi, Sarah; Ashkar, Motaz; Balk, Ethan M.; Stel, Vianda S.; Wright, Seth; Jaber, Bertrand L.

2012-01-01

Background The proportion of patients with advanced chronic kidney disease (CKD) initiating dialysis at higher glomerular filtration rate (GFR) has increased over the past decade. Recent data suggest that higher GFR may be associated with increased mortality. Study Design A meta-analysis of cohort studies and trials. Setting & Population Patients with advanced CKD. Selection Criteria for Studies We performed a systematic literature search in MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, American Society of Nephrology abstracts, and bibliographies of retrieved articles to identify studies reporting on GFR at dialysis initiation and mortality. Predictor estimated or calculated GFR at dialysis initiation. Outcome Pooled adjusted hazard ratio (HR) of continuous GFR for all-cause mortality. Results Sixteen cohort studies and one randomized controlled trial were identified (n=1,081,116). By meta-analysis, restricted to the 15 cohorts (n=1,079,917), higher GFR at dialysis initiation was associated with a higher pooled adjusted HR for all-cause mortality (1.04; 95% CI, 1.03–1.05; P<0.001). However, there was significant heterogeneity (I2=97%; P<0.001). The association persisted among the 9 cohorts that adjusted analytically for nutritional covariates (HR 1.03; 95% CI 1.02, 1.04; P<0.001; residual I2=97%). The highest mortality risk was observed in hemodialysis cohorts (HR 1.05; 95% CI 1.02, 1.08; P<0.001) whereas there was no association between GFR and mortality in peritoneal dialysis cohorts (HR 1.04; 95% CI 0.99, 1.08, P=0.11; residual I2=98%). Finally, higher GFR was associated with a lower mortality risk in cohorts that calculated GFR (HR 0.80; 95% CI 0.71, 0.91; P=0.003), contrasting with a higher mortality risk in cohorts that estimated GFR (HR 1.04; 95% CI 1.03, 1.05; P<0.001; residual I2=97%). Limitations Paucity of randomized controlled trials; different methods for determining GFR; and substantial heterogeneity. Conclusions Higher estimated rather than calculated GFR at dialysis initiation is associated with a higher mortality risk among patients with advanced CKD, independent of nutritional status. Although there was substantial heterogeneity of effect size estimates across studies, this observation requires further study. PMID:22465328

Effectiveness of litter removal in preventing mortality of yellow barked ponderosa pine in northern Arizona

Treesearch

James F. Fowler; Carolyn H. Sieg; Linda Wadleigh; Sally Haase

2007-01-01

Removal of deep litter and duff from the base of mature southwestern ponderosa pine trees is commonly recommended to reduce mortality following prescribed burns, but experimental studies that quantify the effectiveness of such practices in reducing mortality are lacking. Following a pilot study, on each of four sites in northern Arizona we monitored 15-16 sets of 8...

26 CFR 1.430(h)(3)-2 - Plan-specific substitute mortality tables used to determine present value.

Code of Federal Regulations, 2010 CFR

2010-04-01

... to determine present value. 1.430(h)(3)-2 Section 1.430(h)(3)-2 Internal Revenue INTERNAL REVENUE... § 1.430(h)(3)-2 Plan-specific substitute mortality tables used to determine present value. (a) In general. This section sets forth rules for the use of substitute mortality tables under section 430(h)(3...

Measles vaccination improves the equity of health outcomes: evidence from Bangladesh.

PubMed

Bishai, David; Koenig, Michael; Ali Khan, Mehrab

2003-05-01

This paper asks whether measles vaccination can reduce socioeconomic differentials in under five mortality rates (U5MR) in a setting characterized by extreme poverty and high levels of childhood mortality. Longitudinal cohort study based on quasi experimental design. Data come from the phased introduction of a measles vaccine intervention in Matlab, Bangladesh in 1982. There were 16 270 Bangladeshi children aged 9-60 months. The intervention cohort received measles vaccine. Socioeconomic differentials in U5MR between the lowest and highest socioeconomic status (SES) quintiles in a cohort of 8135 vaccinated children and a cohort of unvaccinated age matched controls. Mantel-Haenszel rate ratios for the lowest to highest SES quintile were computed. SES was measured by factor analysis of maternal schooling, land holdings, dwelling size, and number of rooms. The U5MR ratio of lowest SES to highest was 2.27 (95% CI=1.62-3.19) in the unvaccinated population and 1.42 (95%CI=0.94-2.15) in the vaccinated population. The difference between unvaccinated and vaccinated U5MR ratios was statistically significant (p<0.10) and robust across alternative measures of SES. Children from the poorest quintile were more than twice as likely to die as those from the least quintile in the absence of measles vaccination. Universal distribution of measles vaccination largely nullified SES related mortality differentials within a high mortality population of children. Copyright 2002 John Wiley & Sons, Ltd.

Poor Self-Reported Sleep Quality Predicts Mortality within One Year of Inpatient Post-Acute Rehabilitation among Older Adults

PubMed Central

Martin, Jennifer L.; Fiorentino, Lavinia; Jouldjian, Stella; Mitchell, Michael; Josephson, Karen R.; Alessi, Cathy A.

2011-01-01

Study Objective: To evaluate the association between self-reported sleep quality among older adults during inpatient post-acute rehabilitation and one-year survival. Design: Prospective, observational cohort study. Setting: Two inpatient post-acute rehabilitation sites (one community and one Veterans Administration). Participants: Older patients (aged ≥ 65 years, n = 245) admitted for inpatient post-acute rehabilitation. Interventions: None. Measurements and Results: Within one year of post-acute rehabilitation, 57 participants (23%) were deceased. Cox proportional hazards models showed that worse Pittsburgh Sleep Quality Index (PSQI) total scores during the post-acute care stay were associated with increased mortality risk when controlling for amount of rehabilitation therapy received, comorbidities, and cognitive functioning (Hazard ratio [95% CI] = 1.11 [1.02-1.20]). Actigraphically estimated sleep was unrelated to mortality risk. Conclusions: Poorer self-reported sleep quality, but not objectively estimated sleep parameters, during post-acute rehabilitation was associated with shorter survival among older adults. This suggests self-reported poor sleep may be an important and potentially modifiable risk factor for negative outcomes in these vulnerable older adults. Studies of interventions to improve sleep quality during inpatient rehabilitation should therefore be undertaken, and the long-term health benefits of improved sleep should be explored. Citation: Martin JL; Fiorentino L; Jouldjian S; Mitchell M; Josephson KR; Alessi CA. Poor self-reported sleep quality predicts mortality within one year of inpatient post-acute rehabilitation among older adults. SLEEP 2011;34(12):1715-1721. PMID:22131610

Clinical outcomes and mortality before and after implementation of a pediatric sepsis protocol in a limited resource setting: A retrospective cohort study in Bangladesh.

PubMed

Kortz, Teresa Bleakly; Axelrod, David M; Chisti, Mohammod J; Kache, Saraswati

2017-01-01

Pediatric sepsis has a high mortality rate in limited resource settings. Sepsis protocols have been shown to be a cost-effective strategy to improve morbidity and mortality in a variety of populations and settings. At Dhaka Hospital in Bangladesh, mortality from pediatric sepsis in high-risk children previously approached 60%, which prompted the implementation of an evidenced-based protocol in 2010. The clinical effectiveness of this protocol had not been measured. We hypothesized that implementation of a pediatric sepsis protocol improved clinical outcomes, including reducing mortality and length of hospital stay. This was a retrospective cohort study of children 1-59 months old with a diagnosis of sepsis, severe sepsis or septic shock admitted to Dhaka Hospital from 10/25/2009-10/25/2011. The primary outcome was inpatient mortality pre- and post-protocol implementation. Secondary outcomes included fluid overload, heart failure, respiratory insufficiency, length of hospital stay, and protocol compliance, as measured by antibiotic and fluid bolus administration within 60 minutes of hospital presentation. 404 patients were identified by a key-word search of the electronic medical record; 328 patients with a primary diagnosis of sepsis, severe sepsis, or septic shock were included (143 pre- and185 post-protocol) in the analysis. Pre- and post-protocol mortality were similar and not statistically significant (32.17% vs. 34.59%, p = 0.72). The adjusted odds ratio (AOR) for post-protocol mortality was 1.55 (95% CI, 0.88-2.71). The odds for developing fluid overload were significantly higher post-protocol (AOR 3.45, 95% CI, 2.04-5.85), as were the odds of developing heart failure (AOR 4.52, 95% CI, 1.43-14.29) and having a longer median length of stay (AOR 1.81, 95% CI 1.10-2.96). There was no statistically significant difference in respiratory insufficiency (pre- 65.7% vs. post- 70.3%, p = 0.4) or antibiotic administration between the cohorts (pre- 16.08% vs. post- 12.43%, p = 0.42). Implementation of a pediatric sepsis protocol did not improve all-cause mortality or length of stay and may have been associated with increased fluid overload and heart failure during the study period in a large, non-governmental hospital in Bangladesh. Similar rates of early antibiotic administration may indicate poor protocol compliance. Though evidenced-based protocols are a potential cost-effective strategy to improve outcomes, future studies should focus on optimal implementation of context-relevant sepsis protocols in limited resource settings.

Temperature modifies the association between particulate air pollution and mortality: A multi-city study in South Korea.

PubMed

Kim, Satbyul Estella; Lim, Youn-Hee; Kim, Ho

2015-08-15

Substantial epidemiologic literature has demonstrated the effects of air pollution and temperature on mortality. However, there is inconsistent evidence regarding the temperature modification effect on acute mortality due to air pollution. Herein, we investigated the effects of temperature on the relationship between air pollution and mortality due to non-accidental, cardiovascular, and respiratory death in seven cities in South Korea. We applied stratified time-series models to the data sets in order to examine whether the effects of particulate matter <10 μm (PM10) on mortality were modified by temperature. The effect of PM10 on daily mortality was first quantified within different ranges of temperatures at each location using a time-series model, and then the estimates were pooled through a random-effects meta-analysis using the maximum likelihood method. From all the data sets, 828,787 non-accidental deaths were registered from 2000-2009. The highest overall risk between PM10 and non-accidental or cardiovascular mortality was observed on extremely hot days (daily mean temperature: >99th percentile) in individuals aged <65 years. In those aged ≥65 years, the highest overall risk between PM10 and non-accidental or cardiovascular mortality was observed on very hot days and not on extremely hot days (daily mean temperature: 95-99th percentile). There were strong harmful effects from PM10 on non-accidental mortality with the highest temperature range (>99th percentile) in men, with a very high temperature range (95-99th percentile) in women. Our findings showed that temperature can affect the relationship between the PM10 levels and cause-specific mortality. Moreover, the differences were apparent after considering the age and sex groups. Copyright © 2015 Elsevier B.V. All rights reserved.

Derivation and validation of different machine-learning models in mortality prediction of trauma in motorcycle riders: a cross-sectional retrospective study in southern Taiwan

PubMed Central

Kuo, Pao-Jen; Wu, Shao-Chun; Chien, Peng-Chen; Rau, Cheng-Shyuan; Chen, Yi-Chun; Hsieh, Hsiao-Yun; Hsieh, Ching-Hua

2018-01-01

Objectives This study aimed to build and test the models of machine learning (ML) to predict the mortality of hospitalised motorcycle riders. Setting The study was conducted in a level-1 trauma centre in southern Taiwan. Participants Motorcycle riders who were hospitalised between January 2009 and December 2015 were classified into a training set (n=6306) and test set (n=946). Using the demographic information, injury characteristics and laboratory data of patients, logistic regression (LR), support vector machine (SVM) and decision tree (DT) analyses were performed to determine the mortality of individual motorcycle riders, under different conditions, using all samples or reduced samples, as well as all variables or selected features in the algorithm. Primary and secondary outcome measures The predictive performance of the model was evaluated based on accuracy, sensitivity, specificity and geometric mean, and an analysis of the area under the receiver operating characteristic curves of the two different models was carried out. Results In the training set, both LR and SVM had a significantly higher area under the receiver operating characteristic curve (AUC) than DT. No significant difference was observed in the AUC of LR and SVM, regardless of whether all samples or reduced samples and whether all variables or selected features were used. In the test set, the performance of the SVM model for all samples with selected features was better than that of all other models, with an accuracy of 98.73%, sensitivity of 86.96%, specificity of 99.02%, geometric mean of 92.79% and AUC of 0.9517, in mortality prediction. Conclusion ML can provide a feasible level of accuracy in predicting the mortality of motorcycle riders. Integration of the ML model, particularly the SVM algorithm in the trauma system, may help identify high-risk patients and, therefore, guide appropriate interventions by the clinical staff. PMID:29306885

Nonesterified Fatty Acids and Cardiovascular Mortality in Elderly Men with CKD

PubMed Central

Xiong, Zibo; Xu, Hong; Huang, Xiaoyan; Ärnlöv, Johan; Qureshi, Abdul Rashid; Cederholm, Tommy; Sjögren, Per; Lindholm, Bengt; Risérus, Ulf

2015-01-01

Background and objectives Although nonesterified fatty acids (NEFAs) are essential as energy substrate for the myocardium, an excess of circulating NEFAs can be harmful. This study aimed to assess plausible relationships between serum NEFA and mortality due to cardiovascular disease (CVD) in individuals with CKD. Design, setting, participants, & measurements This was a prospective cohort study from the third examination cycle of the Uppsala Longitudinal Study of Adult Men, a population-based survey of 1221 elderly men aged 70–71 years residing in Uppsala, Sweden. Data collection took place during 1991–1995. All participants had measures of kidney function; this study investigated 623 (51.7%) of these patients with manifest CKD (defined as either eGFR<60 ml/min per 1.73 m2 or urine albumin excretion rate ≥20 µg/min). Follow-up for mortality was done from examination date until death or December 31, 2007. After a median follow-up of 14 years (interquartile range, 8–16.8), associations of NEFAs with mortality (related to all causes, CVD, ischemic heart disease [IHD], or acute myocardial infarction) were ascertained. Results The median serum NEFA was 14.1 mg/dl (interquartile range, 11.3–17.8). No association was found with measures of kidney function. Diabetes and serum triglycerides were the only multivariate correlates of NEFA. During follow-up, 453 participants died, of which 209 deaths were due to CVD, including 88 IHD deaths, with 41 attributed to acute myocardial infarction (AMI). In fully adjusted covariates, serum NEFA was an independent risk factor for all-cause mortality (hazard ratio [HR] per log2 increase, 1.22; 95% confidence interval [95% CI], 1.00 to 1.48) and CVD-related death (HR, 1.51; 95% CI, 1.15 to 1.99), including both IHD (HR, 1.51; 95% CI, 1.00 to 2.32) and AMI mortality (HR, 2.08; 95% CI, 1.09 to 3.98). Conclusions Elevated serum NEFA associated with CVD mortality, and particularly with mortality due to AMI, in a homogeneous population of older men with moderate CKD. PMID:25637632

Association of Sleep Duration with Mortality from Cardiovascular Disease and Other Causes for Japanese Men and Women: the JACC Study

PubMed Central

Ikehara, Satoyo; Iso, Hiroyasu; Date, Chigusa; Kikuchi, Shogo; Watanabe, Yoshiyuki; Wada, Yasuhiko; Inaba, Yutaka; Tamakoshi, Akiko

2009-01-01

Study Objectives: To examine sex-specific associations between sleep duration and mortality from cardiovascular disease and other causes. Design: Cohort study. Setting: Community-based study. Participants: A total of 98,634 subjects (41,489 men and 57,145 women) aged 40 to 79 years from 1988 to 1990 and were followed until 2003. Interventions: N/A. Measurements and Results: During a median follow-up of 14.3 years, there were 1964 deaths (men and women: 1038 and 926) from stroke, 881 (508 and 373) from coronary heart disease, 4287 (2297 and 1990) from cardiovascular disease, 5465 (3432 and 2033) from cancer, and 14,540 (8548 and 5992) from all causes. Compared with a sleep duration of 7 hours, sleep duration of 4 hours or less was associated with increased mortality from coronary heart disease for women and noncardiovascular disease/noncancer and all causes in both sexes. The respective multivariable hazard ratios were 2.32 (1.19–4.50) for coronary heart disease in women, 1.49 (1.02–2.18) and 1.47 (1.01–2.15) for noncardiovascular disease/noncancer, and 1.29 (1.02–1.64) and 1.28 (1.03–1.60) for all causes in men and women, respectively. Long sleep duration of 10 hours or longer was associated with 1.5- to 2-fold increased mortality from total and ischemic stroke, total cardiovascular disease, noncardiovascular disease/noncancer, and all causes for men and women, compared with 7 hours of sleep in both sexes. There was no association between sleep duration and cancer mortality in either sex. Conclusions: Both short and long sleep duration were associated with increased mortality from cardiovascular disease, noncardiovascular disease/noncancer, and all causes for both sexes, yielding a U-shaped relationship with total mortality with a nadir at 7 hours of sleep. Citation: Ikehara S; Iso H; Date C; Kikuchi S; Watanabe Y; Wada Y; Inaba Y; Tamakoshi A. Association of sleep duration with mortality from cardiovascular disease and other causes for Japanese men and women: the JACC study. SLEEP 2009;32(3):259–301. PMID:19294949

Social and geographic inequalities in premature adult mortality in Japan: a multilevel observational study from 1970 to 2005

PubMed Central

Kashima, Saori; Kawachi, Ichiro

2012-01-01

Objectives To examine trends in social and geographic inequalities in all-cause premature adult mortality in Japan. Design Observational study of the vital statistics and the census data. Setting Japan. Participants Entire population aged 25 years or older and less than 65 years in 1970, 1975, 1980, 1985, 1990, 1995, 2000 and 2005. The total number of decedents was 984 022 and 532 223 in men and women, respectively. Main outcome measures For each sex, ORs and 95% CIs for mortality were estimated by using multilevel logistic regression models with ‘cells’ (cross-tabulated by age and occupation) at level 1, 8 years at level 2 and 47 prefectures at level 3. The prefecture-level variance was used as an estimate of geographic inequalities of mortality. Results Adjusting for age and time-trends, compared with production process and related workers, ORs ranged from 0.97 (95% CI 0.96 to 0.98) among administrative and managerial workers to 2.22 (95% CI 2.19 to 2.24) among service workers in men. By contrast, in women, the lowest odds for mortality was observed among production process and related workers (reference), while the highest OR was 12.22 (95% CI 11.40 to 13.10) among security workers. The degree of occupational inequality increased in both sexes. Higher occupational groups did not experience reductions in mortality throughout the period and was overtaken by lower occupational groups in the early 1990s, among men. Conditional on individual age and occupation, overall geographic inequalities of mortality were relatively small in both sexes; the ORs ranged from 0.87 (Okinawa) to 1.13 (Aomori) for men and from 0.84 (Kanagawa) to 1.11 (Kagoshima) for women, even though there is a suggestion of increasing inequalities across prefectures since 1995 in both sexes. Conclusions The present findings suggest that both social and geographic inequalities in all-cause mortality have increased in Japan during the last 3 decades. PMID:22389360

Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study

PubMed Central

Wilkins, Russell; Tjepkema, Michael; O’Campo, Patricia J; Dunn, James R

2009-01-01

Objective To examine mortality in a representative nationwide sample of homeless and marginally housed people living in shelters, rooming houses, and hotels. Design Follow-up study. Setting Canada 1991-2001. Participants 15 100 homeless and marginally housed people enumerated in 1991 census. Main outcome measures Age specific and age standardised mortality rates, remaining life expectancies at age 25, and probabilities of survival from age 25 to 75. Data were compared with data from the poorest and richest income fifths as well as with data for the entire cohort Results Of the homeless and marginally housed people, 3280 died. Mortality rates among these people were substantially higher than rates in the poorest income fifth, with the highest rate ratios seen at younger ages. Among those who were homeless or marginally housed, the probability of survival to age 75 was 32% (95% confidence interval 30% to 34%) in men and 60% (56% to 63%) in women. Remaining life expectancy at age 25 was 42 years (42 to 43) and 52 years (50 to 53), respectively. Compared with the entire cohort, mortality rate ratios for men and women, respectively, were 11.5 (8.8 to 15.0) and 9.2 (5.5 to 15.2) for drug related deaths, 6.4 (5.3 to 7.7) and 8.2 (5.0 to 13.4) for alcohol related deaths, 4.8 (3.9 to 5.9) and 3.8 (2.7 to 5.4) for mental disorders, and 2.3 (1.8 to 3.1) and 5.6 (3.2 to 9.6) for suicide. For both sexes, the largest differences in mortality rates were for smoking related diseases, ischaemic heart disease, and respiratory diseases. Conclusions Living in shelters, rooming houses, and hotels is associated with much higher mortality than expected on the basis of low income alone. Reducing the excessively high rates of premature mortality in this population would require interventions to address deaths related to smoking, alcohol, and drugs, and mental disorders and suicide, among other causes. PMID:19858533

Occupational mortality of women aged 15-59 years at death in England and Wales.

PubMed Central

Moser, K A; Goldblatt, P O

1991-01-01

STUDY OBJECTIVE--The aim was to analyse occupational mortality differences among women using follow up data from a large nationally representative sample. DESIGN--Occupational information was obtained from the 1971 census records of women in the Longitudinal Study carried out by the Office of Population Censuses and Surveys (OPCS) and related to their subsequent mortality in the period between the 1971 and 1981 censuses. SETTING--In the Longitudinal Study, census, vital statistics, and other OPCS records are linked for a 1% sample of the population of England and Wales. The women studied in this paper were drawn from the 513,071 persons in the 1971 census who were included in the Longitudinal Study and whose entries were traced at the National Health Service Central Register by 1977. PARTICIPANTS--The analysis was based on 77,081 women aged 15-59 years in the Longitudinal Study for whom occupational information was collected in the 1971 census (99% of whom were in paid employment in the week before the census). There were 1553 deaths among these women in the follow up period analysed here. MEASUREMENTS AND MAIN RESULTS--Numbers of deaths in each occupational group at census were compared to those expected on the basis of age specific death rates among all women in the study. "Professional, technical workers, and artists" had significantly low mortality while "Engineering and allied trades workers nec" had significantly high mortality. Among the latter, cancer mortality of electrical production process workers was extremely high. A number of other cause specific associations (which appear to confirm proportionate Decennial Supplement analyses) were suggested by the data; examples include high levels of mortality from ischaemic heart disease among cooks, lung cancer and respiratory disease among charwomen and cleaners, and accidents, poisonings, and violence among several groups of professional and technical workers. CONCLUSIONS--By using prospective follow up from the census, occupational differences in mortality can be identified among women in paid employment. As follow up of this study continues, numbers of deaths available for analysis will increase, allowing increasingly comprehensive analyses to be undertaken. PMID:2072070

Benchmarking life expectancy and cancer mortality: global comparison with cardiovascular disease 1981-2010

PubMed Central

Bray, Freddie; Beltrán-Sánchez, Hiram; Ginsburg, Ophira; Soneji, Samir; Soerjomataram, Isabelle

2017-01-01

Objective To quantify the impact of cancer (all cancers combined and major sites) compared with cardiovascular disease (CVD) on longevity worldwide during 1981-2010. Design Retrospective demographic analysis using aggregated data. Setting National civil registration systems in member states of the World Health Organization. Participants 52 populations with moderate to high quality data on cause specific mortality. Main outcome measures Disease specific contributions to changes in life expectancy in ages 40-84 (LE40-84) over time in populations grouped by two levels of Human Development Index (HDI) values. Results Declining CVD mortality rates during 1981-2010 contributed to, on average, over half of the gains in LE40-84; the corresponding gains were 2.3 (men) and 1.7 (women) years, and 0.5 (men) and 0.8 (women) years in very high and medium and high HDI populations, respectively. Declines in cancer mortality rates contributed to, on average, 20% of the gains in LE40-84, or 0.8 (men) and 0.5 (women) years in very high HDI populations, and to over 10% or 0.2 years (both sexes) in medium and high HDI populations. Declining lung cancer mortality rates brought about the largest LE40-84 gain in men in very high HDI populations (up to 0.7 years in the Netherlands), whereas in medium and high HDI populations its contribution was smaller yet still positive. Among women, declines in breast cancer mortality rates were largely responsible for the improvement in longevity, particularly among very high HDI populations (up to 0.3 years in the United Kingdom). In contrast, losses in LE40-84 were observed in many medium and high HDI populations as a result of increasing breast cancer mortality rates. Conclusions The control of CVD has led to substantial gains in LE40-84 worldwide. The inequality in improvement in longevity attributed to declining cancer mortality rates reflects inequities in implementation of cancer control, particularly in less resourced populations and in women. Global actions are needed to revitalize efforts for cancer control, with a specific focus on less resourced countries. PMID:28637656

Adherence to cancer prevention guidelines and cancer incidence, cancer mortality, and total mortality: a prospective cohort study1234

PubMed Central

Kabat, Geoffrey C; Matthews, Charles E; Kamensky, Victor; Hollenbeck, Albert R; Rohan, Thomas E

2015-01-01

Background: Several health agencies have issued guidelines promoting behaviors to reduce chronic disease risk; however, little is known about the impact of such guidelines, particularly on cancer incidence. Objective: The objective was to determine whether greater adherence to the American Cancer Society (ACS) cancer prevention guidelines is associated with a reduction in cancer incidence, cancer mortality, and total mortality. Design: The NIH-AARP Diet and Health Study, a prospective cohort study of 566,401 adults aged 50–71 y at recruitment in 1995–1996, was followed for a median of 10.5 y for cancer incidence, 12.6 y for cancer mortality, and 13.6 y for total mortality. Participants who reported a history of cancer or who had missing data were excluded, yielding 476,396 subjects for analysis. We constructed a 5-level score measuring adherence to ACS guidelines, which included baseline body mass index, physical activity, alcohol intake, and several aspects of diet. Cox proportional hazards models were used to compute HRs and 95% CIs for the association of the adherence score with cancer incidence, cancer mortality, and total mortality. All analyses included fine adjustment for cigarette smoking. Results: Among 476,396 participants, 73,784 incident first cancers, 16,193 cancer deaths, and 81,433 deaths from all causes were identified in the cohort. Adherence to ACS guidelines was associated with reduced risk of all cancers combined: HRs (95% CIs) for the highest compared with the lowest level of adherence were 0.90 (0.87, 0.93) in men and 0.81 (0.77, 0.84) in women. Fourteen of 25 specific cancer sites showed a reduction in risk associated with increased adherence. Adherence was also associated with reduced cancer mortality [HRs (95% CIs) were 0.75 (0.70, 0.80) in men and 0.76 (0.70, 0.83) in women] and reduced all-cause mortality [HRs (95% CIs) were 0.74 (0.72, 0.76) in men and 0.67 (0.65, 0.70) in women]. Conclusions: In both men and women, adherence to the ACS guidelines was associated with reductions in all-cancer incidence and the incidence of cancer at specific sites, as well as with reductions in cancer mortality and total mortality. These data suggest that, after accounting for cigarette smoking, adherence to a set of healthy behaviors may have considerable health benefits. This trial was registered at www.clinicaltrials.gov as NCT00340015. PMID:25733641

[Probabilistic models of mortality for patients hospitalized in conventional units].

PubMed

Rué, M; Roqué, M; Solà, J; Macià, M

2001-09-29

We have developed a tool to measure disease severity of patients hospitalized in conventional units in order to evaluate and compare the effectiveness and quality of health care in our setting. A total of 2,274 adult patients admitted consecutively to inpatient units from the Medicine, Surgery and Orthopaedic Surgery, and Trauma Departments of the Corporació Sanitària Parc Taulí of Sabadell, Spain, between November 1, 1997 and September 30, 1998 were included. The following variables were collected: demographic data, previous health state, substance abuse, comorbidity prior to admission, characteristics of the admission, clinical parameters within the first 24 hours of admission, laboratory results and data from the Basic Minimum Data Set of hospital discharges. Multiple logistic regression analysis was used to develop mortality probability models during the hospital stay. The mortality probability model at admission (MPMHOS-0) contained 7 variables associated with mortality during hospital stay: age, urgent admission, chronic cardiac insufficiency, chronic respiratory insufficiency, chronic liver disease, neoplasm, and dementia syndrome. The mortality probability model at 24-48 hours from admission (MPMHOS-24) contained 9 variables: those included in the MPMHOS-0 plus two statistically significant laboratory variables: hemoglobin and creatinine. Severity measures, in particular those presented in this study, can be helpful for the interpretation of hospital mortality rates and can guide mortality or quality committees at the time of investigating health care-related problems.

Crohn's disease and ulcerative colitis are associated with elevated standardized mortality ratios: a meta-analysis.

PubMed

Bewtra, Meenakshi; Kaiser, Lisa M; TenHave, Tom; Lewis, James D

2013-03-01

Evidence regarding all-cause and cause-specific mortality in inflammatory bowel disease (IBD) is conflicting, and debate exists over appropriate study design to examine these important outcomes. We conducted a comprehensive meta-analysis of all-cause and cause-specific mortality in both Crohn's disease (CD) and ulcerative colitis (UC), and additionally examined various effects of study design on this outcome. A systematic search of PubMed and EMBASE was conducted to identify studies examining mortality rates relative to the general population. Pooled summary standardized mortality ratios (SMR) were calculated using random effect models. Overall, 35 original articles fulfilled the inclusion and exclusion criteria, reporting all-cause mortality SMRs varying from 0.44 to 7.14 for UC and 0.71 to 3.20 for CD. The all-cause mortality summary SMR for inception cohort and population cohort UC studies was 1.19 (95% confidence interval, 1.06-1.35). The all-cause mortality summary SMR for inception cohort and population cohort CD studies was 1.38 (95% confidence interval, 1.23-1.55). Mortality from colorectal cancer, pulmonary disease, and nonalcoholic liver disease was increased, whereas mortality from cardiovascular disease was decreased. Patients with UC and CD have higher rates of death from all causes, colorectal-cancer, pulmonary disease, and nonalcoholic liver disease.

Association with Mortality and Heritability of the Scale of Aging Vigor in Epidemiology (SAVE)

PubMed Central

Sanders, Jason L.; Singh, Jatinder; Minster, Ryan L.; Walston, Jeremy D.; Matteini, Amy M.; Christensen, Kaare; Mayeux, Richard; Borecki, Ingrid B.; Perls, Thomas; Newman, Anne B.

2016-01-01

Background Vigor may be an important phenotype of healthy aging. Factors that prevent frailty or conversely promote vigor are of interest. Using the Long Life Family Study (LLFS), we investigated the association with mortality and heritability of a rescaled Fried frailty index, the Scale of Aging Vigor in Epidemiology (SAVE), to determine its value for genetic analyses. Design/Setting Longitudinal, community-based cohort study of long lived individuals and their families (N=4075 genetically-related individuals) in the United States and Denmark. Methods The SAVE was measured in 3599 participants and included weight change, weakness (grip strength), fatigue (questionnaire), physical activity (days walked in prior 2 weeks), and slowness (gait speed), each component scored 0, 1 or 2 using approximate tertiles, and summed from 0 (vigorous) to 10 (frail). Heritability was determined with a variance-component based family analysis using a polygenic model. Association with mortality in the proband generation (N=1421) was calculated with Cox proportional hazards mixed effect models. Results Heritability of the SAVE was 0.23 (p = 1.72 × 10−13) overall (n=3599), 0.31 (p = 2.00 × 10−7) in probands (n=1479), and 0.26 (p = 2.00 × 10−6) in offspring (n=2120). In adjusted models, compared with lower SAVE scores (0–2), higher scores were associated with higher mortality (score 5–6 HR, 95%CI = 2.83, 1.46–5.51; score 7–10 HR, 95% CI = 3.40, 1.72–6.71). Conclusion The SAVE was associated with mortality and was moderately heritable in the LLFS, suggesting a genetic component to age-related vigor and frailty and supporting its use for further genetic analyses. PMID:27294813

Examining mortality risk and rate of ageing among Polish Olympic athletes: a survival follow-up from 1924 to 2012

PubMed Central

Lin, Yuhui; Gajewski, Antoni; Poznańska, Anna

2016-01-01

Objectives Population-based studies have shown that an active lifestyle reduces mortality risk. Therefore, it has been a longstanding belief that individuals who engage in frequent exercise will experience a slower rate of ageing. It is uncertain whether this widely-accepted assumption holds for intense wear-and-tear. Here, using the 88 years survival follow-up data of Polish Olympic athletes, we report for the first time on whether frequent exercise alters the rate of ageing. Design Longitudinal survival data of male elite Polish athletes who participated in the Olympic Games from year 1924 to 2010 were used. Deaths occurring before the end of World War II were excluded for reliable estimates. Setting and participants Recruited male elite athletes N=1273 were preassigned to two categorical birth cohorts—Cohort I 1890–1919; Cohort II 1920–1959—and a parametric frailty survival analysis was conducted. An event-history analysis was also conducted to adjust for medical improvements from year 1920 onwards: Cohort II. Results Our findings suggest (1) in Cohort I, for every threefold reduction in mortality risk, the rate of ageing decelerates by 1%; (2) socioeconomic transitions and interventions contribute to a reduction in mortality risk of 29% for the general population and 50% for Olympic athletes; (3) an optimum benefit gained for reducing the rate of ageing from competitive sports (Cohort I 0.086 (95% CI 0.047 to 0.157) and Cohort II 0.085 (95% CI 0.050 to 0.144)). Conclusions This study further suggests that intensive physical training during youth should be considered as a factor to improve ageing and mortality risk parameters. PMID:27091824

Heterogeneity in Rate of Decline in Grip, Hip, and Knee Strength and the Risk of All-Cause Mortality: The Women’s Health and Aging Study II

PubMed Central

Xue, Qian-Li; Beamer, Brock A.; Chaves, Paulo H.M.; Guralnik, Jack M.; Fried, Linda P.

2010-01-01

OBJECTIVES To assess the relationship between rate of change in muscle strength and all-cause mortality. DESIGN A prospective observational study of the causes and course of physical disability. SETTING Twelve contiguous ZIP code areas in Baltimore, Maryland. PARTICIPANTS Three hundred and seven community-dwelling women aged 70–79 years at study baseline. MEASUREMENTS The outcome is all-cause mortality (1994–2009); predictors include up to seven repeated measurements of handgrip, knee extension, and hip flexion strength, with a median follow-up time of 9 years. Demographic factors, body mass index, smoking status, number of chronic diseases, depressive symptoms, physical activity, Interlukin-6, and albumin were assessed at baseline and included as confounders. The associations between declining muscle strength and mortality were assessed using a joint longitudinal and survival model.. RESULTS Grip and hip strength declined an average of 1.10 and 1.31 kg per year between age 70 and 75and 0.50 and 0.39 kg/year thereafter, respectively; knee strength declined at a constant rate of 0.57 kg/year. Faster rates of decline in grip and hip strength, but not knee strength, independently predicted of mortality after accounting for their baseline levels and potential confounders (Hazard Ratio (HR)=1.33 (95% confidence interval (CI)=1.06–1.67), 1.14 (CI=0.91–1.41), and 2.62 (CI=1.43–4.78) for every 0.5 standard deviation increase in rate of decline in grip, knee, and hip strength, respectively. CONCLUSION Monitoring the rate of decline in grip and hip flexion strength in addition to the absolute levels may greatly improve the identification of women most at risk of dying. PMID:21054287

Effect of time and day of admission on hospital care quality for patients with chronic obstructive pulmonary disease exacerbation in England and Wales: single cohort study

PubMed Central

Roberts, Christopher Michael; Lowe, Derek; Skipper, Emma; Steiner, Michael C; Jones, Rupert; Gelder, Colin; Hurst, John R; Lowrey, Gillian E; Thompson, Catherine; Stone, Robert A

2017-01-01

Objective To evaluate if observed increased weekend mortality was associated with poorer quality of care for patients admitted to hospital with chronic obstructive pulmonary disease (COPD) exacerbation. Design Prospective case ascertainment cohort study. Setting 199 acute hospitals in England and Wales, UK. Participants Consecutive COPD admissions, excluding subsequent readmissions, from 1 February to 30 April 2014 of whom 13 414 cases were entered into the study. Main outcomes Process of care mapped to the National Institute for Health and Care Excellence clinical quality standards, access to specialist respiratory teams and facilities, mortality and length of stay, related to time and day of the week of admission. Results Mortality was higher for weekend admissions (unadjusted OR 1.20, 95% CI 1.00 to 1.43), and for case-mix adjusted weekend mortality when calculated for admissions Friday morning through to Monday night (adjusted OR 1.19, 95% CI 1.00 to 1.43). Median time to death was 6 days. Some clinical processes were poorer on Mondays and during normal working hours but not weekends or out of hours. Specialist respiratory care was less available and less prompt for Friday and Saturday admissions. Admission to a specialist ward or high dependency unit was less likely on a Saturday or Sunday. Conclusions Increased mortality observed in weekend admissions is not easily explained by deficiencies in early clinical guideline care. Further study of out-of-hospital factors, specialty care and deaths later in the admission are required if effective interventions are to be made to reduce variation by day of the week of admission. PMID:28882909

A Bayesian hierarchical model for mortality data from cluster-sampling household surveys in humanitarian crises.

PubMed

Heudtlass, Peter; Guha-Sapir, Debarati; Speybroeck, Niko

2018-05-31

The crude death rate (CDR) is one of the defining indicators of humanitarian emergencies. When data from vital registration systems are not available, it is common practice to estimate the CDR from household surveys with cluster-sampling design. However, sample sizes are often too small to compare mortality estimates to emergency thresholds, at least in a frequentist framework. Several authors have proposed Bayesian methods for health surveys in humanitarian crises. Here, we develop an approach specifically for mortality data and cluster-sampling surveys. We describe a Bayesian hierarchical Poisson-Gamma mixture model with generic (weakly informative) priors that could be used as default in absence of any specific prior knowledge, and compare Bayesian and frequentist CDR estimates using five different mortality datasets. We provide an interpretation of the Bayesian estimates in the context of an emergency threshold and demonstrate how to interpret parameters at the cluster level and ways in which informative priors can be introduced. With the same set of weakly informative priors, Bayesian CDR estimates are equivalent to frequentist estimates, for all practical purposes. The probability that the CDR surpasses the emergency threshold can be derived directly from the posterior of the mean of the mixing distribution. All observation in the datasets contribute to the estimation of cluster-level estimates, through the hierarchical structure of the model. In a context of sparse data, Bayesian mortality assessments have advantages over frequentist ones already when using only weakly informative priors. More informative priors offer a formal and transparent way of combining new data with existing data and expert knowledge and can help to improve decision-making in humanitarian crises by complementing frequentist estimates.

The Association of Coloproctology of Great Britain and Ireland Study of Large Bowel Obstruction Caused by Colorectal Cancer

PubMed Central

Tekkis, Paris P.; Kinsman, Robin; Thompson, Michael R.; Stamatakis, Jeffrey D.

2004-01-01

Background: This study was designed to investigate the early outcomes after surgical treatment of malignant large bowel obstruction (MBO) and to identify risk factors affecting operative mortality. Methods: Data were prospectively collected from 1046 patients with MBO by 294 surgeons in 148 UK hospitals during a 12-month period from April 1998. A predictive model of in-hospital mortality was developed using a 3-level Bayesian logistic regression analysis. Results: The median age of patients was 73 years (interquartile range 64–80). Of the 989 patients having surgery, 91.7% underwent bowel resection with an overall mortality of 15.7%. The multilevel model used the following independent risk factors to predict mortality: age (odds ratio [OR] 1.85 per 10 year increase), American Society of Anesthesiologists grade (OR for American Society of Anesthesiologists grade I versus II,III,IV-V = 3.3,11.7,22.2), Dukes’ staging (OR for Dukes’ A versus B,C,D = 2.0, 2.1, 6.0), and mode of surgery (OR for scheduled versus urgent, emergency = 1.6, 2.3). A significant interhospital variability in operative mortality was evident with increasing age (variance = 0.004, SE = 0.001, P < 0.001). No detectable caseload effect was demonstrated between specialist colorectal and other general surgeons. Conclusions: Using prognostic models, it was possible to develop a risk-stratification index that accurately predicted survival in patients presenting with malignant large bowel obstruction. The methodology and model for risk adjusted survival can set the reference point for more accurate and reliable comparative analysis and be used as an adjunct to the process of informed consent. PMID:15213621

Effects of intravenous magnesium in suspected acute myocardial infarction: overview of randomised trials.

PubMed Central

Teo, K K; Yusuf, S; Collins, R; Held, P H; Peto, R

1991-01-01

OBJECTIVE--To investigate the effect of intravenous magnesium on mortality in suspected acute myocardial infarction. DESIGN--Systematic overview of all available randomised trials in which patients were allocated to receive either intravenous magnesium or otherwise similar treatment without magnesium. SETTING--Coronary care units of several hospitals. PATIENTS--1301 patients in seven randomised trials. MAIN OUTCOME MEASURE--Short term mortality. RESULTS--Considering the seven trials collectively there were 25 (3.8%) deaths among 657 patients allocated to receive magnesium and 53 (8.2%) deaths among 644 patients allocated control, generally during hospital follow up. This represents a 55% reduction in the odds of death (p less than 0.001) with 95% confidence intervals ranging from about one third to about two thirds. 70 of 648 patients allocated magnesium compared with 109 of 641 controls had serious ventricular arrhythmias, suggesting that magnesium reduces the incidence, though the definition varied among trials. Other adverse effects were rare in the limited number of patients for whom this data were available. CONCLUSION--Despite the limited number of patients randomised this overview suggests that intravenous magnesium therapy may reduce mortality in patients with acute myocardial infarction. Further large scale trials to confirm (or refute) these findings are desirable. PMID:1838289

Out-of-Hospital Administration of Intravenous Glucose-Insulin-Potassium in Patients With Suspected Acute Coronary Syndromes

PubMed Central

Selker, Harry P.; Beshansky, Joni R.; Sheehan, Patricia R.; Massaro, Joseph M.; Griffith, John L.; D’Agostino, Ralph B.; Ruthazer, Robin; Atkins, James M.; Sayah, Assaad J.; Levy, Michael K.; Richards, Michael E.; Aufderheide, Tom P.; Braude, Darren A.; Pirrallo, Ronald G.; Doyle, Delanor D.; Frascone, Ralph J.; Kosiak, Donald J.; Leaming, James M.; Van Gelder, Carin M.; Walter, Gert-Paul; Wayne, Marvin A.; Woolard, Robert H.; Opie, Lionel H.; Rackley, Charles E.; Udelson, James E.

2014-01-01

Context Laboratory studies suggest that in the setting of cardiac ischemia, immediate intravenous glucose-insulin-potassium (GIK) reduces ischemia-related arrhythmias and myocardial injury. Clinical trials have not consistently shown these benefits, possibly due to delayed administration. Objective To test out-of hospital emergency medical service (EMS) administration of GIK in the first hours of suspected acute coronary syndromes (ACS). Design, Setting, and Participants Randomized, placebo-controlled, double-blind effectiveness trial in 13 US cities (36 EMS agencies), from December 2006 through July 31, 2011, in which paramedics, aided by electrocardiograph (ECG)-based decision support, randomized 911 (871 enrolled) patients (mean age, 63.6 years; 71.0% men) with high probability of ACS. Intervention Intravenous GIK solution (n=411) or identical-appearing 5% glucose placebo (n=460) administered by paramedics in the out-of-hospital setting and continued for 12 hours. Main Outcome Measures The prespecified primary end point was progression of ACS to myocardial infarction (MI) within 24 hours, as assessed by biomarkers and ECG evidence. Prespecified secondary end points included survival at 30 days and a composite of prehospital or in-hospital cardiac arrest or in-hospital mortality, analyzed by intent-to-treat and by presentation with ST-segment elevation. Results There was no significant difference in the rate of progression to MI among patients who received GIK (n=200; 48.7%) vs those who received placebo (n=242; 52.6%) (odds ratio [OR], 0.88; 95% CI, 0.66–1.13; P=.28). Thirty-day mortality was 4.4% with GIK vs 6.1% with placebo (hazard ratio [HR], 0.72; 95% CI, 0.40–1.29; P=.27). The composite of cardiac arrest or in-hospital mortality occurred in 4.4% with GIK vs 8.7% with placebo (OR, 0.48; 95% CI, 0.27–0.85; P=.01). Among patients with ST-segment elevation (163 with GIK and 194 with placebo), progression to MI was 85.3% with GIK vs 88.7% with placebo (OR, 0.74; 95% CI, 0.40–1.38; P=.34); 30-day mortality was 4.9% with GIK vs 7.7% with placebo (HR, 0.63; 95% CI, 0.27–1.49; P=.29). The composite outcome of cardiac arrest or in-hospital mortality was 6.1% with GIK vs 14.4% with placebo (OR, 0.39; 95% CI, 0.18–0.82; P=.01). Serious adverse events occurred in 6.8% (n=28) with GIK vs 8.9% (n=41) with placebo (P=.26). Conclusions Among patients with suspected ACS, out-of-hospital administration of intravenous GIK, compared with glucose placebo, did not reduce progression to MI. Compared with placebo, GIK administration was not associated with improvement in 30-day survival but was associated with lower rates of the composite outcome of cardiac arrest or in-hospital mortality. Trial Registration clinicaltrials.gov Identifier: NCT00091507 PMID:22452807

Childbirth attendance strategies and their impact on maternal mortality and morbidity in low-income settings: a systematic review.

PubMed

Pyone, Thidar; Sorensen, Bjarke Lund; Tellier, Siri

2012-09-01

To review quantitative evidence of the effect on maternal health of different childbirth attendance strategies in low-income settings. Systematic review. Studies using quantitative methods, referring to the period 1987-2011, written in English and reporting the impact of childbirth attendance strategies on maternal mortality or morbidity in low-income settings were included. Guidelines developed by the Cochrane collaboration and the Centre for Review and Dissemination, University of York were followed. The included articles were read and sorted by category of strategy that emerged from the reading. The search criteria yielded 29 articles. The following three main categories of strategy emerged: (i) those primarily intended to improve quality of care; (ii) "centrifugal strategies," which sought to bring services to the women; and (iii) "centripetal strategies," which sought to bring the women to the services. Few of the studies had a design that provided strong evidence for the impact of the strategy concerned. The evidence emerging from the studies was difficult to compare, because concepts were not defined in a consistent manner (such as "skilled birth attendance") and many studies examined the impact of a package of interventions without ferreting out the impact of individual components. Yet, some studies described individual aspects with great promise (such as cost, transport, outreach-friendly drugs or targeted training). There is a need for clearer conceptual frameworks, including some which permit assessment of packages of interventions. © 2012 The Authors  Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

Estimation of mortality among HIV-infected people on antiretroviral treatment in East Africa: a sampling based approach in an observational, multisite, cohort study.

PubMed

Geng, Elvin H; Odeny, Thomas A; Lyamuya, Rita E; Nakiwogga-Muwanga, Alice; Diero, Lameck; Bwana, Mwebesa; Muyindike, Winnie; Braitstein, Paula; Somi, Geoffrey R; Kambugu, Andrew; Bukusi, Elizabeth A; Wenger, Megan; Wools-Kaloustian, Kara K; Glidden, David V; Yiannoutsos, Constantin T; Martin, Jeffrey N

2015-03-01

Mortality in HIV-infected people after initiation of antiretroviral treatment (ART) in resource-limited settings is an important measure of the effectiveness and comparative effectiveness of the global public health response. Substantial loss to follow-up precludes accurate accounting of deaths and limits our understanding of effectiveness. We aimed to provide a better understanding of mortality at scale and, by extension, the effectiveness and comparative effectiveness of public health ART treatment in east Africa. In 14 clinics in five settings in Kenya, Uganda, and Tanzania, we intensively traced a sample of patients randomly selected using a random number generator, who were infected with HIV and on ART and who were lost to follow-up (>90 days late for last scheduled visit). We incorporated the vital status outcomes for these patients into analyses of the entire clinic population through probability-weighted survival analyses. We followed 34 277 adults on ART from Mbarara and Kampala in Uganda, Eldoret, and Kisumu in Kenya, and Morogoro in Tanzania. The median age was 35 years (IQR 30-42), 11 628 (34%) were men, and median CD4 count count before therapy was 154 cells per μL (IQR 70-234). 5780 patients (17%) were lost to follow-up, 991 (17%) were selected for tracing between June 10, 2011, and Aug 27, 2012, and vital status was ascertained for 860 (87%). With incorporation of outcomes from the patients lost to follow-up, estimated 3 year mortality increased from 3·9% (95% CI 3·6-4·2) to 12·5% (11·8-13·3). The sample-corrected, unadjusted 3 year mortality across settings was lowest in Mbarara (7·2%) and highest in Morogoro (23·6%). After adjustment for age, sex, CD4 count before therapy, and WHO stage, the sample-corrected hazard ratio comparing the settings with highest and lowest mortalities was 2·2 (95% CI 1·5-3·4) and the risk difference for death at 3 years was 11% (95% CI 5·0-17·7). A sampling-based approach is widely feasible and important to an understanding of mortality after initiation of ART. After adjustment for measured biological drivers, mortality differs substantially across settings despite delivery of a similar clinical package of treatment. Implementation research to understand the systems, community, and patients' behaviours driving these differences is urgently needed. The US National Institutes of Health and President's Emergency Fund for AIDS Relief. Copyright © 2015 Elsevier Ltd. All rights reserved.

Low sensitivity of qSOFA, SIRS criteria and sepsis definition to identify infected patients at risk of complication in the prehospital setting and at the emergency department triage.

PubMed

Tusgul, Selin; Carron, Pierre-Nicolas; Yersin, Bertrand; Calandra, Thierry; Dami, Fabrice

2017-11-03

Sepsis is defined as life-threatening organ dysfunction caused by a host response to infection. The quick SOFA (qSOFA) score has been recently proposed as a new bedside clinical score to identify patients with suspected infection at risk of complication (intensive care unit (ICU) admission, in-hospital mortality). The aim of this study was to measure the sensitivity of the qSOFA score, SIRS criteria and sepsis definitions to identify the most serious sepsis cases in the prehospital setting and at the emergency department (ED) triage. We performed a retrospective study of all patients transported by emergency medical services (EMS) to the Lausanne University Hospital (CHUV) over twelve months. All patients with a suspected or proven infection after the ED workup were included. We retrospectively analysed the sensitivity of the qSOFA score (≥2 criteria), SIRS criteria (≥2 clinical criteria) and sepsis definition (SIRS criteria + one sign of organ dysfunction or hypoperfusion) in the pre-hospital setting and at the ED triage as predictors of ICU admission, ICU stay of ≥3 days and early (i.e. 48 h) mortality. No direct comparison between the three tools was attempted. Among 11,411 patients transported to the University hospital, 886 (7.8%) were included. In the pre-hospital setting, the sensitivity of qSOFA reached 36.3% for ICU admission, 17.4% for ICU stay of three days or more and 68.0% for 48 h mortality. The sensitivity of SIRS criteria reached 68.8% for ICU admission, 74.6% for ICU stay of three days or more and 64.0% for 48 h mortality. The sensitivity of sepsis definition did not reach 60% for any outcome. At ED triage, the sensitivity of qSOFA reached 31.2% for ICU admission, 30.5% for ICU stay of ≥3 days and 60.0% for mortality at 48 h. The sensitivity of SIRS criteria reached 58.8% for ICU admission, 57.6% for ICU stay of ≥3 days 80.0% for mortality at 48 h. The sensitivity of sepsis definition reached 60.0% for 48 h mortality. Incidence of sepsis in the ED among patients transported by ambulance was 3.8 percent. This rate, associated to the mortality of sepsis, confirms the necessity to dispose of a test to early identify those patients. The sensitivity performance of all three tools was suboptimal. The qSOFA score, SIRS criteria and sepsis definition have low identification sensitivity in selecting septic patients in the pre-hospital setting or upon arrival in the ED at risk of complication.

Association Between Teaching Status and Mortality in US Hospitals

PubMed Central

Burke, Laura G.; Frakt, Austin B.; Khullar, Dhruv; Orav, E. John

2017-01-01

Importance Few studies have analyzed contemporary data on outcomes at US teaching hospitals vs nonteaching hospitals. Objective To examine risk-adjusted outcomes for patients admitted to teaching vs nonteaching hospitals across a broad range of medical and surgical conditions. Design, Setting, and Participants Use of national Medicare data to compare mortality rates in US teaching and nonteaching hospitals for all hospitalizations and for common medical and surgical conditions among Medicare beneficiaries 65 years and older. Exposures Hospital teaching status: major teaching hospitals (members of the Council of Teaching Hospitals), minor teaching hospitals (other hospitals with medical school affiliation), and nonteaching hospitals (remaining hospitals). Main Outcomes and Measures Primary outcome was 30-day mortality rate for all hospitalizations and for 15 common medical and 6 surgical conditions. Secondary outcomes included 30-day mortality stratified by hospital size and 7-day mortality and 90-day mortality for all hospitalizations as well as for individual medical and surgical conditions. Results The sample consisted of 21 451 824 total hospitalizations at 4483 hospitals, of which 250 (5.6%) were major teaching, 894 (19.9%) were minor teaching, and 3339 (74.3%) were nonteaching hospitals. Unadjusted 30-day mortality was 8.1% at major teaching hospitals, 9.2% at minor teaching hospitals, and 9.6% at nonteaching hospitals, with a 1.5% (95% CI, 1.3%-1.7%; P < .001) mortality difference between major teaching hospitals and nonteaching hospitals. After adjusting for patient and hospital characteristics, the same pattern persisted (8.3% mortality at major teaching vs 9.2% at minor teaching and 9.5% at nonteaching), but the difference in mortality between major and nonteaching hospitals was smaller (1.2% [95% CI, 1.0%-1.4%]; P < .001). After stratifying by hospital size, 187 large (≥400 beds) major teaching hospitals had lower adjusted overall 30-day mortality relative to 76 large nonteaching hospitals (8.1% vs 9.4%; 1.2% difference [95% CI, 0.9%-1.5%]; P < .001). This same pattern of lower overall 30-day mortality at teaching hospitals was observed for medium-sized (100-399 beds) hospitals (8.6% vs 9.3% and 9.4%; 0.8% difference between 61 major and 1207 nonteaching hospitals [95% CI, 0.4%-1.3%]; P = .003). Among small (≤99 beds) hospitals, 187 minor teaching hospitals had lower overall 30-day mortality relative to 2056 nonteaching hospitals (9.5% vs 9.9%; 0.4% difference [95% CI, 0.1%-0.7%]; P = .01). Conclusions and Relevance Among hospitalizations for US Medicare beneficiaries, major teaching hospital status was associated with lower mortality rates for common conditions compared with nonteaching hospitals. Further study is needed to understand the reasons for these differences. PMID:28535236

Fine and Gray competing risk regression model to study the cause-specific under-five child mortality in Bangladesh.

PubMed

Mohammad, Khandoker Akib; Fatima-Tuz-Zahura, Most; Bari, Wasimul

2017-01-28

The cause-specific under-five mortality of Bangladesh has been studied by fitting cumulative incidence function (CIF) based Fine and Gray competing risk regression model (1999). For the purpose of analysis, Bangladesh Demographic and Health Survey (BDHS), 2011 data set was used. Three types of mode of mortality for the under-five children are considered. These are disease, non-disease and other causes. Product-Limit survival probabilities for the under-five child mortality with log-rank test were used to select a set of covariates for the regression model. The covariates found to have significant association in bivariate analysis were only considered in the regression analysis. Potential determinants of under-five child mortality due to disease is size of child at birth, while gender of child, NGO (non-government organization) membership of mother, mother's education level, and size of child at birth are due to non-disease and age of mother at birth, NGO membership of mother, and mother's education level are for the mortality due to other causes. Female participation in the education programs needs to be increased because of the improvement of child health and government should arrange family and social awareness programs as well as health related programs for women so that they are aware of their child health.

Limitations of basing screening policies on screening trials: The US Preventive Services Task Force and Prostate Cancer Screening.

PubMed

Etzioni, Ruth; Gulati, Roman; Cooperberg, Matt R; Penson, David M; Weiss, Noel S; Thompson, Ian M

2013-04-01

The US Preventive Services Task Force recently recommended against prostate-specific antigen screening for prostate cancer based primarily on evidence from the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the US Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial. : To examine limitations of basing screening policy on evidence from screening trials. We reviewed published modeling studies that examined population and trial data. The studies (1) project the roles of screening and changes in primary treatment in the US mortality decline; (2) extrapolate the ERSPC mortality reduction to the long-term US setting; (3) estimate overdiagnosis based on US incidence trends; and (4) quantify the impact of control arm screening on PLCO mortality results. Screening plausibly explains 45% and changes in primary treatment can explain 33% of the US prostate cancer mortality decline. Extrapolating the ERSPC results to the long-term US setting implies an absolute mortality reduction at least 5 times greater than that observed in the trial. Approximately 28% of screen-detected cases are overdiagnosed in the United States versus 58% of screen-detected cases suggested by the ERSPC results. Control arm screening can explain the null result in the PLCO trial. Modeling studies indicate that population trends and trial results extended to the long-term population setting are consistent with greater benefit of prostate-specific antigen screening-and more favorable harm-benefit tradeoffs-than has been suggested by empirical trial evidence.

[Comparison of survival under domestic or institutional care: the Hannover morbidity and mortality long-term care study].

PubMed

Seger, W; Sittaro, N-A; Lohse, R; Rabba, J

2011-07-01

Empirical data, representative of the total population are necessary for medico-actuarial risk calculations. Our study compares mortalities of long-term care (LTC) patients with regard to age, gender and distribution of care levels when in home or institutional care. The data of 88.575 long-term care patients were analysed longitudinally for ten years, using routine data on the files of the German Federal Health Insurance fund (average observation period 2.5 years, a total of 221.625 observation years). The numbers of LTC patients and their care levels while remaining in home or institutional care were calculated, as were any changes to another care level or discontinuation of long-term care benefits (as a result of the need for care falling below the eligibility criteria for care level I or to death) during 1 - 10 years after the onset of long-term care. Total mortality was found to increase with age and care level in homecare as well as in institutional settings for both sexes. It is greatly influenced by the first year mortality, which for both genders was lower for care level 1 in home care settings but higher for care level 2 and much higher for care level 3 than in institutional care settings. Follow-up mortality (second to tenth year after the start of LTC) was lower for care level 1 and 2 in home care settings than for institutional care. But for care level 3 the follow-up mortality was conversely higher in home care settings than in institutional care (for both genders). The number of patients returning to an active life after rehabilitation is much higher for home care patients than those who had been in institutional care. The transfer rate from homecare to institutional care increased during the first three years after onset of care, descending thereafter, and was much higher than conversely. The slogan "outpatient care before inpatient care" must be differentiated and considered carefully with regard to the character and constellation of diseases, age attained, length of time after onset of care, care level, potential for resuming an active life, as well as level of compensation and number and nature of activities of daily life together with being given the necessary help when choosing between homecare or institutional care. Differentiation between first year and follow-up mortalities is recommended when undertaking medico-actuarial calculations. Georg Thieme Verlag KG Stuttgart · New York.

The role of the Data and Safety Monitoring Board in a clinical trial: the CRISIS study.

PubMed

Holubkov, Richard; Casper, T Charles; Dean, J Michael; Anand, K J S; Zimmerman, Jerry; Meert, Kathleen L; Newth, Christopher J L; Berger, John; Harrison, Rick; Willson, Douglas F; Nicholson, Carol

2013-05-01

Randomized clinical trials are commonly overseen by a Data and Safety Monitoring Board comprised of experts in medicine, ethics, and biostatistics. Data and Safety Monitoring Board responsibilities include protocol approval, interim review of study enrollment, protocol compliance, safety, and efficacy data. Data and Safety Monitoring Board decisions can affect study design and conduct, as well as reported findings. Researchers must incorporate Data and Safety Monitoring Board oversight into the design, monitoring, and reporting of randomized trials. Case study, narrative review. The Data and Safety Monitoring Board's role during the comparative pediatric Critical Illness Stress-Induced Immune Suppression (CRISIS) Prevention Trial is described. The National Institutes of Health-appointed CRISIS Data and Safety Monitoring Board was charged with monitoring sample size adequacy and feasibility, safety with respect to adverse events and 28-day mortality, and efficacy with respect to the primary nosocomial infection/sepsis outcome. The Federal Drug Administration also requested Data and Safety Monitoring Board interim review before opening CRISIS to children below 1 yr of age. The first interim analysis found higher 28-day mortality in one treatment arm. The Data and Safety Monitoring Board maintained trial closure to younger children and requested a second interim data review 6 months later. At this second meeting, mortality was no longer of concern, whereas a weak efficacy trend of lower infection/sepsis rates in one study arm emerged. As over 40% of total patients had been enrolled, the Data and Safety Monitoring Board elected to examine conditional power and unmask treatment arm identities. On finding somewhat greater efficacy in the placebo arm, the Data and Safety Monitoring Board recommended stopping CRISIS due to futility. The design and operating procedures of a multicenter randomized trial must consider a pivotal Data and Safety Monitoring Board role. Maximum study design flexibility must be allowed, and investigators must be prepared for protocol modifications due to interim findings. The Data and Safety Monitoring Board must have sufficient clinical and statistical expertise to assess potential importance of interim treatment differences in the setting of multiple looks at accumulating data with numerous outcomes and subgroups.

Source Contributions to Premature Mortality Due to Ambient Particulate Matter in China

NASA Astrophysics Data System (ADS)

Hu, J.; Huang, L.; Ying, Q.; Zhang, H.; Shi, Z.

2016-12-01

Outdoor air pollution is linked to various health effects. Globally it is estimated that ambient air pollution caused 3.3 million premature deaths in 2010. The health risk occurs predominantly in developing countries, particularly in Asia. China has been suffering serious air pollution in recent decades. The annual concentrations of ambient PM2.5 are more than five times higher than the WHO guideline value in many populous Chinese cities. Sustained exposure to high PM2.5 concentrations greatly threatens public health in this country. Recognizing the severity of the air pollution situation, the Chinese government has set a target in 2013 to reduce PM2.5 level by up to 25% in major metropolitan areas by 2017. It is urgently needed for China to assess premature mortality caused by outdoor air pollution, identify source contributions of the premature mortality, and evaluate responses of the premature mortality to air quality improvement, in order to design effective control plans and set priority for air pollution controls to better protect public health. In this study, we determined the spatial distribution of excess mortality (ΔMort) due to adult (> 30 years old) ischemic heart disease (IHD), cerebrovascular disease (CEV), chronic obstructive pulmonary disease (COPD) and lung cancer (LC) at 36-km horizontal resolution for 2013 from the predicted annual-average surface PM2.5 concentrations using an updated source-oriented Community Multiscale Air Quality (CMAQ) model along with an ensemble of four regional and global emission inventories. Observation data fusing was applied to provide additional correction of the biases in the PM2.5 concentration field from the ensemble. Source contributions to ΔMort were determined based on total ΔMort and fractional source contributions to PM2.5 mass concentrations. We estimated that ΔMort due to COPD, LC, IHD and CEV are 0.329, 0.148, 0.239 and 0.953 million in China, respectively, leading to a total ΔMort of 1.669 million. Industries and residential sources were the two leading sources to ΔMort, contributing to 0.508 (30.5%) and 0.366 (21.9%) mp, respectively. Secondary ammonium ion from agriculture sources, secondary organic aerosol and aerosols from power generation sources were responsible for ΔMort of 0.204, 0.179 and 0.172 mp, respectively.

Associations between ventilator settings during extracorporeal membrane oxygenation for refractory hypoxemia and outcome in patients with acute respiratory distress syndrome: a pooled individual patient data analysis : Mechanical ventilation during ECMO.

PubMed

Serpa Neto, Ary; Schmidt, Matthieu; Azevedo, Luciano C P; Bein, Thomas; Brochard, Laurent; Beutel, Gernot; Combes, Alain; Costa, Eduardo L V; Hodgson, Carol; Lindskov, Christian; Lubnow, Matthias; Lueck, Catherina; Michaels, Andrew J; Paiva, Jose-Artur; Park, Marcelo; Pesenti, Antonio; Pham, Tài; Quintel, Michael; Marco Ranieri, V; Ried, Michael; Roncon-Albuquerque, Roberto; Slutsky, Arthur S; Takeda, Shinhiro; Terragni, Pier Paolo; Vejen, Marie; Weber-Carstens, Steffen; Welte, Tobias; Gama de Abreu, Marcelo; Pelosi, Paolo; Schultz, Marcus J

2016-11-01

Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for patients with acute respiratory distress syndrome (ARDS). The aim of this study was to evaluate associations between ventilatory settings during ECMO for refractory hypoxemia and outcome in ARDS patients. In this individual patient data meta-analysis of observational studies in adult ARDS patients receiving ECMO for refractory hypoxemia, a time-dependent frailty model was used to determine which ventilator settings in the first 3 days of ECMO had an independent association with in-hospital mortality. Nine studies including 545 patients were included. Initiation of ECMO was accompanied by significant decreases in tidal volume size, positive end-expiratory pressure (PEEP), plateau pressure, and driving pressure (plateau pressure - PEEP) levels, and respiratory rate and minute ventilation, and resulted in higher PaO 2 /FiO 2 , higher arterial pH and lower PaCO 2 levels. Higher age, male gender and lower body mass index were independently associated with mortality. Driving pressure was the only ventilatory parameter during ECMO that showed an independent association with in-hospital mortality [adjusted HR, 1.06 (95 % CI, 1.03-1.10)]. In this series of ARDS patients receiving ECMO for refractory hypoxemia, driving pressure during ECMO was the only ventilator setting that showed an independent association with in-hospital mortality.

Frailty as a Novel Predictor of Mortality and Hospitalization in Hemodialysis Patients of All Ages

PubMed Central

McAdams-DeMarco, Mara A.; Law, Andrew; Salter, Megan L.; Boyarsky, Brian; Gimenez, Luis; Jaar, Bernard G.; Walston, Jeremy D.; Segev, Dorry L.

2013-01-01

Objectives To quantify the prevalence of frailty in adult patients of all ages undergoing chronic hemodialysis, its relationship to comorbidity and disability, and its association with adverse outcomes of mortality and hospitalization. Design Prospective cohort study. Setting Single hemodialysis center in Baltimore, Maryland. Participants 146 prevalent hemodialysis patients enrolled between January 2009 and March 2010 and followed through August 2012. Measurements Frailty, comorbidity, and disability on enrollment into the study and subsequent mortality and hospitalizations. Results At enrollment, 50.0% of older (age≥65) and 35.4% of younger (age<65) hemodialysis patients were frail; 35.9% and 29.3% were intermediately frail, respectively. The 3-year mortality was 16.2% for non frail, 34.4% for intermediately frail, and 40.2% for frail participants. Intermediate frailty and frailty were associated with a 2.68-fold (95% CI: 1.02-7.07, P=0.046) and 2.60-fold (95%CI: 1.04-6.49, P=0.041) higher risk of death independent of age, sex, comorbidity, and disability. In the year after enrollment, median number of hospitalizations was 1 (IQR 0-3). The proportion with 2 or more hospitalizations was 28.2% for non frail, 25.5% for intermediately frail, and 42.6% for frail participants. While intermediate frailty was not associated with the number of hospitalizations (RR=0.76, 95%CI:0.49-1.16, P=0.21), frailty was associated with a 1.43-fold (95%CI:1.00-2.03, P=0.049) higher number of hospitalizations independent of age, sex, comorbidity, and disability. The association of frailty with mortality and hospitalizations did not differ between older and younger participants (Interaction P=0.64 and P=0.14, respectively). Conclusions Adults of all ages undergoing hemodialysis have a very high prevalence of frailty, more than 5-fold higher than community dwelling older adults. In this population, regardless of age, frailtyis a strong, independent predictor of mortality and number of hospitalizations. PMID:23711111

The natural history of Dandy-Walker syndrome in the United States: A population-based analysis

PubMed Central

McClelland, Shearwood; Ukwuoma, Onyinyechi I.; Lunos, Scott; Okuyemi, Kolawole S.

2015-01-01

Background: Dandy-Walker syndrome (DWS) is a congenital disorder typically manifesting with hydrocephalus. The classic anatomic hallmarks of DWS are hypoplasia of the cerebellar vermis, anterior-posterior enlargement of the posterior fossa, upward displacement of the torcula and transverse sinuses, and cystic dilatation of the fourth ventricle. Aims: Although optimal treatment of DWS typically requires neurosurgical intervention to prevent intracranial pressure increases incompatible with life, the natural history of this disorder has yet to be evaluated on a nationwide level. Settings and Design/Materials and Methods: The Kids’ Inpatient Database covering 1997-2003 was used for analysis. Children younger than age 18 admitted for DWS (ICD-9-CM = 742.3) were analyzed with a matched control group. The primary procedure codes for operative CSF drainage were coded into the analysis. The incidence of DWS was 0.136%; 14,599 DWS patients were included. Statistical Analysis Used: Multiple logistic regression models were used. Odds ratios (OR) were reported with 95% confidence intervals. Results and Conclusions: Mortality (OR = 10.02; P < 0.0001) and adverse discharge disposition (OR = 4.59; P < 0.0001) were significantly greater in DWS patients compared with controls. 20.4% of DWS patients received operative cerebrospinal fluid (CSF) drainage, 81-times more than controls (P < 0.0001). CSF drainage reduced mortality by 44% among DWS patients (P < 0.0001). Although DWS is associated with a 10-fold increase in mortality, operative CSF drainage nearly halves the mortality rate. Based on these findings (Class IIB evidence), it is likely that the increased mortality associated with DWS is directly attributable to the nearly 80% of DWS patients who did not receive operative CSF drainage for hydrocephalus. Consequently, increased access to neurosurgical intervention could reduce the mortality rate of DWS towards that of the general population. PMID:25552847

Spatial variation of heart failure and air pollution in Warwickshire, UK: an investigation of small scale variation at the ward-level

PubMed Central

Bennett, Oscar; Kandala, Ngianga-Bakwin; Ji, Chen; Linnane, John; Clarke, Aileen

2014-01-01

Objectives To map using geospatial modelling techniques the morbidity and mortality caused by heart failure within Warwickshire to characterise and quantify any influence of air pollution on these risks. Design Cross-sectional. Setting Warwickshire, UK. Participants Data from all of the 105 current Warwickshire County wards were collected on hospital admissions and deaths due to heart failure. Results In multivariate analyses, the presence of higher mono-nitrogen oxide (NOx) in a ward (3.35:1.89, 4.99), benzene (Ben) (31.9:8.36, 55.85) and index of multiple deprivation (IMD; 0.02: 0.01, 0.03), were consistently associated with a higher risk of heart failure morbidity. Particulate matter (Pm; −12.93: −20.41, −6.54) was negatively associated with the risk of heart failure morbidity. No association was found between sulfur dioxide (SO2) and heart failure morbidity. The risk of heart failure mortality was higher in wards with a higher NOx (4.30: 1.68, 7.37) and wards with more inhabitants 50+ years old (1.60: 0.47, 2.92). Pm was negatively associated (−14.69: −23.46, −6.50) with heart failure mortality. SO2, Ben and IMD scores were not associated with heart failure mortality. There was a prominent variation in heart failure morbidity and mortality risk across wards, the highest risk being in the regions around Nuneaton and Bedworth. Conclusions This study showed distinct spatial patterns in heart failure morbidity and mortality, suggesting the potential role of environmental factors beyond individual-level risk factors. Air pollution levels should therefore be taken into account when considering the wider determinants of public health and the impact that changes in air pollution might have on the health of a population. PMID:25468504

Determinants of the risk of dying of HIV/AIDS in a rural South African community over the period of the decentralised roll-out of antiretroviral therapy: a longitudinal study

PubMed Central

Mee, Paul; Collinson, Mark A.; Madhavan, Sangeetha; Kabudula, Chodziwadziwa; Gómez-Olivé, Francesc Xavier; Kahn, Kathleen; Tollman, Stephen M.; Hargreaves, James; Byass, Peter

2014-01-01

Background Antiretroviral treatment (ART) has significantly reduced HIV mortality in South Africa. The benefits have not been experienced by all groups. Here we investigate the factors associated with these inequities. Design This study was located in a rural South African setting and used data collected from 2007 to 2010, the period when decentralised ART became available. Approximately one-third of the population were of Mozambican origin. There was a pattern of repeated circular migration between urban areas and this community. Survival analysis models were developed to identify demographic, socioeconomic, and spatial risk factors for HIV mortality. Results Among the study population of 105,149 individuals, there were 2,890 deaths. The HIV/TB mortality rate decreased by 27% between 2007–2008 and 2009–2010. For other causes of death, the reduction was 10%. Bivariate analysis found that the HIV/TB mortality risk was lower for: those living within 5 km of the Bhubezi Community Health Centre; women; young adults; in-migrants with a longer period of residence; permanent residents; and members of households owning motorised transport, holding higher socioeconomic positions, and with higher levels of education. Multivariate modelling showed, in addition, that those with South Africa as their country of origin had an increased risk of HIV/TB mortality compared to those with Mozambican origins. For males, those of South African origin, and recent in-migrants, the risk of death associated with HIV/TB was significantly greater than that due to other causes. Conclusions In this community, a combination of factors was associated with an increased risk of dying of HIV/TB over the period of the roll-out of ART. There is evidence for the presence of barriers to successful treatment for particular sub-groups in the population, which must be addressed if the recent improvements in population-level mortality are to be maintained. PMID:25416322

Association of rule of law and health outcomes: an ecological study.

PubMed

Pinzon-Rondon, Angela Maria; Attaran, Amir; Botero, Juan Carlos; Ruiz-Sternberg, Angela Maria

2015-10-29

To explore whether the rule of law is a foundational determinant of health that underlies other socioeconomic, political and cultural factors that have been associated with health outcomes. Global project. Data set of 96 countries, comprising 91% of the global population. The following health indicators, infant mortality rate, maternal mortality rate, life expectancy, and cardiovascular disease and diabetes mortality rate, were included to explore their association with the rule of law. We used a novel Rule of Law Index, gathered from survey sources, in a cross-sectional and ecological design. The Index is based on eight subindices: (1) Constraints on Government Powers; (2) Absence of Corruption; (3) Order and Security; (4) Fundamental Rights; (5) Open Government; (6) Regulatory Enforcement, (7) Civil Justice; and (8) Criminal Justice. The rule of law showed an independent association with infant mortality rate, maternal mortality rate, life expectancy, and cardiovascular disease and diabetes mortality rate, after adjusting for the countries' level of per capita income, their expenditures in health, their level of political and civil freedom, their Gini measure of inequality and women's status (p<0.05). Rule of law remained significant in all the multivariate models, and the following adjustment for potential confounders remained robust for at least one or more of the health outcomes across all eight subindices of the rule of law. Findings show that the higher the country's level of adherence to the rule of law, the better the health of the population. It is necessary to start considering the country's adherence to the rule of law as a foundational determinant of health. Health advocates should consider the improvement of rule of law as a tool to improve population health. Conversely, lack of progress in rule of law may constitute a structural barrier to health improvement. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

"Safe motherhood", family planning and maternal mortality: an Indonesian case study.

PubMed

Smyth, I

1994-06-01

This case study in Indonesia examined some assumptions about the outcome of family planning services. Safe Motherhood programs were flawed, because of the misplaced emphasis on family planning as a strategy to reduce maternal mortality. Family planning programs reduce the exposure to the risks of child-bearing, but they do not reduce the actual risks. Reproductive health should not be linked so tightly to demographic concerns and family planning. That cost saving occurs from family planning is insufficient to justify inattention to the needs of high quality obstetric care. Family planning should be viewed as just one component of a larger, comprehensive set of measures designed to assure the health of women at all stages in the life cycle: as citizens and workers, as mothers, and as adolescents. Interventions must begin before childbearing and include growth in economic, educational, and health opportunities. The aim of reducing maternal mortality by 50% by the year 2000 was included in Indonesia's five-year development plan: Repelita V. The example of Indonesia was important, because of its achievements in reducing poverty and increasing the standard of living of the population, and because of its large population size. Estimated maternal mortality in Indonesia was 450/100,000 live births in 1989, up from 390/100,000 in 1982. There was evidence from other studies that maternal mortality has increased. Criticism has been directed to the misplaced emphasis on family planning and the top-down delivery of professional services for ignoring local health-enhancing practices and the role of families, fathers, and communities as health providers. The realized cost effectiveness of family planning is an abstraction. Fertility has declined with an increase in family planning from 5.6 children to 3.0 children in 1990, but, for example, Bali has both high levels of contraception use and high maternal mortality. Integrated programs and the high risk approach have not been particularly successful.

Association of emphysema-like lung on cardiac computed tomography and mortality in persons without airflow obstruction: the Multi-Ethnic Study of Atherosclerosis (MESA) Lung Study

PubMed Central

Oelsner, Elizabeth C.; Hoffman, Eric A.; Folsom, Aaron R.; Carr, J. Jeffrey; Enright, Paul L.; Kawut, Steven M.; Kronmal, Richard; Lederer, David; Lima, Joao A. C.; Lovasi, Gina S.; Shea, Steven; Barr, R. Graham

2015-01-01

Background Whereas low lung function is known to predict mortality in the general population, the prognostic significance of emphysema on computed tomography (CT) in persons without chronic obstructive pulmonary disease (COPD) remains uncertain. Objective To determine whether greater emphysema-like lung on CT is associated with all-cause mortality among persons without airflow obstruction or COPD in the general population. Design Prospective cohort study. Setting Population-based, multiethnic sample from 6 US communities. Participants 2965 participants ages 45-84 years without airflow obstruction on spirometry. Measurements Emphysema-like lung was defined on cardiac CT as the number of lung voxels less than -950 Hounsfield Units, and was adjusted for the number of total imaged lung voxels. Results Among 2965 participants, 50.9% of whom never smoked, there were 186 deaths over a median of 6.2 years. Greater emphysema-like lung was independently associated with increased mortality (adjusted hazard ratio [HR]1.14 per one-half of the interquartile range, 95% CI 1.04-1.24, P=0.004), adjusting for potential confounders including cardiovascular risk factors and the forced expiratory volume in one second. Generalized additive models supported a linear association between emphysema-like lung and mortality without evidence for a threshold. The association was of greatest magnitude among smokers, although multiplicative interaction terms did not support effect modification by smoking status. Limitations Cardiac CT scans did not include lung apices. The number of deaths was limited among subgroup analyses. Conclusions Emphysema-like lung on CT was associated with all-cause mortality among persons without airflow obstruction or COPD in a general population sample, particularly among smokers. Recognition of the independent prognostic significance of emphysema on CT among patients without COPD on spirometry is warranted. Primary Funding Source NIH/NHLBI. PMID:25506855

Readmissions and mortality in delirious versus non-delirious octogenarian patients after aortic valve therapy: a prospective cohort study

PubMed Central

Eide, Leslie S P; Ranhoff, Anette H; Fridlund, Bengt; Haaverstad, Rune; Kuiper, Karel K J; Nordrehaug, Jan Erik; Norekvål, Tone M

2016-01-01

Objectives To determine whether postoperative delirium predicts first-time readmissions and mortality in octogenarian patients within 180 days after aortic valve therapy with surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI), and to determine the most common diagnoses at readmission. Design Prospective cohort study of patients undergoing elective SAVR or TAVI. Setting Tertiary university hospital that performs all SAVRs and TAVIs in Western Norway. Participants Patients 80+ years scheduled for SAVR or TAVI and willing to participate in the study were eligible. Those unable to speak Norwegian were excluded. Overall, 143 patients were included, and data from 136 are presented. Primary and secondary outcome measures The primary outcome was a composite variable of time from discharge to first all-cause readmission or death. Secondary outcomes were all-cause first readmission alone and mortality within 180 days after discharge, and the primary diagnosis at discharge from first-time readmission. Delirium was assessed with the confusion assessment method. First-time readmissions, diagnoses and mortality were identified in hospital information registries. Results Delirium was identified in 56% of patients. The effect of delirium on readmissions and mortality was greatest during the first 2 months after discharge (adjusted HR 2.9 (95% CI 1.5 to 5.7)). Of 30 first-time readmissions occurring within 30 days, 24 (80%) were patients who experienced delirium. 1 patient (non-delirium group) died within 30 days after therapy. Delirious patients comprised 35 (64%) of 55 first-time readmissions occurring within 180 days. Circulatory system diseases and injuries were common causes of first-time readmissions within 180 days in delirious patients. 8 patients died 180 days after the procedure; 6 (75%) of them experienced delirium. Conclusions Delirium in octogenarians after aortic valve therapy might be a serious risk factor for postoperative morbidity and mortality. Cardiovascular disorders and injuries were associated with first-time readmissions in these patients. PMID:27707832

Impact of improved insulation and heating on mortality risk of older cohort members with prior cardiovascular or respiratory hospitalisations

PubMed Central

Keall, Michael; Telfar-Barnard, Lucy; Grimes, Arthur; Howden-Chapman, Philippa

2017-01-01

Objectives We carried out an evaluation of a large-scale New Zealand retrofit programme using administrative data that provided the statistical power to assess the effect of insulation and/or heating retrofits on cardiovascular and respiratory-related mortality in people aged 65 and over with prior respiratory or circulatory hospitalisations. Design Quasi-experimental cohort study based on administrative data. Setting New Zealand. Participants From a larger study cohort of over 900 000 people, we selected two subcohorts: 3287 people who were aged 65 and over and had experienced pretreatment period cardiovascular-related hospitalisation (ICD-10 chapter 9), and 1561 people aged 65 and over who had experienced pretreatment respiratory-related hospitalisation (ICD-10 chapter 10). Interventions Treatment group individuals lived in a home that received insulation and/or heating retrofits under the Warm Up New Zealand: Heat Smart programme. Control group individuals lived in a home that was matched to a treatment home based on physical characteristics and location. Primary and secondary outcome measures HR for all-cause mortality for treatment with insulation, heating, or insulation and heating relative to control group. Results People with pretreatment circulatory hospitalisation who occupied a household that received only insulation had an HR for all-cause mortality of 0.673 (95% CI 0.535 to 0.847) (p<0.001) relative to control group members. Individuals with a pretreatment respiratory hospitalisation who occupied a household that received only an insulation retrofit had an HR for all-cause mortality of 0.830 (95% CI 0.655 to 1.051) (p=0.122) relative to control group members. There was no evidence of an additional benefit from receiving heating. Conclusions We interpret the hazard rate observed for cardiovascular subcohort individuals who received insulation as evidence of a protective effect, reducing the risk of mortality for vulnerable older adults. There is suggestive evidence of a protective effect of insulation for the respiratory subcohort. PMID:29138207

Trends in Relative Mortality Between Hispanic and Non-Hispanic Whites Initiating Dialysis: A Retrospective Study of the US Renal Data System

PubMed Central

Arce, Cristina M.; Goldstein, Benjamin A.; Mitani, Aya A.; Winkelmayer, Wolfgang C.

2014-01-01

Background Hispanic patients undergoing long-term dialysis experience better survival compared with non-Hispanic whites. It is unknown whether this association differs by age, has changed over time, or is due to differential access to kidney transplantation. Study Design National retrospective cohort study. Setting & Participants Using the US Renal Data System, we identified 615,618 white patients 18 years or older who initiated dialysis therapy between January 1, 1995, and December 31, 2007. Predictors Hispanic ethnicity (vs non-Hispanic whites), year of end-stage renal disease incidence, age (as potential effect modifier). Outcomes All-cause and cause-specific mortality. Results We found that Hispanics initiating dialysis therapy experienced lower mortality, but age modified this association (P < 0.001). Compared with non-Hispanic whites, mortality in Hispanics was 33% lower at ages 18–39 years (adjusted cause-specific HR [HRcs], 0.67; 95% CI, 0.64–0.71) and 40–59 years (HRcs, 0.67; 95% CI, 0.66–0.68), 19% lower at ages 60–79 years (HRcs, 0.81; 95% CI, 0.80–0.82), and 6% lower at 80 years or older (HRcs, 0.94; 95% CI, 0.91–0.97). Accounting for the differential rates of kidney transplantation, the associations were attenuated markedly in the younger age strata; the survival benefit for Hispanics was reduced from 33% to 10% at ages 18–39 years (adjusted subdistribution-specific HR [HRsd], 0.90; 95% CI, 0.85–0.94) and from 33% to 19% among those aged 40–59 years (HRsd, 0.81; 95% CI, 0.80–0.83). Limitations Inability to analyze Hispanic subgroups that may experience heterogeneous mortality outcomes. Conclusions Overall, Hispanics experienced lower mortality, but differential access to kidney transplantation was responsible for much of the apparent survival benefit noted in younger Hispanics. Am J Kidney Dis. 62(2):312–321. PMID:23647836

Visit-to-visit variability of blood pressure and coronary heart disease, stroke, heart failure and mortality: A cohort study

PubMed Central

Muntner, Paul; Whittle, Jeff; Lynch, Amy I.; Colantonio, Lisandro D.; Simpson, Lara M.; Einhorn, Paula T.; Levitan, Emily B.; Whelton, Paul K; Cushman, William C.; Louis, Gail T.; Davis, Barry R.; Oparil, Suzanne

2016-01-01

Background Variability of blood pressure (BP) across outpatient visits is frequently dismissed as random fluctuation around a patient’s underlying BP. Objective: Examine the association between visit-to-visit variability (VVV) of systolic and diastolic BP (SBP and DBP) on cardiovascular disease and mortality outcomes. Design Prospective cohort study Setting Post-hoc analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Participants 25,814 ALLHAT participants. Measurements VVV of SBP was defined as the standard deviation (SD) across BP measurements obtained at 7 visits conducted from 6 to 28 months following ALLHAT enrollment. Participants free of cardiovascular disease events during the first 28 months of follow-up were followed from the month 28 study visit through the end of active ALLHAT follow-up. Outcomes included fatal coronary heart disease or non-fatal myocardial infarction, all-cause mortality, stroke and heart failure. Results There were 1194 cases of fatal CHD or non-fatal MI, 1948 deaths, 606 cases of stroke and 921 cases of heart failure during follow-up. After multivariable adjustment including mean SBP, the hazard ratio comparing participants in the highest versus lowest quintile of SD of SBP (≥14.4 mmHg versus <6.5 mmHg) was 1.30 (1.06–1.59) for fatal coronary heart disease or non-fatal myocardial infarction, 1.58 (1.32–1.90) for all-cause mortality, 1.46 (1.06–2.01) for stroke, and 1.25 (0.97–1.61) for heart failure. Higher VVV of DBP was also associated with cardiovascular disease events and mortality. Limitations Long-term outcomes were not available. Conclusions Higher VVV of SBP is associated with increased cardiovascular disease and mortality risk. Future studies should examine whether reducing VVV of BP lowers this risk. Primary funding source National Institutes of Health PMID:26215765

Carboxyhaemoglobin concentration, smoking habit, and mortality in 25 years in the Renfrew/Paisley prospective cohort study

PubMed Central

Hart, C L; Smith, G Davey; Hole, D J; Hawthorne, V M

2006-01-01

Objective To investigate how carboxyhaemoglobin concentration is related to smoking habit and to assess whether carboxyhaemoglobin concentration is related to mortality. Design Prospective cohort study. Setting Residents of the towns of Renfrew and Paisley in Scotland. Participants The whole Renfrew/Paisley study, conducted between 1972 and 1976, consisted of 7048 men and 8354 women aged 45–64 years. This study was based on 3372 men and 4192 women who were screened after the measurement of carboxyhaemoglobin concentration was introduced about halfway through the study. Main outcome measures Deaths from coronary heart disease (CHD), stroke, chronic obstructive pulmonary disease (COPD), lung cancer, and all causes in 25 years after screening. Results Carboxyhaemoglobin concentration was related to self reported smoking and for each smoking category was higher in participants who reported inhaling than in those who reported not inhaling. Carboxyhaemoglobin concentration was positively related to all causes of mortality analysed (relative rates associated with a 1 SD (2.93) increase in carboxyhaemoglobin for all causes, CHD, stroke, COPD, and lung cancer were 1.26 (95% confidence interval (CI) 1.19 to 1.34), 1.19 (95% CI 1.13 to 1.26), 1.19 (95% CI 1.13 to 1.26), 1.64 (95% CI 1.47 to 1.84), and 1.69 (95% CI 1.60 to 1.79), respectively). Adjustment for self reported cigarette smoking attenuated the associations but they remained relatively strong. Conclusions Self reported smoking data were validated by the objective measure of carboxyhaemoglobin concentration. Since carboxyhaemoglobin concentration remained associated with mortality after adjustment for smoking, carboxyhaemoglobin seems to capture more of the risk associated with smoking tobacco than does self reported tobacco consumption alone. Analysing mortality by self reported cigarette smoking underestimates the strength of association between smoking and mortality. PMID:15939724

Dialysis Dose Scaled to Body Surface Area and Size-Adjusted, Sex-Specific Patient Mortality

PubMed Central

Kapke, Alissa; Port, Friedrich K.; Wolfe, Robert A.; Saran, Rajiv; Pearson, Jeffrey; Hirth, Richard A.; Messana, Joseph M.; Daugirdas, John T.

2012-01-01

Summary Background and objectives When hemodialysis dose is scaled to body water (V), women typically receive a greater dose than men, but their survival is not better given a similar dose. This study sought to determine whether rescaling dose to body surface area (SA) might reveal different associations among dose, sex, and mortality. Design, setting, participants, & measurements Single-pool Kt/V (spKt/V), equilibrated Kt/V, and standard Kt/V (stdKt/V) were computed using urea kinetic modeling on a prevalent cohort of 7229 patients undergoing thrice-weekly hemodialysis. Data were obtained from the Centers for Medicare & Medicaid Services 2008 ESRD Clinical Performance Measures Project. SA-normalized stdKt/V (SAN-stdKt/V) was calculated as stdKt/V × ratio of anthropometric volume to SA/17.5. Patients were grouped into sex-specific dose quintiles (reference: quintile 1 for men). Adjusted hazard ratios (HRs) for 1-year mortality were calculated using Cox regression. Results spKt/V was higher in women (1.7±0.3) than in men (1.5±0.2; P<0.001), but SAN-stdKt/V was lower (women: 2.3±0.2; men: 2.5±0.3; P<0.001). For both sexes, mortality decreased as spKt/V increased, until spKt/V was 1.6–1.7 (quintile 4 for men: HR, 0.62; quintile 3 for women: HR, 0.64); no benefit was observed with higher spKt/V. HR for mortality decreased further at higher SAN-stdKt/V in both sexes (quintile 5 for men: HR, 0.69; quintile 5 for women: HR, 0.60). Conclusions SA-based dialysis dose results in dose-mortality relationships substantially different from those with volume-based dosing. SAN-stdKt/V analyses suggest women may be relatively underdosed when treated by V-based dosing. SAN-stdKt/V as a measure for dialysis dose may warrant further study. PMID:22977208

The ADOPT-LC score: a novel predictive index of in-hospital mortality of cirrhotic patients following surgical procedures, based on a national survey.

PubMed

Sato, Masaya; Tateishi, Ryosuke; Yasunaga, Hideo; Horiguchi, Hiromasa; Matsui, Hiroki; Yoshida, Haruhiko; Fushimi, Kiyohide; Koike, Kazuhiko

2017-03-01

We aimed to develop a model for predicting in-hospital mortality of cirrhotic patients following major surgical procedures using a large sample of patients derived from a Japanese nationwide administrative database. We enrolled 2197 cirrhotic patients who underwent elective (n = 1973) or emergency (n = 224) surgery. We analyzed the risk factors for postoperative mortality and established a scoring system for predicting postoperative mortality in cirrhotic patients using a split-sample method. In-hospital mortality rates following elective or emergency surgery were 4.7% and 20.5%, respectively. In multivariate analysis, patient age, Child-Pugh (CP) class, Charlson Comorbidity Index (CCI), and duration of anesthesia in elective surgery were significantly associated with in-hospital mortality. In emergency surgery, CP class and duration of anesthesia were significant factors. Based on multivariate analysis in the training set (n = 987), the Adequate Operative Treatment for Liver Cirrhosis (ADOPT-LC) score that used patient age, CP class, CCI, and duration of anesthesia to predict in-hospital mortality following elective surgery was developed. This scoring system was validated in the testing set (n = 986) and produced an area under the curve of 0.881. We also developed iOS/Android apps to calculate ADOPT-LC scores to allow easy access to the current evidence in daily clinical practice. Patient age, CP class, CCI, and duration of anesthesia were identified as important risk factors for predicting postoperative mortality in cirrhotic patients. The ADOPT-LC score effectively predicts in-hospital mortality following elective surgery and may assist decisions regarding surgical procedures in cirrhotic patients based on a quantitative risk assessment. © 2016 The Authors Hepatology Research published by John Wiley & Sons Australia, Ltd on behalf of Japan Society of Hepatology.

Antipsychotics and mortality: adjusting for mortality risk scores to address confounding by terminal illness.

PubMed

Park, Yoonyoung; Franklin, Jessica M; Schneeweiss, Sebastian; Levin, Raisa; Crystal, Stephen; Gerhard, Tobias; Huybrechts, Krista F

2015-03-01

To determine whether adjustment for prognostic indices specifically developed for nursing home (NH) populations affect the magnitude of previously observed associations between mortality and conventional and atypical antipsychotics. Cohort study. A merged data set of Medicaid, Medicare, Minimum Data Set (MDS), Online Survey Certification and Reporting system, and National Death Index for 2001 to 2005. Dual-eligible individuals aged 65 and older who initiated antipsychotic treatment in a NH (N=75,445). Three mortality risk scores (Mortality Risk Index Score, Revised MDS Mortality Risk Index, Advanced Dementia Prognostic Tool) were derived for each participant using baseline MDS data, and their performance was assessed using c-statistics and goodness-of-fit tests. The effect of adjusting for these indices in addition to propensity scores (PSs) on the association between antipsychotic medication and mortality was evaluated using Cox models with and without adjustment for risk scores. Each risk score showed moderate discrimination for 6-month mortality, with c-statistics ranging from 0.61 to 0.63. There was no evidence of lack of fit. Imbalances in risk scores between conventional and atypical antipsychotic users, suggesting potential confounding, were much lower within PS deciles than the imbalances in the full cohort. Accounting for each score in the Cox model did not change the relative risk estimates: 2.24 with PS-only adjustment versus 2.20, 2.20, and 2.22 after further adjustment for the three risk scores. Although causality cannot be proven based on nonrandomized studies, this study adds to the body of evidence rejecting explanations other than causality for the greater mortality risk associated with conventional antipsychotics than with atypical antipsychotics. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.

Is ambient air pollution associated with onset of sudden infant death syndrome: a case-crossover study in the UK

PubMed Central

Ayres, Jon G; Mohammed, Nuredin I

2018-01-01

Objectives Air pollution has been associated with increased mortality and morbidity in several studies with indications that its effect could be more severe in children. This study examined the relationship between short-term variations in criteria air pollutants and occurrence of sudden infant death syndrome (SIDS). Design We used a case-crossover study design which is widely applied in air pollution studies and particularly useful for estimating the risk of a rare acute outcome associated with short-term exposure. Setting The study used data from the West Midlands region in the UK. Participants We obtained daily time series data on SIDS mortality (ICD-9: 798.0 or ICD-10: R95) for the period 1996–2006 with a total of 211 SIDS events. Primary outcome measures Daily counts of SIDS events. Results For an IQR increase in previous day pollutant concentration, the percentage increases (95% CI) in SIDS were 16 (6 to 27) for PM10, 1 (−7 to 10) for SO2, 5 (−4 to 14) for CO, −17 (−27 to –6) for O3, 16 (2 to 31) for NO2 and 2 (−3 to 8) for NO after controlling for average temperature and national holidays. PM10 and NO2 showed relatively consistent association which persisted across different lag structures and after adjusting for copollutants. Conclusions The results indicated ambient air pollutants, particularly PM10 and NO2, may show an association with increased SIDS mortality. Thus, future studies are recommended to understand possible mechanistic explanations on the role of air pollution on SIDS incidence and the ways in which we might reduce pollution exposure among infants. PMID:29654005

Impact of neonatal intensive care bed configuration on rates of late-onset bacterial sepsis and methicillin-resistant Staphylococcus aureus colonization

PubMed Central

Julian, Samuel; Burnham, Carey-Ann D.; Sellenriek, Patricia; Shannon, William D.; Hamvas, Aaron; Tarr, Phillip I.; Warner, Barbara B.

2016-01-01

Objectives Infections cause significant morbidity and mortality in neonatal intensive care units (NICUs). The association between nursery design and nosocomial infections has not been delineated. We hypothesized that rates of colonization by methicillin-resistant Staphylococcus aureus (MRSA), late-onset sepsis, and mortality are reduced in single-patient rooms. Design Retrospective cohort study. Setting NICU in a tertiary referral center. Methods Our NICU is organized into single-patient and open-unit rooms. Clinical datasets including bed location and microbiology results were examined over a 29-month period. Differences in outcomes between bed configurations were determined by Chi-square and Cox regression. Patients All NICU patients. Results Among 1823 patients representing 55,166 patient-days, single-patient and open-unit models had similar incidences of MRSA colonization and MRSA colonization-free survival times. Average daily census was associated with MRSA colonization rates only in single-patient rooms (hazard ratio 1.31, p=0.039), while hand hygiene compliance on room entry and exit was associated with lower colonization rates independent of bed configuration (hazard ratios 0.834 and 0.719 per 1% higher compliance, respectively). Late-onset sepsis rates were similar in single-patient and open-unit models as were sepsis-free survival and the combined outcome of sepsis or death. After controlling for demographic, clinical and unit-based variables, multivariate Cox regression demonstrated that bed configuration had no effect on MRSA colonization, late-onset sepsis, or mortality. Conclusions MRSA colonization rate was impacted by hand hygiene compliance, regardless of room configuration, while average daily census only affected infants in single-patient rooms. Single-patient rooms did not reduce the rates of MRSA colonization, late-onset sepsis or death. PMID:26108888

The Post-Myocardial Infarction Pacing Remodeling Prevention Therapy (PRomPT) Trial: Design and Rationale.

PubMed

Chung, Eugene S; Fischer, Trent M; Kueffer, Fred; Anand, Inder S; Bax, Jeroen J; Gold, Michael R; Gorman, Robert C; Theres, Heinz; Udelson, James E; Stancak, Branislav; Svendsen, Jesper H; Stone, Gregg W; Leon, Angel

2015-07-01

Despite considerable improvements in the medical management of patients with myocardial infarction (MI), patients with large MI still have substantial risk of developing heart failure. In the early post-MI setting, implantable cardioverter defibrillators have reduced arrhythmic deaths but have no impact on overall mortality. Therefore, additional interventions are required to further reduce the overall morbidity and mortality of patients with large MI. The Pacing Remodeling Prevention Therapy (PRomPT) trial is designed to study the effects of peri-infarct pacing in preventing adverse post-MI remodeling. Up to 120 subjects with peak creatine phosphokinase >3,000 U/L (or troponin T >10 μg/L) at time of MI will be randomized to either dual-site or single-site biventricular pacing with the left ventricular lead implanted in a peri-infarct region or to a nonimplanted control group. Those randomized to a device will be blinded to the pacing mode, but randomization to a device or control cannot be blinded. Subjects randomized to pacing will have the device implanted within 10 days of MI. The primary objective is to assess the change in left ventricular end-diastolic volume from baseline to 18 months. Secondary objectives are to assess changes in clinical and mechanistic parameters between the groups, including rates of hospitalization for heart failure and cardiovascular events, the incidence of sudden cardiac death and all-cause mortality, New York Heart Association functional class, 6-minute walking distance, and quality of life. The PRomPT trial will provide important evidence regarding the potential of peri-infarct pacing to interrupt adverse remodeling in patients with large MI. Copyright © 2015 Elsevier Inc. All rights reserved.

Abandoning Peracetic Acid-Based Dialyzer Reuse Is Associated with Improved Survival

PubMed Central

Wang, Weiling; Mooney, Ann; Ofsthun, Norma; Lazarus, J. Michael; Hakim, Raymond M.

2011-01-01

Summary Background and objectives Higher mortality risk reported with reuse versus single use of dialyzers is potentially related to reuse reagents that modify membrane surface characteristics and the blood-membrane interface. A key mechanism may involve stimulation of an inflammatory response. Design, setting, participants, & measurements In a prospective crossover design, laboratory markers and mortality from 23 hemodialysis facilities abandoning reuse with peracetic acid mixture were tracked. C-reactive protein (CRP), white blood cell (WBC) count, albumin, and prealbumin were measured for 2 consecutive months before abandoning reuse and subsequently within 3 and 6 months on single use. Survival models were utilized to compare the 6-month period before abandoning reuse (baseline) and the 6-month period on single use of dialyzers after a 3-month “washout period.” Results Patients from baseline and single-use periods had a mean age of approximately 63 years; 44% were female, 54% were diabetic, 60% were white, and the mean vintage was approximately 3.2 years. The unadjusted hazard ratio for death was 0.70 and after case-mix adjustment was 0.74 for single use compared with reuse. Patients with CRP ≥ 5 mg/L during reuse (mean CRP = 26.6 mg/ml in April) declined on single use to 20.2 mg/L by August and 20.4 mg/L by November. WBC count declined slightly during single use, but nutritional markers were unchanged. Conclusions Abandonment of peracetic-acid-based reuse was associated with improved survival and lower levels of inflammatory but not nutritional markers. Further study is needed to evaluate a potential link between dialyzer reuse, inflammation, and mortality. PMID:20947788

Mortality from different causes associated with meat, heme iron, nitrates, and nitrites in the NIH-AARP Diet and Health Study: population based cohort study.

PubMed

Etemadi, Arash; Sinha, Rashmi; Ward, Mary H; Graubard, Barry I; Inoue-Choi, Maki; Dawsey, Sanford M; Abnet, Christian C

2017-05-09

Objective  To determine the association of different types of meat intake and meat associated compounds with overall and cause specific mortality. Design  Population based cohort study. Setting  Baseline dietary data of the NIH-AARP Diet and Health Study (prospective cohort of the general population from six states and two metropolitan areas in the US) and 16 year follow-up data until 31 December 2011. Participants  536 969 AARP members aged 50-71 at baseline. Exposures  Intake of total meat, processed and unprocessed red meat (beef, lamb, and pork) and white meat (poultry and fish), heme iron, and nitrate/nitrite from processed meat based on dietary questionnaire. Adjusted Cox proportional hazards regression models were used with the lowest fifth of calorie adjusted intakes as reference categories. Main outcome measure  Mortality from any cause during follow-up. Results  An increased risk of all cause mortality (hazard ratio for highest versus lowest fifth 1.26, 95% confidence interval 1.23 to 1.29) and death due to nine different causes associated with red meat intake was observed. Both processed and unprocessed red meat intakes were associated with all cause and cause specific mortality. Heme iron and processed meat nitrate/nitrite were independently associated with increased risk of all cause and cause specific mortality. Mediation models estimated that the increased mortality associated with processed red meat was influenced by nitrate intake (37.0-72.0%) and to a lesser degree by heme iron (20.9-24.1%). When the total meat intake was constant, the highest fifth of white meat intake was associated with a 25% reduction in risk of all cause mortality compared with the lowest intake level. Almost all causes of death showed an inverse association with white meat intake. Conclusions  The results show increased risks of all cause mortality and death due to nine different causes associated with both processed and unprocessed red meat, accounted for, in part, by heme iron and nitrate/nitrite from processed meat. They also show reduced risks associated with substituting white meat, particularly unprocessed white meat. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Sleep duration and mortality in the elderly: a systematic review with meta-analysis

PubMed Central

da Silva, Andressa Alves; de Mello, Renato Gorga Bandeira; Schaan, Camila Wohlgemuth; Fuchs, Flávio D; Redline, Susan; Fuchs, Sandra C

2016-01-01

Objective The purpose of our study was to evaluate the association between short and long sleep duration and all-cause and cardiovascular mortality among elderly individuals. Design Systematic review and meta-analysis of population-based cohort studies. Setting Articles were retrieved from international and national electronic databases. Study selection Studies were identified in PubMed, EMBASE, LILACS (Latin American and Caribbean Health Sciences Literature), IBECS (Bibliographic Index on Health Sciences from Spain) and CAPES (PhD thesis repository) between 1980 and 2015. Studies which met all criteria were eligible: participants aged 60 years or over, assessment of sleep duration as 24 h, nighttime or daytime sleep, evaluation of all-cause or cause-specific mortality, population-based cohort studies conducted on representative samples. There was no language restriction and studies published as abstracts were excluded. Data extraction Data were analysed using the Comprehensive Meta-Analysis software (V.3.3.070), and summary estimates (relative risk (RR), 95% CI) were calculated using a random effects model. Heterogeneity and consistency were evaluated through Cochran's Q and the I2 statistics, respectively, and sensitivity analyses were conducted. Primary and secondary outcome measures All-cause and cardiovascular mortality. Results Overall, 27 cohort studies were selected, comprising >70 000 elderly individuals, and followed up from 3.4 to 35 years. In the pooled analysis, long and short sleep duration were associated with increased all-cause mortality (RR 1.33; 95% CI 1.24 to 1.43 and RR 1.07; 95% CI 1.03 to 1.11, respectively), compared with the reference category. For cardiovascular mortality, the pooled relative risks were 1.43 (95% CI 1.15 to 1.78) for long sleep, and 1.18 (95% CI 0.76 to 1.84) for short sleep. Daytime napping ≥30 min was associated with risk of all-cause mortality (RR 1.27; 95% CI 1.08 to 1.49), compared with no daytime sleep, but longer sleep duration (≥2.0 h) was not (RR 1.34; 95% CI 1.95 to 1.90). Conclusions Among elderly individuals, long and short sleep duration are associated with increased risk for all-cause mortality. Long sleep duration is associated with cardiovascular mortality. PMID:26888725

Prison tobacco control policies and deaths from smoking in United States prisons: population based retrospective analysis

PubMed Central

Carson, E Ann; Krueger, Patrick M; Mueller, Shane R; Steiner, John F; Sabol, William J

2014-01-01

Objective To determine the mortality attributable to smoking and years of potential life lost from smoking among people in prison and whether bans on smoking in prison are associated with reductions in smoking related deaths. Design Analysis of cross sectional survey data with the smoking attributable mortality, morbidity, and economic costs system; population based time series analysis. Setting All state prisons in the United States. Main outcome measures Prevalence of smoking from cross sectional survey of inmates in state correctional facilities. Data on state prison tobacco policies from web based searches of state policies and legislation. Deaths and causes of death in US state prisons from the deaths in custody reporting program of the Bureau of Justice Statistics for 2001-11. Smoking attributable mortality and years of potential life lost was assessed from the smoking attributable mortality, morbidity, and economic costs system of the Centers for Disease Control and Prevention. Multivariate Poisson models quantified the association between bans and smoking related cancer, cardiovascular and pulmonary deaths. Results The most common causes of deaths related to smoking among people in prison were lung cancer, ischemic heart disease, other heart disease, cerebrovascular disease, and chronic airways obstruction. The age adjusted smoking attributable mortality and years of potential life lost rates were 360 and 5149 per 100 000, respectively; these figures are higher than rates in the general US population (248 and 3501, respectively). The number of states with any smoking ban increased from 25 in 2001 to 48 by 2011. In prisons the mortality rate from smoking related causes was lower during years with a ban than during years without a ban (110.4/100 000 v 128.9/100 000). Prisons that implemented smoking bans had a 9% reduction (adjusted incidence rate ratio 0.91, 95% confidence interval 0.88 to 0.95) in smoking related deaths. Bans in place for longer than nine years were associated with reductions in cancer mortality (adjusted incidence rate ratio 0.81, 95% confidence interval 0.74 to 0.90). Conclusions Smoking contributes to substantial mortality in prison, and prison tobacco control policies are associated with reduced mortality. These findings suggest that smoking bans have health benefits for people in prison, despite the limits they impose on individual autonomy and the risks of relapse after release. PMID:25097186

Bicarbonate Concentration, Acid-Base Status, and Mortality in the Health, Aging, and Body Composition Study

PubMed Central

Murphy, Rachel A.; Shlipak, Michael G.; Satterfield, Suzanne; Huston, Hunter K.; Sebastian, Anthony; Sellmeyer, Deborah E.; Patel, Kushang V.; Newman, Anne B.; Sarnak, Mark J.; Ix, Joachim H.; Fried, Linda F.

2016-01-01

Background and objectives Low serum bicarbonate associates with mortality in CKD. This study investigated the associations of bicarbonate and acid-base status with mortality in healthy older individuals. Design, setting, participants, & measurements We analyzed data from the Health, Aging, and Body Composition Study, a prospective study of well functioning black and white adults ages 70–79 years old from 1997. Participants with arterialized venous blood gas measurements (n=2287) were grouped into <23.0 mEq/L (low), 23.0–27.9 mEq/L (reference group), and ≥28.0 mEq/L (high) bicarbonate categories and according to acid-base status. Survival data were collected through February of 2014. Mortality hazard ratios (HRs; 95% confidence intervals [95% CIs]) in the low and high bicarbonate groups compared with the reference group were determined using Cox models adjusted for demographics, eGFR, albuminuria, chronic obstructive pulmonary disease, smoking, and systemic pH. Similarly adjusted Cox models were performed according to acid-base status. Results The mean age was 76 years, 51% were women, and 38% were black. Mean pH was 7.41, mean bicarbonate was 25.1 mEq/L, 11% had low bicarbonate, and 10% had high bicarbonate. Mean eGFR was 82.1 ml/min per 1.73 m2, and 12% had CKD. Over a mean follow-up of 10.3 years, 1326 (58%) participants died. Compared with the reference group, the mortality HRs were 1.24 (95% CI, 1.02 to 1.49) in the low bicarbonate and 1.03 (95% CI, 0.84 to 1.26) in the high bicarbonate categories. Compared with the normal acid-base group, the mortality HRs were 1.17 (95% CI, 0.94 to 1.47) for metabolic acidosis, 1.21 (95% CI, 1.01 to 1.46) for respiratory alkalosis, and 1.35 (95% CI, 1.08 to 1.69) for metabolic alkalosis categories. Respiratory acidosis did not associate with mortality. Conclusions In generally healthy older individuals, low serum bicarbonate associated with higher mortality independent of systemic pH and potential confounders. This association seemed to be present regardless of whether the cause of low bicarbonate was metabolic acidosis or respiratory alkalosis. Metabolic alkalosis also associated with higher mortality. PMID:26769766

Suicidal behaviour characteristics and factors associated with mortality in the hospital setting.

PubMed

Sendra-Gutiérrez, Juan Manuel; Esteban-Vasallo, María; Domínguez-Berjón, M Felicitas

2016-04-29

Suicide is a major public health problem worldwide, and an approach is necessary due to its high potential for prevention. This paper examines the main characteristics of people admitted to hospitals in the Community of Madrid (Spain) with suicidal behaviour, and the factors associated with their hospital mortality. A study was conducted on patients with E950-E959 codes of suicide and self-inflicted injuries of the International Classification of Diseases, Ninth Revision, Clinical Modification, contained in any diagnostic field of the minimum basic data set at hospital discharge between 2003 and 2013. Sociodemographic, clinical and health care variables were assessed by uni- and multivariate logistic regression analysis in the evaluation of factors associated with hospital mortality. Hospital suicidal behaviour predominates in women (58.7%) and in middle-age. Hospital mortality is 2.2% (1.6% in women and 3.2% in men), increasing with age. Mental disorders are detected 3-4 times more in secondary diagnoses. The main primary diagnosis (>74%) is poisoning with substances, with lower mortality (∼1%) than injury by hanging and jumping from high places (≥12%), which have the highest numbers. Other factors associated with increased mortality include different medical comorbidities and severity of the injury, while length of stay and mental disorders are protective factors. Type of hospital, poisoning, and Charlson index are associated differently with mortality in men and women. Hospitalised suicidal acts show a low mortality, mainly related to comorbidities and the severity of injuries. Copyright © 2016 SEP y SEPB. Published by Elsevier España. All rights reserved.

Stroke mortality and its determinants in a resource-limited setting: A prospective cohort study in Yaounde, Cameroon.

PubMed

Nkoke, Clovis; Lekoubou, Alain; Balti, Eric; Kengne, Andre Pascal

2015-11-15

About three quarters of stroke deaths occur in developing countries including those in sub-Saharan African. Short and long-term stroke fatality data are needed for health service and policy formulation. We prospectively followed up from stroke onset, 254 patients recruited from the largest reference hospitals in Yaounde (Cameroon). Mortality and determinants were investigated using the accelerated failure time regression analysis. Stroke mortality rates at one-, six- and 12 months were respectively 23.2% (Ischemic strokes: 20.4%, hemorrhagic strokes: 26.1%, and undetermined strokes: 34.8, p=0.219), 31.5% (ischemic strokes: 31.5%, hemorrhagic strokes: 30.4%, and undetermined strokes: 34.8%, p=0.927), and 32.7% (ischemic strokes: 32.1%, hemorrhagic strokes: 30.4%, undetermined strokes: 43.5%, p=0.496). Fever, swallowing difficulties, and admission NIHSS independently predicted mortality at one month, six and 12 months. Elevated systolic blood pressure (BP) predicted mortality at one month. Elevated diastolic blood pressure was a predictor of mortality at one month in participants with hemorrhagic stroke. Low hemoglobin level on admission only predicted long term mortality. In this resource-limited setting, post-stroke mortality was high with 1 out of 5 deaths occurring at one month and up to 30% deaths at six and twelve months after the index event. Fever, stroke severity, elevated BP and anemia increased the risk of death. Our findings add to the body of evidence for the poor outcome after stroke in resource limited environments. Copyright © 2015 Elsevier B.V. All rights reserved.

Mortality in HIV-Infected Alcohol and Drug Users in St. Petersburg, Russia.

PubMed

Fairbairn, Nadia S; Walley, Alexander Y; Cheng, Debbie M; Quinn, Emily; Bridden, Carly; Chaisson, Christine; Blokhina, Elena; Lioznov, Dmitry; Krupitsky, Evgeny; Raj, Anita; Samet, Jeffrey H

2016-01-01

In Russia, up to half of premature deaths are attributed to hazardous drinking. The respective roles of alcohol and drug use in premature death among people with HIV in Russia have not been described. Criminalization and stigmatization of substance use in Russia may also contribute to mortality. We explored whether alcohol, drug use and risk environment factors are associated with short-term mortality in HIV-infected Russians who use substances. Secondary analyses were conducted using prospective data collected at baseline, 6 and 12-months from HIV-infected people who use substances recruited between 2007-2010 from addiction and HIV care settings in a single urban setting of St. Petersburg, Russia. We used Cox proportional hazards models to explore associations between 30-day alcohol hazardous drinking, injection drug use, polysubstance use and environmental risk exposures (i.e. past incarceration, police involvement, selling sex, and HIV stigma) with mortality. Among 700 participants, 59% were male and the mean age was 30 years. There were 40 deaths after a median follow-up of 12 months (crude mortality rate 5.9 per 100 person-years). In adjusted analyses, 30-day NIAAA hazardous drinking was significantly associated with mortality compared to no drinking [adjusted Hazard Ratio (aHR) 2.60, 95% Confidence Interval (CI): 1.24-5.44] but moderate drinking was not (aHR 0.95, 95% CI: 0.35-2.59). No other factors were significantly associated with mortality. The high rates of short-term mortality and the strong association with hazardous drinking suggest a need to integrate evidence-based alcohol interventions into treatment strategies for HIV-infected Russians.

PERITONEAL DIALYSIS FOR AKI IN CAMEROON: COMMERCIAL VS LOCALLY-MADE SOLUTIONS.

PubMed

Palmer, Dennis; Lawton, William J; Barrier, Charles; Fine, Bd; Hemphill, Hayden; Nyah, Norah; Kinne, Virginie; Ringnwi, Njaprim I; Yong, Genevive; Neufeldt, Amy L; Mambou, Yves Mitterand M; Finkelstein, Fredric O; Krahn, Thomas

2018-05-23

Acute kidney injury (AKI) is common in low- and middle-income countries, and is associated with a high mortality. The high mortality rate is in large part due to the inability to perform dialysis in resource-limited settings. Due to significant cost advantages, peritoneal dialysis (PD) has been used to treat AKI in these settings. The costs, however, remain high when commercial solutions are used. This is a retrospective cohort study of the outcome, and of the peritonitis rates, of patients with AKI treated with either commercially manufactured PD solutions or locally-made PD solutions. A program to treat AKI with PD was started at Mbingo Baptist Hospital in Cameroon. Between May 2013 and January 2015, solutions and connection sets were provided by the Saving Young Lives Program. From January 2015 through March 2017, solutions were locally produced and available tubing was used. Mortality in hospitalized AKI patients was 28% during the period when commercial solutions and tubing were utilized, and 33% when locally produced solutions and available tubing were utilized. In both groups, peritonitis occurred in 16% of treatment courses. Locally produced PD solutions, used with locally available tubing, were used to treat AKI with PD. The mortality and peritonitis rates were similar whether locally produced or commercial supplies were used.

Use of and Mortality After Bilateral Mastectomy Compared With Other Surgical Treatments for Breast Cancer in California, 1998–2011

PubMed Central

Kurian, Allison W.; Lichtensztajn, Daphne Y.; Keegan, Theresa H. M.; Nelson, David O.; Clarke, Christina A.; Gomez, Scarlett L.

2017-01-01

IMPORTANCE Bilateral mastectomy is increasingly used to treat unilateral breast cancer. Because it may have medical and psychosocial complications, a better understanding of its use and outcomes is essential to optimizing cancer care. OBJECTIVE To compare use of and mortality after bilateral mastectomy, breast-conserving therapy with radiation, and unilateral mastectomy. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study within the population-based California Cancer Registry; participants were women diagnosed with stages 0–III unilateral breast cancer in California from 1998 through 2011, with median follow-up of 89.1 months. MAIN OUTCOMES AND MEASURES Factors associated with surgery use (from polytomous logistic regression); overall and breast cancer–specific mortality (from propensity score weighting and Cox proportional hazards analysis). RESULTS Among 189 734 patients, the rate of bilateral mastectomy increased from 2.0% (95% CI, 1.7%–2.2%) in 1998 to 12.3% (95% CI, 11.8%–12.9%) in 2011, an annual increase of 14.3% (95% CI, 13.1%–15.5%); among women younger than 40 years, the rate increased from 3.6% (95% CI, 2.3%–5.0%) in 1998 to 33% (95% CI, 29.8%–36.5%) in 2011. Bilateral mastectomy was more often used by non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute (NCI)–designated cancer center (8.6% [95% CI, 8.1%–9.2%] among NCI cancer center patients vs 6.0% [95% CI, 5.9%–6.1%] among non-NCI cancer center patients; odds ratio [OR], 1.13 [95% CI, 1.04–1.22]); in contrast, unilateral mastectomy was more often used by racial/ethnic minorities (Filipina, 52.8% [95% CI, 51.6%–54.0%]; OR, 2.00 [95% CI, 1.90–2.11] and Hispanic, 45.6% [95% CI, 45.0%–46.2%]; OR, 1.16 [95% CI, 1.13–1.20] vs non-Hispanic white, 35.2% [95% CI, 34.9%–35.5%]) and those with public/Medicaid insurance (48.4% [95% CI, 47.8%–48.9%]; OR, 1.08 [95% CI, 1.05–1.11] vs private insurance, 36.6% [95% CI, 36.3%–36.8%]). Compared with breast-conserving surgery with radiation (10-year mortality, 16.8% [95% CI, 16.6%–17.1%]), unilateral mastectomy was associated with higher all-cause mortality (hazard ratio [HR], 1.35 [95% CI, 1.32–1.39]; 10-year mortality, 20.1% [95% CI, 19.9%–20.4%]). There was no significant mortality difference compared with bilateral mastectomy (HR, 1.02 [95% CI, 0.94–1.11]; 10-year mortality, 18.8% [95% CI, 18.6%–19.0%]). Propensity analysis showed similar results. CONCLUSIONS AND RELEVANCE Use of bilateral mastectomy increased significantly throughout California from 1998 through 2011 and was not associated with lower mortality than that achieved with breast-conserving surgery plus radiation. Unilateral mastectomy was associated with higher mortality than were the other 2 surgical options. PMID:25182099

Past and Present ARDS Mortality Rates: A Systematic Review.

PubMed

Máca, Jan; Jor, Ondřej; Holub, Michal; Sklienka, Peter; Burša, Filip; Burda, Michal; Janout, Vladimír; Ševčík, Pavel

2017-01-01

ARDS is severe form of respiratory failure with significant impact on the morbidity and mortality of critical care patients. Epidemiological data are crucial for evaluating the efficacy of therapeutic interventions, designing studies, and optimizing resource distribution. The goal of this review is to present general aspects of mortality data published over the past decades. A systematic search of the MEDLINE/PubMed was performed. The articles were divided according to their methodology, type of reported mortality, and time. The main outcome was mortality. Extracted data included study duration, number of patients, and number of centers. The mortality trends and current mortality were calculated for subgroups consisting of in-hospital, ICU, 28/30-d, and 60-d mortality over 3 time periods (A, before 1995; B, 1995-2000; C, after 2000). The retrospectivity and prospectivity were also taken into account. Moreover, we present the most recent mortality rates since 2010. One hundred seventy-seven articles were included in the final analysis. General mortality rates ranged from 11 to 87% in studies including subjects with ARDS of all etiologies (mixed group). Linear regression revealed that the study design (28/30-d or 60-d) significantly influenced the mortality rate. Reported mortality rates were higher in prospective studies, such as randomized controlled trials and prospective observational studies compared with retrospective observational studies. Mortality rates exhibited a linear decrease in relation to time period (P < .001). The number of centers showed a significant negative correlation with mortality rates. The prospective observational studies did not have consistently higher mortality rates compared with randomized controlled trials. The mortality trends over 3 time periods (before 1995, 1995-2000, and after 2000) yielded variable results in general ARDS populations. However, a mortality decrease was present mostly in prospective studies. Since 2010, the overall rates of in-hospital, ICU, and 28/30-d and 60-d mortality were 45, 38, 30, and 32%, respectively. Copyright © 2017 by Daedalus Enterprises.

The composite dynamic method as evidence for age-specific waterfowl mortality

USGS Publications Warehouse

Burnham, Kenneth P.; Anderson, David R.

1979-01-01

For the past 25 years estimation of mortality rates for waterfowl has been based almost entirely on the composite dynamic life table. We examined the specific assumptions for this method and derived a valid goodness of fit test. We performed this test on 45 data sets representing a cross section of banded sampled for various waterfowl species, geographic areas, banding periods, and age/sex classes. We found that: (1) the composite dynamic method was rejected (P <0.001) in 37 of the 45 data sets (in fact, 29 were rejected at P <0.00001) and (2) recovery and harvest rates are year-specific (a critical violation of the necessary assumptions). We conclude that the restrictive assumptions required for the composite dynamic method to produce valid estimates of mortality rates are not met in waterfowl data. Also we demonstrate that even when the required assumptions are met, the method produces very biased estimates of age-specific mortality rates. We believe the composite dynamic method should not be used in the analysis of waterfowl banding data. Furthermore, the composite dynamic method does not provide valid evidence for age-specific mortality rates in waterfowl.

Clinical outcomes and mortality before and after implementation of a pediatric sepsis protocol in a limited resource setting: A retrospective cohort study in Bangladesh

PubMed Central

Axelrod, David M.; Chisti, Mohammod J.; Kache, Saraswati

2017-01-01

Background Pediatric sepsis has a high mortality rate in limited resource settings. Sepsis protocols have been shown to be a cost-effective strategy to improve morbidity and mortality in a variety of populations and settings. At Dhaka Hospital in Bangladesh, mortality from pediatric sepsis in high-risk children previously approached 60%, which prompted the implementation of an evidenced-based protocol in 2010. The clinical effectiveness of this protocol had not been measured. We hypothesized that implementation of a pediatric sepsis protocol improved clinical outcomes, including reducing mortality and length of hospital stay. Materials and methods This was a retrospective cohort study of children 1–59 months old with a diagnosis of sepsis, severe sepsis or septic shock admitted to Dhaka Hospital from 10/25/2009-10/25/2011. The primary outcome was inpatient mortality pre- and post-protocol implementation. Secondary outcomes included fluid overload, heart failure, respiratory insufficiency, length of hospital stay, and protocol compliance, as measured by antibiotic and fluid bolus administration within 60 minutes of hospital presentation. Results 404 patients were identified by a key-word search of the electronic medical record; 328 patients with a primary diagnosis of sepsis, severe sepsis, or septic shock were included (143 pre- and185 post-protocol) in the analysis. Pre- and post-protocol mortality were similar and not statistically significant (32.17% vs. 34.59%, p = 0.72). The adjusted odds ratio (AOR) for post-protocol mortality was 1.55 (95% CI, 0.88–2.71). The odds for developing fluid overload were significantly higher post-protocol (AOR 3.45, 95% CI, 2.04–5.85), as were the odds of developing heart failure (AOR 4.52, 95% CI, 1.43–14.29) and having a longer median length of stay (AOR 1.81, 95% CI 1.10–2.96). There was no statistically significant difference in respiratory insufficiency (pre- 65.7% vs. post- 70.3%, p = 0.4) or antibiotic administration between the cohorts (pre- 16.08% vs. post- 12.43%, p = 0.42). Conclusions Implementation of a pediatric sepsis protocol did not improve all-cause mortality or length of stay and may have been associated with increased fluid overload and heart failure during the study period in a large, non-governmental hospital in Bangladesh. Similar rates of early antibiotic administration may indicate poor protocol compliance. Though evidenced-based protocols are a potential cost-effective strategy to improve outcomes, future studies should focus on optimal implementation of context-relevant sepsis protocols in limited resource settings. PMID:28753618

Acute Kidney Injury in the Era of the AKI E-Alert

PubMed Central

Holmes, Jennifer; Rainer, Timothy; Geen, John; Roberts, Gethin; May, Kate; Wilson, Nick; Williams, John D.

2016-01-01

Background and objectives Our aim was to use a national electronic AKI alert to define the incidence and outcome of all episodes of community– and hospital–acquired adult AKI. Design, setting, participants, & measurements A prospective national cohort study was undertaken in a population of 3.06 million. Data were collected between March of 2015 and August of 2015. All patients with adult (≥18 years of age) AKI were identified to define the incidence and outcome of all episodes of community- and hospital-acquired AKI in adults. Mortality and renal outcomes were assessed at 90 days. Results There was a total of 31,601 alerts representing 17,689 incident episodes, giving an incidence of AKI of 577 per 100,000 population. Community-acquired AKI accounted for 49.3% of all incident episodes, and 42% occurred in the context of preexisting CKD (Chronic Kidney Disease Epidemiology Collaboration eGFR); 90-day mortality rate was 25.6%, and 23.7% of episodes progressed to a higher AKI stage than the stage associated with the alert. AKI electronic alert stage and peak AKI stage were associated with mortality, and mortality was significantly higher for hospital-acquired AKI compared with alerts generated in a community setting. Among patients who survived to 90 days after the AKI electronic alert, those who were not hospitalized had a lower rate of renal recovery and a greater likelihood of developing an eGFR<60 ml/min per 1.73 m2 for the first time, which may be indicative of development of de novo CKD. Conclusions The reported incidence of AKI is far greater than the previously reported incidence in studies reliant on clinical identification of adult AKI or hospital coding data. Although an electronic alert system is Information Technology driven and therefore, lacks intelligence and clinical context, these data can be used to identify deficiencies in care, guide the development of appropriate intervention strategies, and provide a baseline against which the effectiveness of these interventions may be measured. PMID:27793961

The National Early Warning Score (NEWS) for outcome prediction in emergency department patients with community-acquired pneumonia: results from a 6-year prospective cohort study

PubMed Central

Sbiti-Rohr, Diana; Kutz, Alexander; Christ-Crain, Mirjam; Thomann, Robert; Zimmerli, Werner; Hoess, Claus; Henzen, Christoph; Mueller, Beat; Schuetz, Philipp

2016-01-01

Objective To investigate the accuracy of the National Early Warning Score (NEWS) to predict mortality and adverse clinical outcomes for patients with community-acquired pneumonia (CAP) compared to standard risk scores such as the pneumonia severity index (PSI) and CURB-65. Design Secondary analysis of patients included in a previous randomised-controlled trial with a median follow-up of 6.1 years. Settings Patients with CAP included on admission to the emergency departments (ED) of 6 tertiary care hospitals in Switzerland. Participants A total of 925 patients with confirmed CAP were included. NEWS, PSI and CURB-65 scores were calculated on admission to the ED based on admission data. Main outcome measure Our primary outcome was all-cause mortality within 6 years of follow-up. Secondary outcomes were adverse clinical outcome defined as intensive care unit (ICU) admission, empyema and unplanned hospital readmission all occurring within 30 days after admission. We used regression models to study associations of baseline risk scores and outcomes with the area under the receiver operating curve (AUC) as a measure of discrimination. Results 6-year overall mortality was 45.1% (n=417) with a stepwise increase with higher NEWS categories. For 30 day and 6-year mortality prediction, NEWS showed only low discrimination (AUC 0.65 and 0.60) inferior compared to PSI and CURB-65. For prediction of ICU admission, NEWS showed moderate discrimination (AUC 0.73) and improved the prognostic accuracy of a regression model, including PSI (AUC from 0.66 to 0.74, p=0.001) and CURB-65 (AUC from 0.64 to 0.73, p=0.015). NEWS was also superior to PSI and CURB-65 for prediction of empyema, but did not well predict rehospitalisation. Conclusions NEWS provides additional prognostic information with regard to risk of ICU admission and complications and thereby improves traditional clinical-risk scores in the management of patients with CAP in the ED setting. Trial registration number ISRCTN95122877; Post-results. PMID:27683509

The effectiveness of community-based loan funds for transport during obstetric emergencies in developing countries: a systematic review.

PubMed

Nwolise, Chidiebere Hope; Hussein, Julia; Kanguru, Lovney; Bell, Jacqueline; Patel, Purvi

2015-09-01

Scarcity and costs of transport have been implicated as key barriers to accessing care when obstetric emergencies occur in community settings. Community-based loans have been used to increase utilization of health facilities and potentially reduce maternal mortality by providing funding at community level to provide emergency transport. This review aimed to provide evidence of the effect of community-based loan funds on utilization of health facilities and reduction of maternal mortality in developing countries. Electronic databases of published literature and websites were searched for relevant literature using a pre-defined set of search terms, inclusion and exclusion criteria. Screening of titles, abstracts and full-text articles were done by at least two reviewers independently. Quality assessment was carried out on the selected papers. Data related to deliveries and obstetric complications attended at facilities, maternal deaths and live births were extracted to measure and compare the effects of community-based loan funds using odds ratios (ORs) and reductions in maternal mortality ratio. Forest plots are presented where possible. The results of the review show that groups where community-based loan funds were implemented (alongside other interventions) generally recorded increases in utilization of health facilities for deliveries, with ORs of 3.5 (0.97-15.48) and 3.55 (1.56-8.05); and an increase in utilization of emergency obstetric care with ORs of 2.22 (0.51-10.38) and 3.37 (1.78-6.37). Intervention groups also experienced a positive effect on met need for complications and a reduction in maternal mortality. There is some evidence to suggest that community-based loan funds as part of a multifaceted intervention have positive effects. Conclusions are limited by challenges of study design and bias. Further studies which strengthen the evidence of the effects of loan funds, and mechanism for their functionality, are recommended. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.

Premature mortality in a national cohort of people recently discharged from their first psychiatric inpatient treatment episode

PubMed Central

Walter, Florian; Carr, Matthew J.; Mok, Pearl L.H.; Astrup, Aske; Antonsen, Sussie; Pedersen, Carsten B.; Shaw, Jenny; Webb, Roger T.

2017-01-01

Importance Patients recently discharged from psychiatric inpatient services are at elevated risk of dying prematurely. National cohorts provide sufficient statistical power for examining cause-specific mortality in this population. Objective To comprehensively investigate premature mortality in a national cohort of recently discharged psychiatric patients at 15-44 years of age. Design, setting, and participants Cohort study of all persons born in Denmark during 1967-1996 (N=1,683,385). Participants were followed up from their 15th birthday until their date of death, emigration or December 31st 2011, whichever came first. Exposures First discharge from inpatient psychiatric care. Main outcome measures Incidence rates and incidence rate ratios (IRRs) for all-cause mortality and for an array of unnatural and natural causes among discharged patients versus persons not admitted for psychiatric care. Our primary analysis considered risk within a year of first discharge. Results Compared to persons not admitted, discharged patients had an elevated risk for all-cause mortality within a year (IRR 16.2, 95% CI 14.5-18.0). Relative risk for unnatural death (IRR 25.0, 95% CI 22.0- 28.4) was much higher than for natural death (IRR 8.6, 95% CI 7.0-10.7). The highest IRR found was for suicide: IRR 66.9, 95% CI 56.4-79.4; the IRR for alcohol-related deaths was the second highest observed: IRR 42.0, 95% CI 26.6-66.1. Among the psychiatric diagnostic categories assessed, psychoactive substance abuse conferred the highest risk for all-cause mortality (IRR 24.8, 95% CI 21.0-29.4). Across the array of cause-specific outcomes examined, risk of premature death during the first year post-discharge was markedly elevated compared to longer term follow up. Conclusions and relevance Enhanced liaison between primary and secondary health services post-discharge, as well as early intervention programs for drug and alcohol misuse could substantially decrease the greatly elevated mortality risk among recently discharged psychiatric patients. PMID:28296989

Serum Phosphorus and Risk of Cardiovascular Disease, All-Cause Mortality, or Graft Failure in Kidney Transplant Recipients: An Ancillary Study of the FAVORIT Trial Cohort

PubMed Central

Merhi, Basma; Shireman, Theresa; Carpenter, Myra A.; Kusek, John W.; Jacques, Paul; Pfeffer, Marc; Rao, Madhumathi; Foster, Meredith C.; Kim, S. Joseph; Pesavento, Todd E.; Smith, Stephen R.; Kew, Clifton E.; House, Andrew A.; Gohh, Reginald; Weiner, Daniel E.; Levey, Andrew S.; Ix, Joachim H.; Bostom, Andrew

2017-01-01

Background Mild hyperphosphatemia is a putative risk factor for cardiovascular disease [CVD], loss of kidney function, and mortality. Very limited data are available from sizable multicenter kidney transplant recipient (KTR) cohorts assessing the potential relationships between serum phosphorus levels and the development of CVD outcomes, transplant failure, or all-cause mortality. Study Design Cohort study. Setting & Participants The Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) Trial, a large, multicenter, multiethnic, controlled clinical trial that provided definitive evidence that high-dose vitamin B–based lowering of plasma homocysteine levels did not reduce CVD events, transplant failure, or total mortality in stable KTRs. Predictor Serum phosphorus levels were determined in 3,138 FAVORIT trial participants at randomization. Results During a median follow-up of 4.0 years, the cohort had 436 CVD events, 238 transplant failures, and 348 deaths. Proportional hazards modeling revealed that each 1-mg/dL higher serum phosphorus level was not associated with a significant increase in CVD risk (HR, 1.06; 95% CI, 0.92–1.22), but increased transplant failure (HR, 1.36; 95% CI, 1.15–1.62) and total mortality risk associations (HR, 1.21; 95% CI, 1.04–1.40) when adjusted for treatment allocation, traditional CVD risk factors, kidney measures, type of kidney transplant, transplant vintage, and use of calcineurin inhibitors, steroids, or lipid-lowering drugs. These associations were strengthened in models without kidney measures: CVD (HR, 1.14; 95% CI, 1.00–1.31), transplant failure (HR, 1.72; 95% CI, 1.46–2.01), and mortality (HR, 1.34; 95% CI, 1.15–1.54). Limitations We lacked data for concentrations of parathyroid hormone, fibroblast growth factor 23, or vitamin D metabolites. Conclusions Serum phosphorus level is marginally associated with CVD and more strongly associated with transplant failure and total mortality in long-term KTRs. A randomized controlled clinical trial in KTRs that assesses the potential impact of phosphorus-lowering therapy on these hard outcomes may be warranted. PMID:28579423

Trends in mortality from 1965 to 2008 across the English north-south divide: comparative observational study

PubMed Central

Muller, Sara; Buchan, Iain E

2011-01-01

Objective To compare all cause mortality between the north and south of England over four decades. Design Population wide comparative observational study of mortality. Setting Five northernmost and four southernmost English government office regions. Population All residents in each year from 1965 to 2008. Main outcome measures Death rate ratios of north over south England by age band and sex, and northern excess mortality (percentage of excess deaths in north compared with south, adjusted for age and sex and examined for annual trends, using Poisson regression). Results During 1965 to 2008 the northern excess mortality remained substantial, at an average of 13.8% (95% confidence interval 13.7% to 13.9%). This geographical inequality was significantly larger for males than for females (14.9%, 14.7% to 15.0% v 12.7%, 12.6% to 12.9%, P<0.001). The inequality decreased significantly but temporarily for both sexes from the early 80s to the late 90s, followed by a steep significant increase from 2000 to 2008. Inequality varied with age, being higher for ages 0-9 years and 40-74 years and lower for ages 10-39 years and over 75 years. Time trends also varied with age. The strongest trend over time by age group was the increase among the 20-34 age group, from no significant northern excess mortality in 1965-95 to 22.2% (18.7% to 26.0%) in 1996-2008. Overall, the north experienced a fifth more premature (<75 years) deaths than the south, which was significant: a pattern that changed only by a slight increase between 1965 and 2008. Conclusion Inequalities in all cause mortality in the north-south divide were severe and persistent over the four decades from 1965 to 2008. Males were affected more than females, and the variation across age groups was substantial. The increase in this inequality from 2000 to 2008 was notable and occurred despite the public policy emphasis in England over this period on reducing inequalities in health. PMID:21325004

Red blood cell distribution width: biomarker for red cell dysfunction and critical illness outcome?

PubMed Central

Said, Ahmed S.; Spinella, Philip C.; Hartman, Mary E.; Steffen, Katherine M.; Jackups, Ronald; Holubkov, Richard; Wallendorf, Mike; Doctor, Allan

2016-01-01

Objective Red blood cell distribution width (RDW) is reported to be an independent predictor of outcome in adults with a variety of conditions. We sought to determine if RDW is associated with morbidity or mortality in critically ill children. Design Retrospective observational study. Setting Tertiary pediatric intensive care unit. Patients All admissions to Saint Louis Children’s Hospital Pediatric Intensive Care Unit between 1/1/2005 and 12/31/2012. Interventions We collected demographics, laboratory values, hospitalization characteristics and outcomes. We calculated the relative change in RDW (R-RDW) from admission (A-RDW) to the highest RDW during the first 7 days of hospitalization. Our primary outcome was ICU mortality or use of ECMO as a composite. Secondary outcomes were ICU- and ventilator-free days. Measurements and main results We identified 3,913 eligible subjects with an estimated mortality (by PIM2) of 2.94±9.25% and an actual ICU mortality of 2.91%. For the study cohort, A-RDW was 14.12±1.89% and R-RDW was +2.63±6.23%. On univariate analysis, both A-RDW and R-RDW correlated with mortality or use of ECMO (OR=1.19 [95% CI: 1.12–1.27] and OR=1.06 [95% CI: 1.04–1.08], respectively, p<0.001). After adjusting for confounding variables, including severity of illness, both A-RDW (OR=1.13, 95% CI 1.03–1.24) and R-RDW (OR=1.04, 95% CI 1.01–1.07) remained independently associated with ICU mortality or use of ECMO. A-RDW and R-RDW both weakly correlated with fewer ICU-free (r2=0.038) and ventilator-free days, (r2=0.05), (p<0.001). Conclusions Independent of illness severity in critically ill children, A-RDW is associated with ICU mortality and morbidity. These data suggest that RDW may be a biomarker for RBC injury that is of sufficient magnitude to influence critical illness outcome, possibly via oxygen delivery impairment. PMID:27832023

Health impact assessment of air pollution in Valladolid, Spain

PubMed Central

Cárdaba Arranz, Mario; Muñoz Moreno, María Fe; Armentia Medina, Alicia; Alonso Capitán, Margarita; Carreras Vaquer, Fernando; Almaraz Gómez, Ana

2014-01-01

Objective To estimate the attributable and targeted avoidable deaths (ADs; TADs) of outdoor air pollution by ambient particulate matter (PM10), PM2.5 and O3 according to specific WHO methodology. Design Health impact assessment. Setting City of Valladolid, Spain (around 300 000 residents). Data sources Demographics; mortality; pollutant concentrations collected 1999–2008. Main outcome measures Attributable fractions; ADs and TADs per year for 1999–2008. Results Higher TADs estimates (shown here) were obtained when assuming as ‘target’ concentrations WHO Air Quality Guidelines instead of Directive 2008/50/EC. ADs are considered relative to pollutant background levels. All-cause mortality associated to PM10 (all ages): 52 ADs (95% CI 39 to 64); 31 TADs (95% CI 24 to 39).All-cause mortality associated to PM10 (<5 years): 0 ADs (95% CI 0 to 1); 0 TADs (95% CI 0 to 1). All-cause mortality associated to PM2.5 (>30 years): 326 ADs (95% CI 217 to 422); 231 TADs (95% CI 153 to 301). Cardiopulmonary and lung cancer mortality associated to PM2.5 (>30 years): ▸ Cardiopulmonary: 186 ADs (95% CI 74 to 280); 94 TADs (95% CI 36 to 148). ▸ Lung cancer : 51 ADs (95% CI 21 to 73); 27 TADs (95% CI 10 to 41).All-cause, respiratory and cardiovascular mortality associated to O3 (all ages): ▸ All-cause: 52ADs (95% CI 25 to 77) ; 31 TADs (95% CI 15 to 45). ▸ Respiratory: 5ADs (95% CI −2 to 13) ; 3 TADs (95% CI −1 to 8). ▸ Cardiovascular: 30 ADs (95% CI 8 to 51) ; 17 TADs (95% CI 5 to 30). Negative estimates which should be read as zero were obtained when pollutant concentrations were below counterfactuals or assumed risk coefficients were below one. Conclusions Our estimates suggest a not negligible negative impact on mortality of outdoor air pollution. The implementation of WHO methodology provides critical information to distinguish an improvement range in air pollution control. PMID:25326212

Understanding the determinants of under-five child mortality in Uganda including the estimation of unobserved household and community effects using both frequentist and Bayesian survival analysis approaches.

PubMed

Nasejje, Justine B; Mwambi, Henry G; Achia, Thomas N O

2015-10-01

Infant and child mortality rates are among the health indicators of importance in a given community or country. It is the fourth millennium development goal that by 2015, all the United Nations member countries are expected to have reduced their infant and child mortality rates by two-thirds. Uganda is one of those countries in Sub-Saharan Africa with high infant and child mortality rates, therefore it is important to use sound statistical methods to determine which factors are strongly associated with child mortality which in turn will help inform the design of intervention strategies The Uganda Demographic Health Survey (UDHS) funded by USAID, UNFPA, UNICEF, Irish Aid and the United Kingdom government provides a data set which is rich in information on child mortality or survival. Survival analysis techniques are among the well-developed methods in Statistics for analysing time to event data. These methods were adopted in this paper to examine factors affecting under-five child mortality rates (UMR) in Uganda using the UDHS data for 2011 in R and STATA software. Results obtained by fitting the Cox-proportional hazard model with frailty effects and drawing inference using both the frequentists and Bayesian approaches at 5 % significance level, show evidence of the existence of unobserved heterogeneity at the household level but there was not enough evidence to conclude the existence of unobserved heterogeneity at the community level. Sex of the household head, sex of the child and number of births in the past one year were found to be significant. The results further suggest that over the period of 1990-2015, Uganda reduced its UMR by 52 % . Uganda has not achieved the MDG4 target but the 52 % reduction in the UMR is a move in the positive direction. Demographic factors (sex of the household head) and Biological determinants (sex of the child and number of births in the past one year) are strongly associated with high UMR. Heterogeneity or unobserved covariates were found to be significant at the household but insignificant at the community level.

Impact of coronary collaterals on in-hospital and 5-year mortality after ST-elevation myocardial infarction in the contemporary percutaneous coronary intervention era: a prospective observational study

PubMed Central

Hara, Masahiko; Sakata, Yasuhiko; Nakatani, Daisaku; Suna, Shinichiro; Nishino, Masami; Sato, Hiroshi; Kitamura, Tetsuhisa; Nanto, Shinsuke; Hori, Masatsugu; Komuro, Issei

2016-01-01

Objectives To evaluate the short-term and long-term prognostic impacts of acute phase coronary collaterals to occluded infarct-related arteries (IRA) after ST-elevation myocardial infarction (STEMI) in the percutaneous coronary intervention (PCI) era. Design A prospective observational study. Setting Osaka Acute Coronary Insufficiency Study (OACIS) in Japan. Participants 3340 patients with STEMI from the OACIS database who were admitted to hospitals within 24 hours from the onset and who had a completely occluded IRA. Interventions Patients were divided into 4 groups according to the Rentrop collateral score (RCS) by angiography on admission (RCS-0, no visible collaterals; RCS-1, collaterals without IRA filling; RCS-2, collaterals with partial IRA filling; and RCS-3, collaterals with complete IRA filling). Primary outcome measures In-hospital and 5-year mortality. Results Patients with RCS-0/3 were older than patients with RCS-1/2, and the prevalence of previous myocardial infarction was highest in patients with RCS-3. Median peak creatinine phosphokinase levels decreased as RCS increases (p<0.001), suggesting the acute cardioprotective effects of collaterals. Although RCS-1 and RCS-2 collaterals were associated with better in-hospital mortality (adjusted OR 0.48, p=0.046 and 0.38, p=0.010 for RCS-1 and RCS-2, respectively) and 5-year mortality (adjusted HR 0.53, p=0.004 and 0.46, p<0.001 for RCS-1 and RCS-2, respectively) as compared with R-0, presence of RCS-3 collaterals was not associated with improved in-hospital (adjusted OR 1.35, p=0.331) and 5-year mortality (adjusted HR 0.98, p=0.920), possibly because worse clinical profiles in patients with RCS-3 may mask mortality benefit of coronary collaterals. Conclusions Presence of acute phase coronary collaterals such as RCS-1 and RCS-2 were associated with better in-hospital and 5-year mortality after STEMI in the contemporary PCI era. PMID:27412101

Association Between Hospitals Caring for a Disproportionately High Percentage of Minority Trauma Patients and Increased Mortality

PubMed Central

Haider, Adil H.; Ong’uti, Sharon; Efron, David T.; Oyetunji, Tolulope A.; Crandall, Marie L.; Scott, Valerie K.; Haut, Elliott R.; Schneider, Eric B.; Powe, Neil R.; Cooper, Lisa A.; Cornwell, Edward E.

2012-01-01

Objective To determine whether there is an increased odds of mortality among trauma patients treated at hospitals with higher proportions of minority patients (ie, black and Hispanic patients combined). Design Hospitals were categorized on the basis of the percentage of minority patients admitted with trauma. The adjusted odds of in-hospital mortality were compared between hospitals with less than 25% of patients who were minorities (the reference group) and hospitals with 25% to 50% of patients who were minorities and hospitals with more than 50% of patients who were minorities. Multivariate logistic regression (with generalized linear modeling and a cluster-correlated robust estimate of variance) was used to control for multiple patient and injury severity characteristics. Setting A total of 434 hospitals in the National Trauma Data Bank. Participants Patients aged 18 to 64 years whose medical records were included in the National Trauma Data Bank for the years 2007 and 2008 with an Injury Severity Score of 9 or greater and who were white, black, or Hispanic. Main Outcome Measures Crude mortality and adjusted odds of in-hospital mortality. Results A total of 311 568 patients were examined. Hospitals in which the percentage of minority patients was more than 50% also had younger patients, fewer female patients, more patients with penetrating trauma, and the highest crude mortality. After adjustment for potential confounders, patients treated at hospitals in which the percentage of minority patients was 25% to 50% and at hospitals in which the percentage of minority patients was more than 50% demonstrated increased odds of death (adjusted odds ratio, 1.16 [95% confidence interval, 1.01–1.34] and adjusted odds ratio, 1.37 [95% confidence interval, 1.16–1.61], respectively), compared with the reference group. This disparity increased further on subset analysis of patients with a blunt injury. Uninsured patients had significantly increased odds of mortality within all 3 hospital groups. Conclusions Patients treated at hospitals with higher proportions of minority trauma patients have increased odds of dying, even after adjusting for potential confounders. Differences in outcomes between trauma hospitals may partly explain racial disparities. PMID:21930976

The effect of umbilical cord cleansing with chlorhexidine on omphalitis and neonatal mortality in community settings in developing countries: a meta-analysis

PubMed Central

2013-01-01

Background There is an increased risk of serious neonatal infection arising through exposure of the umbilical cord to invasive pathogen in home and facility births where hygienic practices are difficult to achieve. The World Health Organization currently recommends ‘dry cord care’ because of insufficient data in favor of or against topical application of an antiseptic. The primary objective of this meta-analysis is to evaluate the effects of application of chlorhexidine (CHX) to the umbilical cord to children born in low income countries on cord infection (omphalitis) and neonatal mortality. Standardized guidelines of Child Health Epidemiology Reference Group (CHERG) were followed to generate estimates of effectiveness of topical chlorhexidine application to umbilical cord for prevention of sepsis specific mortality, for inclusion in the Lives Saved Tool (LiST). Methods Systematic review and meta-analysis. Data sources included Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, CINHAL and WHO international clinical trials registry. Only randomized trials were included. Studies of children in hospital settings were excluded. The comparison group received no application to the umbilical cord (dry cord care), no intervention, or a non-CHX intervention. Primary outcomes were omphalitis and all-cause neonatal mortality. Results There were three cluster-randomised community trials (total participants 54,624) conducted in Nepal, Bangladesh and Pakistan that assessed impact of CHX application to the newborn umbilical cord for prevention of cord infection and mortality. Application of any CHX to the umbilical cord of the newborn led to a 23% reduction in all-cause neonatal mortality in the intervention group compared to control [RR 0.77, 95 % CI 0.63, 0.94; random effects model, I2=50 %]. The reduction in omphalitis ranged from 27 % to 56 % compared to control group depending on severity of infection. Based on CHERG rules, effect size for all-cause mortality was used for inclusion to LiST model as a proxy for sepsis specific mortality. Conclusions Application of CHX to newborn umbilical cord can significantly reduce incidence of umbilical cord infection and all-cause mortality among home births in community settings. This inexpensive and simple intervention can save a significant number of newborn lives in developing countries. PMID:24564621

A New Look at Care in Pregnancy: Simple, Effective Interventions for Neglected Populations.

PubMed

Hodgins, Stephen; Tielsch, James; Rankin, Kristen; Robinson, Amber; Kearns, Annie; Caglia, Jacquelyn

2016-01-01

Although this is beginning to change, the content of antenatal care has been relatively neglected in safe-motherhood program efforts. This appears in part to be due to an unwarranted belief that interventions over this period have far less impact than those provided around the time of birth. In this par, we review available evidence for 21 interventions potentially deliverable during pregnancy at high coverage to neglected populations in low income countries, with regard to effectiveness in reducing risk of: maternal mortality, newborn mortality, stillbirth, prematurity and intrauterine growth restriction. Selection was restricted to interventions that can be provided by non-professional health auxiliaries and not requiring laboratory support. In this narrative review, we included relevant Cochrane and other systematic reviews and did comprehensive bibliographic searches. Inclusion criteria varied by intervention; where available randomized controlled trial evidence was insufficient, observational study evidence was considered. For each intervention we focused on overall contribution to our outcomes of interest, across varying epidemiologies. In the aggregate, achieving high effective coverage for this set of interventions would very substantially reduce risk for our outcomes of interest and reduce outcome inequities. Certain specific interventions, if pushed to high coverage have significant potential impact across many settings. For example, reliable detection of pre-eclampsia followed by timely delivery could prevent up to ¼ of newborn and stillbirth deaths and over 90% of maternal eclampsia/pre-eclampsia deaths. Other interventions have potent effects in specific settings: in areas of high P falciparum burden, systematic use of insecticide-treated nets and/or intermittent presumptive therapy in pregnancy could reduce maternal mortality by up to 10%, newborn mortality by up to 20%, and stillbirths by up to 25-30%. Behavioral interventions targeting practices at birth and in the hours that follow can have substantial impact in settings where many births happen at home: in such circumstances early initiation of breastfeeding can reduce risk of newborn death by up to 20%; good thermal care practices can reduce mortality risk by a similar order of magnitude. Simple interventions delivered during pregnancy have considerable potential impact on important mortality outcomes. More programmatic effort is warranted to ensure high effective coverage.

A New Clinicobiological Scoring System for the Prediction of Infection-Related Mortality and Survival after Allogeneic Hematopoietic Stem Cell Transplantation.

PubMed

Forcina, Alessandra; Rancoita, Paola M V; Marcatti, Magda; Greco, Raffaella; Lupo-Stanghellini, Maria Teresa; Carrabba, Matteo; Marasco, Vincenzo; Di Serio, Clelia; Bernardi, Massimo; Peccatori, Jacopo; Corti, Consuelo; Bondanza, Attilio; Ciceri, Fabio

2017-12-01

Infection-related mortality (IRM) is a substantial component of nonrelapse mortality (NRM) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). No scores have been developed to predict IRM before transplantation. Pretransplantation clinical and biochemical data were collected from a study cohort of 607 adult patients undergoing allo-HSCT between January 2009 and February 2017. In a training set of 273 patients, multivariate analysis revealed that age >60 years (P = .003), cytomegalovirus host/donor serostatus different from negative/negative (P < .001), pretransplantation IgA level <1.11 g/L (P = .004), and pretransplantation IgM level <.305 g/L (P = .028) were independent predictors of increased IRM. Based on these results, we developed and subsequently validated a 3-tiered weighted prognostic index for IRM in a retrospective set of patients (n = 219) and a prospective set of patients (n = 115). Patients were assigned to 3 different IRM risk classes based on this index score. The score significantly predicted IRM in the training set, retrospective validation set, and prospective validation set (P < .001, .044, and .011, respectively). In the training set, 100-day IRM was 5% for the low-risk group, 11% for the intermediate-riak group, and 16% for the high-risk groups. In the retrospective validation set, the respective 100-day IRM values were 7%, 17%, and 28%, and in the prospective set, they were 0%, 5%, and 7%. This score predicted also overall survival (P < .001 in the training set, P < 041 in the retrospective validation set, and P < .023 in the prospective validation set). Because pretransplantation levels of IgA/IgM can be modulated by the supplementation of enriched immunoglobulins, these results suggest the possibility of prophylactic interventional studies to improve transplantation outcomes. Copyright © 2017 The American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.

Quantification of HDL Proteins, Cardiac Events, and Mortality in Patients with Type 2 Diabetes on Hemodialysis

PubMed Central

Kopecky, Chantal; Genser, Bernd; Drechsler, Christiane; Krane, Vera; Kaltenecker, Christopher C.; Hengstschläger, Markus; März, Winfried; Wanner, Christoph; Säemann, Marcus D.

2015-01-01

Background and objectives Impairment of HDL function has been associated with cardiovascular events in patients with kidney failure. The protein composition of HDLs is altered in these patients, presumably compromising the cardioprotective effects of HDLs. This post hoc study assessed the relation of distinct HDL-bound proteins with cardiovascular outcomes in a dialysis population. Design, setting, participants, & measurements The concentrations of HDL-associated serum amyloid A (SAA) and surfactant protein B (SP-B) were measured in 1152 patients with type 2 diabetes mellitus on hemodialysis participating in The German Diabetes Dialysis Study who were randomly assigned to double-blind treatment of 20 mg atorvastatin daily or matching placebo. The association of SAA(HDL) and SP-B(HDL) with cardiovascular outcomes was assessed in multivariate regression models adjusted for known clinical risk factors. Results High concentrations of SAA(HDL) were significantly and positively associated with the risk of cardiac events (hazard ratio per 1 SD higher, 1.09; 95% confidence interval, 1.01 to 1.19). High concentrations of SP-B(HDL) were significantly associated with all-cause mortality (hazard ratio per 1 SD higher, 1.10; 95% confidence interval, 1.02 to 1.19). Adjustment for HDL cholesterol did not affect these associations. Conclusions In patients with diabetes on hemodialysis, SAA(HDL) and SP-B(HDL) were related to cardiac events and all-cause mortality, respectively, and they were independent of HDL cholesterol. These findings indicate that a remodeling of the HDL proteome was associated with a higher risk for cardiovascular events and mortality in patients with ESRD. PMID:25424990

Dialyzer Reuse with Peracetic Acid Does Not Impact Patient Mortality

PubMed Central

Bond, T. Christopher; Krishnan, Mahesh; Wilson, Steven M.; Mayne, Tracy

2011-01-01

Summary Background and objectives Numerous studies have shown the overall benefits of dialysis filter reuse, including superior biocompatibility and decreased nonbiodegradable medical waste generation, without increased risk of mortality. A recent study reported that dialyzer reprocessing was associated with decreased patient survival; however, it did not control for sources of potential confounding. We sought to determine the effect of dialyzer reprocessing with peracetic acid on patient mortality using contemporary outcomes data and rigorous analytical techniques. Design, setting, participants, & measurements We conducted a series of analyses of hemodialysis patients examining the effects of reuse on mortality using three techniques to control for potential confounding: instrumental variables, propensity-score matching, and time-dependent survival analysis. Results In the instrumental variables analysis, patients at high reuse centers had 16.2 versus 15.9 deaths/100 patient-years in nonreuse centers. In the propensity-score matched analysis, patients with reuse had a lower death rate per 100 patient-years than those without reuse (15.2 versus 15.5). The risk ratios for the time-dependent survival analyses were 0.993 (per percent of sessions with reuse) and 0.995 (per unit of last reuse), respectively. Over the study period, 13.8 million dialyzers were saved, representing 10,000 metric tons of medical waste. Conclusions Despite the large sample size, powered to detect miniscule effects, neither the instrumental variables nor propensity-matched analyses were statistically significant. The time-dependent survival analysis showed a protective effect of reuse. These data are consistent with the preponderance of evidence showing reuse limits medical waste generation without negatively affecting clinical outcomes. PMID:21566107

Effect of cardiologist care on 6-month outcomes in patients discharged with heart failure: results from an observational study based on administrative data

PubMed Central

Avaldi, Vera Maria; Urbinati, Stefano; Molinazzi, Dario; Descovich, Carlo; Campagna, Anselmo; Taglioni, Martina; Fioritti, Angelo

2017-01-01

Objectives To evaluate the effect of cardiologist care on adherence to evidence-based secondary prevention medications, mortality and readmission within 6 months of discharge in patients with heart failure (HF). Design Retrospective observational study based on administrative data. Setting Local Healthcare Authority (LHA) of Bologna, one of the largest LHAs of Italy with ~870 000 inhabitants. Participants All patients residing in the LHA of Bologna discharged from hospital with a diagnosis of HF between 1 January 2015 and 31 December 2015. Primary and secondary outcome measures Multivariable regression analysis was used to assess the association of inpatient and outpatient cardiologist care with adherence to evidence-based medications, all-cause mortality and hospital readmission (including emergency room visits) within 6 months of discharge. Results The study population included 2650 patients (mean age 82.3 years). 340 (12.8%) patients were discharged from cardiology wards, while 635 (24.0%) were seen by a cardiologist during follow-up. Inpatient and outpatient cardiologist care was associated with an increased likelihood of adherence to ACE inhibitors/angiotensin receptor blockers (ACEIs/ARBs), β-blockers and aldosterone antagonists after discharge. The risk of mortality was significantly lower among patients adherent to ACEIs/ARBs and/or β-blockers (–53% and –28%, respectively); the risk of hospital readmission was significantly lower among patients adherent to ACEIs/ARBs (–28%). Conclusions Compared with non-specialist care, cardiologist care improves patient adherence to evidence-based medications and might thus favourably affect mortality and readmission following HF. PMID:29101146

Early outcome of early-goal directed therapy for patients with sepsis or septic shock: a systematic review and meta-analysis of randomized controlled trials.

PubMed

Chen, Xiaofan; Zhu, Weifeng; Tan, Jing; Nie, Heyun; Liu, Liangming; Yan, Dongmei; Zhou, Xu; Sun, Xin

2017-04-18

Various trials and meta-analyses have reported conflicting results concerning the application of early goal-directed therapy (EGDT) for sepsis and septic shock. The aim of this study was to update the evidence by performing a systematic review and meta-analysis. Multiple databases were searched from initial through August, 2016 for randomized controlled trials (RCTs) which investigated the associations between the use of EGDT and mortality in patients with sepsis or septic shock. Meta-analysis was performed using random-effects model and heterogeneity was examined through subgroup analyses. The primary outcome of interest was patient all-cause mortality including hospital or ICU mortality. Seventeen RCTs including 6207 participants with 3234 in the EGDT group and 2973 in the control group were eligible for this study. Meta-analysis showed that EGDT did not significantly reduce hospital or intensive care unit (ICU) mortality (relative risk [RR] 0.89, 95% CI 0.78 to 1.02) compared with control group for patients with sepsis or septic shock. The findings of subgroup analyses stratified by study region, number of research center, year of enrollment, clinical setting, sample size, timing of EGDT almost remained constant with that of the primary analysis. Our findings provide evidence that EGDT offers neutral survival effects for patients with sepsis or septic shock. Further meta-analyses based on larger well-designed RCTs or individual patient data meta-analysis are required to explore the survival benefits of EDGT in patients with sepsis or septic shock.

An inert pesticide adjuvant synergizes viral pathogenicity and mortality in honey bee larvae

USDA-ARS?s Scientific Manuscript database

Honey bees are highly valued for their pollination services in agricultural settings, and recent declines in managed populations have caused concern. Colony losses following a major pollination event in the United States, almond pollination, have been characterized by brood mortality with specific s...

Lagged PM2.5 effects in mortality time series: Critical impact of covariate model

EPA Science Inventory

The two most common approaches to modeling the effects of air pollution on mortality are the Harvard and the Johns Hopkins (NMMAPS) approaches. These two approaches, which use different sets of covariates, result in dissimilar estimates of the effect of lagged fine particulate ma...

Mortality of trees in loblolly pine plantations

Treesearch

Boris Zeide; Yujia Zhang

2006-01-01

The annual probability of mortality for planted loblolly pine (Pinus taeda L.) trees was estimated using a set of permanent plots covering the entire native range of the species. The recorded causes of death were infestation by the southern pine beetle (Dendroctonus frontalis Zimmermann) and other insects, lightning, and unknown...

50 CFR 229.7 - Monitoring of incidental mortalities and serious injuries.

Code of Federal Regulations, 2011 CFR

2011-10-01

... incidental mortality and serious injury of marine mammals during the course of commercial fishing operations...) Identify changes in fishing methods or technology that may increase or decrease incidental mortality and... fishing trips. (2) After being notified by NMFS, or by a designated contractor providing observer services...

50 CFR 229.7 - Monitoring of incidental mortalities and serious injuries.

Code of Federal Regulations, 2013 CFR

2013-10-01

... incidental mortality and serious injury of marine mammals during the course of commercial fishing operations...) Identify changes in fishing methods or technology that may increase or decrease incidental mortality and... fishing trips. (2) After being notified by NMFS, or by a designated contractor providing observer services...

50 CFR 229.7 - Monitoring of incidental mortalities and serious injuries.

Code of Federal Regulations, 2014 CFR

2014-10-01

... incidental mortality and serious injury of marine mammals during the course of commercial fishing operations...) Identify changes in fishing methods or technology that may increase or decrease incidental mortality and... fishing trips. (2) After being notified by NMFS, or by a designated contractor providing observer services...

50 CFR 229.7 - Monitoring of incidental mortalities and serious injuries.

Code of Federal Regulations, 2012 CFR

2012-10-01

... incidental mortality and serious injury of marine mammals during the course of commercial fishing operations...) Identify changes in fishing methods or technology that may increase or decrease incidental mortality and... fishing trips. (2) After being notified by NMFS, or by a designated contractor providing observer services...

Responses by pacific halibut to air exposure: Lack of correspondence among plasma constituents and mortality

USGS Publications Warehouse

Davis, M.W.; Schreck, C.B.

2005-01-01

Age-1 and age-2 Pacific halibut Hippoglossus stenolepis were exposed to a range of times in air (0-60 min) and air temperatures (10??C or 16??C) that simulated conditions on deck after capture to test for correspondence among responses in plasma constituents and mortality. Pacific halibut mortality generally did not correspond with cortisol, glucose, sodium, and potassium since the maximum observed plasma concentrations were reached after exposure to 30 min in air, while significant mortality occurred only after exposure to 40 min in air for age-1 fish and 60 min in air for age-2 fish. Predicting mortality in discarded Pacific halibut using these plasma constituents does not appear to be feasible. Lactate concentrations corresponded with mortality in age-1 fish exposed to 16??C and may be useful predictors of discard mortality under a limited set of fishing conditions.

Maternal mortality as a Millennium Development Goal of the United Nations: a systematic assessment and analysis of available data in threshold countries using Indonesia as example

PubMed Central

Reinke, Evelyn; Supriyatiningsih; Haier, Jörg

2017-01-01

Background In 2015 the proposed period ended for achieving the Millennium Development Goals (MDG) of the United Nations targeting to lower maternal mortality worldwide by ~ 75%. 99% of these cases appear in developing and threshold countries; but reports mostly rely on incomplete or unrepresentative data. Using Indonesia as example, currently available data sets for maternal mortality were systematically reviewed. Methods Besides analysis of international and national data resources, a systematic review was carried out according to Cochrane methodology to identify all data and assessments regarding maternal mortality. Results Overall, primary data on maternal mortality differed significantly and were hardly comparable. For 1990 results varied between 253/100 000 and 446/100 000. In 2013 data appeared more conclusive (140–199/100 000). An annual reduction rate (ARR) of –2.8% can be calculated. Conclusion Reported data quality of maternal mortality in Indonesia is very limited regarding comprehensive availability and methodology. This limitation appears to be of general importance for the targeted countries of the MDG. Primary data are rare, not uniformly obtained and not evaluated by comparable methods resulting in very limited comparability. Continuous small data set registration should have high priority for analysis of maternal health activities. PMID:28400953

Implications of Demographic Change for the Design of Retirement Programs.

ERIC Educational Resources Information Center

Biggs, John H.

1994-01-01

The influences that demographic changes may have on the design of private pension plans in the twenty-first century are examined. Major demographic factors to be considered include the aging of the population, declining mortality rate, potential for an even lower mortality rate, improved health for all ages and especially for older workers, and…

Post-operative morbidity and mortality of a cohort of steroid refractory acute severe ulcerative colitis: Nationwide multicenter study of the GETECCU ENEIDA Registry.

PubMed

Ordás, I; Domènech, E; Mañosa, M; García-Sánchez, V; Iglesias-Flores, E; Rodríguez-Moranta, F; Márquez, L; Merino, O; Fernández-Bañares, F; Gomollón, F; Vera, M; Gutiérrez, A; LLaó, J; Gisbert, J P; Aguas, M; Arias, L; Rodríguez-Lago, I; Muñoz, C; Alcaide, N; Calvet, X; Rodríguez, C; Montoro, M A; García, S; De Castro, M L; Piqueras, M; Pareja, L; Ribes, J; Panés, J; Esteve, M

2018-05-01

Despite the increased use of rescue medical therapies for steroid refractory acute severe ulcerative colitis, mortality related to this entity still remains high. We aimed to assess the mortality and morbidity related to colectomy and their predictive factors in steroid refractory acute severe ulcerative colitis, and to evaluate the changes in mortality rates, complications, indications of colectomy, and the use of rescue therapy over time. We performed a multicenter observational study of patients with steroid refractory acute severe ulcerative colitis requiring colectomy, admitted to 23 Spanish hospitals included in the ENEIDA registry (GETECCU) from 1989 to 2014. Independent predictive factors of mortality were assessed by binary logistic regression analysis. Mortality along the study was calculated using the age-standardized rate. During the study period, 429 patients underwent colectomy, presenting an overall mortality rate of 6.3% (range, 0-30%). The main causes of death were infections and post-operative complications. Independent predictive factors of mortality were: age ≥50 years (OR 23.34; 95% CI: 6.46-84.311; p < 0.0001), undergoing surgery in a secondary care hospital (OR 3.07; 95% CI: 1.01-9.35; p = 0.047), and in an emergency setting (OR 10.47; 95% CI: 1.26-86.55; p = 0.029). Neither the use of rescue medical treatment nor the type of surgical technique used (laparoscopy vs. open laparotomy) influenced mortality. The proportion of patients undergoing surgery in an emergency setting decreased over time (p < 0.0001), whereas the use of rescue medical therapy prior to colectomy progressively increased (p > 0.001). The mortality rate related to colectomy in steroid refractory acute severe ulcerative colitis varies greatly among hospitals, reinforcing the need for a continuous audit to achieve quality standards. The increasing use of rescue therapy is not associated with a worse outcome and may contribute to reducing emergency surgical interventions and improve outcomes.

A universal definition of ARDS: the PaO2/FiO2 ratio under a standard ventilatory setting--a prospective, multicenter validation study.

PubMed

Villar, Jesús; Pérez-Méndez, Lina; Blanco, Jesús; Añón, José Manuel; Blanch, Lluís; Belda, Javier; Santos-Bouza, Antonio; Fernández, Rosa Lidia; Kacmarek, Robert M

2013-04-01

The PaO2/FiO2 is an integral part of the assessment of patients with acute respiratory distress syndrome (ARDS). The American-European Consensus Conference definition does not mandate any standardization procedure. We hypothesized that the use of PaO2/FiO2 calculated under a standard ventilatory setting within 24 h of ARDS diagnosis allows a more clinically relevant ARDS classification. We studied 452 ARDS patients enrolled prospectively in two independent, multicenter cohorts treated with protective mechanical ventilation. At the time of ARDS diagnosis, patients had a PaO2/FiO2 ≤ 200. In the derivation cohort (n = 170), we measured PaO2/FiO2 with two levels of positive end-expiratory pressure (PEEP) (≥ 5 and ≥ 10 cmH2O) and two levels of FiO2 (≥ 0.5 and 1.0) at ARDS onset and 24 h later. Dependent upon PaO2 response, patients were reclassified into three groups: mild (PaO2/FiO2 > 200), moderate (PaO2/FiO2 101-200), and severe (PaO2/FiO2 ≤ 100) ARDS. The primary outcome measure was ICU mortality. The standard ventilatory setting that reached the highest significance difference in mortality among these categories was tested in a separate cohort (n = 282). The only standard ventilatory setting that identified the three PaO2/FiO2 risk categories in the derivation cohort was PEEP ≥ 10 cmH2O and FiO2 ≥ 0.5 at 24 h after ARDS onset (p = 0.0001). Using this ventilatory setting, patients in the validation cohort were reclassified as having mild ARDS (n = 47, mortality 17 %), moderate ARDS (n = 149, mortality 40.9 %), and severe ARDS (n = 86, mortality 58.1 %) (p = 0.00001). Our method for assessing PaO2/FiO2 greatly improved risk stratification of ARDS and could be used for enrolling appropriate ARDS patients into therapeutic clinical trials.

Animal and plant protein intake and all-cause and cause-specific mortality: results from two prospective US cohort studies

PubMed Central

Song, Mingyang; Fung, Teresa T.; Hu, Frank B.; Willett, Walter C.; Longo, Valter; Chan, Andrew T.; Giovannucci, Edward L.

2016-01-01

Importance Defining what represents a macronutritionally balanced diet remains an open question and a high priority in nutrition research. Although the amount of protein may have specific effects, from a broader dietary perspective, the choice of protein sources will inevitably influence other components of diet and may be a critical determinant for the health outcome. Objective To examine the associations of animal and plant protein intake with risk of mortality Design Prospective cohort study Setting Health professionals in the United States Participants 85,013 women and 46,329 men from the Nurses’ Health Study (1980–2012) and Health Professionals Follow-up Study (1986–2012) Exposure Animal and plant protein intake as assessed by regularly updated validated food questionnaires Main outcomes and measures Hazard ratio (HR) of mortality Results The median intake, as assessed by percentage of energy, was 14% for animal protein (5th–95th percentile: 9–22%) and 4% for plant protein (2–6%). After adjusting for major lifestyle and dietary risk factors, animal protein intake was weakly associated with higher mortality, particularly cardiovascular mortality (HR=1.08 per 10%-energy increment, 95% confidence interval [CI], 1.01–1.16, Ptrend=0.04), whereas plant protein was associated with lower mortality (HR=0.90 per 3%-energy increment, 95% CI, 0.86–0.95, Ptrend<0.001). These associations were confined to participants with at least one of the unhealthy lifestyle factors based on smoking, heavy alcohol drinking, overweight or obesity, and physical inactivity, but not evident among those without any of these risk factors (Pinteraction<0.001). Replacing animal protein of various origins with plant protein was associated with lower mortality. In particular, the HRs (95% CI) of all-cause mortality were 0.66 (0.59–0.75) when 3% of energy from plant protein was substituted for an equivalent amount of protein from processed red meat, 0.88 (0.84–0.92) from unprocessed red meat, and 0.81 (0.75–0.88) from eggs. Conclusions and relevance Higher animal protein intake was positively, whereas plant protein was inversely, associated with mortality, especially among individuals with at least one lifestyle risk factors. Substitution of plant protein for animal protein, especially from processed red meat, was associated with lower mortality, suggesting the importance of protein source. PMID:27479196

Coffee Drinking and Mortality in Ten European Countries – the EPIC Study

PubMed Central

Gunter, Marc J.; Murphy, Neil; Cross, Amanda J.; Dossus, Laure; Dartois, Laureen; Fagherazzi, Guy; Kaaks, Rudolf; Kühn, Tilman; Boeing, Heiner; Aleksandrova, Krasimira; Tjønneland, Anne; Olsen, Anja; Overvad, Kim; Larsen, Sofus Christian; Cornejo, Maria Luisa Redondo; Agudo, Antonio; Pérez, María José Sánchez; Altzibar, Jone M; Navarro, Carmen; Ardanaz, Eva; Khaw, Kay-Tee; Butterworth, Adam; Bradbury, Kathryn E; Trichopoulou, Antonia; Lagiou, Pagona; Trichopoulos, Dimitrios; Palli, Domenico; Grioni, Sara; Vineis, Paolo; Panico, Salvatore; Tumino, Rosario; Bueno-de-Mesquita, Bas; Siersema, Peter; Leenders, Max; Beulens, Joline WJ; Uiterwaal, Cuno U; Wallström, Peter; Nilsson, Lena Maria; Landberg, Rikard; Weiderpass, Elisabete; Skeie, Guri; Braaten, Tonje; Brennan, Paul; Licaj, Idlir; Muller, David C; Sinha, Rashmi; Wareham, Nick; Riboli, Elio

2018-01-01

Background How coffee consumption relates to mortality in diverse European populations, with variable coffee preparation methods and customs, is unclear. Objectives To examine whether coffee consumption is associated with all-cause and cause-specific mortality in men and women. Design Prospective cohort study. Setting Ten European countries. Participants A total of 521,330 men and women enrolled in the European Prospective Investigation into Cancer and Nutrition (EPIC). Main outcome measure Multivariable hazard ratios (HRs) and 95% confidence intervals(CIs) estimated using multivariable Cox proportional hazards models. The association of coffee with serum biomarkers of liver function, inflammation, and metabolic health was evaluated in the EPIC Biomarkers sub-cohort (n=14,800). Results During a mean follow-up of 16.4 years, 41,693 deaths occurred. Compared with non-consumers, participants in the highest quartile of coffee consumption experienced statistically significant lower all-cause mortality (Men: HR=0.88, 95%CI: 0.82–0.95; P-trend<0.001; Women: HR=0.93, 95%CI: 0.87–0.98; P-trend=0.009). These findings did not vary significantly by country. Inverse associations were observed for digestive disease mortality for men (HR=0.41, 95%CI: 0.32–0.54; P-trend<0.0001) and women (HR=0.60, 95%CI: 0.46–0.78; P-trend<0.0001). Among women only, there was a statistically significant inverse association between coffee and circulatory disease mortality, (HR=0.78, 95%CI: 0.68–0.90; P-trend<0.001), cerebrovascular disease mortality (HR=0.70, 95%CI: 0.55–0.90; P-trend=0.002), and a positive association between coffee and ovarian cancer mortality (HR 1.12, 95% CI: 1.02–1.23 P-trend 0.001). In the EPIC-biomarkers sub-cohort, higher coffee consumption was associated with lower serum alkaline phosphatase, alanine transaminase, aspartate transaminase, and C-reactive protein. Limitation Reverse causality may have led to spurious findings; however, results did not differ following exclusion of participants who died within 8-years of baseline. The study is also limited by a single assessment of coffee drinking habits at baseline. Conclusions These results confirm prior findings on the reduced risk of mortality associated with coffee drinking but additionally show that this relationship does not vary by country where coffee preparation and drinking habits may differ. The study also reports novel inverse relationships between coffee drinking and digestive disease mortality. PMID:28693038

Predicting discharge mortality after acute ischemic stroke using balanced data.

PubMed

Ho, King Chung; Speier, William; El-Saden, Suzie; Liebeskind, David S; Saver, Jeffery L; Bui, Alex A T; Arnold, Corey W

2014-01-01

Several models have been developed to predict stroke outcomes (e.g., stroke mortality, patient dependence, etc.) in recent decades. However, there is little discussion regarding the problem of between-class imbalance in stroke datasets, which leads to prediction bias and decreased performance. In this paper, we demonstrate the use of the Synthetic Minority Over-sampling Technique to overcome such problems. We also compare state of the art machine learning methods and construct a six-variable support vector machine (SVM) model to predict stroke mortality at discharge. Finally, we discuss how the identification of a reduced feature set allowed us to identify additional cases in our research database for validation testing. Our classifier achieved a c-statistic of 0.865 on the cross-validated dataset, demonstrating good classification performance using a reduced set of variables.

Mortality in HIV-Infected Alcohol and Drug Users in St. Petersburg, Russia

PubMed Central

Fairbairn, Nadia S.; Walley, Alexander Y.; Cheng, Debbie M.; Quinn, Emily; Bridden, Carly; Chaisson, Christine; Blokhina, Elena; Lioznov, Dmitry; Krupitsky, Evgeny; Raj, Anita; Samet, Jeffrey H.

2016-01-01

In Russia, up to half of premature deaths are attributed to hazardous drinking. The respective roles of alcohol and drug use in premature death among people with HIV in Russia have not been described. Criminalization and stigmatization of substance use in Russia may also contribute to mortality. We explored whether alcohol, drug use and risk environment factors are associated with short-term mortality in HIV-infected Russians who use substances. Secondary analyses were conducted using prospective data collected at baseline, 6 and 12-months from HIV-infected people who use substances recruited between 2007–2010 from addiction and HIV care settings in a single urban setting of St. Petersburg, Russia. We used Cox proportional hazards models to explore associations between 30-day alcohol hazardous drinking, injection drug use, polysubstance use and environmental risk exposures (i.e. past incarceration, police involvement, selling sex, and HIV stigma) with mortality. Among 700 participants, 59% were male and the mean age was 30 years. There were 40 deaths after a median follow-up of 12 months (crude mortality rate 5.9 per 100 person-years). In adjusted analyses, 30-day NIAAA hazardous drinking was significantly associated with mortality compared to no drinking [adjusted Hazard Ratio (aHR) 2.60, 95% Confidence Interval (CI): 1.24–5.44] but moderate drinking was not (aHR 0.95, 95% CI: 0.35–2.59). No other factors were significantly associated with mortality. The high rates of short-term mortality and the strong association with hazardous drinking suggest a need to integrate evidence-based alcohol interventions into treatment strategies for HIV-infected Russians. PMID:27898683

Pneumonia Mortality in Children Aged <5 Years in 56 Countries: A Retrospective Analysis of Trends from 1960 to 2012.

PubMed

Wu, Jie; Yang, Shigui; Cao, Qing; Ding, Cheng; Cui, Yuanxia; Zhou, Yuqing; Li, Yiping; Deng, Min; Wang, Chencheng; Xu, Kaijin; Ruan, Bing; Li, Lanjuan

2017-10-30

Pneumonia is now the second leading cause of death for children aged <5 years worldwide. However, analyses of the long-term evolution of under-5 mortality from pneumonia are still scarce in the literature. We aimed to explore long-term trends of under-5 mortality from pneumonia in 56 countries from 1960 to 2012. Data on under-5 mortality from pneumonia were extracted from the World Health Organization mortality database. Long-term trends were assessed for 56 countries and for 4 national income transition groups. We also used joinpoint regression analysis to detect distinct period segments of long-term trends and estimate the annual percent of changes of each period segment. The average mortality rate from pneumonia for children aged 0-4 years in 56 countries declined from 163.0 per 100000 children (95% confidence interval [CI], 119.4 to 212.8) in 1960 to 9.9 per 100000 children (95% CI, 6.4 to 13.4) in 2012, with an average annual percent of change of -5.6% (95% CI, -7.2% to -3.9%). The temporal trends of childhood mortality were different between national income transition groups. Our findings suggest a striking overall downward trend in under-5 mortality from pneumonia between 1960 and 2012. However, the rate and absolute terms of decline differ by national income transition group. These variable patterns between national income transition groups may inform further intervention setting and priority setting. © The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.

A review of cultural influence on maternal mortality in the developing world.

PubMed

Evans, Emily C

2013-05-01

identify research examining the effect of culture on maternal mortality rates. literature review of CINAHL, Cochrane, PsychInfo, OVID Medline and Web of Science databases. developing countries with typically higher rates of maternal mortality. women, birth attendants, family members, nurse midwives, health-care workers, and community members. reviews, qualitative and mixed-methods research have identified components of culture that have a direct impact on maternal mortality. Examples of culture are given in the text and categorised according to the way in which they impact maternal mortality. cultural customs, practices, beliefs and values profoundly influence women's behaviours during the perinatal period and in some cases increase the likelihood of maternal death in childbirth. The four ways in which culture may increase MMR are as follows: directly harmful acts, inaction, use of care and social status. understanding the specifics of how the culture surrounding childbirth contributes to maternal mortality can assist nurses, midwives and other health-care workers in providing culturally competent care and designing effective programs to help decrease MMR, especially in the developing world. Interventions designed without accounting for these cultural factors are likely to be less effective in reducing maternal mortality. Copyright © 2012 Elsevier Ltd. All rights reserved.

Community based retrospective study of sex in infant mortality in India

PubMed Central

Khanna, R; Kumar, A; Vaghela, J F; Sreenivas, V; Puliyel, J M

2003-01-01

Objective To determine whether the imbalance in the sex ratio in India can be explained by less favourable treatment of girls in infancy. Design Analysis of results of verbal autopsy reports over a five year period. Setting Community health project in urban India. Main outcome measures Deaths from all causes in infants aged less than 1 year. Results The sex ratio at birth was 869 females per 1000 males. The mean infant mortality was 1.3 times higher in females than in males (72 v 55 per 1000). Diarrhoea was responsible for 22% of deaths overall, though twice as many girls died from diarrhoea. There were no significant differences in the numbers of deaths from causes such as birth asphyxia, septicaemia, prematurity, and congenital anomalies. In 10% of deaths there was no preceding illness and no satisfactory cause was found. Three out of every four such deaths were in girls. Conclusions The excess number of unexplained deaths and deaths due to treatable conditions such as diarrhoeal disease in girls may be because girls are regarded and treated less favourably in India. PMID:12869451

Corticosteroids for severe influenza pneumonia: A critical appraisal

PubMed Central

Nedel, Wagner Luis; Nora, David Garcia; Salluh, Jorge Ibrain Figueira; Lisboa, Thiago; Póvoa, Pedro

2016-01-01

Influenza pneumonia is associated with high number of severe cases requiring hospital and intensive care unit (ICU) admissions with high mortality. Systemic steroids are proposed as a valid therapeutic option even though its effects are still controversial. Heterogeneity of published data regarding study design, population demographics, severity of illness, dosing, type and timing of corticosteroids administered constitute an important limitation for drawing robust conclusions. However, it is reasonable to admit that, as it was not found any advantage of corticosteroid therapy in so diverse conditions, such beneficial effects do not exist at all. Its administration is likely to increase overall mortality and such trend is consistent regardless of the quality as well as the sample size of studies. Moreover it was shown that corticosteroids might be associated with higher incidence of hospital-acquired pneumonia and longer duration of mechanical ventilation and ICU stay. Finally, it is reasonable to conclude that corticosteroids failed to demonstrate any beneficial effects in the treatment of patients with severe influenza infection. Thus its current use in severe influenza pneumonia should be restricted to very selected cases and in the setting of clinical trials. PMID:26855898

Hepatitis B virus infection in US correctional facilities: a review of diagnosis, management, and public health implications.

PubMed

Gupta, Shaili; Altice, Frederick L

2009-03-01

Among the blood-borne chronic viral infections, hepatitis B virus (HBV) infection is one that is not only treatable but also preventable by provision of vaccination. Despite the availability of HBV vaccine for the last 15 years, more than 1.25 million individuals in the USA have chronic HBV infection, and about 5,000 die each year from HBV-related complications. From a societal perspective, access to treatment of chronic viral infections, like HIV and viral hepatitis, is highly cost-effective and has lasting benefits by reducing risk behaviors, morbidity, mortality, as well as disease transmission in the community. Individuals in correctional facilities are specially predisposed to such chronic viral infections because of their high-risk behaviors. The explosion of incarceration in the USA over the last few decades and the disproportionate burden of morbidity and mortality from chronic infections among the incarcerated have put incredible strains on an overcrowded system that was not originally designed to provide comprehensive medical care for chronic illnesses. Recently, there has been a call to address medical care for individuals with chronic medical conditions in correctional settings, including those with infectious diseases. The economic and public health burden of chronic hepatitis B and its sequelae, including cirrhosis and hepatocellular carcinoma, is felt most prominently in managed care settings with limited budgets, like correctional facilities. Prevalence of HBV infection among the incarcerated in the USA is fivefold that of the general population. We present a review of diagnosis, prevention, and the recently streamlined treatment guidelines for management of HBV infection in correctional settings, and discuss the implications and public health impact of these measures.

Analysis: Continuous Glucose Monitoring in the Intensive Care Unit

PubMed Central

Kenneth Ward, W.

2012-01-01

Control of glycemia in hospitalized patients is important; hypoglycemia is associated with increased mortality, and hyperglycemia is associated with adverse outcomes. For these reasons, though no such device is currently available, continuous glucose monitoring (CGM) is an attractive option, especially in the critical care setting. Schierenbeck and coauthors, in this issue of Journal of Diabetes Science and Technology, report on the use of a specialized central catheter designed to monitor glucose continuously in post cardiac surgery patients. This catheter, which was indwelled within the great veins, was specially designed with a separate lumen and membrane that allowed continuous glucose microdialysis. Accuracy was quite good, better than has been reported with the use of commercially-available CGM devices. Ideally, further development of this quite promising catheter-based device would allow it to be used also to deliver fluids and drugs, thus avoiding the need for a second catheter elsewhere. PMID:23294782

THE CASE FOR A TYPHOID VACCINE PROBE STUDY AND OVERVIEW OF DESIGN ELEMENTS

PubMed Central

Halloran, M. Elizabeth; Khan, Imran

2015-01-01

Recent advances in typhoid vaccine, and consideration of support from Gavi, the Vaccine Alliance, raise the possibility that some endemic countries will introduce typhoid vaccine into public immunization programs. This decision, however, is limited by lack of definitive information on disease burden. We propose use of a vaccine probe study approach. This approach would more clearly assess the total burden of typhoid across different syndromic groups and account for lack of access to care, poor diagnostics, incomplete laboratory testing, lack of mortality and intestinal perforation surveillance, and increasing antibiotic resistance. We propose a cluster randomized trial design using a mass immunization campaign among all age groups, with monitoring over a 4-year period of a variety of outcomes. The primary outcome would be the vaccine preventable disease incidence of prolonged fever hospitalization. Sample size calculations suggest that such a study would be feasible over a reasonable set of assumptions. PMID:25912286

A Novel Technique for Endovascular Removal of Large Volume Right Atrial Tumor Thrombus

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nickel, Barbara, E-mail: nickel.ba@gmail.com; McClure, Timothy, E-mail: tmcclure@gmail.com; Moriarty, John, E-mail: jmoriarty@mednet.ucla.edu

Venous thromboembolic disease is a significant cause of morbidity and mortality, particularly in the setting of large volume pulmonary embolism. Thrombolytic therapy has been shown to be a successful treatment modality; however, its use somewhat limited due to the risk of hemorrhage and potential for distal embolization in the setting of large mobile thrombi. In patients where either thrombolysis is contraindicated or unsuccessful, and conventional therapies prove inadequate, surgical thrombectomy may be considered. We present a case of percutaneous endovascular extraction of a large mobile mass extending from the inferior vena cava into the right atrium using the Angiovac device,more » a venovenous bypass system designed for high-volume aspiration of undesired endovascular material. Standard endovascular methods for removal of cancer-associated thrombus, such as catheter-directed lysis, maceration, and exclusion, may prove inadequate in the setting of underlying tumor thrombus. Where conventional endovascular methods either fail or are unsuitable, endovascular thrombectomy with the Angiovac device may be a useful and safe minimally invasive alternative to open resection.« less

Aging in the natural world: comparative data reveal similar mortality patterns across primates.

PubMed

Bronikowski, Anne M; Altmann, Jeanne; Brockman, Diane K; Cords, Marina; Fedigan, Linda M; Pusey, Anne; Stoinski, Tara; Morris, William F; Strier, Karen B; Alberts, Susan C

2011-03-11

Human senescence patterns-late onset of mortality increase, slow mortality acceleration, and exceptional longevity-are often described as unique in the animal world. Using an individual-based data set from longitudinal studies of wild populations of seven primate species, we show that contrary to assumptions of human uniqueness, human senescence falls within the primate continuum of aging; the tendency for males to have shorter life spans and higher age-specific mortality than females throughout much of adulthood is a common feature in many, but not all, primates; and the aging profiles of primate species do not reflect phylogenetic position. These findings suggest that mortality patterns in primates are shaped by local selective forces rather than phylogenetic history.

Erythropoietin-Stimulating Agents and Survival in End-Stage Renal Disease: Comparison of Payment Policy Analysis, Instrumental Variables, and Multiple Imputation of Potential Outcomes

PubMed Central

Dore, David D.; Swaminathan, Shailender; Gutman, Roee; Trivedi, Amal N.; Mor, Vincent

2013-01-01

Objective To compare the assumptions and estimands across three approaches to estimating the effect of erythropoietin-stimulating agents (ESAs) on mortality. Study Design and Setting Using data from the Renal Management Information System, we conducted two analyses utilizing a change to bundled payment that we hypothesized mimicked random assignment to ESA (pre-post, difference-in-difference, and instrumental variable analyses). A third analysis was based on multiply imputing potential outcomes using propensity scores. Results There were 311,087 recipients of ESAs and 13,095 non-recipients. In the pre-post comparison, we identified no clear relationship between bundled payment (measured by calendar time) and the incidence of death within six months (risk difference -1.5%; 95% CI - 7.0% to 4.0%). In the instrumental variable analysis, the risk of mortality was similar among ESA recipients (risk difference -0.9%; 95% CI -2.1 to 0.3). In the multiple imputation analysis, we observed a 4.2% (95% CI 3.4% to 4.9%) absolute reduction in mortality risk with use of ESAs, but closer to the null for patients with baseline hematocrit >36%. Conclusion Methods emanating from different disciplines often rely on different assumptions, but can be informative about a similar causal contrast. The implications of these distinct approaches are discussed. PMID:23849152

Long-term outcome of patients with neurotic illness in general practice.

PubMed Central

Lloyd, K. R.; Jenkins, R.; Mann, A.

1996-01-01

OBJECTIVE--To determine the 11 year outcome of neurotic disorder in general practice. DESIGN--Cohort study over 11 years. SETTING--Two general practices in Warwickshire England. SUBJECTS--100 patients selected to be representative of those identified nationally by general practitioners as having neurotic disorders. MAIN OUTCOME MEASURES--Mortality, morbidity, and use of health services. RESULTS--At 11 years 87 subjects were traced. The 11 year standardised mortality ratio was 173 (95% confidence interval 164 to 200). 47 were cases on the general health questionnaire, 32 had a relapsing or chronic psychiatric course, and 49 a relapsing or chronic physical course. Treatment for psychiatric illness was mainly drugs. The mean number of consultations per year was 10.8 (median 8.7). A persistent psychiatric diagnosis at one year follow up was associated with high attendance ( > 12 visits a year for 11 years) at follow up after age, sex, and physical illness were adjusted for. Severity of psychiatric illness (general health questionnaire score) at outset predicted general health questionnaire score at 11 year follow up, course of psychiatric illness, and high consultation rate. CONCLUSION--These data support the view that a neurotic illness can become chronic and is associated with raised mortality from all causes and high use of services. Such patients need effective intervention, particularly those with a more severe illness who do not recover within one year. PMID:8664767

Demographic patterns and trends in Central Ghana: baseline indicators from the Kintampo Health and Demographic Surveillance System

PubMed Central

Owusu-Agyei, Seth; Nettey, Obed Ernest A.; Zandoh, Charles; Sulemana, Abubakari; Adda, Robert; Amenga-Etego, Seeba; Mbacke, Cheikh

2012-01-01

Background The dearth of health and demographic data in sub-Saharan Africa from vital registration systems and its impact on effective planning for health and socio-economic development is widely documented. Health and Demographic Surveillance Systems have the capacity to address the dearth of quality data for policy making in resource-poor settings. Objective This article demonstrates the utility of the Kintampo Health and Demographic Surveillance System (KHDSS) by showing the patterns and trends of population change from 2005 to 2009 in the Kintampo North Municipality and Kintampo South districts of Ghana through data obtained from the KHDSS biannual update rounds. Design Basic demographic rates for fertility, mortality, and migration were computed by year. School enrolment was computed as a percentage in school by age and sex for 6–18 year-olds. Socio-economic status was derived by use of Principal Components Analysis on household assets. Results Over the period, an earlier fertility decline was reversed in 2009; mortality declined slightly for all age-groups, and a significant share of working-age population was lost through out-migration. Large minorities of children of school-going age are not in school. Socio-economic factors are shown to be important determinants of fertility and mortality. Conclusion Strengthening the capacity of HDSSs could offer added value to evidence-driven policymaking at local level. PMID:23273249

Relation between troponin T concentration and mortality in patients presenting with an acute stroke: observational study

PubMed Central

James, P; Ellis, C J; Whitlock, R M L; McNeil, A R; Henley, J; Anderson, N E

2000-01-01

Objective To assess whether a raised serum troponin T concentration would be an independent predictor of death in patients with an acute ischaemic stroke. Design Observational study. Setting Auckland Hospital, Auckland, New Zealand. Subjects All 181 patients with an acute ischaemic stroke admitted over nine months in 1997-8, from a total of 8057 patients admitted to the acute medical service. Main outcome measures Blood samples for measuring troponin T concentration were collected 12-72 hours after admission; other variables previously associated with severity of stroke were also recorded and assessed as independent predictors of inpatient mortality. Results Troponin T concentration was raised (>0.1 μg/l) in 17% (30) of patients admitted with an acute ischaemic stroke. Thirty one patients died in hospital (12/30 (40%) patients with a raised troponin T concentration v 19/151 (13%) patients with a normal concentration (relative risk 3.2 (95% confidence 1.7 to 5.8; P=0.0025)). Of 17 possible predictors of death, assessed in a multivariate stepwise model, only a raised troponin T concentration (P=0.0002), age (P=0.0008), and an altered level of consciousness at presentation (P=0.0074) independently predicted an adverse outcome. Conclusions Serum troponin T concentration at hospital admission is a powerful predictor of mortality in patients admitted with an acute ischaemic stroke. PMID:10834890

Risk factors for postneonatal, infant, child and under-5 mortality in Nigeria: a pooled cross-sectional analysis

PubMed Central

Ezeh, Osita Kingsley; Agho, Kingsley Emwinyore; Dibley, Michael John; Hall, John Joseph; Page, Andrew Nicolas

2015-01-01

Objectives To identify common factors associated with post-neonatal, infant, child and under-5 mortality in Nigeria. Design, setting and participants A cross-sectional data of three Nigeria Demographic and Health Surveys (NDHS) for the years 2003, 2008 and 2013 were used. A multistage, stratified, cluster random sampling method was used to gather information on 63 844 singleton live-born infants of the most recent birth of a mother within a 5-year period before each survey was examined using cox regression models. Main outcome measures Postneonatal mortality (death between 1 and 11 months), infant mortality (death between birth and 11 months), child mortality (death between 12 and 59 months) and under-5 mortality (death between birth and 59 months). Results Multivariable analyses indicated that children born to mothers with no formal education was significantly associated with mortality across all four age ranges (adjusted HR=1.30, 95% CI 1.01 to 1.66 for postneonatal; HR=1.38, 95% CI 1.11 to 1.84 for infant; HR=2.13, 95% CI 1.56 to 2.89 for child; HR=1.19, 95% CI 1.02 to 1.41 for under-5). Other significant factors included living in rural areas (HR=1.48, 95% CI 1.16 to 1.89 for postneonatal; HR=1.23, 95% CI 1.03 to 1.47 for infant; HR=1.52, 95% CI 1.16 to 1.99 for child; HR=1.29, 95% CI 1.11 to 1.50 for under-5), and poor households (HR=2.47, 95% CI 1.76 to 3.47 for postneonatal; HR=1.40, 95% CI 1.10 to 1.78 for infant; HR=1.72, 95% CI 1.19 to 2.49 for child; HR=1.43, 95% CI 1.17 to 1.76 for under-5). Conclusions This study found that no formal education, poor households and living in rural areas increased the risk of postneonatal, infant, child and under-5 mortality among Nigerian children. Community-based interventions for reducing under-5 deaths are needed and should target children born to mothers of low socioeconomic status. PMID:25818271

Relationship between Stroke and Mortality in Dialysis Patients

PubMed Central

Phadnis, Milind A.; Ellerbeck, Edward F.; Shireman, Theresa I.; Rigler, Sally K.; Mahnken, Jonathan D.

2015-01-01

Background and objectives Stroke is common in patients undergoing long-term dialysis, but the implications for mortality after stroke in these patients are not fully understood. Design, setting, participants, & measurements A large cohort of dually-eligible (Medicare and Medicaid) patients initiating dialysis from 2000 to 2005 and surviving the first 90 days was constructed. Medicare claims were used to ascertain ischemic and hemorrhagic strokes occurring after 90-day survival. A semi-Markov model with additive hazard extension was generated to estimate the association between stroke and mortality, to calculate years of life lost after a stroke, and to determine whether race was associated with differential survival after stroke. Results The cohort consisted of 69,371 individuals representing >112,000 person-years of follow-up. Mean age±SD was 60.8±15.5 years. There were 21.1 (99% confidence interval [99% CI], 20.0 to 22.3) ischemic strokes and 4.7 (99% CI, 4.2 to 5.3) hemorrhagic strokes after cohort entry per 1000 patient-years. At 30 days, mortality was 17.9% for ischemic stroke and 53.4% for hemorrhagic stroke. The adjusted hazard ratio (AHR) depended on time since entry into the cohort; for patients who experienced a stroke at 1 year after cohort entry, for example, the AHR of hemorrhagic stroke for mortality was 25.4 (99% CI, 22.4 to 28.4) at 1 week, 9.9 (99% CI, 8.4 to 11.6) at 3 months, 5.9 (99% CI, 5.0 to 7.0) at 6 months, and 1.8 (99% CI, 1.5 to 2.1) at 24 months. The corresponding AHRs for ischemic stroke were 11.7 (99% CI, 10.2 to 13.1) at 1 week, 6.6 (99% CI, 6.4 to 6.7) at 3 months, and 4.7 (99% CI, 4.5 to 4.9) at 6 months, remaining significantly >1.0 even at 48 months. Median months of life lost were 40.7 for hemorrhagic stroke and 34.6 for ischemic stroke. For both stroke types, mortality did not differ by race. Conclusions Dialysis recipients have high mortality after a stroke with corresponding decrements in remaining years of life. Poststroke mortality does not differ by race. PMID:25318759

Impact of Malnutrition on Physical, Cognitive Function and Mortality among Older Men Living in Veteran Homes by Minimum Data Set: A Prospective Cohort Study in Taiwan.

PubMed

Chen, L-Y; Liu, L-K; Hwang, A-C; Lin, M-H; Peng, L-N; Chen, L-K; Lan, C-F; Chang, P-L

2016-01-01

To evaluate the prevalence of malnutrition and its impact on mortality, functional decline and cognitive impairment among elder residents in long-term care settings. A prospective cohort study. Two veteran homes in Taiwan. A total of 1,248 male residents aged equal or more than 65 years. Charlson's comorbidity index (CCI), Minimum data set (MDS), resident assessment protocols (RAP), Activity of daily living-Hierarchy scale, Cognitive Performance Scale, MDS Social engagement scale. The mean age of participants is 83.1 ± 5.1 years, and the prevalence of malnutrition was 6.1%. Inadequate dietary content (57.9%) and unintentional weight loss (31.6%) account for the majority of malnutrition identified by MDS tool. Higher 18-month mortality rate (25% vs. 14.2%), higher baseline CCI (median 1 vs. 0), and higher baseline sum of RAP triggers (median 8.5 vs. 5) were noted among residents with malnutrition. Furthermore, malnutrition was shown predictive for functional decline (OR: 3.096, 95% CI: 1.715-5.587) and potential cognitive improvement (OR: 2.469, 95% CI: 1.188-5.128) among survivors after adjustment for age, body mass index and CCI. Malnutrition among elder men residing in veteran homes was associated with multimorbidities and higher care complexity, and was predictive for mortality and functional decline.

Association between adherence to an antimicrobial stewardship program and mortality among hospitalised cancer patients with febrile neutropaenia: a prospective cohort study

PubMed Central

2014-01-01

Background Initial management of chemotherapy-induced febrile neutropaenia (FN) comprises empirical therapy with a broad-spectrum antimicrobial. Currently, there is sufficient evidence to indicate which antibiotic regimen should be administered initially. However, no randomized trial has evaluated whether adherence to an antimicrobial stewardship program (ASP) results in lower rates of mortality in this setting. The present study sought to assess the association between adherence to an ASP and mortality among hospitalised cancer patients with FN. Methods We conducted a prospective cohort study in a single tertiary hospital from October 2009 to August 2011. All adult patients who were admitted to the haematology ward with cancer and FN were followed up for 28 days. ASP adherence to the initial antimicrobial prescription was determined. The mortality rates of patients who were treated with antibiotics according to the ASP protocol were compared with those of patients treated with other antibiotic regimens. The multivariate Cox proportional hazards model and propensity score were used to estimate 28-day mortality risk. Results A total of 307 FN episodes in 169 subjects were evaluated. The rate of adherence to the ASP was 53%. In a Cox regression analysis, adjusted for propensity scores and other potential confounding factors, ASP adherence was independently associated with lower mortality (hazard ratio, 0.36; 95% confidence interval, 0.14–0.92). Conclusions Antimicrobial selection is important for the initial management of patients with FN, and adherence to the ASP, which calls for the rational use of antibiotics, was associated with lower mortality rates in this setting. PMID:24884397

Association between adherence to an antimicrobial stewardship program and mortality among hospitalised cancer patients with febrile neutropaenia: a prospective cohort study.

PubMed

Rosa, Regis G; Goldani, Luciano Z; dos Santos, Rodrigo P

2014-05-23

Initial management of chemotherapy-induced febrile neutropaenia (FN) comprises empirical therapy with a broad-spectrum antimicrobial. Currently, there is sufficient evidence to indicate which antibiotic regimen should be administered initially. However, no randomized trial has evaluated whether adherence to an antimicrobial stewardship program (ASP) results in lower rates of mortality in this setting. The present study sought to assess the association between adherence to an ASP and mortality among hospitalised cancer patients with FN. We conducted a prospective cohort study in a single tertiary hospital from October 2009 to August 2011. All adult patients who were admitted to the haematology ward with cancer and FN were followed up for 28 days. ASP adherence to the initial antimicrobial prescription was determined. The mortality rates of patients who were treated with antibiotics according to the ASP protocol were compared with those of patients treated with other antibiotic regimens. The multivariate Cox proportional hazards model and propensity score were used to estimate 28-day mortality risk. A total of 307 FN episodes in 169 subjects were evaluated. The rate of adherence to the ASP was 53%. In a Cox regression analysis, adjusted for propensity scores and other potential confounding factors, ASP adherence was independently associated with lower mortality (hazard ratio, 0.36; 95% confidence interval, 0.14-0.92). Antimicrobial selection is important for the initial management of patients with FN, and adherence to the ASP, which calls for the rational use of antibiotics, was associated with lower mortality rates in this setting.

First echelon hospital care before trauma center transfer in a rural trauma system: does it affect outcome?

PubMed

Helling, Thomas S; Davit, Flavia; Edwards, Kim

2010-12-01

Rural trauma has been associated with higher mortality because of a number of geographic and demographic factors. Many victims, of necessity, are first cared for in nearby hospitals, many of which are not designated trauma centers (TCs), and then transferred to identified TCs. This first echelon care might adversely affect eventual outcome. We have sought to examine the fate of trauma patients transferred after first echelon hospital evaluation and treatment. All trauma patients transferred (referred group) to a Pennsylvania Level I TC located in a geographically isolated and rural setting during a 68-month period were retrospectively compared with patients transported directly to the TC (direct group). Outcome measures included mortality, complications, physiologic parameters on arrival at the TC, operations within 6 hours of arrival at the TC, discharge disposition from the TC, and functional outcome. Patients with an injury severity score <9 and those discharged from the TC within 24 hours were excluded. During the study period, 2,388 patients were transported directly and 529 were transferred. Mortality between groups was not different: 6% (referred) versus 9% (direct), p = 0.074. Occurrence of complications was not different between the two groups. Physiologic parameters (systolic blood pressure, heart rate, and Glasgow Coma Scale score) at admission to the Level I TC differed statistically between the two groups but seemed near equivalent clinically. Sixteen percent of patients required an operative procedure within 6 hours in the direct group compared with 10% in the referral group (p = 0.001). Hospital and intensive care unit length of stay were less in the referred group, although this was not statistically significant. Performance scores on discharge were equivalent in all categories except transfer ability. Time from injury to definitive care (TC) was 1.6 hours ± 3.0 hours in the direct group and 5.3 hours ± 3.8 hours in the referred group (p < 0.0001). The most common procedure performed at first echelon hospitals was airway control (55% of referred patients). In this rural setting, care at first echelon hospitals, most (95%) of which were not designated TCs, seemed to augment, rather than detract from, favorable outcomes realized after definitive care at the TC.

Child Mortality in the School Setting. Position Statement

ERIC Educational Resources Information Center

Bergren, Martha Dewey

2012-01-01

It is the position of the National Association of School Nurses (NASN) that data on children's deaths in school should be recorded, analyzed and reported at the local, state and national level. The systematic review of data on child deaths is necessary to drive interventions and policies that will decrease mortality from injuries, violence, acute…

The American College of Preventive Medicine Policy Recommendations on Reducing and Preventing Firearm-Related Injuries and Deaths.

PubMed

Strong, Bethany L; Ballard, Sarah-Blythe; Braund, Wendy

2016-12-01

The American College of Preventive Medicine Policy Committee makes policy guidelines and recommendations on preventive medicine and public health topics for public health decision makers. After a review of the current evidence available in 2016, the College is providing a consensus-based set of policy recommendations designed to reduce firearm-related morbidity and mortality in the U.S. These guidelines address seven general areas pertaining to the public health threat posed by firearms: gun sales and background checks, assault weapons and high-capacity weapons, mental health, research funding, gun storage laws, and physician counseling. Copyright © 2016 American Journal of Preventive Medicine. All rights reserved.

Analysis of underlying and multiple-cause mortality data.

PubMed

Moussa, M A; El Sayed, A M; Sugathan, T N; Khogali, M M; Verma, D

1992-01-01

"A variety of life table models were used for the analysis of the (1984-86) Kuwaiti cause-specific mortality data. These models comprised total mortality, multiple-decrement, cause-elimination, cause-delay and disease dependency. The models were illustrated by application to a set of four chronic diseases: hypertensive, ischaemic heart, cerebrovascular and diabetes mellitus. The life table methods quantify the relative weights of different diseases as hazards to mortality after adjustment for other causes. They can also evaluate the extent of dependency between underlying cause of death and other causes mentioned on [the] death certificate using an extended underlying-cause model." (SUMMARY IN FRE AND ITA) excerpt

Clinical predictors cannot replace biological predictors in HIV-2 infection in a community setting in West Africa

PubMed Central

Gourlay, Annabelle J.; van Tienen, Carla; Dave, Sangeeta S.; Vincent, Tim; Rowland-Jones, Sarah L.; Glynn, Judith R.; Whittle, Hilton C.; van der Loeff, Maarten F. Schim

2012-01-01

Summary Objective To identify clinical predictors of mortality in HIV-2-infected individuals that may be used in place of CD4 count or plasma viral load (PVL) to guide treatment management in resource-limited settings. Methods A prospective community cohort study of HIV-infected and HIV-negative individuals in a rural area of Guinea-Bissau has been ongoing since 1989. In 2003 participants were invited for a clinical examination and blood tests. They were followed-up for vital status until 2010. Antiretroviral treatment (ART) became available in 2007. Cox regression was used to examine the association of clinical measures (World Health Organization (WHO) stage, body mass index (BMI), mid-upper arm circumference (MUAC), and WHO performance scale) measured in 2003 with subsequent mortality. Results In 2003, 146 HIV-2-infected individuals (68% women; mean age 56 years) were examined. Over the next 7 years, 44 (30%) died. BMI < 18.5 kg/m2 was associated with a crude mortality hazard ratio (HR) of 1.9 (95% confidence interval (CI) 1.0–3.9, p = 0.08); adjusted for age and sex, HR 1.8 (95% CI 0.9–3.8, p = 0.1). MUAC <230 mm in women and <240 mm in men was also associated with an elevated mortality HR, though statistical evidence was weak (crude HR 2.2, 95% CI 0.9–5.3, p = 0.1). WHO clinical stage and WHO performance scale were not associated with mortality (p = 0.6 and p = 0.2, respectively, for crude associations). Conclusions Baseline BMI, MUAC, WHO stage, and WHO performance scale were not strong or statistically significant predictors of mortality among HIV-2-infected individuals. CD4 count and PVL are more reliable tools, when available, for the management of HIV-2-infected patients in the community setting. PMID:22387142

Development and Validation of the Nursing Home Minimum Data Set 3.0 Mortality Risk Score (MRS3).

PubMed

Thomas, Kali S; Ogarek, Jessica A; Teno, Joan M; Gozalo, Pedro L; Mor, Vincent

2018-03-05

To develop a score to predict mortality using the Minimum Data Set 3.0 (MDS 3.0) that can be readily calculated from items collected during nursing home (NH) residents' admission assessments. We developed a training cohort of Medicare beneficiaries newly admitted to U.S. NHs during 2012 (N=1,426,815) and a testing cohort from 2013 (N=1,160,964). Data came from the MDS 3.0 assessments linked to the Medicare Beneficiary Summary File. Using the training dataset, we developed a composite MDS 3.0 Mortality Risk Score (MRS3) consisting of 17 clinical items and patients' age groups based on their relation to 30-day mortality. We assessed the calibration and discrimination of the MRS3 in predicting 30-day and 60-day mortality and compared its performance to the Charlson Comorbidity Index and the clinician's assessment of 6-month prognosis measured at admission. The 30-day and 60-day mortality rate for the testing population was 2.8% and 5.6%, respectively. Results from logistic regression models suggest that the MRS3 performed well in predicting death within 30 and 60 days (C-Statistics of 0.744 (95%CL = 0.741, 0.747) and 0.709 (95%CL=0.706, 0.711), respectively). The MRS3 was a superior predictor of mortality compared to the Charlson Comorbidity Index (C-statistics of 0.611 (95%CL=0.607, 0.615) and 0.608 (95%CL=0.605, 0.610)) and the clinicians' assessments of patients' 6-month prognoses (C-statistics of 0.543 (95%CL=0.542, 0.545) and 0.528 (95%CL=0.527, 0.529). The MRS3 is a good predictor of mortality and can be useful in guiding decision-making, informing plans of care, and adjusting for patients' risk of mortality.

Smoking Is So Ew!: College Smokers' Reactions to Health- Versus Social-Focused Antismoking Threat Messages.

PubMed

Wong, Norman C H; Nisbett, Gwendelyn S; Harvell, Lindsey A

2017-04-01

This study utilizes Terror Management Theory (TMT) to examine differences between eliciting social death and physical death anxiety related to smoking, smoking attitudes, and quitting intent among college students. Moreover, an important TMT variable-self-esteem-was used as a moderator. A 2 × 3 between-subjects factorial design crossed smoking-based self-esteem (low, high) with mortality salience manipulation (health-focused, social-focused, control). Results suggest while both making health-focused salient and making social-focused mortality salient were effective at getting smokers to quit, there was less effect for health-focused mortality salience on those whose self-esteem is strongly tied to smoking. Effect of social-focused mortality salience was more pronounced among participants who highly linked self-esteem with smoking. For smokers with low smoking-based self-esteem, both health-focused and social-focused mortality salience were effective at motivating attitude change toward smoking and quitting intentions. Implications for smoking cessation ad design and TMT are discussed.

Identification of an updated set of prescribing-safety indicators for GPs

PubMed Central

Spencer, Rachel; Bell, Brian; Avery, Anthony J; Gookey, Gill; Campbell, Stephen M

2014-01-01

Background Medication error is an important contributor to patient morbidity and mortality and is associated with inadequate patient safety measures. However, prescribing-safety tools specifically designed for use in general practice are lacking. Aim To identify and update a set of prescribing-safety indicators for assessing the safety of prescribing in general practice, and to estimate the risk of harm to patients associated with each indicator. Design and setting RAND/UCLA consensus development of indicators in UK general practice. Method Prescribing indicators were identified from a systematic review and previous consensus exercise. The RAND Appropriateness Method was used to further identify and develop the indicators with an electronic-Delphi method used to rate the risk associated with them. Twelve GPs from all the countries of the UK participated in the RAND exercise, with 11 GPs rating risk using the electronic-Delphi approach. Results Fifty-six prescribing-safety indicators were considered appropriate for inclusion (overall panel median rating of 7–9, with agreement). These indicators cover hazardous prescribing across a range of therapeutic indications, hazardous drug–drug combinations and inadequate laboratory test monitoring. Twenty-three (41%) of these indicators were considered high risk or extreme risk by 80% or more of the participants. Conclusion This study identified a set of 56 indicators that were considered, by a panel of GPs, to be appropriate for assessing the safety of GP prescribing. Twenty-three of these indicators were considered to be associated with high or extreme risk to patients and should be the focus of efforts to improve patient safety. PMID:24686882

Acceleration of recovery in acute renal failure: from cellular mechanisms of tubular repair to innovative targeted therapies.

PubMed

Abbate, M; Remuzzi, G

1996-05-01

Kidney repair from injury is a major focus of interest for research, both clinical and basic, in the field of acute renal failure. This is so because very little progress has been made during the past several years to improve mortality in hospitalized patients with acute renal failure despite the unique potential of the kidney for complete structural and functional recovery. Novel therapeutic options have recently emerged from the knowledge of molecular mechanisms of tissue injury after ischemia, including pathways of endothelial-leukocyte interaction and epithelial cell aggregation mediated by integrin molecules. These strategies are promising because they may target early mechanisms of leukocyte infiltration and tubular obstruction. However, it seems clear that additional interventions should address the reparative program that potentially leads to the full restoration of kidney structure and function. Thus, acceleration of repair from acute renal failure is achieved experimentally by growth factors which besides different renal actions seem to have in common the ability to stimulate proliferation of surviving tubular epithelial cells. We direct attention to cellular processes which characterize, and possibly have role in, renal repair from acute tubular injury as potential targets of therapy. In addition to proliferation, they include epithelial differentiation and apoptosis. Further investigation in the biology of repair should set the stage for rational design of targeted therapies which may accelerate the pace of recovery and hopefully decrease mortality in such a dramatic and potentially reversible setting.

PERSPECTIVES REGARDING ANTENATAL CARE, DELIVERY AND BREAST FEEDING PRACTICES OF WOMEN FROM BALUCHISTAN, PAKISTAN.

PubMed

Khoso, Aneeta; Khan, Ayesha Zahid; Sayed, Sayeeda Amber; Rafique, Ghazala

2016-01-01

Antenatal Care is one of the fundamental rights for women to safeguard their health. Neonatal mortality rates have remained relatively static, compared to the decline in infant and under 5 mortality rates, adverse practices regarding breast feeding and pre-lacteal feeds being the important factors responsible. This study aimed to explore the Antenatal Care, delivery and breastfeeding practices in three districts of Baluchistan. It was a qualitative phenomenological design using Constructivist approach. The study was conducted in three districts of Baluchistan province, Gwadar, Quetta, Qila Saifullah. There were a total of 14 Focus Group Discussions with women regarding Antenatal Care, delivery and Breastfeeding practices, followed by audio taping, transcription as verbatim and analysis through Nvivo version 2. A process was deployed for identification and reporting of the components in order to ensure quality and validity of the qualitative findings. Across the sites, women attended ANC at least once. However, their descriptions of ANC often varied. The women preferred Dais instead of doctors, due to the affordability, customs and availability. A lack of trained doctors and long distances to get a check-up lead to home deliveries in the study setting. Colostrum was discarded by majority of the mothers, while prelacteal feed was a common practice. This paper has explored factors affecting ANC attendance, delivery and breast feeding practices across three settings. Both the demand and supply side factors have an important influence on practices.

Scoping review of potential quality indicators for hip fracture patient care

PubMed Central

Pitzul, Kristen B; Munce, Sarah E P; Perrier, Laure; Beaupre, Lauren; Morin, Suzanne N; McGlasson, Rhona; Jaglal, Susan B

2017-01-01

Objective The purpose of this study is to identify existing or potential quality of care indicators (ie, current indicators as well as process and outcome measures) in the acute or postacute period, or across the continuum of care for older adults with hip fracture. Design Scoping review. Setting All care settings. Search strategy English peer-reviewed studies published from January 2000 to January 2016 were included. Literature search strategies were developed, and the search was peer-reviewed. Two reviewers independently piloted all forms, and all articles were screened in duplicate. Results The search yielded 2729 unique articles, of which 302 articles were included (11.1%). When indicators (eg, in-hospital mortality, acute care length of stay) and potential indicators (eg, comorbidities developed in hospital, walking ability) were grouped by the outcome or process construct they were trying to measure, the most common constructs were measures of mortality (outcome), length of stay (process) and time-sensitive measures (process). There was heterogeneity in definitions within constructs between studies. There was also a paucity of indicators and potential indicators in the postacute period. Conclusions To improve quality of care for patients with hip fracture and create a more efficient healthcare system, mechanisms for the measurement of quality of care across the entire continuum, not just during the acute period, are required. Future research should focus on decreasing the heterogeneity in definitions of quality indicators and the development and implementation of quality indicators for the postacute period. PMID:28325859

Phase angle, frailty and mortality in older adults.

PubMed

Wilhelm-Leen, Emilee R; Hall, Yoshio N; Horwitz, Ralph I; Chertow, Glenn M

2014-01-01

Frailty is a multidimensional phenotype that describes declining physical function and a vulnerability to adverse outcomes in the setting of physical stress such as illness or hospitalization. Phase angle is a composite measure of tissue resistance and reactance measured via bioelectrical impedance analysis (BIA). Whether phase angle is associated with frailty and mortality in the general population is unknown. To evaluate associations among phase angle, frailty and mortality. Population-based survey. Third National Health and Nutritional Examination Survey (1988-1994). In all, 4,667 persons aged 60 and older. Frailty was defined according to a set of criteria derived from a definition previously described and validated. Narrow phase angle (the lowest quintile) was associated with a four-fold higher odds of frailty among women and a three-fold higher odds of frailty among men, adjusted for age, sex, race-ethnicity and comorbidity. Over a 12-year follow-up period, the adjusted relative hazard for mortality associated with narrow phase angle was 2.4 (95 % confidence interval [95 % CI] 1.8 to 3.1) in women and 2.2 (95 % CI 1.7 to 2.9) in men. Narrow phase angle was significantly associated with mortality even among participants with little or no comorbidity. Analyses of BIA and frailty were cross-sectional; BIA was not measured serially and incident frailty during follow-up was not assessed. Participants examined at home were excluded from analysis because they did not undergo BIA. Narrow phase angle is associated with frailty and mortality independent of age and comorbidity.

Improving outcomes in infants of HIV-infected women in a developing country setting.

PubMed

Noel, Francine; Mehta, Sapna; Zhu, Yuwei; Rouzier, Patricia De Matteis; Marcelin, Abdias; Shi, Jian R; Nolte, Claudine; Severe, Linda; Deschamps, Marie Marcelle; Fitzgerald, Daniel W; Johnson, Warren D; Wright, Peter F; Pape, Jean W

2008-01-01

Since 1999 GHESKIO, a large voluntary counseling and HIV testing center in Port-au-Prince, Haiti, has had an ongoing collaboration with the Haitian Ministry of Health to reduce the rate of mother to child HIV transmission. There are limited data on the ability to administer complex regimens for reducing mother to child transmission and on risk factors for continued transmission and infant mortality within programmatic settings in developing countries. We analyzed data from 551 infants born to HIV-infected mothers seen at GHESKIO, between 1999 and 2005. HIV-infected mothers and their infants were given "short-course" monotherapy with antiretrovirals for prophylaxis; and, since 2003, highly active antiretroviral therapy (HAART) when clinical or laboratory indications were met. Infected women seen in the pre-treatment era had 27% transmission rates, falling to 10% in this cohort of 551 infants, and to only 1.9% in infants of women on HAART. Mortality rate after HAART introduction (0.12 per year of follow-up [0.08-0.16]) was significantly lower than the period before the availability of such therapy (0.23 [0.16-0.30], P<0.0001). The effects of maternal health, infant feeding, completeness of prophylaxis, and birth weight on mortality and transmission were determined using univariate and multivariate analysis. Infant HIV-1 infection and low birth weight were associated with infant mortality in less than 15 month olds in multivariate analysis. Our findings demonstrate success in prevention of mother-to-child HIV transmission and mortality in a highly resource constrained setting. Elements contributing to programmatic success include provision of HAART in the context of a comprehensive program with pre and postnatal care for both mother and infant.

Planting of neonicotinoid-coated corn raises honey bee mortality and sets back colony development.

PubMed

Samson-Robert, Olivier; Labrie, Geneviève; Chagnon, Madeleine; Fournier, Valérie

2017-01-01

Worldwide occurrences of honey bee colony losses have raised concerns about bee health and the sustainability of pollination-dependent crops. While multiple causal factors have been identified, seed coating with insecticides of the neonicotinoid family has been the focus of much discussion and research. Nonetheless, few studies have investigated the impacts of these insecticides under field conditions or in commercial beekeeping operations. Given that corn-seed coating constitutes the largest single use of neonicotinoid, our study compared honey bee mortality from commercial apiaries located in two different agricultural settings, i.e. corn-dominated areas and corn-free environments, during the corn planting season. Data was collected in 2012 and 2013 from 26 bee yards. Dead honey bees from five hives in each apiary were counted and collected, and samples were analyzed using a multi-residue LC-MS/MS method. Long-term effects on colony development were simulated based on a honey bee population dynamic model. Mortality survey showed that colonies located in a corn-dominated area had daily mortality counts 3.51 times those of colonies from corn crop-free sites. Chemical analyses revealed that honey bees were exposed to various agricultural pesticides during the corn planting season, but were primarily subjected to neonicotinoid compounds (54% of analysed samples contained clothianidin, and 31% contained both clothianidin and thiamethoxam). Performance development simulations performed on hive populations' show that increased mortality during the corn planting season sets back colony development and bears contributions to collapse risk but, most of all, reduces the effectiveness and value of colonies for pollination services. Our results also have implications for the numerous large-scale and worldwide-cultivated crops that currently rely on pre-emptive use of neonicotinoid seed treatments.

Has beta-blocker use increased in patients with heart failure in internal medicine settings? Prognostic implications: RICA registry.

PubMed

González-García, Andrés; Montero Pérez-Barquero, Manuel; Formiga, Francesc; González-Juanatey, José R; Quesada, M Angustias; Epelde, Francisco; Oropesa, Roberto; Díez-Manglano, Jesús; Cerqueiro, José M; Manzano, Luis

2014-03-01

Underuse of beta-blockers has been reported in elderly patients with heart failure. The aim of this study was to evaluate the current prescription of beta-blockers in the internal medicine setting, and its association with morbidity and mortality in heart failure patients. The information analyzed was obtained from a prospective cohort of patients hospitalized for heart failure (RICA registry] database, patients included from March 2008 to September 2011) with at least one year of follow-up. We investigated the percentage of patients prescribed beta-blockers at hospital discharge, and at 3 and 12 months, and the relationship of beta-blocker use with mortality and readmissions for heart failure. Patients with significant valve disease were excluded. A total of 515 patients were analyzed (53.5% women), with a mean age of 77.1 (8.7) years. Beta-blockers were prescribed in 62.1% of patients at discharge. A similar percentage was found at 3 months (65.6%) and 12 months (67.9%) after discharge. All-cause mortality and the composite of all-cause mortality and readmission for heart failure were significantly lower in patients treated with beta-blockers (hazard ratio=0.59, 95% confidence interval, 0.41-0.84 vs hazard ratio=0.64, 95% confidence interval, 0.49-0.83). This decrease in mortality was maintained after adjusting by age, sex, ejection fraction, functional class, comorbidities, and concomitant treatment. The findings of this study indicate that beta-blocker use is increasing in heart failure patients (mainly elderly) treated in the internal medicine setting, and suggest that the use of these drugs is associated with a reduction in clinical events. Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.

Planting of neonicotinoid-coated corn raises honey bee mortality and sets back colony development

PubMed Central

Samson-Robert, Olivier; Labrie, Geneviève; Chagnon, Madeleine

2017-01-01

Worldwide occurrences of honey bee colony losses have raised concerns about bee health and the sustainability of pollination-dependent crops. While multiple causal factors have been identified, seed coating with insecticides of the neonicotinoid family has been the focus of much discussion and research. Nonetheless, few studies have investigated the impacts of these insecticides under field conditions or in commercial beekeeping operations. Given that corn-seed coating constitutes the largest single use of neonicotinoid, our study compared honey bee mortality from commercial apiaries located in two different agricultural settings, i.e. corn-dominated areas and corn-free environments, during the corn planting season. Data was collected in 2012 and 2013 from 26 bee yards. Dead honey bees from five hives in each apiary were counted and collected, and samples were analyzed using a multi-residue LC-MS/MS method. Long-term effects on colony development were simulated based on a honey bee population dynamic model. Mortality survey showed that colonies located in a corn-dominated area had daily mortality counts 3.51 times those of colonies from corn crop-free sites. Chemical analyses revealed that honey bees were exposed to various agricultural pesticides during the corn planting season, but were primarily subjected to neonicotinoid compounds (54% of analysed samples contained clothianidin, and 31% contained both clothianidin and thiamethoxam). Performance development simulations performed on hive populations’ show that increased mortality during the corn planting season sets back colony development and bears contributions to collapse risk but, most of all, reduces the effectiveness and value of colonies for pollination services. Our results also have implications for the numerous large-scale and worldwide-cultivated crops that currently rely on pre-emptive use of neonicotinoid seed treatments. PMID:28828265

Biological, social, and urban design factors affecting young street tree mortality in New York City

Treesearch

Jacqueline W.T. Lu; Erika S. Svendsen; Lindsay K. Campbell; Jennifer Greenfeld; Jessie Braden; Kristen King; Nancy Falxa-Raymond

2010-01-01

In dense metropolitan areas, there are many factors including traffic congestion, building development and social organizations that may impact the health of street trees. The focus of this study is to better understand how social, biological and urban design factors affect the mortality rates of newly planted street trees. Prior analyses of street trees planted by the...

Ambient temperature and coronary heart disease mortality in Beijing, China: a time series study

PubMed Central

2012-01-01

Background Many studies have examined the association between ambient temperature and mortality. However, less evidence is available on the temperature effects on coronary heart disease (CHD) mortality, especially in China. In this study, we examined the relationship between ambient temperature and CHD mortality in Beijing, China during 2000 to 2011. In addition, we compared time series and time-stratified case-crossover models for the non-linear effects of temperature. Methods We examined the effects of temperature on CHD mortality using both time series and time-stratified case-crossover models. We also assessed the effects of temperature on CHD mortality by subgroups: gender (female and male) and age (age > =65 and age < 65). We used a distributed lag non-linear model to examine the non-linear effects of temperature on CHD mortality up to 15 lag days. We used Akaike information criterion to assess the model fit for the two designs. Results The time series models had a better model fit than time-stratified case-crossover models. Both designs showed that the relationships between temperature and group-specific CHD mortality were non-linear. Extreme cold and hot temperatures significantly increased the risk of CHD mortality. Hot effects were acute and short-term, while cold effects were delayed by two days and lasted for five days. The old people and women were more sensitive to extreme cold and hot temperatures than young and men. Conclusions This study suggests that time series models performed better than time-stratified case-crossover models according to the model fit, even though they produced similar non-linear effects of temperature on CHD mortality. In addition, our findings indicate that extreme cold and hot temperatures increase the risk of CHD mortality in Beijing, China, particularly for women and old people. PMID:22909034

EDUCATIONAL DIFFERENTIALS IN U.S. ADULT MORTALITY: AN EXAMINATION OF MEDIATING FACTORS

PubMed Central

Rogers, Richard G.; Hummer, Robert A.; Everett, Bethany G.

2016-01-01

We use human capital theory to develop hypotheses regarding the extent to which the association between educational attainment and U.S. adult mortality is mediated by such economic and social resources as family income and social support; such health behaviors as inactivity, smoking, and excessive drinking; and such physiological measures as obesity, inflammation, and cardiovascular risk factors. We employ the NHANES Linked Mortality File, a large nationally representative prospective data set that includes an extensive number of factors thought to be important in mediating the education-mortality association. We find that educational differences in mortality for the total population and for specific causes of death are most prominently explained by family income and health behaviors. However, there are age-related differences in the effects of the mediating factors. Higher education enables individuals to effectively coalesce and leverage their diverse and substantial resources to reduce their mortality and increase their longevity. PMID:23347488

Smoothing two-dimensional Malaysian mortality data using P-splines indexed by age and year

NASA Astrophysics Data System (ADS)

Kamaruddin, Halim Shukri; Ismail, Noriszura

2014-06-01

Nonparametric regression implements data to derive the best coefficient of a model from a large class of flexible functions. Eilers and Marx (1996) introduced P-splines as a method of smoothing in generalized linear models, GLMs, in which the ordinary B-splines with a difference roughness penalty on coefficients is being used in a single dimensional mortality data. Modeling and forecasting mortality rate is a problem of fundamental importance in insurance company calculation in which accuracy of models and forecasts are the main concern of the industry. The original idea of P-splines is extended to two dimensional mortality data. The data indexed by age of death and year of death, in which the large set of data will be supplied by Department of Statistics Malaysia. The extension of this idea constructs the best fitted surface and provides sensible prediction of the underlying mortality rate in Malaysia mortality case.

Multiple reservoirs contribute to intraoperative bacterial transmission.

PubMed

Loftus, Randy W; Brown, Jeremiah R; Koff, Matthew D; Reddy, Sundara; Heard, Stephen O; Patel, Hetal M; Fernandez, Patrick G; Beach, Michael L; Corwin, Howard L; Jensen, Jens T; Kispert, David; Huysman, Bridget; Dodds, Thomas M; Ruoff, Kathryn L; Yeager, Mark P

2012-06-01

Intraoperative stopcock contamination is a frequent event associated with increased patient mortality. In the current study we examined the relative contributions of anesthesia provider hands, the patient, and the patient environment to stopcock contamination. Our secondary aims were to identify risk factors for stopcock contamination and to examine the prior association of stopcock contamination with 30-day postoperative infection and mortality. Additional microbiological analyses were completed to determine the prevalence of bacterial pathogens within intraoperative bacterial reservoirs. Pulsed-field gel electrophoresis was used to assess the contribution of reservoir bacterial pathogens to 30-day postoperative infections. In a multicenter study, stopcock transmission events were observed in 274 operating rooms, with the first and second cases of the day in each operating room studied in series to identify within- and between-case transmission events. Reservoir bacterial cultures were obtained and compared with stopcock set isolates to determine the origin of stopcock contamination. Between-case transmission was defined by the isolation of 1 or more bacterial isolates from the stopcock set of a subsequent case (case 2) that were identical to reservoir isolates from the preceding case (case 1). Within-case transmission was defined by the isolation of 1 or more bacterial isolates from a stopcock set that were identical to bacterial reservoirs from the same case. Bacterial pathogens within these reservoirs were identified, and their potential contribution to postoperative infections was evaluated. All patients were followed for 30 days postoperatively for the development of infection and all-cause mortality. Stopcock contamination was detected in 23% (126 out of 548) of cases with 14 between-case and 30 within-case transmission events confirmed. All 3 reservoirs contributed to between-case (64% environment, 14% patient, and 21% provider) and within-case (47% environment, 23% patient, and 30% provider) stopcock transmission. The environment was a more likely source of stopcock contamination than provider hands (relative risk [RR] 1.91, confidence interval [CI] 1.09 to 3.35, P = 0.029) or patients (RR 2.56, CI 1.34 to 4.89, P = 0.002). Hospital site (odds ratio [OR] 5.09, CI 2.02 to 12.86, P = 0.001) and case 2 (OR 6.82, CI 4.03 to 11.5, P < 0.001) were significant predictors of stopcock contamination. Stopcock contamination was associated with increased mortality (OR 58.5, CI 2.32 to 1477, P = 0.014). Intraoperative bacterial contamination of patients and provider hands was linked to 30-day postoperative infections. Bacterial contamination of patients, provider hands, and the environment contributes to stopcock transmission events, but the surrounding patient environment is the most likely source. Stopcock contamination is associated with increased patient mortality. Patient and provider bacterial reservoirs contribute to 30-day postoperative infections. Multimodal programs designed to target each of these reservoirs in parallel should be studied intensely as a comprehensive approach to reducing intraoperative bacterial transmission.

Trends and Patterns of Differences in Chronic Respiratory Disease Mortality Among US Counties, 1980-2014

PubMed Central

Dwyer-Lindgren, Laura; Bertozzi-Villa, Amelia; Stubbs, Rebecca W.; Morozoff, Chloe; Shirude, Shreya; Naghavi, Mohsen; Mokdad, Ali H.

2017-01-01

Importance Chronic respiratory diseases are an important cause of death and disability in the United States. Objective To estimate age-standardized mortality rates by county from chronic respiratory diseases. Design, Setting, and Participants Validated small area estimation models were applied to deidentified death records from the National Center for Health Statistics and population counts from the US Census Bureau, National Center for Health Statistics, and Human Mortality Database to estimate county-level mortality rates from 1980 to 2014 for chronic respiratory diseases. Exposure County of residence. Main Outcomes and Measures Age-standardized mortality rates by county, year, sex, and cause. Results A total of 4 616 711 deaths due to chronic respiratory diseases were recorded in the United States from January 1, 1980, through December 31, 2014. Nationally, the mortality rate from chronic respiratory diseases increased from 40.8 (95% uncertainty interval [UI], 39.8-41.8) deaths per 100 000 population in 1980 to a peak of 55.4 (95% UI, 54.1-56.5) deaths per 100 000 population in 2002 and then declined to 52.9 (95% UI, 51.6-54.4) deaths per 100 000 population in 2014. This overall 29.7% (95% UI, 25.5%-33.8%) increase in chronic respiratory disease mortality from 1980 to 2014 reflected increases in the mortality rate from chronic obstructive pulmonary disease (by 30.8% [95% UI, 25.2%-39.0%], from 34.5 [95% UI, 33.0-35.5] to 45.1 [95% UI, 43.7-46.9] deaths per 100 000 population), interstitial lung disease and pulmonary sarcoidosis (by 100.5% [95% UI, 5.8%-155.2%], from 2.7 [95% UI, 2.3-4.2] to 5.5 [95% UI, 3.5-6.1] deaths per 100 000 population), and all other chronic respiratory diseases (by 42.3% [95% UI, 32.4%-63.8%], from 0.51 [95% UI, 0.48-0.54] to 0.73 [95% UI, 0.69-0.78] deaths per 100 000 population). There were substantial differences in mortality rates and changes in mortality rates over time among counties, and geographic patterns differed by cause. Counties with the highest mortality rates were found primarily in central Appalachia for chronic obstructive pulmonary disease and pneumoconiosis; widely dispersed throughout the Southwest, northern Great Plains, New England, and South Atlantic for interstitial lung disease; along the southern half of the Mississippi River and in Georgia and South Carolina for asthma; and in southern states from Mississippi to South Carolina for other chronic respiratory diseases. Conclusions and Relevance Despite recent declines in mortality from chronic respiratory diseases, mortality rates in 2014 remained significantly higher than in 1980. Between 1980 and 2014, there were important differences in mortality rates and changes in mortality by county, sex, and particular chronic respiratory disease type. These estimates may be helpful for informing efforts to improve prevention, diagnosis, and treatment. PMID:28973621

Clinical outcomes of HIV care delivery models in the US: a systematic review.

PubMed

Kimmel, April D; Martin, Erika G; Galadima, Hadiza; Bono, Rose S; Tehrani, Ali Bonakdar; Cyrus, John W; Henderson, Margaret; Freedberg, Kenneth A; Krist, Alexander H

2016-10-01

With over 1 million people living with HIV, the US faces national challenges in HIV care delivery due to an inadequate HIV specialist workforce and the increasing role of non-communicable chronic diseases in driving morbidity and mortality in HIV-infected patients. Alternative HIV care delivery models, which include substantial roles for advanced practitioners and/or coordination between specialty and primary care settings in managing HIV-infected patients, may address these needs. We aimed to systematically review the evidence on patient-level HIV-specific and primary care health outcomes for HIV-infected adults receiving outpatient care across HIV care delivery models. We identified randomized trials and observational studies from bibliographic and other databases through March 2016. Eligible studies met pre-specified eligibility criteria including on care delivery models and patient-level health outcomes. We considered all available evidence, including non-experimental studies, and evaluated studies for risk of bias. We identified 3605 studies, of which 13 met eligibility criteria. Of the 13 eligible studies, the majority evaluated specialty-based care (9 studies). Across all studies and care delivery models, eligible studies primarily reported mortality and antiretroviral use, with specialty-based care associated with mortality reductions at the clinician and practice levels and with increased antiretroviral initiation or use at the clinician level but not the practice level. Limited and heterogeneous outcomes were reported for other patient-level HIV-specific outcomes (e.g., viral suppression) as well as for primary care health outcomes across all care delivery models. No studies addressed chronic care outcomes related to aging. Limited evidence was available across geographic settings and key populations. As re-design of care delivery in the US continues to evolve, better understanding of patient-level HIV-related and primary care health outcomes, especially across different staffing models and among different patient populations and geographic locations, is urgently needed to improve HIV disease management.

Comparing two types of macrolide antibiotics for the purpose of assessing population-based drug interactions

PubMed Central

Fleet, Jamie L; Shariff, Salimah Z; Bailey, David G; Gandhi, Sonja; Juurlink, David N; Nash, Danielle M; Mamdani, Muhammad; Gomes, Tara; Patel, Amit M; Garg, Amit X

2013-01-01

Objective Clarithromycin strongly inhibits enzyme cytochrome P450 3A4, preventing the metabolism of some other drugs, while azithromycin is a weak inhibitor. Accordingly, blood concentrations of other drugs increase with clarithromycin coprescription leading to adverse events. These macrolide antibiotics also differ on other properties that may impact outcomes. In this study, we compared outcomes in two groups of macrolide antibiotic users in the absence of potentially interacting drugs. Design Population-based retrospective cohort study. Setting Ontario, Canada, from 2003 to 2010. Patients Patients (mean 74 years) prescribed clarithromycin (n=52 251) or azithromycin (referent group, n=46 618). Main outcomes The primary outcomes were hospital admission within 30 days of a new antibiotic prescription with any of the 12 conditions examined separately (acute kidney injury, acute myocardial infarction, neuroimaging (proxy for delirium), hypotension, syncope, hyperkalaemia, hyponatraemia, hyperglycaemia, arrhythmia, ischaemic stroke, gastrointestinal bleeding and sepsis). The secondary outcome was mortality. Results The baseline characteristics of the two groups, including patient demographics, comorbid conditions, infection type and prescribing physician specialty, were nearly identical. The median daily dose was 1000 mg for clarithromycin and 300 mg for azithromycin and the median duration of dispensing antibiotics was 10 and 5 days, respectively. There was no difference between the groups in the risk of hospitalisation for any condition studied (relative risk ranged from 0.67 to 1.23). Compared with azithromycin, clarithromycin was associated with a slightly higher risk of all-cause mortality (0.46% vs 0.37%, relative risk 1.25, 95% CI 1.03 to 1.52). Conclusions Clarithromycin can be used to assess drug interactions in population-based studies with azithromycin serving as a control group. However, any differences in mortality observed between the two antibiotic groups in the setting of other drug use may be partially attributable to factors beyond the inhibition of drug metabolising enzymes and transporters, as the difference for this outcome was significant. PMID:23847265

Prognostic importance of early worsening renal function after initiation of angiotensin-converting enzyme inhibitor therapy in patients with cardiac dysfunction.

PubMed

Testani, Jeffrey M; Kimmel, Stephen E; Dries, Daniel L; Coca, Steven G

2011-11-01

Worsening renal function (WRF) in the setting of heart failure has been associated with increased mortality. However, it is unclear if this decreased survival is a direct result of the reduction in glomerular filtration rate (GFR) or if the mechanism underlying the deterioration in GFR is driving prognosis. Given that WRF in the setting of angiotensin-converting enzyme inhibitor (ACE-I) initiation is likely mechanistically distinct from spontaneously occurring WRF, we investigated the relative early WRF-associated mortality rates in subjects randomized to ACE-I or placebo. Subjects in the Studies Of Left Ventricular Dysfunction (SOLVD) limited data set (n=6337) were studied. The interaction between early WRF (decrease in estimated GFR ≥20% at 14 days), randomization to enalapril, and mortality was the primary end point. In the overall population, early WRF was associated with increased mortality (adjusted hazard ratio [HR], 1.2; 95% CI, 1.0-1.4; P=0.037). When analysis was restricted to the placebo group, this association strengthened (adjusted HR, 1.4; 95% CI, 1.1-1.8; P=0.004). However, in the enalapril group, early WRF had no adverse prognostic significance (adjusted HR, 1.0; 95% CI, 0.8-1.3; P=1.0; P=0.09 for the interaction). In patients who continued to receive study drug despite early WRF, a survival advantage remained with enalapril therapy (adjusted HR, 0.66; 95% CI, 0.5-0.9; P=0.018). These data support the notion that the mechanism underlying WRF is important in determining its prognostic significance. Specifically, early WRF in the setting of ACE-I initiation appears to represent a benign event that is not associated with a loss of benefit from continued ACE-I therapy.

Preemptive spatial competition under a reproduction-mortality constraint.

PubMed

Allstadt, Andrew; Caraco, Thomas; Korniss, G

2009-06-21

Spatially structured ecological interactions can shape selection pressures experienced by a population's different phenotypes. We study spatial competition between phenotypes subject to antagonistic pleiotropy between reproductive effort and mortality rate. The constraint we invoke reflects a previous life-history analysis; the implied dependence indicates that although propagation and mortality rates both vary, their ratio is fixed. We develop a stochastic invasion approximation predicting that phenotypes with higher propagation rates will invade an empty environment (no biotic resistance) faster, despite their higher mortality rate. However, once population density approaches demographic equilibrium, phenotypes with lower mortality are favored, despite their lower propagation rate. We conducted a set of pairwise invasion analyses by simulating an individual-based model of preemptive competition. In each case, the phenotype with the lowest mortality rate and (via antagonistic pleiotropy) the lowest propagation rate qualified as evolutionarily stable among strategies simulated. This result, for a fixed propagation to mortality ratio, suggests that a selective response to spatial competition can extend the time scale of the population's dynamics, which in turn decelerates phenotypic evolution.

Fluid Overload and Fluid Removal in Pediatric Patients on Extracorporeal Membrane Oxygenation Requiring Continuous Renal Replacement Therapy

PubMed Central

Selewski, David T; Cornell, Timothy T; Blatt, Neal B; Han, Yong Y; Mottes, Theresa; Kommareddi, Mallika; Gaies, Michael G; Annich, Gail M; Kershaw, David B; Shanley, Thomas P; Heung, Michael

2012-01-01

Objective In pediatric patients fluid overload (FO) at continuous renal replacement (CRRT) initiation is associated with increased mortality. The aim of this study was to characterize the association between fluid overload at CRRT initiation, fluid removal during CRRT, the kinetics of fluid removal and mortality in a large pediatric population receiving CRRT while on extracorporeal membrane oxygenation (ECMO). Design Retrospective chart review. Setting Tertiary children’s hospital Patients ECMO patients requiring CRRT from July 2006 to September 2010 Interventions None Measurements and Main Results Overall ICU survival was 34% for 53 patients that were initiated on CRRT while on ECMO during the study period. Median FO at CRRT initiation was significantly lower in survivors compared to non-survivors (24.5 vs. 38%, p=0.006). Median FO at CRRT discontinuation was significantly lower in survivors compared to non-survivors (7.1 vs. 17.5%, p=0.035). After adjusting for percent FO at CRRT initiation, age and severity of illness, the change in FO at CRRT discontinuation was not significantly associated with mortality (p=0.212). Models investigating the rates of fluid removal in different periods, age, severity of illness and fluid overload at CRRT initiation found that fluid overload at CRRT initiation was the most consistent predictor of survival. Conclusions Our data demonstrates an association between FO at CRRT initiation and mortality in pediatric patients receiving ECMO. The degree of FO at CRRT discontinuation is also associated with mortality, but appears to reflect the effect of FO at initiation. Furthermore, correction of FO to ≤ 10% was not associated with improved survival. These results suggest that intervening prior to the development of significant FO may be more clinically effective than attempting fluid removal after significant fluid overload has developed. Our findings suggest a role for earlier initiation of CRRT in this population, and warrant further clinical studies. PMID:22743776

Combining Gait Speed and Recall Memory to Predict Survival in Late Life: Population-Based Study

PubMed Central

Marengoni, Alessandra; Bandinelli, Stefania; Maietti, Elisa; Guralnik, Jack; Zuliani, Giovanni; Ferrucci, Luigi; Volpato, Stefano

2017-01-01

OBJECTIVES To evaluate the relationship between gait speed, recall memory, and mortality. DESIGN A cohort study (last follow-up December 2009). SETTING Tuscany, Italy. PARTICIPANTS Individual data from 1,014 community-dwelling older adults aged 60 years or older with baseline gait speed and recall memory measurements and follow-up for a median time of 9.10 (IQR 7.1;9.3) years. Participants were a mean (SD) age of 73.9 (7.3) years, and 55.8% women. Participants walking faster than 0.8 m/s were defined as fast walkers; good recall memory was defined as a score of 2 or 3 in the 3-word delayed recall section of the Mini-Mental State Examination. MEASUREMENTS All-cause mortality. RESULTS There were 302 deaths and the overall 100 person-year death rate was 3.77 (95% CI: 3.37–4.22). Both low gait speed and poor recall memory were associated with mortality when analysed separately (HR = 2.47; 95% CI: 1.87–3.27 and HR = 1.47; 95% CI: 1.16–1.87, respectively). When we grouped participants according to both recall and gait speed, death rates (100 person-years) progressively increased from those with both good gait speed and memory (2.0; 95% CI: 1.6–2.5), to those with fast walk but poor memory (3.4; 95% CI: 2.8–4.2), to those with slow walk and good memory (8.8; 95% CI: 6.4–12.1), to those with both slow walk and poor memory (13.0; 95% CI: 10.6–16.1). In multivariate analysis, poor memory significantly increases mortality risk among persons with fast gait speed (HR = 1.40; 95% CI: 1.04–1.89). CONCLUSION In older persons, gait speed and recall memory are independent predictors of expected survival. Information on memory function might better stratify mortality risk among persons with fast gait speed. PMID:28029688

The short-term association of road traffic noise with cardiovascular, respiratory, and diabetes-related mortality.

PubMed

Recio, Alberto; Linares, Cristina; Banegas, José R; Díaz, Julio

2016-10-01

Road traffic noise has well-documented effects on cardiovascular, respiratory, and metabolic health. Numerous studies have reported long-term associations of urban noise with some diseases and outcomes, including death. However, to date there are no studies on the short-term association between this pollutant and a set of various specific causes of death. To investigate the short-term association of road traffic noise with daily cause-specific mortality. We used a time-stratified case-crossover design with Poisson regression. Predictor variables were daytime, nighttime, and 24-h equivalent noise levels, and maximum daytime and nighttime noise levels. Outcome variables were daily death counts for various specific causes, stratifying by age. We adjusted for primary air pollutants (PM2.5 and NO2) and weather conditions (mean temperature and relative humidity). In the ≥65 age group, increased mortality rates per 1 dBA increase in maximum nocturnal noise levels at lag 0 or 1 day were 2.9% (95% CI 1.0, 4.8%), 3.5% (95% CI 1.1, 6.1%), 2.4% (95% CI 0.1, 4.8%), 3.0% (95% CI 0.2, 5.8%), and 4.0% (95% CI 1.0, 7.0%), for ischemic heart disease, myocardial infarction, cerebrovascular disease, pneumonia, and COPD, respectively. For diabetes, 1 dBA increase in equivalent nocturnal noise levels at lag 1 was associated with an increased mortality rate of 11% (95% CI 4.0, 19%). In the <65 age group, increased mortality rates per 1 dBA increase in equivalent nocturnal noise levels at lag 0 were 11% (95% CI 4.2, 18%) and 11% (95% CI 4.2, 19%) for ischemic heart disease and myocardial infarction, respectively. Road traffic noise increases the short-term risk of death from specific diseases of the cardiovascular, respiratory, and metabolic systems. Copyright © 2016 Elsevier Inc. All rights reserved.

Mortality Among Persons With Obsessive-Compulsive Disorder in Denmark

PubMed Central

Meier, Sandra M.; Mattheisen, Manuel; Mors, Ole; Schendel, Diana E.; Mortensen, Preben B.; Plessen, Kerstin J.

2016-01-01

IMPORTANCE Several mental disorders have consistently been found to be associated with decreased life expectancy, but little is known about whether this is also the case for obsessive-compulsive disorder (OCD). OBJECTIVE To determine whether persons who receive a diagnosis of OCD are at increased risk of death. DESIGN, SETTING, AND PARTICIPANTS Using data from Danish registers, we conducted a nationwide prospective cohort study with 30 million person-years of follow-up. The data were collected from Danish longitudinal registers. A total of 3 million people born between 1955 and 2006 were followed up from January 1, 2002, through December 31, 2011. During this period, 27 236 people died. The data were analyzed primarily in June 2015. MAIN OUTCOMES AND MEASURES We estimated mortality rate ratios (MRRs), adjusted for calendar year, age, sex, maternal and paternal age, place of residence at birth, and somatic comorbidities, to compare persons with OCT with persons without OCD. RESULTS Of 10 155 persons with OCD (5935 women and 4220 men with a mean [SD] age of 29.1 [11.3] years who contributed a total of 54 937 person-years of observation), 110 (1.1%) died during the average follow-up of 9.7 years. The risk of death by natural or unnatural causes was significantly higher among persons with OCD (MRR, 1.68 [95% CI, 1.31–2.12] for natural causes; MRR, 2.61 [95% CI, 1.91–3.47] for unnatural causes) than among the general population. After the exclusion of persons with comorbid anxiety disorders, depression, or substance use disorders, OCD was still associated with increased mortality risk (MRR, 1.88 [95% CI, 1.27–2.67]). CONCLUSIONS AND RELEVANCE The presence of OCD was associated with a significantly increased mortality risk. Comorbid anxiety disorders, depression, or substance use disorders further increased the risk. However, after adjusting for these and somatic comorbidities, we found that the mortality risk remained significantly increased among persons with OCD. PMID:26818216

Investments in cancer research awarded to UK institutions and the global burden of cancer 2000–2013: a systematic analysis

PubMed Central

Maruthappu, Mahiben; Head, Michael G; Zhou, Charlie D; Gilbert, Barnabas J; El-Harasis, Majd A; Raine, Rosalind; Fitchett, Joseph R; Atun, Rifat

2017-01-01

Objectives To systematically categorise cancer research investment awarded to United Kingdom (UK) institutions in the period 2000–2013 and to estimate research investment relative to disease burden as measured by mortality, disability-adjusted life years (DALYs) and years lived with disability (YLDs). Design Systematic analysis of all open-access data. Setting and participants Public and philanthropic funding to all UK cancer research institutions, 2000–2013. Main outcome measures Number and financial value of cancer research investments reported in 2013 UK pounds (UK£). Mortality, DALYs and YLDs data were acquired from the Global Burden of Disease Study. A compound metric was adapted to estimate research investment relative to disease burden as measured by mortality, DALYs and YLDs. Results We identified 4299 funded studies with a total research investment of £2.4 billion. The highest fundings by anatomical sites were haematological, breast, prostate, colorectal and ovarian cancers. Relative to disease burden as determined by a compound metric combining mortality, DALYs and YLDs, gender-specific cancers were found to be highest funded—the five sites that received the most funding were prostate, ovarian, breast, mesothelioma and testicular cancer; the least well-funded sites were liver, thyroid, lung, upper gastrointestinal (GI) and bladder. Preclinical science accounted for 66.2% of award numbers and 62.2% of all funding. The top five areas of primary research focus by funding were pathogenesis, drug therapy, diagnostic, screening and monitoring, women's health and immunology. The largest individual funder was the Medical Research Council. In combination, the five lowest funded site-specific cancers relative to disease burden account for 47.9%, 44.3% and 20.4% of worldwide cancer mortality, DALYs and YLDs. Conclusions Research funding for cancer is not allocated according to relative disease burden. These findings are in line with earlier published studies. Funding agencies and industry should openly document their research investments to improve better targeting of research investment. PMID:28428185

South Asians and coronary disease: is there discordance between effects on incidence and prognosis?

PubMed Central

Zaman, M Justin S; Philipson, Pete; Chen, Ruoling; Farag, Ahmed; Shipley, Martin; Marmot, Michael G; Timmis, Adam D; Hemingway, Harry

2013-01-01

Objective To determine whether the effect of South Asian ethnicity differs between studies of incidence and prognosis of coronary disease. Design Systematic literature review and meta-analysis, and cohort analysis from a national acute coronary syndrome (ACS) registry linked to mortality (National Institute of Cardiovascular Outcomes Research/Myocardial Infarction National Audit Project). Setting International for the review, and England and Wales for the cohort analysis. Patients The numbers of South Asians included in the meta-analysis were 111 555 (incidence) and 14 531 (prognosis) of whom 8251 were from the ACS cohort. Main outcome measures Incidence studies: non-fatal myocardial infarction or fatal coronary heart disease; prognostic studies: mortality; HRs for 1-year all-cause death in ACS cohort. Results South Asians had higher incidence of coronary disease compared with white subjects (HR 1.35 95% CI 1.30 to 1.40) based on meta-analysis of nine studies. Among 10 studies on prognosis, South Asians had better prognosis compared with white subjects (HR 0.78 95% CI 0.74 to 0.82). In the ACS cohort, the impact of diabetes (42.4% of South Asians, 16.9% of white subjects) on 1-year mortality was stronger in South Asians than white subjects (age-adjusted HR 1.83 95% CI 1.59 to 2.11 vs 1.53 95% CI 1.49 to 1.57). However, prognosis was better in South Asians even among diabetics, older people and those living in areas of the highest social deprivation. Conclusions South Asian ethnicity is associated with higher incidence of coronary disease, but lower mortality once coronary disease is manifest. The dissociation between effects on incidence and prognosis suggests that public health initiatives to reduce inequalities in mortality between South Asian and white populations should focus on primary prevention. This is a CALIBER study with ClinicalTrials.gov Identifier: NCT01163513. PMID:23406688

Reduced birthweight in short or primiparous mothers: physiological or pathological?

PubMed Central

Zhang, X; Mumford, SL; Cnattingius, S; Schisterman, EF; Kramer, MS

2011-01-01

Objective Customisation of birthweight-for-gestational-age standards for maternal characteristics assumes that variation in birth weight as a result of those characteristics is physiological, rather than pathological. Maternal height and parity are among the characteristics widely assumed to be physiological. Our objective was to test that assumption by using an association with perinatal mortality as evidence of a pathological effect. Design Population-based cohort study. Setting Sweden. Population A total of 952 630 singletons born at ≥28 weeks of gestation in the period 1992–2001. Methods We compared perinatal mortality among mothers of short stature (<160 cm) versus those of normal height (≥160 cm), and primiparous versus multiparous mothers, using an internal reference of estimated fetal weight for gestational age. The total effects of maternal height and parity were estimated, as well as the effects of height and parity independent of birthweight (controlled direct effects). All analyses were based on fetuses at risk, using marginal structural Cox models for the estimation of total and controlled direct effects. Main outcome measures Perinatal mortality, stillbirth, and early neonatal mortality. Results The estimated total effect (HR; 95% CI) of short stature on perinatal death among short mothers was 1.2 (95% CI 1.1–1.3) compared with women of normal height; the effect of short stature independent of birthweight (controlled direct effect) was 0.8 (95% CI 0.6–1.0) among small-for-gestational-age (SGA) births, but 1.1 (95% CI 1.0–1.3) among non-SGA births. Similar results were observed for primiparous mothers. Conclusions The effect of maternal short stature or primiparity on perinatal mortality is partly mediated through SGA birth. Thus, birthweight differences resulting from these maternal characteristics appear not only to be physiological, but also to have an important pathological component. PMID:20618317

Concurrence of Serum Creatinine and Albumin with Lower Risk for Death in Twice-Weekly Hemodialysis Patients

PubMed Central

Wang, Jialin; Streja, Elani; Soohoo, Melissa; Chen, Joline L.T.; Rhee, Connie M.; Kim, Taehee; Molnar, Miklos Z.; Kovesdy, Csaba P.; Mehrotra, Rajnish; Kalantar-Zadeh, Kamyar

2016-01-01

Objective Markers of better nutritional status including both higher levels of serum albumin (as a measure of visceral proteins) and creatinine (as a measure of the muscle mass) are associated with lower mortality in conventional (thrice-weekly) hemodialysis patients. However, data for these associations in twice-weekly hemodialysis patients, in whom less frequent hemodialysis may confound nutritional predictors, are lacking. Design, Settings and Subjects We identified 1,113 twice-weekly and matched 4,448 thrice-weekly hemodialysis patients from a large national dialysis cohort of incident hemodialysis patients over 5 years (2007-2011). Mortality risk, adjusted for potential confounders, was examined across two-by-two combinations of serum creatinine (<6 mg/dl vs. ≥6 mg/dl) and albumin (<3.5 g/dl vs. ≥3.5 g/dl) for each treatment frequency yielding a total of eight groups. Results Patients were 70±14 years old and included 48% women, and 55% diabetics. Using the thrice-weekly hemodialysis patients with creatinine≥6mg/dl and albumin≥3.5g/dl as reference, patients with creatinine<6mg/dl and albumin<3.5g/dl had a 1.8-fold higher risk of mortality (HR: 1.75, 95%CI: 1.33-2.30) in twice-weekly and 2.2-fold increased risk of mortality (HR: 2.21, 95%CI: 1.81-2.70) in thrice-weekly hemodialysis patients, respectively in fully adjusted models adjusted for demographics, comorbidities and markers of malnutrition and inflammation. A test for interaction showed there was no significant difference in albumin creatinine mortality associations between twice-weekly and thrice-weekly hemodialysis patients (p-for-interaction 0.7667). Conclusions Surrogate markers of higher visceral protein and muscle mass combined may confer greatest survival in both twice-weekly and thrice-weekly hemodialysis patients. PMID:27528412

Effects of economic crises on population health outcomes in Latin America, 1981–2010: an ecological study

PubMed Central

Williams, Callum; Gilbert, Barnabas James; Zeltner, Thomas; Watkins, Johnathan; Atun, Rifat; Maruthappu, Mahiben

2016-01-01

Objectives The relative health effects of changes in unemployment, inflation and gross domestic product (GDP) per capita on population health have not been assessed. We aimed to determine the effect of changes in these economic measures on mortality metrics across Latin America. Design Ecological study. Setting Latin America (21 countries), 1981–2010. Outcome measures Uses multivariate regression analysis to assess the effects of changes in unemployment, inflation and GDP per capita on 5 mortality indicators across 21 countries in Latin America, 1981–2010. Country-specific differences in healthcare infrastructure, population structure and population size were controlled for. Results Between 1981 and 2010, a 1% rise in unemployment was associated with statistically significant deteriorations (p<0.05) in 5 population health outcomes, with largest deteriorations in 1–5 years of age and male adult mortality rates (1.14 and 0.53 rises per 1000 deaths respectively). A 1% rise in inflation rate was associated with significant deteriorations (p<0.05) in 4 population health outcomes, with the largest deterioration in male adult mortality rate (0.0033 rise per 1000 deaths). Lag analysis showed that 5 years after rises in unemployment and inflation, significant deteriorations (p<0.05) occurred in 3 and 5 mortality metrics, respectively. A 1% rise in GDP per capita was associated with no significant deteriorations in population health outcomes either in the short or long term. β coefficient comparisons indicated that the effect of unemployment increases was substantially greater than that of changes in GDP per capita or inflation. Conclusions Rises in unemployment and inflation are associated with long-lasting deteriorations in several population health outcomes. Unemployment exerted much larger effects on health than inflation. In contrast, changes in GDP per capita had almost no association with the explored health outcomes. Contrary to neoclassical development economics, policymakers should prioritise amelioration of unemployment if population health outcomes are to be optimised. PMID:26739715

Surgeon specialization and operative mortality in United States: retrospective analysis

PubMed Central

Dalton, Maurice; Cutler, David M; Birkmeyer, John D; Chandra, Amitabh

2016-01-01

Objective To measure the association between a surgeon’s degree of specialization in a specific procedure and patient mortality. Design Retrospective analysis of Medicare data. Setting US patients aged 66 or older enrolled in traditional fee for service Medicare. Participants 25 152 US surgeons who performed one of eight procedures (carotid endarterectomy, coronary artery bypass grafting, valve replacement, abdominal aortic aneurysm repair, lung resection, cystectomy, pancreatic resection, or esophagectomy) on 695 987 patients in 2008-13. Main outcome measure Relative risk reduction in risk adjusted and volume adjusted 30 day operative mortality between surgeons in the bottom quarter and top quarter of surgeon specialization (defined as the number of times the surgeon performed the specific procedure divided by his/her total operative volume across all procedures). Results For all four cardiovascular procedures and two out of four cancer resections, a surgeon’s degree of specialization was a significant predictor of operative mortality independent of the number of times he or she performed that procedure: carotid endarterectomy (relative risk reduction between bottom and top quarter of surgeons 28%, 95% confidence interval 0% to 48%); coronary artery bypass grafting (15%, 4% to 25%); valve replacement (46%, 37% to 53%); abdominal aortic aneurysm repair (42%, 29% to 53%); lung resection (28%, 5% to 46%); and cystectomy (41%, 8% to 63%). In five procedures (carotid endarterectomy, valve replacement, lung resection, cystectomy, and esophagectomy), the relative risk reduction from surgeon specialization was greater than that from surgeon volume for that specific procedure. Furthermore, surgeon specialization accounted for 9% (coronary artery bypass grafting) to 100% (cystectomy) of the relative risk reduction otherwise attributable to volume in that specific procedure. Conclusion For several common procedures, surgeon specialization was an important predictor of operative mortality independent of volume in that specific procedure. When selecting a surgeon, patients, referring physicians, and administrators assigning operative workload may want to consider a surgeon’s procedure specific volume as well as the degree to which a surgeon specializes in that procedure. PMID:27444190

Association between refill adherence to lipid-lowering medications and the risk of cardiovascular disease and mortality in Swedish patients with type 2 diabetes mellitus: a nationwide cohort study

PubMed Central

Hero, Christel; Svensson, Ann-Marie; Franzén, Stefan; Miftaraj, Mervete; Gudbjörnsdottir, Soffia; Eeg-Olofsson, Katarina; Eliasson, Björn; Andersson Sundell, Karolina

2018-01-01

Objectives To analyse the association between refill adherence to lipid-lowering medications, and the risk of cardiovascular disease (CVD) and mortality in patients with type 2 diabetes mellitus. Design Cohort study. Setting National population-based cohort of Swedish patients with type 2 diabetes mellitus. Participants 86 568 patients aged ≥18 years, registered with type 2 diabetes mellitus in the Swedish National Diabetes Register, who filled at least one prescription for lipid-lowering medication use during 2007–2010, 87% for primary prevention. Exposure and outcome measures Refill adherence of implementation was assessed using the medication possession ratio (MPR), representing the proportion of days with medications on hand during an 18-month exposure period. MPR was categorised by five levels (≤20%, 21%–40%, 41%–60%, 61%–80% and >80%). Patients without medications on hand for ≥180 days were defined as non-persistent. Risk of CVD (myocardial infarction, ischaemic heart disease, stroke and unstable angina) and mortality by level of MPR and persistence was analysed after the exposure period using Cox proportional hazards regression and Kaplan-Meier, adjusted for demographics, socioeconomic status, concurrent medications and clinical characteristics. Results The hazard ratios for CVD ranged 1.33–2.36 in primary prevention patients and 1.19–1.58 in secondary prevention patients, for those with MPR ≤80% (p<0.0001). The mortality risk was similar regardless of MPR level. The CVD risk was 74% higher in primary prevention patients and 33% higher in secondary prevention patients, for those who were non-persistent (p<0.0001). The mortality risk was 6% higher in primary prevention patients and 18% higher in secondary prevention patients, for non-persistent patients (p<0.0001). Conclusions Higher refill adherence to lipid-lowering medications was associated with lower risk of CVD in primary and secondary prevention patients with type 2 diabetes mellitus. PMID:29602853

A quality improvement project to improve early sepsis care in the emergency department.

PubMed

Gatewood, Medley O'Keefe; Wemple, Matthew; Greco, Sheryl; Kritek, Patricia A; Durvasula, Raghu

2015-12-01

Sepsis causes substantial morbidity and mortality in hospitalised patients. Although many studies describe the use of protocols in the management of patients with severe sepsis and septic shock, few have addressed emergency department (ED) screening and management for patients initially presenting with uncomplicated sepsis (ie, patients without organ failure or hypotension). A quality improvement task force at a large, quaternary care referral hospital sought to develop a protocol focusing on early identification of patients with uncomplicated sepsis, in addition to severe sepsis and septic shock. The three-tiered intervention consisted of (1) a nurse-driven screening tool and management protocol to identify and initiate early treatment of patients with sepsis, (2) a computer-assisted screening algorithm that generated a 'Sepsis Alert' pop-up screen in the electronic medical record for treating clinical healthcare providers and (3) automated suggested sepsis-specific order sets for initial workup and resuscitation, antibiotic selection and goal-directed therapy. A before and after retrospective cohort study was undertaken to determine the intervention's impact on compliance with recommended sepsis management, including serum lactate measured in the ED, 2 L of intravenous fluid administered within 2 h of triage, antibiotics administered within 3 h of triage and blood cultures drawn before antibiotic administration. Mortality rates for patients in the ED with a sepsis-designated ICD-9 code present on admission were also analysed. Overall bundle compliance increased by 154%, from 28% at baseline to 71% in the last quarter of the study (p<0.001). Bundle, antibiotic and intravenous fluid compliance all increased significantly after launch of the sepsis initiative (eg, bundle and intravenous fluid compliance increased by 74% and 54%, respectively; p<0.001). Bundle and antibiotic compliance both showed further significant increases after implementation of suggested order sets (31% and 25% increases, respectively; p<0.001). The mortality rate for patients in the ED admitted with sepsis was 13.3% before implementation and fell to 11.1% after (p=0.230); mortality in the last two quarters of the study was 9.3% (p=0.107). The new protocol demonstrates that early screening interventions can lead to expedited delivery of care to patients with sepsis in the ED and could serve as a model for other facilities. Mortality was not significantly improved by our intervention, which included patients with uncomplicated sepsis. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

User-Centered Design of Learn to Quit, a Smoking Cessation Smartphone App for People With Serious Mental Illness

PubMed Central

Rizo, Javier; Zeng, Emily; Kientz, Julie A; Ries, Richard; Otis, Chad; Hernandez, Kayla

2018-01-01

Background Smoking rates in the United States have been reduced in the past decades to 15% of the general population. However, up to 88% of people with psychiatric symptoms still smoke, leading to high rates of disease and mortality. Therefore, there is a great need to develop smoking cessation interventions that have adequate levels of usability and can reach this population. Objective The objective of this study was to report the rationale, ideation, design, user research, and final specifications of a novel smoking cessation app for people with serious mental illness (SMI) that will be tested in a feasibility trial. Methods We used a variety of user-centered design methods and materials to develop the tailored smoking cessation app. This included expert panel guidance, a set of design principles and theory-based smoking cessation content, development of personas and paper prototyping, usability testing of the app prototype, establishment of app’s core vision and design specification, and collaboration with a software development company. Results We developed Learn to Quit, a smoking cessation app designed and tailored to individuals with SMI that incorporates the following: (1) evidence-based smoking cessation content from Acceptance and Commitment Therapy and US Clinical Practice Guidelines for smoking cessation aimed at providing skills for quitting while addressing mental health symptoms, (2) a set of behavioral principles to increase retention and comprehension of smoking cessation content, (3) a gamification component to encourage and sustain app engagement during a 14-day period, (4) an app structure and layout designed to minimize usability errors in people with SMI, and (5) a set of stories and visuals that communicate smoking cessation concepts and skills in simple terms. Conclusions Despite its increasing importance, the design and development of mHealth technology is typically underreported, hampering scientific innovation. This report describes the systematic development of the first smoking cessation app tailored to people with SMI, a population with very high rates of nicotine addiction, and offers new design strategies to engage this population. mHealth developers in smoking cessation and related fields could benefit from a design strategy that capitalizes on the role visual engagement, storytelling, and the systematic application of behavior analytic principles to deliver evidence-based content. PMID:29339346

Persistent threats to validity in single-group interrupted time series analysis with a cross over design.

PubMed

Linden, Ariel

2017-04-01

The basic single-group interrupted time series analysis (ITSA) design has been shown to be susceptible to the most common threat to validity-history-the possibility that some other event caused the observed effect in the time series. A single-group ITSA with a crossover design (in which the intervention is introduced and withdrawn 1 or more times) should be more robust. In this paper, we describe and empirically assess the susceptibility of this design to bias from history. Time series data from 2 natural experiments (the effect of multiple repeals and reinstatements of Louisiana's motorcycle helmet law on motorcycle fatalities and the association between the implementation and withdrawal of Gorbachev's antialcohol campaign with Russia's mortality crisis) are used to illustrate that history remains a threat to ITSA validity, even in a crossover design. Both empirical examples reveal that the single-group ITSA with a crossover design may be biased because of history. In the case of motorcycle fatalities, helmet laws appeared effective in reducing mortality (while repealing the law increased mortality), but when a control group was added, it was shown that this trend was similar in both groups. In the case of Gorbachev's antialcohol campaign, only when contrasting the results against those of a control group was the withdrawal of the campaign found to be the more likely culprit in explaining the Russian mortality crisis than the collapse of the Soviet Union. Even with a robust crossover design, single-group ITSA models remain susceptible to bias from history. Therefore, a comparable control group design should be included, whenever possible. © 2016 John Wiley & Sons, Ltd.

Nutritional status based on Body Mass Index is associated with morbidity and mortality in mechanically ventilated critically ill children in the PICU

PubMed Central

Bechard, Lori J.; Duggan, Christopher; Touger-Decker, Riva; Parrott, J. Scott; Rothpletz-Puglia, Pamela; Byham-Gray, Laura; Heyland, Daren; Mehta, Nilesh M.

2016-01-01

Objective To determine the influence of admission anthropometry on clinical outcomes in mechanically ventilated children in the pediatric intensive care unit (PICU). Design Data from 2 multicenter cohort studies were compiled to examine the unique contribution of nutritional status, defined by BMI Z-score, to 60-day mortality, hospital-acquired infections, length of hospital stay, and ventilator free days (VFD), using multivariate analysis. Setting 90 PICUs from 16 countries with 8 beds. Patients Children aged 1 month to 18 years, admitted to each participating PICU and requiring mechanical ventilation for more that 48 hours Measurements and Main Results Data from 1622 eligible patients, 54.8% male and mean (SD) age 4.5 (5.1) years, were analysed. Subjects were classified as underweight (17.9%), normal weight (54.2%), overweight (14.5%), and obese (13.4%) based on BMI Z-score at admission. After adjusting for severity of illness and site, the odds of 60-day mortality were higher in underweight (OR 1.53, P<0.001) children. The odds of hospital-acquired infections were higher in underweight (OR 1.88, P=0.008) and obese (OR 1.64, P<0.001) children. Hazard ratios for hospital discharge were lower among underweight (HR 0.71, P<0.001) and obese (HR 0.82, P=0.04) children. Underweight was associated with 1.3 (P=0.001) and 1.6 (P<0.001) fewer VFD, compared to normal weight and overweight, respectively. Conclusions Malnutrition is prevalent in mechanically ventilated children on admission to PICUs worldwide. Classification as underweight or obese was associated with higher risk of hospital-acquired infections and lower likelihood of hospital discharge. Underweight children had a higher risk of mortality and fewer ventilator-free days. PMID:26985636

Increased circulating D-lactate levels predict risk of mortality after hemorrhage and surgical trauma in baboons.

PubMed

Sobhian, Babak; Kröpfl, Albert; Hölzenbein, Thomas; Khadem, Anna; Redl, Heinz; Bahrami, Soheyl

2012-05-01

Patients with hemorrhagic shock and/or trauma are at risk of developing colonic ischemia associated with bacterial translocation that may lead to multiple organ failure and death. Intestinal ischemia is difficult to diagnose noninvasively. The present retrospective study was designed to determine whether circulating plasma D-lactate is associated with mortality in a clinically relevant two-hit model in baboons. Hemorrhagic shock was induced in anesthetized baboons (n = 24) by controlled bleeding (mean arterial pressure, 40 mmHg), base excess (maximum -5 mmol/L), and time (maximum 3 h). To mimic clinical setting more closely, all animals underwent a surgical trauma after resuscitation including midshaft osteotomy stabilized with reamed femoral interlocking nailing and were followed for 7 days. Hemorrhagic shock/surgical trauma resulted in 66% mortality by day 7. In nonsurvivor (n = 16) hemorrhagic shock/surgical trauma baboons, circulating D-lactate levels were significantly increased (2-fold) at 24 h compared with survivors (n = 8), whereas the early increase during hemorrhage and resuscitation declined during the early postresuscitation phase with no difference between survivors and nonsurvivors. Moreover, D-lactate levels remained elevated in the nonsurvival group until death, whereas it decreased to baseline in survivors. Prediction of death (receiver operating characteristic test) by D-lactate was accurate with an area under the curve (days 1-3 after trauma) of 0.85 (95% confidence interval, 0.72-0.93). The optimal D-lactate cutoff value of 25.34 μg/mL produced sensitivity of 73% to 99% and specificity of 50% to 83%. Our data suggest that elevation of plasma D-lactate after 24 h predicts an increased risk of mortality after hemorrhage and trauma.

Exploring Delirium’s Heterogeneity: Association between Arousal Subtypes at Initial Presentation and 6-month Mortality in Older Emergency Department Patients

PubMed Central

Han, Jin H.; Brummel, Nathan E.; Chandrasekhar, Rameela; Wilson, Jo Ellen; Liu, Xulei; Vasilevskis, Eduard E.; Girard, Timothy D.; Carlo, Maria E.; Dittus, Robert S.; Schnelle, John F.; Ely, E. Wesley

2016-01-01

Objectives To determine how delirium subtyped by level of arousal at initial presentation affects 6-month mortality. Design This was a preplanned secondary analysis of two prospective cohort studies. Setting Academic tertiary care emergency department (ED). Participants 1,084 ED patients who were 65 years old or older. Measurements At the time of enrollment, trained research personnel performed the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Richmond Agitation Sedation Scale (RASS) to determine delirium and level of arousal, respectively. Patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Death was ascertained by medical record review and the Social Security Death Index. Cox proportional hazard regression was used to analyze the association between delirium arousal subtypes and 6-month mortality. Results Delirium with normal arousal was the only subtype that was significantly associated with increased 6-month mortality (HR=3.1, 95%CI: 1.3 – 7.4) compared with the no delirium group after adjusting for confounders. The HRs for delirium with decreased and increased arousal were 1.4 (95%CI: 0.9 – 2.1) and 1.3 (95%CI: 0.3 – 5.4), respectively. Conclusion Delirious ED patients with normal arousal at initial presentation had a three-fold increased hazard of death within 6-months compared to patients without delirium. There was a trend towards increased hazard of death in delirious ED patients with decreased arousal, but this relationship did not reach statistical significance. These data suggest that subtyping delirium by arousal may have prognostic value but requires confirmation with a larger study. PMID:27623552

Potential clinical and economic outcomes of active beta-D-glucan surveillance with preemptive therapy for invasive candidiasis at intensive care units: a decision model analysis.

PubMed

Pang, Y-K; Ip, M; You, J H S

2017-01-01

Early initiation of antifungal treatment for invasive candidiasis is associated with change in mortality. Beta-D-glucan (BDG) is a fungal cell wall component and a serum diagnostic biomarker of fungal infection. Clinical findings suggested an association between reduced invasive candidiasis incidence in intensive care units (ICUs) and BDG-guided preemptive antifungal therapy. We evaluated the potential cost-effectiveness of active BDG surveillance with preemptive antifungal therapy in patients admitted to adult ICUs from the perspective of Hong Kong healthcare providers. A Markov model was designed to simulate the outcomes of active BDG surveillance with preemptive therapy (surveillance group) and no surveillance (standard care group). Candidiasis-associated outcome measures included mortality rate, quality-adjusted life year (QALY) loss, and direct medical cost. Model inputs were derived from the literature. Sensitivity analyses were conducted to evaluate the robustness of model results. In base-case analysis, the surveillance group was more costly (1387 USD versus 664 USD) (1 USD = 7.8 HKD), with lower candidiasis-associated mortality rate (0.653 versus 1.426 per 100 ICU admissions) and QALY loss (0.116 versus 0.254) than the standard care group. The incremental cost per QALY saved by the surveillance group was 5239 USD/QALY. One-way sensitivity analyses found base-case results to be robust to variations of all model inputs. In probabilistic sensitivity analysis, the surveillance group was cost-effective in 50 % and 100 % of 10,000 Monte Carlo simulations at willingness-to-pay (WTP) thresholds of 7200 USD/QALY and ≥27,800 USD/QALY, respectively. Active BDG surveillance with preemptive therapy appears to be highly cost-effective to reduce the candidiasis-associated mortality rate and save QALYs in the ICU setting.

A community-based cluster randomized controlled trial (cRCT) to evaluate the impact and operational assessment of "safe motherhood and newborn health promotion package": study protocol.

PubMed

Hoque, Dewan Md Emdadul; Chowdhury, Mohiuddin Ahsanul Kabir; Rahman, Ahmed Ehsanur; Billah, Sk Masum; Bari, Sanwarul; Tahsina, Tazeen; Hasan, Mohammad Mehedi; Islam, Sajia; Islam, Tajul; Mori, Rintaro; Arifeen, Shams El

2018-05-03

Despite considerable progress in reduction of both under-five and maternal mortality in recent decades, Bangladesh is still one of the low and middle income countries with high burden of maternal and neonatal mortality. The primary objective of the current study is to measure the impact of a comprehensive package of interventions on maternal and neonatal mortality. In addition, changes in coverage, quality and utilization of maternal and newborn health (MNH) services, social capital, and cost effectiveness of the interventions will be measured. A community-based, cluster randomized controlled trial design will be adopted and implemented in 30 unions of three sub-districts of Chandpur district of Bangladesh. Every union, the lowest administrative unit of the local government with population of around 20,000-30,000, will be considered a cluster. Based on the baseline estimates, 15 clusters will be paired for random assignment as intervention and comparison clusters. The primary outcome measure is neonatal mortality, and secondary outcomes are coverage of key interventions like ANC, PNC, facility and skilled provider delivery. Baseline, midterm and endline household survey will be conducted to assess the key coverage of interventions. Health facility assessment surveys will be conducted periodically to assess facility readiness and utilization of MNH services in the participating health facilities. The current study is expected to provide essential strong evidences on the impact of a comprehensive package of interventions to the Bangladesh government, and other developmental partners. The study results may help in prioritizing, planning, and scaling-up of Safe Motherhood Promotional interventions in other geographical areas of Bangladesh as well as to inform other developing countries of similar settings. NCT03032276 .

Objective Sepsis Surveillance Using Electronic Clinical Data

PubMed Central

Rhee, Chanu; Kadri, Sameer; Huang, Susan S.; Murphy, Michael V.; Li, Lingling; Platt, Richard; Klompas, Michael

2016-01-01

OBJECTIVE To compare the accuracy of surveillance of severe sepsis using electronic health record clinical data vs claims and to compare incidence and mortality trends using both methods. DESIGN We created an electronic health record–based surveillance definition for severe sepsis using clinical indicators of infection (blood culture and antibiotic orders) and concurrent organ dysfunction (vasopressors, mechanical ventilation, and/or abnormal laboratory values). We reviewed 1,000 randomly selected medical charts to characterize the definition’s accuracy and stability over time compared with a claims-based definition requiring infection and organ dysfunction codes. We compared incidence and mortality trends from 2003–2012 using both methods. SETTING Two US academic hospitals. PATIENTS Adult inpatients. RESULTS The electronic health record–based clinical surveillance definition had stable and high sensitivity over time (77% in 2003–2009 vs 80% in 2012, P=.58) whereas the sensitivity of claims increased (52% in 2003–2009 vs 67% in 2012, P=.02). Positive predictive values for claims and clinical surveillance definitions were comparable (55% vs 53%, P=.65) and stable over time. From 2003 to 2012, severe sepsis incidence imputed from claims rose by 72% (95% CI, 57%–88%) and absolute mortality declined by 5.4% (95% CI, 4.6%–6.7%). In contrast, incidence using the clinical surveillance definition increased by 7.7% (95% CI, −1.1% to 17%) and mortality declined by 1.7% (95% CI, 1.1%–2.3%). CONCLUSIONS Sepsis surveillance using clinical data is more sensitive and more stable over time compared with claims and can be done electronically. This may enable more reliable estimates of sepsis burden and trends. PMID:26526737

Protocols and Hospital Mortality in Critically ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study

PubMed Central

Sevransky, Jonathan E.; Checkley, William; Herrera, Phabiola; Pickering, Brian W.; Barr, Juliana; Brown, Samuel M; Chang, Steven Y; Chong, David; Kaufman, David; Fremont, Richard D; Girard, Timothy D; Hoag, Jeffrey; Johnson, Steven B; Kerlin, Mehta P; Liebler, Janice; O'Brien, James; O'Keefe, Terence; Park, Pauline K; Pastores, Stephen M; Patil, Namrata; Pietropaoli, Anthony P; Putman, Maryann; Rice, Todd W.; Rotello, Leo; Siner, Jonathan; Sajid, Sahul; Murphy, David J; Martin, Greg S

2015-01-01

Objective Clinical protocols may decrease unnecessary variation in care and improve compliance with desirable therapies. We evaluated whether highly protocolized intensive care units have superior patient outcomes compared with less highly protocolized intensive care units. Design Observational study in which participating intensive care units completed a general assessment and enrolled new patients one day each week. Setting and Patients 6179 critically ill patients across 59 intensive care units in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study Interventions: None Measurements and Main Results The primary exposure was the number of intensive care unit protocols; the primary outcome was hospital mortality. 5809 participants were followed prospectively and 5454 patients in 57 intensive care units had complete outcome data. The median number of protocols per intensive care unit was 19 (IQR 15 to 21.5). In single variable analyses, there were no differences in intensive care unit and hospital mortality, length of stay, use of mechanical ventilation, vasopressors, or continuous sedation among individuals in intensive care units with a high vs. low number of protocols. The lack of association was confirmed in adjusted multivariable analysis (p=0.70). Protocol compliance with two ventilator management protocols was moderate and did not differ between intensive care units with high vs. low numbers of protocols for lung protective ventilation in ARDS (47% vs. 52%; p=0.28) and for spontaneous breathing trials (55% vs. 51%; p=0.27). Conclusions Clinical protocols are highly prevalent in United States intensive care units. The presence of a greater number of protocols was not associated with protocol compliance or patient mortality. PMID:26110488

Projected health impact of the Los Angeles City living wage ordinance

PubMed Central

Cole, B.; Shimkhada, R.; Morgenstern, H.; Kominski, G.; Fielding, J.; Wu, S.

2005-01-01

Study objective: To estimate the relative health effects of the income and health insurance provisions of the Los Angeles City living wage ordinance. Setting and participants: About 10 000 employees of city contractors are subject to the Los Angeles City living wage ordinance, which establishes an annually adjusted minimum wage ($7.99 per hour in July 2002) and requires employers to contribute $1.25 per hour worked towards employees' health insurance, or, if health insurance is not provided, to add this amount to wages. Design: As part of a comprehensive health impact assessment (HIA), we used estimates of the effects of health insurance and income on mortality from the published literature to construct a model to estimate and compare potential reductions in mortality attributable to the increases in wage and changes in health insurance status among workers covered by the Los Angeles City living wage ordinance. Results: The model predicts that the ordinance currently reduces mortality by 1.4 deaths per year per 10 000 workers at a cost of $27.5 million per death prevented. If the ordinance were modified so that all uninsured workers received health insurance, mortality would be reduced by eight deaths per year per 10 000 workers at a cost of $3.4 million per death prevented. Conclusions: The health insurance provisions of the ordinance have the potential to benefit the health of covered workers far more cost effectively than the wage provisions of the ordinance. This analytical model can be adapted and used in other health impact assessments of related policy actions that might affect either income or access to health insurance in the affected population. PMID:16020640

Patterns of coordination and clinical outcomes: a study of surgical services.

PubMed Central

Young, G J; Charns, M P; Desai, K; Khuri, S F; Forbes, M G; Henderson, W; Daley, J

1998-01-01

OBJECTIVE: To test the hypothesis that surgical services combining relatively high levels of feedback and programming approaches to the coordination of surgical staff would have better quality of care than surgical services using low levels of both coordination approaches as well as those surgical service using low levels of either coordination approach. STUDY SETTING: A study sample of 44 academically affiliated surgical services that are part of the Department of Veterans Affairs. STUDY DESIGN: In a cross-sectional analysis, surgical services were assigned to one of three groups based on their scores on feedback and programming coordination measures: high on both measures; high on one measure, low on the other; and low on both. Univariate and multivariate analyses were used to assess differences among these groups with respect to three quality indicators: risk-adjusted mortality, risk-adjusted morbidity, and staff perceptions of quality. DATA COLLECTION/EXTRACTION METHODS: Risk-adjusted mortality and morbidity came from an outcomes reporting program within the Department of Veterans Affairs that entails the prospective collection of clinical data from patient charts. Data on coordination practices and perceived quality came from a survey of surgical staff at each of the 44 participating surgical services. PRINCIPAL FINDINGS: The group of surgical services using high feedback and high programming had the best perceived quality. This group also had the lowest morbidity, but the difference was statistically significant with respect to only one of the two other groups: the group with low feedback and low programming. No significant group differences were found for mortality. CONCLUSIONS: Study results provide partial support for the hypothesis that high levels of feedback and programming should be combined for optimal quality of care. Study results also suggest that staff coordination is more important for improving morbidity than mortality in surgical services. PMID:9865218

Hydroxymethylglutaryl-CoA Reductase Inhibitors in Older Persons with Acute Myocardial Infarction: Evidence for an Age–Statin Interaction

PubMed Central

Foody, JoAnne Micale; Rathore, Saif S.; Galusha, Deron; Masoudi, Frederick A.; Havranek, Edward P.; Radford, Martha J.; Krumholz, Harlan M.

2009-01-01

OBJECTIVES To characterize the relationship between hydroxymethylglutaryl-CoA reductase inhibitors (statins) and outcomes in older persons with acute myocardial infarction (AMI). DESIGN Observational study. SETTING Acute care hospitals in the United States from April 1998 to June 2001. PARTICIPANTS Medicare patients aged 65 and older with a principal discharge diagnosis of AMI (N = 65,020) who did and did not receive a discharge prescription for statins. MEASUREMENTS The primary outcome of interest was all-cause mortality at 3 years after discharge. RESULTS Of 23,013 patients with AMI assessed, 5,513 (24.0%) were receiving a statin at discharge. Nearly 40% of eligible patients (n =8,452) were aged 80 and older, of whom 1,310 (15.5%) were receiving a statin at discharge. In a multivariable model taking into account demographic, clinical, physician and hospital characteristics, and propensity score, discharge statin therapy was associated with significantly lower 3-year mortality (hazard ratio (HR) =0.89 (95% confidence interval (CI) =0.83–0.96)). In an analysis stratified by age, discharge statins were associated with lower mortality in patients younger than 80 (HR =0.84, 95% CI =0.76–0.92) but not in those aged 80 and older (HR =0.97, 95% CI =0.87–1.09). CONCLUSION Statin therapy is associated with lower mortality in older patients with AMI younger than 80 but not in those aged 80 and older, as a group. This finding questions whether statin efficacy data in younger patients can be broadly applied to the very old and indicates the need for further study of this group. PMID:16551308

Complication Rates of Ostomy Surgery Are High and Vary Significantly Between Hospitals

PubMed Central

Sheetz, Kyle H.; Waits, Seth A.; Krell, Robert W.; Morris, Arden M.; Englesbe, Michael J.; Mullard, Andrew; Campbell, Darrell A.; Hendren, Samantha

2014-01-01

Structured Abstract Background Ostomy surgery is common and has traditionally been associated with high rates of morbidity and mortality, suggesting an important target for quality improvement. Objective To evaluate the variation in outcomes after ostomy creation surgery within Michigan in order to identify targets for quality improvement. Design Retrospective cohort study. Setting The 34-hospital Michigan Surgical Quality Collaborative (MSQC). Patients Patients undergoing ostomy creation surgery between 2006-2011. Main outcome measures We evaluated hospitals' morbidity and mortality rates after risk-adjustment (age, comorbidities, emergency v. elective, procedure type). Results 4,250 patients underwent ostomy creation surgery; 3,866 (91.0%) procedures were open and 384 (9.0%) were laparoscopic. Unadjusted morbidity and mortality rates were 43.9% and 10.7%, respectively. Unadjusted morbidity rates for specific procedures ranged from 32.7% for ostomy-creation-only procedures to 47.8% for Hartmann's procedures. Risk-adjusted morbidity rates varied significantly between hospitals, ranging from 31.2% (95%CI 18.4-43.9) to 60.8% (95%CI 48.9-72.6). There were five statistically-significant high-outlier hospitals and three statistically-significant low-outlier hospitals for risk-adjusted morbidity. The pattern of complication types was similar between high- and low-outlier hospitals. Case volume, operative duration, and use of laparoscopic surgery did not explain the variation in morbidity rates across hospitals. Conclusions Morbidity and mortality rates for modern ostomy surgery are high. While this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity to identify quality improvement practices that could be disseminated among hospitals. PMID:24819104

A SIMPLE FRAILTY QUESTIONNAIRE (FRAIL) PREDICTS OUTCOMES IN MIDDLE AGED AFRICAN AMERICANS

PubMed Central

MORLEY, J.E.; MALMSTROM, T.K.; MILLER, D.K.

2015-01-01

Objective To validate the FRAIL scale. Design Longitudinal study. Setting Community. Participants Representative sample of African Americans age 49 to 65 years at onset of study. Measurements The 5-item FRAIL scale (Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight), at baseline and activities of daily living (ADLs), instrumental activities of daily living (IADLs), mortality, short physical performance battery (SPPB), gait speed, one-leg stand, grip strength and injurious falls at baseline and 9 years. Blood tests for CRP, SIL6R, STNFR1, STNFR2 and 25 (OH) vitamin D at baseline. Results Cross-sectionally the FRAIL scale correlated significantly with IADL difficulties, SPPB, grip strength and one-leg stand among participants with no baseline ADL difficulties (N=703) and those outcomes plus gait speed in those with no baseline ADL dependencies (N=883). TNFR1 was increased in pre-frail and frail subjects and CRP in some subgroups. Longitudinally (N=423 with no baseline ADL difficulties or N=528 with no baseline ADL dependencies), and adjusted for the baseline value for each outcome, being pre-frail at baseline significantly predicted future ADL difficulties, worse one-leg stand scores, and mortality in both groups, plus IADL difficulties in the dependence-excluded group. Being frail at baseline significantly predicted future ADL difficulties, IADL difficulties, and mortality in both groups, plus worse SPPB in the dependence-excluded group. Conclusion This study has validated the FRAIL scale in a late middle-aged African American population. This simple 5-question scale is an excellent screening test for clinicians to identify frail persons at risk of developing disability as well as decline in health functioning and mortality. PMID:22836700

Comparison of outlier identification methods in hospital surgical quality improvement programs.

PubMed

Bilimoria, Karl Y; Cohen, Mark E; Merkow, Ryan P; Wang, Xue; Bentrem, David J; Ingraham, Angela M; Richards, Karen; Hall, Bruce L; Ko, Clifford Y

2010-10-01

Surgeons and hospitals are being increasingly assessed by third parties regarding surgical quality and outcomes, and much of this information is reported publicly. Our objective was to compare various methods used to classify hospitals as outliers in established surgical quality assessment programs by applying each approach to a single data set. Using American College of Surgeons National Surgical Quality Improvement Program data (7/2008-6/2009), hospital risk-adjusted 30-day morbidity and mortality were assessed for general surgery at 231 hospitals (cases = 217,630) and for colorectal surgery at 109 hospitals (cases = 17,251). The number of outliers (poor performers) identified using different methods and criteria were compared. The overall morbidity was 10.3% for general surgery and 25.3% for colorectal surgery. The mortality was 1.6% for general surgery and 4.0% for colorectal surgery. Programs used different methods (logistic regression, hierarchical modeling, partitioning) and criteria (P < 0.01, P < 0.05, P < 0.10) to identify outliers. Depending on outlier identification methods and criteria employed, when each approach was applied to this single dataset, the number of outliers ranged from 7 to 57 hospitals for general surgery morbidity, 1 to 57 hospitals for general surgery mortality, 4 to 27 hospitals for colorectal morbidity, and 0 to 27 hospitals for colorectal mortality. There was considerable variation in the number of outliers identified using different detection approaches. Quality programs seem to be utilizing outlier identification methods contrary to what might be expected, thus they should justify their methodology based on the intent of the program (i.e., quality improvement vs. reimbursement). Surgeons and hospitals should be aware of variability in methods used to assess their performance as these outlier designations will likely have referral and reimbursement consequences.

Tree mortality predicted from drought-induced vascular damage

USGS Publications Warehouse

Anderegg, William R.L.; Flint, Alan L.; Huang, Cho-ying; Flint, Lorraine E.; Berry, Joseph A.; Davis, Frank W.; Sperry, John S.; Field, Christopher B.

2015-01-01

The projected responses of forest ecosystems to warming and drying associated with twenty-first-century climate change vary widely from resiliency to widespread tree mortality1, 2, 3. Current vegetation models lack the ability to account for mortality of overstorey trees during extreme drought owing to uncertainties in mechanisms and thresholds causing mortality4, 5. Here we assess the causes of tree mortality, using field measurements of branch hydraulic conductivity during ongoing mortality in Populus tremuloides in the southwestern United States and a detailed plant hydraulics model. We identify a lethal plant water stress threshold that corresponds with a loss of vascular transport capacity from air entry into the xylem. We then use this hydraulic-based threshold to simulate forest dieback during historical drought, and compare predictions against three independent mortality data sets. The hydraulic threshold predicted with 75% accuracy regional patterns of tree mortality as found in field plots and mortality maps derived from Landsat imagery. In a high-emissions scenario, climate models project that drought stress will exceed the observed mortality threshold in the southwestern United States by the 2050s. Our approach provides a powerful and tractable way of incorporating tree mortality into vegetation models to resolve uncertainty over the fate of forest ecosystems in a changing climate.

Improving antiretroviral therapy scale-up and effectiveness through service integration and decentralization.

PubMed

Suthar, Amitabh B; Rutherford, George W; Horvath, Tara; Doherty, Meg C; Negussie, Eyerusalem K

2014-03-01

Current service delivery systems do not reach all people in need of antiretroviral therapy (ART). In order to inform the operational and service delivery section of the WHO 2013 consolidated antiretroviral guidelines, our objective was to summarize systematic reviews on integrating ART delivery into maternal, newborn, and child health (MNCH) care settings in countries with generalized epidemics, tuberculosis (TB) treatment settings in which the burden of HIV and TB is high, and settings providing opiate substitution therapy (OST); and decentralizing ART into primary health facilities and communities. A summary of systematic reviews. The reviewers searched PubMed, Embase, PsycINFO, Web of Science, CENTRAL, and the WHO Index Medicus databases. Randomized controlled trials and observational cohort studies were included if they compared ART coverage, retention in HIV care, and/or mortality in MNCH, TB, or OST facilities providing ART with MNCH, TB, or OST facilities providing ART services separately; or primary health facilities or communities providing ART with hospitals providing ART. The reviewers identified 28 studies on integration and decentralization. Antiretroviral therapy integration into MNCH facilities improved ART coverage (relative risk [RR] 1.37, 95% confidence interval [CI] 1.05-1.79) and led to comparable retention in care. ART integration into TB treatment settings improved ART coverage (RR 1.83, 95% CI 1.48-2.23) and led to a nonsignificant reduction in mortality (RR 0.55, 95% CI 0.29-1.05). The limited data on ART integration into OST services indicated comparable rates of ART coverage, retention, and mortality. Partial decentralization into primary health facilities improved retention (RR 1.05, 95% CI 1.01-1.09) and reduced mortality (RR 0.34, 95% CI 0.13-0.87). Full decentralization improved retention (RR 1.12, 95% CI 1.08-1.17) and led to comparable mortality. Community-based ART led to comparable rates of retention and mortality. Integrating ART into MNCH, TB, and OST services was often associated with improvements in ART coverage, and decentralization of ART into primary health facilities and communities was often associated with improved retention. Neither integration nor decentralization was associated with adverse outcomes. These data contributed to recommendations in the WHO 2013 consolidated antiretroviral guidelines to integrate ART delivery into MNCH, TB, and OST services and to decentralize ART.

Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study.

PubMed

Schmidt, Matthieu; Stewart, Claire; Bailey, Michael; Nieszkowska, Ania; Kelly, Joshua; Murphy, Lorna; Pilcher, David; Cooper, D James; Scheinkestel, Carlos; Pellegrino, Vincent; Forrest, Paul; Combes, Alain; Hodgson, Carol

2015-03-01

To describe mechanical ventilation settings in adult patients treated for an acute respiratory distress syndrome with extracorporeal membrane oxygenation and assess the potential impact of mechanical ventilation settings on ICU mortality. Retrospective observational study. Three international high-volume extracorporeal membrane oxygenation centers. A total of 168 patients treated with extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from January 2007 to January 2013. We analyzed the association between mechanical ventilation settings (i.e. plateau pressure, tidal volume, and positive end-expiratory pressure) on ICU mortality using multivariable logistic regression model and Cox-proportional hazards model. We obtained detailed demographic, clinical, daily mechanical ventilation settings and ICU outcome data. One hundred sixty-eight patients (41 ± 14 years old; PaO2/FIO2 67 ± 19 mm Hg) fulfilled our inclusion criteria. Median duration of extracorporeal membrane oxygenation and ICU stay were 10 days (6-18 d) and 28 days (16-42 d), respectively. Lower positive end-expiratory pressure levels and significantly lower plateau pressures during extracorporeal membrane oxygenation were used in the French center than in both Australian centers (23.9 ± 1.4 vs 27.6 ± 3.7 and 27.8 ± 3.6; p < 0.0001). Overall ICU mortality was 29%. Lower positive end-expiratory pressure levels (until day 7) and lower delivered tidal volume after 3 days on extracorporeal membrane oxygenation were associated with significantly higher mortality (p < 0.05). In multivariate analysis, higher positive end-expiratory pressure levels during the first 3 days of extracorporeal membrane oxygenation support were associated with lower mortality (odds ratio, 0.75; 95% CI, 0.64-0.88; p = 0.0006). Other independent predictors of ICU mortality included time between ICU admission and extracorporeal membrane oxygenation initiation, plateau pressure greater than 30 cm H2O before extracorporeal membrane oxygenation initiation, and lactate level on day 3 of extracorporeal membrane oxygenation support. Protective mechanical ventilation strategies were routinely used in high-volume extracorporeal membrane oxygenation centers. However, higher positive end-expiratory pressure levels during the first 3 days on extracorporeal membrane oxygenation support were independently associated with improved survival. Further prospective trials on the optimal mechanical ventilation strategy during extracorporeal membrane oxygenation support are warranted.

A New Look at Care in Pregnancy: Simple, Effective Interventions for Neglected Populations

PubMed Central

Hodgins, Stephen; Tielsch, James; Rankin, Kristen; Robinson, Amber; Kearns, Annie; Caglia, Jacquelyn

2016-01-01

Background Although this is beginning to change, the content of antenatal care has been relatively neglected in safe-motherhood program efforts. This appears in part to be due to an unwarranted belief that interventions over this period have far less impact than those provided around the time of birth. In this par, we review available evidence for 21 interventions potentially deliverable during pregnancy at high coverage to neglected populations in low income countries, with regard to effectiveness in reducing risk of: maternal mortality, newborn mortality, stillbirth, prematurity and intrauterine growth restriction. Selection was restricted to interventions that can be provided by non-professional health auxiliaries and not requiring laboratory support. Methods In this narrative review, we included relevant Cochrane and other systematic reviews and did comprehensive bibliographic searches. Inclusion criteria varied by intervention; where available randomized controlled trial evidence was insufficient, observational study evidence was considered. For each intervention we focused on overall contribution to our outcomes of interest, across varying epidemiologies. Results In the aggregate, achieving high effective coverage for this set of interventions would very substantially reduce risk for our outcomes of interest and reduce outcome inequities. Certain specific interventions, if pushed to high coverage have significant potential impact across many settings. For example, reliable detection of pre-eclampsia followed by timely delivery could prevent up to ¼ of newborn and stillbirth deaths and over 90% of maternal eclampsia/pre-eclampsia deaths. Other interventions have potent effects in specific settings: in areas of high P falciparum burden, systematic use of insecticide-treated nets and/or intermittent presumptive therapy in pregnancy could reduce maternal mortality by up to 10%, newborn mortality by up to 20%, and stillbirths by up to 25–30%. Behavioral interventions targeting practices at birth and in the hours that follow can have substantial impact in settings where many births happen at home: in such circumstances early initiation of breastfeeding can reduce risk of newborn death by up to 20%; good thermal care practices can reduce mortality risk by a similar order of magnitude. Conclusions Simple interventions delivered during pregnancy have considerable potential impact on important mortality outcomes. More programmatic effort is warranted to ensure high effective coverage. PMID:27537281

Genetic selection to increase bone strength affects prevalence of keel bone damage and egg parameters in commercially housed laying hens.

PubMed

Stratmann, A; Fröhlich, E K F; Gebhardt-Henrich, S G; Harlander-Matauschek, A; Würbel, H; Toscano, M J

2016-05-01

The prevalence of keel bone damage as well as external egg parameters of 2 pure lines divergently selected for high (H) and low (L) bone strength were investigated in 2 aviary systems under commercial conditions. A standard LSL hybrid was used as a reference group. Birds were kept mixed per genetic line (77 hens of the H and L line and 201 or 206 hens of the LSL line, respectively, per pen) in 8 pens of 2 aviary systems differing in design. Keel bone status and body mass of 20 focal hens per line and pen were assessed at 17, 18, 23, 30, 36, 43, 52, and 63 wk of age. External egg parameters (i.e., egg mass, eggshell breaking strength, thickness, and mass) were measured using 10 eggs per line at both 38 and 57 wk of age. Body parameters (i.e. tarsus and third primary wing feather length to calculate index of wing loading) were recorded at 38 wk of age and mortality per genetic line throughout the laying cycle. Bone mineral density (BMD) of 15 keel bones per genetic line was measured after slaughter to confirm assignment of the experimental lines. We found a greater BMD in the H compared with the L and LSL lines. Fewer keel bone fractures and deviations, a poorer external egg quality, as well as a lower index of wing loading were found in the H compared with the L line. Mortality was lower and production parameters (e.g., laying performance) were higher in the LSL line compared with the 2 experimental lines. Aviary design affected prevalence of keel bone damage, body mass, and mortality. We conclude that selection of specific bone traits associated with bone strength as well as the related differences in body morphology (i.e., lower index of wing loading) have potential to reduce keel bone damage in commercial settings. Also, the housing environment (i.e., aviary design) may have additive effects. © 2016 Poultry Science Association Inc.

Urbanisation and child health in resource poor settings with special reference to under-five mortality in Africa.

PubMed

Garenne, Michel

2010-06-01

The health of children improved dramatically worldwide during the 20th century, although with major contrasts between developed and developing countries, and urban and rural areas. The quantitative evidence on urban child health from a broad historical and comparative perspective is briefly reviewed here. Before the sanitary revolution, urban mortality tended to be higher than rural mortality. However, after World War I, improvements in water, sanitation, hygiene, nutrition and child care resulted in lower urban child mortality in Europe. Despite a similar mortality decline, urban mortality in developing countries since World War II has been generally lower than rural mortality, probably because of better medical care, higher socio-economic status and better nutrition in urban areas. However, higher urban mortality has recently been seen in the slums of large cities in developing countries as a result of extreme poverty, family disintegration, lack of hygiene, sanitation and medical care, low nutritional status, emerging diseases (HIV/AIDS and tuberculosis) and other health hazards (environmental hazards, accidents, violence). These emerging threats need to be addressed by appropriate policies and programmes.

Laboratory tests on heat treatment of ballast water using engine waste heat.

PubMed

Balaji, Rajoo; Lee Siang, Hing; Yaakob, Omar; Koh, Kho King; Adnan, Faizul Amri Bin; Ismail, Nasrudin Bin; Ahmad, Badruzzaman Bin; Ismail, Mohd Arif Bin; Wan Nik, W B

2018-05-01

Waste heat recovery from shipboard machineries could be a potential source for heat treatment of ballast water. Similar to a shipboard schematic arrangement, a laboratory-scale engine-heat exchanger set-up harvesting waste heat from jacket water and exhaust gases was erected to test the level of species' mortalities. Mortalities were also assessed under experimental conditions for cultured and natural plankton communities at laboratory level. Effect of pump impellers on species' mortalities were also tested. Exposures between 60°C and 70°C for 60 sec resulted in 80-100% mortalities. Mortalities due to pump impeller effects were observed in the range of 70-100% for zooplankton. On the laboratory-scale arrangement, >95% mortalities of phytoplankton, zooplankton and bacteria were recorded. It was demonstrated that the temperature of tropical sea waters used as secondary coolant can be raised to cause species' mortalities, employing engine exhaust gases. The results also indicated that pump impeller effects will enhance species' mortalities. The limitations of the shipboard application of this method would be the large ballast volumes, flow rates and time for treatment.

Mexico's path towards the Sustainable Development Goal for health: an assessment of the feasibility of reducing premature mortality by 40% by 2030.

PubMed

González-Pier, Eduardo; Barraza-Lloréns, Mariana; Beyeler, Naomi; Jamison, Dean; Knaul, Felicia; Lozano, Rafael; Yamey, Gavin; Sepúlveda, Jaime

2016-10-01

The United Nations Sustainable Development Goal for health (SDG3) poses complex challenges for signatory countries that will require clear roadmaps to set priorities over the next 15 years. Building upon the work of the Commission on Investing in Health and published estimates of feasible global mortality SDG3 targets, we analysed Mexico's mortality to assess the feasibility of reducing premature (0-69 years) mortality and propose a path to meet SDG3. We developed a baseline scenario applying 2010 age-specific and cause-specific mortality rates from the Mexican National Institute of Statistics and Geography (INEGI) to the 2030 UN Population Division (UNPD) population projections. In a second scenario, INEGI age-specific and cause-specific trends in death rates from 2000 to 2014 were projected to 2030 and adjusted to match the UNPD 2030 mortality projections. A third scenario assumed a 40% reduction in premature deaths across all ages and causes. By comparing these scenarios we quantified shortfalls in mortality reductions by age group and cause, and forecasted life expectancy pathways for Mexico to converge to better performing countries. UNPD-projected death rates yield a 25·9% reduction of premature mortality for Mexico. Accelerated reductions in adult mortality are necessary to reach a 40% reduction by 2030. Mortality declines aggregated across all age groups mask uneven gains across health disorders. Injuries, particularly road traffic accidents and homicides, are the main health challenge for young adults (aged 20-49 years) whereas unabated diabetes mortality is the single most important health concern for older adults (aged 50-69 years). Urgent action is now required to control non-communicable diseases and reduce fatal injuries in Mexico, making a 40% reduction in premature mortality by 2030 feasible and putting Mexico back on a track of substantial life expectancy convergence with better performing countries. Our study provides a roadmap for setting national health priorities. Further analysis of the equity implications of following the suggested pathway remains a subject of future research. Mexico's Ministry of Health, University of California, San Francisco, and Bill & Melinda Gates Foundation. Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.

Fine particulate matter (PM2.5) air pollution and selected causes of postneonatal infant mortality in California.

PubMed

Woodruff, Tracey J; Parker, Jennifer D; Schoendorf, Kenneth C

2006-05-01

Studies suggest that airborne particulate matter (PM) may be associated with postneonatal infant mortality, particularly with respiratory causes and sudden infant death syndrome (SIDS). To further explore this issue, we examined the relationship between long-term exposure to fine PM air pollution and postneonatal infant mortality in California. We linked monitoring data for PM

Measuring hospital performance in congenital heart surgery: administrative versus clinical registry data.

PubMed

Pasquali, Sara K; He, Xia; Jacobs, Jeffrey P; Jacobs, Marshall L; Gaies, Michael G; Shah, Samir S; Hall, Matthew; Gaynor, J William; Peterson, Eric D; Mayer, John E; Hirsch-Romano, Jennifer C

2015-03-01

In congenital heart surgery, hospital performance has historically been assessed using widely available administrative data sets. Recent studies have demonstrated inaccuracies in case ascertainment (coding and inclusion of eligible cases) in administrative versus clinical registry data; however, it is unclear whether this impacts assessment of performance on a hospital level. Merged data from The Society of Thoracic Surgeons (STS) database (clinical registry) and the Pediatric Health Information Systems (PHIS) database (administrative data set) for 46,056 children undergoing cardiac operations (2006-2010) were used to evaluate in-hospital mortality for 33 hospitals based on their administrative versus registry data. Standard methods to identify/classify cases were used: Risk Adjustment in Congenital Heart Surgery, version 1 (RACHS-1) in the administrative data and STS-European Association for Cardiothoracic Surgery (STAT) methodology in the registry. Median hospital surgical volume based on the registry data was 269 cases per year; mortality was 2.9%. Hospital volumes and mortality rates based on the administrative data were on average 10.7% and 4.7% lower, respectively, although this varied widely across hospitals. Hospital rankings for mortality based on the administrative versus registry data differed by 5 or more rank positions for 24% of hospitals, with a change in mortality tertile classification (high, middle, or low mortality) for 18% and a change in statistical outlier classification for 12%. Higher volume/complexity hospitals were most impacted. Agency for Healthcare Quality and Research (AHRQ) methods in the administrative data yielded similar results. Inaccuracies in case ascertainment in administrative versus clinical registry data can lead to important differences in assessment of hospital mortality rates for congenital heart surgery. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Reducing under-five mortality through Hôpital Albert Schweitzer's integrated system in Haiti.

PubMed

Perry, Henry; Cayemittes, Michel; Philippe, Francois; Dowell, Duane; Dortonne, Jean Richard; Menager, Henri; Bottex, Erve; Berggren, Warren; Berggren, Gretchen

2006-05-01

The degree to which local health systems contribute to reductions in under-five mortality in severely impoverished settings has not been well documented. The current study compares the under-five mortality in the Hôpital Albert Schweitzer (HAS) Primary Health Care Service Area with that for Haiti in general. HAS provides an integrated system of community-based primary health care services, hospital care and community development. A sample of 10% of the women of reproductive age in the HAS service area was interviewed, and 2390 live births and 149 child deaths were documented for the period 1995-99. Under-five mortality rates were computed and compared with rates for Haiti. In addition, available data regarding inputs, processes and outputs for the HAS service area and for Haiti were assembled and compared. Under-five mortality was 58% less in the HAS service area, and mortality for children 12-59 months of age was 76% less. These results were achieved with an input of fewer physicians and hospital beds per capita than is available for Haiti nationwide, but with twice as many graduate nurses and auxiliary nurses per capita than are available nationwide, and with three cadres of health workers that do not exist nationwide: Physician Extenders, Health Agents and Community Health Volunteers. The population coverage of targeted child survival services was generally 1.5-2 times higher in the HAS service area than in rural Haiti. These findings support the conclusion that a well-developed system of primary health care, with outreach services to the household level, integrated with hospital referral care and community development programmes, can make a strong contribution to reducing infant and child mortality in severely impoverished settings.

The Effect of Race and Ethnicity on Outcomes Among Patients in the Intensive Care Unit: A Comprehensive Study Involving Socioeconomic Status and Resuscitation Preferences

PubMed Central

Erickson, Sara E.; Vasilevskis, Eduard E.; Kuzniewicz, Michael W.; Cason, Brian A.; Lane, Rondall K.; Dean, Mitzi L.; Rennie, Deborah J.; Dudley, R. Adams

2013-01-01

Objective We sought to determine whether race or ethnicity is independently associated with mortality or intensive care unit (ICU) length of stay (LOS) among critically ill patients after accounting for patients' clinical and demographic characteristics including socioeconomic status and resuscitation preferences. Design Historical cohort study of patients hospitalized in intensive care units. Setting Adult intensive care units in 35 California hospitals during the years 2001-2004. Patients A total of 9,518 ICU patients (6334 white, 655 black, 1917 Hispanic and 612 Asian/Pacific Islander patients). Measurements and Main Results The primary outcome was risk-adjusted mortality and a secondary outcome was risk-adjusted ICU LOS. Crude hospital mortality was 15.9% among the entire cohort. Asian patients had the highest crude hospital mortality at 18.6% and black patients had the lowest at 15.0%. After adjusting for age and gender, Hispanic and Asian patients had a higher risk of death compared to white patients, but these differences were not significant after additional adjustment for severity of illness. Black patients had more acute physiologic derangements at ICU admission and longer unadjusted ICU LOS. ICU LOS was not significantly different among racial/ethnic groups after adjustment for demographic, clinical, socioeconomic factors and do-not-resuscitate status. In an analysis restricted only to those who died, decedent black patients averaged 1.1 additional days in the ICU (95% CI – 0.26 to 2.6) compared to white patients who died, although this was not statistically significant. Conclusions Hospital mortality and ICU LOS did not differ by race or ethnicity among this diverse cohort of critically ill patients after adjustment for severity of illness, resuscitation status, SES, insurance status and admission type. Black patients had more acute physiologic derangements at ICU admission and were less likely to have a DNR order. These results suggest that among ICU patients, there are not racial or ethnic differences in mortality within individual hospitals. If disparities in ICU care exist, they may be explained by differences in the quality of care provided by hospitals that serve high proportions of minority patients. PMID:21187746

Estimating dead-space fraction for secondary analyses of ARDS clinical trials

PubMed Central

Beitler, Jeremy R.; Thompson, B. Taylor; Matthay, Michael A.; Talmor, Daniel; Liu, Kathleen D.; Zhuo, Hanjing; Hayden, Douglas; Spragg, Roger G.; Malhotra, Atul

2015-01-01

Objective Pulmonary dead-space fraction is one of few lung-specific independent predictors of mortality from acute respiratory distress syndrome (ARDS). However, it is not measured routinely in clinical trials and thus altogether ignored in secondary analyses that shape future research directions and clinical practice. This study sought to validate an estimate of dead-space fraction for use in secondary analyses of clinical trials. Design Analysis of patient-level data pooled from ARDS clinical trials. Four approaches to estimate dead-space fraction were evaluated: three required estimating metabolic rate; one estimated dead-space fraction directly. Setting U.S. academic teaching hospitals. Patients Data from 210 patients across three clinical trials were used to compare performance of estimating equations with measured dead-space fraction. A second cohort of 3,135 patients from six clinical trials without measured dead-space fraction was used to confirm whether estimates independently predicted mortality. Interventions None. Measurements and Main Results Dead-space fraction estimated using the unadjusted Harris-Benedict equation for energy expenditure was unbiased (mean ± SD Harris-Benedict 0.59 ± 0.13; measured 0.60 ± 0.12). This estimate predicted measured dead-space fraction to within ± 0.10 in 70% of patients and ± 0.20 in 95% of patients. Measured dead-space fraction independently predicted mortality (OR 1.36 per 0.05 increase in dead-space fraction, 95% CI 1.10–1.68; p < .01). The Harris-Benedict estimate closely approximated this association with mortality in the same cohort (OR 1.55, 95% CI 1.21–1.98; p < .01) and remained independently predictive of death in the larger ARDSNet cohort. Other estimates predicted measured dead-space fraction or its association with mortality less well. Conclusions Dead-space fraction should be measured in future ARDS clinical trials to facilitate incorporation into secondary analyses. For analyses where dead-space fraction was not measured, the Harris-Benedict estimate can be used to estimate dead-space fraction and adjust for its association with mortality. PMID:25738857

Effects of aging on the immunopathological response to sepsis

PubMed Central

Turnbull, Isaiah R.; Clark, Andrew T.; Stromberg, Paul E.; Dixon, David J.; Woolsey, Cheryl A.; Davis, Christopher G.; Hotchkiss, Richard S.; Buchman, Timothy G.; Coopersmith, Craig M.

2009-01-01

Objective Aging is associated with increased inflammation following sepsis. The purpose of this study was to determine if this represents a fundamental age-based difference in the host response or is secondary to the increased mortality seen in aged hosts. Design Prospective, randomized controlled study. Setting Animal laboratory in a university medical center. Subjects Young (6–12 week) and aged (20–24 month) FVB/N mice. Interventions Mice were subjected to 2×25 or 1×30 cecal ligation and puncture (CLP). Measurements and Main Results Survival was similar in young mice subjected to 2×25 CLP and aged mice subjected to 1×30 CLP (p=0.15). Young mice subjected to 1×30 CLP had improved survival compared to both other groups (p<0.05). When injury was held constant but mortality was greater, both systemic and peritoneal levels of TNF-α, IL-6, IL-10 and MCP-1 were elevated 24 hours after CLP in aged animals compared to young animals (p<0.05). When mortality was similar but injury severity was different, there were no significant differences in systemic cytokines between aged mice and young mice. In contrast, peritoneal levels of TNF-α, IL-6, and IL-10 were higher in aged mice subjected to 1×30 CLP than young mice subjected to 2×25 CLP despite their similar mortalities (p<0.05). There were no significant differences in either bacteremia or peritoneal cultures when animals of different ages sustained similar injuries or had different injuries with similar mortalities. Conclusions Aged mice are more likely to die from sepsis than young mice when subjected to an equivalent insult, and this is associated with increases in both systemic and local inflammation. There is an exaggerated local but not systemic inflammatory response in aged mice compared to young mice when mortality is similar. This suggests that systemic processes that culminate in death may be age-independent, but the local inflammatory response may be greater with aging. PMID:19237912

Gender-Based Disparities in Infant and Child Mortality Based on Maternal Exposure to Spousal Violence

PubMed Central

Silverman, Jay G.; Decker, Michele R.; Cheng, Debbie M.; Wirth, Kathleen; Saggurti, Niranjan; McCauley, Heather L.; Falb, Kathryn L.; Donta, Balaiah; Raj, Anita

2014-01-01

Objectives To examine associations between intimate partner violence (IPV) against Indian women and risk of death among their infants and children, as well as related gender-based disparities. Design Analyses of nationally representative data to estimate adjusted hazard ratios (aHRs) and attributable risks for infant and child mortality based on child gender and on IPV against mothers. Setting India. Participants Women aged 15 to 49 years (n=59 467) across all 29 Indian states participating in the Indian National Family Health Survey 3 provided information about 158 439 births and about infant and child mortality occurring during the 20 years before the survey. Main Outcome Measures Maternal IPV and infant and child (<5 years) mortality among boy vs girl children. Results Infant mortality was greater among infants whose mothers experienced IPV (79.2 of 1000 births) vs those whose mothers did not experience IPV (59.1 of 1000 births) (aHR, 1.09; 95% confidence interval [CI], 1.03–1.15); this effect was significant only for girls (1.15; 1.07–1.24; for boys, 1.04; 0.97–1.11). Child mortality was also greater among children whose mothers experienced IPV (103.6 of 1000 births) vs those whose mothers did not experience IPV (74.8 per 1000 births) (aHR, 1.10; 95% CI, 1.05–1.15); again, this effect was significant only for girls (1.14; 1.07–1.21; for boys, 1.05; 0.99–1.12). An estimated 58 021 infant girl deaths and 89 264 girl child deaths were related to spousal violence against wives annually, or approximately 1.2 million female infant deaths and 1.8 million girl deaths in India between December 1985 and August 2005. Conclusion Intimate partner violence against women should be considered an urgent priority within programs and policies aimed at maximizing survival of children in India, particularly those attempting to increase the survival of girls 5 years and younger. PMID:21199976

Indication for Dialysis Initiation and Mortality in Patients With Chronic Kidney Failure: A Retrospective Cohort Study

PubMed Central

Rivara, Matthew B.; Chen, Chang Huei; Nair, Anupama; Cobb, Denise; Himmelfarb, Jonathan; Mehrotra, Rajnish

2016-01-01

Background Initiation of maintenance dialysis for patients with chronic kidney failure is a period of high risk for adverse patient outcomes. Whether indications for dialysis initiation are associated with mortality among this population is unknown. Study Design Retrospective cohort study. Setting & Participants 461 patients who initiated dialysis (hemodialysis, 437; peritoneal dialysis, 24) from January 1st, 2004 through December 31st, 2012 and were treated in facilities operated by a single dialysis organization. Follow-up for the primary outcome was through December 31st, 2013. Predictor Clinically documented primary indication for dialysis initiation, as categorized into four groups: laboratory evidence of kidney function decline (reference category), uremic symptoms, volume overload or hypertension, and other/unknown. Outcomes All-cause mortality Results Over a median follow-up of 2.4 years, 183 (40%) patients died. Crude mortality rates were 10.0 (95% CI, 6.8–14.7), 12.7 (95% CI, 10.2–15.7), 21.7 (95% CI, 16.4–28.6), and 12.2 (95% CI, 6.8–14.7) per 100 patient-years among patients initiating dialysis primarily for laboratory evidence of kidney function decline, uremic symptoms, volume overload or hypertension, and other/unknown reason, respectively. Following adjustment for demographic variables, coexisting illnesses, and estimated glomerular filtration rate, initiation of dialysis for uremic symptoms, volume overload or hypertension, or for other/unknown reasons were associated with 1.12 (95% CI, 0.72–1.77), 1.71 (95% CI, 1.03–2.84), and 1.28 (95% CI, 0.73–2.26) times higher risk, respectively, for subsequent mortality compared to initiation for laboratory evidence of kidney function decline. Limitations Possibility of residual confounding by unmeasured variables; reliance on clinical documentation to ascertain exposure Conclusions Patients initiating dialysis due to volume overload may have increased risk for mortality compared to patients initiating dialysis due to laboratory evidence of kidney function decline. Further studies are needed to identify and test interventions that might reduce this risk. PMID:27637132

Impact of Educational Attainment on Health Outcomes in Moderate to Severe CKD

PubMed Central

Morton, Rachael L.; Schlackow, Iryna; Staplin, Natalie; Gray, Alastair; Cass, Alan; Haynes, Richard; Emberson, Jonathan; Herrington, William; Landray, Martin J.; Baigent, Colin; Mihaylova, Borislava

2016-01-01

Background The inverse association between educational attainment and mortality is well established, but its relevance to vascular events and renal progression in a population with chronic kidney disease (CKD) is less clear. This study aims to determine the association between highest educational attainment and risk of vascular events, cause-specific mortality, and CKD progression. Study Design Prospective epidemiologic analysis among participants in the Study of Heart and Renal Protection (SHARP), a randomized controlled trial. Setting & Participants 9,270 adults with moderate to severe CKD (6,245 not receiving dialysis at baseline) and no history of myocardial infarction or coronary revascularization recruited in Europe, North America, Asia, Australia, and New Zealand. Predictor Highest educational attainment measured at study entry using 6 levels that ranged from “no formal education” to “tertiary education.” Outcomes Any vascular event (any fatal or nonfatal cardiac, cerebrovascular, or peripheral vascular event), cause-specific mortality, and CKD progression during 4.9 years’ median follow-up. Results There was a significant trend (P < 0.001) toward increased vascular risk with decreasing levels of education. Participants with no formal education were at a 46% higher risk of vascular events (relative risk [RR], 1.46; 95% CI, 1.14-1.86) compared with participants with tertiary education. The trend for mortality across education levels was also significant (P < 0.001): all-cause mortality was twice as high among those with no formal education compared with tertiary-educated individuals (RR, 2.05; 95% CI, 1.62-2.58), and significant increases were seen for both vascular (RR, 1.84; 95% CI, 1.21-2.81) and nonvascular (RR, 2.15; 95% CI, 1.60-2.89) deaths. Lifestyle factors and prior disease explain most of the excess mortality risk. Among 6,245 participants not receiving dialysis at baseline, education level was not significantly associated with progression to end-stage renal disease or doubling of creatinine level (P for trend = 0.4). Limitations No data for employment or health insurance coverage. Conclusions Lower educational attainment is associated with increased risk of adverse health outcomes in individuals with CKD. PMID:26385817

Intensive Care Unit Utilization Among Medicare Patients Hospitalized with Non-ST-Segment Elevation Myocardial Infarction

PubMed Central

Fanaroff, Alexander C; Peterson, Eric D; Chen, Anita Y; Thomas, Laine; Doll, Jacob D; Fordyce, Christopher B; Newby, L Kristin; Amsterdam, Ezra A; Kosiborod, Mikhail N; de Lemos, James A; Wang, Tracy Y

2018-01-01

Importance Intensive care unit (ICU) utilization may have important implications for the care and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI). Objectives To examine inter-hospital variation in ICU utilization in the United States for older adults with hemodynamically stable NSTEMI and outcomes associated with ICU utilization among patients with at low, moderate, or high mortality risk. Design, Settings and Participants Retrospective analysis of 28,018 Medicare patients ≥65 years old admitted with NSTEMI to 346 hospitals participating in ACTION Registry-GWTG between April 1, 2011 and December 31, 2012. Patients with cardiogenic shock or cardiac arrest on presentation were excluded. Exposure Hospitals with high (>70% NSTEMI patients treated in an ICU during the index hospitalization), intermediate (30–70%), or low (< 30%) ICU utilization rates Main Outcome and Measure 30-day mortality Results Of NSTEMI patients ≥ 65 years old, 11,934 (43%) had an ICU stay. The proportion of NSTEMI patients treated in the ICU varied across hospitals (median 38% [26%, 54%]), but there were no significant differences in hospital characteristics or NSTEMI patient characteristics between hospitals with high, intermediate, or low ICU utilization rates. Compared with high ICU utilization hospitals, hospitals with low or intermediate ICU utilizations rates were only marginally more selective of higher risk patients, as determined by ACTION in-hospital mortality risk score or initial troponin level. Thirty-day mortality rates did not significantly differ based on hospital ICU utilization (high vs. low: 8.7% vs. 8.7%, adjusted OR 0.91, 95% CI 0.76–1.08; intermediate vs. low: 9.6% vs. 8.7%, adjusted OR 1.06, 95% CI 0.94–1.20). The relationship between hospital ICU utilization and mortality was similar in analyses stratified by low, moderate, or high ACTION risk score categories (adjusted interaction p 0.86). Conclusions and Relevance ICU utilization for older NSTEMI patients varied significantly among hospitals. This variability was not explained by hospital characteristics nor driven by patient risk. Post-MI mortality did not significantly differ among hospitals with high, intermediate, or low ICU utilization. PMID:27806171

Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study

PubMed Central

Macintosh, Mary C M; Fleming, Kate M; Bailey, Jaron A; Doyle, Pat; Modder, Jo; Acolet, Dominique; Golightly, Shona; Miller, Alison

2006-01-01

Objective To provide perinatal mortality and congenital anomaly rates for babies born to women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland. Design National population based pregnancy cohort. Setting 231 maternity units in England, Wales, and Northern Ireland. Participants 2359 pregnancies to women with type 1 or type 2 diabetes who delivered between 1 March 2002 and 28 February 2003. Main outcome measures Stillbirth rates; perinatal and neonatal mortality; prevalence of congenital anomalies. Results Of 2359 women with diabetes, 652 had type 2 diabetes and 1707 had type 1 diabetes. Women with type 2 diabetes were more likely to come from a Black, Asian, or other ethnic minority group (type 2, 48.8%; type 1, 9.1%) and from a deprived area (type 2, 46.3% in most deprived fifth; type 1, 22.8%). Perinatal mortality in babies of women with diabetes was 31.8/1000 births. Perinatal mortality was comparable in babies of women with type 1 (31.7/1000 births) and type 2 diabetes (32.3/1000) and was nearly four times higher than that in the general maternity population. 141 major congenital anomalies were confirmed in 109 offspring. The prevalence of major congenital anomaly was 46/1000 births in women with diabetes (48/1000 births for type 1 diabetes; 43/1000 for type 2 diabetes), more than double that expected. This increase was driven by anomalies of the nervous system, notably neural tube defects (4.2-fold), and congenital heart disease (3.4-fold). Anomalies in 71/109 (65%) offspring were diagnosed antenatally. Congenital heart disease was diagnosed antenatally in 23/42 (54.8%) offspring; anomalies other than congenital heart disease were diagnosed antenatally in 48/67 (71.6%) offspring. Conclusion Perinatal mortality and prevalence of congenital anomalies are high in the babies of women with type 1 or type 2 diabetes. The rates do not seem to differ between the two types of diabetes. PMID:16782722

Variability in Temperature-Related Mortality Projections under Climate Change

PubMed Central

Benmarhnia, Tarik; Sottile, Marie-France; Plante, Céline; Brand, Allan; Casati, Barbara; Fournier, Michel

2014-01-01

Background: Most studies that have assessed impacts on mortality of future temperature increases have relied on a small number of simulations and have not addressed the variability and sources of uncertainty in their mortality projections. Objectives: We assessed the variability of temperature projections and dependent future mortality distributions, using a large panel of temperature simulations based on different climate models and emission scenarios. Methods: We used historical data from 1990 through 2007 for Montreal, Quebec, Canada, and Poisson regression models to estimate relative risks (RR) for daily nonaccidental mortality in association with three different daily temperature metrics (mean, minimum, and maximum temperature) during June through August. To estimate future numbers of deaths attributable to ambient temperatures and the uncertainty of the estimates, we used 32 different simulations of daily temperatures for June–August 2020–2037 derived from three global climate models (GCMs) and a Canadian regional climate model with three sets of RRs (one based on the observed historical data, and two on bootstrap samples that generated the 95% CI of the attributable number (AN) of deaths). We then used analysis of covariance to evaluate the influence of the simulation, the projected year, and the sets of RRs used to derive the attributable numbers of deaths. Results: We found that < 1% of the variability in the distributions of simulated temperature for June–August of 2020–2037 was explained by differences among the simulations. Estimated ANs for 2020–2037 ranged from 34 to 174 per summer (i.e., June–August). Most of the variability in mortality projections (38%) was related to the temperature–mortality RR used to estimate the ANs. Conclusions: The choice of the RR estimate for the association between temperature and mortality may be important to reduce uncertainty in mortality projections. Citation: Benmarhnia T, Sottile MF, Plante C, Brand A, Casati B, Fournier M, Smargiassi A. 2014. Variability in temperature-related mortality projections under climate change. Environ Health Perspect 122:1293–1298; http://dx.doi.org/10.1289/ehp.1306954 PMID:25036003

Do socioeconomic inequalities in mortality vary between different Spanish cities? a pooled cross-sectional analysis

PubMed Central

2013-01-01

Background The relationship between deprivation and mortality in urban settings is well established. This relationship has been found for several causes of death in Spanish cities in independent analyses (the MEDEA project). However, no joint analysis which pools the strength of this relationship across several cities has ever been undertaken. Such an analysis would determine, if appropriate, a joint relationship by linking the associations found. Methods A pooled cross-sectional analysis of the data from the MEDEA project has been carried out for each of the causes of death studied. Specifically, a meta-analysis has been carried out to pool the relative risks in eleven Spanish cities. Different deprivation-mortality relationships across the cities are considered in the analysis (fixed and random effects models). The size of the cities is also considered as a possible factor explaining differences between cities. Results Twenty studies have been carried out for different combinations of sex and causes of death. For nine of them (men: prostate cancer, diabetes, mental illnesses, Alzheimer’s disease, cerebrovascular disease; women: diabetes, mental illnesses, respiratory diseases, cirrhosis) no differences were found between cities in the effect of deprivation on mortality; in four cases (men: respiratory diseases, all causes of mortality; women: breast cancer, Alzheimer’s disease) differences not associated with the size of the city have been determined; in two cases (men: cirrhosis; women: lung cancer) differences strictly linked to the size of the city have been determined, and in five cases (men: lung cancer, ischaemic heart disease; women: ischaemic heart disease, cerebrovascular diseases, all causes of mortality) both kinds of differences have been found. Except for lung cancer in women, every significant relationship between deprivation and mortality goes in the same direction: deprivation increases mortality. Variability in the relative risks across cities was found for general mortality for both sexes. Conclusions This study provides a general overview of the relationship between deprivation and mortality for a sample of large Spanish cities combined. This joint study allows the exploration of and, if appropriate, the quantification of the variability in that relationship for the set of cities considered. PMID:23679869

Sarcopenia increases risk of long-term mortality in elderly patients undergoing emergency abdominal surgery.

PubMed

Rangel, Erika L; Rios-Diaz, Arturo J; Uyeda, Jennifer W; Castillo-Angeles, Manuel; Cooper, Zara; Olufajo, Olubode A; Salim, Ali; Sodickson, Aaron D

2017-12-01

Frailty is associated with poor surgical outcomes in elderly patients but is difficult to measure in the emergency setting. Sarcopenia, or the loss of lean muscle mass, is a surrogate for frailty and can be measured using cross-sectional imaging. We sought to determine the impact of sarcopenia on 1-year mortality after emergency abdominal surgery in elderly patients. Sarcopenia was assessed in patients 70 years or older who underwent emergency abdominal surgery at a single hospital from 2006 to 2011. Average bilateral psoas muscle cross-sectional area at L3, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography. Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was mortality at 1 year. Secondary outcomes were in-hospital mortality and mortality at 30, 90, and 180 days. The association of sarcopenia with mortality was assessed using Cox proportional hazards regression and model performance judged using Harrell's C-statistic. Two hundred ninety-seven of 390 emergency abdominal surgery patients had preoperative imaging and height. The median age was 79 years, and 1-year mortality was 32%. Sarcopenic and nonsarcopenic patients were comparable in age, sex, race, comorbidities, American Society of Anesthesiologists classification, procedure urgency and type, operative severity, and need for discharge to a nursing facility. Sarcopenic patients had lower body mass index, greater need for intensive care, and longer hospital length of stay (p < 0.05). Sarcopenia was independently associated with increased in-hospital mortality (risk ratio, 2.6; 95% confidence interval [CI], 1.6-3.7) and mortality at 30 days (hazard ratio [HR], 3.7; 95% CI, 1.9-7.4), 90 days (HR, 3.3; 95% CI, 1.8-6.0), 180 days (HR, 2.5; 95% CI, 1.4-4.4), and 1 year (HR, 2.4; 95% CI, 1.4-3.9). Sarcopenia is associated with increased risk of mortality over 1 year in elderly patients undergoing emergency abdominal surgery. Sarcopenia defined by TPI is a simple and objective measure of frailty that identifies vulnerable patients for improved preoperative counseling, setting realistic goals of care, and consideration of less invasive approaches. Prognostic study, level III.

Do socioeconomic inequalities in mortality vary between different Spanish cities? a pooled cross-sectional analysis.

PubMed

Martinez-Beneito, Miguel A; Zurriaga, Oscar; Botella-Rocamora, Paloma; Marí-Dell'Olmo, Marc; Nolasco, Andreu; Moncho, Joaquín; Daponte, Antonio; Domínguez-Berjón, M Felicitas; Gandarillas, Ana; Martos, Carmen; Montoya, Imanol; Sánchez-Villegas, Pablo; Taracido, Margarita; Borrell, Carme

2013-05-16

The relationship between deprivation and mortality in urban settings is well established. This relationship has been found for several causes of death in Spanish cities in independent analyses (the MEDEA project). However, no joint analysis which pools the strength of this relationship across several cities has ever been undertaken. Such an analysis would determine, if appropriate, a joint relationship by linking the associations found. A pooled cross-sectional analysis of the data from the MEDEA project has been carried out for each of the causes of death studied. Specifically, a meta-analysis has been carried out to pool the relative risks in eleven Spanish cities. Different deprivation-mortality relationships across the cities are considered in the analysis (fixed and random effects models). The size of the cities is also considered as a possible factor explaining differences between cities. Twenty studies have been carried out for different combinations of sex and causes of death. For nine of them (men: prostate cancer, diabetes, mental illnesses, Alzheimer's disease, cerebrovascular disease; women: diabetes, mental illnesses, respiratory diseases, cirrhosis) no differences were found between cities in the effect of deprivation on mortality; in four cases (men: respiratory diseases, all causes of mortality; women: breast cancer, Alzheimer's disease) differences not associated with the size of the city have been determined; in two cases (men: cirrhosis; women: lung cancer) differences strictly linked to the size of the city have been determined, and in five cases (men: lung cancer, ischaemic heart disease; women: ischaemic heart disease, cerebrovascular diseases, all causes of mortality) both kinds of differences have been found. Except for lung cancer in women, every significant relationship between deprivation and mortality goes in the same direction: deprivation increases mortality. Variability in the relative risks across cities was found for general mortality for both sexes. This study provides a general overview of the relationship between deprivation and mortality for a sample of large Spanish cities combined. This joint study allows the exploration of and, if appropriate, the quantification of the variability in that relationship for the set of cities considered.

Network Type and Mortality Risk in Later Life

ERIC Educational Resources Information Center

Litwin, Howard; Shiovitz-Ezra, Sharon

2006-01-01

Purpose: The purpose of this study was to examine the association of baseline network type and 7-year mortality risk in later life. Design and Methods: We executed secondary analysis of all-cause mortality in Israel using data from a 1997 national survey of adults aged 60 and older (N = 5,055) that was linked to records from the National Death…

Does educational status impact adult mortality in Denmark? A twin approach.

PubMed

Madsen, Mia; Andersen, Anne-Marie Nybo; Christensen, Kaare; Andersen, Per Kragh; Osler, Merete

2010-07-15

To disentangle an independent effect of educational status on mortality risk from direct and indirect selection mechanisms, the authors used a discordant twin pair design, which allowed them to isolate the effect of education by means of adjustment for genetic and environmental confounding per design. The study is based on data from the Danish Twin Registry and Statistics Denmark. Using Cox regression, they estimated hazard ratios for mortality according to the highest attained education among 5,260 monozygotic and 11,088 dizygotic same-sex twin pairs born during 1921-1950 and followed during 1980-2008. Both standard cohort and intrapair analyses were conducted separately for zygosity, gender, and birth cohort. Educational differences in mortality were demonstrated in the standard cohort analyses but attenuated in the intrapair analyses in all subgroups but men born during 1921-1935, and no effect modification by zygosity was observed. Hence, the results are most compatible with an effect of early family environment in explaining the educational inequality in mortality. However, large educational differences were still reflected in mortality risk differences within twin pairs, thus supporting some degree of independent effect of education. In addition, the effect of education may be more pronounced in older cohorts of Danish men.