Mortality In High-risk Group Research Articles

Interhospital transfer of pediatric neurosurgical patients.

OBJECTIVE The purpose of this study was to describe patterns of transfer, resource utilization, and clinical outcomes associated with the interhospital transfer of pediatric neurosurgical patients. METHODS All consecutive, prospectively collected requests for interhospital patient transfer to the pediatric neurosurgical service at Texas Children's Hospital were retrospectively analyzed from October 2013 to September 2014. Demographic patient information, resource utilization, and outcomes were recorded and compared across predefined strata (low [< 5%], moderate [5%-30%], and high [> 30%]) of predicted probability of mortality using the Pediatric Risk of Mortality score. RESULTS Requests for pediatric neurosurgical care comprised 400 (3.7%) of a total of 10,833 calls. Of 400 transfer admissions, 96.5%, 2.8%, and 0.8% were in the low, moderate, and high mortality risk groups, respectively. The median age was 54 months, and 45% were female. The median transit time was 125 minutes. The majority of transfers were after-hours (69.8%); nearly a third occurred during the weekend (32.3%). The median intensive care unit stay for 103 patients was 3 days (range 1-269 days). Median length of hospital stay was 2 days (range 1-269 days). Ninety patients (22.5%) were discharged from the emergency room after transfer. Seventy-seven patients (19.3%) required neurosurgical intervention after transfer, with the majority requiring a cranial procedure (66.2%); 87.3% of patients were discharged home. CONCLUSIONS This study highlights patient characteristics, resource utilization, and outcomes among pediatric neurosurgical patients. Opportunities for quality improvement were identified in diagnosing and managing isolated skull fractures and neck pain after trauma.

Identifying mortality risks in patients with opioid use disorder using brief screening assessment: Secondary mental health clinical records analysis

BackgroundRisk assessments are widely used, but their ability to predict outcomes in opioid use disorder (OUD) treatment remains unclear. Therefore, the aim was to investigate if addiction-specific brief risk screening is effective in identifying high mortality risk groups and if subsequent clinical actions following risk assessment impacts on mortality levels. MethodsOpioid use disorder (OUD) patients were identified in the South London and Maudsley Case Register. Deaths were identified through database linkage to the national mortality dataset. Cox and competing-risk regression were used to model associations between brief risk assessment domains and all-cause and overdose mortality in 4488 OUD patients, with up-to 6-year follow-up time where 227 deaths were registered. Data were stratified by admission to general mental health services. ResultsAll-cause mortality was significantly associated with unsafe injecting (HR 1.53, 95% CI 1.10–2.11) and clinically appraised likelihood of accidental overdose (HR 1.48, 95% CI 1.00–2.19). Overdose-mortality was significantly associated with unsafe injecting (SHR 2.52, 95% CI 1.11–5.70) and clinically appraised suicidality (SHR 2.89, 95% CI 1.38–6.03). Suicidality was associated with a twofold increase in mortality risk among OUD patients who were not admitted to mental health services within 2 months of their risk assessment (HR 2.03, 95% CI 1.67–3.24). ConclusionsDiagnosis-specific brief risk screening can identify OUD patient subgroups at increased risk of all-cause and overdose mortality. OUD patients, where suicidality is evident, who are not admitted into services are particularly vulnerable.

Early detection of oral cancers: current status and future prospects.

This article reviews the current literature and summarizes the latest developments in screening and early detection of oral cancers and looks at the future possibilities. Oral cancer is the best model for screening and prevention. The screening for oral cancer can be population based, opportunistic, or targeted. A long-term 15-year follow-up data of a randomized controlled study from a developing country setting indicated a sustained reduction in oral cancer mortality in high-risk individuals. Visual oral examination remains the mainstay in the screening. Several adjunctive techniques have been described to aid in the clinical examination of these lesions. A Cochrane review revealed that there is no evidence to recommend these adjuncts in clinically visible lesions. Salivary biomarkers seem to be promising as a tool for screening in the future. A Targeted Evidence Update for the US Preventive Services Task Force found no evidence on screening either in the general or selected high-risk population for oral cancer in the United States or on benefit of any adjunctive device affecting the performance of the screening examination. Current evidence shows that community based screening has a value in reducing the oral cancer mortality in high-risk group of population. But this evidence may not be universally applicable.

THE ROLE OF LACTATE CLEARANCE AS A PREDICTOR OF ORGAN DYSFUNCTION AND MORTALITY IN PATIENTS WITH SEVERE SEPSIS.

Background:Little is known about biomarkers which are used to classification of patients in order to diagnosis severity of sepsis among clients of emergency units. It seems that Lactate’s clearance can be used in this regard. This study aimed to determine the relationship between Lactate’s clearance, mortality and organ’s dysfunction with severe sepsis.Materials and methods:In this study 90 patients with severe sepsis, were visited and examined exactly. Para clinical tests, serum venous lactate, organ’s dysfunction scores, Acute Physiology and Chronic Health Evaluation II (APACHE-II) and Sequential Organ Failure Assessment (SOFA) were applied upon admission and 6 hours after it. According to clinical and laboratory criteria, dysfunction in main organs were examined and Lactate’s Clearance was accounted. All the patients were cured according to early goal-directed therapy protocol.Results:Among the participants 49 and 41 were male and female respectively. The mean age of the group was 49.37±1.41. The patients were classified to groups, less or more than 10% lactate’s clearance. Mortality rate of the patients was 18.9% (17 people). Mean age of the dead group was 49.71±13.33. The mean of dysfunctional organs which is assessed in terms of clinical, laboratory and SOFA criteria was significantly higher among the dead group than other. The Lactate’s clearance in the dead group was significantly lower than the other group (p<.05).Conclusion:It was concluded that patients with severe sepsis is a marker which is related to tissue hypoxia, also lactate’s clearance increasing is related to drastic reduction in biomarkers, mortality, and incidence of organ’s dysfunction. Overall, patients with lower lactate’s clearance are counted a high risk group for mortality and organs’ dysfunction.

Contemporary Echographic Characteristics in Diagnosis of Abnormal Placental Invasion

Objective:The main reason of placenta accrete nowadays is the increase in the number of repeated cesarean sections. The aim of our study was to assess the possibilities of ultrasound in placenta accreta diagnostics, to verify the echographic signs of PA in placenta praevia and to compare and analyse our results with Medline findings. Material: 162 pregnant women with non-migrating placenta praevia and at high risk of placenta accreta were examined in the sonographic department from 2006 to 2011. Several echographic markers, allowed to suspect invasion of placental tissue into the myometrium, were noted. When PA was suspected, MRI was performed and than morphologic examination verified our diagnosis. Results:Several echographicmarkers were revealed: lacunae, intensive collateral vasularization, bulging of placenta praevia and thinning of hypoechogenic zone of the myometrium and others.MR imaging was conducted in 9 cases of suspected placenta increta and was verified in 8 cases. C-section and hysterectomy were performed in 13 of 18 cases. No internal injuries of pelvic organs were revealed. Conclusion:Echopraphy is a valuable non-invasive method in the group with placenta praevia, it allows to verify the placental invasion into the myometrium and to exclude this pathology. Obtaining the results of these examination will be helpful in reducing the maternal morbidity and mortality in high-risk group.

Assessment of the value of acute physiology and chronic health evaluation II/IV prognostic models in elderly patients with sepsis

To assess and compare the performance of acute physiology and chronic health evaluation II/IV (APACHEII/IV) prognostic models in elderly patients with sepsis. A totally of 82 elderly patients with sepsis were retrospectively assessed in geriatric intensive care unit of General Hospital of Guangzhou Military Command between July 2011 and December 2011. APACHEII/IV scores were recorded within 24 hours after admission. The prognosis accuracy of both scores was assessed by area under the receiver operating characteristic curve (AUC). Based on the best cutoff value corresponding with the highest accuracy, patients were divided into the low and high risk of hospital mortality group. The predictive power of APACHEII/IV in total population and subgroups was compared. Patients with severe sepsis constituted 57.3% (47/82) of all patients with sepsis, and hospital mortality was 61.0% (50/82). APACHEII/IV scores of the patients were 17.5±6.3 and 55.8±22.3, and mortality rate was 22.5% (18.4/82) and 17.9% (14.6/82) respectively, with significant differences compared with actual mortality (both P<0.01). Both APACHEII/IV scores showed underestimation of hospital mortality in total population [standardized mortality ratio (SMR) with APACHEII=2.71, 95% confidence interval (95%CI) 1.92-3.48 and SMR with APACHEIV=3.33, 95%CI 2.79-4.37]. APACHEII (AUC 0.664±0.066), and APACHEIV presented poor estimation(AUC 0.716±0.056). There was no difference in accuracy in prognosticating hospital death prognosis between the two APACHE models (Z=0.991, P=0.322). Cutoff values of APACHEII/IV were >11 and >59. According to the value, patients were divided into the low and high risk hospital mortality group. There was no significant difference between actual mortality and prognostic mortality in APACHEII low risk group [0-11, 20.0% (3/15) vs. 1.6% (0.2/15), Z=-1.023, P=0.306]. The actual mortality in high risk group with APACHEII (>11) was significantly higher than prognostic mortality [70.1% (47/67) vs. 27.2% (18.2/67), t=6.989, P=0.000]. In the high risk group, APACHEII underestimated mortality (SMR=2.58, 95%CI 2.22-3.51). The actual mortality of the low (0-59) and high (>59) risk group of APACHEIV were higher than prognostic mortality [lower risk group: 44.0% (22/50) vs. 7.5% (3.8/50), Z=-2.235, P=0.025; higher risk group: 87.5% (28/32) vs. 34.1% (10.9/32), Z=-4.712, P=0.000]. Two groups of patients with APACHEIV score, the mortality was underestimated (low risk group: SMR=5.90, 95%CI 5.19-7.07; high risk group: SMR=2.56, 95%CI 2.07-3.24). Mortality rate of the low risk group with APACHEIV score was prone to be underestimated. The accuracy of APACHEII/IV are not ideal in foretelling mortality rate. Hospital mortality was underestimated with APACHEII in high risk patients, and it was underestimated with APACHEIV both in low and high risk patients, and it is even more prone to be underestimated in low risk group of APACHEIV. More accurate prognostic modality is in need in elderly patients with sepsis.

Plasma soluble vascular endothelial growth factor receptor-1 levels predict outcomes of pneumonia-related septic shock patients: a prospective observational study

IntroductionDespite recent advances in the management of septic shock, mortality rates are still unacceptably high. Early identification of the high-mortality risk group for early intervention remains an issue under exploration. Vascular endothelial growth factor (VEGF), soluble vascular endothelial growth factor receptor-1 (sVEGFR1) and urokinase plasminogen activator (uPA) have diverse effects in the pathogenesis of sepsis, which involve pro-inflammation, anti-inflammation, endothelial cell repair, and vascular permeability change. Their roles in predicting mortality and organ dysfunction remain to be clarified.MethodsPneumonia-related septic shock patients from medical intensive care units were enrolled for this prospective observational study. We also included 20 patients with pneumonia without organ dysfunction for comparison. Plasma levels of VEGF and sVEGFR1 and uPA activity within 24 hours of shock onset were measured. We compared plasma levels of these biomarkers with APACHE II scores between subgroups of patients, and evaluated their predictive value for 28-day mortality and organ dysfunction.ResultsA total of 101 patients, including 81 with pneumonia-related septic shock and 20 with pneumonia without organ dysfunction, were enrolled. Non-survivors of septic shock had significantly higher plasma sVEGFR1 levels (659.3 ± 1022.8 vs. 221.1 ± 268.9 pg/mL, respectively, P < 0.001) and uPA activity (47.2 ± 40.6 vs. 27.6 ± 17.2 units, respectively, P = 0.001) when compared with those of the survivors. Kaplan-Meier survival analysis demonstrated significantly higher mortality in patients with higher levels of sVEGFR1 (P < 0.001) and uPA activity (P = 0.031). In Cox regression analysis, plasma sVEGFR1 level was independently associated with, and best predicted, the 28-day mortality of septic shock (HR: 1.55, 95% CI: 1.05-2.30). Plasma sVEGFR1 level and uPA activity had good correlation with renal dysfunction, metabolic acidosis, and hematologic dysfunction; their levels significantly increased when the number of organ dysfunctions increased. In multivariate analysis, plasma sVEGFR1 level (HR: 2.82, 95% CI: 1.17-6.81) and uPA activity (HR: 2.75, 95% CI: 1.06-7.13) were independent predictors of the presence of concomitant multi-organ dysfunction. The predictive value of VEGF for mortality and organ dysfunction was limited in pneumonia-related septic shock patients.ConclusionsHigh plasma sVEGFR1 level in the early stage of pneumonia-related septic shock independently predicted 28-day mortality and multi-organ dysfunction.

Surgical specialty, surgical unit volume and mortality after oesophageal cancer surgery

Background Mortality after oesophagectomy is lower in high-volume than in low-volume surgical units. Case series from cardiothoracic surgeons report lower mortality rates than those from general surgeons. We therefore used a national data set to investigate the effects of surgical specialty and volume on mortality after oesophagectomy. Methods We analysed Hospital Episode Statistics for oesophagectomy for cancer ( n = 9034 cases), linked to data from death certificates, in England from 1998 to 2003. Results After adjustment for patients' age, sex and deprivation score, the odds ratio (OR) for death of general surgeons' (GS) patients, compared with cardiothoracic surgeons' (CTS) patients, was significantly high: 1.62 [95% CI 1.34–1.96] at 30 days and 1.38 [1.18–1.61] at 90 days. The odds ratio for high-volume GS patients was not significantly different from that for high-volume CTS patients. However, the odds ratio for low-volume GS patients compared with high-volume CTS patients was significantly high: 1.72 (1.40–2.11) at 30 days and 1.48 (1.26–1.74) at 90 days. Conclusion Patients treated by general surgeons in low-volume hospitals had worse mortality outcomes than those treated by general surgeons in high-volume hospitals or by cardiothoracic surgeons. This is important because a majority of patients who underwent oesophagectomy for cancer were in this high-mortality risk group.

Cytomegalovirus infection in renal transplant recipients is associated with impaired survival irrespective of expected mortality risk

Cytomegalovirus (CMV) infection and CMV disease are associated with increased mortality post-transplantation. We have thus retrospectively examined whether this association is found both in patients with high and low mortality risk. Between 1994 and 1997, 471 kidney transplant recipients were monitored once weekly for CMV pp65 antigenemia and CMV disease the first 100 d after tx and followed prospectively for median 66.6 months. Patients with nephrosclerosis, diabetic nephropathy and amyloidosis were selected as high mortality risk groups (HRG). Overall and cardiovascular mortality beyond 100 d in the low-risk group (n = 372) was 14% and 3.5%, and in the HRG (n = 99) 31% and 16%, respectively. The effects of CMV infection and disease, recipient age and gender, panel-reactive cytotoxic antibodies, acute rejection, HRG, and graft loss in the whole study period were tested on overall mortality beyond 100 d in multiple analysis. HRG was independently associated with overall mortality, RR = 2.03, and still both CMV infection and disease were significant risk factors for mortality, independent of HRG. The same analysis was repeated for HRG (n = 99). Even in this small group CMV disease was independently associated with overall mortality. These data indicate that CMV increase mortality independently both in patients with otherwise high- or low-risk for long-term mortality.

Characteristics and outcomes of interhospital transfers from level II to level I pediatric intensive care units*

To examine the characteristics, resource utilization, and outcomes for transfer admissions from level II to level I pediatric intensive care units (PICUs). Retrospective study. A 16-bed level I PICU in a tertiary care children's hospital. All transfer admissions from level II PICUs from January 1, 1997, through December 31, 2003; admissions for cardiac surgery were excluded. Patient characteristics, resource utilization, and outcomes were described and then compared across predefined strata (low <5%, moderate 5-30%, and high >30%) of predicted probability of death. None. Of 168 transfer admissions, 45%, 30%, and 25% were in the low, moderate, and high mortality risk groups, respectively. Length of stay at the referring PICU was shortest for the high-risk admissions. The most frequent diagnoses among all risk groups were respiratory failure (49%) and sepsis (14%). High-risk admissions were more likely to receive advanced therapies such as extracorporeal membrane oxygenation (41.5% high risk vs. 39.2% moderate vs. 6.6% low risk, p < .01) and renal replacement therapy (34.2% vs. 17.7% vs. 2.6%, p < .01). The high-risk admissions had longer PICU length of stay and the highest death rates (34% vs. 10% vs. 4%, p < .01) when compared with the moderate- and low-risk admissions, respectively. This study highlights significant differences in patient characteristics, resource utilization, and outcomes across mortality risk-stratified groups of critically ill and injured children transferred from level II to level I PICU care. Further studies are warranted to investigate decision making that prompt inter-PICU transfers.

Mortality among involuntarily admitted psychiatric patients: a survival analysis.

Only a few studies have examined mortality among committed psychiatric patients, and most of them suffer methodologically from selected populations, small samples, and inappropriate methods of data analysis. The purpose of this study was to determine whether involuntarily admitted psychiatric inpatients are a high risk group for mortality compared to a group of voluntarily admitted psychiatric inpatients. A retrospective cohort design was used with a maximum 9-year variable follow-up. A multistage sampling procedure was used to generate the sample, which consisted of 1064 involuntarily admitted patients and 1078 voluntarily admitted patients. During the follow-up period, 107 deaths were identified, 58 involuntary and 49 voluntary [chi 2 (1) = 0.9255, P = 0.336]. No significant differences were observed between the cohorts when survival analysis was used to examine survival experiences in the community. Compared to voluntary patients, involuntary patients do not appear to be at a higher risk for mortality. The high standard mortality ratios observed in both cohorts, however, are consistent with previous findings of high mortality among psychiatric patients in general, and support the need for intensive follow-up in the community following discharge from a psychiatric inpatient unit.

Defining a high mortality risk group among women with primary breast cancer

Increasing interest has been focused on DNA ploidy, hormone receptor status and tumour size as prognostic factors in node-negative breast cancer. We analysed these factors in patients operated on for primary invasive breast cancer between January 1981 and December 1987 in a prospective study of 248 women with no involved axillary nodes and 188 women with positive nodes followed until 15 April 1989. Oestrogen or progesterone receptor negativity, aneuploidy and tumour diameter exceeding 20 mm were studied as negative prognostic signs in life table analyses and Cox proportional hazards models of corrected survival. Corrected survival decreased with increasing number of negative signs. Three to four signs yielded a statistically significant, two- to threefold higher risk than the others. Survival estimates by life table analyses differed by 20% at 5 years. In the whole group, women with three or four negative factors had a relative risk of dying from their disease more than twice that of the others. Women with no involved nodes and with three or four negative factors had a risk of dying from breast cancer similar to that of node-positive women with fewer than three.

Prognosis of Severely Hypoxemic Patients Receiving Long-term Oxygen Therapy

Two hundred seventy severely hypoxemic (PaO2 < or = 55 mm Hg: mean +/- SD = 48 +/- 6) COPD patients (232 men) were selected for long-term oxygen therapy (LTOT). They were old (mean = 66 +/- 8 years), with severe airflow limitation (FEV1 = 30 +/- 12 percent of predicted), some CO2 retention (PaCO2 = 47 +/- 9 mm Hg), and compensated respiratory acidosis. Eighteen percent of the patients presented some complicating pleuropulmonary diseases (pleural thickening, sequelae of tuberculosis, etc). Overall survival proportion was poor: 70, 50, and 43 percent at 1, 2, and 3 years, respectively. The Cox model showed that the factors which independently reduced survival were lower CO transfer coefficient, smaller intrathoracic gas volume, more severe bronchial obstruction, the fact that oxygen administration did not increase PaO2 above 65 mm Hg, increasing age, and the presence of chest wall abnormalities. When the patients were divided into three groups according to mortality risk, the mean clinical and functional profile of the high-mortality risk group was consistent with the prevalence of emphysematous lesions. Moreover, the best survivors fitted better into the "bronchitic" type; they showed a higher mean PaCO2, suggesting that some degree of hypoventilation could delay muscular fatigue and improve survival. The difference in the proportion of "emphysematous" and "bronchitic" patients is a possible explanation for the variability of the mortality rate reported in literature.