Cause Of Hospital Death Research Articles

Venous Thrombo-embolism prophylaxis: Intermittent pneumatic compression

Abstract Pulmonary embolism (PE) is the most preventable cause of hospital deaths in Europe. Autopsy-proven fatal pulmonary emboli were found in 2.5% of 200 hospitalized medical patients followed-up prospectively. The number of venous thrombo-embolism (VTE) related deaths throughout the Europe (543,454) is more than double the amount of deaths attributed to AIDS, breast cancer, prostate cancer and transport accidents combined (209,926). Only 58.5% of surgical patients and 39.5% of medical patients receive the appropriate thrombo-prophylaxis for their conditions. An ideal VTE prophylaxis for any given patient should be (1) risk adjusted, (2) targeted, (3) personalized and (4) effective. Intermittent pneumatic compression (IPC) devices are best suited for: (1) ICU patients who are either bleeding or have a high bleeding risk; (2) low risk elective general abdominal or pelvic surgery patients; (3) high risk elective general abdominal or pelvic surgery patients who have a high bleeding risk. In high risk elective general abdominal or pelvic surgery patients who are not at high risk for major bleeding, combined prophylaxis (IPC+LMWH) are recommended. Combined modalities target virtually all aspects of the Virchow's triad: (1) IPC and stockings prevent “stasis”, (2) stockings prevent “endothelial damage”, (3) IPC increases fibrinolysis, and LMWH exert anti-thrombotic effects to prevent “hypercoagulability”. In patients undergoing major surgery, IPC devices have a broader area of application due to fewer contra-indications and similar efficacy as compared to LMWH. Whenever indicated, every effort should be undertaken to provide a combined prophylaxis method.

PWE-056 Cancer is the Leading Cause of Hospital Death in 30 Day Mortality Audit following Endoscopy

IntroductionMortality post endoscopy is a quality standard for all endoscopy units. Many of the published 30 day mortality studies relate specifically to those presenting with gastro-intestinal bleeding or following a...

Injury death pattern in 2009 in the districts in Sri Lanka: a descriptive study

BackgroundTraumatic injuries have been the leading causes of hospital admissions in Sri Lanka for the past 15 years and were among the ten leading causes of hospital deaths for the same period. The distribution of the pattern of injury deaths (cause of death [CoD]) by district has not been documented. Therefore, we analysed the external causes of morbidity and mortality (ECMM) (V01–Y99) and the gender difference of deaths in the 25 districts to describe their contribution. MethodsWe analysed the 2009 CoD data from the Department of Registrar General and described the contribution made by ECMM in each district and the gender difference. FindingsECMM contributed 14·0% (17 760 of 127 268) of all deaths (18·4% [13 993 of 75 804] in males, 7·3% [3767 of 51 464] in females) in 2009. All other external causes (W20–W64, W75–W99, X10–X39) contributed 49·8% (8850 of 17 760) of ECMM (50·8% [7103 of 13 993] in males, 46·4% [1747 of 3767] in females), while intentional self-harm (X60–X84) and transport accidents (V01–V99) contributed 20·2% (19·9% [2781 of 13 993] in males, 21·2% [800 of 3767] in females) and 13·8% (14·3% [2004 of 13 993] in males, 11·7% [441 of 3767] in females) of ECMM, respectively. ECMM as a percentage of total deaths in each district varied from 5·4% (208 of 3871) in Nuwara Eliya (a rural hill country district) to 18·3% (900 of 4906) in Anuradhapura (a rural north central district). Distribution of categories in ECMM also showed significant variation among the districts. In Colombo (the capital and the main urban district), 50·0% (978 of 1956) of ECMM deaths were by transport accidents (V01–V99), though in a majority of the other districts the main contribution came from intentional self-harm (X60–X84), ranging from 29·6% (246 of 831) in Gampaha to 49·8% (207 of 416) in Badulla, both urban districts. Gender contribution also varied considerably among the districts, with higher rates of deaths due to falls (W00–W19), accidental drowning and submersions (W65–W74), and exposure to smoke, fire, and flames (X00–X09) among females in the majority of districts. InterpretationA significant variation in injury deaths among districts was seen, and the social, economic, demographic, and environmental variations present could have contributed to these differences. Control programmes should address these for them to be effective. FundingNone.

Venous Thromboembolism (VTE) Rates Following the Implementation of Extended Duration Prophylaxis for Patients Undergoing Surgery for Gynecologic Malignancies

The most common preventable cause of hospital death in the United States is venous thromboembolism (VTE). The risk of VTE among women undergoing major surgery for gynecologic cancer can be substantially reduced by use of postoperative VTE prophylaxis consisting of subcutaneous unfractionated heparin or low-molecular-weight heparin (LMWH) and mechanical prophylaxis. Evidence-based guidelines from several national organizations recommend that patients undergoing abdominal or pelvic surgery for malignancy receive this VTE prophylaxis regimen for up to 28 days postoperatively. Despite these recommendations, VTE prophylaxis is widely underused in this patient population. Poor compliance with the VTE prevention guidelines at the MD Anderson Cancer Center in Houston resulted in a higher than expected postoperative VTE rate among gynecologic-oncology patients. In 2009, standardized extended VTE prophylaxis practice guidelines were initiated at this institution for all patients undergoing laparotomy for gynecologic cancer to improve guideline compliance and reduce postoperative VTE rates. The aim of this study was to compare the incidence of VTE before and after the implementation of the standardized prophylaxis guidelines in women undergoing laparotomy for gynecologic cancer. Patients were started on LMWH within 24 hours of surgery, and it was continued for a total of 28 days postoperatively. The incidence of VTE diagnosed within 30 and 90 days of surgery in a postimplementation guideline group (extended-duration LMWH, n = 334) was compared with a preguideline historical group (no extended-duration LMWH, n = 300). The incidence of VTE diagnosed within 30 days of surgery was reduced by 78% in the postguideline group compared with the preguideline group (2.7% vs 0.6%, respectively; P = 0.040). However, the effect was not sustained when the preguideline and postguideline implementation groups were compared for VTE diagnosed within 90 days of surgery (3.7% vs 3.0%, respectively; P = 0.619). The median time between surgery and VTE diagnosis was significantly longer following implementation of the guidelines (57 vs 12 days, respectively; P = 0.012). These data show significant reduction of VTE rates in a cohort of women undergoing laparotomy for gynecologic malignancy who received extended-duration LMWH compared with similar patients who did not receive extended-duration LMWH. This effect was not sustained, however, when the groups were compared for VTE diagnosis within 90 days of surgery.

Weekend versus weekday hospital deaths: Analysis of in-patient data in a Nigerian tertiary healthcare center

This study aims at comparing weekday deaths to weekend deaths of in-patients of a tertiary hospital in Nigeria. This is a 10-year retrospective survey conducted at the Nnamdi Azikiwe University Teaching Hospital in which the death records of the hospital were accessed from the various wards and health records department to extract relevant data pertaining to the time of hospital death. Tests of statistical significance were done using Chi-square test at 95% confidence intervals. A total of 3934 deaths were recorded during the period of study. The ages ranged from a few hours to 94 years with a mean age of 38.5 years. The male to female ratio was 1.2:1. An average of 547 weekend deaths and 568 weekday deaths were recorded, giving a ratio of 0.96:1. A ratio of weekend to weekday death rate of 0.99:1 and 0.93:1 for the males and females, respectively was noted. The labor ward, followed by the intensive care unit (ICU) had the highest weekend to weekday death ratio of 1.72:1 ( P = 0.0461) and 1.41:1 ( P = 0.1440), respectively. Weekend deaths were less in the other wards, with the gynaecological ward having the least ratio of 0.63:1 ( P = 0.7360). The rate of hospital deaths was generally found not to vary significantly over the weekends and weekdays in the hospital except for the labor ward which had significantly higher weekend to weekday death rates of 1.72:1. There is therefore need for confidential enquiry into the causes of hospital deaths, especially in the labor ward, in order to identify and prevent avoidable deaths.

Sounding the Alarm on Chronic Kidney Disease in Farming Communities: María Isabel Rodríguez MD. Minister of Health, El Salvador

In April 2013, consortium of regional health ministries, nongovernmental organizations, aid agencies, clinical specialists and researchers from diverse sectors convened in San Salvador to discuss epidemic of chronic kidney disease of unknown or non-traditional causes (CKDu) plaguing agricultural communities in Central America and beyond. The three-day meeting, where presentation of research on clinical and epidemiological characteristics of CKDu roused significant debate, led Pan American Health Organization to declare CKDu a pressing and serious health problem [which] represents burden for families, communities, health systems and society as whole.[1] This High-level Meeting on Chronic Kidney Disease of Non-Traditional Causes in Central America (24-26 April) followed several international meetings at which Dr Maria Isabel Rodriguez, El Salvador's Minister of Health, presented studies on disease burden in her country, where end-stage renal disease is leading cause of hospital deaths. She outlined results of original scientific research by Dr Carlos Orantes (first published in MEDICC Review), that described an elevated prevalence of chronic kidney disease, chronic renal failure and risk factors among patients studied, noting that the most common [form] was chronic kidney disease of unknown cause, associated with neither diabetes nor hypertension.[2] In this interview with MEDICC Review, Dr Rodriguez discussed gravity of problem in Salvadoran agricultural communities; importance of CKDu research in other countries; and urgent need for intersectoral action and active community participation to confront and control epidemic.

Prognosis of elderly patients hospitalized in the cardiac ward

Abstract Introduction Cardiovascular diseases affect nearly 80% of the elderly, and they are the major cause of death in this population. The aim was to evaluate the clinical profile and prognostic factors for patients aged 80 years and more who have been hospitalized for cardiologic reasons. Material and Methods The study included 100 patients aged 80–91 years (46% men) referred to the Department of Cardiology. We analyzed the reasons and length of hospitalization, clinical factors, results of basic laboratory tests, echocardiography, angiography, comorbidities and number of deaths during the hospitalization and in one year of follow-up. Patients were divided and analyzed, depending on the total mortality rate.Results The most common causes of hospitalization were myocardial infarction (67%) and heart failure (10%). Coronary angiography was performed in 72% of patients and percutaneous coronary intervention in 81%. The most common cause of hospital deaths was myocardial infarction (67%). The proportion of deaths in hospital was 8%, and during a year of observation it was 26%. Deaths were found to be related to ventricular conduction blocks (OR=4.0; P=0.03) and atrial fibrillation (OR=11.15; P=0.04). Conclusions In the elderly hospitalized in cardiac wards, myocardial infarction was the most common cause of hospitalization and hospital death. The mortality rate was high and associated with ventricular conduction blocks and atrial fibrillation.

New Approaches to Sepsis: Molecular Diagnostics and Biomarkers

Sepsis is among the most common causes of death in hospitals. It arises from the host response to infection. Currently, diagnosis relies on nonspecific physiological criteria and culture-based pathogen detection. This results in diagnostic uncertainty, therapeutic delays, the mis- and overuse of antibiotics, and the failure to identify patients who might benefit from immunomodulatory therapies. There is a need for new sepsis biomarkers that can aid in therapeutic decision making and add information about screening, diagnosis, risk stratification, and monitoring of the response to therapy. The host response involves hundreds of mediators and single molecules, many of which have been proposed as biomarkers. It is, however, unlikely that one single biomarker is able to satisfy all the needs and expectations for sepsis research and management. Among biomarkers that are measurable by assays approved for clinical use, procalcitonin (PCT) has shown some usefulness as an infection marker and for antibiotic stewardship. Other possible new approaches consist of molecular strategies to improve pathogen detection and molecular diagnostics and prognostics based on transcriptomic, proteomic, or metabolic profiling. Novel approaches to sepsis promise to transform sepsis from a physiologic syndrome into a group of distinct biochemical disorders and help in the development of better diagnostic tools and effective adjunctive sepsis therapies.

Wells’ prediction rules for pulmonary embolism

Pulmonary embolism is major cause of hospital death. Clinical prediction rules such as Wells' prediction rules can help in selection of at-risk patients who need further testing for pulmonary embolism. We evaluated the usefulness of such criteria for detection of patients with diagnosed pulmonary embolism. Patients enrolled in National Research Institute of Tuberculosis and Lung Disease (NRITLD) deep venous thrombosis (DVT) registry were evaluated and those with objective data about presence or absence of pulmonary embolism were selected for this study. Diagnosis of pulmonary embolism was based on computed tomography pulmonary angiography (CTPA). We calculated the embolic burden in those with CTPA-confirmed pulmonary embolism. Eighty-six patients entered the study (58 males, 28 females, mean age = 54.39 ± 1.74 years). Fifty-four cases had coexisting pulmonary embolism (embolic burden score: 10.77 ± 1.181). Embolic burden score was correlated to presence of massive pulmonary embolism (Pearson rho: 0.43, P = 0.002). There was no association between Wells' pulmonary embolism score and the occurrence of pulmonary embolism (Spearman's rho: 0.085, P = 0.51). Dividing the patients into two, or three, risk groups according to Wells' model did not reveal an association with occurrence of pulmonary embolism either (P = 0.99 and P = 0.261, respectively). Tachycardia and hemoptysis were the only parameters from the Wells' pulmonary embolism score correlated to presence of pulmonary embolism (Spearman's rho: 0.373, P < 0.000 and Spearman's rho: 0.297, P = 0.005, correspondingly). Wells' pulmonary embolism score could not predict the occurrence of pulmonary embolism in DVT patients suspected of having coexisting pulmonary embolism. Until further studies shed light on this patient subset, overreliance on Wells' prediction rules as the solo decision making tool should be cautioned.

Paradoxical thrombosis, part 2: anticoagulant and antiplatelet therapy

Arterial thrombosis is the leading causes of morbidity and mortality worldwide, whereas venous thrombosis is the most common preventable cause of hospital death. In either case, venous and arterial thrombosis should be considered autonomous entities, with only minor overlaps in terms of risk factors, predisposing conditions and pathogenesis. Besides the widespread perception of embolization originating from low-pressure venous system and triggering ischemic stroke or peripheral arterial occlusion, "paradoxical" thrombosis might also develop or occur within clinical or biological circumstances where the blood should be less predisposed to clot, and wherein this risk is mostly unpredictable or overlooked. In this article we review epidemiological evidence and potential pathogenetic mechanisms of paradoxical thrombosis developing during antithrombotic therapy with vitamin K antagonists and heparin (i.e. heparin-induced thrombocytopenia), or antiplatelet agents such as aspirin, glycoprotein IIb/IIIa inhibitors or clopidogrel, and mostly attributable to direct effect of the agent.

Abstract 449: Detection of some selected tumor markers in people from River Nile State - Sudan

Abstract This study was designed to use some selected tumor markers (TMs) as screening tool to discover new cancer cases, and to use these TMs as diagnostic tool for early detection of cancer. The study area is the River Nile State with an area of 122100 Km2 and population of 1026000 persons. The national cancer control program was initiated in 1982 with WHO help, and updated in the early 1990s based on the new WHO guidelines. In 2010 the National Cancer Registry was established but still more efforts are needed to register all cancer cases in such a poor country like Sudan. According to Federal Ministry of Health (FMOH) 2008 data; cancer was ranked as the fourth cause of death in hospitals. Five hundred and ten blood samples were collected from healthy people living in River Nile State; 305 samples were males. (PSA) was measured in all males, (CA125) was used for ovarian cancer in females, (CA15-3) was used for breast cancer in females, and (CEA) Carcino Embryonic Antigen was used for colon cancer in both genders. Samples were measured using RIA technique. Written consent was obtained from all volunteers. There was an elevation in blood level of CEA in 26 samples (6.37%), two of them died during the study, 7 (2.29%) males had PSA concentrations above the upper limit, 5 (2.45%) females showed high CA15-3 concentrations, and increase in CA125 in 6 samples (2.94%). Out of the 510 subjects there were 56 samples (10.98%) had family history with cancer, and only 6 of them (10.71%) showed elevated concentrations. Most of these people are very poor and hospitals are not accessible and the diagnosis and treatment services are not affordable. Table 1 shows the concentrations for the selected TMs.The FMOH documented in 2007 that more than 345 cancer patients came from River Nile State, more cases were reported in other studies e.g. 2899 cancer incidences in Northern Sudan in 2006. In the present study, (8.63%) of the studied population showed elevated concentrations of the selected TMs. Table 1: TMs concentrations. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 449. doi:1538-7445.AM2012-449

82 SYMPTOMATIC PULMONARY EMBOLISM IN MAJOR UROLOGIC CANCER SURGERY

INTRODUCTION AND OBJECTIVES: Venous thromboembolic events (VTE ), which progress from deep vein thrombosis (DVT) to pulmonary embolism (PE), are the most common preventable cause of hospital death. In urology, older obese patients with cancer frequently undergo major abdominal and pelvic surgery, which places them at the highest risk for VTE. Data describing VTE risk in urology is lacking because it is difficult to estimate risk retrospectively and early events (DVT) may be asymptomatic. However, PE is an ideal surrogate measure because it represents the furthest progression of VTE and is often symptomatic. The objective of this study was to evaluate the incidence and outcomes for symptomatic PE in cancer patients after prostatectomy, nephrectomy or cystectomy during a 5year period at a tertiary medical center. METHODS: Clinical and pathologic data was reviewed for all prostatectomy, nephrectomy, and cystectomy patients with a cancer diagnosis from January 1st 2006-December 31st 2010. All patients had mechanical prophylaxis per hospital protocol. Heparin prophylaxis is not routinely given for nephrectomy or prostatectomy. Routine heparin prophylaxis after cystectomy began in 2010. Symptomatic PE was assumed to be related to surgery if diagnosed within 90 days following surgery. Two patients with incidental PE were not included. RESULTS: A total of 1327 patients met eligibility criteria. The overall symptomatic PE incidence was 1.6% (21/1327), including 6/827(0.7%) for prostatectomy, 4/307(1.3%) for nephrectomy and 11/ 189(5.8%) for cystectomy. Death resulted from PE in 2/21(9.5%) of patients (2 postcystectomy). Patients with symptomatic PE had mean age of 64.7 years (44-81). SOB was the most common presenting symptom (58.8%), and diagnosis was most commonly obtained from CT chest angiography (81.0%). The average time from symptoms to diagnosis was 1.3 days (0-11). PE was diagnosed during the initial hospital stay in 11 of 21(52.4%) of patients. PE was diagnosed in 16/21(76.2% )on days 0-30, 3/31 (14.3%)on days 31-60 and 2/21(9.5%) on days 61-90 postoperatively. Hospital readmission for PE was required in 10 patients for 81 hospital days. In post-cystectomy PE patients, 6/11(54%) received heparin prophylaxis at any time (27% presurgery). In post-cystectomy patients without PE, 26/178(15%) were given prophylactic heparin at any time (6.1% presurgery). CONCLUSIONS: Symptomatic PE is rare after prostatectomy or nephrectomy, but common after cystectomy. VTE incidence after cystectomy is significantly elevated and extended heparin prophylaxis should be considered in these patients.

Short-term and long-term outcomes of postinfarction ventricular septal perforation

Ventricular septal perforation represents a serious complication after acute myocardial infarction. This study aimed to evaluate the short-term and longterm outcomes of postinfarction ventricular septal perforation (VSP). We evaluated outcomes for VSP repair for 42 patients over 19 years. A retrospective analysis of clinical records, risk factors for hospital death, and long-term survival was performed. In-hospital mortality was 33.3%. The most common cause of hospital death was left-sided heart failure. A low ejection fraction and short time interval from acute myocardial infarction to the onset of VSP were significant risk factors. The actuarial survival rates of in-hospital survivors at 5 and 10 years were 81.7% and 43.5%, respectively. There were 17 cardiac events among the survivors during the follow-up period. The most influential factor affecting long-term outcomes was the number of diseased coronary arteries. The long-term survival outcome of VSP patients during the postoperative period was comparatively good, but the prognosis of VSP patients with multivessel disease was not satisfactory because of congestive heart failure or ventricular arrhythmia. We believe that postoperative medical treatment for preventing cardiac remodeling is important for improving long-term survival outcomes in such patients.

Prophylaxis for Venous Thromboembolism: A Great Global Divide between Expert Guidelines and Clinical Practice?

Our understanding of development and prevention of venous thromboembolism (VTE) has improved dramatically since Virchow described the triad of stasis, hypercoagulability, and endothelial dysfunction during the mid-1800s. A full arsenal of effective pharmacological and mechanical methods can help prevent VTE and many professional organizations have provided extensive evidence-based statements for VTE prophylaxis. Disappointingly, however, VTE has remained the major preventable cause of hospital death. Adherence rate to clinical guidelines is undesirably low. Many real-world patients have also been excluded from VTE prevention trials and hence practice guidelines recommendations. The comprehensive and repetitious formats of many available guidelines also limit their readability and applicability by nonthrombosis specialists. Moreover, some patients suffer from VTE despite complying with the contemporary prophylaxis regimens. Besides, significant heterogeneity exists in thromboprophylaxis practice and pitfalls between different countries. Last but not the least; although many at-risk patients are underprophylaxed, there is evidence to suggest that overprophylaxis (i.e., prescription of thromboprophylaxis in low-risk patients) comprises another important problem. We review the thromboprophylaxis practice and pitfalls around the world and provide recommendations on how the major obstacles can be overcome.

Midterm results after endovascular treatment of acute, complicated type B aortic dissection: The Talent Thoracic Registry

To assess the efficacy and midterm results of endovascular treatment of acute complicated type B dissection. From January 1998 to March 2004, 29 patients (7 women and 22 men) with acute complicated aortic type B dissection (mean age, 61 years; range, 22-78), defined as aortic rupture, malperfusion, intractable pain, or uncontrolled hypertension, underwent endovascular stent graft placement with the Medtronic Talent device. Five patients (17%) had undergone previous surgery on the ascending aorta and/or aortic valve. The mean aortic diameter at intervention was 48 ± 13 mm. Follow-up was 100% complete and averaged 53 ± 41 months. The technical feasibility and success with deployment proximal to the entry tear was 100%, requiring partial or total coverage of the left subclavian artery in only 1 patient (3%). Hospital mortality was 17% ± 7% (70% confidence limit) with 6 late deaths. The causes of hospital death included multiorgan failure in 2 patients, aortic rupture in 2, and retrograde dissection in 1 patient. Three patients (10%) who survived the procedure developed neurologic complications (2 strokes and 1 transient ischemic attack). One patient required early conversion to surgery because of retrograde type A dissection. Furthermore, 4 patients developed a type Ia endoleak. A postprocedural increase in the distal aortic diameter was observed in 3 patients. The actuarial survival at 1 and 5 years was 79% and 61%, respectively. Freedom from treatment failure at 1 and 5 years (including reintervention, aortic rupture, device-related complications, aortic-related death, or sudden, unexplained late death) was 82% and 77%, respectively. Endovascular stent graft placement in acute complicated type B aortic dissection proves to be a promising alternative therapeutic treatment modality in this relatively difficult patient cohort. Refinements, especially in stent design and application, could further improve the prognosis of patients in this life-threatening situation.

Production of Antibodies in Chicken for Escherichia Coli O157:H7

Escherichia coli serotype O157:H7 is a Gram-negative rod-shaped bacterium. Despite the availability of potent antibiotics, Gram negative bacteraemia and sepsis is currently a frequent cause of death in hospitals. Chicken egg yolk can become an important tool here. Biochemical tests, comparative studies of pH, temperature and media were conducted to pick out the right strain of bacteria. IgY was produced and isolated from yolk using three different protocols to get the highest yield on production. The final product was tested by methods like ELISA, dot blotting and SDS-PAGE. The antibody was purified by affinity chromatography. It was found that the serotype being used was pure and not contaminated. The IgY produced from PEG ethanol method was found to give the best results. This method makes it easy to produce the antibody in bulk, which in turn will help diagnose the symptoms caused by Escherichia coli O157:H7 far more rapidly than other methods. Further the antibody can be formulated for therapeutic uses.

Autopsy and Malpractice Considerations

Department of Pathology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina. ajgarvin@wfubmc.eduIN “Autopsy Utilization in Medicolegal Defense of Anesthesiologists” the authors attempt to correlate autopsy findings with possible culpability in unexpected surgical deaths.1The first paragraph of their discussion highlights the inherent difficulty in using narrative data of autopsy findings in claim reports without access to the original autopsy reports. The thoroughness and quality of the autopsy itself simply cannot be evaluated. Although the College of American Pathologists has guidelines regarding the autopsy report, these guidelines are concerned primarily with appropriate layout and components of the report such as if the descriptions of the external and internal examination are in the body of the report, whether a provisional anatomic diagnosis list has been generated and dispersed to appropriate parties within 24 h, and if autopsy reports have been released within 30 days of the autopsy.2,3The quality or correctness of the autopsy findings is not assessed. In this study, the quality of the thoroughness of the autopsy is paramount; otherwise, the conclusions in this particular study, although important, can only be superficial.The quality of the autopsy reports for the investigation of intraoperative deaths, as in any type of death, can vary widely. If such deaths fall under the coroner or medical examiner's jurisdiction, the often understaffed forensic pathologists are usually reluctant to take on these cases because of the increased time requirement associated with determination of cause of death and high possibility of associated time-consuming civil litigation. In addition, some members of the forensic pathology community think that such investigation belongs in the arena of the hospital pathologist because the performance of autopsies was viewed in the past as quality assurance and control for the hospital.Unfortunately, the performance of the hospital autopsy has decreased, as the authors have already pointed out, partly because of decreased reimbursement and associated perceived lack of importance. This negative attitude has, without a doubt, carried over to the pathologists and hospitals charged with performing the autopsies. The negative view of the autopsy is reinforced by the time constraints often placed on hospital pathologists to perform the autopsy. Often the pathologist is expected to review the patient's hospital chart (which may be extensive), attempt to contact the appropriate clinicians for their assessment, and perform a sometimes complicated dissection, often in addition to performing other duties such as examining surgical pathology specimens within a short amount of time. This rushed atmosphere, in addition to decreased incentive due to lack of reimbursement for a standard hospital autopsy and negative attitude toward the task, is not conducive to thorough examination of the cause of hospital deaths. Such an environment may also encourage assigning a cause of death to any grossly apparent pathology without critically examining whether or not the pathology actually contributed to death.The authors allude to a model for the investigation of intraoperative deaths based on committee review where committee members consist of experts in surgery, anesthesiology, and pathology. The committee investigates those deaths where the patients have been classified as at low risk for surgical and anesthetic complications. Patients at low risk are determined using the American Society of Anesthesiologists classification of physical status. In this classification scheme, the patients are rated I through V where a higher classification denotes a greater intraoperative risk. A subclassification of patients who undergo emergent surgeries is flagged with “E” after their classification number. The authors advocate the adoption of more uniform medical and pathologic investigative procedures such as the one detailed in Reay et al. 4; however, adoption of such procedures will be slow without increased reimbursement to cover the cost of not only the basic autopsy procedure but also toxicology testing and special autopsy procedures.In this article, the authors state that patients in claims for death with autopsy tended to be younger and healthier than those in claims for death without autopsy. Presumably, these patients would have corresponded to lower classification numbers in the American Society of Anesthesiologists classification of physical status. It would be interesting to classify this cohort of patients according to the American Society of Anesthesiologists classification to determine whether these patients fell into one predominant classification. In addition, the authors suggest that the autopsy results helped the defense of the anesthesiologists because other causes of death or significant comorbidities were present. A more interesting paragraph could include more explicit examination of just how the information may have helped the anesthesiologist. Likewise, how were the autopsy results specifically harmful to the anesthesiologist? Given the varying quality of the performance of autopsies that probably exists across this country, the significance of autopsy findings in malpractice cases needs to be carefully scrutinized.

Chronic Kidney Disease and Associated Risk Factors in the Bajo Lempa Region of El Salvador: Nefrolempa Study, 2009

INTRODUCTION: In El Salvador, end-stage renal disease is the leading cause of hospital deaths in adults, the second cause of death in men and the fifth leading cause of death in adults of both sexes in the general population. OBJECTIVE: Identify risk factors for chronic kidney disease and urinary markers of renal and vascular damage, measure kidney function and characterize prevalence of chronic kidney disease in persons aged >18 years in the Bajo Lempa region of El Salvador. METHODS: A cross-sectional analytical epidemiological study was carried out using active screening for chronic kidney disease and associated risk factors in individuals aged >18 years in the Bajo Lempa Region, a rural, coastal area in El Salvador. Door-to-door visits and clinical examinations were conducted. Epidemiological and clinical data were collected including: family and personal clinical history of disease; biological, behavioral, social and environmental risk factors; physical measurements; urinalysis for markers of renal and vascular damage; and blood tests (serum creatinine, serum glucose, lipid profile). Glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula. Chronic kidney disease case confirmation was done three months later. Multiple logistic regression was used for data analysis. RESULTS: A total of 375 families and 775 individuals (343 men, 432 women) were studied-88.3% of the total resident population in the region. Elevated prevalence of risk factors was observed: diabetes mellitus, 10.3%; hypertension,16.9%; family history of chronic kidney disease, 21.6%; dyslipidemias, 63.1%; overweight, 34%; obesity, 22.4%; metabolic syndrome, 28.8%; use of non-steroidal anti-inflammatory drugs, 74.8%; infectious diseases, 86.9%; agricultural occupation, 40.6% (80.6% in men); and contact with agrochemicals, 50.3% (82.5% in men). Prevalence renal damage markers was 15.8% (greater in men): microalbuminuria 6.3%; proteinuria 5.7%; hematuria 3.5%; proteinuria-hematuria 0.3%. Proteinuria of <1 g/L predominated. Prevalence of chronic kidney disease was 17.9% (25.7% in men; 11.8% in women). Distribution by stages: stage 1, 4.6%; stage 2, 3.5%; stage 3, 6.2%; stage 4, 3.0%; stage 5, 0.6%. In patients with chronic kidney disease, most common was non-diabetic chronic kidney disease (86.3%), followed by chronic kidney disease associated with neither diabetes nor hypertension (54.7%). Prevalence of chronic renal failure was 9.8% (17% in men; 4.1% in women). Multiple logistic regression showed significant association with increasing age, male sex, hypertension and family history of chronic kidney disease. CONCLUSIONS: Elevated prevalence of chronic kidney disease, chronic renal failure and risk factors was found, compared to international reports. Most common was chronic kidney disease of unknown cause, associated with neither diabetes nor hypertension. Associations were found with age, male sex, hypertension and family history of chronic kidney disease, with decline in kidney function beginning at early ages. Male farmers have a dual burden of non traditional (occupational, toxic environmental) and traditional (vascular) risk factors that could act in synergy, contributing to kidney damage.

Validating physician-certified verbal autopsy and probabilistic modeling (InterVA) approaches to verbal autopsy interpretation using hospital causes of adult deaths

BackgroundThe most common method for determining cause of death is certification by physicians based either on available medical records, or where such data are not available, through verbal autopsy (VA). The physician-certification approach is costly and inconvenient; however, recent work shows the potential of a computer-based probabilistic model (InterVA) to interpret verbal autopsy data in a more convenient, consistent, and rapid way. In this study we validate separately both physician-certified verbal autopsy (PCVA) and the InterVA probabilistic model against hospital cause of death (HCOD) in adults dying in a district hospital on the coast of Kenya.MethodsBetween March 2007 and June 2010, VA interviews were conducted for 145 adult deaths that occurred at Kilifi District Hospital. The VA data were reviewed by a physician and the cause of death established. A range of indicators (including age, gender, physical signs and symptoms, pregnancy status, medical history, and the circumstances of death) from the VA forms were included in the InterVA for interpretation. Cause-specific mortality fractions (CSMF), Cohen's kappa (κ) statistic, receiver operating characteristic (ROC) curves, sensitivity, specificity, and positive predictive values were applied to compare agreement between PCVA, InterVA, and HCOD.ResultsHCOD, InterVA, and PCVA yielded the same top five underlying causes of adult deaths. The InterVA overestimated tuberculosis as a cause of death compared to the HCOD. On the other hand, PCVA overestimated diabetes. Overall, CSMF for the five major cause groups by the InterVA, PCVA, and HCOD were 70%, 65%, and 60%, respectively. PCVA versus HCOD yielded a higher kappa value (κ = 0.52, 95% confidence interval [CI]: 0.48, 0.54) than the InterVA versus HCOD which yielded a kappa (κ) value of 0.32 (95% CI: 0.30, 0.38). Overall, (κ) agreement across the three methods was 0.41 (95% CI: 0.37, 0.48). The areas under the ROC curves were 0.82 for InterVA and 0.88 for PCVA. The observed sensitivities and specificities across the five major causes of death varied from 43% to 100% and 87% to 99%, respectively, for the InterVA/PCVA against the HCOD.ConclusionBoth the InterVA and PCVA compared well with the HCOD at a population level and determined the top five underlying causes of death in the rural community of Kilifi. We hope that our study, albeit small, provides new and useful data that will stimulate further definitive work on methods of interpreting VA data.

Mortality meetings: ethical considerations and adherence to evidence-based practice from 6 years of experience in a mixed cardiac department

Most patients die unexpectedly in cardiac departments. We analyzed the ethical issues raised by poor outcomes and the leading causes of hospital deaths including organic causes of deaths, system failures, and questionable caregivers' attitudes. We analyzed reports from 99 mortality conferences in a mixed cardiac department (surgery and interventional cardiology) where 146 patients died from 2002 to 2008. Patients were referred for cardiac surgery (n=115), interventional cardiology (n=25), or medical therapy (n=11). Highly recommended class I interventions were performed in most patients (n=120, 82%). A history of renal failure (25%), peripheral artery disease (21%), diabetes (18%), cancer (16%), or respiratory disease (16%) was frequently noticed. The areas most frequently identified as potentially problematic were preoperative strategy (58%), surgical technique (50%), monitoring (47%), reactivity (43%), drug prescription (32%), difficulties or delays in diagnosis (27%), and transfer (21%). At least one transgression from routine medical practice was identified in 66 (45%) patients, and a causal relationship between this transgression and the patient's death was suggested in 33 cases (23%). Serious errors were identified for five patients (3%), with a suggested causal relationship to death in two cases. Ethical discussions focused on alternatives in treatment (73%), good medical practice (44%), secondary recommendations (18%), information (12%), consent (12%), non-malfeasance (7%), and equity (6%). Mortality conferences provide an opportunity to identify many system failures. Poor outcome is multifactorial. Technical and ethical aspects should be considered for quality care improvement.