Kajimoto, Katsuya; Sato, Naoki; Takano, Teruo
The aim of this study was to evaluate the association of anemia and renal dysfunction with in-hospital outcomes in acute heart failure syndromes patients with preserved or reduced ejection fraction. Of the 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 4693 patients were evaluated to investigate the association among anemia, renal dysfunction, a preserved or reduced ejection fraction and in-hospital mortality. They were divided into four groups based on hemoglobin and estimated glomerular filtration rate at admission. The in-hospital mortality rate was 5.9% and 6.9% of the preserved and reduced ejection fraction groups, respectively. After adjustment for multiple comorbidities, there was no association of either anemia or renal dysfunction alone with in-hospital mortality in preserved ejection fraction patients, but the combination of anemia and renal dysfunction was associated with a somewhat higher risk of in-hospital mortality than that without either condition (odds ratio (OR), 2.75; 95% confidence interval (CI), 0.72-10.41; p=0.137). In reduced ejection fraction patients, adjusted analysis showed that a significantly higher risk of in-hospital mortality was associated with anemia alone (OR, 2.56; 95% CI, 1.10 -5.94; p=0.029) and with anemia plus renal dysfunction (OR, 2.34; 95% CI, 1.09-5.03; p=0.029) relative to the risk without either condition. Our findings demonstrate that anemia combined with renal dysfunction is not a risk factor for in-hospital mortality in patients with a preserved ejection fraction, whereas anemia is an independent predictor of in-hospital mortality risk in reduced ejection fraction patients regardless of renal dysfunction.
Zhou, Can; Zhang, Li; Wang, Hua; Ma, Xiaoxia; Shi, Bohui; Chen, Wuke; He, Jianjun; Wang, Ke; Liu, Peijun; Ren, Yu
Compared with open oesophagectomy (OE), minimally invasive oesophagectomy (MIO) proves to have benefits in reducing the risk of pulmonary complications for patients with resectable oesophageal cancer. However, it is unknown whether MIO has superiority in reducing the occurrence of in-hospital mortality (IHM). The objective of this meta-analysis was to explore the effect of MIO vs. OE on the occurrence of in-hospital mortality (IHM). Sources such as Medline (through December 31, 2014), Embase (through December 31, 2014), Wiley Online Library (through December 31, 2014), and the Cochrane Library (through December 31, 2014) were searched. Data of randomized and non-randomized clinical trials related to MIO versus OE were included. Eligible studies were those that reported patients who underwent MIO procedure. The control group included patients undergoing conventional OE. Fixed or random -effects models were used to calculate summary odds ratios (ORs) or relative risks (RRs) for quantification of associations. Heterogeneity among studies was evaluated by using Cochran's Q and I2 statistics. A total of 48 studies involving 14,311 cases of resectable oesophageal cancer were included in the meta-analysis. Compared to patients undergoing OE, patients undergoing MIO had statistically reduced occurrence of IHM (OR=0.69, 95%CI =0.55 -0.86). Patients undergoing MIO also had significantly reduced incidence of pulmonary complications (PCs) (RR=0.73, 95%CI = 0.63-0.86), pulmonary embolism (PE) (OR=0.71, 95%CI= 0.51-0.99) and arrhythmia (OR=0.79, 95%CI = 0.68-0.92). Non-significant reductions were observed among the included studies in the occurrence of anastomotic leak (AL) (OR=0.93, 95%CI =0.78-1.11), or Gastric Tip Necrosis (GTN) (OR=0.89, 95%CI =0.54-1.49). Most of the included studies were non-randomized case-control studies, with a diversity of study designs, demographics of participants and surgical intervention. Minimally invasive oesophagectomy (MIO) has superiority over
Zhou, Can; Zhang, Li; Wang, Hua; Ma, Xiaoxia; Shi, Bohui; Chen, Wuke; He, Jianjun; Wang, Ke; Liu, Peijun; Ren, Yu
Background Compared with open oesophagectomy (OE), minimally invasive oesophagectomy (MIO) proves to have benefits in reducing the risk of pulmonary complications for patients with resectable oesophageal cancer. However, it is unknown whether MIO has superiority in reducing the occurrence of in-hospital mortality (IHM). Objective The objective of this meta-analysis was to explore the effect of MIO vs. OE on the occurrence of in-hospital mortality (IHM). Data Sources Sources such as Medline (through December 31, 2014), Embase (through December 31, 2014), Wiley Online Library (through December 31, 2014), and the Cochrane Library (through December 31, 2014) were searched. Study Selection Data of randomized and non-randomized clinical trials related to MIO versus OE were included. Interventions Eligible studies were those that reported patients who underwent MIO procedure. The control group included patients undergoing conventional OE. Study Appraisal and Synthesis Methods Fixed or random -effects models were used to calculate summary odds ratios (ORs) or relative risks (RRs) for quantification of associations. Heterogeneity among studies was evaluated by using Cochran’s Q and I2 statistics. Results A total of 48 studies involving 14,311 cases of resectable oesophageal cancer were included in the meta-analysis. Compared to patients undergoing OE, patients undergoing MIO had statistically reduced occurrence of IHM (OR=0.69, 95%CI =0.55 -0.86). Patients undergoing MIO also had significantly reduced incidence of pulmonary complications (PCs) (RR=0.73, 95%CI = 0.63-0.86), pulmonary embolism (PE) (OR=0.71, 95%CI= 0.51-0.99) and arrhythmia (OR=0.79, 95%CI = 0.68-0.92). Non-significant reductions were observed among the included studies in the occurrence of anastomotic leak (AL) (OR=0.93, 95%CI =0.78-1.11), or Gastric Tip Necrosis (GTN) (OR=0.89, 95%CI =0.54-1.49). Limitation Most of the included studies were non-randomized case-control studies, with a diversity of study
Gouveia, Miguel; Pinheiro, Luís; Costa, João; Borges, Margarida
In Portugal, the epidemiology of acute pulmonary embolism is poorly understood. In this study, we sought to characterize the pulmonary embolism from the hospital data and evaluate its in-hospital mortality and respective prognostic factors. The study used diagnostic related groups data from National Health System hospitals from 2003 to 2013 and National Statistics Institute population data to establish the evolution of admissions with the diagnosis of pulmonary embolism, their inhospital mortality rates and the population incidence rates. Diagnosis-related group microdata were used in a logit regression modeling in-hospital mortality as a function of individual characteristics and context variables. Between 2003 and 2013 there were 35,200 episodes of hospitalization in patients with 18 or more years in which one of the diagnoses was pulmonary embolism (primary diagnosis in 67% of cases). The estimated incidence rate in 2013 was 35/100,000 population (≥ 18 years). Between 2003 and 2013, the annual number of episodes kept increasing, but the in-hospital mortality rate decreased (from 31.8% to 17% for all cases and from 25% to 11.2% when pulmonary embolism was the main diagnosis). The probability of death decreases when there is a computerized tomography scan registry or when patients are females and increases with age and the presence of co-morbidities. In the last decade there was an increased incidence of pulmonary embolism likely related to an increased number of dependents and bedridden. However, there was a in-hospital mortality reduction of such size that the actual mortality in the general population was reduced. One possible explanation is that there has been an increase in episodes of pulmonary embolism with incrementally lower levels of severity, due to the greater capacity of diagnosis of less severe cases. Another possible explanation is greater effectiveness of hospital care. According to the logistic regression analysis, improvements in hospital care
Hu, Jiachang; Wang, Yimei; Geng, Xuemei; Chen, Rongyi; Zhang, Pan; Lin, Jing; Teng, Jie; Zhang, Xiaoyan; Ding, Xiaoqiang
Background Dysnatremia is a risk factor for poor outcomes. We aimed to describe the prevalence and outcomes of various dysnatremia in hospitalized patients. High-risk patients must be identified to improve the prognosis of dysnatremia. Material/Methods This prospective study included all adult patients admitted consecutively to a university hospital between October 1, 2014 and September 30, 2015. Result All 90 889 patients were included in this study. According to the serum sodium levels during hospitalization, the incidence of hyponatremia and hypernatremia was 16.8% and 1.9%, respectively. Mixed dysnatremia, which was defined when both hyponatremia and hypernatremia happened in the same patient during hospitalization, took place in 0.3% of patients. The incidence of dysnatremia was different in various underlying diseases. Multiple logistic regression analyses showed that all kinds of dysnatremia were independently associated with hospital mortality. The following dysnatremias were strong predictors of hospital mortality: mixed dysnatremia (OR 22.344, 95% CI 15.709–31.783, P=0.000), hypernatremia (OR 13.387, 95% CI 10.642–16.840, P=0.000), and especially hospital-acquired (OR 16.216, 95% CI 12.588–20.888, P=0.000) and persistent (OR 22.983, 95% CI 17.554–30.092, P=0.000) hypernatremia. Hyponatremia was also a risk factor for hospital mortality (OR 2.225, 95% CI 1.857–2.667). However, the OR increased to 56.884 (95% CI 35.098–92.193) if hyponatremia was over-corrected to hypernatremia. Conclusions Dysnatremia was independently associated with poor outcomes. Hospital-acquired and persistent hypernatremia were strong risk factors for hospital mortality. Effective prevention and proper correction of dysnatremia in high-risk patients may reduce the hospital mortality. PMID:28528344
Retraction: 'rhBNP therapy can improve clinical outcomes and reduce in-hospital mortality compared with dobutamine in heart failure patients: a meta-analysis' by Ming-Yi Lv, Shu-Ling Deng and Xiao-Feng Long.
The above article, published online on 28(th) November 2015 in Wiley Online Library (http://onlinelibrary.wiley.com/doi/10.1111/bcp.12788/full), and in volume 81, pp. 174-185, has been retracted by agreement between the authors, the journal Editor in Chief, Professor A Cohen, and John Wiley & Sons Limited. The retraction has been agreed owing to evidence indicating that the peer review of this paper was compromised. The authors were unaware of the actions of the third party responsible for compromising the peer review. Reference Lv M-Y, Deng S-L, Long X-F. rhBNP therapy can improve clinical outcomes and reduce in-hospital mortality compared with dobutamine in heart failure patients: a meta-analysis. Br J Clin Pharmacol 2016; 81: 174-85. doi:10.1111/bcp.12788.
Ong, Cheung-Ter; Wong, Yi-Sin; Wu, Chi-Shun; Su, Yu-Hsiang
Background/purpose In-hospital mortality rate of acute ischemic stroke patients remains between 3% and 18%. For improving the quality of stroke care, we investigated the factors that contribute to the risk of in-hospital mortality in acute ischemic stroke patients. Materials and methods Between January 1, 2007, and December 31, 2011, 2,556 acute ischemic stroke patients admitted to a stroke unit were included in this study. Factors such as demographic characteristics, clinical characteristics, comorbidities, and complications related to in-hospital mortality were assessed. Results Of the 2,556 ischemic stroke patients, 157 received thrombolytic therapy. Eighty of the 2,556 patients (3.1%) died during hospitalization. Of the 157 patients who received thrombolytic therapy, 14 (8.9%) died during hospitalization. History of atrial fibrillation (AF, P<0.01) and stroke severity (P<0.01) were independent risk factors of in-hospital mortality. AF, stroke severity, cardioembolism stroke, and diabetes mellitus were independent risk factors of hemorrhagic transformation. Herniation and sepsis were the most common complications of stroke that were attributed to in-hospital mortality. Approximately 70% of in-hospital mortality was related to stroke severity (total middle cerebral artery occlusion with herniation, basilar artery occlusion, and hemorrhagic transformation). The other 30% of in-hospital mortality was related to sepsis, heart disease, and other complications. Conclusion AF is associated with higher in-hospital mortality rate than in patients without AF. For improving outcome of stroke patients, we also need to focus to reduce serious neurological or medical complications. PMID:27418830
López-Mestanza, Cristina; Andaluz-Ojeda, David; Gómez-López, Juan Ramón; Bermejo Martín, Jesús F
Identification of factors that confer an increased risk of mortality in hospital acquired sepsis (HAS) is necessary to help prevent, and improve the outcome of, this condition. To evaluate the clinical characteristics and factors associated with mortality in patients with HAS. Retrospective study of patients with HAS in a major Spanish Hospital from 2011 to 2015. Data from adults receiving any of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes associated with sepsis were collected. Those fulfilling the SEPSIS-2 definition with no evidence of infection during the first 48 hours following hospitalization were included (n=196). A multivariate analysis was employed to identify the risk factors of mortality. HAS patients were found to have many of the risk factors associated with cardiovascular disease (male sex, ageing, antecedent of cardiac disease, arterial hypertension, dyslipemia, smoking habit) and cancer. Vascular disease or chronic kidney disease were associated with 28 day mortality. Time from hospital admission to sepsis diagnosis, and the presence of organ failure were risk factors for 28-day and hospital mortality. Experiencing more than one episode of sepsis increased the risk of hospital mortality. "Sepsis Code" for the early identification of sepsis was protective against hospital mortality. We have identified a number of major factors associated to mortality in patients suffering from HAS. Implementation of surveillance programmes for the early identification and treatment of sepsis translate into a clear benefit. Copyright © 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Chiesa, Deborah; Marengoni, Alessandra; Nobili, Alessandro; Tettamanti, Mauro; Pasina, Luca; Franchi, Carlotta; Djade, Codjo D; Corrao, Salvatore; Salerno, Francesco; Marcucci, Maura; Romanelli, Giuseppe; Mannucci, Pier Mannuccio
Recent scientific reports have shown that older persons treated with antipsychotics for dementia-related behavioural symptoms have increased mortality. However, the impact of these drugs prescribed during hospitalization has rarely been assessed. We aimed to investigate whether antipsychotics are associated with an increased risk of mortality during hospitalization and at 3-month follow-up in elderly inpatients. We analyzed data gathered during two waves (2010 and 2012) by the REPOSI (Registro Politerapie Società Italiana Medicina Interna). All new prescriptions of antipsychotic drugs during hospitalization, whether maintained or discontinued at discharge, were collected, and logistic regression models were used to analyze their association with in-hospital and 3-month mortality. Covariates were age, sex, the Short Blessed Test (SBT) score, and the Cumulative Illness Rating Scale. Among 2703 patients included in the study, 135 (5%) received new prescriptions for antipsychotic drugs. The most frequently prescribed antipsychotic during hospitalization and eventually maintained at discharge was haloperidol (38% and 36% of cases, respectively). Patients newly prescribed with antipsychotics were older and had a higher Cumulative Illness Rating Scale comorbidity index both at admission and at discharge compared to those who did not receive a prescription. Of those prescribed antipsychotics, 71% had an SBT score ≥10 (indicative of dementia), 12% had an SBT score of 5-9 (indicative of questionable dementia); and 17% had an SBT score <5 (indicative of normal cognition). In-hospital mortality was slightly higher in patients prescribed antipsychotic drugs (14.3% vs 9.4%; P = 0.109), but in multivariate analysis only male sex, older age, and higher SBT scores were significantly related to mortality during hospitalization. At 3-month follow-up, only male sex, older age, and higher SBT scores were associated with mortality. We found that the prescription of antipsychotic
Lalani, Tahaniyat; Chu, Vivian H; Park, Lawrence P; Cecchi, Enrico; Corey, G Ralph; Durante-Mangoni, Emanuele; Fowler, Vance G; Gordon, David; Grossi, Paolo; Hannan, Margaret; Hoen, Bruno; Muñoz, Patricia; Rizk, Hussien; Kanj, Souha S; Selton-Suty, Christine; Sexton, Daniel J; Spelman, Denis; Ravasio, Veronica; Tripodi, Marie Françoise; Wang, Andrew
There are limited prospective, controlled data evaluating survival in patients receiving early surgery vs medical therapy for prosthetic valve endocarditis (PVE). To determine the in-hospital and 1-year mortality in patients with PVE who undergo valve replacement during index hospitalization compared with patients who receive medical therapy alone, after controlling for survival and treatment selection bias. Participants were enrolled between June 2000 and December 2006 in the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS), a prospective, multinational, observational cohort of patients with infective endocarditis. Patients hospitalized with definite right- or left-sided PVE were included in the analysis. We evaluated the effect of treatment assignment on mortality, after adjusting for biases using a Cox proportional hazards model that included inverse probability of treatment weighting and surgery as a time-dependent covariate. The cohort was stratified by probability (propensity) for surgery, and outcomes were compared between the treatment groups within each stratum. Valve replacement during index hospitalization (early surgery) vs medical therapy. In-hospital and 1-year mortality. Of the 1025 patients with PVE, 490 patients (47.8%) underwent early surgery and 535 individuals (52.2%) received medical therapy alone. Compared with medical therapy, early surgery was associated with lower in-hospital mortality in the unadjusted analysis and after controlling for treatment selection bias (in-hospital mortality: hazard ratio [HR], 0.44 [95% CI, 0.38-0.52] and lower 1-year mortality: HR, 0.57 [95% CI, 0.49-0.67]). The lower mortality associated with surgery did not persist after adjustment for survivor bias (in-hospital mortality: HR, 0.90 [95% CI, 0.76-1.07] and 1-year mortality: HR, 1.04 [95% CI, 0.89-1.23]). Subgroup analysis indicated a lower in-hospital mortality with early surgery in the highest surgical propensity quintile (21
Alshayeb, Hala M; Showkat, Arif; Babar, Fatima; Mangold, Therese; Wall, Barry M
Hypernatremia is a common problem in hospitalized patients and is associated with high morbidity and mortality. This study was designed to evaluate whether physicians follow the recommended guidelines for the rate of correction of hypernatremia of ≤0.5 mEq/L/hr and to evaluate the effect of the rate of correction of severe hypernatremia on the mortality of hospitalized patients. A retrospective chart review of 131 consecutively hospitalized patients with severe hypernatremia (serum sodium ≥155 mEq/L) was performed. Primary outcomes were 30-day patient mortality and 72-hour hypernatremia correction. The first 24-hour serum sodium (Na(+)) correction rate was tested as a categorical variable; slow rate (<0.25 mEq/L/hr) and fast rate (≥0.25 mEq/L/hr). The mean admission serum Na level was 159 ± 3 mEq/L. Ninety percent of patients received the recommended <0.5 mEq/L/hr serum Na(+) correction rate; however, hypernatremia was corrected only in 27% of patients after 72 hours of treatment. Thirty-day patient mortality rate was 37%. In multivariable analysis, do not resuscitate status [hazards ratio (HR), 3.85; P < 0.0001], slower correction rate of hypernatremia (HR, 2.63; P = 0.02) and high heart rate (>100 beats/min; HR, 1.99; P = 0.03) were the independent predictors of 30-day mortality. In patients with severe hypernatremia, the rate of correction of hypernatremia was slow and resulted in inadequate correction in majority of the patients. Both slow rate of hypernatremia correction during the first 24 hours and do not resuscitate status were found to be significant predictors of 30-day patient mortality.
Bae, Eun Hui; Kim, Ha Yeon; Kang, Yong Un; Kim, Chang Seong; Ma, Seong Kwon; Kim, Soo Wan
Background Incident hemodialysis patients have the highest mortality in the first several months after starting dialysis. This study evaluated the in-hospital mortality rate after hemodialysis initiation, as well as related risk factors. Methods We examined in-hospital mortality and related factors in 2,692 patients starting incident hemodialysis. The study population included patients with acute kidney injury, acute exacerbation of chronic kidney disease, and chronic kidney disease. To determine the parameters associated with in-hospital mortality, patients who died in hospital (nonsurvivors) were compared with those who survived (survivors). Risk factors for in-hospital mortality were determined using logistic regression analysis. Results Among all patients, 451 (16.8%) died during hospitalization. The highest risk factor for in-hospital mortality was cardiopulmonary resuscitation, followed by pneumonia, arrhythmia, hematologic malignancy, and acute kidney injury after bleeding. Albumin was not a risk factor for in-hospital mortality, whereas C-reactive protein was a risk factor. The use of vancomycin, inotropes, and a ventilator was associated with mortality, whereas elective hemodialysis with chronic kidney disease and statin use were associated with survival. The use of continuous renal replacement therapy was not associated with in-hospital mortality. Conclusion Incident hemodialysis patients had high in-hospital mortality. Cardiopulmonary resuscitation, infections such as pneumonia, and the use of inotropes and a ventilator was strong risk factors for in-hospital mortality. However, elective hemodialysis for chronic kidney disease was associated with survival. PMID:26484040
Metersky, Mark L; Waterer, Grant; Nsa, Wato; Bratzler, Dale W
Many patients who die within 30 days of admission to the hospital for pneumonia die after discharge. Recently, 30-day mortality for patients with pneumonia became a publicly reported performance measure, meaning that hospitals are, in part, being measured based on how the patient fares after discharge from the hospital. This study was undertaken to determine which factors predict in-hospital vs postdischarge mortality in patients with pneumonia. This was a retrospective analysis of a database of 21,223 patients on Medicare aged 65 years and older admitted to the hospital between 2000 and 2001. Multivariate logistic regression analyses were performed to determine the association between 26 patient characteristics and the timing of death (in-hospital vs postdischarge) among those patients who died within 30 days of hospital admission. Among the 21,223 patients, 2,561 (12.1%) died within 30 days of admission: 1,343 (52.4%) during the hospital stay, and 1,218 (47.6%) after discharge. Multivariate logistic regression demonstrated that seven factors were significantly associated with death prior to discharge: systolic BP < 90 mm Hg, respiration rate > 30/min, bacteremia, arterial pH < 7.35, BUN level > 11 mmol/L, arterial Po(2) < 60 mm Hg or arterial oxygen saturation < 90%, and need for mechanical ventilation. Some underlying comorbidities were associated with a nonstatistically significant trend toward death after discharge. Of elderly patients dying within 30 days of admission to the hospital, approximately one-half die after discharge from the hospital. Comorbidities, in general, were equally associated with death in the hospital and death after discharge
Pham-Kanter, Genevieve; Goldman, Noreen
BACKGROUND Although sons are thought to impose greater physiological costs on mothers than daughters, sons may be advantageous for parental survival in some social contexts. We examined the relationship between the sex composition of offspring and parental survival in contemporary China and Taiwan. Because of the importance of sons for the provision of support to elderly parents in these populations, we hypothesized that sons would have a beneficial effect on parental survival relative to daughters. METHODS We used data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) and the Taiwan Longitudinal Study of Aging (TLSA). Our CLHLS sample consisted of 4132 individuals ages 65+ in 2002. Our TLSA sample comprised two cohorts: 3409 persons aged 60+ in 1989 and 2193 persons aged 50–66 in 1996.These cohorts were followed for 3, 18, and 11 years, respectively. We used Cox proportional hazards models to estimate the relationship between the sex composition of offspring and parental mortality. RESULTS Based on 7 measures of sex composition, we find no protective effect of sons in either China or Taiwan. For example, in the 1989 Taiwan sample, the hazard ratio for maternal mortality associated with having an eldest son is 0.979 (95% CI (0.863, 1.111)). In Taiwan, daughters may have been more beneficial than sons in reducing mortality in recent years. CONCLUSION We offer several explanations for these findings, including possible benefits associated with emotional and interpersonal forms of support provided by daughters and negative impacts of conflicts arising between parents and resident daughters-in-law. PMID:21551178
Faraoni, David; DiNardo, James A; Goobie, Susan M
The relationship between preoperative anemia and in-hospital mortality has not been investigated in the pediatric surgical population. We hypothesized that children with preoperative anemia undergoing noncardiac surgery may have an increased risk of in-hospital mortality. We identified all children between 1 and 18 years of age with a recorded preoperative hematocrit (HCT) in the 2012, 2013, and 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) pediatric databases. The endpoint was defined as the incidence of in-hospital mortality. Children with preoperative anemia were identified based on their preoperative HCT. Demographic and surgical characteristics, as well as comorbidities, were considered potential confounding variables in a multivariable logistic regression analysis. A sensitivity analysis was performed using propensity-matched analysis. Among the 183,833 children included in the 2012, 2013, and 2014 ACS NSQIP database, 74,508 had a preoperative HCT recorded (41%). After exclusion of all children <1 year of age (n = 12,063), those with congenital heart disease (n = 8943), and those who received a preoperative red blood cell (RBC) transfusion (n = 1880), 12,551 (24%) children were anemic, and 39,071 (76%) were nonanemic. The median preoperative HCT was 33% (interquartile range, 31-35) in anemic children, and 39% (interquartile range, 37-42) in nonanemic children (P < .001). Using multivariable logistic regression analysis, and after adjustment for RBC transfusion (OR, 2.13; 95% CI, 1.39-3.26; P < .001), we observed that preoperative anemia was associated with higher odds for in-hospital mortality (OR, 2.17; 95% CI, 1.48-3.19; P < .001). After propensity matching, the presence of anemia was also associated with higher odds of in-hospital mortality (OR, 1.75; 95% CI, 1.15-2.65; P = .004). Our study demonstrates that children with preoperative anemia are at increased risk for in-hospital mortality. Further studies are
Zongo, A; Traoré, M; Faye, A; Gueye, M; Fournier, P; Dumont, A
Maternal mortality is still too high in sub-Saharan Africa, particularly in referral hospitals. Solutions exist but their implementation is a great issue in the poor-resources settings. The objective of this study is to assess the effect of the organization of obstetric care services on maternal mortality in referral hospitals in Mali. This is a multicentric observational survey in 22 referral hospitals. Clinical data on 42,929 women delivering in the 22 hospitals within the 2007 to 2008 study period were collected. Organization evaluation was based on explicit criteria defined by an expert committee. The effect of the organization on in-hospital mortality adjusted on individual and institutional characteristics was estimated using multi-level logistic regression models. The results show that an optimal organization of obstetric care services based on eight explicit criteria reduced in-hospital maternal mortality by 41% compared with women delivering in a referral hospital with sub-optimal organization defined as non-compliance with at least one of the eight criteria (ORa=0.59; 95% CI=0.34-0.92). Furthermore, local policies that improved financial access to emergency obstetric care had a significant impact on maternal outcome. Criteria for optimal organization include the management of labor and childbirth by qualified personnel, an organization of human resources that allows timely management of obstetric emergencies, routine use of partography for all patients and availability of guidelines for the management of complications. These conditions could be easily implemented in the context of Mali to reduce in-hospital maternal mortality. Copyright © 2012 Elsevier Masson SAS. All rights reserved.
Comba, Monica; Fonte, Gianfranco; Isaia, Gianluca; Pricop, Larisa; Sciarrillo, Irene; Michelis, Giuliana; Bo, Mario
Increasing evidence has mounted in recent years on the potential prognostic role of biomarkers out of cardiac-specific medical settings. We aimed to test whether cardiac and inflammatory biomarkers are independently associated with in-hospital mortality in older unselected medical inpatients undergoing standardized multidimensional evaluation. Observational study conducted in a metropolitan university-teaching hospital. A standardized, multidimensional analysis was carried out on all patients by using medical and hospital discharge documentation and interview results integrated with information collected from family members or caregivers. Patients older than 65 years consecutively admitted to the acute geriatric ward and to 2 acute medical wards of the hospital. Male sex; low systolic blood pressure; APACHE score; functional impairment in activities of daily living (ADLs), instrumental ADLs, and Short Physical Performance Battery (SPPB); cognitive impairment; malnutrition; low albumin values; and elevated values of inflammatory and cardiac biomarkers were significantly associated with in-hospital mortality at univariate analysis. After multivariate analysis, male sex, low systolic blood pressure values at entry, severe cognitive impairment, and low functional performance measured by the SPPB resulted to be independently associated with in-hospital mortality. The main finding of the present study is that these biomarkers, although associated with in-hospital mortality, do not have independent predictive significance when a comprehensive and multidimensional evaluation is conducted. The main clinical implication is that our findings should discourage the indiscriminate recourse to measurement of cardiac and inflammatory biomarkers, at least in older medical inpatients, thereby reducing a patient's hospital cost and potentially minimizing further unnecessary diagnostic procedures. Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc
Murray, Christopher J. L; Lopez, Alan D; Barofsky, Jeremy T; Bryson-Cahn, Chloe; Lozano, Rafael
Background Cause-of-death data for many developing countries are not available. Information on deaths in hospital by cause is available in many low- and middle-income countries but is not a representative sample of deaths in the population. We propose a method to estimate population cause-specific mortality fractions (CSMFs) using data already collected in many middle-income and some low-income developing nations, yet rarely used: in-hospital death records. Methods and Findings For a given cause of death, a community's hospital deaths are equal to total community deaths multiplied by the proportion of deaths occurring in hospital. If we can estimate the proportion dying in hospital, we can estimate the proportion dying in the population using deaths in hospital. We propose to estimate the proportion of deaths for an age, sex, and cause group that die in hospital from the subset of the population where vital registration systems function or from another population. We evaluated our method using nearly complete vital registration (VR) data from Mexico 1998–2005, which records whether a death occurred in a hospital. In this validation test, we used 45 disease categories. We validated our method in two ways: nationally and between communities. First, we investigated how the method's accuracy changes as we decrease the amount of Mexican VR used to estimate the proportion of each age, sex, and cause group dying in hospital. Decreasing VR data used for this first step from 100% to 9% produces only a 12% maximum relative error between estimated and true CSMFs. Even if Mexico collected full VR information only in its capital city with 9% of its population, our estimation method would produce an average relative error in CSMFs across the 45 causes of just over 10%. Second, we used VR data for the capital zone (Distrito Federal and Estado de Mexico) and estimated CSMFs for the three lowest-development states. Our estimation method gave an average relative error of 20%, 23
Rosenthal, G. E.; Baker, D. W.; Norris, D. G.; Way, L. E.; Harper, D. L.; Snow, R. J.
OBJECTIVE: To examine the relationship of in-hospital and 30-day mortality rates and the association between in-hospital mortality and hospital discharge practices. DATA SOURCES/STUDY SETTING: A secondary analysis of data for 13,834 patients with congestive heart failure who were admitted to 30 hospitals in northeast Ohio in 1992-1994. DESIGN: A retrospective cohort study was conducted. DATA COLLECTION: Demographic and clinical data were collected from patients' medical records and were used to develop multivariable models that estimated the risk of in-hospital and 30-day (post-admission) mortality. Standardized mortality ratios (SMRs) for in-hospital and 30-day mortality were determined by dividing observed death rates by predicted death rates. PRINCIPAL FINDINGS: In-hospital SMRs ranged from 0.54 to 1.42, and six hospitals were classified as statistical outliers (p <.05); 30-day SMRs ranged from 0.63 to 1.73, and seven hospitals were outliers. Although the correlation between in-hospital SMRs and 30-day SMRs was substantial (R = 0.78, p < .001), outlier status changed for seven of the 30 hospitals. Nonetheless, changes in outlier status reflected relatively small differences between in-hospital and 30-day SMRs. Rates of discharge to nursing homes or other inpatient facilities varied from 5.4 percent to 34.2 percent across hospitals. However, relationships between discharge rates to such facilities and in-hospital SMRs (R = 0.08; p = .65) and early post-discharge mortality rates (R = 0.23; p = .21) were not significant. CONCLUSIONS: SMRs based on in-hospital and 30-day mortality were relatively similar, although classification of hospitals as statistical outliers often differed. However, there was no evidence that in-hospital SMRs were biased by differences in post-discharge mortality or discharge practices. PMID:10737447
Gandhi, Rupali; Almond, Christopher; Singh, Tajinder P; Gauvreau, Kimberlee; Piercey, Gary; Thiagarajan, Ravi R
Infants undergoing heart transplantation have the highest early posttransplant mortality of any age group. We sought to determine the pretransplantation factors associated with in-hospital mortality in transplanted infants in the current era. All infants under 12 months of age who underwent primary heart transplantation during a recent 10-year period (1999-2009) in the United States were identified using the Organ Procurement and Transplant Network database. Multivariable logistic regression was used to identify independent pretransplantation factors associated with in-hospital mortality. Of 730 infants in the study (median age 3.8 months), 462 (63%) had congenital heart disease, 282 (39%) were supported by a ventilator, 94 (13%) with extracorporeal membrane oxygenation, and 22 (3%) with a ventricular assist device at the time of transplantation. Overall, 82 (11.2%) infants died before their initial hospital discharge. In adjusted analysis, in-hospital mortality was associated with repaired congenital heart disease (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.8, 7.2), unrepaired congenital heart disease not on prostaglandin E (OR, 2.8; CI, 1.3, 6.1), extracorporeal membrane oxygenator support (OR, 6.1; CI, 2.8, 13.4), ventilator support (OR, 4.4; CI, 2.3, 8.3), creatinine clearance less than 40 mL·min(-1)·1.73 m(-2) (OR, 3.1; CI, 1.7, 5.3), and dialysis (OR, 6.2; CI, 2.1, 18.3) at transplantation. One in 9 infants undergoing heart transplantation dies before hospital discharge. Pretranplantation factors associated with early mortality include congenital heart disease, extracorporeal membrane oxygenator support, mechanical ventilation, and renal failure. Risk stratification for early posttransplant mortality among infants listed for heart transplantation may improve decision-making for transplant eligibility, organ allocation, and posttransplant interventions to reduce mortality. Copyright Â© 2011 The American Association for Thoracic Surgery
Nuño, Miriam; Carico, Christine; Mukherjee, Debraj; Ly, Diana; Ortega, Alicia; Black, Keith L; Patil, Chirag G
The Agency for Healthcare Research and Quality patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services hospital-acquired conditions (HACs) are administrative data-based metrics. The use of these outcomes as standard performance measures has been discussed in previous studies. With the objective of determining the applicability of these events as performance metrics among patients undergoing brain tumor surgery, this study had 2 aims: 1) to evaluate the association between PSIs, HACs, and in-hospital mortality rates; and 2) to determine a correlation between hospital volume, PSIs, and HACs. Patients with brain tumors treated between 1998 and 2009 were captured in the Nationwide Inpatient Sample database. Hospitals were categorized into groups according to surgical volume. Associations between PSIs, HACs, and in-hospital mortality rates were studied. Factors associated with a PSI, HAC, and mortality were evaluated in a multivariate setting. A total of 444,751 patients with brain tumors underwent surgery in 1311 hospitals nationwide. Of these, 7.4% of patients experienced a PSI, 0.4% an HAC, and 1.9% died during their hospitalization. The occurrence of a PSI was strongly associated with mortality. Patients were 7.6 times more likely to die (adjusted odds ratio [aOR] 7.6, CI 6.7-8.7) with the occurrence of a PSI in a multivariate analysis. Moderate to strong associations were found between HACs, PSIs, and hospital volume. Patients treated at the highest-volume hospitals compared with the lowest-volume ones had reduced odds of a PSI (aOR 0.9, CI 0.8-1.0) and HAC (aOR 0.5, CI 0.5-0.08). Patient safety-related adverse events were strongly associated with in-hospital mortality. Moderate to strong correlations were found between PSIs, HACs, and hospital procedural volume. Patients treated at the highest-volume hospitals had consistently lower rates of mortality, PSIs, and HACs compared with those treated at the lowest-volume facilities.
Motta, Fabio Araujo; Dalla-Costa, Libera Maria; Muro, Marisol Dominguez; Cardoso, Mariana Nadal; Picharski, Gledson Luiz; Jaeger, Gregory; Burger, Marion
To evaluate risk factors associated with death due to bloodstream infection caused by Candida spp. in pediatric patients and evaluate the resistance to the main anti-fungal used in clinical practice. This is a cross-sectional, observational, analytical study with retrospective collection that included 65 hospitalized pediatric patients with bloodstream infection by Candida spp. A univariate analysis was performed to estimate the association between the characteristics of the candidemia patients and death. The incidence of candidemia was 0.23 cases per 1000patients/day, with a mortality rate of 32% (n=21). Clinical outcomes such as sepsis and septic shock (p=0.001), comorbidities such as acute renal insufficiency (p=0.01), and risks such as mechanical ventilation (p=0.02) and dialysis (p=0.03) are associated with increased mortality in pediatric patients. The resistance and dose-dependent susceptibility rates against fluconazole were 4.2% and 2.1%, respectively. No resistance to amphotericin B and echinocandin was identified. Data from this study suggest that sepsis and septic shock, acute renal insufficiency, and risks like mechanical ventilation and dialysis are associated with increased mortality in pediatric patients. The mortality among patients with candidemia is high, and there is no species difference in mortality rates. Regarding the resistance rates, it is important to emphasize the presence of low resistance in this series. Copyright © 2016 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.
Shore, Rima; Shore, Barbara
Despite the wide range of expertise that has been brought to bear on reducing infant mortality across the nation, the first year of life remains a time of considerable risk for many babies. Although the U.S. spends more on health care than any other country, its infant mortality rate remains higher than that of most other industrialized nations.…
Joosten, Etienne; Demuynck, Mathias; Detroyer, Elke; Milisen, Koen
The prevalence and significance of frailty are seldom studied in hospitalized patients. Aim of this study is to evaluate the prevalence of frailty and to determine the extent that frailty predicts delirium, falls and mortality in hospitalized older patients. In a prospective study of 220 older patients, frailty was determined using the Cardiovascular Health Study (CHS) and the Study of Osteoporotic Fracture (SOF) frailty index. Patients were classified as nonfrail, prefrail, and frail, according to the specific criteria. Covariates included clinical and laboratory parameters. Outcome variables included in hospital delirium and falls, and 6-month mortality. The CHS frailty index was available in all 220 patients, of which 1.5% were classified as being nonfrail, 58.5% as prefrail, and 40% as frail. The SOF frailty index was available in 204 patients, of which 16% were classified as being nonfrail, 51.5% as prefrail, and 32.5% as frail. Frailty, as identified by the CHS and SOF indexes, was a significant risk factor for 6-month mortality. However, after adjustment for multiple risk factors, frailty remained a strong independent risk factor only for the model with the CHS index (OR 4.7, 95% CI 1.7-12.8). Frailty (identified by CHS and SOF indexes) was not found to be a risk factor for delirium or falls. Frailty, as measured by the CHS index, is an independent risk factor for 6-month mortality. The CHS and the SOF indexes have limited value as risk assessment tools for specific geriatric syndromes (e.g., falls and delirium) in hospitalized older patients.
Background Since the late nineties, no study has assessed the trends in management and in-hospital outcome of acute myocardial infarction (AMI) in Switzerland. Our objective was to fill this gap. Methods Swiss hospital discharge database for years 1998 to 2008. AMI was defined as a primary discharge diagnosis code I21 according to the ICD10 classification. Invasive treatments and overall in-hospital mortality were assessed. Results Overall, 102,729 hospital discharges with a diagnosis of AMI were analyzed. The percentage of hospitalizations with a stay in an Intensive Care Unit decreased from 38.0% in 1998 to 36.2% in 2008 (p for trend < 0.001). Percutaneous revascularizations increased from 6.0% to 39.9% (p for trend < 0.001). Bare stents rose from 1.3% to 16.6% (p for trend < 0.001). Drug eluting stents appeared in 2004 and increased to 23.5% in 2008 (p for trend < 0.001). Coronary artery bypass graft increased from 1.0% to 3.0% (p for trend < 0.001). Circulatory assistance increased from 0.2% to 1.7% (p for trend < 0.001). Among patients managed in a single hospital (not transferred), seven-day and total in-hospital mortality decreased from 8.0% to 7.0% (p for trend < 0.01) and from 11.2% to 10.1%, respectively. These changes were no longer significant after multivariate adjustment for age, gender, region, revascularization procedures and transfer type. After multivariate adjustment, differing trends in revascularization procedures and in in-hospital mortality were found according to the geographical region considered. Conclusion In Switzerland, a steep rise in hospital discharges and in revascularization procedures for AMI occurred between 1998 and 2008. The increase in revascularization procedures could explain the decrease in in-hospital mortality rates. PMID:23530470
Weiss, Avraham; Rudman, Yaron; Beloosesky, Yichayaou; Akirov, Amit; Shochat, Tzippy; Grossman, Alon
The association of blood pressure (BP) variability (BPV) in hospitalized patients, which represents day-to-day variability, with mortality has been extensively reported in patients with stroke, but poorly defined for other medical conditions. To assess the association of day-to-day blood pressure variability in hospitalized patients, 10 BP measurements were obtained in individuals ≥75 years old hospitalized in a geriatric ward. Day-to-day BPV, measured 3 times a day, was calculated in each patient as the coefficient of variation of systolic BP. Patients were stratified by quartiles of coefficient of variation of systolic BP, and 30-day and 1-year mortality data were compared between those in the highest versus the lowest (reference) group. Overall, 469 patients were included in the final analysis. Mean coefficient of variation of systolic BP was 12.1%. 30-day mortality and 1-year mortality occurred in 29/469 (6.2%) and 95/469 (20.2%) individuals respectively. Patients in the highest quartile of BPV were at a significantly higher risk for 30-day mortality (HR =4.12, CI 1.12-15.10) but not for 1-year mortality compared with the lowest BPV quartile (HR =1.61, CI 0.81-3.23). Day-to-day BPV is associated with 30-day, but not with 1-year mortality in hospitalized elderly patients.
Wang, Zhi-Yong; Ma, Xiu-Qiang; Zhao, Yan-Fang; Lu, Jian; Xiang, Chun; Qin, Ying-Yi; Wu, Shun-Quan; Yu, Fei-Fei; He, Jia
Background The incidence and burden of stroke in China is increasing rapidly. However, little is known about trends in mortality during stroke hospitalization. The objectives of this study were to assess trends of in-hospital mortality among patients with stroke and explore influence factors of in-hospital death after stroke in China. Methods 109 grade III class A hospitals were sampled by multistage stratified cluster sampling. All patients admitted to hospitals between 2007 and 2010 with a discharge diagnosis of stroke were included. Trends in in-hospital mortality among patients with stroke were assessed. Influence factors of in-hospital death after stroke were explored using multivariable logistic regression. Results Overall stroke hospitalizations increased from 79,894 in 2007 to 85,475 in 2010, and in-hospital mortality of stroke decreased from 3.16% to 2.30% (P<0.0001). The percentage of severe patients increased while odds of mortality (2010 versus 2007) decreased regardless of stroke type: subarachnoid hemorrhage (OR 0.792, 95% CI = 0.636 to 0.987), intracerebral hemorrhage (OR 0.647, 95% CI = 0.591 to 0.708), and ischemic stroke (OR 0.588, 95% CI = 0.532 to 0.649). In multivariable analyses, older age, male, basic health insurance, multiple comorbidities and severity of disease were linked to higher odds of in-hospital mortality. Conclusions The mortality of stroke hospitalizations decreased likely reflecting advancements in stroke care and prevention. Decreasing of mortality with increasing of severe stroke patients indicated that we should pay more attention to rehabilitation and life quality of stroke patients. Specific individual and hospital-level characteristics may be targets for facilitating further declines. PMID:24651454
Fortney, J A
Maternal mortality in many developing countries remains at distressingly high levels despite improvements in hospital obstetrics. WHO estimates that 1/2 million maternal deaths occur each year, 99% of which are in developing countries. While many people expect that widespread acceptance of family planning will bring down levels of maternal mortality, some analyses have claimed disappointing reductions, though others were more encouraging. The primary reason for this discrepancy lies in the choice of measure of maternal mortality, compounded somewhat by a confusion in terminology. Maternal mortality can be measured by: 1) the number of maternal deaths; 2) the maternal mortality ratio; 3) the maternal mortality rate; or 4) the lifetime risk of death in childbirth. Family planning use influences the maternal mortality ratio only to the extent that it reduces the proportion of pregnancies to high-risk women. The maternal mortality rate can be substantially influenced by the prevalence of contraception, but it is primarily the reduction in the number of births, per se, that exerts the influence. The choice of measure should be determined by the issue being addressed, and which of the 2 determinants of maternal mortality (obstetric risk or prevalence of pregnancy) is the focus. Current levels of maternal mortality in the developed countries have been achieved only with both good obstetric care and with low fertility. In developing countries today, modern obstetric care is often available only in a few teaching hospitals, but family planning programs are feasible even in remote areas. While implementing family planning programs is not easy, it is more feasible than the implementation of significant improvements in the quality and availability of obstetric care. The contribution of family planning to lower maternal mortality and morbidity should not be underestimated.
Zegers, Marieke; Hesselink, Gijs; Geense, Wytske; Vincent, Charles; Wollersheim, Hub
Objective To provide an overview of effective interventions aimed at reducing rates of adverse events in hospitals. Design Systematic review of systematic reviews. Data sources PubMed, CINAHL, PsycINFO, the Cochrane Library and EMBASE were searched for systematic reviews published until October 2015. Study selection English-language systematic reviews of interventions aimed at reducing adverse events in hospitals, including studies with an experimental design and reporting adverse event rates, were included. Two reviewers independently assessed each study's quality and extracted data on the study population, study design, intervention characteristics and adverse patient outcomes. Results Sixty systematic reviews with moderate to high quality were included. Statistically significant pooled effect sizes were found for 14 types of interventions, including: (1) multicomponent interventions to prevent delirium; (2) rapid response teams to reduce cardiopulmonary arrest and mortality rates; (3) pharmacist interventions to reduce adverse drug events; (4) exercises and multicomponent interventions to prevent falls; and (5) care bundle interventions, checklists and reminders to reduce infections. Most (82%) of the significant effect sizes were based on 5 or fewer primary studies with an experimental study design. Conclusions The evidence for patient-safety interventions implemented in hospitals worldwide is weak. The findings address the need to invest in high-quality research standards in order to identify interventions that have a real impact on patient safety. Interventions to prevent delirium, cardiopulmonary arrest and mortality, adverse drug events, infections and falls are most effective and should therefore be prioritised by clinicians. PMID:27687901
The challenge of reducing maternal mortality is increasingly being addressed by area-based efforts to improve access to care of obstetric emergencies. Improving coverage and quality of skilled attendance at birth is also being increasingly emphasized. Post-abortion care, better reproductive health services for adolescents, and improved family planning care are important ingredients in maternal mortality reduction. New developments in malaria, nutrition, violence and HIV/AIDS in relation to maternal health are highlighted, as well as measurement issues. Maternal mortality reduction is also being promoted today by using a human rights approach.
Wood, Adrian D; Gollop, Nicholas D; Bettencourt-Silva, Joao H; Clark, Allan B; Metcalf, Anthony K; Bowles, Kristian M; Flather, Marcus D; Potter, John F
Background and Purpose Little is known about the factors associated with in-hospital mortality following total anterior circulation stroke (TACS). We examined the characteristics and comorbidity data for TACS patients in relation to in-hospital mortality with the aim of developing a simple clinical rule for predicting the acute mortality outcome in TACS. Methods A routine data registry of one regional hospital in the UK was analyzed. The subjects were 2,971 stroke patients with TACS (82% ischemic; median age=81 years, interquartile age range=74–86 years) admitted between 1996 and 2012. Uni- and multivariate regression models were used to estimate in-hospital mortality odds ratios for the study covariates. A 6-point TACS scoring system was developed from regression analyses to predict in-hospital mortality as the outcome. Results Factors associated with in-hospital mortality of TACS were male sex [adjusted odds ratio (AOR)=1.19], age (AOR=4.96 for ≥85 years vs. <65 years), hemorrhagic subtype (AOR=1.70), nonlateralization (AOR=1.75), prestroke disability (AOR=1.73 for moderate disability vs. no symptoms), and congestive heart failure (CHF) (AOR=1.61). Risk stratification using the 6-point TACS Score [T=type (hemorrhage=1 point) and territory (nonlateralization=1 point), A=age (65–84 years=1 point, ≥85 years=2 points), C=CHF (if present=1 point), S=status before stroke (prestroke modified Rankin Scale score of 4 or 5=1 point)] reliably predicted a mortality outcome: score=0, 29.4% mortality; score=1, 46.2% mortality [negative predictive value (NPV)=70.6%, positive predictive value (PPV)=46.2%]; score=2, 64.1% mortality (NPV=70.6, PPV=64.1%); score=3, 73.7% mortality (NPV=70.6%, PPV=73.7%); and score=4 or 5, 81.2% mortality (NPV=70.6%, PPV=81.2%). Conclusions We have identified the key determinants of in-hospital mortality following TACS and derived a 6-point TACS Score that can be used to predict the prognosis of particular patients. PMID:27819414
Sjögren, Petteri; Wårdh, Inger; Zimmerman, Mikael; Almståhl, Annica; Wikström, Maude
The objectives of the study were to compare the effect of intensified oral care interventions given by dental or nursing personnel on mortality from healthcare-associated pneumonia (HAP) in elderly adults in hospitals or nursing homes with the effect of usual oral care. Systematic literature searches were conducted in PubMed, the Cochrane Library, and the Health Technology Assessment database of the National Health Service Centre for Reviews and Dissemination (August 2015). Randomized controlled trials (RCTs) were considered for inclusion. Data were extracted and risk of bias was assessed independently and agreed on in consensus meetings. Five RCTs, with some or major study limitations, fulfilled the inclusion criteria. Based on meta-analyses, oral care interventions given by dental personnel reduced mortality from HAP (risk ratio (RR) = 0.43, 95% confidence interval (CI) = 0.25-0.76, P = .003), whereas oral care interventions given by nursing personnel did not result in a statistically significant difference in mortality from HAP (RR = 1.20, 95% CI = 0.97-1.48, P = .09), in elderly adults in hospitals or nursing homes from usual oral care. Oral care interventions given by dental personnel may reduce mortality from HAP (low certainty of evidence, Grading of Recommendations Assessment, Development and Evaluation (GRADE) ⊕⊕○○), whereas oral care interventions given by nursing personnel probably result in little or no difference from usual care (moderate certainty of evidence, GRADE ⊕⊕⊕○) in elderly adults in hospitals or nursing homes.
Ueda, Sho; Yamaoka, Masatoshi; Sekiya, Yoshiaki; Yamada, Hitoshi; Kawakami, Naoki; Araki, Yuichi; Wakai, Yoko; Saito, Kazuhito; Inagaki, Masaharu; Matsumiya, Naoki
Background. Optimal treatment practices and factors associated with in-hospital mortality in spontaneous pneumothorax (SP) are not fully understood. We evaluated prevalence, clinical characteristics, and in-hospital mortality among Japanese patients with primary or secondary SP (PSP/SSP). Methods. We retrospectively reviewed and stratified 938 instances of pneumothorax in 751 consecutive patients diagnosed with SP into the PSP and SSP groups. Factors associated with in-hospital mortality in SSP were identified by multiple logistic regression analysis. Results. In the SSP group (n = 327; 34.9%), patient age, requirement for emergency transport, and length of stay were greater (all, p < 0.001), while the prevalence of smoking (p = 0.023) and number of surgical interventions (p < 0.001) were lower compared to those in the PSP group (n = 611; 65.1%). Among the 16 in-hospital deceased patients, 12 (75.0%) received emergency transportation and 10 (62.5%) exhibited performance status (PS) of 3-4. In the SSP group, emergency transportation was an independent factor for in-hospital mortality (odds ratio 16.37; 95% confidence interval, 4.85–55.20; p < 0.001). Conclusions. The prevalence and clinical characteristics of PSP and SSP differ considerably. Patients with SSP receiving emergency transportation should receive careful attention. PMID:28386166
Graham, Wendy J; Foster, Lauren B; Davidson, Lisa; Hauke, Elizabeth; Campbell, Oona M R
The need to monitor progress in reducing maternal mortality has a long history, which can be traced back to the 1700s in some parts of the Western world. Today, however, this need is felt most acutely in developing countries, where the priority is to stimulate, evaluate and sustain action to prevent these essentially avoidable deaths. Over the last two decades, considerable efforts have been made to understand and overcome the measurement challenges of maternal mortality in the context of weak information systems, and new and enhanced methods and tools have emerged.
Dahlin, Arielle A; Parsons, Chase C; Barengo, Noël C; Ruiz, Juan Gabriel; Ward-Peterson, Melissa; Zevallos, Juan Carlos
Stroke remains one of the leading causes of death in the United States. Current evidence identified electrocardiographic abnormalities and cardiac arrhythmias in 50% of patients with an acute stroke. The purpose of this study was to assess whether the presence of ventricular arrhythmia (VA) in adult patients hospitalized in Florida with acute stroke increased the risk of in-hospital mortality.Secondary data analysis of 215,150 patients with ischemic and hemorrhagic stroke hospitalized in the state of Florida collected by the Florida Agency for Healthcare Administration from 2008 to 2012. The main outcome for this study was in-hospital mortality. The main exposure of this study was defined as the presence of VA. VA included the ICD-9 CM codes: paroxysmal ventricular tachycardia (427.1), ventricular fibrillation (427.41), ventricular flutter (427.42), ventricular fibrillation and flutter (427.4), and other - includes premature ventricular beats, contractions, or systoles (427.69). Differences in demographic and clinical characteristics and hospital outcomes were assessed between patients who developed versus did not develop VA during hospitalization (χ and t tests). Binary logistic regression was used to estimate unadjusted and adjusted odds ratios and 95% confidence intervals (CIs) between VA and in-hospital mortality.VA was associated with an increased risk of in-hospital mortality after adjusting for all covariates (odds ratio [OR]: 1.75; 95% CI: 1.6-1.2). There was an increased in-hospital mortality in women compared to men (OR: 1.1; 95% CI: 1.1-1.14), age greater than 85 years (OR: 3.9, 95% CI: 3.5-4.3), African Americans compared to Whites (OR: 1.1; 95% CI: 1.04-1.2), diagnosis of congestive heart failure (OR: 2.1; 95% CI: 2.0-2.3), and atrial arrhythmias (OR: 2.1, 95% CI: 2.0-2.2). Patients with hemorrhagic stroke had increased odds of in-hospital mortality (OR: 9.0; 95% CI: 8.6-9.4) compared to ischemic stroke.Identifying VAs in stroke patients may help in
Asiimwe, Stephen B; Muzoora, Conrad; Wilson, L Anthony; Moore, Christopher C
The impact of malnutrition on the outcomes of hospitalized adults in resource-limited settings such as sub-Saharan Africa (SSA) is not fully described. We aimed to determine the association between malnutrition and mortality in adults admitted to hospital in the resource-limited setting of Southwestern Uganda. We performed a cohort study of adults admitted to the medical ward of Mbarara Regional Referral Hospital. Measures of nutritional status included: 1) body mass index (BMI), 2) the mini-nutritional assessment short form (MNA-sf), and 3) mid-upper arm circumference (MUAC). Subjects were followed until death or 30 days from admission. We used proportional hazards regression to assess associations between malnutrition and in-hospital and 30-day mortality. We enrolled 318 subjects. The prevalence of malnutrition was 25-59% depending on the measure used. In-hospital and 30-day mortality were 18% and 37% respectively. In the adjusted analysis, subjects with MNA-sf score 0-7 had a 2.7-fold higher risk of in-hospital mortality (95% CI: 1.3-5.9, p = 0.011) than those with a score of 8-14, and subjects with malnutrition determined by MUAC (<20 cm for males, and <19 cm for females) had a 1.8-fold higher risk of in-hospital mortality (95% CI: 0.98-3.4, p = 0.06) than those normally nourished. MNA-sf (HR 1.6, 95% CI: 1.02-2.6, p = 0.039) and MUAC (HR 1.6, 95% CI: 1.0-2.3, p = 0.048) were independently predictive of 30-day mortality. BMI <18.5 was not associated with in-hospital or 30-day mortality. Malnutrition was common and simple measures of nutritional status predicted in-hospital and 30-day mortality. Further research is needed to understand the pathophysiology of malnutrition during acute illness and mitigate its effects. Copyright © 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Arboix, Adrià; Rivas, Antoni; García-Eroles, Luis; de Marcos, Lourdes; Massons, Joan; Oliveres, Montserrat
Background To compare the characteristics and prognostic features of ischemic stroke in patients with diabetes and without diabetes, and to determine the independent predictors of in-hospital mortality in people with diabetes and ischemic stroke. Methods Diabetes was diagnosed in 393 (21.3%) of 1,840 consecutive patients with cerebral infarction included in a prospective stroke registry over a 12-year period. Demographic characteristics, cardiovascular risk factors, clinical events, stroke subtypes, neuroimaging data, and outcome in ischemic stroke patients with and without diabetes were compared. Predictors of in-hospital mortality in diabetic patients with ischemic stroke were assessed by multivariate analysis. Results People with diabetes compared to people without diabetes presented more frequently atherothrombotic stroke (41.2% vs 27%) and lacunar infarction (35.1% vs 23.9%) (P < 0.01). The in-hospital mortality in ischemic stroke patients with diabetes was 12.5% and 14.6% in those without (P = NS). Ischemic heart disease, hyperlipidemia, subacute onset, 85 years old or more, atherothrombotic and lacunar infarcts, and thalamic topography were independently associated with ischemic stroke in patients with diabetes, whereas predictors of in-hospital mortality included the patient's age, decreased consciousness, chronic nephropathy, congestive heart failure and atrial fibrillation Conclusion Ischemic stroke in people with diabetes showed a different clinical pattern from those without diabetes, with atherothrombotic stroke and lacunar infarcts being more frequent. Clinical factors indicative of the severity of ischemic stroke available at onset have a predominant influence upon in-hospital mortality and may help clinicians to assess prognosis more accurately. PMID:15833108
Giakoumidakis, Konstantinos; Baltopoulos, George I; Charitos, Christos; Patelarou, Evridiki; Fotos, Nikolaos V; Brokalaki-Pananoudaki, Hero
Mortality is an important healthcare index for assessing the quality and the effectiveness of the provided nursing care. The aim of this study was to identify the risk factors for increased in-hospital mortality among cardiac surgery patients. We followed up prospectively 313 consecutive patients who were admitted to the cardiac surgery intensive care unit (ICU) of a general, tertiary hospital in Athens during a 1 year period. Data collection was performed by using a short questionnaire and two instruments, the Nursing Activities Score (NAS) and the logistic EuroSCORE for assessing the nursing workload (NWL) and the perioperative risk for each patient respectively. Patients with a high 1st day NAS had an almost 3.3 times greater probability of death during their hospitalization (OR 3.3, 95%CI 1.4-8). Moreover, patients with increased perioperative risk (OR 4.2, 95%CI 1.50-12) and ICU length of stay (ICU-LOS) (OR 16.8, 95%CI 4.8-58.6) had statistically significant higher in-hospital mortality. Increased level of NWL, patient perioperative risk and ICU-LOS are closely associated with increased in-hospital mortality of cardiac surgery patients. The correlation between NWL and mortality represents the strong link of the nursing profession with the improvement of the effectiveness and quality of care.
Coskun, Isa; Cayli, Murat; Gulcan, Oner
Purpose Redo cardiac operations represent one of the main challenges in heart surgery. The purpose of the study was to analyze the predictors of in-hospital mortality in patients undergoing reoperative cardiac surgery by a single surgical team. Methods A total of 1367 patients underwent cardiac surgical procedures and prospectively entered into a computerized database. Patients were divided into 2 groups based on the reoperative cardiac surgery (n = 109) and control group (n = 1258). Uni- and multivariate logistic regression analysis were performed to evaluate the possible predictors of hospital mortality. Results Mean age was 56 ± 13, and 46% were female in redo group. In-hospital mortality was 4.6 vs. 2.2%, p = 0.11. EuroSCORE (6 vs. 3; p < 0.01), cardiopulmonary bypass time (90 vs. 71 min; p < 0.01), postoperative bleeding (450 vs. 350 ml; p < 0.01), postoperative atrial fibrillation (AF) (29 vs. 16%; p < 0.01), and inotropic support (58 vs. 31%; p = 0.001) were significantly different. These variables were entered into uni- and multivariate regression analysis. Postoperative AF (OR1.76, p = 0.007) and EuroSCORE (OR 1.42, p < 0.01) were significant risk factors predicting hospital mortality. Conclusions Reoperative cardiac surgery can be performed under similar risks as primary operations. Postoperative AF and EuroSCORE are predictors of in-hospital mortality for redo cases. PMID:26527452
Jiang, Rong; Ai, Zi-Sheng; Jiang, Xin; Yuan, Ping; Liu, Dong; Zhao, Qin-Hua; He, Jing; Wang, Lan; Gomberg-Maitland, Mardi; Jing, Zhi-Cheng
The in-hospital mortality of severe pulmonary hypertension (PH) with right heart failure (RHF) is high despite the use of vasoactive and PH-specific therapies. We conducted a prospective analysis evaluating the safety and outcomes of fasudil hydrochloride (Chuan Wei) therapy in acute RHF. PH patients hospitalized between April 2009 and November 2010 were treated with 30 mg of i.v. fasudil three times daily over 30 min, until they experienced relief of RHF symptoms. Adverse and serious adverse events were recorded. Odds ratios (ORs) and 95% confidence intervals were calculated for both in-hospital mortality and re-hospitalization. Multivariate adjustments were made for age, gender and World Health Organization functional class. There were no significant differences between the fasudil group and the control group in demographics, hemodynamics, and PH-specific and vasoactive therapies. Of the 209 study patients, 3 of the 74 patients (4.1%) in the fasudil arm died, and 19 of the 135 patients (14.1%) in the control arm died (P=0.005). Fasudil decreased both in-hospital mortality (OR=0.258 (0.074-0.903); P=0.034) and 30-day re-hospitalization (OR=0.200 (0.059-0.681); P=0.010). Fasudil was well tolerated; one patient discontinued treatment. Intravenous fasudil may be given safely in patients with PH and acute RHF, and may reduce the rates of both in-hospital mortality and 30-day re-hospitalization.
Lin, Shen-Che; Chen, Chun-Kuei; Chen, Jih-Chang; Chan, Yi-Lin; Wu, Chin-Chieh; Blaney, Gerald N.; Liu, Zhen-Ying; Wu, Cho-Ju
Background The associations between dysglycemia and mortality in septic patients with and without diabetes are yet to be confirmed. Our aim was to analyze the association of diabetes and sepsis mortality, and to examine how dysglycemia (hyperglycemia, hypoglycemia and glucose variability) affects in-hospital mortality of patients with suspected sepsis in emergency department (ED) and intensive care units. Methods Clinically suspected septic patients admitted to ED were included, and stratified into subgroups according to in-hospital mortality and the presence of diabetes. We analyzed patients’ demographics, comorbidities, clinical and laboratory parameters, admission glucose levels and severity of sepsis. Odds ratio of mortality was assessed after adjusting for possible confounders. The correlations of admission glucose and CoV (blood glucose coefficients of variation) and mortality in diabetes and non-diabetes were also tested. Results Diabetes was present in 58.3% of the patients. Diabetic patients were older, more likely to have end-stage renal disease and undergoing hemodialysis, but had fewer malignancies, less sepsis severity (lower Mortality in Emergency Department Sepsis Score), less steroid usage in emergency department, and lower in-hospital mortality rate (aOR:0.83, 95% CI 0.65–0.99, p = 0.044). Hyperglycemia at admission (glucose≥200 mg/dL) was associated with higher risks of in-hospital mortality among the non-diabetes patients (OR:1.83 vs. diabetes, 95% CI 1.20–2.80, p = 0.005) with the same elevated glucose levels at admission. In addition, CoV>30% resulted in higher risk of death as well (aOR:1.88 vs. CoV between 10 and 30, 95%CI 1.24–2.86 p = 0.003). Conclusions This study indicates that while diabetes mellitus seems to be a protective factor in sepsis patients, hyper- or hypoglycemia status on admission, and increased blood glucose variation during hospital stays, were independently associated with increased odds ratio of mortality. PMID
Santos, Ana Rita; Piçarra, Bruno Cordeiro; Celeiro, Margarida; Bento, Ângela; Aguiar, José
Multivessel disease in ST-elevation myocardial infarction (STEMI) is associated with a worse prognosis. A multivessel approach at the time of primary percutaneous coronary intervention (PCI) is the subject of debate. To assess the impact of a multivessel approach on in-hospital morbidity and mortality in patients with STEMI undergoing primary PCI. We studied patients from the Portuguese Registry of Acute Coronary Syndromes with STEMI and multivessel disease who underwent primary PCI. The 257 patients were divided into two groups: those who underwent PCI of the culprit artery only and those who underwent multivessel PCI. Cardiovascular risk factors, STEMI location, in-hospital treatment, number and type of diseased and treated arteries, type of stent implanted and ejection fraction were recorded. The primary end-point was defined as in-hospital mortality and the secondary end-point as the presence of at least one of the following complications: major bleeding, need for transfusion, invasive ventilation, heart failure and reinfarction. Multivessel disease was found in 43.3% of the study population and a multivessel approach was adopted in 19.2% of these patients. There were no differences between the groups in cardiovascular risk factors or electrocardiographic presentation of STEMI. Patients undergoing multivessel PCI were more likely to be treated with drug-eluting stents and glycoprotein IIb/IIIa inhibitors, and less likely to receive heparin therapy. There were no differences between the groups with regard to in-hospital mortality or the incidence of complications. In our population of patients with STEMI, a multivessel approach appears to be safe and not associated with increased in-hospital mortality or morbidity. Copyright © 2012 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.
Chen, Chien-Fu; Lin, Ruey-Tay; Lin, Hsiu-Fen; Chao, A-Ching
The early identification of patients with large hemisphere infarctions (LHIs) at risk of fatal brain edema may result in better outcomes. A quantitative model using parameters obtained at admission may be a predictor of in-hospital mortality from LHI.This prospective study enrolled all patients with LHI involving >50% of the middle cerebral artery (MCA) admitted to our neurological intensive care unit within 48 hours of symptom onset. Early clinical and radiographic parameters and the baseline CHADS2 score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke [double weight]) were analyzed regarding their ability to predict patient outcomes.Seventy-seven patients with LHIs were identified, 33 (42.9%) with complete MCA infarction (CMCA), and 44 (57.1%) with incomplete MCA infarction (IMCA). The predictors of CMCA score included: >1/3 early hypodensity in computed tomography findings, hyperdense MCA sign, brain edema, initial National Institutes of Health Stroke Scale (NIHSS) score ≥17, and stroke in progression during the 1st 5 days of admission. The cutoff CMCA score was 2, with a sensitivity of 81.8% and specificity of 70.5%. Mortality score 1, used for predicting in-hospital mortality from LHI, included CMCA and CHADS2 scores ≥4 (sensitivity 100.0%, specificity 57.4%), and mortality score 2 included CMCA and CHADS2 scores ≥4, and NIHSS score ≥26, during the 1st 5 days (sensitivity 100.0%, specificity 91.7%).Patients qualifying for a mortality score of 2 were at high-risk of in-hospital mortality from LHI. These findings may aid in identifying patients who may benefit from invasive therapeutic strategies, and in better describing the characteristics of those at risk of mortality.
Gili-Miner, M; López-Méndez, J; Vilches-Arenas, A; Ramírez-Ramírez, G; Franco-Fernández, D; Sala-Turrens, J; Béjar-Prado, L
The objective of this study was to analyse the impact of alcohol use disorders (AUD) in patients with multiple sclerosis (MS) in terms of in-hospital mortality, extended hospital stays, and overexpenditures. We conducted a retrospective observational study in a sample of MS patients obtained from minimal basic data sets from 87 Spanish hospitals recorded between 2008 and 2010. Mortality, length of hospital stays, and overexpenditures attributable to AUD were calculated. We used a multivariate analysis of covariance to control for such variables as age and sex, type of hospital, type of admission, other addictions, and comorbidities. The 10,249 patients admitted for MS and aged 18-74 years included 215 patients with AUD. Patients with both MS and AUD were predominantly male, with more emergency admissions, a higher prevalence of tobacco or substance use disorders, and higher scores on the Charlson comorbidity index. Patients with MS and AUD had a very high in-hospital mortality rate (94.1%) and unusually lengthy stays (2.4 days), and they generated overexpenditures (1,116.9euros per patient). According to the results of this study, AUD in patients with MS results in significant increases in-hospital mortality and the length of the hospital stay and results in overexpenditures. Copyright © 2016 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.
Harrison, Meredith A; Hegarty, Sarah E; Keith, Scott W; Cowan, Scott W; Evans, Nathaniel R
Using data from the Nationwide Inpatient Sample, we investigated the impact of surgical approach and race on in-hospital mortality after lobectomy for lung cancer. Logistic regression was used to model odds ratios for in-hospital mortality related to surgical technique (thoracotomy vs video assisted thoracoscopic surgery [VATS]) and race using discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality (2008 to 2011). VATS lobectomies increased each year (25.9% to 39.2%, P = .001) in the 19,353 patients identified. A racial disparity was noted, with black patients being 66% more likely to die in the hospital (odds ratio 1.66, 95% confidence interval 1.17 to 2.37, P = .005). Excluding 2010 data suggests that there is evidence of benefit associated with VATS; however, no evidence of an association between race and in-hospital mortality exists. This study elucidates race-related mortality in lobectomy patients. Although racial disparities are present throughout health care, this finding emphasizes one of the challenges in using large databases to assess such disparities. Copyright © 2015 Elsevier Inc. All rights reserved.
Hasegawa, W; Yamauchi, Y; Yasunaga, H; Sunohara, M; Jo, T; Matsui, H; Fushimi, K; Takami, K; Nagase, T
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic small-vessel vasculitis associated with asthma, eosinophilia, and necrotizing vasculitis. EGPA is potentially life-threatening and often involves peripheral neuropathies, peptic ulcers, cerebral vessel disease, and cardiovascular disease. However, there is limited understanding of the prognostics factors for patients with EGPA. We investigated the clinical features and factors affecting patients' in-hospital mortality, using a national inpatient database in Japan. We retrospectively collected data of EGPA patients who required hospitalization between July 2010 and March 2013, using the Diagnosis Procedure Combination database. We evaluated EGPA patients' characteristics and performed multivariate logistic regression analyses to assess the factors associated with in-hospital mortality. A total of 2195 EGPA patients were identified. The mean age was 61.9 years, 42.1% (924/2195) were male, and 41.6% (914/2195) had emergent admission. In-hospital deaths occurred in 97/2195 patients (4.4%). Higher in-hospital mortality was associated with age older than 65 years, disturbance of consciousness on admission, unscheduled admission, respiratory disease, cardio-cerebrovascular disease, renal disease, sepsis, and malignant disease on admission. Lower mortality was associated with female gender and peripheral neuropathies. Our study revealed the clinical features of EGPA patients who required hospitalization and the factors associated with their mortality. These results may be useful for physicians when assessing disease severity or treatments for hospitalized EGPA patients. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Stephenson, P; Chalmers, B; Kirichenko, V F; Repina, M A; Wagner, M
Following the entry of St Petersburg into Europe's Healthy Cities Project in 1991 it was decided that the highest priority should be given to reducing the city's maternal mortality ratio, then standing at approximately 70 deaths per 100,000 live births. Preventing deaths from unsafe, illegal abortion became the main focus of attention. The use of modern contraceptive methods was promoted, information was disseminated to improve the utilization of family planning services, special outreach services for teenagers were established, and providers were given opportunities for education and training. The maternal mortality ratio and the abortion rate have now declined and contraceptive use appears to be increasing. These achievements are attributable in large measure to the commitment of a broad spectrum of St Petersburg society as well as to outside support.
Chung, Wankyo; Sohn, Min
Stroke is one of the leading causes of death in Korea, and a well-qualified, adequate nursing force achieves better patient outcomes. This study examined the association between nurse staffing and in-hospital mortality among stroke patients in a nationally representative sample. This cross-sectional retrospective study was conducted using 2009 National Health Insurance claims data of stroke patients admitted to variously sized Korean hospitals. The data included patient (individual and clinical) and hospital characteristics. Mortality was measured using crude in-hospital mortality rates; nurse staffing was expressed as number of registered nurses per 100 beds. Logistic regression was used to study the association between nurse staffing and patient mortality during hospitalization, after adjusting for related factors. The data of 11 819 stroke inpatients from 615 hospitals were analyzed. Mean patient age was 66.9 ± 13.1 years, 47.5% were women, 77.4% were ischemic patients, and 20.3% underwent surgery. The crude in-hospital mortality rate was 5.5%. Nurse staffing was found to be negatively related to mortality (odds ratio, 0.988; 95% confidence interval, 0.977-0.999), after controlling for major confounders, such as comorbidities, physician-to-bed ratio, and medical costs. Policies to educate sufficient numbers of nurses and retain them in the field are warranted, especially because medical-cost containment has become a dominant concern in most countries. Further studies are needed to understand the mechanisms and other protective roles of nurse staffing to ensure long-term health outcomes after hospital discharge.
Incalzi, R A; Capparella, O; Gemma, A; Camaioni, D; Sanguinetti, C; Carbonin, P U
Ninety-seven patients aged 88 +/- 4 years (range, 80-97 years) (study group), and 74 aged 75 +/- 3 years (range, 70-79 years) (control group), were prospectively studied to investigate whether basic medical variables can predict in-hospital mortality in very old patients undergoing hip surgery because of femoral fracture. Mortality was 16.5% and 6.7% in the study and control groups, respectively (p = 0.054). In the study group, mortality was significantly correlated with age (p < 0.01), venous disorders (p < 0.05), malnutrition (p < 0.0001), duration of surgery (p < 0.006), and postoperative noninfectious complications (p < 0.005). In the control group, age was the only significant correlate of mortality (p < 0.005). After exclusion of surgery-related variables, the logistic regression analysis confirmed the predictive role of venous disorders (odds ratio = 2.04, confidence limits = 1.09-3.79) and malnutrition (odds ratio = 6.01, confidence limits = 1.85-19.47) but not of age in the study group. However, the goodness-of-fit test showed that the statistical model did not fit the data adequately. We conclude that in-hospital mortality after hip surgery in the very old cannot be predicted on the basis of underlying medical conditions alone.
Pérez-López, Paloma; Baré, Marisa; Touma-Fernández, Ángel; Sarría-Santamera, Antonio
The results previously obtained in Spain in the study of the relationship between surgical caseload and in-hospital mortality are inconclusive. The aim of this study is to evaluate the volume-outcome association in Spain in the setting of digestive oncological surgery. An analytical, cross-sectional study was conducted with data from patients who underwent surgical procedures with curative intent of esophageal, gastric, colorectal and pancreatic neoplasms between 2006-2009 with data from the Spanish MBDS. In-hospital mortality was used as outcome variable. Control variables were patient, health care and hospital characteristics. Exposure variable was the number of interventions for each disease, dividing the hospitals in 3 categories: high volume (HV), mid volume (MV) and low volume (LV) according to the number of procedures. An inverse, statistically significant relationship between procedure volume and in-hospital mortality was observed for both volume categories in both gastric (LV: OR=1,50 [IC 95%: 1,28-1,76]; MV: OR=1,49 (IC 95%: 1,28-1,74)) and colorectal (LV: OR=1,44 [IC 95%: 1,33-1,55]; MV: OR=1,24 [IC 95%: 1,15-1,33]) cancer surgery. In pancreatic procedures, this difference was only statistically significant between LV and HV categories (LV: OR=1,89 [IC 95%: 1,29-2,75]; MV: OR=1,21 [IC 95%: 0,82-1,79]). Esophageal surgery also showed an inverse relationship, which was not statistically significant (LV: OR=1,89 [IC 95%: 0,98-3,64]; MV: OR=1,05 [IC 95%: 0,50-2,21]). The results of this study suggest the existence in Spain of an inverse relationship between caseload and in-hospital mortality in digestive oncological surgery for the procedures analyzed. Copyright © 2015 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.
Beatty, Jessica A.; Majumdar, Sumit R.; Tyrrell, Gregory J.; Marrie, Thomas J.; Eurich, Dean T.
Abstract Bacteremic pneumococcal pneumonia (BPP) causes considerable mortality and morbidity. We aimed to identify prognostic factors associated with mortality and major in-hospital complications in BPP. A prospective, population-based clinical registry of 1636 hospitalized adult patients (≥18 years) with BPP was established between 2000 and 2010 in Northern Alberta, Canada. Prognostic factors for mortality and major in-hospital complications (e.g., cardiac events, mechanical ventilation, aspiration) were evaluated using multivariable logistic regression. Average age was 54 (standard deviation 18) years, 57% males, and 59% had high case-fatality rate (CFR) serotypes. Overall, 14% (226/1636) of patients died and 22% (315/1410) of survivors developed at least 1 complication. Independent prognostic factors for mortality were age (adjusted odds ratio [aOR], 1.5 per decade; 95% confidence interval [CI], 1.3–1.7), nursing home residence (aOR, 3.7; 95% CI 1.8–7.4), community-dwelling dementia (aOR 3.7; 95% CI, 1.6–8.6), alcohol abuse (aOR, 2.2; 95% CI, 1.4–3.4), acid-suppressing drugs (aOR, 1.5; 95% CI, 1.0–2.3), guideline-discordant antibiotics (aOR, 3.4; 95% CI, 2.4–4.8), multilobe pneumonia (aOR, 2.6; 95% CI, 1.8–3.6), and high CFR serotypes (aOR, 1.8; 95% CI, 1.2–2.8). Similar prognostic factors were observed for major in-hospital complications. Pneumococcal vaccination was associated with reduced in-hospital mortality (aOR, 0.2; 95% CI, 0.05–0.9) but not major complications (P = 0.2). Older and frailer patients, and those who abuse alcohol or take acid-suppressing drugs, are at increased risk of BPP-related mortality and complications, as are those with high CFR serotypes. Beyond identifying those at highest risk, our findings demonstrate the importance of guideline-concordant antibiotics and pneumococcal vaccination in those with BPP. PMID:27861340
van Rijn, Marjon; Buurman, Bianca M; MacNeil-Vroomen, Janet L; Suijker, Jacqueline J; ter Riet, Gerben; Moll van Charante, Eric P; de Rooij, Sophia E
to compare changes over time in the in-hospital mortality and the mortality from discharge to 30 days post-discharge for six highly prevalent discharge diagnoses in acutely admitted older patients as well as to assess the effect of separately analysing the in-hospital mortality and the mortality from discharge to 30 days post-discharge. retrospective analysis of Dutch hospital and mortality data collected between 2000 and 2010. the participants included 263,746 people, aged 65 years and above, who were acutely admitted for acute myocardial infarction (AMI), heart failure (HF), stroke, chronic obstructive pulmonary disease, pneumonia or hip fracture. we compared changes in the in-hospital mortality and mortality from discharge to 30 days post-discharge in the Netherlands using a logistic- and a multinomial regression model. for all six diagnoses, the mortality from admission to 30 days post-discharge declined between 2000 and 2009. The decline ranged from a relative risk ratio (RRR) of 0.41 [95% confidence interval (CI) 0.38-0.45] for AMI to 0.77 [0.73-0.82] for HF. In separate analyses, the in-hospital mortality decreased for all six diagnoses. The mortality from discharge to 30 days post-discharge in 2009 compared to 2000 depended on the diagnosis, and either declined, remained unchanged or increased. the decline in hospital mortality in acutely admitted older patients was largely attributable to the lower in-hospital mortality, while the change in the mortality from discharge to 30 days post-discharge depended on the diagnosis. Separately reporting the two rate estimates might be more informative than providing an overall hospital mortality rate. © The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: email@example.com.
Bhakoo, O N; Kumar, R
The government of India has set a goal of reducing perinatal mortality from its current rate of 48/1000 to 30-35/1000 by the year 2000. Perinatal deaths result from maternal malnutrition, inadequate prenatal care, complications of delivery, and infections in the postpartum period. Since reductions in perinatal mortality require attention to social, economic, and behavioral factors, as well as improvements in the health care delivery system, a comprehensive strategy is required. Social measures, such as raising the age at marriage to 18 years for females, improving the nutritional status of adolescent girls, reducing the strenuousness of work during pregnancy, improving female literacy, raising women's status in the society and thus in the family, and poverty alleviation programs, would all help eliminate the extent of complications of pregnancy. Measures required to enhance infant survival include improved prenatal care, prenatal tetanus toxoid immunization, use of sterile disposable cord care kits, the provision of mucus extractors and resuscitation materials to birth attendants, the creation of neonatal care units in health facilities, and more efficient referral of high-risk newborns and mothers. Since 90% of births in rural India take place at home priority must be given to training traditional birth attendants in the identification of high risk factors during pregnancy, delivery, and the newborn period.
Chen, Dong; Wang, Xiaoming; Thatcher, Marcus; Barnett, Guy; Kachenko, Anthony; Prince, Robert
The potential benefit of urban vegetation in reducing heat related mortality in the city of Melbourne, Australia is investigated using a two-scale modelling approach. A meso-scale urban climate model was used to quantify the effects of ten urban vegetation schemes on the current climate in 2009 and future climates in 2030 and 2050. The indoor thermal performance of five residential buildings was then simulated using a building simulation tool with the local meso-climates associated with various urban vegetation schemes. Simulation results suggest that average seasonal summer temperatures can be reduced in the range of around 0.5 and 2 °C if the city were replaced by vegetated suburbs and parklands, respectively. With the limited buildings and local meso-climates investigated in this study, around 5-28% and 37-99% reduction in heat related mortality rate have been estimated by doubling the city's vegetation coverage and transforming the city into parklands respectively. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.
Obesity is increasing; in the UK, almost 20% of pregnant women have a body mass index (BMI) of ≥30 kg/m(2). Obese mothers have increased risks of pregnancy complications including miscarriage, congenital anomaly, gestational diabetes, pre-eclampsia, macrosomia, induction of labour, caesarean section, anaesthetic and surgical complications, post-partum haemorrhage, infection and venous thromboembolism. Complications tend to be greater in those with the highest BMIs. In recent triennia, obesity (27-29%) was over-represented in maternal mortality figures. Strategies to reduce morbidity and mortality include calculating BMI at booking visit to identify obese mothers and plan their antenatal care and delivery. This should include nutritional and lifestyle advice, screening for gestational diabetes and pre-eclampsia, thromboembolism risk assessment, antenatal anaesthetic review if BMI is ≥ 40 kg/m(2), ensuring availability of robust theatre tables and other equipment and involving senior doctors, especially in the labour ward. Afterwards, continuing weight reduction should be encouraged to reduce future pregnancy and health risks. Copyright © 2014 Elsevier Ltd. All rights reserved.
Tevik, Kjerstin; Thürmer, Hanne; Husby, Marit Inderhaug; de Soysa, Ann Kristin; Helvik, Anne-Sofie
Mortality among patients with chronic heart failure (CHF) is still high despite progress in medical and surgical treatment. The patients' nutritional condition may play an important role, and needs further investigation. The aim of this study was to evaluate whether nutritional risk in hospitalized patients with CHF was associated with three-year mortality. A prospective study was conducted in 131 hospitalized Norwegian patients with CHF. Nutritional screening was performed using Nutritional Risk Screening (NRS-2002). The primary clinical outcome was death from any cause. The prevalence of nutritional risk was 57% (NRS-2002 score ≥ 3). The overall mortality rate was 52.6% within three-year follow up. More patients at nutritional risk (N = 51) died compared to patients not at nutritional risk (N = 18) (P < 0.001). In adjusted analyses patients at nutritional risk had more than five-time higher odds (OR 5.85; 95% CI 2.10-16.24) to die before three-year follow-up than those not at nutritional risk. In adjusted Cox multivariate analysis, the nutritional risk was associated with increased mortality (HR 2.78; 95% CI 1.53-5.03). Furthermore, in adjusted analysis components in NRS-2002 were associated with mortality, i.e. nutritional status (HR 1.82; 95% CI 1.03-3.22), severity of disease (NYHA-class IV) (HR 1.78; 95% CI 1.00-3.16) and age (≥ 70 year) (HR 3.24; 95% CI 1.48-7.10). Nutritional risk as defined by NRS-2002 in hospitalized patients with CHF was significantly associated with long term mortality. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.
Gili, Miguel; Sala, José; López, Julio; Carrión, Ana; Béjar, Luís; Moreno, Julio; Rosales, Angela; Sánchez, Gabriel
Treatment of acute myocardial infarction has changed notably in recent years. The objective of this study was to analyze trends in in-hospital mortality during the period 2003-2009 and to examine how changes in comorbidity indices affected mortality prediction models for acute myocardial infarction using the minimum basic data set. During the study period, 5275 cases of acute myocardial infarction were admitted. Mortality rates were calculated by age and sex and Charlson and Elixhauser comorbidity index scores were obtained on admission for every patient. Trends were analyzed and their validity studied. Multivariate models predictive of mortality were derived and compared. Mean age and comorbidities increased in all patients over the period 2003-2009. In spite of these trends, acute myocardial infarction mortality decreased. Comorbidity indices remained valid when the criterion "present on admission" was applied. Multivariate predictive models included age, sex, medical treatment, coronary revascularization and a comorbidity index or specific comorbidities. The model with specific comorbidities showed the best predictive ability. All models found that age and comorbidities increased the risk of death, and that coronary revascularization and treatment with anticoagulants, fibrinolytics, and platelet antiaggregants were protective factors. Despite the fact that the mean age and number of comorbidities in acute myocardial infarction patients has increased year over year, acute myocardial infarction mortality has decreased, probably because of more frequent reperfusion and revascularization therapy and better medical treatment. Copyright © 2011 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.
Soto, Graciela J.; Hope, Aluko A.; Ponea, Ana; Gong, Michelle N.
Rationale: Both acute respiratory distress syndrome (ARDS) and intensive care unit (ICU) delirium are associated with significant morbidity and mortality. However, the risk of delirium and its impact on mortality in ARDS patients is unknown. Objectives: To determine if ARDS is associated with a higher risk for delirium compared with respiratory failure without ARDS, and to determine the association between ARDS and in-hospital mortality after adjusting for delirium. Methods: Prospective observational cohort study of adult ICU patients admitted to two urban academic hospitals. Measurements and Main Results: Delirium was assessed daily using the Confusion Assessment Method for the ICU and Richmond Agitation and Sedation Scale. Of the 564 patients in our cohort, 48 had ARDS (9%). Intubated patients with ARDS had the highest prevalence of delirium compared with intubated patients without ARDS and nonintubated patients (73% vs. 52% vs. 21%, respectively; P < 0.001). After adjusting for common risk factors for delirium, ARDS was associated with a higher risk for delirium compared with mechanical ventilation without ARDS (odds ratio [OR], 6.55 [1.56–27.54]; P = 0.01 vs. OR, 1.98 [1.16–3.40]; P < 0.013); reference was nonintubated patients. Although ARDS was significantly associated with hospital mortality (OR, 10.44 [3.16–34.50]), the effect was largely reduced after adjusting for delirium and persistent coma (OR, 5.63 [1.55–20.45]). Conclusions: Our findings suggest that ARDS is associated with a greater risk for ICU delirium than mechanical ventilation alone, and that the association between ARDS and in-hospital mortality is weakened after adjusting for delirium and coma. Future studies are needed to determine if prevention and reduction of delirium in ARDS patients can improve outcomes. PMID:25393331
Hsieh, S Jean; Soto, Graciela J; Hope, Aluko A; Ponea, Ana; Gong, Michelle N
Both acute respiratory distress syndrome (ARDS) and intensive care unit (ICU) delirium are associated with significant morbidity and mortality. However, the risk of delirium and its impact on mortality in ARDS patients is unknown. To determine if ARDS is associated with a higher risk for delirium compared with respiratory failure without ARDS, and to determine the association between ARDS and in-hospital mortality after adjusting for delirium. Prospective observational cohort study of adult ICU patients admitted to two urban academic hospitals. Delirium was assessed daily using the Confusion Assessment Method for the ICU and Richmond Agitation and Sedation Scale. Of the 564 patients in our cohort, 48 had ARDS (9%). Intubated patients with ARDS had the highest prevalence of delirium compared with intubated patients without ARDS and nonintubated patients (73% vs. 52% vs. 21%, respectively; P < 0.001). After adjusting for common risk factors for delirium, ARDS was associated with a higher risk for delirium compared with mechanical ventilation without ARDS (odds ratio [OR], 6.55 [1.56-27.54]; P = 0.01 vs. OR, 1.98 [1.16-3.40]; P < 0.013); reference was nonintubated patients. Although ARDS was significantly associated with hospital mortality (OR, 10.44 [3.16-34.50]), the effect was largely reduced after adjusting for delirium and persistent coma (OR, 5.63 [1.55-20.45]). Our findings suggest that ARDS is associated with a greater risk for ICU delirium than mechanical ventilation alone, and that the association between ARDS and in-hospital mortality is weakened after adjusting for delirium and coma. Future studies are needed to determine if prevention and reduction of delirium in ARDS patients can improve outcomes.
Head, Roy; Murray, Joanna; Sarrassat, Sophie; Snell, Will; Meda, Nicolas; Ouedraogo, Moctar; Deboise, Laurent; Cousens, Simon
Many people recognise that mass media is important in promoting public health but there have been few attempts to measure how important. An ongoing trial in Burkina Faso (ClinicalTrials.gov, NCT01517230) is an attempt to bring together the very different worlds of mass media and epidemiology: to measure rigorously, using a cluster-randomised design, how many lives mass media can save in a low-income country, and at what cost. Application of the Lives Saved Tool predicts that saturation-based media campaigns could reduce child mortality by 10-20%, at a cost per disability-adjusted life-year that is as low as any existing health intervention. In this Viewpoint we explain the scientific reasoning behind the trial, while stressing the importance of the media methodology used. Copyright © 2015 Elsevier Ltd. All rights reserved.
Finks, Jonathan F.; Osborne, Nicholas H.; Birkmeyer, John D.
BACKGROUND There were numerous efforts in the United States during the previous decade to concentrate selected surgical procedures in high-volume hospitals. It remains unknown whether referral patterns for high-risk surgery have changed as a result and how operative mortality has been affected. METHODS We used national Medicare data to study patients undergoing one of eight different cancer and cardiovascular operations from 1999 through 2008. For each procedure, we examined trends in hospital volume and market concentration, defined as the proportion of Medicare patients undergoing surgery in the top decile of hospitals by volume per year. We used regression-based techniques to assess the effects of volume and market concentration on mortality over time, adjusting for case mix. RESULTS Median hospital volumes of four cancer resections (lung, esophagus, pancreas, and bladder) and of repair of abdominal aortic aneurysm (AAA) rose substantially. Depending on the procedure, higher hospital volumes were attributable to an increasing number of cases nationwide, an increasing market concentration, or both. Hospital volumes rose slightly for aortic-valve replacement but fell for coronary-artery bypass grafting and carotid endarterectomy. Operative mortality declined for all eight procedures, ranging from a relative decline of 8% for carotid endarterectomy (1.3% mortality in 1999 and 1.2% in 2008) to 36% for AAA repair (4.4% in 1999 and 2.8% in 2008). Higher hospital volumes explained a large portion of the decline in mortality for pancreatectomy (67% of the decline), cystectomy (37%), and esophagectomy (32%), but not for the other procedures. CONCLUSIONS Operative mortality with high-risk surgery fell substantially during the previous decade. Although increased market concentration and hospital volume have contributed to declining mortality with some high-risk cancer operations, declines in mortality with other procedures are largely attributable to other factors. (Funded
Berry, Jay G; Graham, Robert J; Roberson, David W; Rhein, Lawrence; Graham, Dionne A; Zhou, Jing; O’Brien, Jane; Putney, Heather; Goldmann, Donald A
Objectives To identify children at risk for in-hospital mortality following tracheotomy. Design Retrospective cohort study. Setting 25 746 876 US hospitalisations for children within the Kids’ Inpatient Database 1997, 2000, 2003 and 2006. Participants 18 806 hospitalisations of children ages 0–18 years undergoing tracheotomy, identified from ICD-9-CM tracheotomy procedure codes. Main outcome measure Mortality during the initial hospitalisation when tracheotomy was performed in relation to patient demographic and clinical characteristics (neuromuscular impairment (NI), chronic lung disease, upper airway anomaly, prematurity, congenital heart disease, upper airway infection and trauma) identified with ICD-9-CM codes. Results Between 1997 and 2006, mortality following tracheotomy ranged from 7.7% to 8.5%. In each year, higher mortality was observed in children undergoing tracheotomy who were aged <1 year compared with children aged 1–4 years (mortality range: 10.2–13.1% vs 1.1–4.2%); in children with congenital heart disease, compared with children without congenital heart disease (13.1–18.7% vs 6.2–7.1%) and in children with prematurity, compared with children who were not premature (13.0–19.4% vs 6.8–7.3%). Lower mortality was observed in children with an upper airway anomaly compared with children without an upper airway anomaly (1.5–5.1% vs 9.1–10.3%). In 2006, the highest mortality (40.0%) was observed in premature children with NI and congenital heart disease, who did not have an upper airway anomaly. Conclusions Congenital heart disease, prematurity, the absence of an upper airway anomaly and age <1 year were characteristics associated with higher mortality in children following tracheotomy. These findings may assist provider communication with children and families regarding early prognosis following tracheotomy. PMID:20522454
Kissova, Viera; Rosenberger, Jaroslav; Goboova, Maria; Kiss, Adrian
Malnutrition is common in patients admitted to hospital due to acute illness and contributes to negative patient outcomes. In Slovakia there is a lack of relevant data on malnutrition in hospitalized patients, particularly based on chronic co-morbidity and survival. The aim of the present study was to explore the prevalence of malnutrition in hospitalized chronic patients, its relationship to co-morbidity and its impact on 10-year survival. Retrospective cohort study. Nutritional status was estimated by Subjective Global Assessment (SGA), BMI and serum albumin level. Survival was assessed from the National Insurance Registry over a 10-year period. The association between nutritional status measured by SGA and 10-year survival controlling for age, gender, BMI and serum albumin was analysed using Cox regression. Data were taken from the medical records of 202 consecutively admitted chronic patients. Results Median age was 63·5 years; 55·4 % were males; median BMI was 25·9 kg/m2; median serum albumin level was 39·0 g/l. Based on SGA evaluation, 38·1 % did not have sufficient nutritional status (SGA classification B and C). Malnutrition was more common in patients who were older (P=0·023), with lower BMI (P<0·001), who had gastrointestinal (P=0·049) and oncologic co-morbidity (P=0·021) and lower albumin level (P=0·049). In-hospital mortality was 3 %, but during the following 10 years 52 % died. Cox regression analysis controlling for age, gender, BMI and serum albumin showed that SGA was an independent predictor of death (hazard ratio=1·55; 95 % CI 1·04, 2·32; P=0·031). SGA is a simple screening tool that can be routinely used in hospitalized Slovak medical patients to predict the risk of death. Improving patient nutrition could thus reduce mortality.
Bal, Chinmaya Kumar; Bhatia, Vikram; Daman, Ripu
Culture negative neutrocytic ascites is a variant of spontaneous bacterial peritonitis. But there are conflicting reports regarding the mortality associated with culture negativeneutrocytic ascites. Therefore we aim to determine the predictors of mortality associated with culture negativeneutrocytic ascites in a larger sample population. We analysed 170 patients consecutively admitted to intensive care unit with diagnosis of culture negative neutrocytic ascites. The clinical, laboratory parameters, etiology of liver cirrhosis was determined along with the scores like model for end stage liver disease, child turcotte pugh were recorded. The 50 day in-hospital mortality rate in culture negative neutrocytic ascites was 39.41% (n = 67). In univariate analysis, means of parameters like total leucocyte count, urea, bilirubin, alanine transaminase, aspartate transaminase, international normalized ratio, acute kidney injury, septic shock, hepatic encephalopathy and model for end stage liver disease were significantly different among survived and those who died (P value ≤0.05). Cox proportional regression model showed the hazard ratio (HR) of acute kidney injury was 2.212 (95% CI: 1.334-3.667), septic shock (HR = 1.895, 95% CI: 1.081-3.323) and model for end stage liver disease (HR = 1.054, 95% CI: 1.020-1.090). Receiver operating characteristics curve showed aspartate aminotransferase (AST) had highest area under the curve 0.761 (95% CI: 0.625-0.785). Patients with culture negative neutrocytic ascites have a mortality rate comparable to spontaneous bacterial peritonitis. aspartate aminotransferase, alanine aminotransferase (ALT), acute kidney injury (AKI), model for end stage liver disease (MELD) and septic shock are the independent predictors of 50 days in-hospital mortality in culture negative neutrocytic ascites.
Coelho, Lara E; Ribeiro, Sayonara R; Veloso, Valdilea G; Grinsztejn, Beatriz; Luz, Paula M
In this study, we evaluated trends in hospitalization rates, length of stay and in-hospital mortality in a cohort of HIV-infected patients in Rio de Janeiro, Brazil, from 2007 through 2013. Among the 3991 included patients, 1861 hospitalizations occurred (hospitalization rate of 10.44/100 person-years, 95% confidence interval 9.98-10.93/100 person-years). Hospitalization rates decreased annually (per year incidence rate ratio 0.92, 95% confidence interval 0.89-0.95) as well as length of stay (median of 15 days in 2007 vs. 11 days in 2013, p-value for trend<0.001), and in-hospital mortality (13.4% in 2007 to 8.1% in 2013, p-value for trend=0.053). Our results show that, in a middle-income setting, hospitalization rates are decreasing over time and non-AIDS hospitalizations are currently more frequent than those related to AIDS. Notwithstanding, compared with high-income settings, our patients had longer length of stay and higher in-hospital mortality. Further studies addressing these outcomes are needed to provide information that may guide protocols and interventions to further reduce health-care costs and in-hospital mortality. Copyright © 2016 Sociedade Brasileira de Infectologia. Published by Elsevier Editora Ltda. All rights reserved.
Coelho, Lara E.; Ribeiro, Sayonara R.; Veloso, Valdilea G.; Grinsztejn, Beatriz; Luz, Paula M.
In this study, we evaluated trends in hospitalization rates, length of stay and in-hospital mortality in a cohort of HIV-infected patients in Rio de Janeiro, Brazil, from 2007 through 2013. Among the 3991 included patients, 1861 hospitalizations occurred (hospitalization rate of 10.44/100 person-years, 95% confidence interval 9.98–10.93/100 person-years). Hospitalization rates decreased annually (per year incidence rate ratio 0.92, 95% confidence interval 0.89–0.95) as well as length of stay (median of 15 days in 2007 vs. 11 days in 2013, p-value for trend < 0.001), and in-hospital mortality (13.4% in 2007 to 8.1% in 2013, p-value for trend = 0.053). Our results show that, in a middle-income setting, hospitalization rates are decreasing over time and non-AIDS hospitalizations are currently more frequent than those related to AIDS. Notwithstanding, compared with high-income settings, our patients had longer length of stay and higher in-hospital mortality. Further studies addressing these outcomes are needed to provide information that may guide protocols and interventions to further reduce health-care costs and in-hospital mortality. PMID:27918889
Avelino-Silva, Thiago J; Campora, Flavia; Curiati, Jose A E; Jacob-Filho, Wilson
Hospitalized older adults with preexisting dementia have increased risk of having delirium, but little is known regarding the effect of delirium superimposed on dementia (DSD) on the outcomes of these patients. Our aim was to investigate the association between DSD and hospital mortality and 12-mo mortality in hospitalized older adults. This was a prospective cohort study completed in the geriatric ward of a university hospital in São Paulo, Brazil. We included 1,409 hospitalizations of acutely ill patients aged 60 y and over from January 2009 to June 2015. Main variables and measures included dementia and dementia severity (Informant Questionnaire on Cognitive Decline in the Elderly, Clinical Dementia Rating) and delirium (Confusion Assessment Method). Primary outcomes were time to death in the hospital and time to death in 12 mo (for the discharged sample). Comprehensive geriatric assessment was performed at admission, and additional clinical data were documented upon death or discharge. Cases were categorized into four groups (no delirium or dementia, dementia alone, delirium alone, and DSD). The no delirium/dementia group was defined as the referent category for comparisons, and multivariate analyses were performed using Cox proportional hazards models adjusted for possible confounders (sociodemographic information, medical history and physical examination data, functional and nutritional status, polypharmacy, and laboratory covariates). Overall, 61% were women and 39% had dementia, with a mean age of 80 y. Dementia alone was observed in 13% of the cases, with delirium alone in 21% and DSD in 26% of the cases. In-hospital mortality was 8% for patients without delirium or dementia, 12% for patients with dementia alone, 29% for patients with delirium alone, and 32% for DSD patients (Pearson Chi-square = 112, p < 0.001). DSD and delirium alone were independently associated with in-hospital mortality, with respective hazard ratios (HRs) of 2.14 (95% CI = 1
Curiati, Jose A. E.; Jacob-Filho, Wilson
Background Hospitalized older adults with preexisting dementia have increased risk of having delirium, but little is known regarding the effect of delirium superimposed on dementia (DSD) on the outcomes of these patients. Our aim was to investigate the association between DSD and hospital mortality and 12-mo mortality in hospitalized older adults. Methods and findings This was a prospective cohort study completed in the geriatric ward of a university hospital in São Paulo, Brazil. We included 1,409 hospitalizations of acutely ill patients aged 60 y and over from January 2009 to June 2015. Main variables and measures included dementia and dementia severity (Informant Questionnaire on Cognitive Decline in the Elderly, Clinical Dementia Rating) and delirium (Confusion Assessment Method). Primary outcomes were time to death in the hospital and time to death in 12 mo (for the discharged sample). Comprehensive geriatric assessment was performed at admission, and additional clinical data were documented upon death or discharge. Cases were categorized into four groups (no delirium or dementia, dementia alone, delirium alone, and DSD). The no delirium/dementia group was defined as the referent category for comparisons, and multivariate analyses were performed using Cox proportional hazards models adjusted for possible confounders (sociodemographic information, medical history and physical examination data, functional and nutritional status, polypharmacy, and laboratory covariates). Overall, 61% were women and 39% had dementia, with a mean age of 80 y. Dementia alone was observed in 13% of the cases, with delirium alone in 21% and DSD in 26% of the cases. In-hospital mortality was 8% for patients without delirium or dementia, 12% for patients with dementia alone, 29% for patients with delirium alone, and 32% for DSD patients (Pearson Chi-square = 112, p < 0.001). DSD and delirium alone were independently associated with in-hospital mortality, with respective hazard ratios
Barsheshet, Alon; Leor, Jonathan; Goldbourt, Uri; Garty, Moshe; Schwartz, Roseline; Behar, Solomon; Luria, David; Eldar, Michael; Glikson, Michael
A widened QRS interval is associated with increased mortality in patients with heart failure (HF). However, the prognostic significance of the type of bundle branch block (BBB) pattern in these patients is unclear. The data of 4,102 patients with HF hospitalized during a prospective national survey were analyzed to investigate the association between BBB type and 1-year mortality in 3,737 patients without pacemakers. Right BBB (RBBB) was present in 381 patients (10.2%) and left BBB (LBBB) in 504 patients (13.5%). RBBB and LBBB were associated with increased 1-year mortality on univariate analysis (odds ratio [OR] 1.44, 95% confidence interval [CI] 1.15 to 1.81, and OR 1.20, 95% CI 0.97 to 1.47, respectively). In patients with systolic HF, after adjusting for multiple risk factors, only RBBB was found to be an independent predictor of mortality (RBBB vs no BBB OR 1.62, 95% CI 1.12 to 2.33, and RBBB vs LBBB OR 1.71, 95% CI 1.09 to 2.69). This correlation was stronger in patients with lower left ventricular ejection fractions and was also maintained in patients without acute myocardial infarctions. Analyzing the data for all patients with HF, there was a trend for increased mortality in the RBBB group only (adjusted OR 1.21, 95% CI 0.94 to 1.56). LBBB was not related to mortality in patients with either systolic HF or preserved ejection fractions. In conclusion, RBBB rather than LBBB is an independent predictor of mortality in hospitalized patients with systolic HF. This prognostic marker could be used for risk stratification and the selection of treatment.
Palaniswamy, Chandrasekar; Kolte, Dhaval; Harikrishnan, Prakash; Khera, Sahil; Aronow, Wilbert S; Mujib, Marjan; Mellana, William Michael; Eugenio, Paul; Lessner, Seth; Ferrick, Aileen; Fonarow, Gregg C; Ahmed, Ali; Cooper, Howard A; Frishman, William H; Panza, Julio A; Iwai, Sei
There is a paucity of data regarding the complications and in-hospital mortality after catheter ablation for ventricular tachycardia (VT) in patients with ischemic heart disease. The purpose of this study was to determine the temporal trends in utilization, in-hospital mortality, and complications of catheter ablation of postinfarction VT in the United States. We used the 2002-2011 Nationwide Inpatient Sample (NIS) database to identify all patients ≥18 years of age with a primary diagnosis of VT (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] code 427.1) and who also had a secondary diagnosis of prior history of myocardial infarction (ICD-9-CM 412). Patients with supraventricular arrhythmias were excluded. Patients who underwent catheter ablation were identified using ICD-9-CM procedure code 37.34. Temporal trends in catheter ablation, in-hospital complications, and in-hospital mortality were analyzed. Of 81,539 patients with postinfarct VT, 4653 (5.7%) underwent catheter ablation. Utilization of catheter ablation increased significantly from 2.8% in 2002 to 10.8% in 2011 (Ptrend < .001). The overall rate of any in-hospital complication was 11.2% (523/4653), with vascular complications in 6.9%, cardiac in 4.3%, and neurologic in 0.5%. In-hospital mortality was 1.6% (75/4653). From 2002 to 2011, there was no significant change in the overall complication rates (8.4% to 10.2%, Ptrend = .101; adjusted odds ratio [per year] 1.02, 95% confidence interval 0.98-1.06) or in-hospital mortality (1.3% to 1.8%, Ptrend = .266; adjusted odds ratio [per year] 1.03, 95% confidence interval 0.92-1.15). The utilization rate of catheter ablation as therapy for postinfarct VT has steadily increased over the past decade. However, procedural complication rates and in-hospital mortality have not changed significantly during this period. Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
Maaskant, Jolanda M; Vermeulen, Hester; Apampa, Bugewa; Fernando, Bernard; Ghaleb, Maisoon A; Neubert, Antje; Thayyil, Sudhin; Soe, Aung
checklist. We evaluated the risk of bias of included studies and used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess the quality of the body of evidence. We described results narratively and presented them using GRADE tables. We included seven studies describing five different interventions: participation of a clinical pharmacist in a clinical team (n = 2), introduction of a computerised physician order entry system (n = 2), implementation of a barcode medication administration system (n = 1), use of a structured prescribing form (n = 1) and implementation of a check and control checklist in combination with feedback (n = 1).Clinical and methodological heterogeneity between studies precluded meta-analyses. Although some interventions described in this review show a decrease in MEs, the results are not consistent, and none of the studies resulted in a significant reduction in patient harm. Based on the GRADE approach, the overall quality and strengfh of the evidence are low. Current evidence on effective interventions to prevent MEs in a paediatric population in hospital is limited. Comparative studies with robust study designs are needed to investigate interventions including components that focus on specific paediatric safety issues.
Phelan, Christopher; Alaigh, Vivek; Fortunato, Gil; Staff, Ilene; Sansing, Lauren
Background Ischemic stroke accounts for 85–90% of all strokes and currently has very limited therapeutic options. Recent studies of β-adrenergic antagonists suggest they may have neuroprotective effects that lead to improved functional outcomes in rodent models of ischemic stroke, however there is limited data in patients. We aimed to determine whether there was an improvement in mortality rates among patients who were taking β-blockers during the acute phase of their ischemic stroke. Methods A retrospective analysis of a prospectively collected database of ischemic stroke patients was performed. Patients who were on β-adrenergic antagonists both at home and during the first three days of hospitalization were compared to patients who were not on β-adrenergic antagonists to determine the association with patient mortality rates. Results The study included a patient population of 2804 patients. In univariate analysis, use of β-adrenergic antagonists was associated with older age, atrial fibrillation, hypertension and more severe initial stroke presentation. Despite this, multivariable analysis revealed a reduction in in-hospital mortality among patients who were treated with β-adrenergic antagonists (odds ratio 0.657; 95% confidence interval 0.655–0.658). Conclusions The continuation of home β-adrenergic antagonist medication during the first three days of hospitalization after an ischemic stroke is associated with a decrease in patient mortality. This supports the work done in rodent models suggesting neuroprotective effects of β-blockers after ischemic stroke. PMID:26163891
Sendra Gutiérrez, Juan Manuel; Palma Ruiz, Matilde; Sarría Santamera, Antonio; Puerto Vázquez, María
Pancreatic cancer is becoming an increasingly important health problem in Spain. This study aimed to analyze the hospital management of this process and the factors associated with mortality by using an administrative data base. We performed a descriptive study. Socio-demographic, clinical, diagnostic, and therapeutic variables of episodes registered in the national Hospital Discharge Minimum Data Set for 2004 were gathered. Comorbidity was assessed with the Charlson index. A logistic regression model was built to explain the individual influence of variables on in-hospital mortality. Mortality in the 17 autonomous regions of Spain was analyzed by using standardized mortality rates, through predicted mortality obtained from the multivariate model. The mean age was 68 years and men represented 56%. Readmissions accounted for 80% of the cases. The most frequent localization was in the pancreatic head and the most frequently employed procedures were computed tomography and surgery. In-hospital mortality was 25%, was higher in men, and increased with age. Mortality was higher in new admissions than in readmissions. Factors associated with higher mortality in the multivariate analysis were male sex, age, unspecified location or location in the tail, emergency admission, hospital stay, and comorbidity. Observed mortality was higher than expected in the Canary Islands and Madrid and was lower than expected in Catalonia and the Valencian Community. Future studies with more detailed information should be performed to allow the factors associated with in-hospital mortality from pancreatic cancer to be confirmed and to clarify the reasons for the geographical differences identified.
Lee, Su Jin; Jeon, Doosoo; Cho, Woo Hyun; Kim, Yun Seong
Embolic event is a common and important complication of infective endocarditis (IE). The objective of this study was to investigate the clinical impacts of embolic event in patients with IE and the predictors of in-hospital mortality. Data was collected in Pusan National University Hospital and Pusan National University Yangsan Hospital between January 2009 and December 2010. One hundred ten patients were included. Embolic events occur in 39 of 110 patients (35.5%). Brain (n = 18, 38.5%) was the main site of embolic infarction. Patients with embolism showed higher in-hospital mortality (46.2% vs. 8.5%, respectively, P = 0.03), more frequent ICU admission (53.8% vs. 35.2%, respectively, P = 0.045) and more accompanying other cardiac complication (43.6% vs. 21.1%, respectively, P = 0.017). The in-hospital mortality rate was 18.2%. On the logistic regression analysis of the predictors for in-hospital mortality, age (RR, 1.079; 95% CI, 1.036-1.123, P = 0.001), embolic event (RR, 3.510; 95% CI, 1.271-9.69, P = 0.015) and staphylococcal infection (RR, 5.098; 95% CI, 1.308-18.508, P = 0.023) were independently associated with in-hospital mortality. Embolic events in IE are associated with poor in-hospital outcome; and these data about embolic events and the predictors of in-hospital mortality may improve the management of this disease in hospitals.
Adejumo, Oluwayemisi L; Koelling, Todd M; Hummel, Scott L
Hospitalized advanced heart failure (HF) patients are at high risk for malnutrition and death. The Nutritional Risk Index (NRI) is a simple, well-validated tool for identifying patients at risk for nutrition-related complications. We hypothesized that, in advanced HF patients from the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial, the NRI would improve risk discrimination for 6-month all-cause mortality. We analyzed the 160 ESCAPE index admission survivors with complete follow-up and NRI data, calculated as follows: NRI = (1.519 × discharge serum albumin [in g/dl]) + (41.7 × discharge weight [in kg] / ideal body weight [in kg]); as in previous studies, if discharge weight is greater than ideal body weight (IBW), this ratio was set to 1. The previously developed ESCAPE mortality model includes: age; 6-minute walk distance; cardiopulmonary resuscitation/mechanical ventilation; discharge β-blocker prescription and diuretic dose; and discharge serum sodium, blood urea nitrogen and brain natriuretic peptide levels. We used Cox proportional hazards modeling for the outcome of 6-month all-cause mortality. Thirty of 160 patients died within 6 months of hospital discharge. The median NRI was 96 (IQR 91 to 102), reflecting mild-to-moderate nutritional risk. The NRI independently predicted 6-month mortality, with adjusted HR 0.60 (95% CI 0.39 to 0.93, p = 0.02) per 10 units, and increased Harrell's c-index from 0.74 to 0.76 when added to the ESCAPE model. Body mass index and NRI at hospital admission did not predict 6-month mortality. The discharge NRI was most helpful in patients with high (≥ 20%) predicted mortality by the ESCAPE model, where observed 6-month mortality was 38% in patients with NRI < 100 and 14% in those with NRI > 100 (p = 0.04). The NRI is a simple tool that can improve mortality risk stratification at hospital discharge in hospitalized patients with advanced HF. Published by Elsevier
Dharmarajan, Kumar; Swami, Sunil; Gou, Ray Y; Jones, Richard N; Inouye, Sharon K
(1) To determine the relationship of incident delirium during hospitalization with 90-day mortality; (2) to identify potential in-hospital mediators through which delirium increases 90-day mortality. Analysis of data from Project Recovery, a controlled clinical trial of a delirium prevention intervention from 1995 to 1998 with follow-up through 2000. Large academic hospital. Patients ≥70 years old without delirium at hospital admission who were at intermediate-to-high risk of developing delirium and received usual care only. (1) Incident delirium; (2) potential mediators of delirium on death including use of restraining devices (physical restraints, urinary catheters), development of hospital acquired conditions (HACs) (falls, pressure ulcers), and exposure to other noxious insults (sleep deprivation, acute malnutrition, dehydration, aspiration pneumonia); (3) death within 90 days of admission. Among 469 patients, 70 (15%) developed incident delirium. These patients were more likely to experience restraining devices (37% vs 16%, P < .001), HACs (37% vs 12%, P < .001), other noxious insults (63% vs 49%, P = .03), and 90-day mortality (24% vs 6%, P < .001). The inverse probability weighted hazard of death due to delirium was 4.2 (95% CI = 2.8-6.3) in bivariable analyses, increased in a graded manner with additional exposures to restraining devices, HACs, and other noxious insults, and declined by 10.9% after addition of these potential mediator categories, providing evidence of mediation. Restraining devices, HACs, and additional noxious insults were more frequent among patients with delirium, increased mortality in a graded manner, and were responsible for a significant percentage of the association of delirium with death. Additional efforts to prevent potential downstream mediators through which delirium increases mortality may help to improve outcomes among hospitalized older adults. © 2016, Copyright the Authors Journal compilation © 2016, The American
Suleiman, A. B.; Mathews, A.; Jegasothy, R.; Ali, R.; Kandiah, N.
A confidential system of enquiry into maternal mortality was introduced in Malaysia in 1991. The methods used and the findings obtained up to 1994 are reported below and an outline is given of the resulting recommendations and actions. PMID:10083722
Win, Sithu; Hussain, Imad; Hebl, Virginia B; Dunlay, Shannon M; Redfield, Margaret M
The Acute Decompensated Heart Failure National Registry (ADHERE) and Get With The Guidelines (GWTG) registries have developed simple heart failure (HF) in-hospital mortality risk scores. We hypothesized that HF scores predictive of in-hospital mortality would perform as well for early postdischarge mortality risk stratification. In this single-center, community-based, retrospective study of all consecutive primary HF hospitalizations (6203 hospitalizations in 3745 patients) from 2000 to 2013, the ADHERE and GWTG risk scores were calculated from admission data. There were 176 (3.0%) and 399 (6.7%), 869 (14.7%), and 1272 (21.5%) deaths in-hospital and at 30, 90, and 180 days postdischarge, respectively. The GWTG but not ADHERE risk score was well calibrated for in-hospital mortality. Both the ADHERE (C statistic 0.66 and 0.67, 0.64, and 0.64) and GWTG (C statistic 0.74 and 0.73, 0.71, and 0.70) HF risk scores were similarly predictive of in-hospital and 30-, 90-, and 180-day postdischarge mortality. The ADHERE risk score identified 10% and the GWTG risk score identified 20% of hospitalizations where 180-day postdischarge mortality was 50%, a prognostic bench mark for hospice referral. In contrast, hospitalizations characterized as lowest risk by the ADHERE (57% of hospitalizations; 180-day mortality 16.2%) or GWTG score (20% of hospitalizations; 180-day mortality 8.0%) had substantially lower mortality (odds ratios high versus low risk of 5-8 [ADHERE] and 11-18 [GWTG] across time points; P<0.0001 for all). The simple ADHERE and GWTG scores stratify hospitalized HF patients for both inpatient and early postdischarge mortality risk, allowing comprehensive risk assessment on admission. © 2017 American Heart Association, Inc.
Wilkes, Jacob; Korgenski, Kent; Sheng, Xiaoming
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
Iwamoto, Tetsuya; Hashimoto, Hideki; Horiguchi, Hiromasa; Yasunaga, Hideo
Background Though evidence is limited in Japan, clinical controlled studies overseas have revealed that specialized care units are associated with better outcomes for acute stoke patients. This study aimed to examine the effectiveness of hospital functions for acute care of ischemic stroke on in-hospital mortality, with statistical accounting for referral bias. Methods We derived data from a large Japanese claim-based inpatient database linked to the Survey of Medical Care Institutions and Hospital Report data. We compared the mortality of acute ischemic stroke patients (n = 41 476) in hospitals certified for acute stroke treatment with that in non-certified institutions. To adjust for potential referral bias, we used differential distance to hospitals from the patient’s residence as an instrumental variable and constructed bivariate probit models. Results With the ordinary probit regression model, in-hospital mortality in certified hospitals was not significantly different from that in non-certified institutions. Conversely, the model with the instrumental variable method showed that admission to certified hospitals reduced in-hospital mortality by 30.7% (P < 0.001). This difference remained after adjusting for hospital size, volume, staffing, and intravenous use of tissue plasminogen activator. Conclusions Comparison accounting for referral selection found that certified hospital function for acute ischemic stroke care was associated with significantly lower in-hospital mortality. Our results indicate that organized stroke care—with certified subspecialty physicians and around-the-clock availability of personnel, imaging equipment, and emergency neurosurgical procedures in an intensive stroke care unit—is effective in improving outcomes in acute ischemic stroke care. PMID:26165489
Vriz, Olga; Brosolo, Gabriele; Martina, Stefano; Pertoldi, Franco; Citro, Rodolfo; Mos, Lucio; Ferrara, Francesco; Bossone, Eduardo
Background Takotsubo cardiomyopathy (TTC) is characterized by reversible left ventricular dysfunction, frequently precipitated by a stressful event. Despite the favorable course and good long-term prognosis, a variety of complications may occur in the acute phase of the disease. The aim of this study was to evaluate the in-hospital and long-term outcomes of a cohort of TTC patients. Methods Fifty-five patients (mean age 68.1±12 years) were prospectively followed for a mean of 69.6±32.2 months (64,635 days). In-hospital (death, heart failure, arrhythmias) and long-term events (death and recurrences) were recorded. Results Patients were predominantly women (87.3%) who experienced a recent stressful event (emotional or physical) and were admitted to hospital for chest pain. Eleven patients (20%) had a diagnosis of depressive disorder, and arterial hypertension was the most frequent cardiovascular risk factor. The ECG revealed ST-segment elevation in 43.6% of patients. At angiography, seven cases (12.7%) had at least one significant (≥50%) coronary artery stenosis and four patients (7.3%) had myocardial bridging of the left anterior descending artery. During hospitalization, three patients died (one from cardiac causes) and cardiovascular complications occurred in 12 patients. During follow-up, five patients died (none from cardiac causes), six patients had recurrences within the first year. Two patients had two recurrences: one after 114 days, triggered by an asthma attack as the first event, and the other after 1,850 days. Conclusions In TTC patients, in-hospital and long-term mortality is primarily due to non-cardiovascular causes. Recurrences are not infrequent and coronary artery disease is not an uncommon finding. PMID:27406446
Mbaruku, G; Bergström, S
An intervention programme aiming at a reduction of maternal deaths in the Regional Hospital, Kigoma, Tanzania, is analyzed. A retrospective study was carried out from 1984-86 to constitute a background for an intervention programme in 1987-91. The retrospective study revealed gross under-registration of data and clarified a number of potentially useful issues regarding avoidable maternal mortality. An intervention programme comprising 22 items was launched and the maternal mortality ratio was carefully followed in 1987-91. The intervention programme paid attention to professional responsibilities with regular audit-oriented meeting, utilization of local material resources, schedules for regular maintenance of equipment, maintenance of working skills by regular on-the-job training of staff, norms for patient management, provision of blood, norms for referral of severely ill patients, use of antibiotics, regular staff evaluation, public complaints about patient management, travel distance of all essential staff to the hospital, supply of essential drugs, the need of a small infusion production unit, the creation of culture facilities for improved quality of microbiology findings, and to efforts to stimulate local fund-raising. The results indicate that the maternal mortality ratio fell from 933 to 186 per 100,000 live births over the period 1984-91. Thus it is underscored that the problem of maternal mortality can be successfully approached by a low-cost intervention programme aiming at identifying issues of avoidability and focusing upon locally available problem solutions.
Xie, H X; Yang, F; Jiang, C J; Wang, J H; Hou, D B; Wang, J G; Wang, H; Hou, X T
Objective: To assess the factors associated with outcome of patients undergoing extracorporeal membrane oxygenation (ECMO) in a large ECMO center. Methods: Patients aged >18 years who received ECMO support for postcardiotomy cardiogenic shock were identified between January 2011 and December 2015. One hundred and seventy-seven patients (64.8%) successfully weaned from ECMO. These patients were divided into two groups depending on whether they could survive to hospital discharge: the survival group (group S, n=119) and death group (group D, n=58). Multivariate logistic regression was performed to identify risk factors independently associated with in-hospital mortality. Results: Compared to those from group D, patients in group S exhibited a younger age[(53.4±11.7) vs (58.9±11.5) years], a lower inotrope score at the beginning of ECMO [25(15, 60) vs 35.0(23, 60)], a lower average platelets transfusion [4.0(2.0, 5.2) vs 5.0(3.0, 7.2)U] (all P<0.05). There were shorter duration of ECMO support [95.0(73.0, 131.0) vs 120.0(95.8, 160.2) h], shorter ventilation time [137.0(70.0, 236.8) vs 215.0(164.0, 305.0) h], shorter stay in ICU [182.0(140.0, 236.0) vs 259.0(207.0, 382.0) h] and longer hospital stay after weaned from ECMO [14(11, 24) vs 8(4, 16) d] in group S patients compared to those in group D (all P<0.05). Age>65 years (P=0.046), neurologic complications (P<0.001) and lower extremity ischemia (P<0.001) during ECMO support, left ventricular ejection fraction<35% (P=0.011) and central venous pressure (CVP)>12 cmH(2)O(P=0.018) when weaned from ECMO, and the multi-organ function failure (P<0.001) after weaned from ECMO were independently associated with in-hospital mortality. Conclusions: Neurologic complications and lower extremity ischemia that occurred during ECMO, multi-organ function failure after weaned from ECMO had a significant impact on in-hospital mortality. Further studies are needed to prevent neurologic complications and lower extremity ischemia in
Taheraghdam, Aliakbar; Rikhtegar, Reza; Mehrvar, Kaveh; Mehrara, Mehrdad; Hassasi, Rogayyeh; Aliyar, Hannane; Farzi, Mohammadamin; Hasaneh Tamar, Somayyeh
Background. Intravenous tissue plasminogen activator, a time dependent therapy, can reduce the morbidity and mortality of acute ischemic stroke. This study was designed to assess the effect of simple in-hospital interventions on reducing door-to-CT (DTC) time and reaching door-to-needle (DTN) time of less than 60 minutes. Methods. Before any intervention, DTC time was recorded for 213 patients over a one-year period at our center. Five simple quality-improvement interventions were implemented, namely, call notification, prioritizing patients for CT scan, prioritizing patients for lab analysis, specifying a bed for acute stroke patients, and staff education. After intervention, over a course of 44 months, DTC time was recorded for 276 patients with the stroke code. Furthermore DTN time was recorded for 106 patients who were treated with IV thrombolytic therapy. Results. The median DTC time significantly decreased in the postintervention period comparing to the preintervention period [median (IQR); 20 (12–30) versus 75 (52.5–105), P < 0.001]. At the postintervention period, the median (IQR) DTN time was 55 (40–73) minutes and proportion of patients with DTN time less than 60 minutes was 62.4% (P < 0.001). Conclusion. Our interventions significantly reduced DTC time and resulted in an acceptable DTN time. These interventions are feasible in most hospitals and should be considered. PMID:27478641
Pohlenz, P; Klatt, J; Schmelzle, R; Li, L
Mortality is a rare but disastrous complication of microvascular head and neck reconstruction. The investigators attempt to identify the procedure-related mortality cases and analyse the causes of death. A retrospective analysis of 804 consecutive free flap procedures during a 19-year period was performed and fatal cases were identified (n=42 deaths). Multivariate logistic regression was employed to determine the association of in-hospital mortality with patient-related characteristics. The 30-day post-operative mortality rate was 1% (8 out of 804 patients), and the in-hospital mortality rate (post-operative deaths in-hospital before or after the 30th post-operative day without discharge) was 5.2% (42 out of 804 patients). Cancer recurrence and metastases related pneumonia were the most common causes of death (n=26, 62%), followed by cardiac, pulmonary, infectious and hepatic/renal aetiologies. Logistic regression analysis revealed that patients with stage IV disease and an operation time of >9h were significantly associated with post-operative mortality. Malignancy-related conditions were the most common causes of death following free flap transfer for head and neck reconstruction. For patients with stage IV head and neck cancer, this aggressive surgical approach should be cautiously justified due to its association with post-operative mortality. To shorten the operation time, experienced microsurgical operation teams are necessary.
Ahn, Shin Young; Chin, Ho Jun; Na, Ki Young; Chae, Dong-Wan; Kim, Sejoong
The significance of minimal increases in serum creatinine below the levels indicative of the acute kidney injury (AKI) stage is not well established. We aimed to investigate the influence of pre-stage AKI (pre-AKI) on clinical outcomes. We enrolled a total of 21,261 patients who were admitted to the Seoul National University Bundang Hospital from January 1, 2013 to December 31, 2013. Pre-AKI was defined as a 25–50% increase in peak serum creatinine levels from baseline levels during the hospital stay. In total, 5.4% of the patients had pre-AKI during admission. The patients with pre-AKI were predominantly female (55.0%) and had a lower body weight and lower baseline levels of serum creatinine (0.63 ± 0.18 mg/dl) than the patients with AKI and the patients without AKI (P < 0.001). The patients with pre-AKI had a higher prevalence of diabetes mellitus (25.1%) and malignancy (32.6%). The adjusted hazard ratio of in-hospital mortality for pre-AKI was 2.112 [95% confidence interval (CI), 1.143 to 3.903]. In addition, patients with pre-AKI had an increased length of stay (7.7 ± 9.7 days in patients without AKI, 11.4 ± 11.4 days in patients with pre-AKI, P < 0.001) and increased medical costs (4,061 ± 4,318 USD in patients without AKI, 4,966 ± 5,099 USD in patients with pre-AKI, P < 0.001) during admission. The adjusted hazard ratio of all-cause mortality for pre-AKI during the follow-up period of 2.0 ± 0.6 years was 1.473 (95% CI, 1.228 to 1.684). Although the adjusted hazard ratio of pre-AKI for overall mortality was not significant among the patients admitted to the surgery department or who underwent surgery, pre-AKI was significantly associated with mortality among the non-surgical patients (adjusted HR 1.542 [95% CI, 1.330 to 1.787]) and the patients admitted to the medical department (adjusted HR 1.384 [95% CI, 1.153 to 1.662]). Pre-AKI is associated with increased mortality, longer hospital stay, and increased medical costs during admission. More attention
Berg, Gina M; Lee, Felecia A; Hervey, Ashley M; Hines, Robert B; Basham-Saif, Angela; Harrison, Paul B
A retrospective registry review of adult patients admitted to a Level I trauma center sought to determine whether results regarding in-hospital mortality associated with payer source vary on the basis of methodology. Patients were categorized into 4 literature-derived definitions (Definition 1: insured and uninsured; Definition 2: commercially insured, publicly insured, and uninsured; Definition 3: commercially insured, Medicaid, Medicare, and uninsured; and Definition 4: commercially insured, Medicaid, and uninsured). In-hospital mortality differences were found in Definitions 2 and 3, and when reclassifying dual-eligible Medicare/Medicaid into socioeconomic and age indicators. Variations in methodology culminated in results that could be interpreted with differing conclusions.
Koizumi, Chie; Michihata, Nobuaki; Matsui, Hiroki; Fushimi, Kiyohide; Yasunaga, Hideo
Hepatic portal venous gas (HPVG) is rare but potentially serious condition. Main cause of HPVG is bowel ischemia, while detection of HPVG without bowel ischemia may have been increasing possibly due to widespread use of computed tomography. However, little is known about variation in etiologies of HPVG and mortality of HPVG with each etiology. We examined patient backgrounds, underlying diseases, and in-hospital mortality of HPVG patients using a national inpatient database. Using the Diagnosis Procedure Combination database in Japan, we identified inpatients diagnosed with HPVG from July 1, 2010 to March 31, 2015. Patients' data included age, sex, comorbidities at admission, complications after admission, body mass index, surgical procedures, medications, and discharge status. In-hospital mortality was compared between the subgroups divided by the patient backgrounds and underlying diseases. A total of 1590 patients were identified during the study period. The mean age was 79.3 years old and the proportion of bowel ischemia was 53%. The overall in-hospital mortality was 27.3%. In-hospital mortality of HPVG with bowel ischemia, gastrointestinal tract (GIT) obstruction or dilation, GIT perforation, GIT infection, or sepsis was 26.8, 31.1, 33.3, 13.6, or 56.4%, respectively. Among patients with bowel ischemia, 32.2% patients received operation and their in-hospital mortality was 16.5%. HPVG patients in the present study were relatively older but less likely to die than those in previous studies. Attention should be paid to the fact that mortality of HPVG without bowel ischemia was not always lower compared to that with bowel ischemia.
Stone, Geren S; Tarus, Titus; Shikanga, Mainard; Biwott, Benson; Ngetich, Thomas; Andale, Thomas; Cheriro, Betsy; Aruasa, Wilson
Observational data in the United States suggests that those without health insurance have a higher mortality and worse health outcomes. A linkage between insurance coverage and outcomes in hospitalized patients has yet to be demonstrated in resource-poor settings. To determine whether uninsured patients admitted to the public medical wards at a Kenyan referral hospital have any difference in in-hospital mortality rates compared to patients with insurance, we performed a retrospective observational study of all inpatients discharged from the public medical wards at Moi Teaching and Referral Hospital in Eldoret, Kenya, over a 3-month study period from October through December 2012. The primary outcome of interest was in-hospital death, and the primary explanatory variable of interest was health insurance status. During the study period, 201 (21.3%) of 956 patients discharged had insurance. The National Hospital Insurance Fund was the only insurance scheme noted. Overall, 211 patients (22.1%) died. The proportion who died was greater among the uninsured compared to the insured (24.7% vs. 11.4%, Chi-square = 15.6, p<0.001). This equates to an absolute risk reduction of 13.3% (95% CI 7.9-18.7%) and a relative risk reduction of 53.8% (95% CI 30.8-69.2%) of in-hospital mortality with insurance. After adjusting for comorbid illness, employment status, age, HIV status, and gender, the association between insurance status and mortality remained statistically significant (adjusted odds ratio (AOR) = 0.40, 95% CI 0.24-0.66) and similar in magnitude to the association between HIV status and mortality (AOR = 2.45, 95% CI 1.56-3.86). Among adult patients hospitalized in a public referral hospital in Kenya, insurance coverage was associated with decreased in-hospital mortality. This association was comparable to the relationship between HIV and mortality. Extension of insurance coverage may yield substantial benefits for population health.
Jones, Jenna M; Fingar, Kathryn R; Miller, Melissa A; Coffey, Rosanna; Barrett, Marguerite; Flottemesch, Thomas; Heslin, Kevin C; Gray, Darryl T; Moy, Ernest
As sepsis hospitalizations have increased, in-hospital sepsis deaths have declined. However, reported rates may remain higher among racial/ethnic minorities. Most previous studies have adjusted primarily for age and sex. The effect of other patient and hospital characteristics on disparities in sepsis mortality is not yet well-known. Furthermore, coding practices in claims data may influence findings. The objective of this study was to use a broad method of capturing sepsis cases to estimate 2004-2013 trends in risk-adjusted in-hospital sepsis mortality rates by race/ethnicity to inform efforts to reduce disparities in sepsis deaths. Retrospective, repeated cross-sectional study. Acute care hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases for 18 states with consistent race/ethnicity reporting. Patients diagnosed with septicemia, sepsis, organ dysfunction plus infection, severe sepsis, or septic shock. In-hospital sepsis mortality rates adjusted for patient and hospital factors by race/ethnicity were calculated. From 2004 to 2013, sepsis hospitalizations for all racial/ethnic groups increased, and mortality rates decreased by 5-7% annually. Mortality rates adjusted for patient characteristics were higher for all minority groups than for white patients. After adjusting for hospital characteristics, sepsis mortality rates in 2013 were similar for white (92.0 per 1,000 sepsis hospitalizations), black (94.0), and Hispanic (93.5) patients but remained elevated for Asian/Pacific Islander (106.4) and "other" (104.7; p < 0.001) racial/ethnic patients. Our results indicate that hospital characteristics contribute to higher rates of sepsis mortality for blacks and Hispanics. These findings underscore the importance of ensuring that improved sepsis identification and management is implemented across all hospitals, especially those serving diverse populations.
Peng, Yong; Du, Xin; Rogers, Kris D; Wu, Yangfeng; Gao, Runlin; Patel, Anushka
Currently available risk scores (RSs) were derived from populations with very few participants from China. We aimed to develop an RS based on data from patients with acute coronary syndrome in China and to compare its performance with the commonly promoted Global Registry of Acute Coronary Events (GRACE) RS. Clinical Pathways for Acute Coronary Syndromes-Phase 2 was a trial of a quality improvement intervention in China. Patients recruited from 75 hospitals from October 2007 to August 2010 were divided into training and validation sets based on immediate or delayed implementation. A Clinical Pathways for Acute Coronary Syndromes (CPACS) RS for in-hospital mortality was developed separately by gender, using the training set (6,790 patients). Discrimination and calibration of the CPACS RS and GRACE RS were compared on the validation set (3,801 patients). Although discrimination of the GRACE RS was acceptable, this was improved with the CPACS RS (c-statistic 0.82 vs 0.87, p = 0.012 for men; c-statistic 0.78 vs 0.85, p = 0.006 for women). The absolute bias was significantly lower with CPACS RS for both genders (7.6% vs 97.5% in men and 21.5% vs 77.2% in women), compared with the GRACE RS, which systematically overestimated risk. The CPACS RS underestimated risk in women, but only in those already above threshold levels currently used to define a clinical high-risk population. In conclusion, the GRACE RS substantially overestimates the risk of in-hospital death in patients presenting to the hospital with a suspected acute coronary syndrome in China. We have developed and independently validated a new RS utilizing data from Chinese patients. Copyright © 2017 Elsevier Inc. All rights reserved.
Caso, Valeria; Agnelli, Giancarlo; Alberti, Andrea; Venti, Michele; Acciarresi, Monica; Palmerini, Francesco; Paciaroni, Maurizio
Complete middle cerebral artery (MCA) stroke is a life-threatening condition, which can lead to death in the form of "malignant MCA syndrome"; characterized by massive brain edema and cerebral herniation. Moreover, patients with complete MCA infarct have high mortality due to complications. The aim of this study was to evaluate the clinical predictors of in-hospital mortality in patients with complete MCA stroke. Consecutive patients with complete MCA stroke were enrolled in a prospective single center in-hospital outcome study having mortality as its end point. Among 780 ischemic stroke patients, 125 had complete MCA strokes (16%) and 44 (35.2%) of these died in hospital. A high NIHSS-score (OR 1.17 95%CI 1.03-1.34, P=0.013) and high diastolic blood pressure on admission (OR 1.05 95%CI 1.01-1.09) resulted being independent predictors of in-hospital mortality in patients with complete MCA stroke. The median value of diastolic blood pressure at admission was 90 mmHg in patients who died and 80 mmHg in survivors (P=0.01). The risk of death increased by 5% for each mmHg increase in diastolic blood pressure on admission after adjusting for other risk factors. The rate of mortality was 22% in patients with diastolic blood pressure lower than 90 mmHg, 56% for those with diastolic blood pressure between 90 and 109 mmHg and 67% for those with diastolic blood pressure higher than 110 mmHg. This study suggests that high diastolic blood pressure on admission in acute MCA stroke patients is linearly correlated with in-hospital mortality.
Bertomeu, Vicente; Cequier, Ángel; Bernal, José L; Alfonso, Fernando; Anguita, Manuel P; Muñiz, Javier; Barrabés, José A; García-Dorado, David; Goicolea, Javier; Elola, Francisco J
To investigate the relationship between in-hospital mortality due to acute myocardial infarction and type of hospital, discharge service, and treatment provided. Retrospective analysis of 100 993 hospital discharges with a principal diagnosis of myocardial infarction in hospitals of the Spanish National Health Service. In-hospital mortality was adjusted for risk following the models of the Institute for Clinical Evaluative Sciences (Canada) and the Centers for Medicare & Medicaid Services (United States). Hospital characteristics are relevant to explain the variation in the individual probability of dying from myocardial infarction (median odds ratio: 1.3561). The risk-adjusted in-hospital mortality in cluster 3 and especially in cluster 4 hospitals (500 beds to 1000 beds and medium-high complexity) was significantly lower than in hospitals with less than 200 beds. Cluster 5 (more than 1000 beds), which includes a diverse group of hospitals, had a higher mortality rate than clusters 3 and 4. The adjusted mortality in the groups with the best and worst outcomes was 6.74% (cluster 4) and 8.49% (cluster 1), respectively. Mortality was also lower when the cardiology unit was responsible for the discharge or when angioplasty had been performed. The typology of the hospital, treatment in a cardiology unit, and percutaneous coronary intervention are significantly associated with the survival of a patient hospitalized for myocardial infarction. We recommend that the Spanish National Health Service establish health care networks that favor percutaneous coronary intervention and the participation of cardiology units in the management of patients with acute myocardial infarction. Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.
Dégano, Irene R; Subirana, Isaac; Torre, Marina; Grau, María; Vila, Joan; Fusco, Danilo; Kirchberger, Inge; Ferrières, Jean; Malmivaara, Antti; Azevedo, Ana; Meisinger, Christa; Bongard, Vanina; Farmakis, Dimitros; Davoli, Marina; Häkkinen, Unto; Araújo, Carla; Lekakis, John; Elosua, Roberto; Marrugat, Jaume
Hospital performance models in acute myocardial infarction (AMI) are useful to assess patient management. While models are available for individual countries, mainly US, cross-European performance models are lacking. Thus, we aimed to develop a system to benchmark European hospitals in AMI and percutaneous coronary intervention (PCI), based on predicted in-hospital mortality. We used the EURopean HOspital Benchmarking by Outcomes in ACS Processes (EURHOBOP) cohort to develop the models, which included 11,631 AMI patients and 8276 acute coronary syndrome (ACS) patients who underwent PCI. Models were validated with a cohort of 55,955 European ACS patients. Multilevel logistic regression was used to predict in-hospital mortality in European hospitals for AMI and PCI. Administrative and clinical models were constructed with patient- and hospital-level covariates, as well as hospital- and country-based random effects. Internal cross-validation and external validation showed good discrimination at the patient level and good calibration at the hospital level, based on the C-index (0.736-0.819) and the concordance correlation coefficient (55.4%-80.3%). Mortality ratios (MRs) showed excellent concordance between administrative and clinical models (97.5% for AMI and 91.6% for PCI). Exclusion of transfers and hospital stays ≤1day did not affect in-hospital mortality prediction in sensitivity analyses, as shown by MR concordance (80.9%-85.4%). Models were used to develop a benchmarking system to compare in-hospital mortality rates of European hospitals with similar characteristics. The developed system, based on the EURHOBOP models, is a simple and reliable tool to compare in-hospital mortality rates between European hospitals in AMI and PCI. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Muus, Kyle J.; Knudson, Alana D.; Klug, Marilyn G.; Wynne, Joshua
Context/Purpose: Most rural hospitals can provide medical care to acute myocardial infarction (AMI) patients, but a need for advanced cardiac care requires timely transfer to a tertiary hospital. There is little information on AMI in-hospital mortality predictors among rural transfer patients. Methods: Cross-sectional retrospective analyses on…
Kiatchoosakun, Songsak; Wongwipaporn, Chaiyasith; Pussadhamma, Burabha
Background The prognostic factors of in-hospital mortality in all comers and unselected patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have not been well established. Objective To identify the predictive factors of in-hospital mortality in patients with STEMI undergoing primary PCI in a tertiary heart centre. Methods Between January 2008 and December 2011, all patients with STEMI undergoing primary PCI were retrospectively included in this study. Baseline characteristics and angiographic data were reviewed and recorded. The study endpoint was all-cause in-hospital mortality. Results Of the 541 patients included in the study, 63 (11.6%) died during hospitalisation. Cardiogenic shock at admission was recorded in 301 patients (55.6%) and 424 patients (78%) had multivessel disease. Median door-to-device time was 65 min. After adjustment for baseline variables, the factors associated with in-hospital mortality included age >60 years (OR 2.98, 95% CI 1.17 to 7.05; p=0.01), left ventricular ejection fraction <40% (OR 2.53, 95% CI 1.20 to 5.36; p=0.02), and final TIMI flow grade 0/1 (OR 20.55, 95% CI 3.49 to 120.94; p=0.001). Conclusions Age, left ventricular function and final TIMI flow are significant predictors of adverse outcomes in unselected patients with STEMI undergoing primary PCI. PMID:27347008
Matsue, Yuya; Kagiyama, Nobuyuki; Yoshida, Kazuki; Kume, Teruyoshi; Okura, Hiroyuki; Suzuki, Makoto; Matsumura, Akihiko; Yoshida, Kiyoshi; Hashimoto, Yuji
Carperitide (α-human A-type natriuretic peptide) has been used for more than one-half of all acute heart failure (AHF) patients in Japan. However, its clinical effectiveness is not well documented. We retrospectively identified AHF patients presenting with acute onset or worsening of symptoms and admitted to 1 of the 3 participating hospitals. Propensity score-matched analysis was performed. The primary end point was in-hospital mortality. Of all of the AHF patients included in this study, 402 (38.7%) were treated with carperitide, and in-hospital mortality rate for the total cohort was 7.6%. We matched 367 pairs of patients treated with and without carperitide according to propensity score. In this matched cohort, treatment with carperitide was associated with in-hospital mortality (odds ratio [OR] 2.13, 95% confidence interval [CI] 1.17-3.85; P = .013). Potentially more harmful effects were observed in elderly patients (OR 2.93, 95% CI 1.54-5.91). Carperitide was significantly associated with increased in-hospital mortality rate in AHF patients. Our results strongly suggest the necessity for well designed randomized clinical trials of carperitide to determine its clinical safety and effectiveness. Copyright © 2015 Elsevier Inc. All rights reserved.
Muus, Kyle J.; Knudson, Alana D.; Klug, Marilyn G.; Wynne, Joshua
Context/Purpose: Most rural hospitals can provide medical care to acute myocardial infarction (AMI) patients, but a need for advanced cardiac care requires timely transfer to a tertiary hospital. There is little information on AMI in-hospital mortality predictors among rural transfer patients. Methods: Cross-sectional retrospective analyses on…
Ahmed, Vazeer; Palmer, Christopher R; Bennett, Tom J H; Robinson, Susan M
Objectives Reducing emergency admissions is a priority for the NHS. A single hospital's emergency care system was reorganised with the principles of front-loaded investigations, integration of specialties, reduced duplication, earlier decision making by senior clinicians and a combined emergency assessment area. The authors relocated our Medical Assessment Unit into our emergency department in 2006. The authors evaluated changes in admissions and mortality before and after 2006, compared with other similar hospitals. Design Quasi-experimental before and after study using routinely collected data. Setting and participants 1 acute hospital in England, the intervention site, was compared with 23 other English hospitals between 2001 and 2009. Outcome measures Our outcome measures were hospital standardised mortality ratios (HSMRs) for non-elective admissions and standardised admission ratios (SARs). Results The authors observed a statistically and clinically significant decrease in HSMR and SAR. The intervention hospital had the lowest HSMR and SAR of all the hospitals in our sample. This was statistically significant, p=0.0149 and p=0.0002, respectively. Conclusion Integrating emergency care in one location is associated with a meaningful reduction in mortality and emergency admissions to hospital. PMID:22858459
Poeran, Jashvant; Borsboom, Gerard J J M; de Graaf, Johanna P; Birnie, Erwin; Steegers, Eric A P; Bonsel, Gouke J
The main objective of this study was to estimate the contributing role of maternal, child, and organizational risk factors in perinatal mortality by calculating their population attributable risks (PAR). The primary dataset comprised 1,020,749 singleton hospital births from ≥22 weeks' gestation (The Netherlands Perinatal Registry 2000-2008). PARs for single and grouped risk factors were estimated in four stages: (1) creating a duplicate dataset for each PAR analysis in which risk factors of interest were set to the most favorable value (e.g., all women assigned 'Western' for PAR calculation of ethnicity); (2) in the primary dataset an elaborate multilevel logistic regression model was fitted from which (3) the obtained coefficients were used to predict perinatal mortality in each duplicate dataset; (4) PARs were then estimated as the proportional change of predicted- compared to observed perinatal mortality. Additionally, PARs for grouped risk factors were estimated by using sequential values in two orders: after PAR estimation of grouped maternal risk factors, the resulting PARs for grouped child, and grouped organizational factors were estimated, and vice versa. The combined PAR of maternal, child and organizational factors is 94.4 %, i.e., when all factors are set to the most favorable value perinatal mortality is expected to be reduced with 94.4 %. Depending on the order of analysis, the PAR of maternal risk factors varies from 1.4 to 13.1 %, and for child- and organizational factors 58.7-74.0 and 7.3-34.3 %, respectively. In conclusion, the PAR of maternal-, child- and organizational factors combined is 94.4 %. Optimization of organizational factors may achieve a 34.3 % decrease in perinatal mortality.
Skinner, Jonathan; Chandra, Amitabh; Staiger, Douglas; Lee, Julie; McClellan, Mark
Background African-Americans are more likely be seen by physicians with less clinical training or treated at hospitals with deficient times to acute reperfusion therapies. Less is known about differences in health outcomes. This paper compares risk-adjusted mortality following Acute Myocardial Infarction (AMI) between U.S. hospitals with high and low fractions of elderly black AMI patients. Methods and Results A prospective cohort study was performed for fee-for-service Medicare patients hospitalized for AMI during 1997–2001 (N = 1,136,736). Hospitals (N =4289) were classified into approximate deciles depending on the extent to which the hospital served the African-American population. The lowest category (12.5 percent of AMI patients) included hospitals without any African-American AMI admissions during 1997–2001. Decile 10 (10 percent of AMI patients) included hospitals with the highest fraction of black AMI patients (33.6 percent). The main outcome measures were 90-day and 30-day mortality following AMI. Patients admitted to hospitals disproportionately serving African-Americans experienced no greater level of morbidities or severity of the infarction. Yet hospitals in Decile 10 experienced risk-adjusted 90-day mortality rate of 23.7 percent (95% CI: 23.2–24.2) compared to 20.1 percent (95% CI: 19.7–20.4) in Decile 1 hospitals. Differences in outcomes between hospitals were not explained by income, hospital ownership status, hospital volume, Census region, urban status, or hospital surgical treatment intensity. Conclusions Risk-adjusted mortality following AMI is significantly higher in U.S. hospitals that disproportionately serve African-Americans. A reduction in overall mortality at these hospitals could reduce dramatically black-white disparities in health care outcomes. PMID:16246963
Ohinmaa, Arto; Zheng, Yufei; Jeerakathil, Thomas; Klarenbach, Scott; Häkkinen, Unto; Nguyen, Thanh; Friesen, Dan; Ruseski, Jane; Kaul, Padma; Ariste, Ruolz; Jacobs, Philip
This study aimed to evaluate the trends and regional variation of stroke hospital care in 30-day in-hospital mortality, hospital length of stay (LOS), and 1-year total hospitalization cost after implementation of the Alberta Provincial Stroke Strategy. New ischemic stroke patients (N = 7632) admitted to Alberta acute care hospitals between 2006 and 2011 were followed for 1 year. We analyzed in-hospital mortality with logistic regression, LOS with negative binomial regression, and the hospital costs with generalized gamma model (log link). The risk-adjusted results were compared over years and between zones using observed/expected results. The risk-adjusted mortality rates decreased from 12.6% in 2006/2007 to 9.9% in 2010/2011. The regional variations in mortality decreased from 8.3% units in 2008/2009 to 5.6 in 2010/2011. The LOS of the first episode dropped significantly in 2010/2011 after a 4-year slight increase. The regional variation in LOS was 15.5 days in 2006/2007 and decreased to 10.9 days in 2010/2011. The 1-year hospitalization cost increased initially, and then kept on declining during the last 3 years. The South and Calgary zones had the lowest costs over the study period. However, this gap was diminishing. After implementation of the Alberta Provincial Stroke Strategy, both mortality and hospital costs demonstrated a decreasing trend during the later years of study. The LOS increased slightly during the first 4 years but had a significant drop at the last year. In general, the regional variations in all 3 indicators had a diminishing trend. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.
Westphal, Glauco A; Koenig, Álvaro; Caldeira Filho, Milton; Feijó, Janaína; de Oliveira, Louise Trindade; Nunes, Fernanda; Fujiwara, Kênia; Martins, Sheila Fonseca; Roman Gonçalves, Anderson R
We evaluate the impact that implementing an in-hospital protocol for the early detection of sepsis risk has on mortality from severe sepsis/septic shock. This was a prospective cohort study conducted in 2 phases at 2 general hospitals in Brazil. In phase I, patients with severe sepsis/septic shock were identified and treated in accordance with the Surviving Sepsis Campaign guidelines. Over the subsequent 12 months (phase II), patients with severe sepsis/septic shock were identified by means of active surveillance for signs of sepsis risk (SSR). We compared the 2 cohorts in terms of demographic variables, the time required for the identification of at least 2 SSRs, compliance with sepsis bundles (6- and 24-hour), and mortality rates. We identified 217 patients with severe sepsis/septic shock (102 during phase I and 115 during phase II). There were significant differences between phases I and II in terms of the time required for the identification of at least 2 SSRs (34 ± 48 vs 11 ± 17 hours; P < .001) and in terms of in-hospital mortality (61.7% vs 38.2%; P < .001). The early detection of sepsis promoted early treatment, reducing in-hospital mortality from severe sepsis/septic shock. Copyright © 2011 Elsevier Inc. All rights reserved.
Wolff, Anthony; Stuckler, David; McKee, Martin
To compare risks of hypernatraemia on admission to hospital in persons who were with those who were not identified as care home residents and evaluate the association of hypernatraemia with in-hospital mortality. Retrospective observational study. A National Health Service Trust in London. A total of 21,610 patients aged over 65 years whose first admission to the Trust was between 1 January 2011 and 31 December 2013. Hypernatraemia on admission (plasma Na > 145 mmol/L) and in-hospital death. Patients admitted from care homes had 10-fold higher prevalence of hypernatraemia than those from their own homes (12.0% versus 1.3%, respectively; odds ratio [OR]: 10.5, 95% confidence interval [CI]: 8.43-13.0). Of those with hypernatraemia, nine in 10 cases were associated with nursing home ECOHOST residency (attributable fraction exposure: 90.5%), and the population attributable fraction of hypernatraemia on admission associated with care homes was 36.0%. After correcting for age, gender, mode of admission and dementia, care home residents were significantly more likely to be admitted with hypernatraemia than were own-home residents (adjusted odds ratio [AOR]: 5.32, 95% CI: 3.85-7.37). Compared with own-home residents, care home residents were also at about a two-fold higher risk of in-hospital mortality compared with non-care home residents (AOR: 1.97, 95% CI: 1.59-2.45). Consistent with evidence that hypernatraemia is implicated in higher mortality, the association of nursing homes with in-hospital mortality was attenuated after adjustment for it (AOR: 1.61, 95% CI: 1.26-2.06). Patients admitted to hospital from care homes are commonly dehydrated on admission and, as a result, appear to experience significantly greater risks of in-hospital mortality. © The Royal Society of Medicine.
Wolff, Anthony; Stuckler, David
Objectives To compare risks of hypernatraemia on admission to hospital in persons who were with those who were not identified as care home residents and evaluate the association of hypernatraemia with in-hospital mortality. Design Retrospective observational study. Setting A National Health Service Trust in London. Participants A total of 21,610 patients aged over 65 years whose first admission to the Trust was between 1 January 2011 and 31 December 2013. Main outcome measures Hypernatraemia on admission (plasma Na > 145 mmol/L) and in-hospital death. Results Patients admitted from care homes had 10-fold higher prevalence of hypernatraemia than those from their own homes (12.0% versus 1.3%, respectively; odds ratio [OR]: 10.5, 95% confidence interval [CI]: 8.43–13.0). Of those with hypernatraemia, nine in 10 cases were associated with nursing home ECOHOST residency (attributable fraction exposure: 90.5%), and the population attributable fraction of hypernatraemia on admission associated with care homes was 36.0%. After correcting for age, gender, mode of admission and dementia, care home residents were significantly more likely to be admitted with hypernatraemia than were own-home residents (adjusted odds ratio [AOR]: 5.32, 95% CI: 3.85–7.37). Compared with own-home residents, care home residents were also at about a two-fold higher risk of in-hospital mortality compared with non-care home residents (AOR: 1.97, 95% CI: 1.59–2.45). Consistent with evidence that hypernatraemia is implicated in higher mortality, the association of nursing homes with in-hospital mortality was attenuated after adjustment for it (AOR: 1.61, 95% CI: 1.26–2.06). Conclusions Patients admitted to hospital from care homes are commonly dehydrated on admission and, as a result, appear to experience significantly greater risks of in-hospital mortality. PMID:25592963
Ruiz, Eloy; Payet, Carlos; Montalbetti, Juan Antonio; Celis, Juan; Payet, Eduardo; Berrospi, Francisco; Chavez, Ivan; Young, Frank
Determine the postoperative morbidity and in-hospital mortality of gastrectomy due to gastric cancer. The study involved the review of the clinical records of all patients with histologically confirmed diagnostic of gastric adenocarcinoma, which underwent a gastrectomy at the Peruvian Institute of Neoplastic Diseases between January 1950 and December 1999. During that period, 2,033 gastrectomies were performed, 503 of which were total gastrectomies and 1,447 were distal subtotal gastrectomies. Postoperative morbidity of total and distal subtotal gastrectomy dropped from 23.7% and 14.3% during the 1950 decade, to 19.8% and 7.4% during the 1990 decade, respectively, while the in-hospital mortality of total and subtotal gastrectomy dropped from 28.9% and 19.4% during the 50s to 4.4% and 2.2% during the 90's. The most common complications were the esophagojejunal, gastrojejunal and duodenal fistulas, respiratory infections, intra-abdominal abscesses, pancreatic fistula, early intestinal obstruction, hemorrhage from the anastomosis site and surgical site infection. Multivariate logistics regression analysis showed that the risk factors for in-hospital mortality of total gastrectomy were hypoalbuminemia, intraoperative blood transfusion and re-resection (OR: 2.4, 5.9 and 1.7, respectively). For distal subtotal gastrectomy, the risk factors for in-hospital mortality were hypoalbuminemia, intraoperative blood transfusion, splenectomy and re-resection (OR: 2.6, 2.46, 2.42 and 6.3, respectively). Based on our results, the in-hospital mortality risk depends on the postoperative variables (hypoalbuminemia, intraoperative blood transfusion, splenectomy and re-resection) more than on the pre-operative variables, beyond the surgeon's control (age, sex, clinical stage, etc.).
Skok, P; Sinkovič, A
This prospective, cohort study assessed the independent predictors of in-hospital mortality in patients with acute upper gastrointestinal haemorrhage admitted to the medical intensive care unit (MICU) at the University Clinical Centre Maribor, Slovenia. Using univariate, multivariate and logistic regression methods the predictors of mortality in 54 upper gastrointestinal haemorrhage patients (47 men, mean ± SD age 61.6 ± 14.2 years) were investigated. The mean ± SD duration of treatment in the MICU was 2.8 ± 2.9 days and the mortality rate was 31.5%. Significant differences between nonsurvivors and survivors were observed in haemorrhagic shock, heart failure, infection, diastolic blood pressure at admission, haemoglobin and red blood cell count at admission, and lowest haemoglobin and red blood cell count during treatment. Heart failure (odds ratio 59.13) was the most significant independent predictor of in-hospital mortality. Haemorrhagic shock and the lowest red blood cell count during treatment were also important independent predictive factors of in-hospital mortality.
Williams, Mallory; Alban, Rodrigo F; Hardy, James P; Oxman, David A; Garcia, Edward R; Hevelone, Nathanael; Frendl, Gyorgy; Rogers, Selwyn O
Staff coverage strategies of intensive care units (ICUs) impact clinical outcomes. High-intensity staff coverage strategies are associated with lower morbidity and mortality. Accessible clinical expertise, team work, and effective communication have all been attributed to the success of this coverage strategy. We evaluate the impact of in-hospital fellow coverage (IHFC) on improving communication of cardiorespiratory events. A prospective observational study performed in an academic tertiary care center with high-intensity staff coverage. The main outcome measure was resident to fellow communication of cardiorespiratory events during IHFC vs home coverage (HC) periods. Three hundred twelve cardiorespiratory events were collected in 114 surgical ICU patients in 134 study days. Complete data were available for 306 events. One hundred three communication errors occurred. IHFC was associated with significantly better communication of events compared to HC (P<.0001). Residents communicated 89% of events during IHFC vs 51% of events during HC (P<.001). Communication patterns of junior and midlevel residents were similar. Midlevel residents communicated 68% of all on-call events (87% IHFC vs 50% HC, P<.001). Junior residents communicated 66% of events (94% IHFC vs 52% HC, P<.001). Communication errors were lower in all ICUs during IHFC (P<.001). IHFC reduced communication errors. Copyright © 2014 Elsevier Inc. All rights reserved.
Volpp, Kevin G M; Buckley, Edward
To determine whether changes in health maintenance organization (HMO) penetration or payer mix affected in-hospital mortality and treatment patterns of patients with acute myocardial infarction (AMI). Observational study using patient-level logistic regression analysis and hospital and year fixed effects of data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Nationwide Inpatient Sample, a geographically diverse sample of 20% of the hospitalized patients in the United States. Discharges of patients (n = 340,064) with a primary diagnosis of acute myocardial infarction who were treated in general medical or surgical hospitals that contributed at least 2 years of data to the HealthCare Cost and Utilization Project Nationwide Inpatient Sample from 1989 to 1996. In-hospital mortality and rates of cardiac catheterization, angioplasty, or coronary artery bypass grafting for Medicare patients or non-Medicare patients were the main outcome measures. Among Medicare patients, increases in HMO penetration were associated with reduced odds of receiving cardiac catheterization, angioplasty, or coronary artery bypass grafting of 3% to 16%, but were not associated with any change in mortality risk. Increases in the number of HMOs within a metropolitan statistical area, our measure of HMO competition, were associated with small but significant increases in the odds of cardiac catheterization and angioplasty of about 2%. There was no pattern of changes in cardiac procedure rates or in-hospital mortality among non-Medicare patients. Increases in HMO penetration reduced cardiac procedure rates by statistically significant but small amounts among Medicare patients with AMI, without affecting mortality rates.
Stein, Marco; Misselwitz, Björn; Hamann, Gerhard F; Kolodziej, Malgorzata; Reinges, Marcus H T; Uhl, Eberhard
Pre-treatment with antiplatelet agents is described to be a risk factor for mortality after spontaneous intracerebral hemorrhage (ICH). However, the impact of antithrombotic agents on mortality in patients who undergo hematoma evacuation compared to conservatively treated patients with ICH remains controversial. This analysis is based on a prospective registry for quality assurance in stroke care in the State of Hesse, Germany. Patients' data were collected between January 2008 and December 2012. Only patients with the diagnosis of spontaneous ICH were included (International Classification of Diseases 10th Revision codes I61.0-I61.9). Predictors of in-hospital mortality were determined by univariate analysis. Predictors with P<0.1 were included in a binary logistic regression model. The binary logistic regression model was adjusted for age, initial Glasgow Coma Score (GCS), the presence of intraventricular hemorrhage (IVH), and pre-ICH disability prior to ictus. In 8,421 patients with spontaneous ICH, pre-treatment with oral anticoagulants or antiplatelet agents was documented in 16.3% and 25.1%, respectively. Overall in-hospital mortality was 23.2%. In-hospital mortality was decreased in operatively treated patients compared to conservatively treated patients (11.6% versus 24.0%; P<0.001). Patients with antiplatelet pre-treatment had a significantly higher risk of death during the hospital stay after hematoma evacuation (odds ratio [OR]: 2.5; 95% confidence interval [CI]: 1.24-4.97; P=0.010) compared to patients without antiplatelet pre-treatment treatment (OR: 0.9; 95% CI: 0.79-1.09; P=0.376). In conclusion a higher rate of in-hospital mortality after pre-treatment with antiplatelet agents in combination with hematoma evacuation after spontaneous ICH was observed in the presented cohort.
Benamer, Sufyan; Eljazwi, Imhemed; Mohamed, Rima; Masoud, Heba; Tuwati, Mussa; Elbarsha, Abdulwahab M.
Objective Hyperglycemia on admission and during hospital stay is a well-established predictor of short-term and long-term mortality in patients with acute myocardial infarction. Our study investigated the impact of blood glucose levels on admission and in-hospital hyperglycemia on the morbidity and mortality of Libyan patients admitted with acute coronary syndromes (acute myocardial infarction and unstable angina). Methods In this retrospective study, the records of patients admitted with acute coronary syndrome to The 7th Of October Hospital, Benghazi, Libya, between January 2011 and December 2011 were reviewed. The level of blood glucose on admission, and the average blood glucose during the hospital stay were recorded to determine their effects on in-hospital complications (e.g. cardiogenic shock, acute heart failure, arrhythmias, and/or heart block) and mortality. Results During the study period, 121 patients with diabetes were admitted with acute coronary syndrome. The mortality rate in patients with diabetes and acute coronary syndrome was 12.4%. Patients with a mean glucose level greater than 200mg/dL had a higher in-hospital mortality and a higher rate of complications than those with a mean glucose level ≤200mg/dL (27.5% vs. 2.6%, p<0.001 and 19.7% vs. 45.5%, p=0.004, respectively). There was no difference in in-hospital mortality between patients with a glucose level at admission ≤140mg/dL and those admitted with a glucose level >140mg/dL (6.9% vs. 14.3%; p=0.295), but the rate of complications was higher in the latter group (13.8% vs. 34.1%; p=0.036). Patients with admission glucose levels >140mg/dL also had a higher rate of complications at presentation (26.4% vs. 6.9%; p=0.027). Conclusion In patients with diabetes and acute coronary syndrome, hyperglycemia during hospitalization predicted a worse outcome in terms of the rates of in-hospital complications and in-hospital mortality. Hyperglycemia at the time of admission was also associated with
We investigated the causes of inpatient death after intensive care unit (ICU) discharge and determined predictors of in-hospital mortality in Korea. Using medical ICU registry data of Seoul National University Hospital, we performed a retrospective cohort study involving patients who were discharged alive from their first ICU admission with at least 24 hours of ICU length of stay (LOS). From January 2011 to August 2013, 723 patients were admitted to ICU and 383 patients were included. The estimated in-hospital mortality rate was 11.7% (45/383). The most common cause of death was respiratory failure (n = 25, 56%) followed by sepsis and cancer progression; the causes of hospital death and ICU admission were the same in 64% of all deaths; sudden unexpected deaths comprised about one-fifth of all deaths. In order to predict in-hospital mortality among ICU survivors, multivariate analysis identified presence of solid tumor (odds ratio [OR], 4.06; 95% confidence interval [CI], 2.01–8.2; P < 0.001), hematologic disease (OR, 4.75; 95% CI, 1.51–14.96; P = 0.013), Sequential Organ Failure Assessment (SOFA) score upon ICU admission (OR, 1.08; 95% CI, 0.99–1.17; P = 0.075), and hemoglobin (Hb) level (OR, 0.67; 95% CI, 0.52–0.86; P = 0.001) and platelet count (Plt) (OR, 0.99; 95% CI, 0.99–1.00; P = 0.033) upon ICU discharge as significant factors. In conclusion, a significant proportion of in-hospital mortality is predictable and those who die in hospital after ICU discharge tend to be severely-ill, with comorbidities of hematologic disease and solid tumor, and anemic and thrombocytopenic upon ICU discharge. PMID:28145659
Uematsu, Hironori; Kunisawa, Susumu; Yamashita, Kazuto; Fushimi, Kiyohide; Imanaka, Yuichi
Little is known about the consequences of weekend admission on the quality of care in patients with severe community-acquired pneumonia. We compared the outcomes of weekend versus weekdays' admission for these patients on risk-adjusted mortality. Using a large nationwide administrative database, we analysed patients with severe pneumonia who had been hospitalized in 1044 acute care hospitals between 2012 and 2013. We compared risk-adjusted in-hospital mortality of guideline-concordant care between patients admitted weekdays and patients admitted on weekends. The study sample comprised 17 342 patients admitted on weekdays and 6190 patients admitted on weekends. The mortality rate of the weekend admission group was significantly higher than that of the weekday admission group (23.7% vs 20.5%; P < 0.001). Even after adjusting for baseline patient severity and need for urgent care, weekend admissions were associated with higher mortality (odds ratio: 1.10; 95% confidence interval: 1.02-1.19). The implementation rates of guideline-concordant microbiological tests (including sputum cultures and urine antigen tests) were significantly lower in the weekend admission group. These tests were found to be associated with lower in-hospital mortality. Our findings showed that weekend admission was associated with increased mortality in patients with severe community-acquired pneumonia in Japan. This may have been influenced by lower implementation of microbiological testing. © 2016 Asian Pacific Society of Respirology.
Yamauchi, Yasuhiro; Yasunaga, Hideo; Hasegawa, Wakae; Sakamoto, Yukiyo; Takeshima, Hideyuki; Jo, Taisuke; Matsui, Hiroki; Fushimi, Kiyohide; Nagase, Takahide
Background and objectives Inhaled corticosteroids (ICS) and long-acting inhaled bronchodilators (IBD) are beneficial for the management of COPD. Although ICS has been reported to increase the risk of pneumonia in patients with COPD, it remains controversial whether it influences mortality. Using a Japanese national database, we examined the association between preadmission ICS therapy and in-hospital mortality from pneumonia in patients with COPD. Methods We retrospectively collected data from 1,165 hospitals in Japan on patients with COPD who received outpatient inhalation therapy and were admitted with pneumonia. Patients were categorized into those who received ICS with IBD and those who received IBD alone. We performed multivariate logistic regression analysis to examine the association between outpatient ICS therapy and in-hospital mortality, adjusting for the patients’ backgrounds. Results Of the 7,033 eligible patients, the IBD alone group (n=3,331) was more likely to be older, have lower body mass index, poorer general conditions, and more severe pneumonia than the ICS with IBD group (n=3,702). In-hospital mortality was 13.2% and 8.1% in the IBD alone and the ICS with IBD groups, respectively. After adjustment for patients’ backgrounds, the ICS with IBD group had significantly lower mortality than the IBD alone group (adjusted odds ratio, 0.80; 95% confidence interval, 0.68–0.94). Higher mortality was associated with older age, being male, lower body mass index, poorer general status, and more severe pneumonia. Conclusion Outpatient inhaled ICS and IBD therapy was significantly associated with lower mortality from pneumonia in patients with COPD than treatment with IBD alone. PMID:27382276
Yamauchi, Yasuhiro; Yasunaga, Hideo; Hasegawa, Wakae; Sakamoto, Yukiyo; Takeshima, Hideyuki; Jo, Taisuke; Matsui, Hiroki; Fushimi, Kiyohide; Nagase, Takahide
Inhaled corticosteroids (ICS) and long-acting inhaled bronchodilators (IBD) are beneficial for the management of COPD. Although ICS has been reported to increase the risk of pneumonia in patients with COPD, it remains controversial whether it influences mortality. Using a Japanese national database, we examined the association between preadmission ICS therapy and in-hospital mortality from pneumonia in patients with COPD. We retrospectively collected data from 1,165 hospitals in Japan on patients with COPD who received outpatient inhalation therapy and were admitted with pneumonia. Patients were categorized into those who received ICS with IBD and those who received IBD alone. We performed multivariate logistic regression analysis to examine the association between outpatient ICS therapy and in-hospital mortality, adjusting for the patients' backgrounds. Of the 7,033 eligible patients, the IBD alone group (n=3,331) was more likely to be older, have lower body mass index, poorer general conditions, and more severe pneumonia than the ICS with IBD group (n=3,702). In-hospital mortality was 13.2% and 8.1% in the IBD alone and the ICS with IBD groups, respectively. After adjustment for patients' backgrounds, the ICS with IBD group had significantly lower mortality than the IBD alone group (adjusted odds ratio, 0.80; 95% confidence interval, 0.68-0.94). Higher mortality was associated with older age, being male, lower body mass index, poorer general status, and more severe pneumonia. Outpatient inhaled ICS and IBD therapy was significantly associated with lower mortality from pneumonia in patients with COPD than treatment with IBD alone.
Pagès, Pierre-Benoit; Cottenet, Jonathan; Mariet, Anne-Sophie; Bernard, Alain; Quantin, Catherine
Our aim was to determine the effect of a national strategy for quality improvement in cancer management (the "Plan Cancer") according to time period and to assess the influence of type and volume of hospital activity on in-hospital mortality (IHM) within a large national cohort of patients operated on for lung cancer.From January 2005 to December 2013, 76 235 patients were included in the French Administrative Database. Patient characteristics, hospital volume of activity and hospital type were analysed over three periods: 2005-2007, 2008-2010 and 2011-2013.Global crude IHM was 3.9%: 4.3% during 2005-2007, 4% during 2008-2010 and 3.5% during 2011-2013 (p<0.01). 296, 259 and 209 centres performed pulmonary resections in 2005-2007, 2008-2010 and 2011-2013, respectively (p<0.01). The risk of death was higher in centres performing <13 resections per year than in centres performing >43 resections per year (adjusted (a)OR 1.48, 95% CI 1.197-1.834). The risk of death was lower in the period 2011-2013 than in the period 2008-2010 (aOR 0.841, 95% CI 0.764-0.926). Adjustment variables (age, sex, Charlson score and type of resection) were significantly linked to IHM, whereas the type of hospital was not.The French national strategy for quality improvement seems to have induced a significant decrease in IHM. Copyright ©ERS 2016.
Barsheshet, Alon; Goldenberg, Ilan; Garty, Moshe; Gottlieb, Shmuel; Sandach, Amir; Laish-Farkash, Avishag; Eldar, Michael; Glikson, Michael
There is controversy regarding type of bundle branch block (BBB) that is associated with increased mortality risk in patients with heart failure (HF). The present study was designed to explore the association between BBB pattern and long-term mortality in hospitalized patients with systolic HF. Risk of 4-year all-cause mortality was assessed in 1,888 hospitalized patients with systolic HF (left ventricular ejection function <50%) without a pacemaker in a prospective national survey. Cox proportional hazards regression modeling was used to compare mortality risk in patients with right BBB (RBBB; 10%), left BBB (LBBB; 14%), and no BBB (76%) on admission electrocardiogram. At 4 years of follow up, mortality rates were highest in patients with RBBB (69%), intermediate in those with LBBB (63%), and lowest in those without BBB (50%, p <0.001). Multivariate analysis demonstrated a significant 36% increased mortality risk in patients with RBBB versus no BBB (p = 0.002) but no significant difference in mortality risk for patients with LBBB versus no BBB (hazard ratio 1.04, p = 0.66). RBBB versus LBBB was associated with a 29% (p = 0.035) increased risk for 4-year mortality in the total population and with a 58% (p = 0.015) increased risk in patients with ejection fraction <30%. In conclusion, RBBB but not LBBB on admission electrocardiogram is associated with a significant increased long-term mortality risk in hospitalized patients with systolic HF. Deleterious effects of RBBB compared to LBBB appear to be more pronounced in patients with more advanced left ventricular dysfunction. Copyright © 2011 Elsevier Inc. All rights reserved.
Meijide, Héctor; Mena, Álvaro; Rodríguez-Osorio, Iria; Pértega, Sonia; Castro-Iglesias, Ángeles; Rodríguez-Martínez, Guillermo; Pedreira, José; Poveda, Eva
New patterns in epidemiological characteristics of people living with HIV infection (PLWH) and the introduction of Highly Active Antiretroviral Therapy (HAART) have changed the profile of hospital admissions in this population. The aim of this study was to evaluate trends in hospital admissions, re-admissions, and mortality rates in HIV patients and to analyze the role of HCV co-infection. A retrospective cohort study conducted on all hospital admissions of HIV patients between 1993 and 2013. The study time was divided in two periods (1993-2002 and 2003-2013) to be compared by conducting a comparative cross-sectional analysis. A total of 22,901 patient-years were included in the analysis, with 6917 hospital admissions, corresponding to 1937 subjects (75% male, mean age 36±11 years, 37% HIV/HCV co-infected patients). The median length of hospital stay was 8 days (5-16), and the 30-day hospital re-admission rate was 20.1%. A significant decrease in hospital admissions related with infectious and psychiatric diseases was observed in the last period (2003-2013), but there was an increase in those related with malignancies, cardiovascular, gastrointestinal, and chronic respiratory diseases. In-hospital mortality remained high (6.8% in the first period vs. 6.3% in the second one), with a progressive increase of non-AIDS-defining illness deaths (37.9% vs. 68.3%, P<.001). The admission rate significantly dropped after 1996 (4.9% yearly), but it was less pronounced in HCV co-infected patients (1.7% yearly). Hospital admissions due to infectious and psychiatric disorders have decreased, with a significant increase in non-AIDS-defining malignancies, cardiovascular, and chronic respiratory diseases. In-hospital mortality is currently still high, but mainly because of non-AIDS-defining illnesses. HCV co-infection increased the hospital stay and re-admissions during the study period. Copyright © 2016 Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y
Cappello, Silvia; Cereda, Emanuele; Rondanelli, Mariangela; Klersy, Catherine; Cameletti, Barbara; Albertini, Riccardo; Magno, Daniela; Caraccia, Marilisa; Turri, Annalisa; Caccialanza, Riccardo
Background: Elevated plasma vitamin B12 concentrations were identified as predictors of mortality in patients with oncologic, hepatic and renal diseases, and in elderly and critically ill medical patients. The association between vitamin B12 concentrations and in-hospital mortality in adult patients at nutritional risk has not been assessed. Methods: In this five-year prospective study, we investigated whether high vitamin B12 concentrations (>1000 pg/mL) are associated with in-hospital mortality in 1373 not-bed-ridden adult patients at nutritional risk (Nutrition Risk Index <97.5), admitted to medical and surgical departments. Results: Three hundred and ninety-six (28.8%) patients presented vitamin B12 > 1000 pg/mL. Two hundred and four patients died in the hospital (14.9%). The adjusted odds ratio of in-hospital mortality in patients with high vitamin B12 was 2.20 (95% CI, 1.56-3.08; p < 0.001); it was independent of age, gender, body mass index, six-month previous unintentional weight loss, admission ward, presence of malignancy, renal function, C-reactive protein and prealbumin. Patients with high vitamin B12 also had a longer length of stay (LOS) than those with normal concentrations (median 25 days, (IQR 15-41) versus 23 days (IQR 14-36); p = 0.014), and elevated vitamin B12 was an independent predictor of LOS (p = 0.027). Conclusions: An independent association between elevated vitamin B12 concentrations, mortality and LOS was found in our sample of hospitalized adult patients at nutritional risk. Although the underlying mechanisms are still unknown and any cause-effect relation cannot be inferred, clinicians should be aware of the potential negative impact of high vitamin B12 concentrations in hospitalized patients at nutritional risk and avoid inappropriate vitamin supplementation.
Cappello, Silvia; Cereda, Emanuele; Rondanelli, Mariangela; Klersy, Catherine; Cameletti, Barbara; Albertini, Riccardo; Magno, Daniela; Caraccia, Marilisa; Turri, Annalisa; Caccialanza, Riccardo
Background: Elevated plasma vitamin B12 concentrations were identified as predictors of mortality in patients with oncologic, hepatic and renal diseases, and in elderly and critically ill medical patients. The association between vitamin B12 concentrations and in-hospital mortality in adult patients at nutritional risk has not been assessed. Methods: In this five-year prospective study, we investigated whether high vitamin B12 concentrations (>1000 pg/mL) are associated with in-hospital mortality in 1373 not-bed-ridden adult patients at nutritional risk (Nutrition Risk Index <97.5), admitted to medical and surgical departments. Results: Three hundred and ninety-six (28.8%) patients presented vitamin B12 > 1000 pg/mL. Two hundred and four patients died in the hospital (14.9%). The adjusted odds ratio of in-hospital mortality in patients with high vitamin B12 was 2.20 (95% CI, 1.56–3.08; p < 0.001); it was independent of age, gender, body mass index, six-month previous unintentional weight loss, admission ward, presence of malignancy, renal function, C-reactive protein and prealbumin. Patients with high vitamin B12 also had a longer length of stay (LOS) than those with normal concentrations (median 25 days, (IQR 15–41) versus 23 days (IQR 14–36); p = 0.014), and elevated vitamin B12 was an independent predictor of LOS (p = 0.027). Conclusions: An independent association between elevated vitamin B12 concentrations, mortality and LOS was found in our sample of hospitalized adult patients at nutritional risk. Although the underlying mechanisms are still unknown and any cause-effect relation cannot be inferred, clinicians should be aware of the potential negative impact of high vitamin B12 concentrations in hospitalized patients at nutritional risk and avoid inappropriate vitamin supplementation. PMID:28025528
Raghunathan, Karthik; Shaw, Andrew; Nathanson, Brian; Stürmer, Til; Brookhart, Alan; Stefan, Mihaela S; Setoguchi, Soko; Beadles, Chris; Lindenauer, Peter K
Isotonic saline is the most commonly used crystalloid in the ICU, but recent evidence suggests that balanced fluids like Lactated Ringer's solution may be preferable. We examined the association between choice of crystalloids and in-hospital mortality during the resuscitation of critically ill adults with sepsis. A retrospective cohort study of patients admitted with sepsis, not undergoing any surgical procedures, and treated in an ICU by hospital day 2. We used propensity score matching to control for confounding and compared the following outcomes after resuscitation with balanced versus with no-balanced fluids: in-hospital mortality, acute renal failure with and without dialysis, and hospital and ICU lengths of stay. We also estimated the dose-response relationship between receipt of increasing proportions of balanced fluids and in-hospital mortality. Three hundred sixty U.S. hospitals that were members of the Premier Healthcare alliance between November 2005 and December 2010. A total of 53,448 patients with sepsis, treated with vasopressors and crystalloids in an ICU by hospital day 2 including 3,396 (6.4%) that received balanced fluids. None. Patients treated with balanced fluids were younger and less likely to have heart or chronic renal failure, but they were more likely to receive mechanical ventilation, invasive monitoring, colloids, steroids, and larger crystalloid volumes (median 7 vs 5 L). Among 6,730 patients in a propensity-matched cohort, receipt of balanced fluids was associated with lower in-hospital mortality (19.6% vs 22.8%; relative risk, 0.86; 95% CI, 0.78, 0.94). Mortality was progressively lower among patients receiving larger proportions of balanced fluids. There were no significant differences in the prevalence of acute renal failure (with and without dialysis) or in-hospital and ICU lengths of stay. Among critically ill adults with sepsis, resuscitation with balanced fluids was associated with a lower risk of in-hospital mortality. If
Noll, Donald R; Degenhardt, Brian F; Johnson, Jane C
%]) than the CCO group (6 of 19 [32%]) but not the LT group (2 of 15 [13%]). Subgroup analyses suggested adjunctive OMT for pneumonia reduced LOS in adults aged 50 to 74 years and lowered in-hospital mortality rates in adults aged 75 years or older. Adjunctive OMT may also reduce LOS and in-hospital mortality rates in older adults with more severe pneumonia. Interestingly, LT also reduced in-hospital mortality rates in adults aged 75 years or older relative to CCO. (ClinicalTrials.gov number NCT00258661).
Payvar, Saeed; Orlandi, Cesare; Stough, Wendy Gattis; Elkayam, Uri; Ouyang, John; Casscells, S Ward; Gheorghiade, Mihai
The use of aggressive treatments and the modification of current treatment in patients with heart failure (HF) relies heavily on the assessment of disease severity using prognostic markers. However, many such markers are unavailable in routine clinical practice, and others have little prognostic value. This study tested the hypothesis that low body temperature could predict short-term survival after discharge in patients hospitalized for HF. Data from the Acute and Chronic Therapeutic Impact of a Vasopressin Antagonist in Congestive Heart Failure (ACTIV in CHF) trial, which randomized 319 patients hospitalized for HF to receive placebo or tolvaptan, were retrospectively analyzed. Hypothermia was defined a priori as an oral body temperature <35.8 degrees C at randomization. Cox regression was used to analyze survival within a 60-day follow-up period. Hypothermia was observed in 32 patients (10%). Mortality rates at 60 days after discharge were 6.3% (20 of 319) overall, 9.4% (3 of 32) in hypothermic patients, and 5.9% (17 of 287) in nonhypothermic patients. Hypothermia was a strong multivariate predictor of mortality; hypothermic patients were 3.9 times more likely to die within 60 days than nonhypothermic patients (95% confidence interval 1.002 to 15.16, p = 0.0497) after adjustment for treatment group, age, and other confounders. Hypothermia was associated with such indicators of low cardiac output as an elevated blood urea nitrogen/creatinine ratio, narrow pulse pressure, and a reduced ejection fraction. In conclusion, hypothermia appears to be a strong predictor of mortality in patients with HF.
Oliver, M. Norman; Stukenborg, George J.; Wagner, Douglas P.; Harrell, Frank E.; Kilbridge, Kerry L.; Lyman, Jason A.; Einbinder, Jonathan; Connors, Alfred F.
BACKGROUND: Racial and ethnic disparities in mortality have been demonstrated in several diseases. African Americans are hospitalized at a significantly higher rate than whites for aspiration pneumonia; however, no studies have investigated racial and ethnic disparities in mortality in this population. OBJECTIVE: To assess the independent effect of race and ethnicity on in-hospital mortality among aspiration pneumonia discharges while comprehensively controlling for comorbid diseases, and to assess whether the prevalence and effects of comorbid illness differed across racial and ethnic categories. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 41,581 patients admitted to California hospitals for aspiration pneumonia from 1996 through 1998, using principal and secondary diagnoses present on admission. MEASUREMENT: The primary outcome measure was in-hospital mortality. RESULTS: The adjusted odds of in-hospital death for African-American compared with white discharges [odds ratio (OR)=1.01; 95% confidence interval (CI), 0.91-1.11] was not significantly different. The odds of death for Asian compared with white discharges was significantly lower (OR=0.83; 95% CI, 0.75-0.91). Hispanics had a significantly lower odds of death (OR=0.90; 95% CI, 0.82-0.988) compared to non-Hispanics. Comorbid diseases were more prevalent among African Americans and Asians than whites, and among Hispanics compared to non-Hispanics. Differences in effects of comorbid disease on mortality risk by race and ethnicity were not statistically significant. CONCLUSION: Asians have a lower risk of death, and the risk of death for African Americans is not significantly different from whites in this analysis of aspiration pneumonia discharges. Hispanics have a lower risk of death than non-Hispanics. While there are differences in prevalence of comorbid disease by racial and ethnic category, the effects of comorbid disease on mortality risk do not differ meaningfully by race or
Kuimi, Brice L Batomen; Moore, Lynne; Cissé, Brahim; Gagné, Mathieu; Lavoie, André; Bourgeois, Gilles; Lapointe, Jean
Few data are available on population-based access to specialised trauma care and its influence on patient outcomes in an integrated trauma system. We aimed to evaluate the influence of access to an integrate trauma system on in-hospital mortality and length of stay (LOS). All adults admitted to acute care hospitals for major trauma [International Classification of Diseases Injury Severity Score (ICISS<0.85)] in a Canadian province with an integrated trauma system between 2006 and 2011 were included using an administrative hospital discharge database. The influence of access to an integrated trauma system on in-hospital mortality and LOS was assessed globally and for critically injured patients (ICISS<0.75), according to the type of injury [traumatic brain injury (TBI), abdominal/thoracic, spine, orthopaedic] using logistic and linear multivariable regression models. We identified 22,749 injury admissions. In-hospital mortality was 7% and median LOS was 9 days for all injuries. Overall, 92% of patients were treated within the trauma system. Globally, patients who did not have access had similar mortality and LOS compared to patients who had access. However, we observed a 62% reduction in mortality for critical abdominal/thoracic injuries (odds ratio=0.38; 95% CI, 0.16-0.92) and an 8% increase in LOS for TBI patients (geometric mean ratio=1.08; 95% CI, 1.02-1.14) treated within the trauma system. Results provides evidence that in a health system with an integrated mature trauma system, access to specialised trauma care is high and the small proportion of patients treated outside the system, have similar mortality and LOS compared to patients treated within the system. This study suggests that the Québec trauma system performs well in its mandate to offer appropriate treatment to victims of injury that require specialised care. Copyright © 2015 Elsevier Ltd. All rights reserved.
Seghieri, Chiara; Mimmi, Stefano; Lenzi, Jacopo; Fantini, Maria Pia
Coronary heart disease is the leading cause of mortality in the world. One of the outcome indicators recently used to measure hospital performance is 30-day mortality after acute myocardial infarction (AMI). This indicator has proven to be a valid and reproducible indicator of the appropriateness and effectiveness of the diagnostic and therapeutic process for AMI patients after hospital admission. The aim of this study was to examine the determinants of inter-hospital variability on 30-day in-hospital mortality after AMI in Tuscany. This indicator is a proxy of 30-day mortality that includes only deaths occurred during the index or subsequent hospitalizations. The study population was identified from hospital discharge records (HDRs) and included all patients with primary or secondary ICD-9-CM codes of AMI (ICD-9 codes 410.xx) that were discharged between January 1, 2009 and November 30, 2009 from any hospital in Tuscany. The outcome of interest was 30-day all-cause in-hospital mortality, defined as a death occurring for any reason in the hospital within 30 days of the admission date. Because of the hierarchical structure of the data, with patients clustered into hospitals, random-effects (multilevel) logistic regression models were used. The models included patient risk factors and random intercepts for each hospital. The study included 5,832 patients, 61.90% male, with a mean age of 72.38 years. During the study period, 7.99% of patients died within 30 days of admission. The 30-day in-hospital mortality rate was significantly higher among patients with ST segment elevation myocardial infarction (STEMI) compared with those with non-ST segment elevation myocardial infarction (NSTEMI). The multilevel analysis which included only the hospital variance showed a significant inter-hospital variation in 30-day in-hospital mortality. When patient characteristics were added to the model, the hospital variance decreased. The multilevel analysis was then carried out
Kesinger, Matthew R; Nagy, Lisa R; Sequeira, Denisse J; Charry, Jose D; Puyana, Juan C; Rubiano, Andres M
Standardized trauma protocols (STP) have reduced morbidity and in-hospital mortality in mature trauma systems. Most hospitals in low- and middle-income countries (LMICs) have not implemented STPs, often because of financial and logistic limitations. We report the impact of an STP designed for the care of trauma patients in the emergency department (ED) at an LMIC hospital on patients with severe traumatic brain injury (STBI). We developed an STP based on generally accepted best practices and damage control resuscitation for a level I trauma centre in Colombia. Without a pre-existing trauma registry, we adapted an administrative electronic database to capture clinical information of adult patients with TBI, a head abbreviated injury score (AIS) ≥3, and who presented ≤12h from injury. Demographics, mechanisms of injury, and injury severity were compared. Primary outcome was in-hospital mortality. Secondary outcomes were Glasgow Coma Score (GCS), length of hospital and ICU stay, and prevalence of ED interventions recommended in the STP. Logistic regression was used to control for potential confounders. The pre-STP group was hospitalized between August 2010 and August 2011, the post-STP group between September 2011 and June 2012. There were 108 patients meeting inclusion criteria, 68 pre-STP implementation and 40 post-STP. The pre- and post-STP groups were similar in age (mean 37.1 vs. 38.6, p=0.644), head AIS (median 4.5 vs. 4.0, p=0.857), Injury Severity Scale (median 25 vs. 25, p=0.757), and initial GCS (median 7 vs. 7, p=0.384). Post-STP in-hospital mortality decreased (38% vs. 18%, p=0.024), and discharge GCS increased (median 10 vs. 14, p=0.034). After controlling for potential confounders, odds of in-hospital mortality post-STP compared to pre-STP were 0.248 (95%CI: 0.074-0.838, p=0.025). Hospital and ICU stay did not significantly change. The use of many ED interventions increased post-STP, including bladder catheterization (49% vs. 73%, p=0
Rostagno, Carlo; Buzzi, Roberto; Campanacci, Domenico; Boccacini, Alberto; Cartei, Alessandro; Virgili, Gianni; Belardinelli, Andrea; Matarrese, Daniela; Ungar, Andrea; Rafanelli, Martina; Gusinu, Roberto; Marchionni, Niccolò
Objectives Medical comorbidities affect outcome in elderly patients with hip fracture. This study was designed to preliminarily evaluate the usefulness of a hip-fracture unit led by an internal medicine specialist. Methods In-hospital and 3-month outcomes in patients with hip fracture were prospectively evaluated in 121 consecutive patients assessed before and followed after surgery by a multidisciplinary team led by internal medicine specialist; 337 consecutive patients were recalled from ICD-9 discharge records and considered for comparison regarding in-hospital mortality. Results In the intervention period, patients treated within 48 hours were 54% vs. 26% in the historical cohort (P<0.0001). In-hospital mortality remained stable at about 2.3 per 1000 person-days. At 3 months, 10.3% of discharged patients had died, though less than 8% of patients developed postoperative complications (mainly pneumonia and respiratory failure). The presence of more than 2 major comorbidities and the loss of 3 or more BADL were independent predictors of death. 50/105 patients recovered previous functional capacity, but no independent predictor of functional recovery could be identified. Mean length of hospital stay significantly decreased in comparison to the historical cohort (13.6± 4.7 vs 17 ± 5 days, p = 0.0001). Combined end-point of mortality and length of hospitalization < 12 days was significantly lower in study period (27 vs 34%, p <0.0132). Conclusions Identification and stabilization of concomitant clinical problems by internal medicine specialists may safely decrease time to surgery in frail subjects with hip fracture. Moreover, integrated perioperative clinical management may shorten hospital stay with no apparent increase in in-hospital mortality and ultimately improve the outcome. These results are to be confirmed by a larger study presently ongoing at our institution. PMID:27389193
Mizuno, Seiko; Kunisawa, Susumu; Sasaki, Noriko; Fushimi, Kiyohide; Imanaka, Yuichi
Many hospitals experience a reduction in the number of available physicians on days when national scientific meetings are conducted. This study investigates the relationship between in-hospital mortality in acute myocardial infarction (AMI) patients and admission during national cardiology meeting dates. Using an administrative database, we analyzed patients with AMI admitted to acute care hospitals in Japan from 2011 to 2013. There were 3 major national cardiology meetings held each year. A hierarchical logistic regression model was used to compare in-hospital mortality and treatment patterns between patients admitted on meeting dates and those admitted on identical days during the week before and after the meeting dates. We identified 6,332 eligible patients, with 1,985 patients admitted during 26 meeting days and 4,347 patients admitted during 52 non-meeting days. No significant differences between meeting and non-meeting dates were observed for in-hospital mortality (7.4% vs. 8.5%, respectively; p=0.151, unadjusted odds ratio: 0.861, 95% confidence interval: 0.704-1.054) and the proportion of percutaneous coronary intervention (PCI) performed on the day of admission (75.9% vs. 76.2%, respectively; p=0.824). We also found that some low-staffed hospitals did not treat AMI patients during meeting dates. Little or no "national meeting effect" was observed on in-hospital mortality in AMI patients, and PCI rates were similar for both meeting and non-meeting dates. Our findings also indicated that during meeting dates, AMI patients may have been consolidated to high-performance and sufficiently staffed hospitals. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Wei, Xue-Biao; Liu, Yuan-Hui; He, Peng-Cheng; Yu, Dan-Qing; Tan, Ning; Zhou, Ying-Ling; Chen, Ji-Yan
Infective endocarditis (IE) is associated with increased neutrophil and reduced platelet counts. We assessed the relationship between the neutrophil-to-platelet ratio (NPR) on admission and adverse outcomes in patients with IE. Patients diagnosed with IE between January 2009 and July 2015 (n=1293) were enrolled, and 1046 were finally entered into the study. Study subjects were categorized into four groups according to NPR quartiles: Q1<18.9 (n=260); Q2: 18.9-27.7 (n=258); Q3: 27.7-43.3 (n=266); and Q4>43.3 (n=262). Cox proportional hazards regression was performed to identify risk factors for long-term mortality; the optimal cut-off was evaluated by receiver operating characteristic curves. Risk of in-hospital death increased progressively with NPR group number (1.9 vs. 5.0 vs. 9.8 vs. 14.1%, p<0.001). The follow-up period was a median of 28.8 months, during which 144 subjects (14.3%) died. Long-term mortality increased from the lowest to the highest NPR quartiles (7.6, 11.8, 17.4, and 26.2%, respectively, p<0.001). Multivariate Cox proportional hazard analysis revealed that lgNPR (HR=2.22) was an independent predictor of long-term mortality. Kaplan-Meier survival curves showed that subjects in Q4 had an increased long-term mortality compared with the other groups. Increased NPR was associated with in-hospital and long-term mortality in patients with IE. As a simple and inexpensive index, NPR may be a useful and rapid screening tool to identify IE patients at high risk of mortality.
Background Infectious diseases are a common cause of increased morbidity and mortality in elderly patients. Bacteraemia in the elderly is a difficult diagnosis and a therapeutic challenge due to age-related vicissitudes and to their comorbidities. The main purpose of the study was to assess independent risk factors for in-hospital mortality among the elderly with bacteraemia admitted to an Internal Medicine Ward. Methods Overall, a cohort of 135 patients, 65 years of age and older, with bacteraemia were retrospectively studied. Data related to demographic information, comorbidities, clinical parameters on admission, source and type of infection, microorganism isolated in the blood culture, laboratory data and empirical antibiotic treatment was recorded from each patient. Multivariate logistic regression was performed to identify independent predictors of all-cause in-hospital mortality. Results Of these 135 patients, 45.9% were women. The most common infections in this group of patients were urinary tract infections (46.7%). The main microorganisms isolated in the blood cultures were Escherichia coli (14.9%), Methicillin-resistant Staphylococcus aureus (MRSA) (12.0%), non-MRSA (11.4%), Klebsiella pneumoniae (9.1%) and Enterococcus faecalis (8.0%). The in-hospital mortality was 22.2%. Independent prognostic factors associated with in-hospital mortality were age ≥ 85 years, chronic renal disease, bacteraemia of unknown focus and cognitive impairment at admission (OR, 2.812 [95% CI, 1.039-7.611; p = 0.042]; OR, 6.179 [95% CI, 1.840-20.748; p = 0.003]; OR, 8.673 [95% CI, 1.557-48.311; p = 0.014] and OR, 3.621 [95% CI, 1.226-10.695; p = 0.020], respectively). By multivariate analysis appropriate antibiotic therapy was not associated with lower odds of mortality. Conclusion Bacteraemia in the elderly has a high mortality rate. There are no set of signs or clinical features that can predict bacteraemia in the elderly. However, older age (≥ 85 years), chronic renal
Diamant, Michael J; Coward, Stephanie; Buie, W Donald; MacLean, Anthony; Dixon, Elijah; Ball, Chad G; Schaffer, Samuel; Kaplan, Gilaad G
BACKGROUND: Previous studies have found that a higher volume of colorectal surgery was associated with lower mortality rates. While diverticulitis is an increasingly common condition, the effect of hospital volume on outcomes among diverticulitis patients is unknown. OBJECTIVE: To evaluate the relationship between hospital volume and other factors on in-hospital mortality among patients admitted for diverticulitis. METHODS: Data from the Nationwide Inpatient Sample (years 1993 to 2008) were analyzed to identify 822,865 patients representing 4,108,726 admissions for diverticulitis. Hospitals were divided into quartiles based on the volume of diverticulitis cases admitted over the study period, adjusted for years contributed to the dataset. Mortality according to hospital volume was modelled using logistic regression adjusting for age, sex, race, comorbidities, health care insurance, admission type, calendar year, colectomy, disease severity and clustering. Risk estimates were expressed as adjusted ORs with 95% CIs. RESULTS: Patients at high-volume hospitals were more likely to be admitted emergently, undergo surgical treatment and have more severe disease. In-hospital mortality was higher among the lowest quartile of hospital volume compared with the highest volume (OR 1.13 [95% CI 1.05 to 1.21]). In-hospital mortality was increased among patients admitted emergently (OR 2.58 [95% CI 2.40 to 2.78]) as well as those receiving surgical treatment (OR 3.60 [95% CI 3.42 to 3.78]). CONCLUSIONS: Diverticulitis patients admitted to hospitals with a low volume of diverticulitis cases had an increased risk for death compared with those admitted to high-volume centres. PMID:25965439
de Andrade Falcão, Felipe José; Alves, Cláudia Maria Rodrigues; Barbosa, Adriano Henrique Pereira; Caixeta, Adriano; Sousa, José Marconi Almeida; Souza, José Augusto Marcondes; Amaral, Amaury; Wilke, Luiz Carlos; Perez, Fátima Cristina A.; Gonçalves, Iran; Stefanini, Edson; Carvalho, Antônio Carlos
OBJECTIVES: To identify predictors of in-hospital mortality in patients with acute myocardial infarction undergoing pharmacoinvasive treatment. METHODS: This was an observational, prospective study that included 398 patients admitted to a tertiary center for percutaneous coronary intervention within 3 to 24 hours after thrombolysis with tenecteplase. ClinicalTrials.gov: NCT01791764 RESULTS: The overall in-hospital mortality rate was 5.8%. Compared with patients who survived, patients who died were more likely to be older, have higher rates of diabetes and chronic renal failure, have a lower left ventricular ejection fraction, and demonstrate more evidence of heart failure (Killip class III or IV). Patients who died had significantly lower rates of successful thrombolysis (39% vs. 68%; p = 0.005) and final myocardial blush grade 3 (13.0% vs. 61.9%; p<0.0001). Based on the multivariate analysis, the Global Registry of Acute Coronary Events score (odds ratio 1.05, 95% confidence interval (CI) 1.02-1.09; p = 0.001), left ventricular ejection fraction (odds ratio 0.9, 95% CI 0.89-0.97; p = 0.001), and final myocardial blush grade of 0-2 (odds ratio 8.85, 95% CI 1.34-58.57; p = 0.02) were independent predictors of mortality. CONCLUSIONS: In this prospective study that evaluated patients with ST-segment elevation myocardial infarction treated by a pharmacoinvasive strategy, the in-hospital mortality rate was 5.8%. The Global Registry of Acute Coronary Events score, left ventricular ejection fraction, and myocardial blush were independent predictors of mortality in this high-risk group of acute coronary syndrome patients. PMID:24473509
Anton-Martin, Pilar; Papacostas, Michael; Lee, Elisabeth; Nakonezny, Paul A; Green, Michael L
Malnutrition is associated with an increased risk of mortality in patients admitted to the intensive care unit. Children requiring extracorporeal membrane oxygenation (ECMO) support represent an extremely ill subset of this population. There is a lack of data on the impact of nutrition state on survival in this cohort. We examined the association between being underweight and in-hospital mortality among children supported with ECMO. This article reports on an observational retrospective cohort study performed among neonatal and pediatric patients supported with ECMO in a tertiary children's hospital from May 1996 through June 2013. Nutrition status on intensive care unit admission was defined with z scores on weight for length and body mass index. Patients (N = 491) had a median age of 31 days (interquartile range, 2-771): 24.4% were underweight, and 8.9% were obese. During ECMO support, 88.3% received total parenteral nutrition, and 30.3% received enteral nutrition. Median maximum energy intake while receiving ECMO was 82 kcal/kg/d (interquartile range, 54.7-105). Multiple logistic regression showed that underweight status was associated with increased predicted odds of in-hospital mortality when compared with normal weight (odds ratio: 1.99, 95% confidence interval: 1.21-3.25, P = .006). Other factors associated with increased odds of mortality included extracorporeal cardiopulmonary resuscitation and the need for continuous renal replacement therapy. Underweight status was an independent predictor for in-hospital mortality in our cohort of pediatric ECMO patients. Prospective studies evaluating the impact of metabolic state of children on ECMO should further define this relationship. © 2016 American Society for Parenteral and Enteral Nutrition.
Nepal reportedly reduced the maternal mortality ratio by 48% within one decade between 1996-2005 and received the Millennium development goal award for this. However, there is debate regarding the accuracy of this figure. On the basis of framework of determinants of maternal mortality proposed by McCarthy and Maine in 1992 and successive data from Nepal demographic health survey of 1996, 2001 and 2006, a literature analysis was done to identify the important factors behind this decline. Although facility delivery and skilled birth attendants are acclaimed as best strategy of reducing maternal mortality, a proportionate increase in these factors was not found to account the maternal mortality rate reduction in Nepal. Alternatively, intermediate factors particularly women awareness, family planning and safe abortion might have played a significant role. Hence, Nepal as well as similar other developing countries should pay equal attention to such intermediate factors while concentrating on biomedical care strategy.
van Zaane, Bas; van Klei, Wilton A; Buhre, Wolfgang F; Bauer, Peter; Boerma, E Christiaan; Hoeft, Andreas; Metnitz, Philipp; Moreno, Rui P; Pearse, Rupert; Pelosi, Paolo; Sander, Michael; Vallet, Benoit; Pettilä, Ville; Vincent, Jean-Louis; Rhodes, Andrew
Evidence suggests that sleep deprivation associated with night-time working may adversely affect performance resulting in a reduction in the safety of surgery and anaesthesia. Our primary objective was to evaluate an association between nonelective night-time surgery and in-hospital mortality. We hypothesised that urgent surgery performed during the night was associated with higher in-hospital mortality and also an increase in the duration of hospital stay and the number of admissions to critical care. A prospective cohort study. This is a secondary analysis of a large database related to perioperative care and outcome (European Surgical Outcome Study). Four hundred and ninety-eight hospitals in 28 European countries. Men and women older than 16 years who underwent nonelective, noncardiac surgery were included according to time of the procedure. None. Primary outcome was in-hospital mortality; the secondary outcome was the duration of hospital stay and critical care admission. Eleven thousand two hundred and ninety patients undergoing urgent surgery were included in the analysis with 636 in-hospital deaths (5.6%). Crude mortality odds ratios (ORs) increased sequentially from daytime [426 deaths (5.3%)] to evening [150 deaths (6.0%), OR 1.14; 95% confidence interval 0.94 to 1.38] to night-time [60 deaths (8.3%), OR 1.62; 95% confidence interval 1.22 to 2.14]. Following adjustment for confounding factors, surgery during the evening (OR 1.09; 95% confidence interval 0.91 to 1.31) and night (OR 1.20; 95% confidence interval 0.9 to 1.6) was not associated with an increased risk of postoperative death. Admittance rate to an ICU increased sequentially from daytime [891 (11.1%)], to evening [347 (13.8%)] to night time [149 (20.6%)]. In patients undergoing nonelective urgent noncardiac surgery, in-hospital mortality was associated with well known risk factors related to patients and surgery, but we did not identify any relationship with the time of day at which the
Pochop, P.A.; Cummings, J.L.; Yoder, C.A.; Gossweiler, W.A.
White phosphorus (WP) has been identified as the cause of mortality to certain species of water-fowl at Eagle River Flats, a tidal marsh in Alaska, used as an ordinance impact area by the US Army. A blend of calcium bentonite/organo clays, gravel, and binding polymers was tested for effectiveness as a barrier to reduce duck foraging and mortality. Following the application of the barrier to one of two contaminated ponds, the authors observed greater duck foraging and higher mortality in the untreated pond and no mortality in the treated pond after a year of tidal inundations and ice effects. Emergent vegetation recovered within a year of treatment. WP levels in the barrier were less than the method limit of detection, indicating no migration of WP into the materials. Barrier thickness remained relatively stable over a period of 4 years, and vegetation was found to be important in stabilizing the barrier material.
Sigakis, Matthew J G; Bittner, Edward A; Wanderer, Jonathan P
External validation of published risk stratification models is essential to determine their generalizability. This study evaluates the performance of the Risk Stratification Indices (RSIs) and 30-day mortality Risk Quantification Index (RQI). 108,423 adult hospital admissions with anesthetics were identified (2006-2011). RSIs for mortality and length-of-stay endpoints were calculated using published methodology. 91,128 adult, noncardiac inpatient surgeries were identified with administrative data required for RQI calculation. RSI in-hospital mortality and RQI 30-day mortality Brier scores were 0.308 and 0.017, respectively. RSI discrimination, by area under the receiver operating curves, was excellent at 0.966 (95% CI, 0.963-0.970) for in-hospital mortality, 0.903 (0.896-0.909) for 30-day mortality, 0.866 (0.861-0.870) for 1-yr mortality, and 0.884 (0.882-0.886) for length-of-stay. RSI calibration, however, was poor overall (17% predicted in-hospital mortality vs. 1.5% observed after inclusion of the regression constant) as demonstrated by calibration plots. Removal of self-fulfilling diagnosis and procedure codes (20,001 of 108,423; 20%) yielded similar results. RQIs were calculated for only 62,640 of 91,128 patients (68.7%) due to unmatched procedure codes. Patients with unmatched codes were younger, had higher American Society of Anesthesiologists physical status and 30-day mortality. The area under the receiver operating curve for 30-day mortality RQI was 0.888 (0.879-0.897). The model also demonstrated good calibration. Performance of a restricted index, Procedure Severity Score + American Society of Anesthesiologists physical status, performed as well as the original RQI model (age + American Society of Anesthesiologists + Procedure Severity Score). Although the RSIs demonstrated excellent discrimination, poor calibration limits their generalizability. The 30-day mortality RQI performed well with age providing a limited contribution.
Chin, Bum Sik; Kim, Myung Soo; Han, Sang Hoon; Shin, So Youn; Choi, Hee Kyung; Chae, Yun Tae; Jin, Sung Joon; Baek, Ji-Hyeon; Choi, Jun Yong; Song, Young Goo; Kim, Chang Oh; Kim, June Myung
Urinary tract infection (UTI) is the most frequent cause of bacteremia/sepsis in elderly people and increasing antimicrobial resistance in uropathogens has been observed. To describe the characteristics of bacteremic UTI in elderly patients and to identify the independent risk factors of all-cause in-hospital mortality, a retrospective cohort study of bacteremic UTI patients of age over 65 was performed at a single 2000-bed tertiary hospital. Bacteremic UTI was defined as the isolation of the same organism from both urine and blood within 48 h. Eighty-six elderly bacteremic UTI patients were enrolled. Community-acquired infection was the case for most patients (79.1%), and Escherichia coli accounted for 88.6% (70/79) among Gram-negative organisms. Non-E. coli Gram-negative organisms were more frequent in hospital-acquired cases and male patients while chronic urinary catheter insertion was related with Gram-positive urosepsis. The antibiotic susceptibility among Gram-negative organisms was not different depending on the source of bacteremic UTI, while non-E. coli Gram-negative organisms were less frequently susceptible for cefotaxime, cefoperazone/sulbactam, and aztreonam. All-cause in-hospital mortality was 11.6%, and functional dependency (adjusted hazard ratio=HR=10.9, 95% confidence interval=95%CI=2.2-54.6) and low serum albumin (adjusted HR=27.0, 95%CI=2.0-361.2) were independently related with increased all-cause in-hospital mortality. Crown Copyright © 2010. Published by Elsevier Ireland Ltd. All rights reserved.
Soto-Martínez, Manuel; Avila, Lydiana; Soto, Natalia; Chaves, Albin; Celedón, Juan C; Soto-Quiros, Manuel E
Little is known about trends in morbidity and/or mortality due to asthma in Latin America. To examine trends in hospitalizations and mortality due to asthma from 1997-2000 to 2011 in Costa Rica. The rates of hospitalization due to asthma were calculated for each sex in 3 age groups from 1997 to 2011. The number of deaths due to asthma was first calculated for all groups and then for each sex in 3 age groups from 2000 to 2011. All analyses were conducted over the entire period and separately for the periods before and after a National Asthma Program (NAP) in 2003. Data also were available for prescriptions for beclomethasone since 2004. All analyses were conducted by using Epi Info. Substantial reductions were found in hospitalizations and deaths due to asthma in Costa Ricans (eg, from 25 deaths in 2000 to 5 deaths in 2011). Although, the percentage decrement in the rates of hospitalization for asthma in subjects <20 years old was similar before and after the NAP, the reduction in both deaths due to asthma and rates of asthma hospitalizations in older subjects were more pronounced after the NAP, when prescriptions for beclomethasone were also increased by approximately 129%. In Costa Rica, there was a marked decrement in hospitalizations and mortality due to asthma from 1997-2000 to 2011. In younger subjects, this is likely due to guidelines that, since 1988, recommend inhaled corticosteroids for persistent asthma. In older adults, the NAP probably enhanced reductions in hospitalizations and deaths due to asthma through inhaled corticosteroid use. Copyright © 2013 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
Ho, Chung-Han; Chen, Zhih-Cherng; Chu, Chin-Chen; Wang, Jhi-Joung; Chiang, Chun-Yen
Intra-aortic balloon pumping (IABP) is widely used for hemodynamic support in critical patients with cardiogenic shock (CS). We examined whether the in-hospital mortality of patients in Taiwan treated with IABP has recently declined. We used Taiwan's National Health Insurance Research Database to retrospectively review the in-hospital all-cause mortality of 9952 (7146 men [71.8%]) 18-year-old and older patients treated with IABP between 1998 and 2008. The mortality rate was 13.84% (n = 1377). The urbanization levels of the hospitals, and the number of days in the intensive care unit, of hospitalization, and of IABP treatment, and prior percutaneous coronary intervention (PCI) were associated with mortality. Seven thousand six hundred thirty-five patients (76.72%) underwent coronary artery bypass grafting (CABG) surgery, and 576 (5.79%) underwent high-risk PCI with IABP treatment. The number of patients treated with IABP significantly increased during this decade (ptrend < 0.0001), the in-hospital all-cause mortality for patients treated with IABP significantly decreased (ptrend = 0.0243), but the in-hospital all-cause mortality of patients who underwent CABG and PCI plus IABP did not decrease. In conclusion, the in-hospital mortality rate of IABP treatment decreased annually in Taiwan during the study period. However, high-risk patients who underwent coronary revascularization with IABP had a higher and unstable in-hospital mortality rate.
Cortés, Jorge Alberto; Reyes, Patricia; Gómez, Carlos Hernando; Cuervo, Sonia Isabel; Rivas, Pilar; Casas, Christian A; Sánchez, Ricardo
Bloodstream infection by Candida species has a high mortality in Latin American countries. The aim of this study was to describe the characteristics of patients with documented bloodstream infections caused by Candida species in third level hospitals and determine the risk factors for in-hospital-mortality. Patients from seven tertiary-care hospitals in Bogotá, Colombia, with isolation of a Candida species from a blood culture were followed prospectively from March 2008 to March 2009. Epidemiologic information, risk factors, and mortality were prospectively collected. Isolates were sent to a reference center, and fluconazole susceptibility was tested by agar-based E-test. The results of susceptibility were compared by using 2008 and 2012 breakpoints. A multivariate analysis was used to determinate risk factors for mortality. We identified 131 patients, with a median age of 41.2 years. Isolates were most frequently found in the intensive care unit (ICU). Candida albicans was the most prevalent species (66.4% of the isolates), followed by C. parapsilosis (14%). Fluconazole resistance was found in 3.2% and 17.6% of the isolates according to the 2008 and 2012 breakpoints, respectively. Fluconazole was used as empirical antifungal therapy in 68.8% of the cases, and amphotericin B in 22%. Hospital crude mortality rate was 35.9%. Mortality was associated with age and the presence of shock at the time of Candida detection. Fluconazole therapy was a protective factor for mortality. Candidemia is associated with a high mortality rate. Age and shock increase mortality, while the use of fluconazole was shown to be a protective factor. A higher resistance rate with new breakpoints was noted. Copyright © 2014 Elsevier Editora Ltda. All rights reserved.
Longhurst, Christopher A; Parast, Layla; Sandborg, Christy I; Widen, Eric; Sullivan, Jill; Hahn, Jin S; Dawes, Christopher G; Sharek, Paul J
Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates. The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic children's hospital. We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80,063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17,432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation. After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008-0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%-40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame. Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic children's hospital.
Wang, Tsai-Yu; Hung, Chia-Yen; Shie, Shian-Sen; Chou, Pai-Chien; Kuo, Chih-Hsi; Chung, Fu-Tsai; Lo, Yu-Lun; Lin, Shu-Min
Abstract Recent epidemiologic studies have showed that candidemia is an important nosocomial infection in hospitalized patients. The majority of candidemia patients were non-neutropenic rather than neutropenic status. The aim of this study was to determine the clinical outcome of non-neutropenic patients with candidemia and to measure the contributing factors for mortality. A total of 163 non-neutropenic patients with candidemia during January 2010 to December 2013 were retrospectively enrolled. The patients’ risk factors for mortality, clinical outcomes, treatment regimens, and Candida species were analyzed. The overall mortality was 54.6%. Candida albicans was the most frequent Candida species (n = 83; 50.9% of patients). Under multivariate analyses, hemodialysis (OR, 4.554; 95% CI, 1.464–14.164) and the use of amphotericin B deoxycholate (OR, 8.709; 95% CI, 1.587–47.805) were independent factors associated with mortality. In contrast, abdominal surgery (OR, 0.360; 95% CI, 0.158–0.816) was associated with a better outcome. The overall mortality is still high in non-neutropenic patients with candidemia. Hemodialysis and use of amphotericin B deoxycholate were independent factors associated with mortality, whereas prior abdominal surgery was associated with a better outcome. PMID:27281087
Wang, Tsai-Yu; Hung, Chia-Yen; Shie, Shian-Sen; Chou, Pai-Chien; Kuo, Chih-Hsi; Chung, Fu-Tsai; Lo, Yu-Lun; Lin, Shu-Min
Recent epidemiologic studies have showed that candidemia is an important nosocomial infection in hospitalized patients. The majority of candidemia patients were non-neutropenic rather than neutropenic status. The aim of this study was to determine the clinical outcome of non-neutropenic patients with candidemia and to measure the contributing factors for mortality. A total of 163 non-neutropenic patients with candidemia during January 2010 to December 2013 were retrospectively enrolled. The patients' risk factors for mortality, clinical outcomes, treatment regimens, and Candida species were analyzed. The overall mortality was 54.6%. Candida albicans was the most frequent Candida species (n = 83; 50.9% of patients). Under multivariate analyses, hemodialysis (OR, 4.554; 95% CI, 1.464-14.164) and the use of amphotericin B deoxycholate (OR, 8.709; 95% CI, 1.587-47.805) were independent factors associated with mortality. In contrast, abdominal surgery (OR, 0.360; 95% CI, 0.158-0.816) was associated with a better outcome. The overall mortality is still high in non-neutropenic patients with candidemia. Hemodialysis and use of amphotericin B deoxycholate were independent factors associated with mortality, whereas prior abdominal surgery was associated with a better outcome.
Togha, Mansooreh; Bakhtavar, Khadigeh
Background Primary intracerebral hemorrhage (ICH) is one of the common vascular insults with a relatively high rate of mortality. The aim of the current study was to determine the mortality rate and to evaluate the influence of various factors on the mortality of patients with intracerebral hemorrhage (ICH). Demographic characteristics along with clinical features and neuroimaging information on 122 patients with primary ICH admitted to Sina Hospital between 1999–2002 were assessed by multivariate analysis. Results Of 122 patients diagnosed with intracerebral hemorrhage, 70 were men and 52 were women. Sixtynine percent of subjects were between 60 to 80 years of age. A history of hypertension was the primary cause in 67.2% of participants and it was found more frequent compared to other cardiovascular risk factors such as a history of ischemic heart disease (17.2%), diabetes mellitus (18%) and cigarette smoking (13.1%). The overall mortality rate among ICH patients admitted to the hospital was 46.7%. About one third of the deaths occurred within the first two days after brain injury. Factor independently associated with in-hospital mortality were Glasgow Coma Scale (GCS) score (≤ 8), diabetes mellitus disease, volume of hematoma and and intraventricular hematoma. Conclusion Higher rate of mortality were observed during the first two weeks of hospitalization following ICH. Neuroimaging features along with GCS score can help the clinicians in developing their prognosis. PMID:15193159
Riquelme, R; Jiménez, P; Videla, A J; Lopez, H; Chalmers, J; Singanayagam, A; Riquelme, M; Peyrani, P; Wiemken, T; Arbo, G; Benchetrit, G; Rioseco, M L; Ayesu, K; Klotchko, A; Marzoratti, L; Raya, M; Figueroa, S; Saavedra, F; Pryluka, D; Inzunza, C; Torres, A; Alvare, P; Fernandez, P; Barros, M; Gomez, Y; Contreras, C; Rello, J; Bordon, J; Feldman, C; Arnold, F; Nakamatsu, R; Riquelme, J; Blasi, F; Aliberti, S; Cosentini, R; Lopardo, G; Gnoni, M; Welte, T; Saad, M; Guardiola, J; Ramirez, J
Community-acquired pneumonia (CAP) severity scores can identify patients at low risk for mortality who may be suitable for ambulatory care. Here, we follow the clinical course of hospitalized patients with CAP due to 2009 H1N1 influenza. To evaluate the role of CAP severity scores as predictors of mortality. This was a secondary data analysis of patients hospitalized with CAP due to 2009 H1N1 influenza confirmed by reverse transcriptase polymerase chain reaction enrolled in the CAPO (Community-Acquired Pneumonia Organization) international cohort study. CAP severity scores PSI (Pneumonia Severity Index), CURB-65 (confusion, urea, respiratory rate, blood pressure, age ≥ 65 years) and CRB-65 (confusion, respiratory rate, blood pressure, age ≥ 65 years) were calculated. Actual and predicted mortality rates were compared. A total of 37 predictor variables were evaluated to define those associated with mortality. Data from 250 patients with CAP due to 2009 H1N1 influenza were analyzed. Patients with low predicted mortality rates (0-1.5%) had actual mortality rates ranging from 2.6% to 17.5%. Obesity and wheezing were the only novel variables associated with mortality. The decision to hospitalize a patient with CAP due to 2009 H1N1 influenza should not be based on current CAP severity scores, as they underestimate mortality rates in a significant number of patients. Patients with obesity or wheezing should be considered at an increased risk for mortality.
Chao, Chia-Ter; Lin, Yu-Feng; Tsai, Hung-Bin; Hsu, Nin-Chieh; Tseng, Chia-Lin; Ko, Wen-Je
Background/Aims The elderly constitute an increasing proportion of admitted patients worldwide. We investigate the determinants of hospital length of stay and outcomes in patients aged 90 years and older. Methods We retrospectively analyzed all admitted patients aged >90 years from the general medical wards in a tertiary referral medical center between August 31, 2009 and August 31, 2012. Patients’ clinical characteristics, admission diagnosis, concomitant illnesses at admission, and discharge diagnosis were collected. Each patient was followed until discharge or death. Multivariate logistic regression analysis was utilized to study factors associated with longer hospital length of stay (>7 days) and in-hospital mortality. Results A total of 283 nonagenarian in-patients were recruited, with 118 (41.7%) hospitalized longer than one week. Nonagenarians admitted with pneumonia (p = 0.04) and those with lower Barthel Index (p = 0.012) were more likely to be hospitalized longer than one week. Multivariate logistic regression analysis revealed that patients with lower Barthel Index (odds ratio [OR] 0.98; p = 0.021) and those with heart failure (OR 3.05; p = 0.046) had hospital stays >7 days, while patients with lower Barthel Index (OR 0.93; p = 0.005), main admission nephrologic diagnosis (OR 4.83; p = 0.016) or acute kidney injury (OR 30.7; p = 0.007) had higher in-hospital mortality. Conclusion In nonagenarians, presence of heart failure at admission was associated with longer hospital length of stay, while acute kidney injury at admission predicted higher hospitalization mortality. Poorer functional status was associated with both prolonged admission and higher in-hospital mortality. PMID:24223127
Orman, Eric S.; Hayashi, Paul H.; Bataller, Ramon; Barritt, A. Sidney
Background & Aims Diagnostic paracentesis is recommended for patients with cirrhosis admitted to the hospital for ascites or encephalopathy. However, it is not known if clinicians in the United States adhere to this recommendation; a relationship between paracentesis and clinical outcome has not been reported. We analyzed a US database to determine the frequency of paracentesis and its association with mortality. Methods The 2009 Nationwide Inpatient Sample (which contains data from approximately 8 million hospital discharges each year) was used to identify patients with cirrhosis and ascites admitted with a primary diagnosis of ascites or encephalopathy. In-hospital mortality, length of stay, and hospital charges were compared for those who did and did not undergo paracentesis. Outcomes were compared for those who received an early paracentesis (within 1 day of admission) and those who received one later. Results Of 17,711 eligible admissions, only 61% underwent paracentesis. In-hospital mortality was reduced by 24% among patients who underwent paracentesis (6.5% vs 8.5%, adjusted odds ratio [OR], 0.55; 95% confidence interval [CI], 0.41–0.74). Most paracenteses (66%) occurred ≤1 day after admission. In-hospital mortality was lower among patients who received early paracentesis than those who received it later (5.7% vs 8.1%; P=.049), although this difference was not significant after adjustment for confounders (OR, 1.26; 95% CI, 0.78–2.02). Among patients who underwent paracentesis, the mean hospital stay was 14% longer, and hospital charges were 29% greater than for patients that did not receive the procedure. Conclusions Paracentesis is underused for patients admitted to the hospital with ascites; the procedure is associated with increased short-term survival. These data support practice guidelines derived from expert opinion. Studies are needed to identify barriers to guideline adherence. PMID:23978348
Cavallaro, Paul; Rhee, Amanda J; Chiang, Yuting; Itagaki, Shinobu; Seigerman, Matthew; Chikwe, Joanna
The objective of this study was to assess the impact of robotic approaches on outcomes of coronary bypass surgery. Retrospective national database analysis. United States hospitals. A weighted sample of 484,128 patients undergoing isolated coronary artery surgery identified from the Nationwide Inpatient Sample from 2008 through 2010. Robotically assisted coronary artery bypass surgery versus conventional bypass surgery. Robotic approaches were used in 2,582 patients (0.4%). Patients undergoing robotic surgery were less likely to be female (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.57-0.87), present with acute myocardial infarction (OR 0.53, 95% CI 0.38-0.73), or have cerebrovascular disease (OR 0.41, 95% CI 0.23-0.71) compared to patients undergoing conventional surgery. In 59% of robotic cases, a single bypass was performed, and 2 bypasses were performed in 25% of cases. After adjusting for comorbidity, reduced postoperative stroke (0.0% v 1.5%, p = 0.045) and transfusion (13.5% v 24.4%, p = 0.001) rates were observed in patients who underwent robotic single-bypass surgery compared to conventional surgery. In patients undergoing multiple bypass grafts, higher mortality (1.1% v 0.5%), and cardiovascular complications (12.2% v 10.6%) were observed when robotic assistance was used, but the differences were not statistically significant (p = 0.5). The mean number of robotic cases carried out annually at institutions sampled was 6. Robotic assistance is associated with lower rates of postoperative complications in highly selected patients undergoing single coronary artery bypass surgery, but the benefits of this approach are reduced in patients who require multiple coronary artery bypass grafts. Copyright © 2014 Elsevier Inc. All rights reserved.
protect these women from developing ovarian cancer. In addition, oral contraceptives , which reduce the frequency of ovulation, have been shown to be...effective in reducing the incidence and mortality of ovarian cancer (1). However, neither of these approaches is without concern. Oral contraceptive use...Hermon C, Peto R, Reeves G. Ovarian cancer and oral contraceptives : collaborative reanalysis of data from 45 epidemiological studies including 23,257
Marmo, Riccardo; Koch, Maurizio; Cipolletta, Livio; Bianco, Maria Antonia; Grossi, Enzo; Rotondano, Gianluca
Nonvariceal upper GI bleeding (NVUGIB) that occurs in patients already hospitalized for another condition is associated with increased mortality, but outcome predictors have not been consistently identified. To assess clinical outcomes of NVUGIB and identify predictors of mortality from NVUGIB in patients with in-hospital bleeding compared with outpatients. Secondary analysis of prospectively collected data from 2 nationwide multicenter databases. Descriptive, inferential, and multivariate logistic regression models were carried out in 338 inpatients (68.6 ± 16.4 years of age, 68% male patients) and 1979 outpatients (67.8 ± 17 years of age, 66% male patients). A predictive model was constructed using the risk factors identified at multivariate analysis, weighted according to the contribution of each factor. A total of 23 Italian community and tertiary care centers. Consecutive patients admitted for acute NVUGIB. Early endoscopy, medical and endoscopic treatment as appropriate. Recurrent bleeding, surgery, and 30-day mortality. The mortality rate in patients with in-hospital bleeding was significantly higher than that in outpatients (8.9% vs 3.8%; odds ratio [OR] 2.44; 95% confidence interval [CI], 1.57-3.79; P < .0001). Hemodynamic instability on presentation (OR 7.31; 95% CI, 2.71-19.65) and the presence of severe comorbidity (OR 6.72; 95% CI, 1.87-24.0) were the strongest predictors of death for in-hospital bleeders. Other independent predictors of mortality were a history of peptic ulcer disease and failed endoscopic treatment. Rebleeding was a strong predictor of death only for outpatients (OR 5.22; 95% CI, 2.45-11.10). Risk factors had a different prognostic impact on the 2 populations, resulting in a significantly different prognostic accuracy of the model (area under the receiver-operating characteristic curve = 0.83; 95% CI, 0.77-0-93 vs 0.74; 95% CI, 0.68-0.80; P < .02). Study design not experimental, no data on ward specialty, potential referral bias
Pieralli, Filippo; Vannucchi, Vieri; Mancini, Antonio; Grazzini, Maddalena; Paolacci, Giulia; Morettini, Alessandro; Nozzoli, Carlo
Community acquired pneumonia (CAP) is a common reason for hospitalization and death in elderly people. Many predictors of in-hospital outcome have been studied in the general population with CAP. However, data are lacking on the prognostic significance of conditions unique to older patients, such as delirium and the coexistence of multiple comorbidities. The aim of this study was to evaluate predictors of in-hospital outcome in elderly patients hospitalized for CAP. In this retrospective study, consecutive patients with CAP aged ≥65 years were enrolled between January 2011 and June 2012 in two general wards. Clinical and laboratory characteristics were collected from electronic medical records. The end-point of the study was the occurrence of in-hospital death. 443 patients (mean age 81.8 ± 7.5, range 65-99 years) were enrolled. More than 3 comorbidities were present in 31 % of patients. Mean confusion, blood urea nitrogen, respiratory rate, blood pressure and age ≥65 years (CURB-65) score was 2.5 ± 0.7 points. Mean length of stay was 7.6 ± 5.7 days. In-hospital death occurred in 54 patients (12.2 %). At multivariate analysis, independent predictors of in-hospital death were: chronic obstructive pulmonary disease (COPD) (OR 6.21, p = 0.005), occurrence of at least one episode of delirium (OR 5.69, p = 0.017), male sex (OR 5.10, p < 0.0001), and CURB-65 score (OR 3.98, p < 0.0001). Several predictors of in-hospital death (COPD, male gender, CURB-65) in patients with CAP older than 65 years are similar to those of younger patients. In this cohort of elderly patients, the occurrence of delirium was highly prevalent and represented a distinctive predictor of death.
Zhu, ShaoMing; Waili, Yulituzi; Qi, XiaoTing; Chen, YueMei; Lou, YuFeng; Chen, Bo
The serum C-reactive protein (CRP) is an inflammatory marker. The aim of the present study was to elucidate whether CRP could serve as a potential surrogate marker for 30-day mortality in hospitalized patients with HBV-related decompensated cirrhosis (HBV-DeCi).This was a retrospective cohort study that included 140 patients with HBV-DeCi. All patients were followed up for 1-month. A panel of clinical and biochemical variables were analyzed for potential associations with outcomes using multiple regression models.The serum CRP was significantly higher in nonsurviving patients than in surviving patients. Multivariate analysis demonstrated that CRP levels (odds ratio: 1.047, P = 0.002) and the model for end-stage liver disease score (odds ratio: 1.370, P = 0.001) were independent predictors for mortality.Serum CRP is a simple marker that may serve as an additional predictor of 1-month mortality in hospitalized patients with HBV-DeCi.
Zhu, ShaoMing; Waili, Yulituzi; Qi, XiaoTing; Chen, YueMei; Lou, YuFeng; Chen, Bo
Abstract The serum C-reactive protein (CRP) is an inflammatory marker. The aim of the present study was to elucidate whether CRP could serve as a potential surrogate marker for 30-day mortality in hospitalized patients with HBV-related decompensated cirrhosis (HBV-DeCi). This was a retrospective cohort study that included 140 patients with HBV-DeCi. All patients were followed up for 1-month. A panel of clinical and biochemical variables were analyzed for potential associations with outcomes using multiple regression models. The serum CRP was significantly higher in nonsurviving patients than in surviving patients. Multivariate analysis demonstrated that CRP levels (odds ratio: 1.047, P = 0.002) and the model for end-stage liver disease score (odds ratio: 1.370, P = 0.001) were independent predictors for mortality. Serum CRP is a simple marker that may serve as an additional predictor of 1-month mortality in hospitalized patients with HBV-DeCi. PMID:28121954
Torssander, Jenny; Ahlbom, Anders; Modig, Karin
The inverse association between education and mortality has grown stronger the last decades in many countries. During the same period, gains in life expectancy have been concentrated to older ages; still, old-age mortality is seldom the focus of attention when analyzing trends in the education-mortality gradient. It is further unknown if increased educational inequalities in mortality are preceded by increased inequalities in morbidity of which hospitalization may be a proxy. Using administrative population registers from 1971 and onwards, education-specific annual changes in the risk of death and hospital admission were estimated with complimentary log-log models. These risk changes were supplemented by estimations of the ages at which 25, 50, and 75% of the population had been hospitalized or died (after age 60). The mortality decline among older people increasingly benefitted the well-educated over the less well-educated. This inequality increase was larger for the younger old, and among men. Educational inequalities in the age of a first hospital admission generally followed the development of growing gaps, but at a slower pace than mortality and inequalities did not increase among the oldest individuals. Education continues to be a significant predictor of health and longevity into old age. That the increase in educational inequalities is greater for mortality than for hospital admissions (our proxy of overall morbidity) may reflect that well-educated individuals gradually have obtained more possibilities or resources to survive a disease than less well-educated individuals have the last four decades.
Hu, Guoping; Wu, Yankui; Zhou, Yumin; Wu, Zelong; Wei, Liping; Li, Yuqun; Peng, GongYong; Liang, Weiqiang; Ran, Pixin
Background and objective Serum D-dimer is elevated in respiratory disease. The objective of our study was to investigate the effect of D-dimer on in-hospital and 1-year mortality after acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Methods Upon admission, we measured 343 AECOPD patients’ serum D-dimer levels and arterial blood gas analysis, and recorded their clinical characteristics. The level of D-dimer that discriminated survivors and non-survivors was determined using a receiver operator curve (ROC). The risk factors for in-hospital mortality were identified through univariate analysis and multiple logistic regression analyses. To evaluate the predictive role of D-dimer for 1-year mortality, univariate and multivariate Cox regression analyses were performed. Results In all, 28 patients died, and 315 patients survived in the in-hospital period. The group of dead patients had lower pH levels (7.35±0.11 vs 7.39±0.05, P<0.0001), higher D-dimer, arterial carbon dioxide tension (PaCO2), C-reactive protein (CRP), and blood urea nitrogen (BUN) levels (D-dimer 2,244.9±2,310.7 vs 768.2±1,078.4 µg/L, P<0.0001; PaCO2: 58.8±29.7 vs 46.1±27.0 mmHg, P=0.018; CRP: 81.5±66, P=0.001; BUN: 10.20±6.87 vs 6.15±3.15 mmol/L, P<0.0001), and lower hemoglobin levels (118.6±29.4 vs 128.3±18.2 g/L, P=0.001). The areas under the ROC curves of D-dimer for in-hospital death were 0.748 (95% confidence interval (CI): 0.641–0.854). D-dimer ≥985 ng/L was a risk factor for in-hospital mortality (relative risk =6.51; 95% CI 3.06–13.83). Multivariate logistic regression analysis also showed that D-dimer ≥985 ng/L and heart failure were independent risk factors for in-hospital mortality. Both univariate and multivariate Cox regression analyses showed that D-dimer ≥985 ng/L was an independent risk factor for 1-year death (hazard ratio (HR) 3.48, 95% CI 2.07–5.85 for the univariate analysis; and HR 1.96, 95% CI 1.05–3.65 for the multivariate analysis
Janssen, Saskia; Schutz, Charlotte; Ward, Amy M; Huson, Mischa A M; Wilkinson, Robert J; Burton, Rosie; Maartens, Gary; Wilkinson, Katalin A; Meijers, Joost C M; Lutter, René; Grobusch, Martin P; Meintjes, Graeme; van der Poll, Tom
Mortality rates remain high for human immunodeficiency virus (HIV)-associated tuberculosis, and our knowledge of contributing mechanisms is limited. We aimed to determine whether hemostatic changes in HIV-tuberculosis were associated with mortality or decreased survival time and the contribution of mycobacteremia to these effects. We conducted a prospective study in Khayelitsha, South Africa, in hospitalized HIV-infected patients with CD4 cell counts <350/µL and microbiologically proved tuberculosis. HIV-infected outpatients without tuberculosis served as controls. Plasma biomarkers reflecting activation of procoagulation and anticoagulation, fibrinolysis, endothelial cell activation, matricellular protein release, and tissue damage were measured at admission. Cox proportional hazard models were used to assess variables associated with 12-week mortality rates. Of 59 patients with HIV-tuberculosis, 16 (27%) died after a median of 12 days (interquartile range, 0-24 days); 29 (64%) of the 45 not receiving anticoagulants fulfilled criteria for disseminated intravascular coagulation. Decreased survival time was associated with higher concentrations of markers of fibrinolysis, endothelial activation, matricellular protein release, and tissue damage and with decreased concentrations for markers of anticoagulation. In patients who died, coagulation factors involved in the common pathway were depleted (factor II, V, X), which corresponded to increased plasma clotting times. Mycobacteremia modestly influenced hemostatic changes without affecting mortality. Patients with severe HIV-tuberculosis display a hypercoagulable state and activation of the endothelium, which is associated with mortality.
Mnatzaganian, George; Braitberg, George; Hiller, Janet E; Kuhn, Lisa; Chapman, Rose
Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated. Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated. Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or
Guo, Lu; Chughtai, Aamer Rasheed; Jiang, Hongli; Gao, Lingyun; Yang, Yan; Yang, Yang; Liu, Yuejian
Backgrounds Pulmonary embolism (PE) is frequent in subjects with chronic obstructive pulmonary disease (COPD) and associated with high mortality. This multi-center retrospective study was performed to investigate if secondary polycythemia is associated with in-hospital mortality in COPD patients with low-risk PE. Methods We identified COPD patients with proven PE between October, 2005 and October, 2015. Patients in risk classes III–V on the basis of the PESI score were excluded. We extracted demographic, clinical and laboratory information at the time of admission from medical records. All subjects were followed until hospital discharge to identify all-cause mortality. Results We enrolled 629 consecutive patients with COPD and PE at low risk: 132 of them (21.0%) with and 497 (79.0%) without secondary polycythemia. Compared with those without polycythemia, the polycythemia group had significantly lower forced expiratory volume in one second (FEV1) level (0.9±0.3 vs. 1.4±0.5, P=0.000), lower PaO2 and SpO2 as well as higher PaCO2 (P=0.03, P=0.03 and P=0.000, respectively). COPD patients with polycythemia had a higher proportion of arrhythmia in electrocardiogram (ECG) (49.5% vs. 35.7%, P=0.02), a longer hospital duration time (15.3±10.1 vs. 9.7±9.1, P=0.001), a higher mechanical ventilation rate (noninvasive and invasive, 51.7% vs. 30.3%, P=0.04 and 31.0% vs. 7.9%, P=0.04, respectively), and a higher in-hospital mortality (12.1% vs. 6.6%, P=0.04). Multivariate logistic regression analysis revealed that polycythemia was associated with mortality in COPD patients with low-risk PE (adjusted OR 1.11; 95% CI, 1.04–1.66). Conclusions Polycythemia is an independent risk factor for all-cause in-hospital mortality in COPD patients with PE at low risk. PMID:28066591
Raghunathan, Karthik; Bonavia, Anthony; Nathanson, Brian H; Beadles, Christopher A; Shaw, Andrew D; Brookhart, M Alan; Miller, Timothy E; Lindenauer, Peter K
Currently, guidelines recommend initial resuscitation with intravenous (IV) crystalloids during severe sepsis/septic shock. Albumin is suggested as an alternative. However, fluid mixtures are often used in practice, and it is unclear whether the specific mixture of IV fluids used impacts outcomes. The objective of this study is to test the hypothesis that the specific mixture of IV fluids used during initial resuscitation, in severe sepsis, is associated with important in-hospital outcomes. Retrospective cohort study includes patients with severe sepsis who were resuscitated with at least 2 l of crystalloids and vasopressors by hospital day 2, patients who had not undergone any major surgical procedures, and patients who had a hospital length of stay (LOS) of at least 2 days. Inverse probability weighting, propensity score matching, and hierarchical regression methods were used for risk adjustment. Patients were grouped into four exposure categories: recipients of isotonic saline alone ("Sal" exclusively), saline in combination with balanced crystalloids ("Sal + Bal"), saline in combination with colloids ("Sal + Col"), or saline in combination with balanced crystalloids and colloids ("Sal + Bal + Col"). In-hospital mortality was the primary outcome, and hospital LOS and costs per day (among survivors) were secondary outcomes. In risk-adjusted Inverse Probability Weighting analyses including 60,734 adults admitted to 360 intensive care units across the United States between January 2006 and December 2010, in-hospital mortality was intermediate in the Sal group (20.2%), lower in the Sal + Bal group (17.7%, P < 0.001), higher in the Sal + Col group (24.2%, P < 0.001), and similar in the Sal + Bal + Col group (19.2%, P = 0.401). In pairwise propensity score-matched comparisons, the administration of balanced crystalloids by hospital day 2 was consistently associated with lower mortality, whether colloids were used (relative risk, 0.84; 95% CI, 0.76 to 0.92) or not
Pai, Menaka; Cook, Richard; Barty, Rebecca; Eikelboom, John; Lee, Ker-Ai; Heddle, Nancy
Transfusing ABO-compatible blood avoids most acute hemolytic reactions, but donor units that are ABO compatible are not necessarily ABO identical. Emerging data have raised concerns that ABO-nonidentical blood products lead to adverse outcomes. A large multihospital registry (Transfusion Registry for Utilization, Surveillance, and Tracking) was used to determine the association between exposure to ABO-nonidentical blood and in-hospital mortality. Cox regression analyses controlled for sex, age, hemoglobin, creatinine, and in-hospital interventions and stratified by age of blood and admission year. Data from 18,843 non-group O patients admitted between 2002 and 2011 and receiving at least 1 unit of blood were analyzed. Overall, group A patients had significantly increased risk of in-hospital death upon receiving a nonidentical unit (RR , 1.79; 95% CI, 1.20-2.67; p = 0.005). There was no evidence of increased risk for group B or AB patients. Similar results were seen when only patients with circulatory disorders were considered. When patients with an injury or poisoning diagnosis were excluded, the risk of in-hospital death after receiving a non-identical unit was significantly higher in group A patients and significantly lower in Group B patients. Our study demonstrates an adverse effect of ABO-nonidentical blood in a broad range of patients with group A blood, after adjustment for potential confounders. Further research in this area is required to study possible mechanisms. Increased mortality associated with exposure to nonidentical blood in these patients would have a substantial impact at the population level; it would challenge how blood suppliers manage inventory and recruit donors and how health care providers administer blood. © 2015 AABB.
Kliger, Julie; Singer, Sara J; Hoffman, Frank H
The Integrated Nurse Leadership Program (INLP) is a collaborative improvement model focused on developing practical leadership skills of nurses and other frontline clinicians to lead quality improvement efforts. Sepsis is a major challenge to treat because it arises unpredictably and can progress rapidly. Nine San Francisco Bay Area hospitals participated in a 22-month INLP Sepsis Mortality Reduction Project to improve sepsis detection and management. The INLP focused on developing leadership and process improvement skills of nurses and other frontline clinicians. Teams of trained clinicians then implemented three strategies to improve early identification and timely treatment of sepsis: (1) sepsis screening of all patients, with diagnostic testing according to protocol; (2) timely treatment on the basis of key elements of Early Goal-Directed Therapy (EGDT); and (3) ongoing data review. Each hospital agreed to pursue the goal of reducing sepsis mortality by 15% by the end of the project. In the data collection period (baseline, July-December 2008 and project completion, January-June 2011), team members showed strong improvement in perceived leadership skills, team effectiveness, and ability to improve care quality. During this period, sepsis mortality for eight of the participating hospitals (Hospital 9 joined the project six months after it began) decreased by 43.7%-from 28% in the baseline period to 16% at project completion. Sepsis mortality rates trended downward for all hospitals, significantly decreasing (p<.05 at one hospital, p<.01 for four hospitals). In addition to improvement in safety culture and management of septic patients, hospitals participating in the INLP Sepsis Mortality Reduction Project achieved reductions in sepsis mortality during the study period and sustained reductions for more than one year later. The INLP model can be readily applied beyond sepsis management and mortality to other quality problems.
López-Herce, Jesús; Del Castillo, Jimena; Matamoros, Martha; Cañadas, Sonia; Rodriguez-Calvo, Ana; Cecchetti, Corrado; Rodriguez-Núñez, Antonio; Alvarez, Angel Carrillo
To analyze prognostic factors associated with in-hospital cardiac arrest (CA) in children. A prospective, multicenter, multinational, observational study was performed on pediatric in-hospital CA in 12 countries and included 502 children between 1 month and 18 years. The primary endpoint was survival at hospital discharge. Univariate and multivariate logistic regression analyses were performed to assess the influence of each factor on mortality. Return of spontaneous circulation was achieved in 69.5 % of patients; 39.2 % survived to hospital discharge and 88.9 % of survivors had good neurological outcome. The pre-arrest factors related to mortality were lower Human Development Index [odds ratio (OR) 2.32, 95 % confidence interval (CI) 1.28-4.21], oncohematologic disease (OR 3.33, 95 % CI 1.60-6.98), and treatment with inotropic drugs at the time of CA (OR 2.35, 95 % CI 1.55-3.56). CA and resuscitation factors related to mortality were CA due to neurological disease (OR 5.19, 95 % CI 1.49-18.73) and duration of cardiopulmonary resuscitation greater than 10 min (OR 4.00, 95 % CI 1.49-18.73). Factors related to survival were CA occurring in the pediatric intensive care unit (PICU) (OR 0.38, 95 % CI 0.16-0.86) and shockable rhythm (OR 0.26, 95 % CI 0.09-0.73). In-hospital CA in children has a low survival but most of the survivors have a good neurological outcome. Some prognostic risk factors cannot be modified, making it important to focus efforts on improving hospital organization to care for children at risk of CA in the PICU and, in particular, in other hospital areas.
Arboix, Adrià; Rodríguez-Aguilar, Raquel; Oliveres, Montserrat; Comes, Emili; García-Eroles, Luis; Massons, Joan
Background There is a paucity of clinical studies focused specifically on intracerebral haemorrhages of subcortical topography, a subject matter of interest to clinicians involved in stroke management. This single centre, retrospective study was conducted with the following objectives: a) to describe the aetiological, clinical and prognostic characteristics of patients with thalamic haemorrhage as compared with that of patients with internal capsule-basal ganglia haemorrhage, and b) to identify predictors of in-hospital mortality in patients with thalamic haemorrhage. Methods Forty-seven patients with thalamic haemorrhage were included in the "Sagrat Cor Hospital of Barcelona Stroke Registry" during a period of 17 years. Data from stroke patients are entered in the stroke registry following a standardized protocol with 161 items regarding demographics, risk factors, clinical features, laboratory and neuroimaging data, complications and outcome. The region of the intracranial haemorrhage was identified on computerized tomographic (CT) scans and/or magnetic resonance imaging (MRI) of the brain. Results Thalamic haemorrhage accounted for 1.4% of all cases of stroke (n = 3420) and 13% of intracerebral haemorrhage (n = 364). Hypertension (53.2%), vascular malformations (6.4%), haematological conditions (4.3%) and anticoagulation (2.1%) were the main causes of thalamic haemorrhage. In-hospital mortality was 19% (n = 9). Sensory deficit, speech disturbances and lacunar syndrome were significantly associated with thalamic haemorrhage, whereas altered consciousness (odds ratio [OR] = 39.56), intraventricular involvement (OR = 24.74) and age (OR = 1.23), were independent predictors of in-hospital mortality. Conclusion One in 8 patients with acute intracerebral haemorrhage had a thalamic hematoma. Altered consciousness, intraventricular extension of the hematoma and advanced age were determinants of a poor early outcome. PMID:17919332
Otsubo, Tetsuya; Goto, Etsu; Morishima, Toshitaka; Ikai, Hiroshi; Yokota, Chiaki; Minematsu, Kazuo; Imanaka, Yuichi
Little is known about the regional variations in ischemic stroke care in Japan. This study investigates the regional variations and associations among outcomes, care processes, spending, and physician workforce availability in acute ischemic stroke care. Using administrative claims data from National Claims Database, we identified National Health Insurance beneficiaries aged 65 years and older and Long Life Medical Care System beneficiaries from 9 prefectures who had been hospitalized for acute ischemic stroke between April 2010 and March 2012. Patients were grouped according to their subprefectural regions of residence known as secondary medical areas (SMAs). Performances in 8 outcome and process of care measures were analyzed in each SMA. Multilevel regression models with 2 levels (patient and regional) were used to analyze age- and sex-adjusted in-hospital mortality, hospitalization spending, and tissue plasminogen activator (tPA) utilization rate. The associations between regional supply of physicians for stroke care and the various quality measures were investigated. We analyzed 49,440 acute ischemic stroke patients. The regional variations among SMAs in in-hospital mortality, spending, and tPA utilization were 3.2-, 1.7-, and 5.9-fold, respectively. Higher physician supply was significantly associated with lower in-hospital mortality and higher spending. Additionally, spending had a significantly negative correlation with regional continuity of care planning rate but a significantly positive correlation with rehabilitation rate. The study revealed substantial regional variations in Japanese ischemic stroke care. Improving the allocative efficiency of physicians and establishing continuity of care networks may be useful in mitigating regional disparities and reconstructing the stroke care system. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.
Lisk, Radcliffe; Yeong, Keefai
Hip fracture is one of the most serious consequences of falls in the elderly, with a mortality of 10% at one month and 30% at one year. Elderly patients with hip fractures have complex medical, surgical, and rehabilitation needs, and a well-coordinated multidisciplinary team approach is essential for the best outcome. The model of best practice for hip fracture care is set out in the Orthopaedic Blue Book and is incentivised by the best practice tariff. In 2009 to 2010, only 39.6% of our patients were being operated on within 36 hours, 19% achieved best practice tariff , and mortality was 7.8%. We were ranked as one of the worst hospitals to achieve best practice tariff  and our mortality was average. The orthogeriatrics team at Ashford & St Peter's NHS Trust (SPH) was implemented in 2010. Through a system redesign, regular governance meetings, audits and quality improvement projects, we have managed to improve care for our patients and reduce mortality. Over the last three years we have successfully achieved best care for our hip fracture patients, demonstrating a steady improvement in our attainment of the best practice tariff and a reduction in mortality to 5.3% in 2013, which ranks us amongst the best trusts nationally.
Lisk, Radcliffe; Yeong, Keefai
Hip fracture is one of the most serious consequences of falls in the elderly, with a mortality of 10% at one month and 30% at one year. Elderly patients with hip fractures have complex medical, surgical, and rehabilitation needs, and a well-coordinated multidisciplinary team approach is essential for the best outcome. The model of best practice for hip fracture care is set out in the Orthopaedic Blue Book and is incentivised by the best practice tariff. In 2009 to 2010, only 39.6% of our patients were being operated on within 36 hours, 19% achieved best practice tariff , and mortality was 7.8%. We were ranked as one of the worst hospitals to achieve best practice tariff  and our mortality was average. The orthogeriatrics team at Ashford & St Peter's NHS Trust (SPH) was implemented in 2010. Through a system redesign, regular governance meetings, audits and quality improvement projects, we have managed to improve care for our patients and reduce mortality. Over the last three years we have successfully achieved best care for our hip fracture patients, demonstrating a steady improvement in our attainment of the best practice tariff and a reduction in mortality to 5.3% in 2013, which ranks us amongst the best trusts nationally. PMID:27493729
Shen, Yu-Sheng; Lung, Shih-Chun Candice
Previous studies have shown that green spaces are beneficial to health; however, few studies have analyzed the relationship between green structure and mortality of cardiovascular disease. Green structure may mediate the effects of air pollution and temperature on health. This work applies partial least squares (PLS) modeling to analyze the degree to which green structure reduces mortality of cardiovascular disease, using Taipei Metropolitan Area as an empirical case. In addition to clarifying the complex relationships and effects of green structure, air pollution, temperature, and mortality of cardiovascular disease, this study demonstrates that green structure has a significant influence on mortality of cardiovascular disease because it reduces the effects of air pollution and heat. The most crucial elements for planning a healthy living environment are the maximization of the largest green patch proportion and the minimization of green space fragmentation. Moreover, to enhance the benefits of greening city spaces on health, this work proposes several strategies for connecting fragmentary green spaces, expanding green patches to the largest possible proportion, and managing green spaces. The proposed strategies may serve as a reference for other metropolitan areas with features similar to those of the study area.
Vaduganathan, Muthiah; Dei Cas, Alessandra; Mentz, Robert J; Greene, Stephen J; Khan, Sadiya; Subacius, Haris P; Chioncel, Ovidiu; Maggioni, Aldo P; Konstam, Marvin A; Senni, Michele; Fonarow, Gregg C; Butler, Javed; Gheorghiade, Mihai
Despite the well-established benefits of mineralocorticoid receptor agonists (MRAs) in heart failure with reduced ejection fraction, safety concerns remain in patients with concomitant diabetes mellitus (DM) because of common renal and electrolyte abnormalities in this population. We analyzed all-cause mortality and composite cardiovascular mortality and HF hospitalization over a median 9.9 months among 1,998 patients in the placebo arm of the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial by DM status and discharge MRA use. Of the 750 patients with DM, 59.2% were receiving MRAs compared with 62.5% in the non-DM patients. DM patients not receiving MRAs were older, more likely to be men, with an ischemic heart failure etiology and slightly worse renal function compared with those receiving MRAs. After adjustment for baseline risk factors, among DM patients, MRA use was not associated with either mortality (hazard ratio [HR] 0.93; 95% confidence interval [CI] 0.75 to 1.15) or the composite end point (HR 0.94; 95% CI 0.80 to 1.10). Similar findings were seen in non-DM patients (mortality [HR 1.01; 95% CI 0.84 to 1.22] or the composite end point [HR 0.98; 95% CI 0.85 to 1.13] [p >0.43 for DM interaction]). In conclusion, in-hospital initiation of MRA therapy was low (15% to 20%), and overall discharge MRA use was only 60% (with regional variation), regardless of DM status. There does not appear to be clear, clinically significant in-hospital hemodynamic or even renal differences between those on and off MRA. Discharge MRA use was not associated with postdischarge end points in patients hospitalized for worsening heart failure with reduced ejection fraction and co-morbid DM. DM does not appear to influence the effectiveness of MRA therapy. Copyright © 2014 Elsevier Inc. All rights reserved.
Torssander, Jenny; Ahlbom, Anders; Modig, Karin
Background The inverse association between education and mortality has grown stronger the last decades in many countries. During the same period, gains in life expectancy have been concentrated to older ages; still, old-age mortality is seldom the focus of attention when analyzing trends in the education-mortality gradient. It is further unknown if increased educational inequalities in mortality are preceded by increased inequalities in morbidity of which hospitalization may be a proxy. Methods Using administrative population registers from 1971 and onwards, education-specific annual changes in the risk of death and hospital admission were estimated with complimentary log-log models. These risk changes were supplemented by estimations of the ages at which 25, 50, and 75% of the population had been hospitalized or died (after age 60). Results The mortality decline among older people increasingly benefitted the well-educated over the less well-educated. This inequality increase was larger for the younger old, and among men. Educational inequalities in the age of a first hospital admission generally followed the development of growing gaps, but at a slower pace than mortality and inequalities did not increase among the oldest individuals. Conclusions Education continues to be a significant predictor of health and longevity into old age. That the increase in educational inequalities is greater for mortality than for hospital admissions (our proxy of overall morbidity) may reflect that well-educated individuals gradually have obtained more possibilities or resources to survive a disease than less well-educated individuals have the last four decades. PMID:27031107
Moore, Brian J; White, Susan; Washington, Raynard; Coenen, Natalia; Elixhauser, Anne
We extend the literature on comorbidity measurement by developing 2 indices, based on the Elixhauser Comorbidity measures, designed to predict 2 frequently reported health outcomes: in-hospital mortality and 30-day readmission in administrative data. The Elixhauser measures are commonly used in research as an adjustment factor to control for severity of illness. We used a large analysis file built from all-payer hospital administrative data in the Healthcare Cost and Utilization Project State Inpatient Databases from 18 states in 2011 and 2012. The final models were derived with bootstrapped replications of backward stepwise logistic regressions on each outcome. Odds ratios and index weights were generated for each Elixhauser comorbidity to create a single index score per record for mortality and readmissions. Model validation was conducted with c-statistics. Our index scores performed as well as using all 29 Elixhauser comorbidity variables separately. The c-statistic for our index scores without inclusion of other covariates was 0.777 (95% confidence interval, 0.776-0.778) for the mortality index and 0.634 (95% confidence interval, 0.633-0.634) for the readmissions index. The indices were stable across multiple subsamples defined by demographic characteristics or clinical condition. The addition of other commonly used covariates (age, sex, expected payer) improved discrimination modestly. These indices are effective methods to incorporate the influence of comorbid conditions in models designed to assess the risk of in-hospital mortality and readmission using administrative data with limited clinical information, especially when small samples sizes are an issue.
Keller, Jesse; Gage, Brian F.; Luo, Suhong; Wang, Tzu-Fei; Moskowitz, Gerald; Gumbel, Jason; Blue, Brandon; O’Brian, Katiuscia; Carson, Kenneth R.
Purpose The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) have activity in one of the pathways influenced by nitrogen-containing bisphosphonates, which are associated with improved survival in multiple myeloma (MM). To understand the benefit of statins in MM, we evaluated the association between statin use and mortality in a large cohort of patients with MM. Patients and Methods From the Veterans Administration Central Cancer Registry, we identified patients diagnosed with MM between 1999 and 2013. We defined statin use as the presence of any prescription for a statin within 3 months before or any time after MM diagnosis. Cox proportional hazards regression assessed the association of statin use with mortality, while controlling for known MM prognostic factors. Results We identified a cohort of 4,957 patients, of whom 2,294 received statin therapy. Statin use was associated with a 21% decrease in all-cause mortality (adjusted hazard ratio, 0.79; 95% CI, 0.73 to 0.86; P < .001) as well as a 24% decrease in MM-specific mortality (adjusted hazard ratio, 0.76; 95% CI, 0.67 to 0.86; P < .001). This association remained significant across all sensitivity analyses. In addition to reductions in mortality, statin use was associated with a 31% decreased risk of developing a skeletal-related event. Conclusion In this cohort study of US veterans with MM, statin therapy was associated with a reduced risk of both all-cause and MM-specific mortality. Our findings suggest a potential role for statin therapy in patients with MM. The putative benefit of statin therapy in MM should be corroborated in prospective studies. PMID:27646948
Ma, Li; Liu, Cui-Qing; Meng, Ling-Zhi; Jiao, Jian-Cheng; Xia, Yao-Fang
To describe the clinical features, treatments and prognosis of very low birth weight infants (VLBWIs) requring mechanical ventilation, to assess the risk factors associated with the mortality of VLBWIs, and to evaluate the significance of the scoring system based on clinical risk index for babies (CRIB) and the score for neonatal acute physiology-perinatal extension II (SNAPPE-II) for predicting mortality risk for premature infants in China. Perinatal data were collected from 127 VLBWIs requring mechanical ventilation who were admitted to the neonatal intensive care unit (NICU) from January 2010 to October 2011. The enrolled infants had a mean gestational age of 31±2 weeks, a mean birth weight of 1290±170 g, a male/female ratio of 1.23∶1, and extremely low birth weight infant accounting for 6.3%. Of the 127 cases, 48.0% were administered with pulmonary surfactant (PS), and 49.6% received endotracheal intubation ventilation. The overall in-hospital mortality was 41.7%. Multivariate logistic regression revealed the following independent risk factors for mortality: low birth weight, multiple birth, cesarean section, and low PaO2/FiO2 ratio (OR = 1.611, 7.572, 4.062, and 0.133 respectively; P<0.05). SNAPPE-II and CRIB showed good performance in predicting prognosis, with areas under the ROC curve of 0.806 and 0.777 respectively. The overall mortality rate of VLBWIs is still relatively high. The high-risk factors for VLBWI mortality include low birth weight, multiple birth, cesarean section, and low PaO2/FiO2 ratio. The neonatal illness severity scoring system (using SNAPPE-II and CRIB) can be used to quantify illness severity in premature infants.
Laserna, Elena; Sibila, Oriol; Aguilar, Patrick R.; Mortensen, Eric M.; Anzueto, Antonio; Blanquer, Jose M.; Sanz, Francisco; Rello, Jordi; Marcos, Pedro J.; Velez, Maria I.; Aziz, Nivin
Objective: The purpose of our study was to examine in patients hospitalized with community-acquired pneumonia (CAP) the association between abnormal Paco2 and ICU admission and 30-day mortality. Methods: A retrospective cohort study was conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of CAP. Arterial blood gas analyses were obtained with measurement of Paco2 on admission. Multivariate analyses were performed using 30-day mortality and ICU admission as the dependent measures. Results: Data were abstracted on 453 subjects with a documented arterial blood gas analysis. One hundred eighty-nine patients (41%) had normal Paco2 (35-45 mm Hg), 194 patients (42%) had a Paco2 < 35 mm Hg (hypocapnic), and 70 patients (15%) had a Paco2 > 45 mm Hg (hypercapnic). In the multivariate analysis, after adjusting for severity of illness, hypocapnic patients had greater 30-day mortality (OR = 2.84; 95% CI, 1.28-6.30) and a higher need for ICU admission (OR = 2.88; 95% CI, 1.68-4.95) compared with patients with normal Paco2. In addition, hypercapnic patients had a greater 30-day mortality (OR = 3.38; 95% CI, 1.38-8.30) and a higher need for ICU admission (OR = 5.35; 95% CI, 2.80-10.23). When patients with COPD were excluded from the analysis, the differences persisted between groups. Conclusion: In hospitalized patients with CAP, both hypocapnia and hypercapnia were associated with an increased need for ICU admission and higher 30-day mortality. These findings persisted after excluding patients with CAP and with COPD. Therefore, Paco2 should be considered for inclusion in future severity stratification criteria to appropriate identified patients who will require a higher level of care and are at risk for increased mortality. PMID:22677348
Sipilä, Jussi O T; Rautava, Päivi; Kytö, Ville
Circadian rhythm disturbance increases cardiovascular risk but the effects of daylight saving time (DST) transitions on the risk of myocardial infarction (MI) are unclear. We studied association of DST transitions in 2001-2009 with incidence and in-hospital mortality of MI admissions nationwide in Finland. Incidence rations (IR) of observed incidences on seven days following DST transition were compared to expected incidences. Incidence of MI increased on Wednesday (IR 1.16; CI 1.01-1.34) after spring transition (6298 patients' cohort). After autumn transition (8161 patients' cohort), MI incidence decreased on Monday (IR 0.85; CI 0.74-0.97) but increased on Thursday (IR 1.15; CI 1.02-1.30). The overall incidence of MI during the week after each DST transition did not differ from control weeks. Patient age or gender, type of MI or in-hospital mortality were not associated with transitions. Renal insufficiency was more common among MI patients after spring transition (OR 1.81; CI 1.06-3.09; p < 0.05). Diabetes was less common after spring transition (OR 0.71; CI 0.55-0.91; p = 0.007), but more common after autumn transition (OR 1.21; 1.00-1.46; p < 0.05). DST transitions are followed by changes in the temporal pattern but not the overall rate of MI incidence. Comorbidities may modulate the effects DST transitions.
Griesser, Michael; Nystrand, Magdalena; Ekman, Jan
Delayed dispersal is the key to family formation in most kin-societies. Previous explanations for the evolution of families have focused on dispersal constraints. Recently, an alternative explanation was proposed, emphasizing the benefits gained through philopatry. Empirical data have confirmed that parents provide their philopatric offspring with preferential treatment through enhanced access to food and predator protection. Yet it remains unclear to what extent such benefits translate into fitness benefits such as reduced mortality, which ultimately can select for the evolution of families. Here, we demonstrate that philopatric Siberian jay (Perisoreus infaustus) offspring have an odds ratio of being killed by predators 62% lower than offspring that dispersed promptly after independence to join groups of unrelated individuals (20.6% versus 33.3% winter mortality). Predation was the sole cause of mortality, killing 20 out of 73 juveniles fitted with radio tags. The higher survival rate among philopatric offspring was associated with parents providing nepotistic predator protection that was withheld from unrelated group members. Natal philopatry usually involves the suppression of personal reproduction. However, a lower mortality of philopatric offspring can overcome this cost and may thus select for the formation of families and set the scene for cooperative kin-societies. PMID:16822747
Chen, Yi-Hung; Chuang, Chieh-Min; Lu, Dah-Yuu; Lin, Jaung-Geng
The aims of this study were to characterize the protective profile of electroacupuncture (EA) on cocaine-induced seizures and mortality in mice. Mice were treated with EA (2 Hz, 50 Hz, and 100 Hz), or they underwent needle insertion without anesthesia at the Dazhui (GV14) and Baihui (GV20) acupoints before cocaine administration. EA at 50 Hz applied to GV14 and GV20 significantly reduced the seizure severity induced by a single dose of cocaine (75 mg/kg; i.p.). Furthermore, needle insertion into GV14 and GV20 and EA at 2 Hz and 50 Hz at both acupoints significantly reduced the mortality rate induced by a single lethal dose of cocaine (125 mg/kg; i.p.). In the sham control group, EA at 50 Hz applied to bilateral Tianzong (SI11) acupoints had no protective effects against cocaine. In addition, EA at 50 Hz applied to GV14 and GV20 failed to reduce the incidence of seizures and mortality induced by the local anesthetic procaine. In an immunohistochemistry study, EA (50 Hz) pretreatment at GV14 and GV20 decreased cocaine (75 mg/kg; i.p.)-induced c-Fos expression in the paraventricular thalamus. While the dopamine D3 receptor antagonist, SB-277011-A (30 mg/kg; s.c), did not by itself affect cocaine-induced seizure severity, it prevented the effects of EA on cocaine-induced seizures. These results suggest that EA alleviates cocaine-induced seizures and mortality and that the dopamine D3 receptor is involved, at least in part, in the anticonvulsant effects of EA in mice. PMID:23690833
Avelino-Silva, Thiago J; Farfel, Jose M; Curiati, Jose A E; Amaral, Jose R G; Campora, Flavia; Jacob-Filho, Wilson
Comprehensive Geriatric Assessment (CGA) provides detailed information on clinical, functional and cognitive aspects of older patients and is especially useful for assessing frail individuals. Although a large proportion of hospitalized older adults demonstrate a high level of complexity, CGA was not developed specifically for this setting. Our aim was to evaluate the application of a CGA model for the clinical characterization and prognostic prediction of hospitalized older adults. This was a prospective observational study including 746 patients aged 60 years and over who were admitted to a geriatric ward of a university hospital between January 2009 and December 2011, in Sao Paulo, Brazil. The proposed CGA was applied to evaluate all patients at admission. The primary outcome was in-hospital death, and the secondary outcomes were delirium, nosocomial infections, functional decline and length of stay. Multivariate binary logistic regression was performed to assess independent factors associated with these outcomes, including socio-demographic, clinical, functional, cognitive, and laboratory variables. Impairment in ten CGA components was particularly investigated: polypharmacy, activities of daily living (ADL) dependency, instrumental activities of daily living (IADL) dependency, depression, dementia, delirium, urinary incontinence, falls, malnutrition, and poor social support. The studied patients were mostly women (67.4%), and the mean age was 80.5±7.9 years. Multivariate logistic regression analysis revealed the following independent factors associated with in-hospital death: IADL dependency (OR=4.02; CI=1.52-10.58; p=.005); ADL dependency (OR=2.39; CI=1.25-4.56; p=.008); malnutrition (OR=2.80; CI=1.63-4.83; p<.001); poor social support (OR=5.42; CI=2.93-11.36; p<.001); acute kidney injury (OR=3.05; CI=1.78-5.27; p<.001); and the presence of pressure ulcers (OR=2.29; CI=1.04-5.07; p=.041). ADL dependency was independently associated with both delirium
Thalme, Anders; Westling, Katarina; Julander, Inger
In a retrospective study, in-hospital and long-term mortality for patients with infective endocarditis (IE) was analysed. The study was conducted at a department of infectious diseases in Stockholm, Sweden. Mortality was compared between injecting drug users (IDUs) and patients without drug abuse (non-IDUs). 192 episodes of IE from 1995 to 2000 were analysed, 60 in IDUs and 135 in non-IDUs, median follow-up 4.4 y. Episodes were classified using the Duke criteria: 145 definite and 47 possible. Of 53 definite episodes in IDUs, 55% were right-sided IE and 43% left-sided IE (including combined left- and right-sided). Surgical treatment was used in 34/145 definite episodes, all being left-sided IE. The in-hospital mortality was 14/145 (9.6%). There was no difference in in-hospital mortality between patient groups with left-sided IE. The IDU patients with left-sided IE had a higher long-term mortality with the increased mortality rate explained by late deaths in the surgically treated IDUs. Treatment results for IDUs with right-sided IE were good with no in-hospital mortality, no relapses and no increase in long-term mortality. This difference in prognosis between left-sided and right-sided IE in IDUs makes high quality echocardiography important to identify patients with left-sided IE and worse prognosis.
Budzyński, Jacek; Tojek, Krzysztof; Czerniak, Beata; Banaszkiewicz, Zbigniew
We have no "gold standard" for the diagnosis of malnutrition. The aim of this study was to determine the importance of many of the parameters used in nutritional status screening and assessment among inpatients for the prediction of in-hospital mortality, readmission and length of hospitalization. On the base of the medical documentation a retrospective analysis was performed of nutritional status screening and assessment parameters for all 20,237 non-selected, consecutive hospitalizations in 15,013 patients over 18 years of age treated in one hospital during the course of one year. The risk of malnutrition expressed as a Nutritional Risk Screening (NRS)-2002 score ≥ 3 concerned 6.4% hospitalizations. The greater risk of in-hospital death, as well as readmission within 14 days and 30 days, was related to an NRS-2002 score ≥3, age >65 years, male gender, urgent admission, body mass deficit calculated as the difference between actual body mass and ideal weight determined according to the Lorentz formula, higher degree of Instant Nutritional Assessment (INA), greater value of a C-reactive protein (CRP)/albumin ratio, and plasma glucose concentration. Whereas, greater blood concentration of albumin, hemoglobin, cholesterol and triglycerides, as well as a greater blood lymphocyte count, were associated with reduced risk of the measured outcomes. NRS-2002 score, blood albumin, CRP/albumin ratio, and INA seem to be good predictors of in-hospital mortality, readmission rate and length of hospital stay. Copyright © 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Introduction Hyperoxia has recently been reported as an independent risk factor for mortality in patients resuscitated from cardiac arrest. We examined the independent relationship between hyperoxia and outcomes in such patients. Methods We divided patients resuscitated from nontraumatic cardiac arrest from 125 intensive care units (ICUs) into three groups according to worst PaO2 level or alveolar-arterial O2 gradient in the first 24 hours after admission. We defined 'hyperoxia' as PaO2 of 300 mmHg or greater, 'hypoxia/poor O2 transfer' as either PaO2 < 60 mmHg or ratio of PaO2 to fraction of inspired oxygen (FiO2 ) < 300, 'normoxia' as any value between hypoxia and hyperoxia and 'isolated hypoxemia' as PaO2 < 60 mmHg regardless of FiO2. Mortality at hospital discharge was the main outcome measure. Results Of 12,108 total patients, 1,285 (10.6%) had hyperoxia, 8,904 (73.5%) had hypoxia/poor O2 transfer, 1,919 (15.9%) had normoxia and 1,168 (9.7%) had isolated hypoxemia (PaO2 < 60 mmHg). The hyperoxia group had higher mortality (754 (59%) of 1,285 patients; 95% confidence interval (95% CI), 56% to 61%) than the normoxia group (911 (47%) of 1,919 patients; 95% CI, 45% to 50%) with a proportional difference of 11% (95% CI, 8% to 15%), but not higher than the hypoxia group (5,303 (60%) of 8,904 patients; 95% CI, 59% to 61%). In a multivariable model controlling for some potential confounders, including illness severity, hyperoxia had an odds ratio for hospital death of 1.2 (95% CI, 1.1 to 1.6). However, once we applied Cox proportional hazards modelling of survival, sensitivity analyses using deciles of hypoxemia, time period matching and hyperoxia defined as PaO2 > 400 mmHg, hyperoxia had no independent association with mortality. Importantly, after adjustment for FiO2 and the relevant covariates, PaO2 was no longer predictive of hospital mortality (P = 0.21). Conclusions Among patients admitted to the ICU after cardiac arrest, hyperoxia did not have a robust or
Kuruvilla, Shyama; Schweitzer, Julian; Bishai, David; Chowdhury, Sadia; Caramani, Daniele; Frost, Laura; Cortez, Rafael; Daelmans, Bernadette; de Francisco, Andres; Adam, Taghreed; Cohen, Robert; Alfonso, Y Natalia; Franz-Vasdeki, Jennifer; Saadat, Seemeen; Pratt, Beth Anne; Eugster, Beatrice; Bandali, Sarah; Venkatachalam, Pritha; Hinton, Rachael; Murray, John; Arscott-Mills, Sharon; Axelson, Henrik; Maliqi, Blerta; Sarker, Intissar; Lakshminarayanan, Rama; Jacobs, Troy; Jack, Susan; Jacks, Susan; Mason, Elizabeth; Ghaffar, Abdul; Mays, Nicholas; Presern, Carole; Bustreo, Flavia
Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Women's and Children's Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula--fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in women's and children's health towards 2015 and beyond.
Hobbs, William R.; Burke, Moira; Christakis, Nicholas A.; Fowler, James H.
Social interactions increasingly take place online. Friendships and other offline social ties have been repeatedly associated with human longevity, but online interactions might have different properties. Here, we reference 12 million social media profiles against California Department of Public Health vital records and use longitudinal statistical models to assess whether social media use is associated with longer life. The results show that receiving requests to connect as friends online is associated with reduced mortality but initiating friendships is not. Additionally, online behaviors that indicate face-to-face social activity (like posting photos) are associated with reduced mortality, but online-only behaviors (like sending messages) have a nonlinear relationship, where moderate use is associated with the lowest mortality. These results suggest that online social integration is linked to lower risk for a wide variety of critical health problems. Although this is an associational study, it may be an important step in understanding how, on a global scale, online social networks might be adapted to improve modern populations’ social and physical health. PMID:27799553
Blencowe, Hannah; Lawn, Joy; Vandelaer, Jos; Roper, Martha
Background Neonatal tetanus remains an important and preventable cause of neonatal mortality globally. Large reductions in neonatal tetanus deaths have been reported following major increases in the coverage of tetanus toxoid immunization, yet the level of evidence for the mortality effect of tetanus toxoid immunization is surprisingly weak with only two trials considered in a Cochrane review. Objective To review the evidence for and estimate the effect on neonatal tetanus mortality of immunization with tetanus toxoid of pregnant women, or women of childbearing age. Methods We conducted a systematic review of multiple databases. Standardized abstraction forms were used. Individual study quality and the overall quality of evidence were assessed using an adaptation of the GRADE approach. Meta-analyses were performed. Results Only one randomised controlled trial (RCT) and one well-controlled cohort study were identified, which met inclusion criteria for meta-analysis. Immunization of pregnant women or women of childbearing age with at least two doses of tetanus toxoid is estimated to reduce mortality from neonatal tetanus by 94% [95% confidence interval (CI) 80–98%]. Additionally, another RCT with a case definition based on day of death, 3 case–control studies and 1 before-and-after study gave consistent results. Based on the consistency of the mortality data, the very large effect size and that the data are all from low/middle-income countries, the overall quality of the evidence was judged to be moderate. Conclusion This review uses a standard approach to provide a transparent estimate of the high impact of tetanus toxoid immunization on neonatal tetanus. PMID:20348112
Blencowe, Hannah; Lawn, Joy; Vandelaer, Jos; Roper, Martha; Cousens, Simon
Neonatal tetanus remains an important and preventable cause of neonatal mortality globally. Large reductions in neonatal tetanus deaths have been reported following major increases in the coverage of tetanus toxoid immunization, yet the level of evidence for the mortality effect of tetanus toxoid immunization is surprisingly weak with only two trials considered in a Cochrane review. To review the evidence for and estimate the effect on neonatal tetanus mortality of immunization with tetanus toxoid of pregnant women, or women of childbearing age. We conducted a systematic review of multiple databases. Standardized abstraction forms were used. Individual study quality and the overall quality of evidence were assessed using an adaptation of the GRADE approach. Meta-analyses were performed. Only one randomised controlled trial (RCT) and one well-controlled cohort study were identified, which met inclusion criteria for meta-analysis. Immunization of pregnant women or women of childbearing age with at least two doses of tetanus toxoid is estimated to reduce mortality from neonatal tetanus by 94% [95% confidence interval (CI) 80-98%]. Additionally, another RCT with a case definition based on day of death, 3 case-control studies and 1 before-and-after study gave consistent results. Based on the consistency of the mortality data, the very large effect size and that the data are all from low/middle-income countries, the overall quality of the evidence was judged to be moderate. This review uses a standard approach to provide a transparent estimate of the high impact of tetanus toxoid immunization on neonatal tetanus.
Chiefs of state attending the Millennium Summit (2000) set a goal of reducing maternal mortality by 75% before 2015. Based on knowledge of the epidemiology of maternal mortality/morbidity and on growing experience in the field, the international community defined a relatively low-cost program of evidence-based initiatives. However implementation of that program has been stymied by the reality that increasing geographical accessibility to a full range of quality emergency obstetric care of quality will require large investments of money and time. Increasing financial accessibility remains difficult given the low standard of living of populations and budget cutbacks by national governments. The problems facing women and health workers are mostly overlooked by public health policy. There is need for a multi-disciplinary approach with equal participation of specialists in public health, gyneco-obstetrics, anthropology, health care economics, political science and social and community mobilization.
Liu, Fu-Chao; Chiou, Hung-Jr; Kuo, Chang-Fu; Chung, Ting-Ting; Yu, Huang-Ping
Anaphylactic shock is potentially life-threatening. However, there is a paucity of data about its incidence and associated mortality, particularly in Asian populations. We aimed to investigate the epidemiology of anaphylactic shock and its related mortality after the hospitalization of patients in the general population of Taiwan. The National Health Insurance Research Database was used to identify patients with anaphylactic shock and estimate its incidence for inpatients sampled from 2005 to 2012. The pattern of anaphylactic shock and anaphylactic shock-related mortality rate was also examined. Of 22,080,199 patients who were admitted to hospitals from 2005 to 2012, there were 2289 incident cases of anaphylactic shock and 2219 people were included. Incidence of hospitalizations due to anaphylactic shock ranged from 12.71 to 13.23 per million of the population between 2005 and 2012. The incidence of anaphylactic shock in our study was substantially lower than other western countries, including the United States. There were 24 deaths due to drug-induced anaphylactic shock among the hospitalizations; overall mortality rate was 1.08%. Eighteen (0.81%) patients died within 30 days; 22 (0.99%) died within two months following the anaphylactic shock. The highest incidence occurred in patients aged 70-79 years. Conversely, food-induced anaphylactic shock was not influenced by age. In conclusion, drug-induced anaphylactic shock was a major cause of deaths due to anaphylactic shock in hospitalized patients. Most cases of anaphylactic shock occurred in the older population, and the mortality rate was lower in females than in males, though the difference was not significant.
Ritt, M; Bollheimer, L C; Sieber, C C; Gaßmann, K G
Data comparing the ability of different major frailty instruments for predicting mortality in hospitalized geriatric patients are scare. 307 patients ≥65years who were hospitalized on geriatric wards were included in this prospective analysis. A fifty-item frailty index (FI), a ten-domain+co-morbidity frailty index based on a standardized comprehensive geriatric assessment (FI-CGA), the nine category Clinical Frailty Scale (CFS-9), the CSHA rules-based frailty definition (CSHA-RBFD), and the frailty phenotype (FP) were assessed during the patients' hospital stays. Patients were followed up over a one-year period. Follow-up data after one year could be obtained from 305 out of the 307 participants. Sixty two participants (20.3%) had died after that time. The FI, FI-CGA, CFS-9, CSHA-RBFD, and FP could all discriminate between patients who died and those who survived during follow-up (areas under the ROC curves: 0.805, 0.808, 0.852, 0.703 and 0.757, all P<0.001, respectively). The CFS-9 showed a better discriminative ability for one-year mortality compared to the FI, FI-CGA, CSHA-RBFD, and FP (all P<0.05, respectively). The FI and the FI-CGA did not differ in their discriminative ability for one-year mortality (P=0.440). The CSHA-RBFD and the FP demonstrated a comparable discriminative ability (P=0.241) and, when compared to the CFS-9, FI, and FI-CGA, an inferior discriminative ability for one-year mortality (all P<0.05, respectively). Among those frailty instruments that were evaluated, the CFS-9 emerged as the most powerful for prediction of one-year mortality. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Cecconi, M; Hochrieser, H; Chew, M; Grocott, M; Hoeft, A; Hoste, A; Jammer, I; Posch, M; Metnitz, P; Pelosi, P; Moreno, R; Pearse, R M; Vincent, J L; Rhodes, A
Abnormal serum sodium concentrations are common in patients presenting for surgery. It remains unclear whether these abnormalities are independent risk factors for postoperative mortality. This is a secondary analysis of the European Surgical Outcome Study (EuSOS) that provided data describing 46 539 patients undergoing inpatient non-cardiac surgery. Patients were included in this study if they had a recorded value of preoperative serum sodium within the 28 days immediately before surgery. Data describing preoperative risk factors and serum sodium concentrations were analysed to investigate the relationship with in-hospital mortality using univariate and multivariate logistic regression techniques. Of 35 816 (77.0%) patients from the EuSOS database, 21 943 (61.3%) had normal values of serum sodium (138-142 mmol litre(-1)) before surgery, 8538 (23.8%) had hyponatraemia (serum sodium ≤137 mmol litre(-1)) and 5335 (14.9%) had hypernatraemia (serum sodium ≥143 mmol litre(-1)). After adjustment for potential confounding factors, moderate to severe hypernatraemia (serum sodium concentration ≥150 mmol litre(-1)) was independently associated with mortality [odds ratio 3.4 (95% confidence interval 2.0-6.0), P<0.0001]. Hyponatraemia was not associated with mortality. Preoperative abnormalities in serum sodium concentrations are common, and hypernatraemia is associated with increased mortality after surgery. Abnormalities of serum sodium concentration may be an important biomarker of perioperative risk resulting from co-morbid disease. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
Chen, Yiping; Jiang, Lixin; Smith, Margaret; Pan, Hongchao; Collins, Rory; Peto, Richard; Chen, Zhengming
To assess the sex difference in hospital mortality following ST elevation myocardial infarction (STEMI) in China. Observational study of patients enrolled into a large trial, adjusting for age, presenting characteristics and hospital treatments using logistic regression. 1250 hospitals in China during 1999-2005. 42 683 STEMI patients, including 31 309 men and 11 374 women. In the original trial, all patients received 162 mg of aspirin plus 75 mg of clopidogrel daily or matching placebo and metoprolol (15 mg intravenous then 200 mg oral daily) or matching placebo. All other aspects of patients' treatments were at the discretion of responsible doctors. Hospital mortality from any cause during the scheduled trial treatment period (ie, up to 4 weeks in hospital). Overall, 8% of the patients died in hospital, with the crude hospital mortality being twice as high in women as in men (12.6% vs 6.3%). After adjusting for age, the sex difference in hospital mortality attenuated but remained highly significant (OR 1.54; 95% CI 1.43 to 1.66). Further adjustment for other baseline characteristics and for the treatments given in hospital had little effect on the sex difference in hospital mortality (OR 1.50, 95% CI 1.38 to 1.62). The difference in hospital mortality was greater at a younger age, with the adjusted ORs being 2.14, 1.70, 1.48 and 1.18, respectively, for ages <55, 55-64, 65-74 and ≥75 years (p=0.0001 for trend). Compared with men of the same age, women had approximately a 50% higher mortality following hospital admission for STEMI, with a particularly higher excess risk at age <55 years.
Capuzzo, Maurizia; Volta, Carlo; Tassinati, Tania; Moreno, Rui; Valentin, Andreas; Guidet, Bertrand; Iapichino, Gaetano; Martin, Claude; Perneger, Thomas; Combescure, Christophe; Poncet, Antoine; Rhodes, Andrew
The aim of the study was to assess whether adults admitted to hospitals with both Intensive Care Units (ICU) and Intermediate Care Units (IMCU) have lower in-hospital mortality than those admitted to ICUs without an IMCU. An observational multinational cohort study performed on patients admitted to participating ICUs during a four-week period. IMCU was defined as any physically and administratively independent unit open 24 hours a day, seven days a week providing a level of care lower than an ICU but higher than a ward. Characteristics of hospitals, ICUs and patients admitted to study ICUs were recorded. The main outcome was all-cause in-hospital mortality until hospital discharge (censored at 90 days). One hundred and sixty-seven ICUs from 17 European countries enrolled 5,834 patients. Overall, 1,113 (19.1%) patients died in the ICU and 1,397 died in hospital, with a total of 1,397 (23.9%) deaths. The illness severity was higher for patients in ICUs with an IMCU (median Simplified Acute Physiology Score (SAPS) II: 37) than for patients in ICUs without an IMCU (median SAPS II: 29, P <0.001). After adjustment for patient characteristics at admission such as illness severity, and ICU and hospital characteristics, the odds ratio of mortality was 0.63 (95% CI 0.45 to 0.88, P = 0.007) in favour of the presence of IMCU. The protective effect of the IMCU was absent in patients who were admitted for basic observation, for example, after surgery (odds ratio 1.15, 95% CI 0.65 to 2.03, P = 0.630) but was strong in patients admitted to an ICU for other reasons (odds ratio 0.54, 95% CI 0.37 to 0.80, P = 0.002). The presence of an IMCU in the hospital is associated with significantly reduced adjusted hospital mortality for adults admitted to the ICU. This effect is relevant for the patients requiring full intensive treatment. Clinicaltrials.gov NCT01422070. Registered 19 August 2011.
Reeves, Mathew J; Fonarow, Gregg C; Xu, Haolin; Matsouaka, Roland A; Xian, Ying; Saver, Jeffrey; Schwamm, Lee; Smith, Eric E
Hospital profiling is typically undertaken using risk-standardized 30-day mortality, but obtaining these data for hospitals can be difficult. We sought to determine whether risk-standardized in-hospital mortality could serve as an adequate proxy for risk-standardized 30-day mortality data for the purposes of identifying outlier hospitals. Acute ischemic stroke cases entered into GWTG (Get With The Guidelines)-Stroke between 2003 and 2013 were linked to fee-for-service Medicare files to obtain 30-day mortality. Risk-standardized mortality rates (RSMR) for in-hospital and 30-day mortality were generated using previously developed risk score models, and the proportion of hospitals classified as statistical outliers compared. We also assessed the impact of using the combined outcome of in-hospital mortality or discharge to hospice. A total of 535 332 ischemic stroke patients from 1494 GWTG-Stroke hospitals were included; mean age was 80 years, 59% female, and 19% nonwhite. At the hospital level, mean in-hospital RSMRs and 30-day RSMRs were 6.0% and 14.6%, respectively, but the correlation between the 2 was modest (r=0.53). Overall agreement in the designation of outlier hospitals between in-hospital and 30-day RSMRs was 78%, but chance-corrected agreement was only fair (κ=0.29). However, when using the combined outcome of in-hospital mortality or discharge to hospice (risk-standardized mean =11.8%), the correlation with 30-day RSMR was much stronger (r= 0.83) and outlier agreement improved substantially (κ=0.60). When used to identify outlier hospitals with high or low mortality, the agreement between risk-standardized in-hospital mortality and 30-day mortality was modest. However, the combined outcome of in-hospital mortality or discharge to hospice showed much better agreement with 30-day mortality. This composite outcome could serve as a proxy for 30-day mortality when used to identify low- or high-performing hospitals. © 2017 American Heart Association, Inc.
Enayatollahi, Mohammad Ali; Novack, Thomas A; Maltenfort, Mitchell G; Tabatabaee, Reza Mostafavi; Chen, Antonia F; Parvizi, Javad
Given the growing patient population with hemoglobinopathies needing total joint arthroplasty (TJA) and paucity of literature addressing this cohort, we examined the in-hospital complications in patients with hemoglobinopathies undergoing TJA. International Classification of Diseases, Ninth Revision codes were used to search the Nationwide Inpatient Sample database for hemoglobinopathy patients undergoing primary or revision TJA. Hemoglobinopathy patients had a significant increase in cardiac, respiratory, and wound complications; blood product transfusion; pulmonary embolism; surgical site infection; and systemic infection events, while there was no significant effect on deaths, deep vein thrombosis, and renal complications. It may be prudent to implement blood conservation strategies as well as diligent postoperative protocols to minimize the need for transfusion and related complications in this patient population.
Lalezarzadeh, Fariborz; Wisniewski, Paul; Huynh, Katie; Loza, Maria; Gnanadev, Dev
Hypotension is a trauma activation criterion validated by multiple studies. However, field systolic blood pressures (SBP) are still met with skepticism. How significant is the role of prehospital (PH) and emergency department (ED) SBP in the patient's overall condition? A review of the trauma registry over a 5-year period was conducted. PH SBPs were stratified into four categories: severe (SBP 80 mmHg or less), moderate (81-100 mmHg), mild hypotension (101-120 mmHg), and normotension (greater than 120 mmHg). These four groups were further subcategorized into the patients who were hypotensive, SBP 90 mmHg or less in the ED, versus those that were not (SBP greater than 90 mmHg). Data for 6964 patients were analyzed. Patients with PH SBP of 80 mmHg or less compared with patients who had PH SBP of greater than 80 mmHg had higher mortality (OR, 9; 95% CI, 6.45-12.84). Patients with both PH SBP 80 mmHg or less and ED SBP 90 mmHg or less had the highest risk of mortality (50%) and highest need for emergent operative intervention (54%). PH and ED hypotension is a strong predictor of in-hospital mortality and need for emergent surgical intervention in trauma patients. Field or ED blood pressures should serve as a significant marker of the patient's condition.
Scott, J. Anthony G.; Brooks, W. Abdullah; Peiris, J.S. Malik; Holtzman, Douglas; Mulhollan, E. Kim
Pneumonia is an illness, usually caused by infection, in which the lungs become inflamed and congested, reducing oxygen exchange and leading to cough and breathlessness. It affects individuals of all ages but occurs most frequently in children and the elderly. Among children, pneumonia is the most common cause of death worldwide. Historically, in developed countries, deaths from pneumonia have been reduced by improvements in living conditions, air quality, and nutrition. In the developing world today, many deaths from pneumonia are also preventable by immunization or access to simple, effective treatments. However, as we highlight here, there are critical gaps in our understanding of the epidemiology, etiology, and pathophysiology of pneumonia that, if filled, could accelerate the control of pneumonia and reduce early childhood mortality. PMID:18382741
Gong, Inna Y; Goodman, Shaun G; Brieger, David; Gale, Chris P; Chew, Derek P; Welsh, Robert C; Huynh, Thao; DeYoung, J Paul; Baer, Carolyn; Gyenes, Gabor T; Udell, Jacob A; Fox, Keith A A; Yan, Andrew T
Although there are sex differences in management and outcome of acute coronary syndromes (ACS), sex is not a component of Global Registry of Acute Coronary Events (GRACE) risk score (RS) for in-hospital mortality prediction. We sought to determine the prognostic utility of GRACE RS in men and women, and whether its predictive accuracy would be augmented through sex-based modification of its components. Canadian men and women enrolled in GRACE and Canadian Registry of Acute Coronary Events were stratified as ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation ACS (NSTE-ACS). GRACE RS was calculated as per original model. Discrimination and calibration were evaluated using the c-statistic and Hosmer-Lemeshow goodness-of-fit test, respectively. Multivariable logistic regression was undertaken to assess potential interactions of sex with GRACE RS components. For the overall cohort (n=14,422), unadjusted in-hospital mortality rate was higher in women than men (4.5% vs. 3.0%, p<0.001). Overall, GRACE RS c-statistic and goodness-of-fit test p-value were 0.85 (95% CI 0.83-0.87) and 0.11, respectively. While the RS had excellent discrimination for all subgroups (c-statistics >0.80), discrimination was lower for women compared to men with STEMI [0.80 (0.75-0.84) vs. 0.86 (0.82-0.89), respectively, p<0.05]. The goodness-of-fit test showed good calibration for women (p=0.86), but suboptimal for men (p=0.031). No significant interaction was evident between sex and RS components (all p>0.25). The GRACE RS is a valid predictor of in-hospital mortality for both men and women with ACS. The lack of interaction between sex and RS components suggests that sex-based modification is not required. Copyright © 2017 Elsevier B.V. All rights reserved.
Liang, Hao; Guo, Yi Chen; Chen, Li Ming; Li, Min; Han, Wei Zhong; Zhang, Xu; Jiang, Shi Liang
Previous studies have demonstrated that elevated admission and fasting glucose (FG) is associated with worse outcomes in patients with acute myocardial infarction (AMI). However, the quantitative relationship between FG levels and in-hospital mortality in patients with AMI remains unknown. The aim of the study is to assess the prevalence of elevated FG levels in hospitalized Chinese patients with AMI and diabetes mellitus and to determine the quantitative relationship between FG levels and the in-hospital mortality as well as the optimal level of FG in patients with AMI and diabetes mellitus. A retrospective study was carried out in 1856 consecutive patients admitted for AMI and diabetes mellitus from 2002 to 2013. Clinical variables of baseline characteristics, in-hospital management and in-hospital adverse outcomes were recorded and compared among patients with different FG levels. Among all patients recruited, 993 patients (53.5 %) were found to have FG ≥100 mg/dL who exhibited a higher in-hospital mortality than those with FG < 100 mg/dL (P < 0.001). Although there was a high correlation between FG levels and in-hospital mortality in all patients (r = 0.830, P < 0.001), the relationship showed a J-curve configuration with an elevated mortality when FG was less than 80 mg/dL. Using multivariate logistic regression models, we identified that age, FG levels and Killip class of cardiac function were independent predictors of in-hospital mortality in AMI patients with diabetes mellitus. More than half of patients with AMI and diabetes mellitus have FG ≥100 mg/dL and the relationship between in-hospital mortality and FG level was a J-curve configuration. Both FG ≥ 100 mg/dL and FG <80 mg/dL were identified to be independent predictors of in-hospital mortality and thus the optimal FG level in AMI patients with diabetes mellitus appears to be 80-100 mg/dL.
Finkelstein, Juliana Zoe; Duhau, Mariana; Abeyá Gilardon, Enrique; Ferrario, Claudia; Speranza, Ana; Asciutto, Carolina; Marconi, Élida; Guevel, Carlos; Fernández, María de las Mercedes; Martínez, María Laura; Santoro, Adrián; Loiacono, Karina; Lomuto, Celia
The infant mortality rate is an indicator of quality of life, development, and quality and accessibility of health care. Improvements in science, technology and better access to health care have contributed to a major decrease in the infant mortality rate in Argentina. Since the 1980s, infant deaths have been classified based on the opportunities for reducibility yielded by scientific knowledge and available technologies, in order to obtain a basis for the monitoring and implementation of health policies. The last review of this classification was in 2011. In 2012, a total of 5,541 neonatal deaths (less than 28 days of life) were registered and, under this new classification, over 61% were reducible mainly by the improvement of perinatal health care and adequate and timely treatment of the at-risk newborn. In 2012, a total of 2,686 post-neonatal deaths (from 28 days of life to a year) were registered and, under this new classification, over 66.8% were reducible by improving prevention strategies and providing adequate and timely treatment. This new analysis demonstrates the need to improve the opportunity, accessibility and quality of perinatal care starting at pregnancy, guaranteeing quality care at delivery and reinforcing prevention and timely treatment of common diseases in childhood over the first year of life.
Palejwala, Sheri K.; Zangeneh, Tirdad T.; Goldstein, Stephen A.; Lemole, G. Michael
Background: Rhinocerebral mucormycosis occurs in immunocompromised hosts with uncontrolled diabetes, solid organ transplants, and hematologic malignancies. Primary disease is in the paranasal sinuses but often progresses intracranially, via direct extension or angioinvasion. Rhinocerebral mucormycosis is rapidly fatal with a mortality rate of 85%, even when maximally treated with surgical debridement, antifungal therapy, and correction of underlying processes. Methods: We performed a retrospective chart review of patients with rhinocerebral mucormycosis from 2011 to 2014. These patients were analyzed for symptoms, surgical and medical management, and outcome. We found four patients who were diagnosed with rhinocerebral mucormycosis. All patients underwent rapid aggressive surgical debridement and were started on antifungal therapy on the day of diagnosis. Overall, we observed a mortality rate of 50%. Results: An early aggressive multidisciplinary approach with surgical debridement, antifungal therapy, and correction of underlying disease have been shown to improve survivability in rhinocerebral mucormycosis. Conclusion: A multidisciplinary approach to rhinocerebral mucormycosis with otolaryngology, neurosurgery, and ophthalmology, infectious disease and medical intensivists can help reduce mortality in an otherwise largely fatal disease. Even despite these measures, outcomes remain poor, and a high index of suspicion must be maintained in at-risk populations, in order to rapidly execute a multifaceted approach. PMID:27280057
Shi, Hon-Yi; Hwang, Shiuh-Lin; Lee, King-Teh; Lin, Chih-Lung
Most reports compare artificial neural network (ANN) models and logistic regression models in only a single data set, and the essential issue of internal validity (reproducibility) of the models has not been adequately addressed. This study proposes to validate the use of the ANN model for predicting in-hospital mortality after traumatic brain injury (TBI) surgery and to compare the predictive accuracy of ANN with that of the logistic regression model. The authors of this study retrospectively analyzed 16,956 patients with TBI nationwide who were surgically treated in Taiwan between 1998 and 2009. For every 1000 pairs of ANN and logistic regression models, the area under the receiver operating characteristic curve (AUC), Hosmer-Lemeshow statistics, and accuracy rate were calculated and compared using paired t-tests. A global sensitivity analysis was also performed to assess the relative importance of input parameters in the ANN model and to rank the variables in order of importance. The ANN model outperformed the logistic regression model in terms of accuracy in 95.15% of cases, in terms of Hosmer-Lemeshow statistics in 43.68% of cases, and in terms of the AUC in 89.14% of cases. The global sensitivity analysis of in-hospital mortality also showed that the most influential (sensitive) parameters in the ANN model were surgeon volume followed by hospital volume, Charlson comorbidity index score, length of stay, sex, and age. This work supports the continued use of ANNs for predictive modeling of neurosurgery outcomes. However, further studies are needed to confirm the clinical efficacy of the proposed model.
Lavalle, C; Aguilar, J C; Peña, F; Estrada-Aguilar, J L; Aviña-Zubieta, J A; Madrazo, M
The objective of this study was to analyze hospitalization costs, morbidity, disability, and mortality in patients with acquired immunodeficiency syndrome (AIDS) treated with protease inhibitors (PI). This is a self-controlled, ambispective study of a total of 581 patients with human immunodeficiency virus (HIV)/AIDS seen at the Hospital de Infectología, Centro Médico La Raza, IMSS, in Mexico City during 1997. A total of 210 (36.14%) patients initiated protease inhibitor (PI) treatment at the onset of the study. Thirty-eight patients satisfied the inclusion criteria for this study and were analyzed retrospectively during the year prior to PI treatment, and then prospectively throughout the year on PI treatment. As concerns main outcome measures, financial costs, number of hospitalizations, number of infections, and productivity and laboratory parameters (CD4(+) counts and viral load) were analyzed during the year prior to PI treatment and then prospectively during the year on PI prescription. Our hypothesis was that the hospital costs, morbidity, disability, and mortality of patients with AIDS decreased while on PI treatment. During the year prior to PI prescription, the 38 patients enrolled in the study were admitted on a total of 59 occasions (1.55 hospitalizations/patient), whereas during the year on PI therapy, all 38 patients had only seven admissions (0.18 hospitalizations/patient). Hospitalization costs decreased 35% when annual PI costs for the 38 patients studied were taken into account. The number of microorganisms detected during hospitalization decreased from 24 prior to PI to five on PI. The number of disability days involved in patients on PI decreased significantly (p <0.0002). None of the 38 patients studied died during the year of follow-up under PI treatment. Mortality decreased significantly, from 116/481 (23.2%) in 1996, to 77/581 (13.2%) in 1997, to 40/740 (6.4%) in 1998. There were no deaths among the 38 patients studied during the 1-year
Kagiyama, Nobuyuki; Okura, Hiroyuki; Matsue, Yuya; Tamada, Tomoko; Imai, Koichiro; Yamada, Ryotaro; Kume, Teruyoshi; Hayashida, Akihiro; Neishi, Yoji; Yoshida, Kiyoshi
echocardiographic findings in takotsubo cardiomyopathy are not uncommon and are associated with increased in-hospital events and mortality. Copyright Â© 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.
Hill, Kenneth; You, Danzhen; Inoue, Mie; Oestergaard, Mikkel Z
Monitoring development indicators has become a central interest of international agencies and countries for tracking progress towards the Millennium Development Goals. In this review, which also provides an introduction to a collection of articles, we describe the methodology used by the United Nations Inter-agency Group for Child Mortality Estimation to track country-specific changes in the key indicator for Millennium Development Goal 4 (MDG 4), the decline of the under-five mortality rate (the probability of dying between birth and age five, also denoted in the literature as U5MR and (5)q(0)). We review how relevant data from civil registration, sample registration, population censuses, and household surveys are compiled and assessed for United Nations member states, and how time series regression models are fitted to all points of acceptable quality to establish the trends in U5MR from which infant and neonatal mortality rates are generally derived. The application of this methodology indicates that, between 1990 and 2010, the global U5MR fell from 88 to 57 deaths per 1,000 live births, and the annual number of under-five deaths fell from 12.0 to 7.6 million. Although the annual rate of reduction in the U5MR accelerated from 1.9% for the period 1990-2000 to 2.5% for the period 2000-2010, it remains well below the 4.4% annual rate of reduction required to achieve the MDG 4 goal of a two-thirds reduction in U5MR from its 1990 value by 2015. Thus, despite progress in reducing child mortality worldwide, and an encouraging increase in the pace of decline over the last two decades, MDG 4 will not be met without greatly increasing efforts to reduce child deaths.
Nogueira, Glaucia R.; Azevedo, Paula S.; Polegato, Bertha F.; Zornoff, Leonardo A.M.; Paiva, Sergio A.R.; Nogueira, Celia R.; Araujo, Natalia C.; Carmona, Bruno H.M.; Conde, Sandro J.; Minicucci, Marcos F.
OBJECTIVE: The aim of this study was to evaluate the roles of the Taql and Bsml vitamin D receptor gene polymorphisms in hospital mortality of burn patients. METHODS: In total, 105 consecutive burn injury patients over 18 years in age who were admitted to the Burn Unit of Bauru State Hospital from January to December 2013 were prospectively evaluated. Upon admission, patient demographic information was recorded and a blood sample was taken for biochemical analysis to identify the presence of the Taql(rs731236) and Bsml(rs1544410) polymorphisms. All of the patients were followed over their hospital stay and mortality was recorded. RESULTS: Eighteen of the patients did not sign the informed consent form, and there were technical problems with genotype analysis for 7 of the patients. Thus, 80 patients (mean age, 42.5±16.1 years) were included in the final analysis. In total, 60% of the patients were male, and 16.3% died during the hospital stay. The genotype frequencies for the Taql polymorphism were 51.25% TT, 41.25% TC and 7.50% CC; for the Bsml polymorphism, they were 51.25% GG, 42.50% GA and 6.25% AA. In logistic regression analysis, after adjustments for age, gender and total body surface burn area, there were no associations between the Taql (OR: 1.575; CI95%: 0.148-16.745; p=0.706) or Bsml (OR: 1.309; CI95%: 0.128-13.430; p=0.821) polymorphisms and mortality for the burn patients. CONCLUSIONS: Our results suggest that the Taql and Bsml vitamin D receptor gene polymorphisms are not associated with hospital mortality of burn patients. PMID:27626478
Lewis, Jason; Dindyal, Shiva; Raynor, Hannah; Abidia, Ahmed; Refson, Jonathan
Lower limb amputation due to peripheral arterial disease is common. The comorbid nature of this patient group makes management challenging. The aims of the study were 1) to introduce a novel "preamputation care pathway" to facilitate perioperative care and 2) to evaluate whether such a pathway is able to reduce morbidity and mortality. All patients undergoing lower limb amputation over 12 months were prospectively identified. Patient demographics were recorded before statistical analysis was performed. Twelve limbs were amputated (mean age, 69 years; mean American Association of Anesthesiologists score, 3.36). The mean time from presentation to amputation was 16.83 days. Eighty percent of patients were admitted to a critical care bed postoperatively. The mean time that patients stayed in a critical care environment was 2.62 days (range, 0-6 days). After a stay in the critical care unit, 90% of patients were stepped down to a health care of the elderly ward. One patient died in less than 30 days, representing a 10% 30-day mortality rate. The mean inpatient stay was 47 days (range, 19-121 days). Eighty percent of patients who underwent amputation in less than 10 days survived to discharge. In contrast, only 25% of patients who underwent amputation after day 11 survived to discharge (P = .0384). In conclusion, the implementation of the "preamputation care pathway" has reduced the 30-day mortality rate to 10%. A similar model of care currently exists for fractured neck of femur patients and is outlined by the care standards into "Best Practice Tariff" for the care of fractured neck of femur. A similar model should be implemented for patients undergoing lower limb amputation. Copyright © 2016 Society for Vascular Nursing, Inc. Published by Elsevier Inc. All rights reserved.
Blencowe, Hannah; Cousens, Simon; Modell, Bernadette; Lawn, Joy
Background Neural tube defects (NTDs) remain an important, preventable cause of mortality and morbidity. High-income countries have reported large reductions in NTDs associated with folic acid supplementation or fortification. The burden of NTDs in low-income countries and the effectiveness of folic acid fortification/supplementation are unclear. Objective To review the evidence for, and estimate the effect of, folic acid fortification/supplementation on neonatal mortality due to NTDs, especially in low-income countries. Methods We conducted systematic reviews, abstracted data meeting inclusion criteria and evaluated evidence quality using adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Where appropriate, meta-analyses were performed. Results Meta-analysis of three randomized controlled trials (RCTs) of folic acid supplementation for women with a previous pregnancy with NTD indicates a 70% [95% confidence interval (CI): 35–86] reduction in recurrence (secondary prevention). For NTD primary prevention through folic acid supplementation, combining one RCT with three cohort studies which adjusted for confounding, suggested a reduction of 62% (95% CI: 49–71). A meta-analysis of eight population-based observational studies examining folic acid food fortification gave an estimated reduction in NTD incidence of 46% (95% CI: 37–54). In low-income countries an estimated 29% of neonatal deaths related to visible congenital abnormalities are attributed to NTD. Assuming that fortification reduces the incidence of NTDs, but does not alter severity or case-fatality rates, we estimate that folic acid fortification could prevent 13% of neonatal deaths currently attributed to congenital abnormalities in low-income countries. Discussion Scale-up of periconceptional supplementation programmes is challenging. Our final effect estimate was therefore based on folic acid fortification data. If folic acid food fortification achieved
Schweitzer, Julian; Bishai, David; Chowdhury, Sadia; Caramani, Daniele; Frost, Laura; Cortez, Rafael; Daelmans, Bernadette; de Francisco, Andres; Adam, Taghreed; Cohen, Robert; Alfonso, Y Natalia; Franz-Vasdeki, Jennifer; Saadat, Seemeen; Pratt, Beth Anne; Eugster, Beatrice; Bandali, Sarah; Venkatachalam, Pritha; Hinton, Rachael; Murray, John; Arscott-Mills, Sharon; Axelson, Henrik; Maliqi, Blerta; Sarker, Intissar; Lakshminarayanan, Rama; Jacobs, Troy; Jacks, Susan; Mason, Elizabeth; Ghaffar, Abdul; Mays, Nicholas; Presern, Carole; Bustreo, Flavia
Abstract Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Women’s and Children’s Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula – fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in women’s and children’s health towards 2015 and beyond. PMID:25110379
Archbald-Pannone, Laurie R; McMurry, Timothy L; Guerrant, Richard L; Warren, Cirle A
Clostridium difficile infection (CDI) severity has increased, especially among hospitalized older adults. We evaluated clinical factors to predict mortality after CDI. We collected data from inpatients diagnosed with CDI at a U.S. academic medical center (HSR-IRB#13630). We evaluated age, Charlson comorbidity index (CCI), whether patients were admitted from a long-term care facility, whether patients were in an intensive care unit (ICU) at the time of diagnosis, white blood cell count (WBC), blood urea nitrogen (BUN), low body mass index, and delirium as possible predictors. A parsimonious predictive model was chosen using the Akaike information criterion (AIC) and a best subsets model selection algorithm. The area under the receiver operating characteristic curve was used to assess the model's comparative, with the AIC as the selection criterion for all subsets to measure fit and control for overfitting. From the 362 subjects, the selected model included CCI, WBC, BUN, ICU, and delirium. The logistic regression coefficients were converted to a points scale and calibrated so that each unit on the CCI contributed 2 points, ICU admission contributed 5 points, each unit of WBC (natural log scale) contributed 3 points, each unit of BUN contributed 5 points, and delirium contributed 11 points.Our model shows substantial ability to predict short-term mortality in patients hospitalized with CDI. Patients who were diagnosed in the ICU and developed delirium are at the highest risk for dying within 30 days of CDI diagnosis. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Sobolev, Boris G; Fradet, Guy; Hayden, Robert; Kuramoto, Lisa; Levy, Adrian R; FitzGerald, Mark J
Background Many health care systems now use priority wait lists for scheduling elective coronary artery bypass grafting (CABG) surgery, but there have not yet been any direct estimates of reductions in in-hospital mortality rate afforded by ensuring that the operation is performed within recommended time periods. Methods We used a population-based registry to identify patients with established coronary artery disease who underwent isolated CABG in British Columbia, Canada. We studied whether postoperative survival during hospital admission for CABG differed significantly among patients who waited for surgery longer than the recommended time, 6 weeks for patients needing semi-urgent surgery and 12 weeks for those needing non-urgent surgery. Results Among 7316 patients who underwent CABG, 97 died during the same hospital admission, for a province-wide death rate at discharge of 1.3%. The observed proportion of patients who died during the same admission was 1.0% (27 deaths among 2675 patients) for patients treated within the recommended time and 1.5% (70 among 4641) for whom CABG was delayed. After adjustment for age, sex, anatomy, comorbidity, calendar period, hospital, and mode of admission, patients with early CABG were only 2/3 as likely as those for whom CABG was delayed to experience in-hospital death (odds ratio 0.61; 95% confidence interval [CI] 0.39 to 0.96). There was a linear trend of 5% increase in the odds of in-hospital death for every additional month of delay before surgery, adjusted OR = 1.05 (95% CI 1.00 to 1.11). Conclusion We found a significant survival benefit from performing surgical revascularization within the time deemed acceptable to consultant surgeons for patients requiring the treatment on a semi-urgent or non-urgent basis. PMID:18803823
Gómez-de-Segura, I A; Prieto, I; Grande, A G; García, P; Guerra, A; Mendez, J; De Miguel, E
Growth hormone stimulates the growth of intestinal mucosa and may reduce the severity of injury caused by radiation. Male Wistar rats underwent abdominal irradiation (12 Gy) and were treated with either human growth hormone (hGH) or saline, and sacrificed at day 4 or 7 post-irradiation. Bacterial translocation, and the ileal mucosal thickness, proliferation, and disaccharidase activity were assessed. Mortality was 65% in irradiated animals, whereas hGH caused a decrement (29%, p < 0.05). Bacterial translocation was also reduced by hGH (p < 0.05). Treating irradiated rats with hGH prevented body weight loss (p < 0.05). Mucosal thickness increased faster in irradiated hGH-treated animals. The proliferative index showed an increment in hGH-treated animals (p < 0.05). Giving hGH to irradiated rats prevented decrease in sucrose activity, and increment in lactase activity. In conclusion, giving hGH to irradiated rats promotes the adaptative process of the intestine and acute radiation-related negative effects, including mortality, bacterial translocation, and weight loss.
George, Antony; Jagannath, Pushpa; Joshi, Shreedhar S.; Jagadeesh, A. M.
Objective: To study the distribution of weight for age standard score (Z score) in pediatric cardiac surgery and its effect on in-hospital mortality. Introduction: WHO recommends Standard Score (Z score) to quantify and describe anthropometric data. The distribution of weight for age Z score and its effect on mortality in congenital heart surgery has not been studied. Methods: All patients of younger than 5 years who underwent cardiac surgery from July 2007 to June 2013, under single surgical unit at our institute were enrolled. Z score for weight for age was calculated. Patients were classified according to Z score and mortality across the classes was compared. Discrimination and calibration of the for Z score model was assessed. Improvement in predictability of mortality after addition of Z score to Aristotle Comprehensive Complexity (ACC) score was analyzed. Results: The median Z score was -3.2 (Interquartile range -4.24 to -1.91] with weight (mean±SD) of 8.4 ± 3.38 kg. Overall mortality was 11.5%. 71% and 52.59% of patients had Z score < -2 and < -3 respectively. Lower Z score classes were associated with progressively increasing mortality. Z score as continuous variable was associated with O.R. of 0.622 (95% CI- 0.527 to 0.733, P < 0.0001) for in-hospital mortality and remained significant predictor even after adjusting for age, gender, bypass duration and ACC score. Addition of Z score to ACC score improved its predictability for in-hosptial mortality (δC - 0.0661 [95% CI - 0.017 to 0.0595, P = 0.0169], IDI- 3.83% [95% CI - 0.017 to 0.0595, P = 0.00042]). Conclusion: Z scores were lower in our cohort and were associated with in-hospital mortality. Addition of Z score to ACC score significantly improves predictive ability for in-hospital mortality. PMID:26139742
Sato, Masaya; Tateishi, Ryosuke; Yasunaga, Hideo; Horiguchi, Hiromasa; Matsui, Hiroki; Yoshida, Haruhiko; Fushimi, Kiyohide; Koike, Kazuhiko
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.
Ahmed, Bina; Davis, Herbert T; Laskey, Warren K
Case-fatality rates in acute myocardial infarction (AMI) have significantly decreased; however, the prevalence of diabetes mellitus (DM), a risk factor for AMI, has increased. The purposes of the present study were to assess the prevalence and clinical impact of DM among patients hospitalized with AMI and to estimate the impact of important clinical characteristics associated with in-hospital mortality in patients with AMI and DM. We used the National Inpatient Sample to estimate trends in DM prevalence and in-hospital mortality among 1.5 million patients with AMI from 2000 to 2010, using survey data-analysis methods. Clinical characteristics associated with in-hospital mortality were identified using multivariable logistic regression. There was a significant increase in DM prevalence among AMI patients (year 2000, 22.2%; year 2010, 29.6%, Ptrend<0.0001). AMI patients with DM tended to be older and female and to have more cardiovascular risk factors. However, age-standardized mortality decreased significantly from 2000 (8.48%) to 2010 (4.95%) (Ptrend<0.0001). DM remained independently associated with mortality (adjusted odds ratio 1.069, 95% CI 1.051 to 1.087; P<0.0001). The adverse impact of DM on in-hospital mortality was unchanged over time. Decreased death risk over time was greatest among women and elderly patients. Among younger patients of both sexes, there was a leveling off of this decrease in more recent years. Despite increasing DM prevalence and disease burden among AMI patients, in-hospital mortality declined significantly from 2000 to 2010. The adverse impact of DM on mortality remained unchanged overall over time but was age and sex dependent. © 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.
Sanchez, Larysa; Sylvester, Michael; Parrondo, Ricardo; Mariotti, Veronica; Eloy, Jean Anderson; Chang, Victor T
Autologous hematopoietic stem cell transplantation (auto-HSCT) has improved survival in patients with multiple myeloma (MM) and is increasingly used in elderly patients. The aim of this study was to characterize and compare in-hospital complications and mortality after auto-HSCT in younger (< age 65) vs. elderly (≥ age 65) MM patients utilizing the Nationwide Inpatient Sample (NIS). Over a three-year period (2008-2010), 2209 patients with MM were admitted to U.S. Hospitals for auto-HSCT. The median age was 59 years, with 1650 patients (74.7%) younger than age 65 and 559 patients (25.3%) age 65 or older. Overall, in-hospital mortality in MM patients following auto-HSCT was rare (1.5%) and there was no significant difference in mortality between elderly and younger patients. Elderly patients did have a significantly increased mean length of stay (18.6 days + 10.8 days (standard deviation) vs. 16.8 days + 7.2 days, p<0.001) and mean total hospital charges ($161,117 + $105,008 vs. $151,192 + $78,342, p=0.018) compared to younger pts. Elderly patients were significantly more likely than younger patients to develop major in-hospital post-transplant complications such as severe sepsis (OR 2.70, 95% CI: 1.40-5.21, p=0.003), septic shock, (OR 3.10, 95% CI: 1.43-6.71, p=0.004), pneumonia (OR 1.62, 95% CI: 1.06-2.46, p=0.024), acute respiratory failure (OR 3.44, 95% CI: 1.70-6.96, p=0.001), endotracheal intubation requiring prolonged mechanical ventilation (OR 2.19, 95% CI: 1.06-4.55, p=0.035), acute renal failure (OR 2.14, 95% CI: 1.38-3.33, p=0.001), and cardiac arrhythmias (OR 2.06, 95% CI: 1.52-2.79, <0.001). This data may help guide informed consent discussions and provide a focus for future studies to reduce treatment-related morbidity in elderly MM patients undergoing auto-HSCT.
Miranda-Hernández, D; Cruz-Reyes, C; Monsebaiz-Mora, C; Gómez-Bañuelos, E; Ángeles, U; Jara, L J; Saavedra, M Á
The aim of this study was to estimate the impact of the haematological manifestations of systemic lupus erythematosus (SLE) on mortality in hospitalized patients. For that purpose a case-control study of hospitalized patients in a medical referral centre from January 2009 to December 2014 was performed. For analysis, patients hospitalized for any haematological activity of SLE ( n = 103) were compared with patients hospitalized for other manifestations of SLE activity or complications of treatment ( n = 206). Taking as a variable outcome hospital death, an analysis of potential associated factors was performed. The most common haematological manifestation was thrombocytopenia (63.1%), followed by haemolytic anaemia (30%) and neutropenia (25.2%). In the group of haematological manifestations, 17 (16.5%) deaths were observed compared to 10 (4.8%) deaths in the control group ( P < 0.001). The causes of death were similar in both groups. In the analysis of the variables, it was found that only haematological manifestations were associated with intra-hospital death (odds ratio 3.87, 95% confidence interval 1.8-88, P < 0.001). Our study suggests that apparently any manifestation of haematological activity of SLE is associated with poor prognosis and contributes to increased hospital mortality.
Allareddy, Veerajalandhar; Asad, Rahimullah; Lee, Min Kyeong; Nalliah, Romesh P; Rampa, Sankeerth; Speicher, David G; Rotta, Alexandre T; Allareddy, Veerasathpurush
To describe nationally representative outcomes of physical abuse injuries in children necessitating Emergency Department (ED) visits in United States. The impact of various injuries on mortality is examined. We hypothesize that physical abuse resulting in intracranial injuries are associated with worse outcome. We performed a retrospective analysis of the Nationwide Emergency Department Sample (NEDS), the largest all payer hospital based ED database, for the years 2008-2010. All ED visits and subsequent hospitalizations with a diagnosis of "Child physical abuse" (Battered baby or child syndrome) due to various injuries were identified using ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) codes. In addition, we also examined the prevalence of sexual abuse in this cohort. A multivariable logistic regression model was used to examine the association between mortality and types of injuries after adjusting for a multitude of patient and hospital level factors. Of the 16897 ED visits that were attributed to child physical abuse, 5182 (30.7%) required hospitalization. Hospitalized children were younger than those released treated and released from the ED (1.9 years vs. 6.4 years). Male or female partner of the child's parent/guardian accounted for >45% of perpetrators. Common injuries in hospitalized children include- any fractures (63.5%), intracranial injuries (32.3%) and crushing/internal injuries (9.1%). Death occurred in 246 patients (13 in ED and 233 following hospitalization). Amongst the 16897 ED visits, 1.3% also had sexual abuse. Multivariable analyses revealed each 1 year increase in age was associated with a lower odds of mortality (OR = 0.88, 95% CI = 0.81-0.96, p < 0.0001). Females (OR = 2.39, 1.07-5.34, p = 0.03), those with intracranial injuries (OR = 65.24, 27.57-154.41, p<0.0001), or crushing/internal injury (OR = 4.98, 2.24-11.07, p<0.0001) had higher odds of mortality compared to their male counterparts. In this
Allareddy, Veerajalandhar; Asad, Rahimullah; Lee, Min Kyeong; Nalliah, Romesh P.; Rampa, Sankeerth; Speicher, David G.; Rotta, Alexandre T.; Allareddy, Veerasathpurush
Objectives To describe nationally representative outcomes of physical abuse injuries in children necessitating Emergency Department (ED) visits in United States. The impact of various injuries on mortality is examined. We hypothesize that physical abuse resulting in intracranial injuries are associated with worse outcome. Materials and Methods We performed a retrospective analysis of the Nationwide Emergency Department Sample (NEDS), the largest all payer hospital based ED database, for the years 2008–2010. All ED visits and subsequent hospitalizations with a diagnosis of “Child physical abuse” (Battered baby or child syndrome) due to various injuries were identified using ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) codes. In addition, we also examined the prevalence of sexual abuse in this cohort. A multivariable logistic regression model was used to examine the association between mortality and types of injuries after adjusting for a multitude of patient and hospital level factors. Results Of the 16897 ED visits that were attributed to child physical abuse, 5182 (30.7%) required hospitalization. Hospitalized children were younger than those released treated and released from the ED (1.9 years vs. 6.4 years). Male or female partner of the child’s parent/guardian accounted for >45% of perpetrators. Common injuries in hospitalized children include- any fractures (63.5%), intracranial injuries (32.3%) and crushing/internal injuries (9.1%). Death occurred in 246 patients (13 in ED and 233 following hospitalization). Amongst the 16897 ED visits, 1.3% also had sexual abuse. Multivariable analyses revealed each 1 year increase in age was associated with a lower odds of mortality (OR = 0.88, 95% CI = 0.81–0.96, p<0.0001). Females (OR = 2.39, 1.07–5.34, p = 0.03), those with intracranial injuries (OR = 65.24, 27.57–154.41, p<0.0001), or crushing/internal injury (OR = 4.98, 2.24–11.07, p<0
Bukur, Marko; Lustenberger, Thomas; Cotton, Bryan; Arbabi, Saman; Talving, Peep; Salim, Ali; Ley, Eric J; Inaba, Kenji
The effect of β-blockade in trauma patients without significant head injuries is unknown. The purpose of this investigation was to determine the impact of β-blocker exposure on mortality in critically injured trauma patients who did not sustain significant head injuries. Critically ill trauma patients (Injury Severity Score ≥ 25) admitted to the surgical intensive care unit from January 2000 to December 2008 without severe traumatic brain injuries (head Abbreviated Injury Score ≥ 3) were included in this retrospective review. Patients who received β-blockers within 30 days of intensive care unit admission were compared with those who did not. The primary outcome measure evaluated was in-hospital mortality. During the 9-year study period, 663 critically injured patients (Injury Severity Score ≥ 25) were admitted to the intensive care unit. Of these, 98 patients (14.8%) received β-blockers. Patients exposed to β-blockers had significantly lower in-hospital mortality (11.2% vs 19.3%, P = .006). Stepwise logistic regression identified β-blocker use as an independent protective factor for mortality (adjusted odds ratio, .37; P = .007) in critically injured patients. Beta-blocker exposure was associated with reduced mortality in critically injured patients without head injuries. Prospective validation of this finding is warranted. Copyright © 2012 Elsevier Inc. All rights reserved.
Claeson, M.; Bos, E. R.; Mawji, T.; Pathmanathan, I.
Globally, child mortality rates have been halved over the last few decades, a developmental success story. Nevertheless, progress has been uneven and in recent years mortality rates have increased in some countries. The present study documents the slowing decline in infant mortality rates in india; a departure from the longer-term trends. The major causes of childhood mortality are also reviewed and strategic options for the different states of India are proposed that take into account current mortality rates and the level of progress in individual states. The slowing decline in childhood mortality rates in India calls for new approaches that go beyond disease-, programme- and sector-specific approaches. PMID:11100614
This article reviews the technologies used to diagnose pregnancy and manage abortion in developing countries. The author discusses methods of diagnosing pregnancy--including physical examination, laboratory and home testing, and ultrasound--as well as methods for performing safe abortions. Due to manual vacuum aspiration (MVA) advances, vacuum aspiration has become safer and more feasible in low-resource settings. The discussion of medical abortion includes the advantages and limitations of mifepristone, misoprostol-only regimens, methotrexate, and other methods. The author stresses the importance of post-abortion care and post-abortion contraception and, in the conclusion, identifies six areas in which technology can reduce abortion-related morbidity and mortality: pregnancy prevention, early diagnosis of pregnancy, accurate assessment of gestation, standardization and supply of MVA technology, and simple and affordable regimens for medical abortion.
Protty, Majd B; Lacey, Arron; Smith, Dave; Hannoodee, Sahar; Freeman, Phillip
Psychiatric and cardiac comorbidities form the top two budget categories for health systems in high-income countries with evidence that psychiatric pre-morbidities lead to worse outcomes in patients with acute coronary syndrome (ACS). There are no studies examining this relationship in a national multicentre population level study in the UK, and no studies examining their impact on length of in-hospital stay (LoS) in ACS. Recognizing at-risk populations and reducing LoS in ACS is an essential part of improving patient care and cost-effectiveness. We investigated the impact of psychiatric diagnoses on morbidity, all-cause mortality and LoS amongst 57,668 ACS patients between Jan-2004 and Dec-2014 using the Secure-Anonymized-Information-Linkage (SAIL) databank. Demographics, admissions, cardiac and psychiatric comorbidities were identified using coded data. There were a total of 3857 out of 57,668 patients who had a pre-morbid psychiatric diagnosis. The mean LoS in patients without psychiatric comorbidities was 9.78days (95% CI: 9.66-9.91). This was higher (p<0.01) in the presence of any psychiatric diagnosis (14.72), dementia (20.87), schizophrenia (15.67), and mood disorders (13.41). Patients with psychiatric comorbidities had worse net adverse cardiac events (HR 1.18, 95% CI: 1.16-1.21) and mortality rates (HR 1.26, 95% CI: 1.23-1.30). Our results demonstrate that psychiatric comorbidities have a significant and clinically important impact on morbidity, mortality and LoS in ACS patients in Wales, UK. Clinicians' awareness and active management of psychiatric conditions amongst ACS patients is needed to reduce poor outcomes and LoS and ultimately the risk for patients and financial burden for the health-service. Copyright © 2016. Published by Elsevier B.V.
Giede-Jeppe, Antje; Bobinger, Tobias; Gerner, Stefan T; Sembill, Jochen A; Sprügel, Maximilian I; Beuscher, Vanessa D; Lücking, Hannes; Hoelter, Philip; Kuramatsu, Joji B; Huttner, Hagen B
Stroke-associated immunosuppression and inflammation are increasingly recognized as factors that trigger infections and thus, potentially influence the outcome after stroke. Several studies demonstrated that elevated neutrophil-to-lymphocyte ratio (NLR) is a significant predictor of adverse outcomes in patients with ischemic stroke. However, little is known about the impact of NLR on short-term mortality in intracerebral hemorrhage (ICH). This observational study included 855 consecutive ICH-patients. Patient demographics, clinical, laboratory, and in-hospital measures as well as neuroradiological data were retrieved from institutional databases. Functional 3-months-outcome was assessed and categorized as favorable (modified Rankin Scale [mRS] 0-3) and unfavorable (mRS 4-6). We (i) studied the natural course of NLR in ICH, (ii) analyzed parameters associated with NLR on admission (NLROA), and (iii) evaluated the clinical impact of NLR on mortality and functional outcome. The median NLROA of the entire cohort was 4.66 and it remained stable during the entire hospital stay. Patients with NLR ≥4.66 showed significant associations with poorer neurological status (National Institute of Health Stroke Scale [NIHSS] 18 [9-32] vs. 10 [4-21]; p < 0.001), larger hematoma volume on admission (17.6 [6.9-47.7] vs. 10.6 [3.8-31.7] mL; p = 0.001), and more frequently unfavorable outcome (mRS 4-6 at 3 months: 317/427 [74.2%] vs. 275/428 [64.3%]; p = 0.002). Patients with an NLR under the 25th percentile (NLR <2.606) - compared to patients with NLR >2.606 - presented with a better clinical status (NIHSS 12 [5-21] vs. 15 [6-28]; p = 0.005), lower hematoma volumes on admission (10.6 [3.6-30.1] vs. 15.1 [5.7-42.3] mL; p = 0.004) and showed a better functional outcome (3 months mRS 0-3: 82/214 [38.3%] vs. 185/641 [28.9%]; p = 0.009). Patients associated with high NLR (≥8.508 = above 75th-percentile) showed the worst neurological status on admission (NIHSS 21 [12-32] vs. 12 [5-23]; p
Diya, Luwis; Van den Heede, Koen; Sermeus, Walter; Lesaffre, Emmanuel
The aim of this article was to assess the relationship between (1) in-hospital mortality and/or (2) unplanned readmission to intensive care units or operating theatre and nurse staffing variables. Adverse events are used as surrogates for patient safety in nurse staffing and patient safety research. A single adverse event cannot adequately capture the multi-dimensional attributes of patient safety; hence, there is a need to consider composite measures. Unplanned readmission into the postoperative Intensive Care nursing unit and/or operating Theatre and in-hospital mortality can be viewed as measures that incorporate the effects of several adverse events. We conducted a Bayesian multilevel analysis on a subset of the 2003 Belgian Hospital Discharge and Nursing Minimum Data sets. The sample included 9054 patients who underwent coronary artery bypass surgery or heart valve procedures from 28 Belgian acute hospitals. Two proxies of patient safety were considered, namely postoperative in-hospital mortality in the first postoperative intensive care unit and unplanned readmission into the intensive care and/or operating theatre (including mortality beyond the first postoperative intensive care unit) after the first-operative intensive care nursing unit. There is an association between in-hospital mortality and/or unplanned readmissions and nurse staffing levels, but the relationship is moderated by volume and severity of illness respectively. In addition, the relationship differs between the two endpoints. Higher nurse staffing levels on postoperative general nursing cardiac surgery units protected patients from unplanned readmission to intensive care units or operating theatre and in-hospital mortality. © 2011 Blackwell Publishing Ltd.
figures published in the international literature, though the hospital mortality rate is higher. We feel that it is essential to conduct more studies with a view to a more detailed characterisation of the situation in Portugal and a better understanding of the reasons for the discrepancies between the regions. This would possibly also enable us to implement measures to reduce the mortality rate.
Broderick, Ryan C; Fuchs, Hans F; Harnsberger, Cristina R; Chang, David C; Sandler, Bryan J; Jacobsen, Garth R; Horgan, Santiago
Healthcare costs in the United States (U.S.) are rising. As outcomes improve, such as decreased length of stay and decreased mortality, it is expected that costs should go down. The aim of this study is to analyze hospital charges, cost of care, and mortality in bariatric surgery over time. A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Adults with morbid obesity who underwent gastric bypass or sleeve gastrectomy were identified by ICD-9 codes. Multivariate analyses identified independent predictors of changes in hospital charges and in-hospital mortality. Results were adjusted for age, race, gender, Charlson comorbidity index, surgical approach (open versus laparoscopic), hospital volume, and insurance status. In order to estimate baseline surgical inflation, changes in hospital charges over time were also calculated for appendectomy. From 1998 to 2011, 209,106 patients were identified who underwent bariatric surgery. Adjusted in-hospital mortality for bariatric surgery decreased significantly by 2003 compared to 1998 (p < 0.001, OR 0.47, 95 % CI 0.22-0.92) and remained significantly decreased for the remainder of the study period. As such, a 60-80 % decrease in mortality was maintained from 2003 to 2010 compared to 1998. After adjusting for inflation, the cumulative increase in hospital charges per day of a bariatric surgery admission was 130 % from 1998 to 2011. Charges per stay increased by 2.1 % annually for bariatric surgery compared to 5.5 % for appendectomy. In-hospital mortality rate following bariatric surgery underwent a ninefold decrease since 1998 while maintaining surgical inflation costs less than appendectomy. Innovation in bariatric surgical technique and technology has resulted in improvement of outcomes while providing overall cost savings.
Zayas, G.J.; Bonilla, A.M.; Saliba, M.J
between 1998 and 1999 was significant (p < 0.008). The survivors had notably smooth skin. Conclusions. The use of heparin in this study relieved burn pain, significantly reduced mortality and sepsis with fewer procedures, and discernibly improved cosmetic results. PMID:21991064
Rutter, Harry; Cavill, Nick; Racioppi, Francesca; Dinsdale, Hywell; Oja, Pekka; Kahlmeier, Sonja
Increasing regular physical activity is a key public health goal. One strategy is to change the physical environment to encourage walking and cycling, requiring partnerships with the transport and urban planning sectors. Economic evaluation is an important factor in the decision to fund any new transport scheme, but techniques for assessing the economic value of the health benefits of cycling and walking have tended to be less sophisticated than the approaches used for assessing other benefits. This study aimed to produce a practical tool for estimating the economic impact of reduced mortality due to increased cycling. The tool was intended to be transparent, easy to use, reliable, and based on conservative assumptions and default values, which can be used in the absence of local data. It addressed the question: For a given volume of cycling within a defined population, what is the economic value of the health benefits? The authors used published estimates of relative risk of all-cause mortality among regular cyclists and applied these to levels of cycling defined by the user to produce an estimate of the number of deaths potentially averted because of regular cycling. The tool then calculates the economic value of the deaths averted using the "value of a statistical life." The outputs of the tool support decision making on cycle infrastructure or policies, or can be used as part of an integrated economic appraisal. The tool's unique contribution is that it takes a public health approach to a transport problem, addresses it in epidemiologic terms, and places the results back into the transport context. Examples of its use include its adoption by the English and Swedish departments of transport as the recommended methodologic approach for estimating the health impact of walking and cycling.
Background Clinicians informally assess changes in patients' status over time to prognosticate their outcomes. The incorporation of trends in patient status into regression models could improve their ability to predict outcomes. In this study, we used a unique approach to measure trends in patient hospital death risk and determined whether the incorporation of these trend measures into a survival model improved the accuracy of its risk predictions. Methods We included all adult inpatient hospitalizations between 1 April 2004 and 31 March 2009 at our institution. We used the daily mortality risk scores from an existing time-dependent survival model to create five trend indicators: absolute and relative percent change in the risk score from the previous day; absolute and relative percent change in the risk score from the start of the trend; and number of days with a trend in the risk score. In the derivation set, we determined which trend indicators were associated with time to death in hospital, independent of the existing covariates. In the validation set, we compared the predictive performance of the existing model with and without the trend indicators. Results Three trend indicators were independently associated with time to hospital mortality: the absolute change in the risk score from the previous day; the absolute change in the risk score from the start of the trend; and the number of consecutive days with a trend in the risk score. However, adding these trend indicators to the existing model resulted in only small improvements in model discrimination and calibration. Conclusions We produced several indicators of trend in patient risk that were significantly associated with time to hospital death independent of the model used to create them. In other survival models, our approach of incorporating risk trends could be explored to improve their performance without the collection of additional data. PMID:21777460
Huang, Ya-Ting; Tseng, Yuan-Teng; Chu, Tung-Wei; Chen, John; Lai, Min-Yu; Tang, Woung-Ru; Shiao, Chih-Chung
Serum N-terminal pro b-type natriuretic peptide (NT-pro-BNP) testing is recommended in the patients with heart failure (HF). We hypothesized that NT-pro-BNP, in combination with other clinical factors in terms of a novel NT-pro BNP-based score, may provide even better predictive power for in-hospital mortality among patients with HF. A retrospective study enrolled adult patients with hospitalization-requiring HF who fulfilled the predefined criteria during the period from January 2011 to December 2013. We proposed a novel scoring system consisting of several independent predictors including NT-pro-BNP for predicting in-hospital mortality, and then compared the prognosis-predictive power of the novel NT-pro BNP-based score with other prognosis-predictive scores. A total of 269 patients were enrolled in the current study. Factors such as "serum NT-pro-BNP level above 8100 mg/dl," "age above 79 years," "without taking angiotensin converting enzyme inhibitors/angiotensin receptor blocker," "without taking beta-blocker," "without taking loop diuretics," "with mechanical ventilator support," "with non-invasive ventilator support," "with vasopressors use," and "experience of cardio-pulmonary resuscitation" were found as independent predictors. A novel NT-pro BNP-based score composed of these risk factors was proposed with excellent predictability for in-hospital mortality. The proposed novel NT-pro BNP-based score was extremely effective in predicting in-hospital mortality in HF patients.
Background While the benefits or otherwise of early hip fracture repair is a long-running controversy with studies showing contradictory results, this practice is being adopted as a quality indicator in several health care organizations. The aim of this study is to analyze the association between early hip fracture repair and in-hospital mortality in elderly people attending public hospitals in the Spanish National Health System and, additionally, to explore factors associated with the decision to perform early hip fracture repair. Methods A cohort of 56,500 patients of 60-years-old and over, hospitalized for hip fracture during the period 2002 to 2005 in all the public hospitals in 8 Spanish regions, were followed up using administrative databases to identify the time to surgical repair and in-hospital mortality. We used a multivariate logistic regression model to analyze the relationship between the timing of surgery (< 2 days from admission) and in-hospital mortality, controlling for several confounding factors. Results Early surgery was performed on 25% of the patients. In the unadjusted analysis early surgery showed an absolute difference in risk of mortality of 0.57 (from 4.42% to 3.85%). However, patients undergoing delayed surgery were older and had higher comorbidity and severity of illness. Timeliness for surgery was not found to be related to in-hospital mortality once confounding factors such as age, sex, chronic comorbidities as well as the severity of illness were controlled for in the multivariate analysis. Conclusions Older age, male gender, higher chronic comorbidity and higher severity measured by the Risk Mortality Index were associated with higher mortality, but the time to surgery was not. PMID:22257790
Librero, Julián; Peiró, Salvador; Leutscher, Edith; Merlo, Juan; Bernal-Delgado, Enrique; Ridao, Manuel; Martínez-Lizaga, Natalia; Sanfélix-Gimeno, Gabriel
While the benefits or otherwise of early hip fracture repair is a long-running controversy with studies showing contradictory results, this practice is being adopted as a quality indicator in several health care organizations. The aim of this study is to analyze the association between early hip fracture repair and in-hospital mortality in elderly people attending public hospitals in the Spanish National Health System and, additionally, to explore factors associated with the decision to perform early hip fracture repair. A cohort of 56,500 patients of 60-years-old and over, hospitalized for hip fracture during the period 2002 to 2005 in all the public hospitals in 8 Spanish regions, were followed up using administrative databases to identify the time to surgical repair and in-hospital mortality. We used a multivariate logistic regression model to analyze the relationship between the timing of surgery (< 2 days from admission) and in-hospital mortality, controlling for several confounding factors. Early surgery was performed on 25% of the patients. In the unadjusted analysis early surgery showed an absolute difference in risk of mortality of 0.57 (from 4.42% to 3.85%). However, patients undergoing delayed surgery were older and had higher comorbidity and severity of illness. Timeliness for surgery was not found to be related to in-hospital mortality once confounding factors such as age, sex, chronic comorbidities as well as the severity of illness were controlled for in the multivariate analysis. Older age, male gender, higher chronic comorbidity and higher severity measured by the Risk Mortality Index were associated with higher mortality, but the time to surgery was not.
Ong, Cheung-Ter; Wong, Yi-Sin; Sung, Sheng-Feng; Wu, Chi-Shun; Hsu, Yung-Chu; Su, Yu-Hsiang; Hung, Ling-Chien
Sex-related differences in the clinical presentation and outcomes of stroke patients are issues that have attracted increased interest from the scientific community. The present study aimed to investigate sex-related differences in the risk factors for in-hospital mortality and outcome in ischemic stroke patients. A total of 4278 acute ischemic stroke patients admitted to a stroke unit between January 1, 2007 and December 31, 2014 were included in the study. We considered demographic characteristics, clinical characteristics, co-morbidities, and complications, among others, as factors that may affect clinical presentation and in-hospital mortality. Good and poor outcomes were defined as modified Ranking Score (mRS)≦2 and mRS>2. Neurological deterioration (ND) was defined as an increase of National Institutes of Health Stroke Score (NIHSS) ≥ 4 points. Hemorrhagic transformation (HT) was defined as signs of hemorrhage in cranial CT or MRI scans. Transtentorial herniation was defined by brain edema, as seen in cranial CT or MRI scans, associated with the onset of acute unilateral or bilateral papillary dilation, loss of reactivity to light, and decline of ≥ 2 points in the Glasgow coma scale score. Of 4278 ischemic stroke patients (women 1757, 41.1%), 269 (6.3%) received thrombolytic therapy. The in hospital mortality rate was 3.35% (139/4278) [4.45% (80/1757) for women and 2.34% (59/2521) for men, p < 0.01]. At discharge, 41.2% (1761/4278) of the patients showed good outcomes [35.4% (622/1757) for women and 45.2% (1139/2521) for men]. Six months after stroke, 56.1% (1813/3231) showed good outcomes [47.4% (629/1328) for women and 62.2% (1184/1903) for men, p < 0.01]. Atrial fibrillation (AF), diabetes mellitus, stroke history, and old age were factors contributing to poor outcomes in men and women. Hypertension was associated with poor outcomes in women but not in men in comparison with patients without hypertension. Stroke severity and increased intracranial
Hendriksen, Ilse C. E.; Ferro, Josefo; Montoya, Pablo; Chhaganlal, Kajal D.; Seni, Amir; Gomes, Ermelinda; Silamut, Kamolrat; Lee, Sue J.; Lucas, Marcelino; Chotivanich, Kesinee; Fanello, Caterina I.; Day, Nicholas P. J.; White, Nicholas J.; von Seidlein, Lorenz; Dondorp, Arjen M.
Background. Severe falciparum malaria with human immunodeficiency virus (HIV) coinfection is common in settings with a high prevalence of both diseases, but there is little information on whether HIV affects the clinical presentation and outcome of severe malaria. Methods. HIV status was assessed prospectively in hospitalized parasitemic adults and children with severe malaria in Beira, Mozambique, as part of a clinical trial comparing parenteral artesunate versus quinine (ISRCTN50258054). Clinical signs, comorbidity, complications, and disease outcome were compared according to HIV status. Results. HIV-1 seroprevalence was 11% (74/655) in children under 15 years and 72% (49/68) in adults with severe malaria. Children with HIV coinfection presented with more severe acidosis, anemia, and respiratory distress, and higher peripheral blood parasitemia and plasma Plasmodium falciparum histidine-rich protein-2 (PfHRP2). During hospitalization, deterioration in coma score, convulsions, respiratory distress, and pneumonia were more common in HIV-coinfected children, and mortality was 26% (19/74) versus 9% (53/581) in uninfected children (P < .001). In an age- and antimalarial treatment–adjusted logistic regression model, significant, independent predictors for death were renal impairment, acidosis, parasitemia, and plasma PfHRP2 concentration. Conclusions. Severe malaria in HIV-coinfected patients presents with higher parasite burden, more complications, and comorbidity, and carries a higher case fatality rate. Early identification of HIV coinfection is important for the clinical management of severe malaria. PMID:22752514
Dawson, Kristine; Gordon, Barbara J; Guend, Abdelhani
Despite recent advances in the prevention and treatment of stroke, it remains one of the leading causes of death in Wisconsin and the nation. This report examines trends in stroke mortality in Wisconsin over the past two decades and assesses progress toward reaching the Healthier People in Wisconsin 2000 objective of a 33% reduction in stroke mortality. Trends in stroke mortality for Wisconsin were examined across gender, age, and racial subgroups. Stroke mortality rates (ICD-9 430-438) were extracted from the Centers for Disease Control and Prevention's database via WONDER, for the period 1979-1998. Overall stroke mortality rates in Wisconsin decreased 11% from 1984-1986 to 1996-1998. Blacks had higher stroke mortality rates than whites, and males had higher rates than females. From 1984 to 1998, stroke mortality decreased more in men than in women for both races. In blacks under 65, both males and females experienced an increase in stroke mortality from 1984 to 1998. This analysis indicates mixed progress in the reduction of stroke mortality in Wisconsin. As of 1998, Wisconsin had not made enough progress to enable it to meet the public health agenda goal for the year 2000.
Dobson, Gregory; Haas, Curtis E.; Tilson, David
Abstract In recent years, many US hospitals embarked on “lean” projects to reduce waste. One advantage of the lean operational improvement methodology is that it relies on process observation by those engaged in the work and requires relatively little data. However, the thoughtful analysis of the data captured by operational systems allows the modeling of many potential process options. Such models permit the evaluation of likely waste reductions and financial savings before actual process changes are made. Thus the most promising options can be identified prospectively, change efforts targeted accordingly, and realistic targets set. This article provides one example of such a datadriven process redesign project focusing on waste reduction in an in-hospital pharmacy. A mathematical model of the medication prepared and delivered by the pharmacy is used to estimate the savings from several potential redesign options (rescheduling the start of production, scheduling multiple batches, or reordering production within a batch) as well as the impact of information system enhancements. The key finding is that mathematical modeling can indeed be a useful tool. In one hospital setting, it estimated that waste could be realistically reduced by around 50% by using several process changes and that the greatest benefit would be gained by rescheduling the start of production (for a single batch) away from the period when most order cancellations are made. PMID:25477580
Taylor, Mark; Macpherson, Melanie; Macleod, Callum; Lyons, Donald
Aims and method Community treatment orders (CTOs) were introduced in Scotland in 2005, but are controversial owing to a lack of supportive randomised evidence. The non-randomised studies provide mixed results on their efficacy and utility. We aimed to examine hospital bed day usage across Scotland both before and after CTOs were initiated in a national cohort of patients, spanning 5 years. Results In total, 1558 individuals who were subject to a CTO between 2007 and 2012, of whom 63% were male, were included. After CTO initiation the number of hospital bed days fell, on average, from 66 to 39 per annum per patient. Those with a longer psychiatric history appeared to benefit more from a CTO, in terms of reduced time in hospital. Clinical implications Our data offer cautious support for the use of CTOs in routine practice, in terms of reducing time spent in psychiatric hospital. This finding is balanced by the more rigorous randomised studies which do not find any benefit to CTOs. PMID:27280031
Tilson, Vera; Dobson, Gregory; Haas, Curtis E; Tilson, David
In recent years, many US hospitals embarked on "lean" projects to reduce waste. One advantage of the lean operational improvement methodology is that it relies on process observation by those engaged in the work and requires relatively little data. However, the thoughtful analysis of the data captured by operational systems allows the modeling of many potential process options. Such models permit the evaluation of likely waste reductions and financial savings before actual process changes are made. Thus the most promising options can be identified prospectively, change efforts targeted accordingly, and realistic targets set. This article provides one example of such a datadriven process redesign project focusing on waste reduction in an in-hospital pharmacy. A mathematical model of the medication prepared and delivered by the pharmacy is used to estimate the savings from several potential redesign options (rescheduling the start of production, scheduling multiple batches, or reordering production within a batch) as well as the impact of information system enhancements. The key finding is that mathematical modeling can indeed be a useful tool. In one hospital setting, it estimated that waste could be realistically reduced by around 50% by using several process changes and that the greatest benefit would be gained by rescheduling the start of production (for a single batch) away from the period when most order cancellations are made.
Itoh, Tomonori; Nakajima, Satoshi; Tanaka, Fumitaka; Nishiyama, Osamu; Matsumoto, Tatsuya; Endo, Hiroshi; Sakai, Toshiaki; Nakamura, Motoyuki; Morino, Yoshihiro
The aims of this study were to evaluate reperfusion rate, therapeutic time course and in-hospital mortality pre- and post-Japan earthquake disaster, comparing patients with ST-elevation myocardial infarction (STEMI) treated in the inland area or the Tsunami-stricken area of Iwate prefecture. Subjects were 386 consecutive STEMI patients admitted to the four percutaneous coronary intervention (PCI) centers in Iwate prefecture in 2010 and 2011. Patients were divided into two groups: those treated in the inland or Tsunami-stricken area. We compared clinical characteristics, time course and in-hospital mortality in both years in the two groups. PCI was performed in 310 patients (80.3%). Door-to-balloon (D2B) time in the Tsunami-stricken area in 2011 was significantly shorter than in 2010 in patients treated with PCI. However, the rate of PCI performed in the Tsunami-stricken area in March-April 2011 was significantly lower than that in March-April 2010 (41.2% vs 85.7%; p=0.03). In-hospital mortality increased three-fold from 7.1% in March-April 2010 to 23.5% in March-April 2011 in the Tsunami-stricken area. Standardized mortality ratio (SMR) in March-April 2011 in the Tsunami-stricken area was significantly higher than the control SMR (SMR 4.72: 95% confidence interval (CI): 1.77-12.6: p=0.007). The rate of PCI decreased and in-hospital mortality increased immediately after the Japan earthquake disaster in the Tsunami-stricken area. Disorder in hospitals and in the distribution systems after the disaster impacted the clinical care and outcome of STEMI patients. © The European Society of Cardiology 2014.
Nimptsch, Ulrike; Peschke, Dirk; Mansky, Thomas
In 2008 the 'Initiative Qualitätsmedizin' (initiative for quality in medical care, IQM) was established as a voluntary non-profit association of hospital providers of all kinds of ownership. Currently, about 350 hospitals from Germany and Switzerland participate in IQM. Member hospitals are committed to a quality strategy based on measuring outcome indicators using administrative data, peer review procedures to improve medical quality, and transparency by public reporting. This study aims to investigate whether voluntary implementation of this approach is associated with improvements in medical outcome. Within a retrospective before-after study 63 hospitals, which started to participate in IQM between 2009 and 2011, were monitored. In-hospital mortality in these hospitals was studied for 14 selected inpatient services in comparison to the German national average. The analyses examine whether in-hospital mortality declined after participation of the studied hospitals in IQM, independently of secular trends or deviations in case mix when compared to the national average, and whether such findings were associated with initial hospital performance or peer review procedures. Declining in-hospital mortality was observed in hospitals with initially subpar performance. These declines were statistically significant for treatment of myocardial infarction, heart failure, pneumonia, and septicemia. Similar, but statistically non-significant trends were observed for nine further treatments. Following peer-review procedures significant declines in in-hospital mortality were observed for treatments of myocardial infarction, heart failure, and pneumonia. Mortality declines after peer reviews regarding stroke, hip fracture and colorectal resection were not significant, and after peer reviews regarding mechanically ventilated patients no changes were observed. The results point to a positive impact of the quality approach applied by IQM on clinical outcomes. A more targeted
Argalious, Maged Y; You, Jing; Mao, Guangmei; Ramos, Daniel; Khanna, Sandeep; Maheshwari, Kamal; Trombetta, Carlos
Whether patients on testosterone replacement therapy undergoing noncardiac surgery have an increased risk of postoperative in-hospital mortality and cardiovascular events remains unknown. We therefore sought to identify the impact of testosterone replacement on the incidence of a composite of postoperative in-hospital mortality and cardiovascular events in men undergoing noncardiac surgery. Data from male American Society of Anesthesiologists I through IV patients 40 yr or older who underwent noncardiac surgery between May 2005 and December 2015 at the Cleveland Clinic (Cleveland, Ohio) main campus were included. The primary exposure was preoperative testosterone use. The primary outcome was a composite of postoperative in-hospital mortality and cardiovascular events. We compared patients who received testosterone and those who did not using propensity score matching within surgical procedure matches. Among 49,273 patients who met inclusion and exclusion criteria, 947 patients on testosterone were matched to 4,598 nontestosterone patients. The incidence of in-hospital mortality was 1.3% in the testosterone group and 1.1% in the nontestosterone group, giving an odds ratio of 1.17 (99% CI, 0.51 to 2.68; P = 0.63). The incidence of myocardial infarction was 0.2% in the testosterone group and 0.6% in the nontestosterone group (odds ratio = 0.34; 99% CI, 0.05 to 2.28; P = 0.15). Similarly, no significant difference was found in stroke (testosterone vs. nontestosterone: 2.0% vs. 2.1%), pulmonary embolism (0.5% vs. 0.7%), or deep venous thrombosis (2.0% vs. 1.7%). Preoperative testosterone is not associated with an increased incidence of a composite of postoperative in-hospital mortality and cardiovascular events.
Impact of chronic obstructive pulmonary disease on in-hospital morbidity and mortality in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention.
Șerban, Răzvan Constantin; Hadadi, Laszlo; Șuș, Ioana; Lakatos, Eva Katalin; Demjen, Zoltan; Scridon, Alina
Patients with chronic obstructive pulmonary disease (COPD) presenting with ST-segment elevation myocardial infarction (STEMI) are less likely to beneficiate of primary percutaneous coronary intervention (pPCI), and have poorer prognosis. We aimed to evaluate the impact of COPD on the in-hospital outcomes of pPCI-treated STEMI patients. Data were collected from 418 STEMI patients treated by pPCI. Inotropics and diuretics usage, cardiogenic shock, asystole, kidney dysfunction, and left ventricular ejection fraction were used as markers of hemodynamic complications. Atrial and ventricular fibrillation, conduction disorders, and antiarrhythmics usage were used as markers of arrhythmic complications. In-hospital mortality was evaluated. The associations between these parameters and COPD were assessed. COPD was present in 7.42% of STEMI patients. COPD patients were older (p=0.02) and less likely to receive beta-blockers (OR 0.29; 95%CI 0.13-0.64; p<0.01). They had higher Killip class on admission (p<0.001), received more often inotropics (p<0.001) and diuretics (p<0.01), and presented more often atrial (p=0.01) and ventricular fibrillation (p=0.02). Unadjusted in-hospital mortality was higher in COPD patients (OR 4.18, 95%CI 1.55-11.30, p<0.01). After adjustment for potentially confounding factors except beta-blockers, COPD remained an independent predictor of in-hospital mortality (p=0.02). After further adjustment with beta-blocker therapy, no excess mortality was noted in COPD patients. Despite being treated by pPCI, COPD patients with STEMI are more likely to develop hemodynamic and arrhythmic complications, and have higher in-hospital mortality. This appears to be due to lower beta-blockers usage in COPD patients. Increasing beta-blockers usage in COPD patients with STEMI may improve survival. Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.
Ahmadi, Ali; Khaledifar, Arsalan; Sajjadi, Homeira; Soori, Hamid
Since no hospital-based, nationwide study has been yet conducted on the association between risk factors and in-hospital mortality due to myocardial infarction (MI) by educational level in Iran, the present study was conducted to investigate relationship between risk factors and in-hospital mortality due to MI by educational level. In this nationwide hospital-based, prospective analysis, follow-up duration was from definite diagnosis of MI to death. The cohort of the patients was defined in view of the date at diagnosis, hospitalization and the date at discharge (recovery or in-hospital death due to MI). 20750 patients hospitalized for newly diagnosed MI between April, 2012 and March, 2013 comprised sample size. Totally, 2511 deaths due to MI were obtained. The data on education level (four-level) were collected based on years of schooling. To determine in-hospital mortality rate and the associated factors with mortality, seven statistical models were developed using Cox proportional hazards models. Of the studied patients, 9611 (6.1%) had no education. in-hospital mortality rate was 8.36 (95% CI: 7.81-8.9) in women and 6.12 (95% CI: 5.83-6.43) in men per 100 person-years. This rate was 5.56 in under 65-year-old patients and 8.37 in over 65-year-old patients. This rate in the patients with no, primary, high school, and academic education was respectively 8.11, 6.11, 4.85 and 5.81 per 100 person-years. Being woman, chest pain prior to arriving in hospital, lack of thrombolytic therapy, right bundle branch block, ventricular tachycardia, smoking and ST-segment elevation myocardial infarction were significantly associated with increased hazard ratio (HR) of death. The adjusted HR of mortality was 1.27 (95% CI: 1.06-1.52), 0.93 (95% CI: 0.77-1.13), 0.72 (95% CI: 0.57-0.91) and 0.82 (95% CI: 0.66-1.01) in the patients with respectively illiterate, primary, secondary and high school education compared to academic education. A disparity was noted in post-MI mortality
Fabbian, Fabio; Pala, Marco; De Giorgi, Alfredo; Manfredini, Fabio; Mallozzi Menegatti, Alessandra; Salmi, Raffaella; Portaluppi, Francesco; Gallerani, Massimo; Manfredini, Roberto
In-hospital mortality of patients with myocardial infarction (MI) in different European populations and renal dysfunction is variable. We aimed to evaluate in-hospital mortality for MI in chronic kidney disease (CKD), in end-stage renal disease (ESRD), and in subjects admitted for MI without renal dysfunction living in the Emilia-Romagna region of Italy. We considered all cases of MI (first event) recorded in the database of hospital admissions of the region Emilia-Romagna of Italy, from January 1999 to December 2009. The criterion for inclusion was the presence, as a first discharge diagnosis, of acute MI (International Classification of Diseases, 9th Revision, Clinical Modification). The Charlson comorbidity index (CCI), with the exclusion of CKD, was calculated. The outcome variable was in-hospital mortality for MI, and its association with comorbidities, CKD and ESRD, was analyzed. During the considered period, 88,014 cases of first MI were recorded. The percentage of patients admitted with MI and died during hospitalization were higher in patients with ESRD (38.3 %) and CKD (16.5 %) than in those without renal dysfunction (14 %) (p < 0.01). In CKD and ESRD patients, data of in-hospital mortality for MI exhibited a twofold increase in the analyzed period. In-hospital mortality for MI was independently associated with age (OR 1.077, 95 % CI 1.075-1.080, p < 0.001), CCI excluding CKD (OR 1.101, 95 % CI 1.069-1.134, p < 0.001), cerebrovascular disease (OR 1.450, 95 % CI 1.349-1.557, p < 0.001), malignancy (OR 1.234, 95 % CI 1.153-1.320, p < 0.001), and ESRD (OR 4.137, 95 % CI 3.511-4.875, p < 0.001). As for the Emilia-Romagna region of Italy, in-hospital mortality for MI is increasing over the last years, and mortality seems to be related with patients' comorbidities and presence of advanced stages of CKD.
Hentzien, Maxime; Strady, Christophe; Vernet-Garnier, Véronique; Servettaz, Amélie; De Champs, Christophe; Delmer, Alain; Bani-Sadr, Firouzé; N'Guyen, Yohan
The impact of a minimum inhibitory concentration (MIC) of vancomycin ≥2 mg/L on mortality and the potential benefit of new antistaphylococcal treatments in coagulase-negative Staphylococcus (CoNS) bacteraemia remain unknown. We assessed the impact of vancomycin MIC on 30-day in-hospital mortality and identified factors independently associated with 30-day in-hospital mortality. All patients presenting significant CoNS bacteraemia in the university hospital of Reims, between 01 January 2008 and 31 December 2012, were included. Data were retrospectively extracted from the patient records. Vancomycin MIC was assessed using the E-test method, and antimicrobial susceptibility testing was performed in accordance with the recommendations of the Antibiogram Committee of the French Microbiology Society. Cox's Proportional Hazards model was used for multivariate analysis. Two hundred and sixty-nine patients (mean age 61.2 ± 15.7 years) were included. Foreign material was present in 92% of patients and 78.4% of isolated methicillin-resistant strains had vancomycin MIC ≥2 mg/l. Thirty-day in-hospital mortality was 16%. There was no association between vancomycin MIC ≥2 mg/l and 30-day in-hospital mortality (adjusted Hazard Ratio (aHR) = .80, 95% confidence interval (95%CI) [.30-2.19], p = .67). Factors independently associated with 30-day in-hospital mortality were age ≥75 vs. ≤60 years (aHR =3.72, 95%CI [1.39-9.97], p = .009), absence of active antibiotic treatment (aHR =5.52, 95%CI [1.13-26.87], p = .03) and acute renal failure (aHR =4.45, 95%CI [2.08-9.56], p < .0001). Removal of an infected device had a protective effect against 30-day in-hospital mortality (aHR = .23, 95%CI [.11-.48], p < .0001). These results suggest that CoNS bacteraemia should be managed by removal of the infected device and antibiotic treatment such as vancomycin.
Bergstrom, Carl T; Lo, Monique; Lipsitch, Marc
Hospital-acquired infections caused by antibiotic-resistant bacteria pose a grave and growing threat to public health. Antimicrobial cycling, in which two or more antibiotic classes are alternated on a time scale of months to years, seems to be a leading candidate in the search for treatment strategies that can slow the evolution and spread of antibiotic resistance in hospitals. We develop a mathematical model of antimicrobial cycling in a hospital setting and use this model to explore the efficacy of cycling programs. We find that cycling is unlikely to reduce either the evolution or the spread of antibiotic resistance. Alternative drug-use strategies such as mixing, in which each treated patient receives one of several drug classes used simultaneously in the hospital, are predicted to be more effective. A simple ecological explanation underlies these results. Heterogeneous antibiotic use slows the spread of resistance. However, at the scale relevant to bacterial populations, mixing imposes greater heterogeneity than does cycling. As a consequence, cycling is unlikely to be effective and may even hinder resistance control. These results may explain the limited success reported thus far from clinical trials of antimicrobial cycling.
Johnson, Natalie A; Kypri, Kypros; Latter, Joanna; Attia, John; McEvoy, Mark; Dunlop, Adrian; Scott, Rodney
reduce their drinking after receiving the feedback, and 37% reported that the feedback would affect how much they drink in the future. Results of this study suggest it would be feasible to conduct a methodologically robust trial estimating the effect of genetic susceptibility feedback on alcohol consumption in hospital outpatients with risky drinking.
Rickard, Greg; Lenthall, Sue; Dollard, Maureen; Opie, Tessa; Knight, Sabina; Dunn, Sandra; Wakerman, John; MacLeod, Martha; Seller, Jo; Brewster-Webb, Denise
To evaluate the impact of an organisational intervention aimed to reduce occupational stress and turnover rates of 55% in hospital nurses. The evaluation used a pre- and post-intervention design, triangulating data from surveys and archival information. Two public hospitals (H1 and H2) in the Northern Territory (NT) Australia participated in the intervention. 484 nurses from the two NT hospitals (H1, Wave 1, N = 103, Wave 2, N = 173; H2, Wave 1, N = 75, Wave 2, N = 133) responded to questionnaires administered in 2008 and in 2010. The intervention included strategies such as the development and implementation of a nursing workload tool to assess nurse workloads, roster audits, increased numbers of nursing personnel to address shortfall, increased access to clinical supervision and support for graduates, increased access to professional development including postgraduate and short courses, and a recruitment campaign for new graduates and continuing employees. We used an extended Job Demand-Resources framework to evaluate the intervention and 17 evaluation indicators canvassing psychological distress, emotional exhaustion, work engagement, job satisfaction, job demands, job resources, and system factors such as psychosocial safety climate. Turnover rates were obtained from archival data. Results demonstrated a significant reduction in psychological distress and emotional exhaustion and a significant improvement in job satisfaction, across both hospitals, and a reduction in turnover in H2 from 2008 and 2010. Evidence suggests that the intervention led to significant improvements in system capacity (adaptability, communication) in combination with a reduction in job demands in both hospitals, and an increase in resources (supervisor and coworker support, and job control) particularly in H1. The research addresses a gap in the theoretical and intervention literature regarding system/organisation level approaches to occupational stress. The approach was very successful
Targher, Giovanni; Dauriz, Marco; Laroche, Cécile; Temporelli, Pier Luigi; Hassanein, Mahmoud; Seferovic, Petar M; Drozdz, Jaroslaw; Ferrari, Roberto; Anker, Stephan; Coats, Andrew; Filippatos, Gerasimos; Crespo-Leiro, Maria G; Mebazaa, Alexandre; Piepoli, Massimo F; Maggioni, Aldo Pietro; Tavazzi, Luigi
The aim of this study was to evaluate the in-hospital and 1-year prognostic impact of diabetes and elevated blood glucose levels at hospital admission in patients with acute heart failure (HF). We studied a multinational cohort of 6926 hospitalized patients with acute HF enrolled in the European Society of Cardiology (ESC) and Heart Failure Association (HFA) Long-Term Registry, of whom 49.4% (n = 3422) had known or previously undiagnosed diabetes (defined as self-reported history, or medication use, or fasting glucose levels ≥7.0 mmol/L or haemoglobin A1c ≥6.5%). Compared with those without diabetes, patients with known or previously undiagnosed diabetes had higher cumulative rates of in-hospital mortality, 1-year mortality, and 1-year HF re-hospitalization that occurred independently of multiple clinical risk factors: in-hospital mortality [6.8 vs. 4.4%; adjusted hazard ratio (HR) 1.774; 95% confidence interval (CI) 1.282-2.456, P < 0.001], 1-year all-cause mortality (27.5 vs. 24%; adjusted HR 1.162; 95% CI 1.020-1.325, P = 0.024), and 1-year hospital re-admissions for HF (23.2 vs. 18.5%; adjusted HR 1.320; 95% CI 1.139-1.530, P < 0.001). Moreover, elevated admission blood glucose concentrations were powerfully prognostic for in-hospital mortality, but not for 1-year mortality or re-hospitalizations, in both patients with and without diabetes. Among patients hospitalized for acute HF, the presence of diabetes is independently associated with an increased risk of in-hospital mortality, 1-year all-cause mortality, and 1-year re-hospitalizations for HF, underscoring the need for more effective and personalized treatments of diabetes in this particularly high-risk patient population. © 2016 The Authors. European Journal of Heart Failure © 2016 European Society of Cardiology.
Lopez-de-Andres, Ana; Hernandez-Barrera, Valentin; Lopez, Roberto; Martin-Junco, Pablo; Jimenez-Trujillo, Isabel; Alvaro-Meca, Alejandro; Salinero-Fort, Miguel Angel; Jimenez-Garcia, Rodrigo
Outcome prediction is important in the clinical decision-making process. Artificial neural networks (ANN) have been used to predict the risk of post-operative events, including survival, and are increasingly being used in complex medical decision making. We aimed to use ANN analysis to estimate predictive factors of in-hospital mortality (IHM) in patients with type 2 diabetes (T2DM) after major lower extremity amputation (LEA) in Spain. We design a retrospective, observational study using ANN models. We used the Spanish National Hospital Discharge Database to select all hospital admissions of major LEA procedure in T2DM patients. Predictors of IHM using 4 ANN models: i) with all discharge diagnosis included in the database; ii) with all discharge diagnosis included in the database, excluding infectious diseases; iii) comorbidities included in the Charlson Comorbidities Index; iv) comorbidities included in the Elixhauser Comorbidity Index. From 2003 to 2013, 40,857 major LEAs in patients with T2DM were identified with a 10.0% IHM. We found that Elixhauser Comorbidity Index model performed better in terms of sensitivity, specificity and precision than Charlson Comorbidity Index model (0.7634 vs 0.7444; 0.9602 vs 0.9121; 0.9511 vs 0.888, respectively). The area under the ROC curve for Elixhauser comorbidity model was 91.7% (95% CI 90.3-93.0) and for Charlson comorbidity model was 88.9% (95% CI; 87.590.2) p = 0.043. Models including all discharge diagnosis with and without infectious diseases showed worse results. In the Elixhauser Comorbidity Index model the most sensitive parameter was age (variable sensitive ratio [VSR] 1.451) followed by female sex (VSR 1.433), congestive heart failure (VSR 1.341), renal failure (VSR 1.274) and chronic pulmonary disease (VSR 1.266). Elixhauser Comorbidity Index is a superior comorbidity risk-adjustment model for major LEA survival prediction in patients with T2DM than Charlson Comorbidity Index model using ANN models. Female
Sakhnini, Ali; Saliba, Walid; Schwartz, Naama; Bisharat, Naiel
Limited information is available about clinical predictors of in-hospital mortality in acute unselected medical admissions. Such information could assist medical decision-making.To develop a clinical model for predicting in-hospital mortality in unselected acute medical admissions and to test the impact of secondary conditions on hospital mortality.This is an analysis of the medical records of patients admitted to internal medicine wards at one university-affiliated hospital. Data obtained from the years 2013 to 2014 were used as a derivation dataset for creating a prediction model, while data from 2015 was used as a validation dataset to test the performance of the model. For each admission, a set of clinical and epidemiological variables was obtained. The main diagnosis at hospitalization was recorded, and all additional or secondary conditions that coexisted at hospital admission or that developed during hospital stay were considered secondary conditions.The derivation and validation datasets included 7268 and 7843 patients, respectively. The in-hospital mortality rate averaged 7.2%. The following variables entered the final model; age, body mass index, mean arterial pressure on admission, prior admission within 3 months, background morbidity of heart failure and active malignancy, and chronic use of statins and antiplatelet agents. The c-statistic (ROC-AUC) of the prediction model was 80.5% without adjustment for main or secondary conditions, 84.5%, with adjustment for the main diagnosis, and 89.5% with adjustment for the main diagnosis and secondary conditions. The accuracy of the predictive model reached 81% on the validation dataset.A prediction model based on clinical data with adjustment for secondary conditions exhibited a high degree of prediction accuracy. We provide a proof of concept that there is an added value for incorporating secondary conditions while predicting probabilities of in-hospital mortality. Further improvement of the model performance
de Almeida, Carlos Podalirio Borges; Couban, Rachel; Kallyth, Sun Makosso; Cabral, Vagner Kunz; Craigie, Samantha; Busse, Jason Walter; Silva, Denise Rossato
Introduction Tuberculosis (TB) continues to be a major public health issue worldwide, with 1.4 million deaths occurring annually. There is uncertainty regarding which factors are associated with in-hospital mortality among patients with pulmonary TB. This knowledge gap complicates efforts to identify and improve the management of those individuals with TB at greatest risk of death. The aim of this systematic review and meta-analysis is to establish predictors of in-hospital mortality among patients with pulmonary TB to enhance the evidence base for public policy. Methods and analysis Studies will be identified by a MEDLINE, EMBASE and Global Health search. Eligible studies will be cohort and case–control studies that report predictors or risk factors for in-hospital mortality among patients with pulmonary TB and an adjusted analysis to explore factors associated with in-hospital mortality. We will use the Grading of Recommendations Assessment, Development and Evaluation approach to summarise the findings of some reported predictors. Teams of 2 reviewers will screen the titles and abstracts of all citations identified in our search, independently and in duplicate, extract data, and assess scientific quality using standardised forms quality assessment and tools tailored. We will pool all factors that were assessed for an association with mortality that were reported by >1 study, and presented the OR and the associated 95% CI. When studies provided the measure of association as a relative risk (RR), we will convert the RR to OR using the formula provided by Wang. For binary data, we will calculate a pooled OR, with an associated 95% CI. Ethics and dissemination This study is based on published data, and therefore ethical approval is not a requirement. Findings will be disseminated through publication in peer-reviewed journals and conference presentations at relevant conferences. Trial registration number CRD42015025755. PMID:27884842
Morshed, Saam; Miclau, Theodore; Bembom, Oliver; Cohen, Mitchell; Knudson, M Margaret; Colford, John M
Fractures of the femoral shaft are common and have potentially serious consequences in patients with multiple injuries. The appropriate timing of fracture repair is controversial. The purpose of the present study was to assess the effect of timing of internal fixation on mortality in patients with multisystem trauma. We performed a retrospective cohort study with use of data from public and private trauma centers throughout the United States that were reported to the National Trauma Data Bank (version 5.0 for 2000 through 2004). The study included 3069 patients with multisystem trauma (Injury Severity Score, > or =15) who underwent internal fixation of a femoral shaft fracture. The time to treatment was defined in categories as the time from admission to internal fixation: t(0) (twelve hours or less), t(1) (more than twelve hours to twenty-four hours), t(2) (more than twenty-four hours to forty-eight hours), t(3) (more than forty-eight hours to 120 hours), and t(4) (more than 120 hours). The relative risk of in-hospital mortality when the four later periods were compared with the earliest one was estimated with inverse probability of treatment-weighted analysis. Subgroups with serious head or neck, chest, abdominal, and additional extremity injury were investigated. When compared with that during the first twelve hours after admission, the estimated mortality risk was significantly lower in three time categories: t(1) (relative risk, 0.45; 95% confidence interval, 0.15 to 0.98; p = 0.03), t(3) (relative risk, 0.58; 95% confidence interval, 0.28 to 0.93; p = 0.03), and t(4) (relative risk, 0.43; 95% confidence interval, 0.10 to 0.94; p = 0.03). Patients with serious abdominal trauma (Abbreviated Injury Score, > or =3) experienced the greatest benefit from a delay of internal fixation beyond twelve hours (relative risk, 0.82 [95% confidence interval, 0.54 to 1.35] for patients with an Abbreviated Injury Score of <3, compared with 0.36 [95% confidence interval, 0
Moretti, Maurizio; Fagnani, Stefano
Purpose Mucolytics can improve disease outcome in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The objectives of this study were to investigate the effects of erdosteine (ER), a mucolytic agent with antioxidant activity, on systemic inflammation, symptoms, recurrence of exacerbation, and time to first exacerbation postdischarge in hospitalized patients with AECOPD. Patients and methods Patients admitted to hospital with AECOPD were randomized to receive either ER 900 mg daily (n=20) or a matching control (n=20). Treatment was continued for 10 days until discharge. Patients also received standard treatment with steroids, nebulized bronchodilators, and antibiotics as appropriate. Serum C-reactive protein levels, lung function, and breathlessness–cough–sputum scale were measured on hospital admission and thereafter at days 10 and 30 posttreatment. Recurrence of AECOPD-requiring antibiotics and/or oral steroids and time to first exacerbation in the 2 months (days 30 and 60) postdischarge were also assessed. Results Mean serum C-reactive protein levels were lower in both groups at days 10 and 30, compared with those on admission, with significantly lower levels in the ER group at day 10. Improvements in symptom score and forced expiratory volume in 1 second were greater in the ER than the control group, which reached statistical significance on day 10. ER was associated with a 39% lower risk of exacerbations and a significant delay in time to first exacerbation (log-rank test P=0.009 and 0.075 at days 30 and 60, respectively) compared with controls. Conclusion Results confirm that the addition of ER (900 mg/d) to standard treatment improves outcomes in patients with AECOPD. ER significantly reduced airway inflammation, improved the symptoms of AECOPD, and prolonged time to first exacerbation. The authors suggest ER could be most beneficial in patients with recurring, prolonged, and/or severe exacerbations of COPD. PMID
Dehghan, Niloofar; Mah, Jeffrey M; Schemitsch, Emil H; Nauth, Aaron; Vicente, Milena; McKee, Michael D
To determine the prevalence, management and outcomes of patients with flail chest injuries, compared to patients without flail chest injuries (single rib fractures and multiple rib fractures without a flail segment). Retrospective cohort study SETTING:: Ontario, Canada PARTICIPANTS:: Ontario residents over the age of 16 who had been admitted to hospital with a chest wall injury from 2004 to 2015 were identified using administrative health care databases. Outcomes included treatment modalities such as rate of surgical repair, days on mechanical ventilation, days in the intensive care unit (ICU), days in hospital, rate of chest tube placement; and rates of complication, including pneumonia, tracheostomy, readmission, and death. In total 117,204 patients with fractures of the chest wall were identified. Of the entire cohort, 1.5% of had a flail chest injury, 41% had multiple rib fractures and 58% had single rib fractures. Flail chest patients had significantly worst outcomes compared to multiple rib fracture patients in all categories (p<0.0001). Similarly, multiple rib fracture patients had significantly worst outcomes compared to single rib fracture patients (p<0.0001). Only 4.5% of flail chest patients were treated surgically, however the number increased from 1% prior to 2010 to 10% after 2010 (p<0.0001). After adjustment for potential confounders, patients with flail chest injuries treated surgically had a reduced risk of early mortality compared to those treated non-operatively (OR 0.16, p=0.019). Surgical stabilization of flail chest has increased significantly in recent years. The results of this study provide preliminary evidence that the increasing rate of surgical intervention may be warranted by reducing mortality. Level III.
Delano, Matthew J.; Ward, Peter A.
Sepsis is a systemic inflammatory response induced by an infection, leading to organ dysfunction and mortality. Historically, sepsis-induced organ dysfunction and lethality were attributed to the interplay between inflammatory and antiinflammatory responses. With advances in intensive care management and goal-directed interventions, early sepsis mortality has diminished, only to surge later after “recovery” from acute events, prompting a search for sepsis-induced alterations in immune function. Sepsis is well known to alter innate and adaptive immune responses for sustained periods after clinical “recovery,” with immunosuppression being a prominent example of such alterations. Recent studies have centered on immune-modulatory therapy. These efforts are focused on defining and reversing the persistent immune cell dysfunction that is associated with mortality long after the acute events of sepsis have resolved. PMID:26727230
Sasaki, Noriko; Kunisawa, Susumu; Ikai, Hiroshi; Imanaka, Yuichi
Objectives Although current case-mix classifications in prospective payment systems were developed to estimate patient resource usage, whether these classifications reflect clinical outcomes remains unknown. The efficient management of acute heart failure (AHF) with high mortality is becoming more important in many countries as its prevalence and associated costs are rapidly increasing. Here, we investigate the determinants of in-hospital mortality and hospitalisation costs to clarify the impact of severity factors on these outcomes in patients with AHF, and examine the level of agreement between the predicted values of mortality and costs. Design Cross-sectional observational study. Setting and participants A total of 19 926 patients with AHF from 261 acute care hospitals in Japan were analysed using administrative claims data. Main outcome measures Multivariable logistic regression analysis and linear regression analysis were performed to examine the determinants of in-hospital mortality and hospitalisation costs, respectively. The independent variables were grouped into patient condition on admission, postadmission procedures indicating disease severity (eg, intra-aortic balloon pumping) and other high-cost procedures (eg, single-photon emission CT). These groups of independent variables were cumulatively added to the models, and their effects on the models' abilities to predict the respective outcomes were examined. The level of agreement between the quartiles of predicted mortality and predicted costs was analysed using Cohen's κ coefficient. Results In-hospital mortality was associated with patient's condition on admission and severity-indicating procedures (C-statistics 0.870), whereas hospitalisation costs were associated with severity-indicating procedures and high-cost procedures (R2 0.32). There were substantial differences in determinants between the outcomes. In addition, there was no consistent relationship observed (κ=0.016, p<0.0001) between the
López-Herce, Jesús; del Castillo, Jimena; Matamoros, Martha; Canadas, Sonia; Rodriguez-Calvo, Ana; Cecchetti, Corrado; Rodríguez-Núnez, Antonio; Carrillo, Ángel
Most studies have analyzed pre-arrest and resuscitation factors associated with mortality after cardiac arrest (CA) in children, but many patients that reach return of spontaneous circulation die within the next days or weeks. The objective of our study was to analyze post-return of spontaneous circulation factors associated with in-hospital mortality after cardiac arrest in children. A prospective multicenter, multinational, observational study in 48 hospitals from 12 countries was performed. A total of 502 children aged between 1 month and 18 years with in-hospital cardiac arrest were analyzed. The primary endpoint was survival to hospital discharge. Univariate and multivariate logistic regression analyses were performed to assess the influence of each post-return of spontaneous circulation factor on mortality. Return of spontaneous circulation was achieved in 69.5% of patients; 39.2% survived to hospital discharge and 88.9% of survivors had good neurological outcome. In the univariate analysis, post- return of spontaneous circulation factors related with mortality were pH, base deficit, lactic acid, bicarbonate, FiO2, need for inotropic support, inotropic index, dose of dopamine and dobutamine at 1 hour and at 24 hours after return of spontaneous circulation as well as Pediatric Intensive Care Unit and total hospital length of stay. In the multivariate analysis factors associated with mortality at 1 hour after return of spontaneous circulation were PaCO2 < 30 mmHg and >50 mmHg, inotropic index >14 and lactic acid >5 mmol/L. Factors associated with mortality at 24 hours after return of spontaneous circulation were PaCO2 > 50 mmHg, inotropic index >14 and FiO2 ≥ 0.80. Secondary in-hospital mortality among the initial survivors of CA is high. Hypoventilation, hyperventilation, FiO2 ≥ 0.80, the need for high doses of inotropic support, and high levels of lactic acid were the most important post-return of spontaneous circulation factors associated with in-hospital
van Rheenen, Susan; Watson, Timothy W J; Alexander, Shelley; Hill, Michael D
Despite advances in the quality and delivery of stroke care, regional disparities in stroke incidence and outcome persist. Spatial analysis using geographic information systems (GIS) can assist in identifying high-risk populations and regional differences in efficacy of stroke care. The aim of this study was to identify and locate geographic clusters of high or low rates of stroke, risk factors, and in-hospital mortality across a provincial health care network in Alberta, Canada. This study employed a spatial epidemiological approach using population-based hospital administrative data. Getis-Ord Gi* and Spatial Scan statistics were used to identify and locate statistically significant "hot" and "cold" spots of stroke occurrence by type, risk factors, and in-hospital mortality. Marked regional variations were found. East central Alberta was a significant hot spot for ischemic stroke (relative risk [RR] 1.43, p<0.001), transient ischemic attack (RR 2.25, p<0.05), and in-hospital mortality (RR 1.50, p<0.05). Hot spots of intracerebral hemorrhage (RR 1.80, p<0.05) and subarachnoid hemorrhage (RR 1.64, p<0.05) were identified in a major urban centre. Unexpectedly, stroke risk factor hot spots (RR 2.58, p<0.001) were not spatially associated (did not overlap) with hot spots of ischemic stroke, transient ischemic attack, or in-hospital mortality. Integration of health care administrative data sets with geographic information systems contributes valuable information by identifying the existence and location of regional disparities in the spatial distribution of stroke occurrence and outcomes. Findings from this study raise important questions regarding why regional differences exist and how disparities might be mitigated.
Huang, Ya-Ting; Tseng, Yuan-Teng; Chu, Tung-Wei; Chen, John; Lai, Min-Yu; Tang, Woung-Ru; Shiao, Chih-Chung
Serum N-terminal pro b-type natriuretic peptide (NT-pro-BNP) testing is recommended in the patients with heart failure (HF). We hypothesized that NT-pro-BNP, in combination with other clinical factors in terms of a novel NT-pro BNP-based score, may provide even better predictive power for in-hospital mortality among patients with HF. A retrospective study enrolled adult patients with hospitalization-requiring HF who fulfilled the predefined criteria during the period from January 2011 to December 2013. We proposed a novel scoring system consisting of several independent predictors including NT-pro-BNP for predicting in-hospital mortality, and then compared the prognosis-predictive power of the novel NT-pro BNP-based score with other prognosis-predictive scores. A total of 269 patients were enrolled in the current study. Factors such as “serum NT-pro-BNP level above 8100 mg/dl,” “age above 79 years,” “without taking angiotensin converting enzyme inhibitors/angiotensin receptor blocker,” “without taking beta-blocker,” “without taking loop diuretics,” “with mechanical ventilator support,” “with non-invasive ventilator support,” “with vasopressors use,” and “experience of cardio-pulmonary resuscitation” were found as independent predictors. A novel NT-pro BNP-based score composed of these risk factors was proposed with excellent predictability for in-hospital mortality. The proposed novel NT-pro BNP-based score was extremely effective in predicting in-hospital mortality in HF patients. PMID:27411951
Mamic, Petra; Heidenreich, Paul A; Hedlin, Haley; Tennakoon, Lakshika; Staudenmayer, Kristan L
Patients with heart failure (HF) are frequently hospitalized with common bacterial infections. It is unknown whether they experience concomitant Clostridium difficile infection (CDI) more frequently than patients without HF, and whether CDI affects their mortality. We used 2012 National Inpatient Sample data to determine the rate of CDI and associated in-hospital mortality for hospitalized patients with comorbid HF and urinary tract infection (UTI), pneumonia (PNA), or sepsis. Univariate and multivariate analyses were performed. Weighted data are presented. There were an estimated 5,851,582 patient hospitalizations with discharge diagnosis of UTI, PNA, or sepsis in 2012 in the United States. Of these, 23.4% had discharge diagnosis of HF. Patients with HF were on average older and had more comorbidities. CDI rates were higher in hospitalizations with discharge diagnosis of HF compared with those without HF (odds ratio 1.13, 95% confidence interval 1.10-1.16) after controlling for patient demographics and comorbidities and hospital characteristics. Among HF hospitalizations with UTI, PNA, or sepsis, those with concomitant CDI had a higher in-hospital mortality than those without concomitant CDI (odds ratio 1.81, 95% confidence interval 1.71-1.92) after controlling for the covariates outlined previously. HF is associated with higher CDI rates among hospitalized patients with other common bacterial infections, even when adjusting for other known risk factors for CDI. Among these patients with comorbid HF, CDI is associated with markedly higher in-hospital mortality. These findings may suggest an opportunity to improve outcomes for hospitalized patients with HF and common bacterial infections, possibly through improved Clostridium difficile screening and prophylaxis protocols. Copyright © 2016 Elsevier Inc. All rights reserved.
Collier, C J; Waycott, M
Extreme heating (up to 43 °C measured from five-year temperature records) occurs in shallow coastal seagrass meadows of the Great Barrier Reef at low tide. We measured effective quantum yield (ϕPSII), growth, senescence and mortality in four tropical seagrasses to experimental short-duration (2.5h) spikes in water temperature to 35 °C, 40 °C and 43 °C, for 6 days followed by one day at ambient temperature. Increasing temperature to 35 °C had positive effects on ϕPSII (the magnitude varied between days and was highly correlated with PPFD), with no effects on growth or mortality. 40 °C represented a critical threshold as there were strong species differences and there was a large impact on growth and mortality. At 43 °C there was complete mortality after 2-3 days. These findings indicate that increasing duration (more days in a row) of thermal events above 40 °C is likely to affect the ecological function of tropical seagrass meadows. Copyright © 2014 Elsevier Ltd. All rights reserved.
Rasooly, Mohammad Hafiz; Govindasamy, Pav; Aqil, Anwer; Rutstein, Shea; Arnold, Fred; Noormal, Bashiruddin; Way, Ann; Brock, Susan; Shadoul, Ahmed
After the collapse of the Taliban regime in 2002, Afghanistan adopted a new development path and billions of dollars were invested in rebuilding the country's economy and health systems with the help of donors. These investments have led to substantial improvements in maternal and child health in recent years and ultimately to a decrease in maternal and child mortality. The 2010 Afghanistan Mortality Survey (AMS) provides important new information on the levels and trends in these indicators. The AMS estimated that there are 327 maternal deaths for every 100,000 live births (95% confidence interval = 260-394) and 97 deaths before the age of five years for every 1000 children born. Decreases in these mortality rates are consistent with changes in key determinants of mortality, including an increasing age at marriage, higher contraceptive use, lower fertility, better immunisation coverage, improvements in the percentage of women delivering in health facilities and receiving antenatal and postnatal care, involvement of community health workers and increasing access to the Basic Package of Health Services. Despite the impressive gains in these areas, many challenges remain. Further improvements in health services in Afghanistan will require sustained efforts on the part of both the Government of Afghanistan and international donors.
Sarhangian, V; Abouee-Mehrizi, H; Baron, O; Berman, O; Heddle, N M; Barty, R
Although recent randomized controlled trials have not found increased risk of morbidity/mortality with older red blood cells (RBCs), several large trials will be completed soon providing power to detect smaller risks if indeed they exist. Hence, there may still be a need for inventory management policies that could reduce the age of transfused RBCs without compromising availability or resulting in excessive outdates. We developed a computer simulation model based on data from an acute care hospital in Hamilton, Ontario. We evaluated and compared the performance of certain practical ordering and allocation policies in terms of outdate rate, shortage rate and the distribution of the age of issued RBCs. During the 1-year period for which we analysed the data, 10349 RBC units were transfused with an average issue age of 20·7 days and six units were outdated (outdate rate: 0·06%). Adopting a strict first in, first out (FIFO) allocation policy and an order-up-to ordering policy with target levels set to five times the estimated daily demand for each blood type, reduced the average issue age by 29·4% (to 14·6 days), without an increase in the outdate rate (0·05%) or resulting in any unmet demand. Further reduction of issue age without a significant increase in outdate rate was observed when adopting non-FIFO threshold-based allocation policies and appropriately adjusting the order-up-to levels. A significant reduction of issue age could be possible, without compromising availability or resulting in excessive outdates, by properly adjusting the ordering and allocation policies at the hospital level. © 2016 International Society of Blood Transfusion.
Zhou, Qin; Chai, Xiang-Ping; Fang, Zhen-Fei; Hu, Xin-Qun; Tang, Liang
Background: Acute aortic dissection is a life-threatening cardiovascular emergency. Pentraxin-3 (PTX3) is proposed as a prognostic marker and found to be related to worse clinical outcomes in various cardiovascular diseases. This study sought to investigate the association of circulating PTX3 levels with in-hospital mortality in patients with acute Type A aortic dissection (TAAD). Methods: A total of 98 patients with TAAD between January 2012 and December 2015 were enrolled in this study. Plasma concentrations of PTX3 were measured upon admission using a high-sensitivity enzyme-linked immunosorbent assay system. Patients were divided into two groups as patients died during hospitalization (Group 1) and those who survived (Group 2). The clinical, laboratory variables, and imaging findings were analyzed between the two groups, and predictors for in-hospital mortality were evaluated using multivariate analysis. Results: During the hospital stay, 32 (33%) patients died and 66 (67%) survived. The patients who died during hospitalization had significantly higher PTX3 levels on admission compared to those who survived. Pearson's correlation analysis demonstrated that PTX3 correlated positively with high-sensitivity C-reactive protein (hsCRP), maximum white blood cell count, and aortic diameter. Multivariate logistic regression analysis demonstrated that PTX3 levels, coronary involvement, cardiac tamponade, and a conservative treatment strategy are significant independent predictors of in-hospital mortality in patients with TAAD. The receiver operating characteristic curve analysis further illustrated that PTX3 levels on admission were strong predictors of mortality with an area under the curve of 0.89. A PTX3 level ≥5.46 ng/ml showed a sensitivity of 88% and a specificity of 79%, and an hsCRP concentration ≥9.5 mg/L had a sensitivity of 80% and a specificity of 69% for predicting in-hospital mortality. Conclusion: High PTX3 levels on admission are independently
KELLES, Silvana Márcia Bruschi; MACHADO, Carla Jorge; BARRETO, Sandhi Maria
Background Bariatric surgery is an option for sustained weight loss for the morbidly obese patient. In Brazil coexists the Unified Health System (SUS) with universal coverage and from which depend 150 million Brazilians and supplemental health security, predominantly private, with 50 million beneficiaries. Aim To compare access, in-hospital mortality, length of stay and costs for patients undergoing bariatric surgery, assisted in one or another system. Methods Data from DATASUS and IBGE were used for SUS patients' and database from one health plan of southeastern Brazil for the health insurance patients. Results Between 2001 and 2010 there were 24,342 and 4,356 surgeries performed in SUS and in the health insurance company, respectively. The coverage rates for surgeries performed in 2010 were 5.3 and 91/100.000 individuals in SUS and health insurance respectively. The rate of in-hospital mortality in SUS, considering the entire country, was 0.55 %, 0.44 % considering SUS Southeast, and 0.30 % for the health insurance. The costs of surgery in the SUS and in the health insurance trend to equalization over the years. Conclusion Despite differences in access and characteristics that may compromise the outcome of bariatric surgery, patients treated at the Southeast SUS had similar rate of in-hospital mortality compared to the health insurance patients. PMID:25626935
Shalaka, N S; Garred, N A; Zeglam, H T; Awasi, S A; Abukathir, L A; Altagdi, M E; Rayes, A A
In Libya, little is known about HIV-related hospitalizations and in-hospital mortality. This was a retrospective analysis of HIV-related hospitalizations at Tripoli Medical Centre in 2013. Of 227 cases analysed, 82.4% were males who were significantly older (40.0 versus 36.5 years), reported injection drug use (58.3% versus 0%) and were hepatitis C virus co-infected (65.8% versus 0%) compared with females. Severe immunosuppression was prevalent (median CD4 count = 42 cell/μL). Candidiasis was the most common diagnosis (26.0%); Pneumocystis pneumonia was the most common respiratory disease (8.8%), while cerebral toxoplasmosis was diagnosed in 8.4% of patients. Current HAART use was independently associated with low risk of in-hospital mortality (OR 0.33), while central nervous system symptoms (OR 4.12), sepsis (OR 6.98) and low total lymphocyte counts (OR 3.60) were associated with increased risk. In this study, late presentation with severe immunosuppression was common, and was associated with significant in-hospital mortality.
Anderson, Mary E; Glasheen, Jeffrey J; Anoff, Debra; Pierce, Read; Lane, Molly; Jones, Christine D
Medicaid is often associated with longer hospitalizations and higher in-hospital mortality than other insurance types. To characterize the impact of state Medicaid expansion status under the Affordable Care Act (ACA) on payer mix, length of stay (LOS), and in-hospital mortality. Retrospective cohort study of general medicine patients discharged from academic medical centers (AMCs) within the University HealthSystem Consortium from October 1, 2012 to September 30, 2015. Hospitals were stratified according to state Medicaid expansion status. The proportion of discharges by primary payer, LOS index, and mortality index were compared between Medicaid-expansion and nonexpansion hospitals before and after ACA implementation. ACA implementation was defined as January 1, 2014, for all states except Michigan, New Hampshire, Pennsylvania, and Indiana, which had unique dates of Medicaid expansion. We identified 3,144,488 discharges from 156 hospitals in 24 Medicaid-expansion states and Washington, DC, and 1,114,464 discharges from 55 hospitals in 14 nonexpansion states during the study period. Hospitals in Medicaid-expansion states experienced a significant 3.7% increase in Medicaid discharges (P = 0.013) and a 2.9% decrease in uninsured discharges (P < 0.001) after ACA implementation, whereas hospitals in nonexpansion states saw no significant change in payer mix. In a difference-in-differences analysis, the changes in LOS and mortality indices pre- to post-ACA implementation did not differ significantly between hospitals in Medicaid-expansion versus nonexpansion states. The differential shift in payer mix between Medicaid-expansion and nonexpansion states under the ACA did not influence LOS or in-hospital mortality for general medicine patients at AMCs in the United States. Journal of Hospital Medicine 2015;11:847-852. © 2015 Society of Hospital Medicine. © 2016 Society of Hospital Medicine.
Rogers, B A; Carrothers, A D; Jones, Chris
Over 40 million surgical procedures are performed per annum in the USA and Europe, including several million patients who are considered to be high risk (Bennett-Guerrero et al 2003). Overall, the risk of death or major complications after surgery in the general surgical patient population is low, with a post-operative mortality rate of less than1% during the same hospital admission (Niskanen et al 2001).
Ali, Mujtaba M; Flahive, Julie; Schanzer, Andres; Simons, Jessica P; Aiello, Francesco A; Doucet, Danielle R; Messina, Louis M; Robinson, William P
Previous studies have reported that endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) has lower postoperative mortality than open repair (OR). However, comparisons involved heterogeneous populations that lacked adjustment for preoperative risk. We hypothesize that for RAAA patients stratified by a validated measure of preoperative mortality risk, EVAR has a lower in-hospital mortality and morbidity than does OR. In-hospital mortality and morbidity after EVAR and OR of RAAA were compared in patients from the Vascular Quality Initiative (2003-2013) stratified by the validated Vascular Study Group of New England RAAA risk score into low-risk (score 0-1), medium-risk (score 2-3), and high-risk (score 4-6) groups. Among 514 patients who underwent EVAR and 651 patients who underwent OR of RAAA, EVAR had lower in-hospital mortality (25% vs 33%, P = .001). In risk-stratified patients, EVAR trended toward a lower mortality in the low-risk group (n = 626; EVAR, 10% vs OR, 15%; P = .07), had a significantly lower mortality in the medium-risk group (n = 457; EVAR, 37% vs OR, 48%; P = .02), and no advantage in the high-risk group (n = 82; EVAR, 95% vs OR, 79%; P = .17). Across all risk groups, cardiac complications (EVAR, 29% vs OR, 38%; P = .001), respiratory complications (EVAR, 28% vs OR, 46%; P < .0001), renal insufficiency (EVAR, 24% vs OR, 38%; P < .0001), lower extremity ischemia (EVAR, 2.7% vs OR, 8.1%; P < .0001), and bowel ischemia (EVAR, 3.9% vs OR, 10%; P < .0001) were significantly lower after EVAR than after OR. Across all risk groups, median (interquartile range) intensive care unit length of stay (EVAR, 2 [1-5] days vs OR, 6 [3-13] days; P < .0001) and hospital length of stay (EVAR, 6 [4-12] days vs OR, 13 [8-22] days; P < .0001) were lower after EVAR. This novel risk-stratified comparison using a national clinical database showed that EVAR of RAAA has a lower mortality and morbidity compared with OR in low-risk and medium-risk patients
Pogorevici, Antoanela; Citu, Ioana Mihaela; Bordejevic, Diana Aurora; Caruntu, Florina; Tomescu, Mirela Cleopatra
Background Several risk scores were developed for acute coronary syndrome (ACS) patients, but their use is limited by their complexity. Purpose The purpose of this study was to identify predictors at admission for in-hospital mortality in ACS patients in western Romania, using a simple risk-assessment tool – the new Canada acute coronary syndrome (C-ACS) risk score. Patients and methods The baseline risk of patients admitted with ACS was retrospectively assessed using the C-ACS risk score. The score ranged from 0 to 4; 1 point was assigned for the presence of each of the following parameters: age ≥75 years, Killip class >1, systolic blood pressure <100 mmHg, and heart rate >100 bpm. Results A total of 960 patients with ACS were included, 409 (43%) with ST-segment elevation myocardial infarction (STEMI) and 551 (57%) with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). The C-ACS score predicted in-hospital mortality in all ACS patients with a C-statistic of 0.95 (95% CI: 0.93–0.96), in STEMI patients with a C-statistic of 0.92 (95% confidence interval [CI]: 0.89–0.94), and in NSTE-ACS patients with a C-statistic of 0.97 (95% CI: 0.95–0.98). Of the 960 patients, 218 (22.7%) were aged ≥75 years. The proportion of patients aged ≥75 years was 21.7% in the STEMI subgroup and 23.4% in the NSTE-ACS subgroup (P>0.05). Age ≥75 years was significantly associated with in-hospital mortality in ACS patients (odds ratio [OR]: 3.25, 95% CI: 1.24–8.25) and in the STEMI subgroup (OR >3.99, 95% CI: 1.28–12.44). Female sex was strongly associated with mortality in the NSTE-ACS subgroup (OR: 27.72, 95% CI: 1.83–39.99). Conclusion We conclude that C-ACS score was the strongest predictor of in-hospital mortality in all ACS patients while age ≥75 years predicted the mortality well in the STEMI subgroup. PMID:27217732
Jain, Amit; Brooks, Jaysson T; Rao, Sandesh S; Ain, Michael C; Sponseller, Paul D
Cervical spine fractures with spinal cord injury (CFSCI) can be devastating. We describe the epidemiology of children and adolescents with CFSCI. Using the Nationwide Inpatient Sample (NIS) database, we identified 4418 patients (≤18 years old) who had CFSCI from 2000 through 2010. Outcomes of interest were patient characteristics (age, sex), injury characteristics [fracture location, spinal cord injury (SCI) pattern], economic variables (duration of hospital stay, total hospital charges), and mortality. Upper cervical fractures (UCFs) occurred half as often (31.4 %) as lower cervical fractures (LCFs; 68.8 %). Among patients <8 years old, 73.6 % had UCFs; among patients ≥8 years old, 72.3 % had LCFs. Overall, 68.7 % had incomplete SCI, 22.4 % had complete SCI, 6.6 % had central cord syndrome, and 2.3 % had anterior cord syndrome. Patients with complete SCI had the longest hospital stays and highest hospital charges. The overall in-hospital mortality rate was 7.3 %, with a sixfold higher rate in patients <8 (30.6 %) vs. those ≥8 (5.1 %) years old (p < 0.001). There was a threefold higher mortality rate in patients with upper (13.5 %) vs. lower (4.3 %) cervical fractures (p < 0.001). Patients with complete SCI had a 1.85-fold higher mortality rate than patients with other cord syndromes (p < 0.001). Patients <8 years old were more likely than older patients to sustain UCFs. Patients with UCFs had a significantly higher mortality rate than those with LCFs. Patients with complete SCI had the longest duration of hospital stay and highest hospital charges and in-hospital mortality rate.
Hamburger, S.A.; McCay, P.B. )
The goal of these investigations was to determine if nitrone spin-trapping agents can alter mortality associated with endotoxemia in the rat. Reactive free radicals attack nitrone spin-trapping agents forming relatively reactive, persistent free radical spin adducts. We administered 85 mM (10 ml/kg) of alpha-phenyl N-tert-butyl nitrone (PBN), alpha-4-pyridyl-N-oxide N-tert-butyl nitrone (4-POBN), 5,5-dimethyl-1-pyrroline-N-oxide (DMPO), or vehicle (saline i.p.) 30 min before endotoxin (25 mg/kg i.p.) or vehicle to Sprague-Dawley (SD) or Holtzman virus-free (HVF) rats (n = 10-17/group). All vehicle-treated rats receiving endotoxin were dead by 1 day. At 7 days, 83% of PBN-treated SD, 42% of PBN- or POBN-treated HVF, and 25% of DMPO-treated HVF rats were alive. The difference in survival of PBN-treated animals between strains may reflect the higher susceptibility of HVF rats to endotoxin. The observed reduction in mortality may be related to the well-established capacity of spin-trapping agents to capture reactive free radicals that may be generated in target tissues in response to endotoxin, and that would otherwise react with cell components and produce tissue injury.
Barbir, M.; Lazem, F.; Ilsley, C.; Mitchell, A.; Khaghani, A.; Yacoub, M.
OBJECTIVE--To determine differences in coronary risk factors between women and men and their relation to in-hospital mortality associated with coronary artery bypass grafting. DESIGN--Prospective observational study. SETTING--A regional cardiothoracic centre. PATIENTS--482 (362 (75%) men and 120 (25%) women) consecutive patients who had primary isolated coronary artery bypass grafting. RESULTS--The women were on average three years older than the men (63 v 60 years, P < 0.001). Women more frequently had hypertension (47% v 33%, P < 0.01), diabetes mellitus (21% v 10%, P < 0.005), hypothyroidism (9% v 2%, P < 0.003), and a family history of premature coronary heart disease (49% v 31%, P < 0.0006). More of the men were cigarette smokers (67% v 45%, P > 0.00001). Many of the women and men had dyslipidaemia. Postmenopausal women had a higher concentration of serum total cholesterol than men of a comparable age, (7.3 mmol/l v 6.5 mmol/l, P = 0.0002). Although arterial grafts were often used in both sexes, they were more often used in men than in women (91% v 78% respectively, P = 0.0003). In-hospital mortality was 2.1% (1.4% in men and 4.2% in women, P = 0.14). The estimated one year probability of survival in men who had survived 30 days was 0.99 with 95% confidence interval 0.98 to approximately 1 while that for women was 0.97 with 95% confidence interval 0.91 to approximately 1. Univariate analysis showed that preoperative history of diabetes mellitus was a predictor of mortality (P = 0.03). CONCLUSION--There were differences in the incidence and type of risk factors in men and women who had coronary artery bypass grafting. Preoperative diabetes mellitus was a predictor of in-hospital mortality. PMID:8011402
In-hospital outcomes and long-term mortality according to sex and management strategy in acute myocardial infarction. Insights from the French ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2005 Registry.
Donataccio, Maria Pia; Puymirat, Etienne; Parapid, Biljana; Steg, Philippe Gabriel; Eltchaninoff, Hélène; Weber, Simon; Ferrari, Emile; Vilarem, Didier; Charpentier, Sandrine; Manzo-Silberman, Stéphane; Ferrières, Jean; Danchin, Nicolas; Simon, Tabassome
The early mortality of acute myocardial infarction (AMI) has dramatically decreased in the recent past. Whether the previously reported sex disparities in use of invasive strategies (IS) persist and translate into differences in outcomes deserves to be examined. We used the data from a nationwide French prospective multicentre registry from 3,670 AMI patients (1155 women (31.5%), 2515 men (68.5%)) recruited in 223 centres in 2005 and followed-up for 5 years. We examined in-hospital outcomes and 5-year mortality in patients categorized according to sex and use of IS (i.e. coronary angiography during the hospitalisation with a view to revascularisation). IS was less frequently used in women than in men (adjusted OR=0.66; 95% CI: 0.52-0.85), regardless of the type of AMI, age group or risk category, while use of recommended medications was similar at 48 hours and discharge. In-hospital mortality did not differ according to sex, whatever the age group and use of an IS. At 5 years, overall and post-discharge mortality were similar in men and women. However, IS was associated with lower 5-year mortality in women (HR=0.66; 95% CI: 0.51-0.86) as in men (HR=0.48; 95% CI: 0.38-0.60) and there was no sex-strategy interaction. Invasive strategy remains less frequently used in women than in men, yet is associated with improved five-year survival irrespective of sex. Whether reducing the sex gap in its use would translate into a higher survival in women remains an open question. NCT 00673036. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Shah, Mahek; Patnaik, Soumya; Patel, Brijesh; Arora, Shilpkumar; Patel, Nilay; Lahewala, Sopan; Figueredo, Vincent M; Martinez, Matthew W; Jacobs, Larry
In-hospital care may be constrained during the weekend due to lesser resources. Impact on outcomes of weekend versus weekday care in congestive heart failure (HF) needs further study. Admissions with a primary diagnosis of HF using ICD-9CM codes were studied. 22,287 HF-admissions from Einstein Medical Center (2003-2013) and 2,248,482 HF-admissions from the 2002-2012 Nationwide Inpatient Sample (NIS) were analyzed separately. Primary outcomes were 30-day HF-readmission and in-hospital mortality. Logistic regression models were used to evaluate outcomes. Weekends experienced lower rates of admission and discharge. Mondays experienced the highest admission rate and Fridays experienced the highest discharge rate. Friday was independently associated with highest 30-day HF-readmission rates (Adjusted OR 1.12, CI 1.01-1.23; p=0.02) in addition to risk factors such as African-American race, hypertension, diabetes, hyperlipidemia, end-stage renal disease and coronary artery disease. Within the NIS sample, 85,479 in-hospital deaths (3.8%) were recorded. Compared to weekdays, patients admitted over the weekend had greater comorbidities, higher incidence of acute myocardial infarction (AMI) (15.8% vs. 16.8%; p<0.01), higher Charlson-comorbidity index and underwent less procedures such as echocardiography, right heart catheterization, coronary angiography, coronary revascularization or mechanical circulatory support. Weekend HF admission predicted higher in-hospital mortality (aOR 1.07, 95%CI 1.05-1.08; p<0.01) on multivariate analysis. This relationship was applicable for teaching and non-teaching hospitals. Friday was associated with the highest discharge and 30-day HF-readmission rate. Weekend HF admissions experienced more AMI, had greater comorbidities, received less cardiac procedures and predicted higher in-hospital mortality. Higher weekend mortality may be related to the greater degree of severity of illness among admitted patients. Copyright © 2017 Elsevier Ireland
Tran, Dat T; Welsh, Robert C; Ohinmaa, Arto; Thanh, Nguyen X; Bagai, Akshay; Kaul, Padma
The recently released Canadian cardiac care quality indicators include 30-day in-hospital mortality and readmission rates after percutaneous coronary intervention (PCI) and isolated coronary artery bypass grafting (CABG). We examined long-term trends and provincial variations in these outcomes among acute myocardial infarction (AMI) patients. We included patients aged 18 years and older who were hospitalized with a primary diagnosis of AMI between 2004 and 2013 in all Canadian provinces except Quebec. We calculated 30-day in-hospital death and readmission rates after PCI as well as isolated CABG. We used logistic regressions to evaluate baseline-adjusted temporal trends and provincial variations in mortality and readmission. Among 341,001 AMI episodes in 323,862 unique patients, 43.1% and 7% received PCI and CABG, respectively. Mortality after PCI (2.8%) remained stable (odds ratio [OR], 1.01; P = 0.399), whereas mortality after isolated CABG (2.5%) decreased over time (OR, 0.96; P = 0.017). Readmission after PCI (8.8%) increased (OR, 1.06; P < 0.001), whereas readmission after isolated CABG (11.4%) remained stable over time (OR, 0.99; P = 0.116). Compared with Alberta, mortality and readmission after PCI were highest in Saskatchewan (mortality: OR, 1.32; P = 0.001; readmission: OR, 1.24; P < 0.001), whereas mortality after isolated CABG was highest in Newfoundland and Labrador (OR, 2.05; P = 0.010) and readmission after isolated CABG was highest in New Brunswick (OR, 1.49; P = 0.001). There was no change in mortality, and a slight increase in readmission rates after PCI, and modest improvements in mortality and readmission rates after CABG among AMI patients during the study period. Significant interprovincial variations remained. A stronger focus on pan-Canadian coordination in AMI care and a set of standard benchmarks for AMI-specific PCI- and CABG-related quality indicators are needed. Copyright © 2017 Canadian Cardiovascular Society. Published by
Vohra, R S; Evison, F; Bejaj, I; Ray, D; Patel, P; Pinkney, T D
Ethnicity has complex effects on health and the delivery of health care in part related to language and cultural barriers. This may be important in patients requiring emergency abdominal surgery where delays have profound impact on outcomes. The aim here was to test if variations in outcomes (e.g. in-hospital mortality) exist by ethnic group following emergency abdominal surgery. Retrospective cohort study using population-level routinely collected administrative data from England (Hospital Episode Statistics). Adult patients undergoing emergency abdominal operations between April 2008 and March 2012 were identified. Operations were divided into: 'major', 'hepatobiliary' or 'appendectomy/minor'. The primary outcome was all cause in-hospital mortality. Univariable and multivariable analysis odds ratios (OR with 95% confidence intervals, CI) adjusting for selected factors were performed. 359,917 patients were identified and 80.7% of patients were White British, 4.7% White (Other), 2.4% Afro-Caribbean, 1.6% Indian, 2.6% Chinese, 3.1% Asian (Other) and 4.9% not known, with crude in-hospital mortality rates of 4.4%, 3.1%, 2.0%, 2.6%, 1.6%, 1.7% and 5.17%, respectively. The majority of patients underwent appendectomy/minor (61.9%) compared to major (20.9%) or hepatobiliary (17.2%) operations (P < 0.001) with an in-hospital mortality of 1.7%, 11.5% and 3.9% respectively. Adjusted mortality was largely similar across ethnic groups except where ethnicity was not recorded (compared to White British patients following major surgery OR 2.05, 95% 1.82-2.31, P < 0.01, hepatobiliary surgery OR 2.78, 95% CI 2.31-3.36, P = 0.01 and appendectomy/minor surgery OR 1.78, 95% 1.52-2.08, P < 0.01). Ethnicity is not associated with poorer outcomes following emergency abdominal surgery. However, ethnicity is not recorded in 5% of this cohort and this represents an important, yet un-definable, group with significantly poorer outcomes. Copyright © 2015 The Royal Society for Public Health
Chandrasekaran, Aravind; Anand, Gopesh; Sharma, Luv; Pesavanto, Todd; Hauenstein, Mary Lou; Nguyen, Michelle; Gadkari, Mrinalini; Moffatt-Bruce, Susan
A total of 17,000 patients receive kidney transplants each year in the United States. The 30-day readmission rate for kidney transplant recipients is over 30%. Our research focuses on the relationship between the quality of care delivered during the patient's hospital stay for a kidney transplant, and the patient health outcomes and readmissions related to the transplant. We interviewed 20 kidney transplant recipients at a major transplant center in the United States. Findings from these interviews were used to inform the data collection using structured surveys, which were administered to an additional 77 kidney transplant recipients. We used ordinary least squares regression to predict the effects of two dimensions of in-hospital care quality-information consistency and empathetic care delivery-on level of patient anxiety 1 week following discharge. Further, we estimated a logistic regression to predict the effect of anxiety, combined with the two dimensions of in-hospital care quality, on occurrence of 30-day readmissions. Patient anxiety levels 1 wk after discharge are significantly associated with information consistency and empathetic delivery of care. Patient anxiety 1 wk after discharge is associated with occurrence of 30-d readmissions. The logistic regression model indicates that the risk of getting readmitted is 110% higher for a one unit increase in patient anxiety level 1 wk after discharge. Finally, patient anxiety fully mediates the effects of consistency of information and empathetic care delivery on occurrence of 30-d readmissions (50.96% of the effect is mediated). Our study suggests two ways of preventing readmissions through reduction of postdischarge anxiety: (1) standardizing in-hospital care, so that information received by patients is consistent, and (2) by training caregivers to be more empathetic toward patients during the delivery of this information. Copyright © 2016 Elsevier Inc. All rights reserved.
Olveira, Gabriel; Tapia, María José; Ocón, Julia; Cabrejas-Gómez, Carmen; Ballesteros-Pomar, María D.; Vidal-Casariego, Alfonso; Arraiza-Irigoyen, Carmen; Olivares, Josefina; Conde-García, Maria del Carmen; García-Manzanares, Álvaro; Botella-Romero, Francisco; Quílez-Toboso, Rosa P.; Cabrerizo, Lucio; Matia, Pilar; Chicharro, Luisa; Burgos, Rosa; Pujante, Pedro; Ferrer, Mercedes; Zugasti, Ana; Prieto, Javier; Diéguez, Marta; Carrera, María José; Vila-Bundo, Anna; Urgelés, Juan Ramón; Aragón-Valera, Carmen; Rovira, Adela; Bretón, Irene; García-Peris, Pilar; Muñoz-Garach, Araceli; Márquez, Efren; del Olmo, Dolores; Pereira, José Luis; Tous, María C.
OBJECTIVE Hyperglycemia may increase mortality in patients who receive total parenteral nutrition (TPN). However, this has not been well studied in noncritically ill patients (i.e., patients in the nonintensive care unit setting). The aim of this study was to determine whether mean blood glucose level during TPN infusion is associated with increased mortality in noncritically ill hospitalized patients. RESEARCH DESIGN AND METHODS This prospective multicenter study involved 19 Spanish hospitals. Noncritically ill patients who were prescribed TPN were included prospectively, and data were collected on demographic, clinical, and laboratory variables as well as on in-hospital mortality. RESULTS The study included 605 patients (mean age 63.2 ± 15.7 years). The daily mean TPN values were 1.630 ± 323 kcal, 3.2 ± 0.7 g carbohydrates/kg, 1.26 ± 0.3 g amino acids/kg, and 0.9 ± 0.2 g lipids/kg. Multiple logistic regression analysis showed that the patients who had mean blood glucose levels >180 mg/dL during the TPN infusion had a risk of mortality that was 5.6 times greater than those with mean blood glucose levels <140 mg/dL (95% CI 1.47–21.4 mg/dL) after adjusting for age, sex, nutritional state, presence of diabetes or hyperglycemia before starting TPN, diagnosis, prior comorbidity, carbohydrates infused, use of steroid therapy, SD of blood glucose level, insulin units supplied, infectious complications, albumin, C-reactive protein, and HbA1c levels. CONCLUSIONS Hyperglycemia (mean blood glucose level >180 mg/dL) in noncritically ill patients who receive TPN is associated with a higher risk of in-hospital mortality. PMID:23223407
Olveira, Gabriel; Tapia, María José; Ocón, Julia; Cabrejas-Gómez, Carmen; Ballesteros-Pomar, María D; Vidal-Casariego, Alfonso; Arraiza-Irigoyen, Carmen; Olivares, Josefina; Conde-García, Maria Del Carmen; García-Manzanares, Alvaro; Botella-Romero, Francisco; Quílez-Toboso, Rosa P; Cabrerizo, Lucio; Matia, Pilar; Chicharro, Luisa; Burgos, Rosa; Pujante, Pedro; Ferrer, Mercedes; Zugasti, Ana; Prieto, Javier; Diéguez, Marta; Carrera, María José; Vila-Bundo, Anna; Urgelés, Juan Ramón; Aragón-Valera, Carmen; Rovira, Adela; Bretón, Irene; García-Peris, Pilar; Muñoz-Garach, Araceli; Márquez, Efren; Del Olmo, Dolores; Pereira, José Luis; Tous, María C
Hyperglycemia may increase mortality in patients who receive total parenteral nutrition (TPN). However, this has not been well studied in noncritically ill patients (i.e., patients in the nonintensive care unit setting). The aim of this study was to determine whether mean blood glucose level during TPN infusion is associated with increased mortality in noncritically ill hospitalized patients. This prospective multicenter study involved 19 Spanish hospitals. Noncritically ill patients who were prescribed TPN were included prospectively, and data were collected on demographic, clinical, and laboratory variables as well as on in-hospital mortality. The study included 605 patients (mean age 63.2 ± 15.7 years). The daily mean TPN values were 1.630 ± 323 kcal, 3.2 ± 0.7 g carbohydrates/kg, 1.26 ± 0.3 g amino acids/kg, and 0.9 ± 0.2 g lipids/kg. Multiple logistic regression analysis showed that the patients who had mean blood glucose levels >180 mg/dL during the TPN infusion had a risk of mortality that was 5.6 times greater than those with mean blood glucose levels <140 mg/dL (95% CI 1.47-21.4 mg/dL) after adjusting for age, sex, nutritional state, presence of diabetes or hyperglycemia before starting TPN, diagnosis, prior comorbidity, carbohydrates infused, use of steroid therapy, SD of blood glucose level, insulin units supplied, infectious complications, albumin, C-reactive protein, and HbA1c levels. Hyperglycemia (mean blood glucose level >180 mg/dL) in noncritically ill patients who receive TPN is associated with a higher risk of in-hospital mortality.
Sabaté, Manel; Cánovas, Sergio; García, Eulogio; Hernández Antolín, Rosana; Maroto, Luis; Hernández, José María; Alonso Briales, Juan H; Muñoz García, Antonio J; Gutiérrez-Ibañes, Enrique; Rodríguez-Roda, Jorge
The treatment of severe symptomatic aortic stenosis has been revolutionized by the technique of transcatheter valve replacement. The purpose of this study was to present the outcomes and predictors of mortality in patients enrolled between 2010 and 2011 in the Transcatheter Aortic Valve Replacement National Registry. We collected 131 preprocedural, 31 periprocedural, and 76 follow-up variables, and analyzed the immediate implant success rate, the 30-day safety endpoint, and all-cause 30-day and mid-term (mean follow-up, 244 days) mortality. From January 2010 to December 2011, a total of 1416 patients were included: 806 with Edwards valves and 610 with CoreValves. The implant success and 30-day mortality rates were 94% and 8%, respectively, without differences between types of valves and approaches. The 30-day safety endpoint and mid-term mortality rates were 14% and 16%, respectively, which were also similar between groups. The presence of comorbidities (renal failure, peripheral vascular disease, ejection fraction, and atrial fibrillation), the need for conversion to surgery, and at least moderate aortic regurgitation after transcatheter aortic valve implantation were identified as independent predictors of in-hospital and mid-term mortality. The prognosis of valve implant patients could be improved by including comorbidities in patient selection and by minimizing the degree of residual aortic regurgitation to optimize the results of the procedure. Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.
Thompson, Trevor D.; Soman, Ashwini; Møller, Bjorn; Leadbetter, Steven; White, Mary C.
Introduction Healthy People 2020 (HP2020) calls for a 10% to 15% reduction in death rates from 2007 to 2020 for selected cancers. Trends in death rates can be used to predict progress toward meeting HP2020 targets. Methods We used mortality data from 1975 through 2009 and population estimates and projections to predict deaths for all cancers and the top 23 cancers among men and women by race. We apportioned changes in deaths from population risk and population growth and aging. Results From 1975 to 2009, the number of cancer deaths increased among white and black Americans primarily because of an aging white population and a growing black population. Overall, age-standardized cancer death rates (risk) declined in all groups. From 2007 to 2020, rates are predicted to continue to decrease while counts of deaths are predicted to increase among men (15%) and stabilize among women (increase <10%). Declining death rates are predicted to meet HP2020 targets for cancers of the female breast, lung and bronchus, cervix and uterus, colon and rectum, oral cavity and pharynx, and prostate, but not for melanoma. Conclusion Cancer deaths among women overall are predicted to increase by less than 10%, because of, in part, declines in breast, cervical, and colorectal cancer deaths among white women. Increased efforts to promote cancer prevention and improve survival are needed to counter the impact of a growing and aging population on the cancer burden and to meet melanoma target death rates. PMID:26133647
Ahn, Sung Soo; Yoo, Byung-Woo; Jung, Seung Min; Lee, Sang-Won; Park, Yong-Beom; Song, Jason Jungsik
To evaluate the clinical significance of the 2016 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR)/Pediatric Rheumatology International Trials Organization (PRINTO) classification criteria for macrophage activation syndrome (MAS) in patients with febrile systemic lupus erythematosus (SLE). We performed a retrospective analysis of SLE patients with fever, who were admitted to Severance Hospital between December 2005 and May 2016. Patients were evaluated for MAS using the 2016 classification criteria for MAS. Clinical features and laboratory findings were compared and overall survival rate was analyzed. Forward and backward stepwise logistic regression analysis was used to evaluate the factors associated with in-hospital mortality. Among 157 patients with SLE, 54 (34.3%) were considered to have MAS on admission (n = 42) and during admission (n = 12). For patients who already have MAS on admission, their baseline laboratory findings demonstrated lower CRP, platelets, total protein, albumin, complement C3, fibrinogen and higher AST, ALT, total bilirubin, ferritin, and triglyceride. The overall survival rate was significantly lower in patients with MAS than without MAS (64.8% vs. 97.0%, p < 0.001). Multivariate analysis showed that the presence of MAS was significantly associated with in-hospital mortality in febrile SLE patients (OR = 64.5; 95% CI: 7.6-544.4; p < 0.001). The 2016 classification criteria for MAS is useful to identify febrile SLE patients at high risk for in-hospital mortality. Monitoring febrile SLE patients with the new 2016 classification criteria might aid in the early detection of MAS. Copyright © 2017 Elsevier Inc. All rights reserved.
Gradual decline in the age-adjusted in-hospital mortality rate from STEMI-related cardiogenic shock irrespective of cause, race or gender with persistent higher mortality rates in women despite multivariate adjustment.
Movahed, Mohammad Reza; Khan, Muhammad F; Hashemzadeh, Mehrtash; Hashemzadeh, Mehrnoosh
Recent improvements in the care of critically ill patients with cardiogenic shock (CS) should be associated with improved outcomes. The goal of this study was to evaluate the trends of age-adjusted mortality rates for all-cause and ST-elevation myocardial infarction (STEMI)-related CS in the United States. The Nationwide Inpatient Sample (NIS) database was utilized to calculate the age-adjusted mortality rate of all-cause and STEMI-related CS from 1996 to 2006. We used specific ICD- 9 codes for CS and STEMI based on race and gender. We found a gradual decrease in mortality over the 10-year period in patients suffering from all causes or STEMI-related CS irrespective of gender and race with a persistently higher mortality rates in women and African Americans. However, after multivariate adjustment, only female gender remains associated with persistently higher mortality. The age-adjusted mortality rate from STEMI-related CS in women was 2.2% in 1996, with a gradual reduction to the lowest level of 1.7% in 2006 (P<.01). Likewise, the age-adjusted mortality rate from STEMI-related CS in men was 1.7% in 1996, which declined to the lowest level of 1.4% in 2006 (P<.01). Regardless of gender and race, age-adjusted in-hospital mortality is gradually declining in patients presenting with all causes or STEMI-related CS. However, as compared to men, women suffer from persistently higher mortality rates in the setting of STEMI-related CS despite multivariate adjustment.
Matz, Carsten; Jürgens, Klaus
We tested the impact of bacterial swimming speed on the survival of planktonic bacteria in the presence of protozoan grazers. Grazing experiments with three common bacterivorous nanoflagellates revealed low clearance rates for highly motile bacteria. High-resolution video microscopy demonstrated that the number of predator-prey contacts increased with bacterial swimming speed, but ingestion rates dropped at speeds of >25 microm s(-1) as a result of handling problems with highly motile cells. Comparative studies of a moderately motile strain (<25 microm s(-1)) and a highly motile strain (>45 microm s(-1)) further revealed changes in the bacterial swimming speed distribution due to speed-selective flagellate grazing. Better long-term survival of the highly motile strain was indicated by fourfold-higher bacterial numbers in the presence of grazing compared to the moderately motile strain. Putative constraints of maintaining high swimming speeds were tested at high growth rates and under starvation with the following results: (i) for two out of three strains increased growth rate resulted in larger and slower bacterial cells, and (ii) starved cells became smaller but maintained their swimming speeds. Combined data sets for bacterial swimming speed and cell size revealed highest grazing losses for moderately motile bacteria with a cell size between 0.2 and 0.4 microm(3). Grazing mortality was lowest for cells of >0.5 microm(3) and small, highly motile bacteria. Survival efficiencies of >95% for the ultramicrobacterial isolate CP-1 (< or =0.1 microm(3), >50 microm s(-1)) illustrated the combined protective action of small cell size and high motility. Our findings suggest that motility has an important adaptive function in the survival of planktonic bacteria during protozoan grazing.
The infant mortality rate in the District of Columbia is higher than that for any other state. This high rate stems from the great number of infants born seriously underweight and reflects the area's high percentage of births to impoverished black women. Efforts to reduce the mortality rate have centered around the medical treatment approach,…
F.H. Eyre; F.R. Longwood
To convert uncut old-growth stands of northern hardwoods to a thrifty forest through partial cutting it is necessary both to provide growing Space for promising trees and to reduce mortality. If the mortality normal in a virgin stand is not checked through proper cutting, there may be very little net growth. How then should cutting be done to stimulate growth and at...
The infant mortality rate in the District of Columbia is higher than that for any other state. This high rate stems from the great number of infants born seriously underweight and reflects the area's high percentage of births to impoverished black women. Efforts to reduce the mortality rate have centered around the medical treatment approach,…
Kenneth W. Outcalt; Dale D. Wade
The objective was to determine the effectiveness of a regular prescribed burning program for reducing tree mortality in southern pine forests burned by wildfire. This study was conducted on public and industry lands in northeast Florida. On the Osceola National Forest, mean mortality was 3.5% in natural stands and 43% in plantations two growing seasons after a June...
Ofek, Fanny; Magnezi, Racheli; Kurzweil, Yaffa; Gazit, Inbal; Berkovitch, Sofia; Tal, Orna
Intravenous potassium chloride (IV KCl) solutions are widely used in hospitals for treatment of hypokalemia. As ampoules of concentrated KCL must be diluted before use, critical incidents have been associated with its preparation and administration. Currently, we have introduced ready-to-use diluted KCl infusion solutions to minimize the use of high-alert concentrated KCl. Since this process may be associated with considerable risks, we embraced a proactive hazard analysis as a tool to implement a change in high-alert drug usage in a hospital setting. Failure mode and effect analysis (FMEA) is a systematic tool to analyze and identify risks in system operations. We used FMEA to examine the hazards associated with the implementation of the ready-to-use solutions. A multidisciplinary team analyzed the risks by identifying failure modes, conducting a hazard analysis and calculating the criticality index (CI) for each failure mode. A 1-day survey was performed as an evaluation step after a trial run period of approximately 4 months. Six major possible risks were identified. The most severe risks were prioritized and specific recommendations were formulated. Out of 28 patients receiving IV KCl on the day of the survey, 22 received the ready-to-use solutions and 6 received the concentrated solutions as instructed. Only 1 patient received inappropriate ready-to-use KCl. Using the FMEA tool in our study has proven once again that by creating a gradient of severity of potential vulnerable elements, we are able to proactively promote safer and more efficient processes in health care systems. This article presents a utilization of this method for implementing a change in hospital policy regarding the routine use of IV KCl.
Ahmadi, Ali; Khaledifar, Arsalan; Etemad, Koorosh
Background: The data and determinants of mortality due to stroke in myocardial infarction (MI) patients are unknown. This study was conducted to evaluate the differences in risk factors for hospital mortality among MI patients with and without stroke history. Materials and Methods: This study was a retrospective, cohort study; 20,750 new patients with MI from April, 2012 to March, 2013 were followed up and their data were analyzed according to having or not having the stroke history. Stroke and MI were defined based on the World Health Organization's definition. The data were analyzed by logistic regression in STATA software. Results: Of the 20,750 studied patients, 4293 had stroke history. The prevalence of stroke in the studied population was derived 20.96% (confidence interval [CI] 95%: 20.13–21.24). Of the patients, 2537 (59.1%) had ST-elevation MI (STEMI). Mortality ratio in patients with and without stroke was obtained 18.8% and 10.3%, respectively. The prevalence of risk factors in MI patients with and without a stroke is various. The adjusted odds ratio of mortality in patients with stroke history was derived 7.02 (95% CI: 5.42–9) for chest pain resistant to treatment, 2.39 (95% CI: 1.97–2.9) for STEMI, 3.02 (95% CI: 2.5–3.64) for lack of thrombolytic therapy, 2.2 (95% CI: 1.66–2.91) for heart failure, and 2.17 (95% CI: 1.6–2.9) for ventricular tachycardia. Conclusion: With regards to the factors associated with mortality in this study, it is particularly necessary to control the mortality in MI patients with stroke history. More emphasis should be placed on the MI patients with the previous stroke over those without in the interventions developed for prevention and treatment, and for the prevention of avoidable mortalities. PMID:27904619
López-Messa, Juan B; Andrés-de Llano, Jesús M; López-Fernández, Laura; García-Cruces, Jesús; García-Crespo, Julio; Prieto González, Miryam
To analyze hospitalization and mortality rates due to acute cardiovascular disease (ACVD). We conducted a cross-sectional study of the hospital discharge database of Castile and León from 2001 to 2015, selecting patients with a principal discharge diagnosis of acute myocardial infarction (AMI), unstable angina, heart failure, or acute ischemic stroke (AIS). Trends in the rates of hospitalization/100 000 inhabitants/y and hospital mortality/1000 hospitalizations/y, overall and by sex, were studied by joinpoint regression analysis. A total of 239 586 ACVD cases (AMI 55 004; unstable angina 15 406; heart failure 111 647; AIS 57 529) were studied. The following statistically significant trends were observed: hospitalization: ACVD, upward from 2001 to 2007 (5.14; 95%CI, 3.5-6.8; P < .005), downward from 2011 to 2015 (3.7; 95%CI, 1.0-6.4; P < .05); unstable angina, downward from 2001 to 2010 (-12.73; 95%CI, -14.8 to -10.6; P < .05); AMI, upward from 2001 to 2003 (15.6; 95%CI, 3.8-28.9; P < .05), downward from 2003 to 2015 (-1.20; 95%CI, -1.8 to -0.6; P < .05); heart failure, upward from 2001 to 2007 (10.70; 95%CI, 8.7-12.8; P < .05), upward from 2007 to 2015 (1.10; 95%CI, 0.1-2.1; P < .05); AIS, upward from 2001 to 2007 (4.44; 95%CI, 2.9-6.0; P < .05). Mortality rates: downward from 2001 to 2015 in ACVD (-1.16; 95%CI, -2.1 to -0.2; P < .05), AMI (-3.37, 95%CI, -4.4 to -2, 3, P < .05), heart failure (-1.25; 95%CI, -2.3 to -0.1; P < .05) and AIS (-1.78; 95%CI, -2.9 to -0.6; P < .05); unstable angina, upward from 2001 to 2007 (24.73; 95%CI, 14.2-36.2; P < .05). The ACVD analyzed showed a rising trend in hospitalization rates from 2001 to 2015, which was especially marked for heart failure, and a decreasing trend in hospital mortality rates, which were similar in men and women. These data point to a stabilization and a decline in hospital mortality, attributable to established prevention measures. Copyright © 2017 Sociedad Española de Cardiología. Published by
Prasad, Priya A; Shea, Erica R; Shiboski, Stephen; Sullivan, Mary C; Gonzales, Ralph; Shimabukuro, David
Sepsis is a systemic response to infection that can lead to tissue damage, organ failure, and death. Efforts have been made to develop evidence-based intervention bundles to identify and manage sepsis early in the course of the disease to decrease sepsis-related morbidity and mortality. We evaluated the relationship between a minimally invasive sepsis intervention bundle and in-hospital mortality using robust methods for observational data. We performed a retrospective cohort study at the University of California, San Francisco, Medical Center among adult patients discharged between January 1, 2012, and December 31, 2014, and who received a diagnosis of severe sepsis/septic shock (SS/SS). Sepsis intervention bundle elements included measurement of blood lactate; drawing of blood cultures before starting antibiotics; initiation of broad spectrum antibiotics within 3 hours of sepsis presentation in the emergency department or 1 hour of presentation on an inpatient unit; administration of intravenous fluid bolus if the patient was hypotensive or had a lactate level >4 mmol/L; and starting intravenous vasopressors if the patient remained hypotensive after fluid bolus administration. Poisson regression for a binary outcome variable was used to estimate an adjusted incidence-rate ratio (IRR) comparing mortality in groups defined by bundle compliance measured as a binary predictor, and to estimate an adjusted number needed to treat (NNT). Complete bundle compliance was associated with a 31% lower risk of mortality (adjusted IRR, 0.69, 95% confidence interval [CI], 0.53-0.91), adjusting for SS/SS presentation in the emergency department, SS/SS present on admission (POA), age, admission severity of illness and risk of mortality, Medicaid/Medicare payor status, immunocompromised host status, and congestive heart failure POA. The adjusted NNT to save one life was 15 (CI, 8-69). Other factors independently associated with mortality included SS/SS POA (adjusted IRR, 0.55; CI, 0
Cid Pedraza, Camilo; Herrera, Cristian A; Prieto Toledo, Lorena; Oyarzún, Felipe
Public, private not-for-profit (PNFP) and private for-profit (PFP) hospitals may have different behaviour and performance in different indicators such as health outcomes, cost-efficiency and quality. Chile has a mixed healthcare system both in financing and service delivery. The public National Health Fund (Fondo Nacional de Salud) covers 76% of the population-poorer and with higher health risks-whereas private health insurers cover 16% of the population-richer and with lower health risks. The aim of the study was to analyse the in-patient mortality outcomes by hospital ownership in Chile. We use hospital discharge data in Chile for the period 2001-10 with a total of 16,205,314 discharges in 20 public, 6 PNFP and 15 PFP hospitals. We analyse in-patient mortality considering all diagnoses and a subsample considering only myocardial infarction and stroke diagnoses. Using a probit regression, we estimate how hospital ownership explains in-patient mortality controlling for other confounding variables like health and socioeconomic status, and hospital characteristics. The discharge condition was reported as death in 3.5% of the public hospitals' discharges, 1.3% in PNFP and 0.7% in PFP. PNFP and PFP hospitals show a lower risk of in-hospital mortality for all diagnoses, myocardial infarction and stroke in comparison with public hospitals. The question about which type of hospital ownership performs better in Chile remains open. Policy decisions regarding health service provision requires more evidence explaining differences by ownership. Better controls for health risk and hospital characteristics are suggested to address these differences in hospital performance. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2015; all rights reserved.
Konstanty-Kalandyk, Janusz; Kiełbasa, Grzegorz; Olszewska, Marta; Song, Bryan HyoChan; Wierzbicki, Karol; Milaniak, Irena; Darocha, Tomasz; Sobczyk, Dorota; Kapelak, Bogusław
Background Age remains a significant and unmodifiable risk factor for cardiovascular diseases, and an increasing number of patients older than 80 years of age undergo Coronary Artery Bypass Grafting (CABG). Old age is also an independent risk factor for postoperative complications. The aim of this study is to describe the population of patients 80 years of age or older who underwent CABG procedure and to assess the mortality rate and risk factors for in-hospital mortality. Methods A retrospective case-series study analyzing 388 consecutive patients aged 80 years of age or older who underwent isolated CABG procedure between 2010 and 2014 in the Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow. Results In-hospital mortality stood at 7%, compared to 3.4% for all isolated CABG procedures at our Institution. In an univariate logistic regression analysis, risk factors for in-hospital mortality were as follows: NYHA class (p = 0.005, OR 1.95, 95% CI [1.23–3.1]), prolonged mechanical ventilation (p < 0.001, OR 7.08, 95% CI [2.47–20.3]), rethoracotomy (p = 0.04, OR 3.31, 95% CI [1.04–10.6]), duration of the procedure and ECC (for every 10 min p = 0.01, OR 1.01, 95% CI [1.0–1.01]; p = 0.03, OR 1.01, 95% CI [1.0–1.02], respectively), PRBC, FFP, and PLT transfusion (for every unit transfused p = 0.004, OR 1.42, 95% CI [1.12–1.8]; p = 0.002, OR 1.55, 95% CI [1.18–2.04]; p = 0.009, OR 1.93, 95% CI [1.18–3.14], respectively). Higher LVEF (p = 0.02, OR 0.97, 95% CI [0.94–0.99]) and LIMA graft implantation (p = 0.04, OR 0.36, 95% CI [0.13–0.98) decreased the in-hospital mortality. Death before discharge was more often observed in patients with multiple risk factors for cardiovascular diseases (0–2 –5.7%; 3–7.4%, 4–26.6%; p = 0.03). Conclusions Older age is associated with higher in-hospital mortality after isolated CABG at our Institution. Risk stratification scores and individualized risk
Li, Jian-ping; Momin, Mohetaboer; Huo, Yong; Wang, Chun-yan; Zhang, Yan; Gong, Yan-jun; Liu, Zhao-ping; Wang, Xin-gang; Zheng, Bo
Objective: To investigate the relationship between renal function and clinical outcomes among patients with acute ST-segment elevation myocardial infarction (ASTEMI), who were treated with emergency percutaneous coronary intervention (PCI). Methods: 420 patients hospitalized in Peking University First Hospital, diagnosed with ASTEMI treated with emergency (PCI) from January 2001 to June 2011 were enrolled in this study. Estimated glomerular filtration rate (eGFR) was used as a measure of renal function. We compared the clinical parameters and outcomes between ASTEMI patients combined renal insufficiency and the patients with normal renal function. Results: There was a significant increase in the concentrations of fibrinogen and D-Dimer (P<0.05) and a much higher morbidity of diabetes mellitus in the group of patients with chronic kidney disease (CKD; eGFR<60 ml/(min·1.73 m2)) (P<0.01). CKD (eGFR<60 ml/(min·1.73 m2)) was an independent predictor of in-hospital mortality for patients hospitalized with ASTEMI receiving PCI therapy rapidly (P=0.032, odds ratio (OR) 4.159, 95% confidence interval (CI) 1.127–15.346). Conclusions: Renal insufficiency is an independent predictor of in-hospital mortality for patients hospitalized with ASTEMI treated with primary PCI. PMID:22843184
Miura, Makoto; Kuwahara, Akiko; Tomozawa, Akinori; Omae, Naoki; Yamamori, Motohiro; Kadoyama, Kaori; Sakaeda, Toshiyuki
Objectives: A retrospective examination was conducted to identify risk factors for in-hospital mortality of elderly patients (65 years or older) treated with the beta-lactam/beta-lactamase inhibitor combination antibiotic, ampicillin/sulbactam (ABPC/SBT). Methods: Clinical data from 96 patients who were hospitalized with infectious diseases and treated with ABPC/SBT (9 g/day or 12 g/day) were analyzed. Risk factors examined included demographic and clinical laboratory parameters. Parameter values prior to treatment and changes after treatment were compared between survivors and non-survivors. Results: The study patients had an average age of 81.9±8.4 years (±SD) and body mass index (BMI) of 19.9±4.2 kg/m(2). They were characterized by anemia (low hemoglobin and hematocrit levels), inflammation (high leukocyte count, neutrophil count, C-reactive protein level, and body temperature), and hepatic and renal dysfunction (high aspartate aminotransferase, alanine aminotransferase and blood urea nitrogen levels). The BMI of non-survivors, 16.2±2.9 kg/m(2), was lower than that of survivors, 20.4±4.1 kg/m(2). In addition, the hematological parameters deteriorated more remarkably, inflammation markers were not altered (or the decrease was marginal), and hepatic function was not improved, in non-survivors. Conclusions: A lower BMI value is a risk factor for in-hospital mortality of elderly patients treated with ABPC/SBT.
Rantz, Marilyn J.; Banerjee, Tanvi S.; Cattoor, Erin; Scott, Susan D.; Skubic, Marjorie; Popescu, Mihail
The purpose of this study was to test the implementation of a fall detection and “rewind” privacy-protecting technique using the Microsoft® Kinect™ to not only detect but prevent falls from occurring in hospitalized patients. Kinect sensors were placed in six hospital rooms in a step-down unit and data were continuously logged. Prior to implementation with patients, three researchers performed a total of 18 falls (walking and then falling down or falling from the bed) and 17 non-fall events (crouching down, stooping down to tie shoe laces, and lying on the floor). All falls and non-falls were correctly identified using automated algorithms to process Kinect sensor data. During the first 8 months of data collection, processing methods were perfected to manage data and provide a “rewind” method to view events that led to falls for post-fall quality improvement process analyses. Preliminary data from this feasibility study show that using the Microsoft Kinect sensors provides detection of falls, fall risks, and facilitates quality improvement after falls in real hospital environments unobtrusively, while taking into account patient privacy. PMID:24296567
Kamr, Ahmed M; Dembek, Katarzyna A; Reed, Stephen M; Slovis, Nathan M; Zaghawa, Ahmed A; Rosol, Thomas J; Toribio, Ramiro E
Hypocalcemia is a frequent abnormality that has been associated with disease severity and outcome in hospitalized foals. However, the pathogenesis of equine neonatal hypocalcemia is poorly understood. Hypovitaminosis D in critically ill people has been linked to hypocalcemia and mortality; however, information on vitamin D metabolites and their association with clinical findings and outcome in critically ill foals is lacking. The goal of this study was to determine the prevalence of vitamin D deficiency (hypovitaminosis D) and its association with serum calcium, phosphorus, and parathyroid hormone (PTH) concentrations, disease severity, and mortality in hospitalized newborn foals. One hundred newborn foals ≤72 hours old divided into hospitalized (n = 83; 59 septic, 24 sick non-septic [SNS]) and healthy (n = 17) groups were included. Blood samples were collected on admission to measure serum 25-hydroxyvitamin D3 [25(OH)D3], 1,25-dihydroxyvitamin D3 [1,25(OH) 2D3], and PTH concentrations. Data were analyzed by nonparametric methods and univariate logistic regression. The prevalence of hypovitaminosis D [defined as 25(OH)D3 <9.51 ng/mL] was 63% for hospitalized, 64% for septic, and 63% for SNS foals. Serum 25(OH)D3 and 1,25(OH) 2D3 concentrations were significantly lower in septic and SNS compared to healthy foals (P<0.0001; P = 0.037). Septic foals had significantly lower calcium and higher phosphorus and PTH concentrations than healthy and SNS foals (P<0.05). In hospitalized and septic foals, low 1,25(OH)2D3 concentrations were associated with increased PTH but not with calcium or phosphorus concentrations. Septic foals with 25(OH)D3 <9.51 ng/mL and 1,25(OH) 2D3 <7.09 pmol/L were more likely to die (OR=3.62; 95% CI = 1.1-12.40; OR = 5.41; 95% CI = 1.19-24.52, respectively). Low 25(OH)D3 and 1,25(OH)2D3 concentrations are associated with disease severity and mortality in hospitalized foals. Vitamin D deficiency may contribute to a pro-inflammatory state in equine
Ardigo, Sheila; Herrmann, François R; Moret, Véronique; Déramé, Laurence; Giannelli, Sandra; Gold, Gabriel; Pautex, Sophie
Chronic pain is a common and serious health problem in older patients. Treatment often includes non pharmacological approaches despite a relatively modest evidence base in this population. Hypnosis has been used in younger adults with positive results. The main objective of this study was to measure the feasibility and efficacy of hypnosis (including self hypnosis) in the management of chronic pain in older hospitalized patients. A single center randomized controlled trial using a two arm parallel group design (hypnosis versus massage). Inclusion criteria were chronic pain for more than 3 months with impact on daily life activities, intensity of > 4; adapted analgesic treatment; no cognitive impairment. Brief pain inventory was completed. Fifty-three patients were included (mean age: 80.6 ± 8.2--14 men; 26 hypnosis; 27 massage. Pain intensity decreased significantly in both groups after each session. Average pain measured by the brief pain index sustained a greater decrease in the hypnosis group compared to the massage group during the hospitalisation. This was confirmed by the measure of intensity of the pain before each session that decreased only in the hypnosis group over time (P = 0.008). Depression scores improved significantly over the time only in the hypnosis group (P = 0.049). There was no effect in either group 3 months post hospitals discharge. Hypnosis represents a safe and valuable tool in chronic pain management of hospitalized older patients. In hospital interventions did not provide long term post discharge relief. ISRCTN15615614; registered 2/1/2015.
Sarosiek, Shayna; Rybin, Denis; Weinberg, Janice; Burke, Peter A; Kasotakis, George; Sloan, J Mark
Trauma patients admitted to the hospital are at increased risk of bleeding and thrombosis. The use of inferior vena cava (IVC) filters in this population has been increasing, despite a lack of high-quality evidence to demonstrate their efficacy. To determine if IVC filter insertion in trauma patients affects overall mortality. This retrospective cohort study used stratified 3:1 propensity matching to select a control population similar to patients who underwent IVC filter insertion at Boston Medical Center (a level I trauma center at Boston University School of Medicine) between August 1, 2003, and December 31, 2012. Among patients with an IVC filter and matched controls, age, sex, race/ethnicity, and Injury Severity Score were entered into a multivariable logistic regression model to calculate a propensity score. Matching was stratified by the date of injury. Multivariable logistic regression was used to compare hospital mortality across both groups, adjusting for age, sex, race/ethnicity, Injury Severity Score, and brain injury severity using the head and neck Abbreviated Injury Score. To determine any significant difference in mortality, patient characteristics and mortality data from the National Death Index were analyzed in all patients and in those who survived 24, 48, and 72 hours after injury, as well as at hospital discharge. Among 451 trauma patients with an IVC filter and 1343 matched controls without an IVC filter, the mean (SD) age was 47.4 (21.5) years. The median Injury Severity Score overall was 24 (range, 1-75). Based on a mean follow-up of 3.8 years (range, 0-9.4 years), there was no significant difference in overall mortality or cause of mortality in patients with vs without an IVC filter who survived more than 24 hours from the time of injury, independent of the presence or absence of deep vein thrombosis or pulmonary embolism at the time of IVC filter placement. Additional analyses at shorter intervals of 6 months and 1 year after discharge
Nicolaou, Vassilios N.; Papadakis, John E.; Chrysohoou, Christina; Panagiotakos, Demosthenes B.; Krinos, Xenofon; Skoufas, Panagiotis D.; Stefanadis, Christodoulos
BACKGROUND: Several studies have illustrated the role played by serum glucose levels in cardiovascular morbidity and mortality in general and, more particularly, after an acute coronary event. AIM: The aim of this study was to evaluate the impact of serum potassium and glucose levels on in-hospital mortality in patients with ischemic heart disease, who exhibited severe ventricular arrhythmia. METHODS: We enrolled 162 consecutive patients who were referred to our institution for an acute coronary event and presented with sustained ventricular tachycardia or ventricular fibrillation during the first 24 hours of hospitalization. Serum potassium and glucose levels were measured in all patients at the onset of tachycardia and after 2, 4, 6, 12, 36, 48 hours. RESULTS: During hospitalization, 23 out of 162 patients died (61% males). Serum glucose levels at the onset of the arrhythmia, as well as after 2, 12, 36 and 48 hours, were higher in the deceased (onset: 228.8 ± 108 vs. 158 ± 68 mg/dl, p = 0.0001, 2 h: 182 ± 109 vs. 149 ± 59 mg/dl, p = 0.03, 12 h: 155.5 ± 72 vs. 128 ± 48 mg/dl, p = 0.025, 36 h: 163.8 ± 63 vs.116 ± 42 mg/dl, p = 0.002, and 48 h: 138 ± 64 vs. 122 ± 42 mg/dl, p = 0.05, respectively), even after adjustment for age, sex, diabetes, left ventricular ejection fraction, type of acute coronary syndrome and site of infarction and medication intake. There was no difference in serum potassium levels between the deceased and survivors. CONCLUSION: Serum glucose levels at the onset of arrhythmia and 2, 36 and 48 hours later seem to have prognostic significance for in-hospital mortality in patients hospitalized for an acute coronary event, who exhibit severe ventricular arrhythmia. PMID:18548170
O'Connor, G T; Morton, J R; Diehl, M J; Olmstead, E M; Coffin, L H; Levy, D G; Maloney, C T; Plume, S K; Nugent, W; Malenka, D J
A prospective study of patients undergoing coronary artery bypass graft surgery (CABG) was conducted to examine differences in hospital mortality by sex. Outcome data on 3055 CABG patients undergoing operation between 1987 and 1989 were examined for differences in patient, disease, and treatment factors. Odds ratios (OR), risk differences, and 95% confidence intervals (CI95%) were calculated. Mortality rates for women (7.1%) and men (3.3%) differed, the OR (women versus men) being 2.23 (CI95%, 1.58 to 3.15). Women were older, more often diabetic, and had more urgent or emergent surgery; adjustment yielded an OR (women versus men) of 1.75 (CI95%, 1.17 to 2.63). Body surface area (BSA) was associated with risk of death in both sexes (P = .007) and positively associated with coronary artery luminal diameters. After adjustment for BSA, sex was no longer significantly associated with mortality (OR [women versus men] of 1.18; CI95%, 0.72 to 1.95). Internal mammary artery (IMA) grafting was performed less frequently among women than men (64.8% versus 78.4%, P < .001). Smaller BSA and absence of IMA grafting were each associated with increased risk of death (RD) from heart failure. Risk of death from heart failure (RD [women minus men] = 2.05; CI95%, 0.89 to 3.22) and hemorrhage (RD [women minus men] = 0.63; CI95%, 0.13 to 1.13) was greater among women; these accounted for 71.1% of the sex-specific difference in mortality rates. Excess risk of hospital mortality among women having CABG was largely the consequence of death from heart failure and, to a lesser extent, from hemorrhage. Smaller BSA (probably because of its association with coronary artery luminal diameter) and the absence of IMA grafting were each associated with increased risk of death from heart failure.
Cummins, Justin S; Koval, Kenneth J; Cantu, Robert V; Spratt, Kevin F
We studied National Trauma Data Bank data to determine the effectiveness of car safety devices in reducing mortality and injury severity in 184,992 patients between 1988 and 2004. Safety device variables were seat belt used plus air bag deployed; only seat belt used; only air bag deployed; and, as explicitly coded, no device used. Overall mortality was 4.17%. Compared with the no-device group, the seat-belt-plus-air-bag group had a 67% reduction in mortality (adjusted odds ratio [AOR], 0.33; 99% confidence interval [CI], 0.28-0.39), the seatbelt- only group had a 51% mortality reduction (AOR, 0.49; 99% CI, 0.45-0.52), and the air-bag-only group had a 32% mortality reduction (AOR, 0.68, 99% CI, 0.57-0.80). Injury Severity Scores showed a similar pattern.
Isley, C F; Nelson, P F; Taylor, M P; Stelcer, E; Atanacio, A J; Cohen, D D; Mani, F S; Maata, M
Health implications of air pollution vary dependent upon pollutant sources. This work determines the value, in terms of reduced mortality, of reducing ambient particulate matter (PM2.5: effective aerodynamic diameter 2.5μm or less) concentration due to different emission sources. Suva, a Pacific Island city with substantial input from combustion sources, is used as a case-study. Elemental concentration was determined, by ion beam analysis, for PM2.5 samples from Suva, spanning one year. Sources of PM2.5 have been quantified by positive matrix factorisation. A review of recent literature has been carried out to delineate the mortality risk associated with these sources. Risk factors have then been applied for Suva, to calculate the possible mortality reduction that may be achieved through reduction in pollutant levels. Higher risk ratios for black carbon and sulphur resulted in mortality predictions for PM2.5 from fossil fuel combustion, road vehicle emissions and waste burning that surpass predictions for these sources based on health risk of PM2.5 mass alone. Predicted mortality for Suva from fossil fuel smoke exceeds the national toll from road accidents in Fiji. The greatest benefit for Suva, in terms of reduced mortality, is likely to be accomplished by reducing emissions from fossil fuel combustion (diesel), vehicles and waste burning. Copyright © 2017. Published by Elsevier B.V.
Pines, Jesse M; Batt, Robert J; Hilton, Joshua A; Terwiesch, Christian
Some have suggested that emergency department (ED) boarding is prevalent because it maximizes revenue as hospitals prioritize non-ED admissions, which reimburse higher than ED admissions. We explore the revenue implications to the overall hospital of reducing boarding in the ED. We quantified the revenue effect of reducing boarding-the balance of higher ED demand and the reduction of non-ED admissions-using financial modeling informed by regression analysis and discrete-event simulation with data from 1 inner-city teaching hospital during 2 years (118,000 ED visits, 22% ED admission rate, 7% left without being seen rate, 36,000 non-ED admissions). Various inpatient bed management policies for reducing non-ED admissions were tested. Non-ED admissions generated more revenue than ED admissions ($4,118 versus $2,268 per inpatient day). A 1-hour reduction in ED boarding time would result in $9,693 to $13,298 of additional daily revenue from capturing left without being seen and diverted ambulance patients. To accommodate this demand, we found that simulated management policies in which non-ED admissions are reduced without consideration to hospital capacity (ie, static policies) mostly did not result in higher revenue. Many dynamic policies requiring cancellation of various proportions of non-ED admissions when the hospital reaches specific trigger points increased revenue. The optimal strategies tested resulted in an estimated $2.7 million and $3.6 in net revenue per year, depending on whether left without being seen patients were assumed to be outpatients or mirrored ambulatory admission rates, respectively. Dynamic inpatient bed management in inner-city teaching hospitals in which non-ED admissions are occasionally reduced to ensure that EDs have reduced boarding times is a financially attractive strategy. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
Goss, Louisa B; Ortiz, Justin R; Okamura, Daryl M; Hayward, Kristen; Goss, Christopher H
Background Systemic lupus erythematosus (SLE or lupus) is an autoimmune multisystem disease. While a complete understanding of lupus’ origins, mechanisms, and progression is not yet available, a number of studies have demonstrated correlations between disease prevalence and severity, gender, and race. There have been few population based studies in the United States Objectives To assess temporal changes in demographics and hospital mortality of patients with lupus in Washington State from 2003 to 2011 Study Design This study used data from the Healthcare Cost and Utilization Project (HCUP), a patient information database, and data from the Washington State census to study a group of patients in the state. Lupus hospitalizations were defined as any hospitalization with an ICD-9-CM diagnosis code for systemic lupus erythematosus. Regression analysis was used to assess the effect of calendar time on demographics and hospital outcomes. Results There were a total of 18,905 patients in this study with a diagnostic code for lupus. The mean age of the group was 51.5 years (95% CI: 50.6-52.3) in 2003 and 51.3 years (95% CI: 50.6-52.0) in 2011. The population was 88.6% female. Blacks were 2.8 times more likely to have a lupus hospitalization than whites when compared to the Washington population. While hospital mortality decreased during this eight year period (3.12% in 2003 to 1.28% in 2011, p=0.001) hospital length of stay remained statistically unchanged at an average of 4.9 days during that eight year period. We found a significant decrease in annual hospital mortality over the study period [odds ratio(OR): 0.92 per year, 95% CI 0.88-0.96, P<0.001]. Hospital mortality was higher in males (2.6% male death to 1.8% female death) Conclusions In this large group of hospitalized lupus patients in Washington, hospital length of stay remained relatively stable over time but hospital mortality decreased by over 50% over the eight year study period. PMID:26087254
Goss, Louisa B; Ortiz, Justin R; Okamura, Daryl M; Hayward, Kristen; Goss, Christopher H
Systemic lupus erythematosus (SLE or lupus) is an autoimmune multisystem disease. While a complete understanding of lupus' origins, mechanisms, and progression is not yet available, a number of studies have demonstrated correlations between disease prevalence and severity, gender, and race. There have been few population based studies in the United States. To assess temporal changes in demographics and hospital mortality of patients with lupus in Washington State from 2003 to 2011. This study used data from the Healthcare Cost and Utilization Project (HCUP), a patient information database, and data from the Washington State census to study a group of patients in the state. Lupus hospitalizations were defined as any hospitalization with an ICD-9-CM diagnosis code for systemic lupus erythematosus. Regression analysis was used to assess the effect of calendar time on demographics and hospital outcomes. There were a total of 18,905 patients in this study with a diagnostic code for lupus. The mean age of the group was 51.5 years (95% CI: 50.6-52.3) in 2003 and 51.3 years (95% CI: 50.6-52.0) in 2011. The population was 88.6% female. Blacks were 2.8 times more likely to have a lupus hospitalization than whites when compared to the Washington population. While hospital mortality decreased during this eight year period (3.12% in 2003 to 1.28% in 2011, p=0.001) hospital length of stay remained statistically unchanged at an average of 4.9 days during that eight year period. We found a significant decrease in annual hospital mortality over the study period [odds ratio(OR): 0.92 per year, 95% CI 0.88-0.96, P<0.001]. Hospital mortality was higher in males (2.6% male death to 1.8% female death). In this large group of hospitalized lupus patients in Washington, hospital length of stay remained relatively stable over time but hospital mortality decreased by over 50% over the eight year study period.
Báez-Saldaña, Renata; Villafuerte-García, Adriana; Cruz-Hervert, Pablo; Delgado-Sánchez, Guadalupe; Ferreyra-Reyes, Leticia; Ferreira-Guerrero, Elizabeth; Mongua-Rodríguez, Norma; Montero-Campos, Rogelio; Melchor-Romero, Ada; García-García, Lourdes
Respiratory manifestations of HIV disease differ globally due to differences in current availability of effective highly active antiretroviral therapy (HAART) programs and epidemiology of infectious diseases. To describe the association between HAART and discharge diagnosis and all-cause in-hospital mortality among hospitalized patients with infectious respiratory disease and HIV/AIDS. We retrospectively reviewed the records of patients hospitalized at a specialty hospital for respiratory diseases in Mexico City between January 1st, 2010 and December 31st, 2011. We included patients whose discharge diagnosis included HIV or AIDS and at least one infectious respiratory diagnosis. The information source was the clinical chart. We analyzed the association between HAART for 180 days or more and type of respiratory disease using polytomous logistic regression and all-cause hospital mortality by multiple logistic regressions. We studied 308 patients, of whom 206 (66.9%) had been diagnosed with HIV infection before admission to the hospital. The CD4+ lymphocyte median count was 68 cells/mm3 [interquartile range (IQR): 30-150]. Seventy-five (24.4%) cases had received HAART for more than 180 days. Pneumocystis jirovecii pneumonia (PJP) (n = 142), tuberculosis (n = 63), and bacterial community-acquired pneumonia (n = 60) were the most frequent discharge diagnoses. Receiving HAART for more than 180 days was associated with a lower probability of PJP [Adjusted odd ratio (aOR): 0.245, 95% Confidence Interval (CI): 0.08-0.8, p = 0.02], adjusted for sociodemographic and clinical covariates. HAART was independently associated with reduced odds (aOR 0.214, 95% CI 0.06-0.75) of all-cause in-hospital mortality, adjusting for HIV diagnosis previous to hospitalization, age, access to social security, low socioeconomic level, CD4 cell count, viral load, and discharge diagnoses. HAART for 180 days or more was associated with 79% decrease in all-cause in-hospital mortality and lower
Báez-Saldaña, Renata; Villafuerte-García, Adriana; Cruz-Hervert, Pablo; Delgado-Sánchez, Guadalupe; Ferreyra-Reyes, Leticia; Ferreira-Guerrero, Elizabeth; Mongua-Rodríguez, Norma; Montero-Campos, Rogelio; Melchor-Romero, Ada; García-García, Lourdes
Background Respiratory manifestations of HIV disease differ globally due to differences in current availability of effective highly active antiretroviral therapy (HAART) programs and epidemiology of infectious diseases. Objective To describe the association between HAART and discharge diagnosis and all-cause in-hospital mortality among hospitalized patients with infectious respiratory disease and HIV/AIDS. Material and Methods We retrospectively reviewed the records of patients hospitalized at a specialty hospital for respiratory diseases in Mexico City between January 1st, 2010 and December 31st, 2011. We included patients whose discharge diagnosis included HIV or AIDS and at least one infectious respiratory diagnosis. The information source was the clinical chart. We analyzed the association between HAART for 180 days or more and type of respiratory disease using polytomous logistic regression and all-cause hospital mortality by multiple logistic regressions. Results We studied 308 patients, of whom 206 (66.9%) had been diagnosed with HIV infection before admission to the hospital. The CD4+ lymphocyte median count was 68 cells/mm3 [interquartile range (IQR): 30–150]. Seventy-five (24.4%) cases had received HAART for more than 180 days. Pneumocystis jirovecii pneumonia (PJP) (n = 142), tuberculosis (n = 63), and bacterial community-acquired pneumonia (n = 60) were the most frequent discharge diagnoses. Receiving HAART for more than 180 days was associated with a lower probability of PJP [Adjusted odd ratio (aOR): 0.245, 95% Confidence Interval (CI): 0.08–0.8, p = 0.02], adjusted for sociodemographic and clinical covariates. HAART was independently associated with reduced odds (aOR 0.214, 95% CI 0.06–0.75) of all-cause in-hospital mortality, adjusting for HIV diagnosis previous to hospitalization, age, access to social security, low socioeconomic level, CD4 cell count, viral load, and discharge diagnoses. Conclusions HAART for 180 days or more was associated
Moreso, Francesc; Pons, Mercedes; Ramos, Rosa; Mora-Macià, Josep; Carreras, Jordi; Soler, Jordi; Torres, Ferran; Campistol, Josep M.; Martinez-Castelao, Alberto
Retrospective studies suggest that online hemodiafiltration (OL-HDF) may reduce the risk of mortality compared with standard hemodialysis in patients with ESRD. We conducted a multicenter, open-label, randomized controlled trial in which we assigned 906 chronic hemodialysis patients either to continue hemodialysis (n=450) or to switch to high-efficiency postdilution OL-HDF (n=456). The primary outcome was all-cause mortality, and secondary outcomes included cardiovascular mortality, all-cause hospitalization, treatment tolerability, and laboratory data. Compared with patients who continued on hemodialysis, those assigned to OL-HDF had a 30% lower risk of all-cause mortality (hazard ratio [HR], 0.70; 95% confidence interval [95% CI], 0.53–0.92; P=0.01), a 33% lower risk of cardiovascular mortality (HR, 0.67; 95% CI, 0.44–1.02; P=0.06), and a 55% lower risk of infection-related mortality (HR, 0.45; 95% CI, 0.21–0.96; P=0.03). The estimated number needed to treat suggested that switching eight patients from hemodialysis to OL-HDF may prevent one annual death. The incidence rates of dialysis sessions complicated by hypotension and of all-cause hospitalization were lower in patients assigned to OL-HDF. In conclusion, high-efficiency postdilution OL-HDF reduces all-cause mortality compared with conventional hemodialysis. PMID:23411788
Shelton, James D
Reduced mortality has been the predominant cause of the marked global population growth over the last 3/4 of a century. While improved child survival increases motivation to reduce fertility, it comes too little and too late to forestall substantial population growth. And, beyond motivation, couples need effective means to control their fertility. It is an inconvenient truth that reducing child mortality contributes considerably to the population growth destined to compromise the quality of life of many, particularly in sub-Saharan Africa. Vigorous child survival programming is of course imperative. Wide access to voluntary family planning can help mitigate that growth and provide many other benefits.
Weidner, KJ; El-Battrawy, I; Behnes, M; Schramm, K; Fastner, C; Kuschyk, J; Hoffmann, U; Ansari, U; Borggrefe, M; Akin, I
Background Previous studies revealed that patients with Takotsubo cardiomyopathy (TTC) have a higher mortality rate than the general population. It is still unclear whether sex differences may influence long-term prognosis of TTC patients. The purpose of this study was to determine whether sex differences do influence the short- and long-term outcomes of TTC. Methods and results A total of 114 patients with TTC were admitted to the University Medical Centre Mannheim from January 2003 to September 2015 and entered into the TTC database of the University Medical Centre Mannheim, and retrospectively analyzed. Patients were diagnosed by the Mayo Clinic criteria. All-cause mortality over mean follow-up of 1,529±1,121 days was revealed. Significantly more male patients died within long-term follow-up compared to female TTC patients (log-rank test; P=0.01). Most males died of noncardiac causes. In multivariate Cox regression analysis, the male sex (P=0.02, hazard ratio [HR] 2.8, 95% CI 1.1–7.2), the ejection fraction ≤35% (P=0.01, HR 3.3, 95% CI 1.2–9.2) and glomerular filtration rate <60 mL/min (P<0.01, HR 3.1, 95% CI 1.4–7.0) figured out as independent predictors of the adverse outcome. Conclusion This study shows that males suffering from TTC reveal a higher long-term all-cause mortality rate than females over a 5 year follow-up period. PMID:28744135
Callister, Lynn Clark; Edwards, Joan E
Innovative programs introduced in response to the Millennium Development Goals show promise to reduce the global rate of maternal mortality. The Sustainable Development Goals, introduced in 2015, were designed to build on this progress. In this article, we describe the global factors that contribute to maternal mortality rates, outcomes of the implementation of the Millennium Development Goals, and the new, related Sustainable Development Goals. Implications for clinical practice, health care systems, research, and health policy are provided.
Lee, Duck-chul; Pate, Russell R.; Lavie, Carl J.; Sui, Xuemei; Church, Timothy S.; Blair, Steven N.
Background Although running is a popular leisure-time physical activity, little is known about the long-term effects of running on mortality. The dose-response relations between running, as well as the change in running behaviors over time and mortality remain uncertain. Objectives We examined the associations of running with all-cause and cardiovascular mortality risks in 55,137 adults, aged 18 to 100 years (mean age, 44). Methods Running was assessed on the medical history questionnaire by leisure-time activity. Results During a mean follow-up of 15 years, 3,413 all-cause and 1,217 cardiovascular deaths occurred. Approximately, 24% of adults participated in running in this population. Compared with non-runners, runners had 30% and 45% lower adjusted risks of all-cause and cardiovascular mortality, respectively, with a 3-year life expectancy benefit. In dose-response analyses, the mortality benefits in runners were similar across quintiles of running time, distance, frequency, amount, and speed, compared with non-runners. Weekly running even <51 minutes, <6 miles, 1-2 times, <506 metabolic equivalent-minutes, or <6 mph was sufficient to reduce risk of mortality, compared with not running. In the analyses of change in running behaviors and mortality, persistent runners had the most significant benefits with 29% and 50% lower risks of all-cause and cardiovascular mortality, respectively, compared with never-runners. Conclusions Running, even 5-10 minutes per day and slow speeds <6 mph, is associated with markedly reduced risks of death from all causes and cardiovascular disease. This study may motivate healthy but sedentary individuals to begin and continue running for substantial and attainable mortality benefits. PMID:25082581
Lee, Duck-Chul; Pate, Russell R; Lavie, Carl J; Sui, Xuemei; Church, Timothy S; Blair, Steven N
Although running is a popular leisure-time physical activity, little is known about the long-term effects of running on mortality. The dose-response relations between running, as well as the change in running behaviors over time, and mortality remain uncertain. We examined the associations of running with all-cause and cardiovascular mortality risks in 55,137 adults, 18 to 100 years of age (mean age 44 years). Running was assessed on a medical history questionnaire by leisure-time activity. During a mean follow-up of 15 years, 3,413 all-cause and 1,217 cardiovascular deaths occurred. Approximately 24% of adults participated in running in this population. Compared with nonrunners, runners had 30% and 45% lower adjusted risks of all-cause and cardiovascular mortality, respectively, with a 3-year life expectancy benefit. In dose-response analyses, the mortality benefits in runners were similar across quintiles of running time, distance, frequency, amount, and speed, compared with nonrunners. Weekly running even <51 min, <6 miles, 1 to 2 times, <506 metabolic equivalent-minutes, or <6 miles/h was sufficient to reduce risk of mortality, compared with not running. In the analyses of change in running behaviors and mortality, persistent runners had the most significant benefits, with 29% and 50% lower risks of all-cause and cardiovascular mortality, respectively, compared with never-runners. Running, even 5 to 10 min/day and at slow speeds <6 miles/h, is associated with markedly reduced risks of death from all causes and cardiovascular disease. This study may motivate healthy but sedentary individuals to begin and continue running for substantial and attainable mortality benefits. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Kucukarslan, Suzan N; Peters, Michael; Mlynarek, Mark; Nafziger, Daniel A
Previous studies found that medication errors result from lack of sufficient information during the prescribing step. Therefore, it is proposed that having a pharmacist available when patients are evaluated during the rounding process may reduce the likelihood of preventable adverse drug events (ADEs). The objectives of this study were to evaluate the impact of having a pharmacist participate with a physician rounding team on preventable ADEs in general medicine units and to document pharmacist interventions made during the rounding process. A single-blind, standard care-controlled study design was used to compare patients receiving care from a rounding team including a pharmacist with patients receiving standard care (no pharmacist on rounding team). Patients admitted to and discharged from the same general medicine unit were included in the study. The main outcome measure of this study was preventable ADEs. Patient records were randomly selected and evaluated by a blinded process involving independent senior pharmacist specialists and a senior staff physician. Interventions made by the pharmacists in the treatment group were documented. The rate of preventable ADEs was reduced by 78%, from 26.5 per 1000 hospital days to 5.7 per 1000 hospital days. There were 150 documented interventions recommended during the rounding process, 147 of which were accepted by the team. The most common interventions were (1) dosing-related changes and (2) recommendations to add a drug to therapy. Pharmacist participation with the medical rounding team on a general medicine unit contributes to a significant reduction in preventable ADEs.
Nicolau, S; Teodoru, G; Popa, I; Nicolescu, S; Feldioreanu, E
-30/1000 live births and the total annual toll reaches 750,000 to 1 million globally mostly because of nonsterile instruments. 90% of tetanus incidence in Romania was eradicated by vaccination. Preventive measures can reduce mortality: education of women on health and hygiene, avoidance of heavy labor during pregnancy, family planning services, aseptic techniques, vaccination against tetanus and other infectious diseases, chemical prophylaxis against malaria, improved obstetrical care, consolidated support system, and community participation.
Gagné, Mathieu; Moore, Lynne; Beaudoin, Claudia; Batomen Kuimi, Brice Lionel; Sirois, Marie-Josée
The International Classification of Diseases (ICD) is the main classification system used for population-based injury surveillance activities but does not contain information on injury severity. ICD-based injury severity measures can be empirically derived or mapped, but no single approach has been formally recommended. This study aimed to compare the performance of ICD-based injury severity measures to predict in-hospital mortality among injury-related admissions. A systematic review and a meta-analysis were conducted. MEDLINE, EMBASE, and Global Health databases were searched from their inception through September 2014. Observational studies that assessed the performance of ICD-based injury severity measures to predict in-hospital mortality and reported discriminative ability using the area under a receiver operating characteristic curve (AUC) were included. Metrics of model performance were extracted. Pooled AUC were estimated under random-effects models. Twenty-two eligible studies reported 72 assessments of discrimination on ICD-based injury severity measures. Reported AUC ranged from 0.681 to 0.958. Of the 72 assessments, 46 showed excellent (0.80 ≤ AUC < 0.90) and 6 outstanding (AUC ≥ 0.90) discriminative ability. Pooled AUC for ICD-based Injury Severity Score (ICISS) based on the product of traditional survival proportions was significantly higher than measures based on ICD mapped to Abbreviated Injury Scale (AIS) scores (0.863 vs. 0.825 for ICDMAP-ISS [p = 0.005] and ICDMAP-NISS [p = 0.016]). Similar results were observed when studies were stratified by the type of data used (trauma registry or hospital discharge) or the provenance of survival proportions (internally or externally derived). However, among studies published after 2003 the Trauma Mortality Prediction Model based on ICD-9 codes (TMPM-9) demonstrated superior discriminative ability than ICISS using the product of traditional survival proportions (0.850 vs. 0.802, p = 0.002). Models
Bradley, Elizabeth H; Sipsma, Heather; Brewster, Amanda L; Krumholz, Harlan M; Curry, Leslie
Survival rates after acute myocardial infarction (AMI) vary markedly across U.S. hospitals. Although substantial efforts have been made to improve hospital performance, we lack contemporary evidence about changes in hospital strategies and features of organizational culture that might contribute to reducing hospital AMI mortality rates. We sought to describe current use of several strategies and features of organizational culture linked to AMI mortality in a national sample of hospitals and examine changes in use between 2010 and 2013. We conducted a cross-sectional survey of 543 hospitals (70% response rate) in 2013, and longitudinal analysis of a subsample of 107 hospitals that had responded to a survey in 2010 (67% response rate). Between 2010 and 2013, the use of many strategies increased, but the use of only two strategies increased significantly: the percentage of hospitals providing regular training to Emergency Medical Service (EMS) providers about AMI care increased from 36% to 71% (P-value < 0.001) and the percentage of hospitals using computerized assisted physician order entry more than doubled (P-value < 0.001). Most, but not all, hospitals reported having environments conducive to communication, coordination and problem solving. We found few significant changes between 2010 and 2013 in hospital strategies or in key features of organizational culture that have been associated with lower AMI mortality rates. Findings highlight several opportunities to help close remaining performance gaps in AMI mortality among hospitals.
Cao, P; Toyabe, S; Kurashima, S; Okada, M; Akazawa, K
Activity-based costing (ABC) is widely used to precisely allocate indirect costs to medical services. In the ABC method, the indirect cost is divided among the medical services in proportion to the volume of "cost drivers", for example, labor hours and the number of hours of surgery. However, the workload of data collection of cost drivers can be time-consuming and a considerable burden if there are many cost drivers. The authors aim to develop a method for objectively reducing the cost drivers used in the ABC method. In the ABC method, the cost driver is assigned for each activity. We assume that these activities and cost drivers are the best combination. Our method, that is cost driver reduction (CDR), can objectively select surrogates of the cost drivers for each activity in ABC from candidate cost drivers. Concretely, the total indirect cost of an activity is temporarily allocated to the medical services using each candidate of cost drivers. The difference between the costs calculated by each candidate and the proper cost driver used in ABC is calculated to evaluate the similarity by the evaluation function. We estimated the cost of laboratory tests using our method and revealed that the number of cost drivers could be reduced from seven in the ABC to four. Similarly, the results of cost estimation obtained by our method were as accurate as those calculated using the ABC. Our method provides two advantages compared to the ABC method: 1) it provides results that are as accurate as those of the ABC method, and 2) it is simpler to perform complicated estimation of hospital costs.
Uscinska, Ewa; Sobkowicz, Bozena; Sawicki, Robert; Kiluk, Izabela; Baranicz, Malgorzata; Stepek, Tomasz; Dabrowska, Milena; Szmitkowski, Maciej; Musial, Wlodzimierz J; Tycinska, Agnieszka M
We investigated the incidence and prognostic value of anemia as well as of the iron status in non-selected patients admitted to an intensive cardiac care unit (ICCU). 392 patients (mean age 70 ± 13.8 years, 43% women), 168 with acute coronary syndromes (ACS), 122 with acute decompensated heart failure, and 102 with other acute cardiac disorders were consecutively, prospectively assessed. The biomarkers of iron status-serum iron concentration (SIC), total iron binding capacity (TIBC), and transferrin saturation (TSAT) together with standard clinical, biochemical and echocardiographic variables-were analyzed. In-hospital mortality was 3.8% (15 patients). The prevalences of anemia (according to WHO criteria), and iron deficiency (ID) were 64 and 63%, respectively. The level of biomarkers of iron status, but not anemia, was lower in patients who died (p < 0.05). Anemia was less frequent in patients with ACS as compared to the remaining ICCU population (p = 0.019). The analysis by logistic regression indicated the highest risk of death for age [odds ratio (OD) 1.38, 95% CI 1.27-1.55], SIC (OR 0.85, 95% CI 0.78-0.94), TIBC (OR 0.95, 95% CI 0.91-0.98), left ventricle ejection fraction (OR 0.85, 95% CI 0.77-0.93), as well as hospitalization for non-ACS (OR 0.25, 95% CI 0.14-0.46), (p < 0.05). The risk of death during hospitalization tended to increase with decreasing levels of TIBC (p = 0.49), as well as with the absence of ACS (p = 0.54). The incidence of anemia and ID in heterogeneous ICCU patients is high. Parameters of the iron status, but not anemia per se, independently influence in-hospital mortality. The prevalence of anemia is higher in non-ACS patients, and tends to worsen the prognosis.
Background Jumping from heights is a readily available and lethal method of suicide. This study examined the effectiveness of a minimal structural intervention in preventing suicide jumps at a Swiss general teaching hospital. Following a series of suicide jumps out of the hospital’s windows, a metal guard rail was installed at each window of the high-rise building. Results In the 114 months prior to the installation of the metal guard rail, 10 suicides by jumping out of the hospital’s windows occurred among 119,269 inpatients. This figure was significantly reduced to 2 fatal incidents among 104,435 inpatients treated during the 78 months immediately following the installation of the rails at the hospital’s windows (χ2 = 4.34, df = 1, p = .037). Conclusions Even a minimal structural intervention might prevent suicide jumps in a general hospital. Further work is needed to examine the effectiveness of minimal structural interventions in preventing suicide jumps. PMID:22862804
John B Bradford; David M Bell
Increasing aridity as a result of climate change is expected to exacerbate tree mortality. Reducing forest basal area â the cross-sectional area of tree stems within a given ground area â can decrease tree competition, which may reduce drought-induced tree mortality. However, neither the magnitude of expected mortality increases, nor the potential effectiveness of...
Han, Guang-Ming; Meza, Jane L; Soliman, Ghada A; Islam, K M Monirul; Watanabe-Galloway, Shinobu
Metabolic syndrome increases the risk of mortality. Increased oxidative stress and inflammation may play an important role in the high mortality of individuals with metabolic syndrome. Previous studies have suggested that lycopene intake might be related to the reduced oxidative stress and decreased inflammation. Using data from the National Health and Nutrition Examination Survey, we examined the hypothesis that lycopene is associated with mortality among individuals with metabolic syndrome. A total of 2499 participants 20 years and older with metabolic syndrome were divided into 3 groups based on their serum concentration of lycopene using the tertile rank method. The National Health and Nutrition Examination Survey from years 2001 to 2006 was linked to the mortality file for mortality follow-up data through December 31, 2011, to determine the mortality rate and hazard ratios (HR) for the 3 serum lycopene concentration groups. The mean survival time was significantly higher in the group with the highest serum lycopene concentration (120.6 months; 95% confidence interval [CI], 118.8-122.3) and the medium group (116.3 months; 95% CI, 115.2-117.4), compared with the group with lowest serum lycopene concentration (107.4 months; 95% CI, 106.5-108.3). After adjusting for possible confounding factors, participants in the highest (HR, 0.61; P = .0113) and in the second highest (HR, 0.67; P = .0497) serum lycopene concentration groups showed significantly lower HRs of mortality when compared with participants in the lower serum lycopene concentration. The data suggest that higher serum lycopene concentration has a significant association with the reduced risk of mortality among individuals with metabolic syndrome.
Loprinzi, Paul D
An elevated (≥3.1g/dl) gamma gap (Total Protein (g/dl)-Albumin (g/dl)) is associated with increased heart failure risk and an increased mortality risk. Adequate muscular strength is associated with reduced mortality risk, but the potential protective effects of muscular strength on mortality among those with an elevated gamma gap has yet to be investigated, which was this study's purpose. Data from the 1999-2002 NHANES were utilized, with follow-up through 2011. Lower extremity strength was objectively-measured via a knee extensor test. Gamma gap was measured from a blood sample. 2776 participants (50-85yrs) constituted the analytic sample. After adjustments, and among those with an elevated gamma gap, a 50N increase in lower extremity strength was associated with a 27% reduced risk of all-cause mortality (HRadjusted=0.73; 95% CI: 0.65-0.82; P<0.001). Having adequate lower extremity strength in middle-age and older adult years may be of critical importance in reducing mortality risk, particularly among those with an elevated gamma gap. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Anders, Katherine L.; Nguyet, Nguyen Minh; Van Vinh Chau, Nguyen; Hung, Nguyen Thanh; Thuy, Tran Thi; Lien, Le Bich; Farrar, Jeremy; Wills, Bridget; Hien, Tran Tinh; Simmons, Cameron P.
Understanding trends in dengue disease burden and risk factors for severe disease can inform health service allocation, clinical management, and planning for vaccines and therapeutics. Dengue admissions at three tertiary hospitals in Ho Chi Minh City, Vietnam, increased between 1996 and 2009, peaking at 22,860 in 2008. Children aged 6–10 years had highest risk of dengue shock syndrome (DSS); however, mortality was highest in younger children and decreased with increasing age (odds ratio [OR] = 0.52, 95% confidence interval [CI] = 0.36–0.75 in 6- to 10- year-old children and OR = 0.27, 95% CI = 0.16–0.44 in 11- to 15-year-old children compared with 1- to 5-year-old children). Males were overrepresented among dengue cases; however, girls had higher risk of DSS (OR = 1.19, 95% CI = 1.14–1.24) and death (OR = 1.57, 95% CI = 1.14–2.17). Young children with dengue had greatest risk of death and should be targeted in dengue vaccine and drug trials. The increased risk of severe outcomes in girls warrants further attention in studies of pathogenesis, health-seeking behavior, and clinical care. PMID:21212214
Comparison of In-Hospital Mortality, Length of Stay, Postprocedural Complications, and Cost of Single-Vessel Versus Multivessel Percutaneous Coronary Intervention in Hemodynamically Stable Patients With ST-Segment Elevation Myocardial Infarction (from Nationwide Inpatient Sample [2006 to 2012]).
Panaich, Sidakpal S; Arora, Shilpkumar; Patel, Nilay; Schreiber, Theodore; Patel, Nileshkumar J; Pandya, Bhavi; Gupta, Vishal; Grines, Cindy L; Deshmukh, Abhishek; Badheka, Apurva O
The primary objective of our study was to evaluate the in-hospital outcomes in terms of mortality, procedural complications, hospitalization costs, and length of stay (LOS) after multivessel percutaneous coronary intervention (MVPCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). The study cohort was derived from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database, years 2006 to 2012. Percutaneous coronary interventions (PCI) performed during STEMI were identified using appropriate International Classification of Diseases, Ninth Revision, diagnostic and procedural codes. Patients in cardiogenic shock were excluded. Hierarchical mixed-effects logistic regression models were used for categorical dependent variables such as in-hospital mortality and composite of in-hospital mortality and complications, and hierarchical mixed-effects linear regression models were used for continuous dependent variables such as cost of hospitalization and LOS. We identified 106,317 (weighted n = 525,161) single-vessel PCI and 15,282 (weighted n = 74,543) MVPCIs. MVPCI (odds ratio, 95% confidence interval [CI], p value) was not associated with significant increase in in-hospital mortality (0.99, 0.85 to 1.15, 0.863) but predicted a higher composite end point of in-hospital mortality and postprocedural complications (1.09, 1.02 to 1.17, 0.013) compared to single-vessel PCI. MVPCI was also predictive of longer LOS (LOS +0.19 days, 95% CI +0.14 to +0.23 days, p <0.001) and higher hospitalization costs (cost +$4,445, 95% CI +$4,128 to +$4,762, p <0.001). MVPCI performed during STEMI in hemodynamically stable patients is associated with no increase in in-hospital mortality but a higher rate of postprocedural complications and longer LOS and greater hospitalization costs compared to single-vessel PCI.
Lionte, Catalina; Sorodoc, Victorita; Jaba, Elisabeta; Botezat, Alina
Abstract Acute poisoning with drugs and nonpharmaceutical agents represents an important challenge in the emergency department (ED). The objective is to create and validate a risk-prediction nomogram for use in the ED to predict the risk of in-hospital mortality in adults from acute poisoning with drugs and nonpharmaceutical agents. This was a prospective cohort study involving adults with acute poisoning from drugs and nonpharmaceutical agents admitted to a tertiary referral center for toxicology between January and December 2015 (derivation cohort) and between January and June 2016 (validation cohort). We used a program to generate nomograms based on binary logistic regression predictive models. We included variables that had significant associations with death. Using regression coefficients, we calculated scores for each variable, and estimated the event probability. Model validation was performed using bootstrap to quantify our modeling strategy and using receiver operator characteristic (ROC) analysis. The nomogram was tested on a separate validation cohort using ROC analysis and goodness-of-fit tests. Data from 315 patients aged 18 to 91 years were analyzed (n = 180 in the derivation cohort; n = 135 in the validation cohort). In the final model, the following variables were significantly associated with mortality: age, laboratory test results (lactate, potassium, MB isoenzyme of creatine kinase), electrocardiogram parameters (QTc interval), and echocardiography findings (E wave velocity deceleration time). Sex was also included to use the same model for men and women. The resulting nomogram showed excellent survival/mortality discrimination (area under the curve [AUC] 0.976, 95% confidence interval [CI] 0.954–0.998, P < 0.0001 for the derivation cohort; AUC 0.957, 95% CI 0.892–1, P < 0.0001 for the validation cohort). This nomogram provides more precise, rapid, and simple risk-analysis information for individual patients acutely exposed to
Elmunzer, B Joseph; Singal, Amit G; Sussman, Jeremy B; Deshpande, Amar R; Sussman, Daniel A; Conte, Marisa L; Dwamena, Ben A; Rogers, Mary A M; Schoenfeld, Philip S; Inadomi, John M; Saini, Sameer D; Waljee, Akbar K
Comparative effectiveness data pertaining to competing colorectal cancer (CRC) screening tests do not exist but are necessary to guide clinical decision making and policy. To perform a comparative synthesis of clinical outcomes studies evaluating the effects of competing tests on CRC-related mortality. Traditional and network meta-analyses. Two reviewers identified studies evaluating the effect of guaiac-based fecal occult blood testing (gFOBT), flexible sigmoidoscopy (FS), or colonoscopy on CRC-related mortality. gFOBT, FS, colonoscopy. Traditional meta-analysis was performed to produce pooled estimates of the effect of each modality on CRC mortality. Bayesian network meta-analysis (NMA) was performed to indirectly compare the effectiveness of screening modalities. Multiple sensitivity analyses were performed. Traditional meta-analysis revealed that, compared with no intervention, colonoscopy reduced CRC-related mortality by 57% (relative risk [RR] 0.43; 95% confidence interval [CI], 0.33-0.58), whereas FS reduced CRC-related mortality by 40% (RR 0.60; 95% CI, 0.45-0.78), and gFOBT reduced CRC-related mortality by 18% (RR 0.82; 95% CI, 0.76-0.88). NMA demonstrated nonsignificant trends favoring colonoscopy over FS (RR 0.71; 95% CI, 0.45-1.11) and FS over gFOBT (RR 0.74; 95% CI, 0.51-1.09) for reducing CRC-related deaths. NMA-based simulations, however, revealed that colonoscopy has a 94% probability of being the most effective test for reducing CRC mortality and a 99% probability of being most effective when the analysis is restricted to screening studies. Randomized trials and observational studies were combined within the same analysis. Clinical outcomes studies demonstrate that gFOBT, FS, and colonoscopy are all effective in reducing CRC-related mortality. Network meta-analysis suggests that colonoscopy is the most effective test. Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
Malik, Ali Osama; Abela, Oliver; Allenback, Gayle; Devabhaktuni, Subodh; Lui, Calvin; Singh, Aditi; Diep, Jimmy; Yamashita, Takashi; Yoo, Ji Won; Malhotra, Sanjay; Ahsan, Chowdhury
Regional trends for ST-segment elevation myocardial infarction (STEMI) treatment is not known in the state of Nevada. Great disparity exists for treatment for STEMI in different geographical areas of Nevada. There is a great potential to improve treatment and outcomes of STEMI patients in the State of Nevada. Admissions to non-federal hospitals in the state of Nevada, using 2011 to 2013 discharge data from the Nevada State Inpatient Data Base (acquired from Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality), were analyzed. Outpatient-onset STEMI patients were identified. The state of Nevada was divided into three divisions based on population densities, defined as population per square mile. Division A included counties with population density of <50 per square mile, Division B included counties with population density of 50 to 200 per square mile, and Division C included counties with population density of >200 per square mile. Trends in use of STEMI-related therapies and the impact on in-hospital mortality rates were compared. Almost 20% of the patients with outpatient-onset STEMI do not get any STEMI-related therapy and have significantly higher mortality rate. Patients from Division A do not have direct access to percutaneous coronary intervention (PCI) centers. These patients receive less STEMI-related therapies. Low-volume PCI centers had equivalent mortality rates for STEMI patients who got PCI, compared to high-volume PCI centers. Policies must be created and processes streamlined so all STEMI patients in Nevada receive appropriate treatment. Copyright © 2017. Published by Elsevier B.V.
Sara B. Zielin; Jalene Littlejohn; Catherine E. de Rivera; Winston P. Smith; Sandra L. Jacobson
Whereas roads that bisect habitat are known to decrease population size through animal-vehicle collisions or interruption of key life history events, it is not always obvious how to reduce such impacts, especially for flying organisms. We needed a quick, cost-efficient and effective way to determine how best to decrease vehicle-caused mortality while maintaining...
Arunda, Malachi; Emmelin, Anders; Asamoah, Benedict Oppong
Although global neonatal mortality declined by about 40 percent from 1990 to 2013, it still accounted for about 2.6 million deaths globally and constituted 42 percent of global under-five deaths. Most of these deaths occur in developing countries. Antenatal care (ANC) is a globally recommended strategy used to prevent neonatal deaths. In Kenya, over 90 percent of pregnant women attend at least one ANC visit during pregnancy. However, Kenya is currently among the 10 countries that contribute the most neonatal deaths globally. The aim of this study is to examine the effectiveness of ANC services in reducing neonatal mortality in Kenya. We used binary logistic regression to analyse cross-sectional data from the 2014 Kenya Demographic and Health Survey to investigate the effectiveness of ANC services in reducing neonatal mortality in Kenya. We determined the population attributable neonatal mortality fraction for the lack of selected antenatal interventions. The highest odds of neonatal mortality were among neonates whose mothers did not attend any ANC visit (adjusted odds ratio [aOR] 4.0, 95% confidence interval [CI] 1.7-9.1) and whose mothers lacked skilled ANC attendance during pregnancy (aOR 3.0, 95% CI 1.4-6.1). Lack of tetanus injection relative to one tetanus injection was significantly associated with neonatal mortality (aOR 2.5, 95% CI 1.0-6.0). About 38 percent of all neonatal deaths in Kenya were attributable to lack of check-ups for pregnancy complications. Lack of check-ups for pregnancy complications, unskilled ANC provision and lack of tetanus injection were associated with neonatal mortality in Kenya. Integrating community ANC outreach programmes in the national policy strategy and training geared towards early detection of complications can have positive implications for neonatal survival.
Pfister, John; Chou, Chia-Hung
To assess progress in reducing mortality between 1980 and 1999 among Wisconsin residents aged 65-74, to identify disparities, and to propose future goals. Mortality rates for 1980-1984 were compared to those from 1995-1999 using data obtained from the Centers for Disease Control and Prevention's WONDER database. Percent change in rates were calculated and projected to 2010, and annual numbers of lives saved were estimated. The mortality rate for persons aged 65-74 has decreased 12.4%-17.5% in men and 6.3% in women. However, no reductions were observed for blacks. An estimated 1325 fewer deaths occur each year, with white men accounting for >80% of these savings. Mortality rates decreased for heart disease (-38%) and stroke (-26%), but increased for cancer (+6%). Significant progress has been made in reducing mortality among Wisconsin residents aged 65-74, but not among blacks. Most of the progress is due to decreased deaths from heart disease and stroke, particularly for white men.
Sun, Li-Min; Lin, Ming-Chia; Lin, Cheng-Li; Chang, Shih-Ni; Liang, Ji-An; Lin, I-Ching; Kao, Chia-Hung
Studies have suggested that statin use is related to cancer risk and prostate cancer mortality. We conducted a population-based cohort study to determine whether using statins in prostate cancer patients is associated with reduced all-cause mortality rates. Data were obtained from the Taiwan National Health Insurance Research Database. The study cohort comprised 5179 patients diagnosed with prostate cancer who used statins for at least 6 months between January 1, 1998 and December 31, 2010. To form a comparison group, each patient was randomly frequency-matched (according to age and index date) with a prostate cancer patient who did not use any type of statin-based drugs during the study period. The study endpoint was mortality. The hazard ratio (HR) and 95% confidence interval (CI) were estimated using Cox regression models. Among prostate cancer patients, statin use was associated with significantly decreased all-cause mortality (adjusted HR = 0.65; 95% CI = 0.60-0.71). This phenomenon was observed among various types of statin, age groups, and treatment methods. Analyzing the defined daily dose of statins indicated that both low- and high-dose groups exhibited significantly decreased death rates compared with nonusers, suggesting a dose-response relationship. The results of this population-based cohort study suggest that using statins reduces all-cause mortality among prostate cancer patients, and a dose-response relationship may exist.
Patel, M S; Jones, M A; Jiggins, M; Williams, S C
Despite the lack of robust evidence, numerous different "track and trigger" warning systems have been implemented. These have only been validated in an emergency medical admissions setting. The Modified Early Warning Score (MEWS) is the chosen track and trigger system used in the University Hospitals of Leicester trauma unit, but has not been validated in trauma patients. A considerable proportion of all trauma admissions are elderly patients with proximal femoral fractures and significant co-morbidities. Early recognition of physiological deterioration and prompt action could therefore be lifesaving in this patient group. To identify whether the implementation of the MEWS system coupled with a critical care outreach service resulted in a reduction in mortality in a busy trauma unit. A retrospective study. The MEWS system was implemented in all trauma and orthopaedic wards at the Leicester Royal Infirmary in the summer of 2005. The numbers of emergency trauma inpatient admissions and deaths from January 2002 to December 2009 were obtained. The diagnosis, primary procedures and cause of death, if known, were noted. Comparisons were made pre- and post-MEWS. Student's t-test was used for statistical analysis. 32,149 patients were admitted (55% male; 45% female). Overall there were 889 deaths (77% female; 33% male, P<0.0001). The in-hospital mortality rate for orthopaedic trauma patients was 2.8% throughout the 7-year study period. 61% of those who died were admitted with proximal femoral fractures. The modal age group with the highest mortality was 81-90 years. Overall, females had a considerably greater mortality rate than males. The mortality rate was lower post-MEWS in males (1.82-1.418%; P=0.214), females (4.871-3.364%; P=0.108) and all patients (3.215-2.294%; P=0.092), but this was not statistically significant. The use of a track and trigger warning system has not led to a statistically significant reduction in mortality in trauma patients. In view of the
Abbasi Nazari, Mohammad; Salamzadeh, Jamshid; Hajebi, Giti; Gilbert, Benjamin
Drug-food interactions can increase or decrease drug effects, resulting in therapeutic failure or toxicity. Activities that reduce these interactions play an important role for clinical pharmacists. This study was planned and performed in order to determine the role of clinical pharmacist in the prevention of absorption drug-food interactions through educating the nurses in a teaching hospital affiliated to Shahid Beheshti University of Medical Sciences, Tehran, Iran. The rate of interactions was determined using direct observation methods before and after the nurse training courses in four wards including gastrointestinal-liver, endocrine, vascular surgery and nephrology. Training courses consisted of the nurse attendance lecture delivered by a clinical pharmacist which included receiving information pamphlets. Total incorrect drug administration fell down from 44.6% to 31.5%. The analysis showed that the rate of absorption drug-food interactions significantly decreased after the nurse training courses (p < 0.001). Clinical pharmacist can play an important role in nurse training as an effective method to reduce drug-food interactions in hospitals.
Shen, Yu-Sheng; Lung, Shih-Chun Candice
Previous studies have shown both health and environmental benefits of green spaces, especially in moderating temperature and reducing air pollution. However, the characteristics of green structures have been overlooked in previous investigations. In addition, the mediation effects of green structures on respiratory mortality have not been assessed. This study explores the potential mediation pathways and effects of green structure characteristics on respiratory mortality through temperature, primary and secondary air pollutants separately using partial least squares model with data from Taiwan. The measurable characteristics of green structure include the largest patch percentage, landscape proportion, aggregation, patch distance, and fragmentation. The results showed that mortality of pneumonia and chronic lower respiratory diseases could be reduced by minimizing fragmentation and increasing the largest patch percentage of green structure, and the mediation effects are mostly through reducing air pollutants rather than temperature. Moreover, a high proportion of but fragmented green spaces would increase secondary air pollutants and enhance health risks; demonstrating the deficiency of traditional greening policy with primary focus on coverage ratio. This is the first research focusing on mediation effects of green structure characteristics on respiratory mortality, revealing that appropriate green structure planning can be a useful complementary strategy in environmental health management. PMID:28230108
Shen, Yu-Sheng; Lung, Shih-Chun Candice
Previous studies have shown both health and environmental benefits of green spaces, especially in moderating temperature and reducing air pollution. However, the characteristics of green structures have been overlooked in previous investigations. In addition, the mediation effects of green structures on respiratory mortality have not been assessed. This study explores the potential mediation pathways and effects of green structure characteristics on respiratory mortality through temperature, primary and secondary air pollutants separately using partial least squares model with data from Taiwan. The measurable characteristics of green structure include the largest patch percentage, landscape proportion, aggregation, patch distance, and fragmentation. The results showed that mortality of pneumonia and chronic lower respiratory diseases could be reduced by minimizing fragmentation and increasing the largest patch percentage of green structure, and the mediation effects are mostly through reducing air pollutants rather than temperature. Moreover, a high proportion of but fragmented green spaces would increase secondary air pollutants and enhance health risks; demonstrating the deficiency of traditional greening policy with primary focus on coverage ratio. This is the first research focusing on mediation effects of green structure characteristics on respiratory mortality, revealing that appropriate green structure planning can be a useful complementary strategy in environmental health management.
Shen, Yu-Sheng; Lung, Shih-Chun Candice
Previous studies have shown both health and environmental benefits of green spaces, especially in moderating temperature and reducing air pollution. However, the characteristics of green structures have been overlooked in previous investigations. In addition, the mediation effects of green structures on respiratory mortality have not been assessed. This study explores the potential mediation pathways and effects of green structure characteristics on respiratory mortality through temperature, primary and secondary air pollutants separately using partial least squares model with data from Taiwan. The measurable characteristics of green structure include the largest patch percentage, landscape proportion, aggregation, patch distance, and fragmentation. The results showed that mortality of pneumonia and chronic lower respiratory diseases could be reduced by minimizing fragmentation and increasing the largest patch percentage of green structure, and the mediation effects are mostly through reducing air pollutants rather than temperature. Moreover, a high proportion of but fragmented green spaces would increase secondary air pollutants and enhance health risks; demonstrating the deficiency of traditional greening policy with primary focus on coverage ratio. This is the first research focusing on mediation effects of green structure characteristics on respiratory mortality, revealing that appropriate green structure planning can be a useful complementary strategy in environmental health management.
Taylor, R Andrew; Pare, Joseph R; Venkatesh, Arjun K; Mowafi, Hani; Melnick, Edward R; Fleischman, William; Hall, M Kennedy
Predictive analytics in emergency care has mostly been limited to the use of clinical decision rules (CDRs) in the form of simple heuristics and scoring systems. In the development of CDRs, limitations in analytic methods and concerns with usability have generally constrained models to a preselected small set of variables judged to be clinically relevant and to rules that are easily calculated. Furthermore, CDRs frequently suffer from questions of generalizability, take years to develop, and lack the ability to be updated as new information becomes available. Newer analytic and machine learning techniques capable of harnessing the large number of variables that are already available through electronic health records (EHRs) may better predict patient outcomes and facilitate automation and deployment within clinical decision support systems. In this proof-of-concept study, a local, big data-driven, machine learning approach is compared to existing CDRs and traditional analytic methods using the prediction of sepsis in-hospital mortality as the use case. This was a retrospective study of adult ED visits admitted to the hospital meeting criteria for sepsis from October 2013 to October 2014. Sepsis was defined as meeting criteria for systemic inflammatory response syndrome with an infectious admitting diagnosis in the ED. ED visits were randomly partitioned into an 80%/20% split for training and validation. A random forest model (machine learning approach) was constructed using over 500 clinical variables from data available within the EHRs of four hospitals to predict in-hospital mortality. The machine learning prediction model was then compared to a classification and regression tree (CART) model, logistic regression model, and previously developed prediction tools on the validation data set using area under the receiver operating characteristic curve (AUC) and chi-square statistics. There were 5,278 visits among 4,676 unique patients who met criteria for sepsis. Of
An, Ruopeng; Wang, Peizhong Peter
Purpose In this study, we examined the length of stay, hospitalization cost, and risk of in-hospital mortality among US adult inpatients with immune thrombocytopenic purpura (ITP). Methods We analyzed nationally representative data obtained from Nationwide/National Inpatient Sample database of discharges from 2006 to 2012. Results In the US, there were an estimated 296,870 (95% confidence interval [CI]: 284,831–308,909) patient discharges recorded for ITP from 2006 to 2012, during which ITP-related hospitalizations had increased steadily by nearly 30%. The average length of stay for an ITP-related hospitalization was found to be 6.02 days (95% CI: 5.93–6.10), which is 28% higher than that of the overall US discharge population (4.70 days, 95% CI: 4.66–4.74). The average cost of ITP-related hospitalizations was found to be US$16,594 (95% CI: US$16,257–US$16,931), which is 48% higher than that of the overall US discharge population (US$11,200; 95% CI: US$11,033–US$11,368). Gender- and age-adjusted mortality risk in inpatients with ITP was 22% (95% CI: 19%–24%) higher than that of the overall US discharge population. Across diagnosis related groups, length of stay for ITP-related hospitalizations was longest for septicemia (7.97 days, 95% CI: 7.55–8.39) and splenectomy (7.40 days, 95% CI: 6.94–7.86). Splenectomy (US$25,262; 95% CI: US$24,044–US$26,481) and septicemia (US$18,430; 95% CI: US$17,353–US$19,507) were associated with the highest cost of hospitalization. The prevalence of mortality in ITP-related hospitalizations was highest for septicemia (11.11%, 95% CI: 9.60%–12.63%) and intracranial hemorrhage (9.71%, 95% CI: 7.65%–11.77%). Conclusion Inpatients with ITP had longer hospital stay, bore higher costs, and faced greater risk of mortality than the overall US discharge population. PMID:28176930
An, Ruopeng; Wang, Peizhong Peter
In this study, we examined the length of stay, hospitalization cost, and risk of in-hospital mortality among US adult inpatients with immune thrombocytopenic purpura (ITP). We analyzed nationally representative data obtained from Nationwide/National Inpatient Sample database of discharges from 2006 to 2012. In the US, there were an estimated 296,870 (95% confidence interval [CI]: 284,831-308,909) patient discharges recorded for ITP from 2006 to 2012, during which ITP-related hospitalizations had increased steadily by nearly 30%. The average length of stay for an ITP-related hospitalization was found to be 6.02 days (95% CI: 5.93-6.10), which is 28% higher than that of the overall US discharge population (4.70 days, 95% CI: 4.66-4.74). The average cost of ITP-related hospitalizations was found to be US$16,594 (95% CI: US$16,257-US$16,931), which is 48% higher than that of the overall US discharge population (US$11,200; 95% CI: US$11,033-US$11,368). Gender- and age-adjusted mortality risk in inpatients with ITP was 22% (95% CI: 19%-24%) higher than that of the overall US discharge population. Across diagnosis related groups, length of stay for ITP-related hospitalizations was longest for septicemia (7.97 days, 95% CI: 7.55-8.39) and splenectomy (7.40 days, 95% CI: 6.94-7.86). Splenectomy (US$25,262; 95% CI: US$24,044-US$26,481) and septicemia (US$18,430; 95% CI: US$17,353-US$19,507) were associated with the highest cost of hospitalization. The prevalence of mortality in ITP-related hospitalizations was highest for septicemia (11.11%, 95% CI: 9.60%-12.63%) and intracranial hemorrhage (9.71%, 95% CI: 7.65%-11.77%). Inpatients with ITP had longer hospital stay, bore higher costs, and faced greater risk of mortality than the overall US discharge population.
Kusnetzky, Lisa L; Khalid, Adnan; Khumri, Taiyeb M; Moe, Tabitha G; Jones, Philip G; Main, Michael L
We sought to define acute mortality in hospitalized patients undergoing clinically indicated echocardiography with and without use of an ultrasound contrast agent. The U.S. Food and Drug Administration recently issued a boxed warning and new contraindications for the perflutren-containing ultrasound contrast agents following post-marketing reports of 4 patient deaths that were temporally related to Definity (Bristol-Myers Squibb Medical Imaging, Billerica, Massachusetts) administration. To appreciate the incremental risk of any medical procedure, the ambient risk of untoward outcome in the population in question must first be defined. There are no published data on short-term major adverse cardiac events in hospitalized patients undergoing echocardiography, either with or without administration of an ultrasound contrast agent. A retrospective analysis of hospitalized patients undergoing clinically indicated echocardiography between January 2005 and October 2007, within Saint Luke's Health System, Kansas City, Missouri, was performed. Studies were separated into 2 groups, those performed without contrast enhancement (n = 12,475) and those performed with Definity (n = 6,196). Vital status within 24 h of the echocardiographic study was available for all patients using a combination of the Social Security Death Master File and Saint Luke's Health System medical records. Incidence of death within 24 h was compared by chi-square test between Definity and unenhanced procedures. Of the 18,671 patient events, 72 patients died within 24 h. Of those that underwent unenhanced echocardiography, 46 died within 24 h (0.37%). Of patients receiving Definity during the echocardiogram, 26 died within 24 h (0.42%). There was no statistical difference between these 2 groups (p = 0.60). No patient died within 1 h of the echocardiographic study. In a random sampling from the unenhanced (n = 201) and Definity groups (n = 202), patients who underwent Definity-enhanced echocardiography
Buchanan, Gordon F; Murray, Nicholas M; Hajek, Michael A; Richerson, George B
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in patients with refractory epilepsy. Defects in central control of breathing are important contributors to the pathophysiology of SUDEP, and serotonin (5-HT) system dysfunction may be involved. Here we examined the effect of 5-HT neurone elimination or 5-HT reduction on seizure risk and seizure-induced mortality. Adult Lmx1bf/f/p mice, which lack >99% of 5-HT neurones in the CNS, and littermate controls (Lmx1bf/f) were subjected to acute seizure induction by maximal electroshock (MES) or pilocarpine, variably including electroencephalography, electrocardiography, plethysmography, mechanical ventilation or pharmacological therapy. Lmx1bf/f/p mice had a lower seizure threshold and increased seizure-induced mortality. Breathing ceased during most seizures without recovery, whereas cardiac activity persisted for up to 9 min before terminal arrest. The mortality rate of mice of both genotypes was reduced by mechanical ventilation during the seizure or 5-HT2A receptor agonist pretreatment. The selective serotonin reuptake inhibitor citalopram reduced mortality of Lmx1bf/f but not of Lmx1bf/f/p mice. In C57BL/6N mice, reduction of 5-HT synthesis with para-chlorophenylalanine increased MES-induced seizure severity but not mortality. We conclude that 5-HT neurones raise seizure threshold and decrease seizure-related mortality. Death ensued from respiratory failure, followed by terminal asystole. Given that SUDEP often occurs in association with generalised seizures, some mechanisms causing death in our model might be shared with those leading to SUDEP. This model may help determine the relationship between seizures, 5-HT system dysfunction, breathing and death, which may lead to novel ways to prevent SUDEP. PMID:25107926
Belmi, Peter; Pfeffer, Jeffrey
According to Terror Management Theory, people respond to reminders of mortality by seeking psychological security and bolstering their self-esteem. Because previous research suggests that having power can provide individuals a sense of security and self-worth, we hypothesize that mortality salience leads to an increased motivation to acquire power, especially among men. Study 1 found that men (but not women) who wrote about their death reported more interest in acquiring power. Study 2A and Study 2B demonstrated that when primed with reminders of death, men (but not women) reported behaving more dominantly during the subsequent week, while both men and women reported behaving more prosocially during that week. Thus, mortality salience prompts people to respond in ways that help them manage their death anxiety but in ways consistent with normative gender expectations. Furthermore, Studies 3-5 showed that feeling powerful reduces anxiety when mortality is salient. Specifically, we found that when primed to feel more powerful, both men and women experienced less mortality anxiety. (PsycINFO Database Record (c) 2016 APA, all rights reserved).
Schneider, MD, J S; II, PhD, D; MD, PhD, M
Worldwide incidence of cutaneous malignant melanoma has increased substantially, and no screening program has yet demonstrated reduction in mortality. We evaluated the education, self examination and targeted screening campaign at the Lawrence Livermore National Laboratory (LLNL) from its beginning in July 1984 through 1996. The thickness and crude incidence of melanoma from the years before the campaign were compared to those obtained during the 13 years of screening. Melanoma mortality during the 13-year period was based on a National Death Index search. Expected yearly deaths from melanoma among LLNL employees were calculated by using California mortality data matched by age, sex, and race/ethnicity and adjusted to exclude deaths from melanoma diagnosed before the program began or before employment at LLNL. After the program began, crude incidence of melanoma thicker than 0.75 mm decreased from 18 to 4 cases per 100,000 person-years (p = 0.02), while melanoma less than 0.75mm remained stable and in situ melanoma increased substantially. No eligible melanoma deaths occurred among LLNL employees during the screening period compared with a calculated 3.39 expected deaths (p = 0.034). Education, self examination and selective screening for melanoma at LLNL significantly decreased incidence of melanoma thicker than 0.75 mm and reduced the melanoma-related mortality rate to zero. This significant decrease in mortality rate persisted for at least 3 yr after employees retired or otherwise left the laboratory.
González-Melchor, Laila; Kimura-Hayama, Eric; Díaz-Zamudio, Mariana; Higuera-Calleja, Jesús; Choque, Cinthia; Soto-Nieto, Gabriel I
Cardiac complications in infectious endocarditis (IE) are seen in nearly 50% of cases, and systemic complications may occur. The aim of the present study was to determine the characteristics of inpatients with IE who suffered acute neurologic complications and the factors associated with early mortality. From January 2004 to May 2010, we reviewed clinical and imaging charts of all of the patients diagnosed with IE who presented a deficit suggesting a neurologic complication evaluated with Computed Tomography or Magnetic Resonance within the first week. This was a descriptive and retrolective study. Among 325 cases with IE, we included 35 patients (10.7%) [19 males (54%), mean age 44-years-old]. The most common underlying cardiac disease was rheumatic valvulopathy (n=8, 22.8%). Twenty patients survived (57.2%, group A) and 15 patients died (42.8%, group B) during hospitalization. The main cause of death was septic shock (n=7, 20%). There was no statistical difference among groups concerning clinical presentation, vegetation size, infectious agent and vascular territory. The overall number of lesions was significantly higher in group B (3.1 vs. 1.6, p=0.005) and moderate to severe cerebral edema were more frequent (p=0.09). Sixteen patients (45.7%) (12 in group A and 4 in group B, p=0.05) were treated by cardiac surgery. Only two patients had a favorable outcome with conservative treatment (5.7%). In patients with IE complicated with stroke, the number of lesions observed in neuroimaging examinations and conservative treatment were associated with higher in-hospital mortality. Copyright © 2014 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. All rights reserved.
Hahnhaussen, Jens; Hak, David J; Weckbach, Sebastian; Ertel, Wolfgang; Stahel, Philip F
There is limited information in the literature on the outcomes and complications in elderly patients who sustain high-energy hip fractures. As the population ages, the incidence of high-energy geriatric hip fractures is expected to increase. The purpose of this study was to analyze the outcomes and complications in patients aged 65 years or older, who sustained a high-energy proximal femur fracture. Retrospective review of a prospective trauma database from January 2000 to April 2011 at a single US academic level-1 trauma center. Inclusion criteria consisted of all patients of age 65 years or older, who sustained a proximal femur fracture related to a high-energy trauma mechanism. Details concerning injury, acute treatment, and clinical course and outcome were obtained from medical records and radiographs. We identified 509 proximal femur fractures in patients older than 65 years of age, of which 32 (6.3%) were related to a high-energy trauma mechanism. The mean age in the study group was 72.2 years (range 65-87), with a mean injury severity score of 20 points (range 9-57). Three patients died before discharge (9.4%), and 22 of 32 patients sustained at least one complication (68.8%). Blunt chest trauma represented the most frequently associated injury, and the main root cause of pulmonary complications. The patients' age and comorbidities did not significantly correlate with the rate of complications and the 1-year mortality. High-energy proximal femur fractures in elderly patients are not very common and are associated with a low in-hospital mortality rate of less than 10%, despite high rate of complications of nearly 70%. This selective cohort of patients requires a particular attention to respiratory management due to the high incidence of associated chest trauma.
Gyaltsen, Kunchok; Jianzan, Gongque; Gyal, Lhusham; Xianjia, Li; Gipson, Jessica D; Kyi, Tsering; Rangji, Cai; Pebley, Anne R
Among the Millennium Development Goals, maternal mortality reduction has proven especially difficult to achieve. Unlike many countries, China is on track to meeting these goals on a national level, through a programme of institutionalizing deliveries. Nonetheless, in rural, disadvantaged, and ethnically diverse areas of western China, maternal mortality rates remain high. To reduce maternal mortality in western China, we developed and implemented a three-level approach as part of a collaboration between a regional university, a non-profit organization, and local health authorities. Through formative research, we identified seven barriers to hospital delivery in a rural Tibetan county of Qinghai Province: (1) difficulty in travel to hospitals; (2) hospitals lack accommodation for accompanying families; (3) the cost of hospital delivery; (4) language and cultural barriers; (5) little confidence in western medicine; (6) discrepancy in views of childbirth; and (7) few trained community birth attendants. We implemented a three-level intervention: (a) an innovative Tibetan birth centre, (b) a community midwife programme, and (c) peer education of women. The programme appears to be reaching a broad cross-section of rural women. Multilevel, locally-tailored approaches may be essential to reduce maternal mortality in rural areas of western China and other countries with substantial regional, socioeconomic, and ethnic diversity. PMID:25555773
Thomsen, Mette; Varbo, Anette; Tybjærg-Hansen, Anne; Nordestgaard, Børge G
Increased nonfasting plasma triglycerides marking increased amounts of cholesterol in remnant lipoproteins are important risk factors for cardiovascular disease, but whether lifelong reduced concentrations of triglycerides on a genetic basis ultimately lead to reduced all-cause mortality is unknown. We tested this hypothesis. Using individuals from the Copenhagen City Heart Study in a mendelian randomization design, we first tested whether low concentrations of nonfasting triglycerides were associated with reduced all-cause mortality in observational analyses (n = 13 957); second, whether genetic variants in the triglyceride-degrading enzyme lipoprotein lipase, resulting in reduced nonfasting triglycerides and remnant cholesterol, were associated with reduced all-cause mortality (n = 10 208). During a median 24 and 17 years of 100% complete follow-up, 9991 and 4005 individuals died in observational and genetic analyses, respectively. In observational analyses compared to individuals with nonfasting plasma triglycerides of 266-442 mg/dL (3.00-4.99 mmol/L), multivariably adjusted hazard ratios for all-cause mortality were 0.89 (95% CI 0.78-1.02) for 177-265 mg/dL (2.00-2.99 mmol/L), 0.74 (0.65-0.84) for 89-176 mg/dL (1.00-1.99 mmol/L), and 0.59 (0.51-0.68) for individuals with nonfasting triglycerides <89 mg/dL (<1.00 mmol/L). The odds ratio for a genetically derived 89-mg/dL (1-mmol/L) lower concentration in nonfasting triglycerides was 0.50 (0.30-0.82), with a corresponding observational hazard ratio of 0.87 (0.85-0.89). Also, the odds ratio for a genetically derived 50% lower concentration in nonfasting triglycerides was 0.43 (0.23-0.80), with a corresponding observational hazard ratio of 0.73 (0.70-0.77). Genetically reduced concentrations of nonfasting plasma triglycerides are associated with reduced all-cause mortality, likely through reduced amounts of cholesterol in remnant lipoproteins.
Shlezinger, Meital; Amitai, Yona; Goldenberg, Ilan; Shechter, Michael
Consuming desalinated seawater (DSW) as drinking water (DW) may reduce magnesium in water intake causing hypomagnesemia and adverse cardiovascular effects. We evaluated 30-day and 1-year all-cause mortality of acute myocardial infarction (AMI) patients enrolled in the biannual Acute Coronary Syndrome Israeli Survey (ACSIS) during 2002-2013. Patients (n=4678) were divided into 2 groups: those living in regions supplied by DSW (n=1600, 34.2%) and non-DSW (n=3078, 65.8%). Data were compared between an early period [2002-2006 surveys (n=2531) - before desalination] and a late period [2008-2013 surveys (n=2147) - during desalination]. Thirty-day all-cause-mortality was significantly higher in the late period in patients from the DSW regions compared with those from the non-DSW regions (HR=2.35 CI 95% 1.33-4.15, P<0.001) while in the early period there was no significant difference (HR=1.37 CI 95% 0.9-2, P=0.14). Likewise, there was a significantly higher 1-year all-cause mortality in the late period in patients from DSW regions compared with those from the non-DSW regions (HR=1.87 CI 95% 1.32-2.63, P<0.0001), while in the early period there was no significant difference (HR=1.17 CI 95% 0.9-1.5, P=0.22). Admission serum magnesium level (M±SD) in the DSW regions (n=130) was 1.94±0.24mg/dL compared with 2.08±0.27mg/dL in 81 patients in the non-DSW (P<0.0001). Higher 30-day and 1-year all-cause mortality in AMI patients, found in the DSW regions may be attributed to reduced magnesium intake secondary to DSW consumption. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Schmeichel, Brandon J; Martens, Andy
To the extent that cultural worldviews provide meaning in the face of existential concerns, specifically the inevitability of death, affirming a valued aspect of one's worldview should render reminders of death less threatening. The authors report two studies in support of this view. In Study 1, mortality salience led to derogation of a worldview violator unless participants had first affirmed an important value. In Study 2, self-affirmation before a reminder of death was associated with reduced accessibility of death-related thoughts a short while thereafter. The authors propose that actively affirming one's worldview alters reactions to reminders of mortality by reducing the accessibility of death-related thoughts, not by boosting self-esteem. These studies attest to the flexible nature of psychological self-defense and to the central role of cultural worldviews in managing death-related concerns.
Reducing postoperative morbidity and mortality is important not only for patients' outcome but for reduction of financial burden on society. Precise and accurate preoperative evaluation of surgical risk factors is crucial to plan appropriate postoperative allocation of medical resources. American Society of Anesthesiologists physical status is a traditional measure to describe preoperative risk of patients undergoing surgery. In the last decade, several scoring systems with better sensitivity and specificity were reported and validated. Charlson Age-comorbidity Index, Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) are frequently used scoring systems. Several lines of evidence indicate that negligence of medical caregivers cause substantial numbers of errors to patients and often leads to severe complications or deaths. Full compliances to surgical checklists and implementation of medical team will help reduce these errors and lead to better patients' postoperative outcomes.
Hua, Alina; Pattenden, Holly; Leung, Maria; Davies, Simon; George, David A.; Raubenheimer, Hilgardt; Niwaz, Zakiyah
Background Myocardial injury after non-cardiac surgery (MINS) is defined as troponin elevation of ≥0.03 ng/mL associated with 3.87-fold increase in early mortality. We sought to determine the impact of cardiology intervention on mortality in patients who developed MINS after general thoracic surgery. Methods A retrospective review was performed in patients over 5 years. Troponin was routinely measured and levels ≥0.04 ng/mL classified as positive. Data acquisition and mortality status was obtained via medical records and NHS tracing systems. Thirty-day mortality was compared on MINS cohort using Fisher’s exact square testing and logistic regression analysis. Results Troponin levels were measured in 491 (96%) of 511 patients. Eighty (16%) patients fulfilled the MINS criteria. Sixty-one (76%) received early cardiology consult and “myocardial infarction” stated in four (5%) patients. Risk assessment (for AMI) was undertaken; 20 (25%) patients were commenced on aspirin, four (5%) on β-blockers and one (1%) underwent percutaneous coronary intervention. Forty-nine (61%) patients received primary risk factor modifications and 26 (33%) had outpatient follow-up. There were no significant differences in the proportion of patients who died within 30 days post-operatively in the MINS group of 2.6% compared to the non-MINS group of 1.6% (P=0.625). The odds ratio for 30-day mortality in the MINS group was 1.69 (95% CI: 0.34 to 8.57, P=0.522). Conclusions MINS is common after general thoracic surgery. Early cardiology intervention reduced the expected hazard ratio of early death from 3.87 to an odds ratio of 1.69 with no significant difference in 30-day mortality for patients who developed MINS. PMID:27162667
Jatoi, Ismail; Parsons, Helen M
Contralateral prophylactic mastectomy (CPM) refers to removal of the opposite uninvolved breast in women with unilateral breast cancer, and rates are increasing worldwide. In observational studies, CPM is often associated with reductions in breast cancer-specific and all-cause mortality when compared to unilateral surgical treatment alone, but this may reflect selection of a healthier cohort for CPM (selection bias). To further explore this possibility, we examined the association between CPM and non-cancer mortality, an indicator of selection bias. We identified 449,178 adult women diagnosed with unilateral, primary American Joint Committee on Cancer (AJCC) stage I-III ductal or lobular breast cancer, utilizing the 1998-2010 Surveillance, Epidemiology, and End Results dataset. Of these, 5.8% (n = 25,961) underwent CPM as their first course of treatment. We examined associations between CPM and breast cancer-specific, all-cause, and non-cancer mortality utilizing multivariate logistic regression, adjusting for age, race, AJCC stage, estrogen receptor status, progesterone receptor status, and histologic grade of the tumor. Among all patients receiving CPM as first course of treatment, CPM was associated with lower breast cancer-specific [HR 0.84 (95% CI 0.79-0.89)], all-cause [HR 0.83 (95% CI 0.80-0.88)], and non-cancer [HR 0.71 (95% CI 0.64-0.80)] 5-year hazard of death. Although our results are consistent with other observational studies showing associations between CPM and reductions in breast cancer-specific and all-cause mortality, we demonstrate an even stronger association between CPM and reduced non-cancer mortality. Thus, the reported associations between CPM and reductions in mortality might at least partly be attributable to selection bias.
Lafleur, John; Lepidi, Hubert; Papazian, Laurent; Rolain, Jean-Marc; Raoult, Didier; Elias, Mikael; Silby, Mark W.; Bzdrenga, Janek; Bregeon, Fabienne; Chabriere, Eric
Rationale The effectiveness of antibiotic molecules in treating Pseudomonas aeruginosa pneumonia is reduced as a result of the dissemination of bacterial resistance. The existence of bacterial communication systems, such as quorum sensing, has provided new opportunities of treatment. Lactonases efficiently quench acyl-homoserine lactone-based bacterial quorum sensing, implicating these enzymes as potential new anti-Pseudomonas drugs that might be evaluated in pneumonia. Objectives The aim of the present study was to evaluate the ability of a lactonase called SsoPox-I to reduce the mortality of a rat P. aeruginosa pneumonia. Methods To assess SsoPox-I-mediated quorum quenching, we first measured the activity of the virulence gene lasB, the synthesis of pyocianin, the proteolytic activity of a bacterial suspension and the formation of biofilm of a PAO1 strain grown in the presence of lactonase. In an acute lethal model of P. aeruginosa pneumonia in rats, we evaluated the effects of an early or deferred intra-tracheal treatment with SsoPox-I on the mortality, lung bacterial count and lung damage. Measurements and Primary Results SsoPox-I decreased PAO1 lasB virulence gene activity, pyocianin synthesis, proteolytic activity and biofilm formation. The early use of SsoPox-I reduced the mortality of rats with acute pneumonia from 75% to 20%. Histological lung damage was significantly reduced but the lung bacterial count was not modified by the treatment. A delayed treatment was associated with a non-significant reduction of mortality. Conclusion These results demonstrate the protective effects of lactonase SsoPox-I in P. aeruginosa pneumonia and open the way for a future therapeutic use. PMID:25350373
The subjective global assessment predicts in-hospital mortality better than other nutrition-related risk indexes in noncritically ill inpatients who receive total parenteral nutrition in Spain (prospective multicenter study).
Malnutrition in hospitalized patients is associated with an increased risk of death and complications. The purpose of this study was to determine which nutrition-related risk index predicts mortality better in patients receiving total parenteral nutrition. This prospective, multicenter study involved noncritically ill patients who were prescribed total parenteral nutrition. Data were collected on Subjective Global Assessment (SGA), Nutritional Risk Index, Geriatric Nutritional Risk Index, body mass index, albumin and prealbumin, as well as in-hospital mortality, length of stay, and infectious complications. Of the 605 patients included in the study, 18.8% developed infectious complications and 9.6% died in the hospital. SGA, albumin, Nutritional Risk Index and Geriatric Nutritional Risk Index were associated with longer hospital stay. Prealbumin levels were associated with infectious complications. Multiple logistic regression analysis showed (after adjustment for age, sex, C-reactive protein levels, mean blood glucose levels, use of corticoids, prior comorbidity, carbohydrates infused, diagnosis, and infectious complications) that the SGA, Geriatric Nutritional Risk Index, body mass index, albumin, and prealbumin were associated with an increased risk for in-hospital mortality. SGA was the tool that best predicted mortality and adequately discriminated the values of the other nutrition-related risk indexes studied. The SGA is a clinically effective and simple tool for nutrition assessment in noncritically ill patients receiving total parenteral nutrition and detects the risk of inpatient mortality better than others. Copyright © 2013 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.
Chau, P. H.; Chan, K. C.; Woo, Jean
While there was evidence on the relationship between extreme hot weather and the increase in mortality, particularly from ischaemic heart disease (IHD) and cerebrovascular disease (stroke), some researchers suggested that early warning systems might reduce mortality. In this study, the relationship between Very Hot Weather Warning (VHWW) and mortality was examined in the context of Hong Kong, which has a sub-tropical climate. An observational study was conducted on the daily number of deaths due to IHD and stroke in the Hong Kong elderly population (aged 65 or above) during summer (May-September) in 1997-2005. Totals of 4,281 deaths from IHD and 4,764 deaths from stroke occurred on days with maximum temperature reaching/exceeding 30.4°C. Multiple linear regression models were used to study the association between VHWW and the daily mortality rates from IHD and from stroke, respectively. Results showed that absence of VHWW was associated with an increase of about 1.23 (95% CI: 0.32, 2.14) deaths from IHD and 0.97 (95% CI: 0.02, 1.92) deaths from stroke among the elderly per day. Public education is required to inform the elderly to take appropriate preventive measures and to remind the public to pay more care and attention to the elderly on days which are not considered to be stressful to the general public. Warning systems tailored for the elderly could also be considered.
Loprinzi, P D; Walker, J F
Emerging research demonstrates an interrelationship between systemic inflammation, physical activity and premature all-cause mortality among chronic obstructive pulmonary disease (COPD) patients. Less common in this literature is the use of objective measures of physical activity and representative samples of COPD patients. To examine the association between objectively measured physical activity and all-cause mortality among a national sample of COPD patients, with stratification by inflammatory status. Data from the 2003 to 2006 NHANES were employed, with follow-up through 2011. Physical activity was objectively measured via accelerometry; COPD was assessed via physician-diagnosis; and inflammation was assessed via C-reactive protein (CRP) levels from a blood sample. Analysis included 385 adults (20+ years) with COPD. The median follow-up period was 78 months (IQR = 64-90), with 82 COPD patients dying during this period. After adjustment, physical activity was not associated with all-cause mortality among the entire sample (HR = 0.80; 95% CI: 0.61-1.05) or those with no systemic inflammation (HR = 0.89; 95% CI: 0.63-1.24). However, for every 60 min increase in physical activity per day, COPD patients with elevated CRP had a 31% reduced risk of all-cause mortality (HR = 0.69; 95% CI: 0.51-0.93). Physical activity may help to promote survival among COPD patients, particularly those with elevated inflammation. © 2016 John Wiley & Sons Ltd.
Lo, Yuan-Ting; Chang, Yu-Hung; Wahlqvist, Mark L; Huang, Han-Bin; Lee, Meei-Shyuan
Few studies have evaluated the linkage between food cost and mortality among older adults. This study considers the hypothesis that greater food expenditure in general, and particularly on more nutritious plant and animal-derived foods, decreases mortality in older adults. This study uses the 1999-2000 Elderly Nutrition and Health Survey in Taiwan and follows the cohort until 2008, collecting 24-hr dietary recall data for 1781 participants (874 men and 907 women) aged 65 y or older. Using monthly mean national food prices and 24-hr recall, this study presents an estimate of daily expenditures for vegetable, fruit, animal-derived, and grain food categories. Participants were linked to the national death registry. Of the 1781 original participants, 625 died during the 10-y follow-up period. Among the 4 food categories, the fourth and fifth expenditure quintiles for vegetables and for fruits had the highest survival rates. After adjusting for co-variates, higher (Q4) vegetable and higher fruit (Q4) food expenditures referent to Q1 were significantly predictive of reduced mortality (HR = 0.55, 95% CI: 0.39-0.78 and HR = 0.64, 95% CI: 0.42-0.99, respectively) and the risk decreased by 12% and 10% for every NT$15 (US$0.50) increase in their daily expenditures. Animal-derived and grain food spending was not predictive of mortality. Greater and more achievable vegetable and fruit affordability may improve food security and longevity for older adults.
Enstrom, James E; Breslow, Lester
The objective is to measure the relationship of several healthy characteristics of the Mormon lifestyle to mortality. We examined 9815 religiously active California Mormon adults followed for mortality during 1980-2004 and 15,832 representative U.S. white adults enrolled in the 1987 National Health Interview Survey (NHIS) and followed for mortality during 1988-1997. The standardized mortality ratio (SMR) and 95% confidence interval (CI) was calculated relative to U.S. whites defined to have a SMR of 1.00. Active California Mormons practice a healthy lifestyle advocated by their religion, which emphasizes a strong family life, education and abstention from tobacco and alcohol. Unusually low SMRs occurred among married never smokers who attended church weekly and had at least 12 years of education. For those aged 25-99 years at entry, the SMR for all causes of death was 0.45 (0.42-0.48) for males and 0.55 (0.51-0.59) for females. For those aged 25-64 years at entry, the SMR for all causes of death was 0.36 (0.32-0.41) for males and 0.46 (0.40-0.53) for females. Life expectancy from age 25 was 84 years for males and 86 years for females. These SMRs were largely replicated among similarly defined persons of all religions within the NHIS cohort. Several healthy characteristics of the Mormon lifestyle are associated with substantially reduced death rates and increased life expectancy.
Tsai, January Y; Pan, Wei; Lemaire, Scott A; Pisklak, Paul; Lee, Vei-Vei; Bracey, Arthur W; Elayda, MacArthur A; Preventza, Ourania; Price, Matt D; Collard, Charles D; Coselli, Joseph S
Selective antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest (HCA) provides cerebral protection during aortic arch surgery. However, the ideal temperature for HCA during ACP remains unknown. Clinical outcomes were compared in patients who underwent moderate (nasopharyngeal temperature, ≥ 20 °C) versus deep (nasopharyngeal temperature, <20 °C) HCA with ACP during aortic arch repair. By using a prospectively maintained clinical database, we analyzed data from 221 consecutive patients who underwent aortic arch replacement with HCA and ACP between December 2006 and May 2009. Seventy-eight patients underwent deep hypothermia (mean lowest temperature, 16.8 °C ± 1.7 °C) and 143 patients underwent moderate hypothermia (mean, 22.9 °C ± 1.4 °C) before systemic circulatory arrest was initiated. Multivariate stepwise logistic and linear regressions were performed to determine whether depth of hypothermia independently predicted postoperative outcomes and blood-product use. Compared with moderate hypothermia, deep hypothermia was associated independently with a greater risk of in-hospital death (7.7% vs 0.7%; odds ratio [OR], 9.3; 95% confidence interval [CI], 1.1-81.6; P = .005) and 30-day all-cause mortality (9.0% vs 2.1%; OR, 4.7; 95% CI, 1.2-18.6; P = .02), and with longer cardiopulmonary bypass time (154 ± 62 vs 140 ± 46 min; P = .008). Deep hypothermia also was associated with a higher incidence of stroke, although this association was not statistically significant (7.6% vs 2.8%; P = .073; OR, 4.3; 95% CI, 0.9-12.5). No difference was seen in acute kidney injury, blood product transfusion, or need for surgical re-exploration. Moderate hypothermia with ACP is associated with lower in-hospital and 30-day mortality, shorter cardiopulmonary bypass time, and fewer neurologic sequelae than deep hypothermia in patients who undergo aortic arch surgery with ACP. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby
Jenkins, Kathy J; Castañeda, Aldo R; Cherian, K M; Couser, Chris A; Dale, Emily K; Gauvreau, Kimberlee; Hickey, Patricia A; Koch Kupiec, Jennifer; Morrow, Debra Forbes; Novick, William M; Rangel, Shawn J; Zheleva, Bistra; Christenson, Jan T
There is little information about congenital heart surgery outcomes in developing countries. The International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries uses a registry and quality improvement strategies with nongovernmental organization reinforcement to reduce mortality. Registry data were used to evaluate impact. Twenty-eight sites in 17 developing world countries submitted congenital heart surgery data to a registry, received annual benchmarking reports, and created quality improvement teams. Webinars targeted 3 key drivers: safe perioperative practice, infection reduction, and team-based practice. Registry data were audited annually; only verified data were included in analyses. Risk-adjusted standardized mortality ratios (SMRs) and standardized infection ratios among participating sites were calculated. Twenty-seven sites had verified data in at least 1 year, and 1 site withdrew. Among 15,049 cases of pediatric congenital heart surgery, unadjusted mortality was 6.3% and any major infection was 7.0%. SMRs for the overall International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries were 0.71 (95% confidence interval [CI] 0.62-0.81) in 2011 and 0.76 (95% CI 0.69-0.83) in 2012, compared with 2010 baseline. SMRs among 7 sites participating in all 3 years were 0.85 (95% CI 0.71-1.00) in 2011 and 0.80 (95% CI 0.66-0.96) in 2012; among 14 sites participating in 2011 and 2012, the SMR was 0.80 (95% CI 0.70-0.91) in 2012. Standardized infection ratios were similarly reduced. Congenital heart surgery risk-adjusted mortality and infections were reduced in developing world programs participating in the collaborative quality improvement project and registry. Similar strategies might allow rapid reduction in global health care disparities. Copyright © 2014 by the American Academy of Pediatrics.
Shabbir, Asad; Wali, Gorav; Steuer, Alan
Prolonged hospital stay not only increases financial stress on the National Health Service but also exposes patients to an unnecessarily high risk of adverse ward events. Each day accumulates approximately £225 in bed costs with additional risks of venousthromboembolism, hospital acquired infections, prescription errors, and falls. Despite being medically fit for discharge (MFFD), patients awaiting care packages with prolonged length of stay (LoS) have poorer outcomes and experience increased rates of mortality as a result. A six cycle prospective audit was carried out to investigate if four simple ward based initiatives could optimise patient flow through a medical ward and reduce LoS of inpatients awaiting social packages and placement. The four daily initiatives were: A morning board round between nurses and doctors to prioritise new or sick patients for early review.A post ward round meeting between the multidisciplinary team to expedite rehabilitation and plan discharges early.An evening board round to highlight which patients needed discharge paperwork for the next day to alleviate the wait for pharmacy.A ‘computer on wheels’ on ward rounds so investigations could be ordered and reviewed at the bedside allowing more time to address patient concerns. A control month in August 2013 and five intervention cycles were completed between September 2013 and January 2014. Prior to intervention, mean time taken for patients to be discharged with a package of care, once declared MFFD, was 25 days. With intervention this value dropped to 1 day. The total LoS fell from 46 days to 16 days. It was also found that the time taken from admission to MFFD status was reduced from 21 days to 15 days. In conclusion this data shows that with four simple modifications to ward behaviour unnecessary inpatient stay can be significantly reduced. PMID:26734432
Shabbir, Asad; Wali, Gorav; Steuer, Alan
Prolonged hospital stay not only increases financial stress on the National Health Service but also exposes patients to an unnecessarily high risk of adverse ward events. Each day accumulates approximately £225 in bed costs with additional risks of venousthromboembolism, hospital acquired infections, prescription errors, and falls. Despite being medically fit for discharge (MFFD), patients awaiting care packages with prolonged length of stay (LoS) have poorer outcomes and experience increased rates of mortality as a result. A six cycle prospective audit was carried out to investigate if four simple ward based initiatives could optimise patient flow through a medical ward and reduce LoS of inpatients awaiting social packages and placement. The four daily initiatives were: A morning board round between nurses and doctors to prioritise new or sick patients for early review.A post ward round meeting between the multidisciplinary team to expedite rehabilitation and plan discharges early.An evening board round to highlight which patients needed discharge paperwork for the next day to alleviate the wait for pharmacy.A 'computer on wheels' on ward rounds so investigations could be ordered and reviewed at the bedside allowing more time to address patient concerns. A control month in August 2013 and five intervention cycles were completed between September 2013 and January 2014. Prior to intervention, mean time taken for patients to be discharged with a package of care, once declared MFFD, was 25 days. With intervention this value dropped to 1 day. The total LoS fell from 46 days to 16 days. It was also found that the time taken from admission to MFFD status was reduced from 21 days to 15 days. In conclusion this data shows that with four simple modifications to ward behaviour unnecessary inpatient stay can be significantly reduced.
Vamvakas, Eleftherios C; Blajchman, Morris A
After reviewing the relative frequency of the causes of allogeneic blood transfusion-related mortality in the United States today, we present 6 possible strategies for further reducing such transfusion-related mortality. These are (1) avoidance of unnecessary transfusions through the use of evidence-based transfusion guidelines, to reduce potentially fatal (infectious as well as noninfectious) transfusion complications; (2) reduction in the risk of transfusion-related acute lung injury in recipients of platelet transfusions through the use of single-donor platelets collected from male donors, or female donors without a history of pregnancy or who have been shown not to have white blood cell (WBC) antibodies; (3) prevention of hemolytic transfusion reactions through the augmentation of patient identification procedures by the addition of information technologies, as well as through the prevention of additional red blood cell alloantibody formation in patients who are likely to need multiple transfusions in the future; (4) avoidance of pooled blood products (such as pooled whole blood-derived platelets) to reduce the risk of transmission of emerging transfusion-transmitted infections (TTIs) and the residual risk from known TTIs (especially transfusion-associated sepsis [TAS]); (5) WBC reduction of cellular blood components administered in cardiac surgery to prevent the poorly understood increased mortality seen in cardiac surgery patients in association with the receipt of non-WBC-reduced (compared with WBC-reduced) transfusion; and (6) pathogen reduction of platelet and plasma components to prevent the transfusion transmission of most emerging, potentially fatal TTIs and the residual risk of known TTIs (especially TAS).
Skripconoka, Vija; Danilovits, Manfred; Pehme, Lea; Tomson, Tarmo; Skenders, Girts; Kummik, Tiina; Cirule, Andra; Leimane, Vaira; Kurve, Anu; Levina, Klavdia; Geiter, Lawrence J.; Manissero, Davide; Wells, Charles D.
Multidrug-resistant and extensively drug-resistant tuberculosis (TB) are associated with worse treatment outcomes for patients, including higher mortality, than for drug-sensitive tuberculosis. Delamanid (OPC-67683) is a novel anti-TB medication with demonstrated activity against multidrug-resistant disease. Patients who participated in the previously reported randomised, placebo-controlled trial of delamanid and the subsequent open-label extension trial were eligible to participate in a 24-month observational study designed to capture treatment outcomes. Treatment outcomes, as assessed by clinicians and defined by the World Health Organization, were categorised as favourable and unfavourable. Delamanid treatment groups were combined for analysis, based on their duration of treatment. In total, for 421 (87.5%) out of 481 patients from the original randomised controlled trial, consent was granted for follow-up assessments. Favourable outcomes were observed in 143 (74.5%) out of 192 patients who received delamanid for ≥6 months, compared to 126 (55%) out of 229 patients who received delamanid for ≤2 months. Mortality was reduced to 1.0% among those receiving long-term delamanid versus short-term/no delamanid (8.3%; p<0.001). Treatment benefit was also seen among patients with extensively drug-resistant TB. This analysis suggests that treatment with delamanid for 6 months in combination with an optimised background regimen can improve outcomes and reduce mortality among patients with both multidrug-resistant and extensively drug-resistant TB. PMID:23018916
Piliponsky, Adrian M; Chen, Ching-Cheng; Nishimura, Toshihiko; Metz, Martin; Rios, Eon J; Dobner, Paul R; Wada, Etsuko; Wada, Keiji; Zacharias, Sherma; Mohanasundaram, Uma M; Faix, James D; Abrink, Magnus; Pejler, Gunnar; Pearl, Ronald G; Tsai, Mindy; Galli, Stephen J
Sepsis is a complex, incompletely understood and often fatal disorder, typically accompanied by hypotension, that is considered to represent a dysregulated host response to infection. Neurotensin (NT) is a 13-amino-acid peptide that, among its multiple effects, induces hypotension. We find that intraperitoneal and plasma concentrations of NT are increased in mice after severe cecal ligation and puncture (CLP), a model of sepsis, and that mice treated with a pharmacological antagonist of NT, or NT-deficient mice, show reduced mortality during severe CLP. In mice, mast cells can degrade NT and reduce NT-induced hypotension and CLP-associated mortality, and optimal expression of these effects requires mast cell expression of neurotensin receptor 1 and neurolysin. These findings show that NT contributes to sepsis-related mortality in mice during severe CLP and that mast cells can lower NT concentrations, and suggest that mast cell-dependent reduction in NT levels contributes to the ability of mast cells to enhance survival after CLP.
The spectacular decline of infant mortality in Costa Rica from 68/1000 live births in 1970 to 20/1000 in 1980 was largely due to the implementation of public health programs in the 1970s. The abrupt decline was even more notable because deaths of infants constituted the major health problem of the country during the 1960s, accounting for 40% of all registered deaths. Socioeconomic development and reduced fertility contributed to the reduction, but 3/4 of the improvement can be attributed to extension of primary health care to previously unserved rural populations and to better secondary health care, according to a study by the Costa Rican demographer Luis Rosero Bixby. The programs targeted at less privileged groups substantially reduced class and geographic differentials in infant mortality. Infant mortality began to decline at an accelerating rate in 1972, coinciding with the first national health plan and the law of universal social security in 1971, the transfer of public hospitals to the social security system and promulgation of a general health law in 1973, and application of the rural health program in 1973 and community health program in 1976. By 1980, home services reached 60% of the population and immunization programs were in place for measles and diphtheria, pertussis, and tetanus. There was a doubling of outpatient services and a tripling of hours contracted by doctors between 1970-80. Also in 1980, 78% of the Costa Rican population was fully covered by health insurance. After 1972, infant mortality declined from all causes except complications of pregnancy and congenital anomalies. The decline was most rapid for deaths due to prematurity, illnesses avoidable by vaccination, and illnesses such as septicemia and meningitis in which prompt diagnosis and treatment can be lifesaving. Although impressive gains were made in neonatal mortality, the main share of the decline between 1970-80 was in postneonatal mortality. Reductions in deaths due to diarrheal
Kidney, Elaine; Winter, Heather R; Khan, Khalid S; Gülmezoglu, A Metin; Meads, Catherine A; Deeks, Jonathan J; MacArthur, Christine
Background The objective was to provide a systematic review of the effectiveness of community-level interventions to reduce maternal mortality. Methods We searched published papers using Medline, Embase, Cochrane library, CINAHL, BNI, CAB ABSTRACTS, IBSS, Web of Science, LILACS and African Index Medicus from inception or at least 1982 to June 2006; searched unpublished works using National Research Register website, metaRegister and the WHO International Trial Registry portal. We hand searched major references. Selection criteria were maternity or childbearing age women, comparative study designs with concurrent controls, community-level interventions and maternal death as an outcome. We carried out study selection, data abstraction and quality assessment independently in duplicate. Results We found five cluster randomised controlled trials (RCT) and eight cohort studies of community-level interventions. We summarised results as odds ratios (OR) and confidence intervals (CI), combined using the Peto method for meta-analysis. Two high quality cluster RCTs, aimed at improving perinatal care practices, showed a reduction in maternal mortality reaching statistical significance (OR 0.62, 95% CI 0.39 to 0.98). Three equivalence RCTs of minimal goal-oriented versus usual antenatal care showed no difference in maternal mortality (1.09, 95% CI 0.53 to 2.25). The cohort studies were of low quality and did not contribute further evidence. Conclusion Community-level interventions of improved perinatal care practices can bring about a reduction in maternal mortality. This challenges the view that investment in such interventions is not worthwhile. Programmes to improve maternal mortality should be evaluated using randomised controlled techniques to generate further evidence. PMID:19154588
Introduction Severe blunt trauma is a leading cause of premature death and handicap. However, the benefit for the patient of pre-hospital management by emergency physicians remains controversial because it may delay admission to hospital. This study aimed to compare the impact of medical pre-hospital management performed by SMUR (Service Mobile d'Urgences et de Réanimation) with non-medical pre-hospital management provided by fire brigades (non-SMUR) on 30-day mortality. Methods The FIRST (French Intensive care Recorded in Severe Trauma) study is a multicenter cohort study on consecutive patients with severe blunt trauma requiring admission to university hospital intensive care units within the first 72 hours. Initial clinical status, pre-hospital life-sustaining treatments and Injury Severity Scores (ISS) were recorded. The main endpoint was 30-day mortality. Results Among 2,703 patients, 2,513 received medical pre-hospital management from SMUR, and 190 received basic pre-hospital management provided by fire brigades. SMUR patients presented a poorer initial clinical status and higher ISS and were admitted to hospital after a longer delay than non-SMUR patients. The crude 30-day mortality rate was comparable for SMUR and non-SMUR patients (17% and 15% respectively; P = 0.61). After adjustment for initial clinical status and ISS, SMUR care significantly reduced the risk of 30-day mortality (odds ratio (OR): 0.55, 95% CI: 0.32 to 0.94, P = 0.03). Further adjustments for the delay to hospital admission only marginally affected these results. Conclusions This study suggests that SMUR management is associated with a significant reduction in 30-day mortality. The role of careful medical assessment and intensive pre-hospital life-sustaining treatments needs to be assessed in further studies. PMID:21251331
Dooley, Suzanna; Patrick, Paul; Lincoln, Alicia; Cline, Janette
The Preparing for a Lifetime, It's Everyone's Responsibility initiative was developed to improve the health and well- being of Oklahoma's mothers and infants. The development phase included systematic data collection, extensive data analysis, and multi-disciplinary partnership development. In total, seven issues (preconception/interconception health, tobacco use, postpartum depression, breastfeeding, infant safe sleep, preterm birth, and infant injury prevention) were identified as crucial to addressing infant mortality in Oklahoma. Workgroups were created to focus on each issue. Data and media communications workgroups were added to further partner commitment and support for policy and programmatic changes across multiple agencies and programs. Leadership support, partnership, evaluation, and celebrating small successes were important factors that lead to large scale adoption and support for the state-wide initiative to reduce infant mortality.
West, J B
Neonatal mortality increases with altitude. For example, in Peru the incidence of neonatal mortality in the highlands has been shown to be about double that at lower altitudes. An important factor is the low inspired PO2 of newborn babies. Typically, expectant mothers at high altitude will travel to low altitude to have their babies if possible, but often this is not feasible because of economic factors. The procedure described here raises the oxygen concentration in the air of rooms where neonates are being housed and, in effect, this means that both the mother and baby are at a much lower altitude. Oxygen conditioning is similar to air conditioning except that the oxygen concentration of the air is increased rather than the temperature being reduced. The procedure is now used at high altitude in many hotels, dormitories and telescope facilities, and has been shown to be feasible and effective.
Huberman, Y D; Terzolo, H R
To determine the most appropriate dose in drinking water of the disinfectant N-alkyl dimethyl benzyl ammonium chloride (TIMSEN), a fowl typhoid challenge trial was carried out using 21-day-old Salmonella-free chickens. In a pretrial, performed with six groups of 10 chickens each, it was shown that the disinfectant was atoxic and safe when administered during 15 days at doses of 0 ppm, 200 ppm, 400 ppm, 800 ppm, 1600 ppm, or 3200 ppm. Thereafter, a challenge trial was performed with 390 chickens divided into six groups of 65 birds each. Chickens were treated during 9 days with oral doses of 0 ppm, 25 ppm, 50 ppm, 100 ppm, 250 ppm, and 500 ppm (groups identified as A, B, C, D, E, and F, respectively). Twenty-four hours after the beginning of the treatment, 30 chickens of each group were orally inoculated with 10(9) colony-forming units of Salmonella Gallinarum strain INTA 91 per bird. The remaining 35 unchallenged chickens from each group were left in the same cage in close contact with the other challenged birds of their group. All surviving chickens were sacrificed 8 days after challenge. Livers from all birds were examined for the presence of Salmonella Gallinarum. Salmonella Gallinarum was isolated from all challenged chickens and from some unchallenged chickens of groups A (4/35), E (3/35), and F (6/35), but not from any unchallenged chicken from groups B, C, and D. Doses of 50 ppm (group C) significantly reduced mortality (30%) in comparison with the untreated control group A (65%). Mortality in group B (45%) was not significantly different from group C. Administration of higher doses of the disinfectant resulted in significantly higher mortality rates, 70% in group E and 85% in groups D and F. Increased infection and mortality rates of groups D, E, and F might have been caused by inhibition of the protective action of the normal gut flora. To reduce horizontal infection and mortality, the manufacturer's prescribed oral dose of 25 ppm may be increased up to 50
Chen, Jian-Guo; Egner, Patricia A; Ng, Derek; Jacobson, Lisa P; Muñoz, Alvaro; Zhu, Yuan-Rong; Qian, Geng-Sun; Wu, Felicia; Yuan, Jian-Min; Groopman, John D; Kensler, Thomas W
Primary liver cancer (PLC) is the third leading cause of cancer mortality globally. In endemic areas of sub-Saharan Africa and Asia, PLC largely arises from chronic infection with hepatitis B virus (HBV) and ingestion of aflatoxins. Although synergistic interactions between these two risk factors have been observed in cohort studies in China, here we determined the impact of agricultural reforms in the 1980s leading to diminished maize consumption and implementation of subsidized universal vaccination against HBV in the 2000s on PLC primary prevention. A population-based cancer registry was used to track PLC mortality in Qidong, China and was compared with the timeline of HBV immunization. Randomly selected serum samples from archived cohort collections from the 1980s to present were analyzed for aflatoxin biomarkers. More than 50% reductions in PLC mortality rates occurred across birth cohorts from the 1960s to the 1980s for Qidongese less than 35 years of age although all were born before universal vaccination of newborns. Median levels of the aflatoxin biomarker decreased from 19.3 pg/mg albumin in 1989 to undetectable (<0.5 pg/mg) by 2009. A population attributable benefit of 65% for reduced PLC mortality was estimated from a government-facilitated switch of dietary staple from maize to rice; 83% of this benefit was in those infected with HBV. Food policy reforms in China resulted in a dramatic decrease in aflatoxin exposure, which, independent of HBV vaccination, reduced liver cancer risk. The extensive HBV vaccine coverage now in place augurs even greater risk reductions in the future.
Chen, Jian-Guo; Egner, Patricia A.; Ng, Derek; Jacobson, Lisa P.; Muñoz, Alvaro; Zhu, Yuan-Rong; Qian, Geng-Sun; Wu, Felicia; Yuan, Jian-Min; Groopman, John D.; Kensler, Thomas W.
Primary liver cancer (PLC) is the third leading cause of cancer mortality globally. In endemic areas of sub-Saharan Africa and Asia PLC largely arises from chronic infection with hepatitis B virus (HBV) and ingestion of aflatoxins. While synergistic interactions between these two risk factors have been observed in cohort studies in China, here we determined the impact of agricultural reforms in the 1980s leading to diminished maize consumption and implementation of subsidized universal vaccination against HBV in the 2000s on PLC primary prevention. A population-based cancer registry was used to track PLC mortality in Qidong, China and was compared to the timeline of HBV immunization. Randomly selected serum samples from archived cohort collections from the 1980s to present were analyzed for aflatoxin biomarkers. Greater than 50% reductions in PLC mortality rates occurred across birth cohorts from the 1960s to the 1980s for Qidongese less than 35 years of age although all were born before universal vaccination of newborns. Median levels of the aflatoxin biomarker decreased from 19.3 pg/mg albumin in 1989 to undetectable (<0.5 pg/mg) by 2009. A population attributable benefit of 65% for reduced PLC mortality was estimated from a government facilitated switch of dietary staple from maize to rice; 83% of this benefit was in those infected with HBV. Food policy reforms in China resulted in a dramatic decrease in aflatoxin exposure, which, independent of HBV vaccination, reduced liver cancer risk. The extensive HBV vaccine coverage now in place augurs even greater risk reductions in the future. PMID:23963804
Castellanos, Daniel Alexander; Herrington, Cynthia; Adler, Stacey; Haas, Karen; Ram Kumar, S; Kung, Grace C
A clinician-driven home monitoring program can improve interstage outcomes in single-ventricle patients. Sociodemographic factors have been independently associated with mortality in interstage patients. We hypothesized that even in a population with high-risk sociodemographic characteristics, a home monitoring program is effective in reducing interstage mortality. We defined interstage period as the time period between discharge following Norwood palliation and second-stage surgery. We reviewed the charts of patients for the three-year period before (group 1) and after (group 2) implementation of the home monitoring program. Clinical variables around Norwood palliation, during the interstage period, and at the time of second-stage surgery were analyzed. There were 74 patients in group 1 and 52 in group 2. 59 % patients were Hispanic, and 84 % lived in neighborhoods where over 5 % families lived below poverty line. There was no significant difference in pre-Norwood variables, Norwood discharge variables, age at second surgery, or outcomes at second surgery. There were more Sano shunts performed at the Norwood procedure as the source of pulmonary blood flow in group 2 (p value <0.05). There were more unplanned hospital admissions and percutaneous re-interventions in group 2. Patients in group 2 whose admission criteria included desaturation had a 45 % likelihood of having an unplanned re-intervention. Group 2 noted an 80 % relative reduction in interstage mortality (p < 0.01). In a multiple regression analysis, after accounting for ethnicity, socio-economic status, and source of pulmonary blood flow, enrollment in a home monitoring program independently predicted improved interstage survival (p < 0.01). A clinician-driven home monitoring program reduces interstage mortality even when the majority of patients has high-risk sociodemographic characteristics.
Park, Soyoung; Lee, Joongyub; Kang, Dong Yoon; Rhee, Chul Woo
Objectives The aim of this study was to investigate whether a medium to high degree of total physical activity and indoor physical activity were associated with reduced all-cause and cardiovascular mortality among elderly Korean women. Methods A prospective cohort study was done to evaluate the association between physical activity and mortality. The cohort was made up of elderly (≥65 years of age) subjects. Baseline information was collected with a self-administered questionnaire and linked to death certificates retrieved from a database. Cox proportional hazard models were used to estimate the hazard ratios (HRs) with 95% confidence interval (CI) levels. Results Women who did not suffer from stroke, cancer, or ischemic heart disease were followed for a median of 8 years (n=5079). A total of 1798 all-cause deaths were recorded, of which 607 (33.8%) were due to cardiovascular disease. The group with the highest level of total physical activity and indoor physical activity was significantly associated to a reduced all-cause mortality (HR, 0.60; 95% CI, 0.51 to 0.71 and HR, 0.58; 95% CI, 0.50 to 0.67, respectively) compared to the group with the lowest level of total physical activity and indoor physical activity. Additionally, the group with the highest level of total physical activity and indoor physical activity was significantly associated to a lower cardiovascular disease mortality (HR, 0.53; 95% CI, 0.40 to 0.71 and HR, 0.51; 95% CI, 0.39 to 0.67, respectively) compared to the group with the lowest level of total physical activity and indoor physical activity. Conclusions Our study showed that regular indoor physical activity among elderly Korean women has healthy benefits. PMID:22389755
Background and Purpose Racial and geographic disparities in stroke mortality have been documented for over 50 years, and for those aged 45 to 64 are among the largest for any disease. The causes of the disparities have been mysterious; however, investments by NINDS, NHLBI and CDC are now providing insights into the causes. Methods Complementary study designs provide information on different aspects of the disparities. Vital statistics data track temporal patterns in stroke mortality, an objective index of the success in overcoming the disparities. Surveillance studies assess of the contributions of incidence versus case fatality to the disparities, a distinction critical to guide efforts to reduce the disparities. Finally, cohort studies give insights to the contribution of specific risk factors to disparities in either incidence or case fatality, allowing targeted interventions. Results While deaths from stroke mortality declined by a third in the most recent eleven years, there has been a 35% increase in the black-white disparity and little change in geographic disparities. Surveillance studies suggest that the black-white disparity is primarily attributable to differences in incidence, and also have potentially unmasked Hispanic-white differences in incidence that are not apparent in mortality trends. Longitudinal cohort studies are suggesting multiple targets for intervention such as a multi-dimensional impact of blood pressure on the black-white differences. Conclusion After suffering these disparities over a half-century, information is now emerging to allow us to better understand the underpinnings of the disparities and potentially enter a new era of targeted interventions to reduce these disparities. PMID:24029634
Liljestrand, Jerker; Pathmanathan, Indra
Developing countries are floundering in their efforts to meet the Millennium Development Goal of reducing maternal mortality by 75% by 2015. Two issues are being debated. Is it doable within this time frame? And is it affordable? Malaysia and Sri Lanka have in the past 50 years repeatedly halved their maternal mortality ratio (MMR) every 7-10 years to reduce MMR from over 500 to below 50. Experience from four other developing countries--Bolivia, Yunan in China, Egypt, and Jamaica-confirms that each was able to halve MMR in less than 10 years beginning from levels of 200-300. Malaysia and Sri Lanka, invested modestly (but wisely)--less than 0.4% of GDP--on maternal health throughout the period of decline, although the large majority of women depended on publicly funded maternal health care. Analysis of their experience suggests that provision of access to and removal of barriers for the use of skilled birth attendance has been the key. This included professionalization of midwifery and phasing out of traditional birth attendants; monitoring births and maternal deaths and use of such information for high profile advocacy on the importance of reducing maternal death; and addressing critical gaps in the health system; and reducing disparities between different groups through special attention to the poor and disadvantaged populations.
Effect of weekend compared with weekday stroke admission on thrombolytic use, in-hospital mortality, discharge disposition, hospital charges, and length of stay in the Nationwide Inpatient Sample Database, 2002 to 2007.
Hoh, Brian L; Chi, Yueh-Yun; Waters, Michael F; Mocco, J; Barker, Fred G
A stroke "weekend effect" on mortality has been demonstrated in other countries with a possible slight effect in the United States. We studied patients with stroke in the Nationwide Inpatient Sample database for a weekend effect on thrombolytic use, in-hospital mortality, discharge disposition, hospital charges, and length of stay. The Nationwide Inpatient Sample 2002 to 2007 was searched for all emergency room admissions for International Classification of Diseases, 9th Revision codes corresponding to ischemic stroke. Generalized estimated equations for generalized linear models were performed, adjusting for gender, age, race, season, median income level, payer, comorbidity score, hospital region, hospital location, teaching status, bed size, and hospital annual stroke case volume to compare weekend versus weekday stroke admission incidence of thrombolytic use, in-hospital mortality, discharge disposition, hospital charges, and length of stay. The same analysis was performed using the International Classification of Diseases, 9th Revision codes for ischemic stroke AND transient cerebral ischemia to check internal validity for coding irregularities that may occur in differentiating stroke from transient ischemic attack. There were 599 087 emergency room admissions for ischemic stroke: 159 906 weekend admissions and 439 181 weekday admissions. Generalized estimated equation for generalized linear model analysis was performed and demonstrated weekend compared with weekday patients with stroke were slightly more likely to receive thrombolytics (OR=1.114; 95% CI=1.039 to 1.194; P=0.003); incur slightly higher total hospital charges (effect ratio=1.011; 95% CI=1.006 to 1.017; P<0.001); and have slightly longer lengths of stay (effect ratio=1.021; 95% CI=1.015 to 1.027; P<0.001). There was no difference in in-hospital mortality or discharge disposition. There is a slight stroke weekend effect on thrombolytic use, total hospital charges, and length of stay, but no
Riegle, Melissa A.; Masicampo, Melissa L.; Shan, Hong Qu; Xu, Victoria; Godwin, Dwayne W.
Aims We recently demonstrated that T-type calcium channels are affected by alcohol abuse and withdrawal. Treatment with ethosuximide, an antiepileptic drug that blocks T-type calcium channels, reduces seizure activity induced by intermittent ethanol exposures and withdrawals. Here, we expand on these findings to test whether ethosuximide can reduce the sensitivity to pentylenetetrazole-induced seizures during ethanol withdrawal. Methods We used an intermittent ethanol exposure model to produce withdrawal-induced hyperexcitability in DBA/2J mice. Results Ethosuximide (250 mg/kg) reduced seizure severity in mice undergoing ethanol withdrawal with concurrent PTZ treatment (20 mg/kg). Importantly, ethosuximide did not produce rebound excitability and protected against ethanol withdrawal-induced mortality produced by concurrent PTZ treatment (40 mg/kg). Conclusion These results, in addition to previous preclinical findings, suggest that ethosuximide should be further evaluated as a safe, effective alternative to benzodiazepines for the treatment of alcohol withdrawal. PMID:25870316
Brown, Jack; Paladino, Joseph A
Patients hospitalized with Staphylococcus aureus bacteraemia have an unacceptably high mortality rate. Literature available to date has shown that timely selection of the most appropriate antibacterial may reduce mortality. One tool that may help with this selection is a polymerase chain reaction (PCR) assay that distinguishes methicillin (meticillin)-resistant S. aureus (MRSA) from methicillin-susceptible S. aureus (MSSA) in less than 1 hour. To date, no information is available evaluating the impact of this PCR technique on clinical or economic outcomes. To evaluate the effect of a rapid PCR assay on mortality and economics compared with traditional empiric therapy, using a literature-derived model. A literature search for peer-reviewed European (EU) and US publications regarding treatment regimens, outcomes and costs was conducted. Information detailing the rates of infection, as well as the specificity and sensitivity of a rapid PCR assay (Xpert MRSA/SA Blood Culture PCR) were obtained from the peer-reviewed literature. Sensitivity analysis varied the prevalence rate of MRSA from 5% to 80%, while threshold analysis was applied to the cost of the PCR test. Hospital and testing resource consumption were valued with direct medical costs, adjusted to year 2009 values. Adjusted life-years were determined using US and WHO life tables. The cost-effectiveness ratio was defined as the cost per life-year saved. Incremental cost-effectiveness ratios (ICERs) were calculated to determine the additional cost necessary to produce additional effectiveness. All analyses were performed using TreeAge Software (2008). The mean mortality rates were 23% for patients receiving empiric vancomycin subsequently switched to semi-synthetic penicillin (SSP) for MSSA, 36% for patients receiving empiric vancomycin treatment for MRSA, 59% for patients receiving empiric SSP subsequently switched to vancomycin for MRSA and 12% for patients receiving empiric SSP for MSSA. Furthermore, with an
Eker, C; Schalén, W; Asgeirsson, B; Grände, P O; Ranstam, J; Nordström, C H
In 1989, a new therapy to reduce intracranial pressure in severely head-injured patients was introduced in Lund. The new treatment reduced mortality significantly. The present study describes the quality of life for the survivors. The study includes 53 patients treated during 1989-1994, according to a new treatment protocol for increased intracranial pressure ('Lund concept' group). During 1982-1986, 38 patients were managed according to a protocol including high dose thiopentone ('Thiopentone' group). The two groups are compared regarding neurophysical and psychiatric symptoms as well as aspects regarding the patient's role, performance, interpersonal relationship, frictions, feelings and satisfaction in work, areas of social and leisure activities, and extended family. Mortality was reduced from 47% to 8%, but the number of patients with a persistent vegetative state and/or remaining severe disability did not increase. However, the number of patients with persisting emotional and intellectual deficits increased significantly. The new treatment regime has dramatically increased the number of survivors after severe head trauma. Although most patients have a favourable outcome, there are more patients with remaining sequelae and disabilities, and the demand for qualified rehabilitation has increased.
Global warming is seen as one of the greatest threats to the world’s coral reefs and, with the continued rise in sea surface temperature predicted into the future, there is a great need for further understanding of how to prevent and address the damaging impacts. This is particularly so for countries whose economies depend heavily on healthy reefs, such as those of the eastern Caribbean. Here, we compare the severity of bleaching and mortality for five dominant coral species at six representative reef sites in Barbados during the two most significant warm-water events ever recorded in the eastern Caribbean, i.e., 2005 and 2010, and describe prevailing island-scale sea water conditions during both events. In so doing, we demonstrate that coral bleaching and subsequent mortality were considerably lower in 2010 than in 2005 for all species, irrespective of site, even though the anomalously warm water temperature profiles were very similar between years. We also show that during the 2010 event, Barbados was engulfed by a transient dark green turbid water mass of riverine origin coming from South America. We suggest that reduced exposure to high solar radiation associated with this transient water mass was the primary contributing factor to the lower bleaching and mortality observed in all corals. We conclude that monitoring these episodic mesoscale oceanographic features might improve risk assessments of southeastern Caribbean reefs to warm-water events in the future. PMID:27326377
Del Piano, Mario; Coggiola, Francesco; Pane, Marco; Amoruso, Angela; Nicola, Stefania; Mogna, Luca
Diarrhea accounts for 9% of the mortality among children under 5 years of age worldwide, and it is significantly associated with malnutrition. Each year, diarrhea kills around 760,000 children under 5 years of age and most of these are in sub-Saharan Africa.In Uganda, the infant mortality rate of 58 per 1000 is unacceptably high, and the major contributors include malnutrition, diarrhea, pneumonia, malaria, prematurity, sepsis, and newborn illnesses.There is an urgent need for intervention to prevent and control diarrheal diseases. Our open-label, randomized controlled study has the primary endpoint of reducing diarrhea and infectious diseases (number of episodes/severity) and the secondary endpoint of decreasing infant mortality. The trial is currently conducted in Luzira, a suburb of Kampala, the capital of Uganda, and in Gulu and Lira, in the north of Uganda.The study is projected to enroll 4000 babies (control=2000 and treatment=2000) who will be followed till 1 year of life. As controls, 2000 babies of the same community are planned to be considered.The probiotic product selected for the trial is composed of 3 designated microorganisms, namely Bifidobacterium breve BR03 (DSM 16604), B. breve B632 (DSM 24706), and Lactobacillus delbrueckii subsp. delbrueckii LDD01 (DSM 22106). The concentration of the 3 bacteria is 10 viable cells/strain/daily dose (5 drops). For a total sample of 4000 babies, the study has an 80% power at a 5% significance level.
Kubo, Hisako; Hoshi, Masato; Mouri, Akihiro; Tashita, Chieko; Yamamoto, Yasuko; Nabeshima, Toshitaka; Saito, Kuniaki
Infection of the encephalomyocarditis virus (EMCV) in mice is an established model for viral myocarditis. Previously, we have demonstrated that indoleamine 2,3-dioxygenase (IDO), an L-tryptophan - kynurenine pathway (KP) enzyme, affects acute viral myocarditis. However, the roles of KP metabolites in EMCV infection remain unclear. Kynurenine 3-monooxygenase (KMO) is one of the key regulatory enzymes, which metabolizes kynurenine to 3-hydroxykynurenine in the KP. Therefore, we examined the role of KMO in acute viral infection by comparing between KMO(-/-) mice and KMO(+/+) mice. KMO deficiency resulted in suppressed mortality after EMCV infection. The number of infiltrating cells and F4/80(+) cells in KMO(-/-) mice was suppressed compared with those in KMO(+/+) mice. KMO(-/-) mice showed significantly increased levels of serum KP metabolites, and induction of KMO expression upon EMCV infection was involved in its effect on mortality through EMCV suppression. Furthermore, KMO(-/-) mice showed significantly suppression of CCL2, CCL3 and CCL4 on day 2 and CXCL1 on day 4 after infection. These results suggest that increased KP metabolites reduced chemokine production, resulting in suppressed mortality upon KMO knockdown in EMCV infection. KP metabolites may thus provide an effective strategy for treating acute viral myocarditis. Copyright © 2016 European Federation of Immunological Societies. Published by Elsevier B.V. All rights reserved.
Kuriyama, Renjiro; Tranaeus, Anders; Ikegami, Tadashi
Although numerous reports have shown that the use of icodextrin solution, as compared with conventional dextrose solutions, provides various clinical benefits, data on the impact of icodextrin solution on mortality and drop-out are sparse. In the present retrospective study, we compared clinical outcomes in a large cohort of patients prescribed either icodextrin or dextrose solution for the long dwell. A total of 7808 patients across Japan who were using Baxter peritoneal dialysis (PD) solutions in 2004 were included in this cross-sectional analysis. Outcomes data were retrieved from the Baxter Japan database. The annual drop-out rate in the icodextrin group (8.9%) was significantly (p < 0.0001) lower than that in the dextrose group (14.5%). The annual mortality rate was also lower (6.6% vs. 13.5%, p < 0.0001). Using data from the 2000 report of the Japanese Society for Dialysis Therapy, the relative risk of death in the icodextrin group, regardless of PD duration, was consistently lower than that in hemodialysis patients. These results indicate that, in PD, the use of icodextrin solution (as compared with dextrose solution) significantly reduces both mortality and drop-out rate.
Oxenford, Hazel A; Vallès, Henri
Global warming is seen as one of the greatest threats to the world's coral reefs and, with the continued rise in sea surface temperature predicted into the future, there is a great need for further understanding of how to prevent and address the damaging impacts. This is particularly so for countries whose economies depend heavily on healthy reefs, such as those of the eastern Caribbean. Here, we compare the severity of bleaching and mortality for five dominant coral species at six representative reef sites in Barbados during the two most significant warm-water events ever recorded in the eastern Caribbean, i.e., 2005 and 2010, and describe prevailing island-scale sea water conditions during both events. In so doing, we demonstrate that coral bleaching and subsequent mortality were considerably lower in 2010 than in 2005 for all species, irrespective of site, even though the anomalously warm water temperature profiles were very similar between years. We also show that during the 2010 event, Barbados was engulfed by a transient dark green turbid water mass of riverine origin coming from South America. We suggest that reduced exposure to high solar radiation associated with this transient water mass was the primary contributing factor to the lower bleaching and mortality observed in all corals. We conclude that monitoring these episodic mesoscale oceanographic features might improve risk assessments of southeastern Caribbean reefs to warm-water events in the future.
Aberle, Denise R; Adams, Amanda M; Berg, Christine D; Black, William C; Clapp, Jonathan D; Fagerstrom, Richard M; Gareen, Ilana F; Gatsonis, Constantine; Marcus, Pamela M; Sicks, JoRean D
The aggressive and heterogeneous nature of lung cancer has thwarted efforts to reduce mortality from this cancer through the use of screening. The advent of low-dose helical computed tomography (CT) altered the landscape of lung-cancer screening, with studies indicating that low-dose CT detects many tumors at early stages. The National Lung Screening Trial (NLST) was conducted to determine whether screening with low-dose CT could reduce mortality from lung cancer. From August 2002 through April 2004, we enrolled 53,454 persons at high risk for lung cancer at 33 U.S. medical centers. Participants were randomly assigned to undergo three annual screenings with either low-dose CT (26,722 participants) or single-view posteroanterior chest radiography (26,732). Data were collected on cases of lung cancer and deaths from lung cancer that occurred through December 31, 2009. The rate of adherence to screening was more than 90%. The rate of positive screening tests was 24.2% with low-dose CT and 6.9% with radiography over all three rounds. A total of 96.4% of the positive screening results in the low-dose CT group and 94.5% in the radiography group were false positive results. The incidence of lung cancer was 645 cases per 100,000 person-years (1060 cancers) in the low-dose CT group, as compared with 572 cases per 100,000 person-years (941 cancers) in the radiography group (rate ratio, 1.13; 95% confidence interval [CI], 1.03 to 1.23). There were 247 deaths from lung cancer per 100,000 person-years in the low-dose CT group and 309 deaths per 100,000 person-years in the radiography group, representing a relative reduction in mortality from lung cancer with low-dose CT screening of 20.0% (95% CI, 6.8 to 26.7; P=0.004). The rate of death from any cause was reduced in the low-dose CT group, as compared with the radiography group, by 6.7% (95% CI, 1.2 to 13.6; P=0.02). Screening with the use of low-dose CT reduces mortality from lung cancer. (Funded by the National Cancer
Harada, Megan Y; Ko, Ara; Barmparas, Galinos; Smith, Eric J T; Patel, Bansuri K; Dhillon, Navpreet K; Thomsen, Gretchen M; Ley, Eric J
Liberal emergency department (ED) resuscitation after trauma may lead to uncontrolled hemorrhage, reduced organ perfusion, and compartment syndrome. Recent guidelines reduced the standard starting point for crystalloid resuscitation from 2 L to 1 L and emphasized "balanced" resuscitation. The purpose of this study was to characterize how an urban, Level 1 trauma center has responded to changes in crystalloid resuscitation practices over time and to describe associated patient outcomes. This is a retrospective review of trauma patients who sustained moderate to severe injury (ISS > 9) and received crystalloid resuscitation in the ED during 1/2004-12/2013 at an urban, Level 1 trauma center. Patient data collected included age, gender, Glasgow Coma Scale (GCS) score, initial systolic blood pressure (SBP), mechanism of injury, regional Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), volume of blood products and crystalloids administered in the ED. Patients who received <2 L of crystalloid were considered low-volume while those who received ≥2 L were high-volume patients. Clinical characteristics and outcomes were compared between high- and low-volume cohorts, and multivariate regression was used to adjust for confounders. Trend analysis examined changes in variables over time. 1571 moderate to severely injured patients received crystalloid resuscitation; 1282 (82%) were low-volume and 289 (18%) were high-volume. Compared to high-volume patients, low-volume patients presented with a higher median SBP (134 vs. 122 mmHg, p < 0.001) and GCS (15 vs. 14, p < 0.001). Low-volume patients also had lower median ISS (15 vs. 19, p < 0.001). Unadjusted mortality was lower in the low-volume cohort (7% vs. 19%, p < 0.001). Multivariate analysis demonstrated that high-volume patients had increased odds of mortality compared to low-volume patients (AOR 1.88, p = 0.008). Decreased rates of high-volume resuscitation and overall mortality were
Background Women in Nigeria face some of the highest maternal mortality risks in the world. We explore the benefits and cost-effectiveness of individual and integrated packages of interventions to prevent pregnancy-related deaths. Methods We adapt a previously validated maternal mortality model to Nigeria. Model outcomes included clinical events, population measures, costs, and cost-effectiveness ratios. Separate models were adapted to Southwest and Northeast zones using survey-based data. Strategies consisted of improving coverage of effective interventions, and could include improved logistics. Results Increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality, was cost saving in the Southwest