Higher Frequency Of Death Research Articles

Association of Time to Treatment With Short-term Outcomes for Pediatric Patients With Refractory Convulsive Status Epilepticus

Treatment delay for seizures can lead to longer seizure duration. Whether treatment delay is associated with major adverse outcomes, such as death, remains unknown. To evaluate whether untimely first-line benzodiazepine treatment is associated with unfavorable short-term outcomes. This multicenter, observational, prospective cohort study included 218 pediatric patients admitted between June 1, 2011, and July 7, 2016, into the 11 tertiary hospitals in the United States within the Pediatric Status Epilepticus Research Group. Patients, ranging in age from 1 month to 21 years, with refractory convulsive status epilepticus (RCSE) that did not stop after the administration of at least 2 antiseizure medications were included. Patients were divided into 2 cohorts: those who received the first-line benzodiazepine treatment in less than 10 minutes and those who received it 10 or more minutes after seizure onset (untimely). Data were collected and analyzed from June 1, 2011, to July 7, 2016. The primary outcome was death during the related hospital admission. The secondary outcome was the need for continuous infusion for seizure termination. Multivariate analysis of mortality controlled for structural cause, febrile RCSE, age, and previous neurological history (including previous RCSE events). Use of continuous infusions was additionally adjusted for generalized RCSE, continuous RCSE, and 5 or more administrations of antiseizure medication. A total of 218 patients were included, among whom 116 (53.2%) were male and the median (interquartile range) age was 4.0 (1.2-9.6) years. The RCSE started in the prehospital setting for 139 patients (63.8%). Seventy-four patients (33.9%) received their first-line benzodiazepine treatment in less than 10 minutes, and 144 (66.1%) received untimely first-line benzodiazepine treatment. Multivariate analysis showed that patients who received untimely first-line benzodiazepine treatment had higher odds of death (adjusted odds ratio [AOR], 11.0; 95% CI, 1.43 to ∞; P = .02), had greater odds of receiving continuous infusion (AOR, 1.8; 95% CI, 1.01-3.36; P = .047), had longer convulsive seizure duration (AOR, 2.6; 95% CI, 1.38-4.88; P = .003), and had more frequent hypotension (AOR 2.3; 95% CI, 1.16-4.63; P = .02). In addition, the timing of the first-line benzodiazepine treatment was correlated with the timing of the second-line (95% CI, 0.64-0.95; P < .001) and third-line antiseizure medications (95% CI, 0.25-0.78; P < .001). Among pediatric patients with RCSE, an untimely first-line benzodiazepine treatment is independently associated with a higher frequency of death, use of continuous infusions, longer convulsion duration, and more frequent hypotension. Results of this study raise the question as to whether poor outcomes could, in part, be prevented by earlier administration of treatment.

The Restriction of Hours of Sales and Liquors: Lima 2010-17: Traffic Accidents (TA) and other Violent Deaths

Objective: Determine the relationship between the hours of sale of spirits Safe Time and those killed by traffic accidents (TA). Material and methods: descriptive research based on the monthly report made by the Metropolitan Municipality of Lima (LM), from the database of the Institute of Legal Medicine registered from 2011 to 2017, with a unit and bivariate analysis characterizing TA, deceased and its relationship with the of occurrence, day of the week, sex and age, alcohol consumption and data from the National Police of Peru, on frequency of AT and age and sex of deceased. Results: It is evident that there is a relationship between the variables, considering also that the growth of the vehicle fleet is parallel to the TA. Thus, the department of Lima has a frequency of cases and deaths lower than expected, showing that it is necessary to measure the occurrence by districts. 67% between 26 to 60 years and in the rest of the country 57%, with fewer young men dying. Temporary deaths decreased every day of the week and hours at dawn. The highest frequency of deaths is related to the number of hours spent selling liquor. Conclusions: The decrease in deaths due to AT in LM is lower than in other countries, possibly due to the lack of commitment of some of the 43 municipalities; however, the change in age and sex after the intervention is like that in Cali. The safe time has evidence for its application throughout the country.

Clinical and epidemiological profile of patients with early stage mycosis fungoides

Background:Mycosis fungoides is the most common form of primary cutaneous lymphoma, with an indolent, slowly progressive course and 88% five-year survival rate. The diagnosis is challenging, especially in the early stages, and usually relies on a good clinical-histopathological correlation. Objective:The aim was to establish the clinical and epidemiological profile of patients with early-stage mycosis fungoides. Methods:This was a retrospective cross-sectional observational study with an exploratory analysis. Outcome variables were disease progression and mycosis fungoides-related death. Results:One hundred and two patients were included. The majority were white males, with a mean age of 55.6 years. Mean time from onset of lesions to diagnosis was 51.08 months. The majority of patients were classified as IB stage according to TNMB. Mean follow-up time was 7.85 years. Disease progression was seen in 29.4% of the patients. Death related to the disease occurred in 7.9% of patients. Plaque lesions, involvement of more than 10% of the body surface, altered lactate dehydrogenase and beta-2-microglobulin, and stage IB were significantly associated with disease progression, and altered lactate dehydrogenase and beta-2-microglobulin also correlated with higher frequency of deaths. Study limitations:Small sample and retrospective design. Conclusions:The clinical and epidemiological profile of patients with early-stage mycosis fungoides in our sample corroborates reports in the literature. Diagnostic delay in our series is also consistent with previous findings, but the rate of disease progression, despite treatment, was higher than reported in the literature.

Chromosomal disorders: estimating baseline birth prevalence and pregnancy outcomes worldwide

Chromosomal disorders, of which Down syndrome is the most common, can cause multi-domain disability. In addition, compared to the general population, there is a higher frequency of death before the age of five. In many settings, large gaps in data availability have hampered policy-making, programme priorities and resource allocation for these important conditions. We have developed methods, which overcome this lack of data and allow estimation of the burden of affected pregnancies and their outcomes in different settings worldwide. For example, the methods include a simple equation relating the percentage of mothers 35 and over to Down syndrome birth prevalence. The results obtained provide a starting point for consideration of services that can be implemented for the care and prevention of these disorders.

Hyperleucocytosis in paediatric acute myeloid leukaemia - the challenge of white blood cell counts above 200×109 /l. The NOPHO experience 1984-2014.

Hyperleucocytosis in paediatric acute myeloid leukaemia (AML) is associated with increased morbidity and mortality. We studied hyperleucocytosis in 890 patients with AML aged 0-18years registered in the Nordic Society of Paediatric Haematology and Oncology (NOPHO) registry, with special focus on very high white blood cell counts (WBC >200×10/l). Eighty-six patients (10%) had WBC 100-199×109 /l and 57 (6%) had WBC ≥200×109 /l. Patients with WBC ≥200×109 /l had a high frequency of t(9;11) and a paucity of trisomy 8. Due to the high frequency of deaths within the first 2weeks (30% vs. 1% for all others), overall survival in this group was inferior to patients with WBC <200×109 /l (39% vs. 61%). Main cause of early death was intracranial haemorrhage and leucostasis. Twenty-six per cent of these patients never started antileukaemic protocol therapy. Leukapheresis or exchange transfusion was used in 24% of patients with hyperleucocytosis without impact on survival. Patients with hyperleucocytosis surviving the first week had identical survival as patients with lower WBC. We conclude that death within the first days after diagnosis is the major challenge in patients with high WBC and advocate rapid initiation of intensive chemotherapy.

Vigilância do óbito fetal: estudo das principais causas

The stillbirth is a major cause of perinatal mortality, and understanding its causes is essential to improve prenatal care provided to pregnant women. In this sense, the study characterized the cases of antepartum intrauterine fetal death recorded in a maternity ward in the North of Minas Gerais between January 2010 and December 2012. Medical records obtained were evaluated by the Child Mortality Committee of Motherhood. They were included in the sample 26 records of pregnant women with fetal death diagnosis occurred before the onset of labor, gestational age less than 20 weeks and birth weight or greater than 500g. Data were collected using a structured questionnaire and evaluated by descriptive statistics. Most of the women were between 18 and 29 years and had a pregnancy to term. It was observed that 69% of cases of death had no associated risk factor, which is a higher rate to those presented in the medical literature. In cases with identifiable causes, attributed to 7.7% of cases the specific hypertensive disorders of pregnancy, 3.8% diabetes mellitus, 3.8% to urinary tract infection, 3.8% to 11.5 and polyhydramnios 11,5% multiple complications. The high frequency of deaths without risk factors indicates that poor quality of information on perinatal death, especially fetal death.

Epidemiology of deaths due to traffic accidents in Kermanshah province (2012)

Background : The increasing trend of traffic accidents is one of the most serious problems of public health. The aim of this paper was to investigate the fatal traffic accidents in Kermanshah province. Method: All research data required were obtained from Legal Medicine Organization and analyzed by Stata-11 software. Traffic statistics available on the Road Maintenance and Transportation Organization website were used to study the death rate per month and day according to traffic level on suburban highways. Results: The incidence rate of age-standardized deaths due to road traffic accidents was 26.1per 100,000 people, and the mean age of the dead was 39.98±21.60 years. The mortality rate was higher in men, those more than 40 years old, married, illiterate and self-employed. Considering the traffic rate on suburban roads, the highest death rate occurred in the warmest months of the year during the day. Furthermore, most deaths were due to collisions and the highest frequency of death was reported for the car occupants. In most cases, head injuries and head traumas were the final cause of death. A significant correlation was reported between the type of vehicle and the cause of death and how the accident occurred (P<0.05). Conclusion: The mortality rate due to traffic accidents in Kermanshah province is high. Surveillance over the suburban roads in hot seasons and male drivers is of particular importance.

Patterns of Mechanical Inefficiency in Pediatric Dilated Cardiomyopathy and Their Relation to Left Ventricular Function and Clinical Outcomes

Pediatric dilated cardiomyopathy (DCM) is associated with death or transplantation and is typically considered a homogeneous process affecting global left ventricular (LV) function. However, assessment of regional abnormalities that contribute to pumping inefficiencies is lacking. The aim of this study was to define regional strain patterns of mechanical inefficiency in the broader context of LV discoordination (dysfunction and timing abnormalities) and to evaluate their associations with LV function and clinical outcomes. Multiplanar apical LV echocardiographic images from patients with pediatric DCM (n=56) and control subjects (n=20) were analyzed by two-dimensional longitudinal speckle-tracking strain analysis to identify segmental strain patterns and global contraction groups. Clinical outcome (death or transplantation vs transplantation-free survival) and echocardiographic data were evaluated. Outcome groups were compared using the Fisher exact test, the χ(2) test, or analysis of variance (with P values≤.05 considered to indicate statistical significance). Of 56 patients with DCM, 29 (52%) progressed to death or transplantation. Five segmental strain patterns were observed that were used to define seven contraction groups by regional contractility and/or timing discoordination. The group(s) with the most discoordination had the most LV dysfunction (P=.0004) and a trend toward the highest frequency of death or transplantation (P=.069). Interreader reproducibility of segmental strain patterns agreed in 165 or 180 (92%) segments tested (κ=0.90). Control subjects had normal strain patterns. A heterogeneous mixture of abnormalities in the regional wall mechanics that lead to inefficient pump mechanics through functional and timing abnormalities were seen in this cohort and were categorized into natural subgroups. More severe LV discoordination was associated with increased LV dysfunction and a trend toward death or transplantation.

Characteristics and Outcomes of Fungal Peritonitis in a Modern North American Cohort

Peritonitis remains a common complication of peritoneal dialysis (PD). Although representing only 1 - 12% of overall peritonitis in dialysis patients, fungal peritonitis (FP) is associated with serious complications, including technique failure and death. Only scarce data have been published regarding FP outcomes in modern cohorts in North America. In this study we evaluated the rates, characteristics and outcomes of FP in a major North American PD center. We conducted a retrospective cohort study including all fungal peritonitis episodes among peritoneal dialysis patients followed in a large PD center between January 2000 and February 2013. Our pre-specified endpoints included rates of FP, characteristics, outcomes and determinants of death. Thirty-six episodes of FP were identified during the follow-up period (one episode per 671 patient-months), representing 4.5% of the total peritonitis events. Patients' mean age and peritoneal dialysis vintage were 61.3 ± 15.5 and 2.9 (1.5 - 4.8) years, respectively. Of the 36 episodes of FP, seven (19%) resulted in death and 17 (47%) led to technique failure with permanent transfer to hemodialysis. Surprisingly, PD was eventually resumed in 33% of cases with a median delay of 15 weeks (interquartile range 8 - 23) between FP and catheter reinsertion. In a univariable analysis, a higher Charlson comorbidity index (Odds ratio [OR] 3.25 per unit increase, 95% confidence interval [CI] 1.23 - 8.58) and PD fluid white blood cell (WBC) count greater than 3,000/mm(3) at presentation (OR 6.56, 95% CI 1.05 - 40.95) predicted death. While fungal peritonitis is still associated with a high frequency of death and technique failure, one third of our patients eventually returned to PD. Patients with a high burden of comorbidities appear at higher risk of death. We postulate that the high mortality associated with FP is partially related to the severity of comorbidity among patients with FP, rather than the infection per se. Importantly, PD can be resumed in a significant proportion of cases.

Intensive Care Unit Admission in Children With Malignant or Nonmalignant Disease

To investigate pediatric intensive care unit (PICU) admission in children with malignant and nonmalignant diseases who developed life-threatening complications. Between 1999 and 2010, of the 1278 eligible pediatric patients treated for a malignant or nonmalignant disease, 54 were admitted to the PICU for respiratory distress (40.7%), neurological events (33.3%), severe sepsis (14.8%), and organ failure (11.2%). Rate of PICU admission was 4.2%, with a 2-year cumulative incidence of 4.5%. Risk factors associated with higher cumulative incidence of PICU admission were older age at study entry (P=0.003), nonmalignant underlying disease (P=0.015), and hematopoietic stem cell transplantation (P<0.001). Patients with leukemia/lymphoma were more likely to be admitted to the PICU compared with patients with solid tumors (P<0.001). Patients admitted because of organ failure had the highest frequency of death within 90 days. Factors significantly associated with survival at 90 days from PICU admission included: no mechanical ventilation (P<0.001), nonmalignant underlying disease (P=0.030), and year of PICU admission after 2005 (P=0.038). Nonmalignant disease and use of alternative hematopoietic stem cell transplantation were associated with higher risk of PICU admission. Close cooperation between hematologists and intensivists and definition of criteria for PICU admission and discharge contributed to increase in survival of these patients.

Avaliação das alterações odontológicas em sincrânios de Cerdocyon thous oriundos de atropelamentos na rodovia ES-060, Espírito Santo

Os cachorros-do-mato (Cerdocyon thous Linnaeus, 1766) são animais amplamente encontrados em países da América do Sul. Apesar de não ser uma espécie ameaçada de extinção, é possível que muitas populações sofram impactos decorrentes de atropelamentos de indivíduos nas rodovias do país, pois, trata-se de uma das espécies de carnívoros com elevada ocorrência de mortes deste tipo. Foram avaliados 32 sincrânios de C. thous, oriundos de vida livre, armazenados na coleção osteológica do Laboratório de Anatomia Veterinária da Universidade Vila Velha (Vila Velha/ES), a fim de diagnosticar doenças que acometeram estes indivíduos enquanto vivos. As lesões macroscópicas identificadas foram: apinhamento dentário, ausência dentária, cálculo dentário, dentina terciária, desgaste, escurecimento dentário, exposição de polpa, fenestração óssea, fratura dentária, fratura de esmalte, giroversão, pigmentação e reabsorção da crista alveolar. Os achados mais comumente observados foram: ausência dentária, desgaste dentário e fratura dentária. Ausências dentárias anteriores à morte, alterações ósseas, cálculos dentários, apinhamento e giroversão aparentemente não causaram quaisquer prejuízos aos animais enquanto vivos.

Management of elderly patients with acute promyelocytic leukemia: progress and problems

Despite substantial progress in the management and outcome of acute promyelocytic leukemia (APL) during the last decades, older age remains a prominent negative prognostic factor. The improvement of long-term stabilization and cure of older APL patients is therefore a particular challenge. Data of unselected population-based studies suggest a high rate of exclusion from clinical trials in older age. The comparison of registry and study data indicates that study patients represent a positive selection. Older APL patients seem as sensitive to therapy as younger patients. With conventional therapy, based on all-trans retinoic acid (ATRA) and chemotherapy, over 50 % of older APL patients can probably be cured. Special problems of advanced age are the high rate of early death before or during induction therapy and the high frequency of death in remission with negative influence on the outcome. Both may be related in part to a higher vulnerability against the common treatment with ATRA and chemotherapy. Alternative less toxic approaches including arsenic trioxide (ATO) with or without ATRA and combinations with gemtuzumab ozogamicin or with reduced chemotherapy can induce long-lasting remission in all stages of APL. Considering the high curative potential and the excellent tolerance of ATO in newly diagnosed and relapsed APL, older patients are probably a particular target group for a chemotherapy-free approach with ATO.

Increasing crude and adjusted mortality rates for colorectal cancer in a developing South American country

Colorectal cancer (CRC) is a major cause of cancer death worldwide. We examined temporal trends in death rates from colorectal cancer in Chile from 1983 to 2008. We analysed the mortality database in Chile from 1983 to 2008. Cases were selected using ICD-9/10 codes. We calculated mortality rates per 100,000 inhabitants according to sex, age group and type of cancer - colon (CC) or rectal (RC). The rates were adjusted by a direct method using the WHO-2000 standard population. Time trends were assessed with Prais-Winsten regression models. There were 26,250 deaths from CRC (75.7% for CC). There was a higher frequency of deaths from CC (57.6%) in women than in men, who had a higher frequency of deaths from RC (51.3%). The crude CC mortality rate increased by 116% (from 3.6 to 7.8), while the overall RC rate increased by 71% (from 1.4 to 2.4). After adjusting for age, a significant increase in mortality rate was found for CC (coefficient 0.09, 95% CI 0.08-0.11, P < 0.001) and RC (coefficient 0.02, 95% CI 0.009-0.04, P = 0.002) in men. In women, this increase was significant for CC (coefficient 0.03, 95% CI 0.005-0.05; P = 0.02), but not for RC (coefficient -0.007, 95% CI -0.02 to 0.005, P = 0.23). The crude mortality rate from CRC has doubled in Chile in this period. After adjustment of mortality rates, it appears that much of this increase is due to the aging population. However, part of this increase could be explained by other factors.

G to C Transition At Position −173 of MIF Gene Associates with Poor Survival in Acute Myeloid Leukemia Patients and After Allogeneic Stem Cell Transplantation (Allo-SCT)

Abstract▪2530▪This icon denotes a clinically relevant abstractMacrophage migration inhibitory factor (MIF) is a key mediator of the innate immune system by promoting pro-inflammatory functions, being involved in the pathogenesis of the sepsis, in inflammatory and autoimmune diseases, growth and cell differentiation, and in carcinogenesis. The recessive CC gene variant in -173G/C in the promoter region causes higher levels of MIF and it has been associated with sepsis, gastric cancer, and autoimmune diseases. We aimed to see whether this genetic variant influenced the clinical outcome of acute myeloid leukemia (AML) patients. Population study consisted of 277 AML patients from the Spanish cooperative CETLAM group. Median age of the patients was 45 (range, 15–74). According to MRC classification, 11% were of good risk, 70% of intermediate risk, and 11% of poor risk. For 8% of the patients MRC cytogenetical data was not available. Multivariate analysis for outcome was performed including age, MRC classification and leukocyte count. Results showed that recessive CC gene variant was associated with worse outcome than the other two genotypes (GG+GC). Thus, this gene variant was associated with lower overall survival (OS): 0% vs 28%, p<0.001, OR=5.19, p=0.002; and disease free survival (DFS): 0% vs 31%, p=0.003, OR=7.35, p=0.007 (Figure 1). Considering only patients with intermediate MRC, this recessive CC gene variant also retained its impact for OS (0% vs 27%, p=0.001; OR=5.96, p=0.003) and for DFS (0% vs 31%, p=0.005, OR=6.82, p=0.01). We restricted the analysis to patients who underwent allo-SCT, and this variant retained the worst prognostic value for OS (0% vs 54%, p=0.014, OR=10.89, p=0.037) and for DFS (0% vs 41%, p=0.027, OR=9.09, p= 0.05). Because this variant is associated with high expression of MIF, we analyzed MIF mRNA expression in healthy donors, in low and high risk myelodisplastic syndrome (MDS) patients, and in AML patients. Results showed a progressive increase of MIF expression from healthy donors to AML, presenting AML patients 31 fold higher MIF expression than donors (p<0.001). Furthermore, we analyzed the clinical impact of this recessive CC variant in MIF gene in a Spanish multicentre study of 490 adult donor-patient pairs who underwent HLA identical sibling allo-SCT. All patients were diagnosed with hematological malignancies. Median age was 45 (range, 16–69), 33% were in advanced phase of disease, and 38% received a reduced intensity conditioning regimen. This recessive CC gene variant when present in the patient was associated with higher frequency of death by sepsis or infection (83% of patients with this variant died of sepsis vs 17%, p=0.005). When the analysis was restricted to acute leukemia and MDS patients (N=234), this recessive CC gene variant was associated with higher transplant related mortality (73% vs 29%, p=0.02). Finally, we analyzed IFNγ production in peripheral blood of 180 blood donors after stimulation with cytomegalovirus (CMV) and phytohemagluttinin (PHA). Results showed that this variant (CC) was associated with higher IFNγ production after CMV exposure (p=0.003) and higher IFNγ production after PHA exposure (p=0.007). In conclusion, these results indicate the adverse prognostic impact of recessive CC gene variant in AML patients. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Postmortem findings of Victims of Sexual Assault: A Study of 15 Autopsies in the Niger Delta Region of Nigeria

To study the frequency, status of the victims and assailants as well as the pattern of death in sexually assaulted females. A eight year (1st January 1995 to 31st December 2002) autopsy study of sexual assault in the Niger Delta region of Nigeria. Coroner's autopsies performed by the authors at different parts of the Niger Delta region of Nigeria, where the circumstances of death and autopsy finding fit into sexual assault and/or complications were studied after being served with the Coroner's inquest forms by the Police. Reports and death certificates were returned to the coroner through the police. A total of 1,265 autopsies were performed by the authors during the period under review of which 15 cases were deaths from sexual assault constituting 1.2% of the total autopsies. The youngest was 7 years old while the oldest was 59 years old. The highest frequency of death n=4(26.7%) occurred in the age group 10-19 years. Unmarried females n=6(40.0%) were the most common victims. Militants n=7(46.7%) were the most common real/suspected assailants and Asphyxial death n=7(46.7%) was the most common pattern of death of which neck break was the foremost n=4(26.7%). Death from sexual assault on women is becoming a common event that is posing an undue social problem to the victims, relations and the government in the Niger Delta region of Nigeria. There should be a government intervention to arrest and prosecute the perpetrators of this crime. This will discourage other assailants from committing the crime and thereby reducing the frequency of death.

Native American New Mexicans Infected With H1N1 Admitted to the ICU in 2009 Experienced Higher Mortality Than Other Ethnicities

PURPOSE: In New Mexico, during the months of September-December 2009, there appeared to be a disproportionate amount of severe H1N1 infection and a higher frequency of death in Native Americans versus non-Hispanic Caucasian and Hispanics. This correlated with national and international trends that were demonstrated previously among Australian and Alaskan Native American populations1.

INFANT AND CHILD MORTALITY AMONG CATHOLICS AND LUTHERANS IN NINETEENTH CENTURY POZNAŃ

The purpose of this study was to show the differences in the mortality rates of children from Catholic and Lutheran families in 19th century Poznań, and to elucidate the causes of these differences. Data from Catholic and Lutheran parish death registers were used. The infant death rate (IDR), neonatal and postneonatal death rates and life table biometric functions were calculated and causes of deaths were characterized. The worst child mortality values (IDR=394.4; neonatal and postneonatal death rates, respectively, 117.1 and 277.4; e0=16.14 years; Crow's Index=2.47) were obtained for the poor Catholic Parish of St Margaret. The lowest infant and neonatal and postneonatal death rates were observed to have occurred in the Catholic Parish of St Maria Magdalena situated in the city's more affluent central area (mortality rates, respectively, 269.9, 93.1 and 176.9; e0=24.63 years; Crow's Index=0.96). The widest range of differences with regard to death rates was found for the Lutheran Parish of St Cross (the infant, neonatal and postneonatal death rates were, respectively, 293.1, 99.1 and 193.9; e0=28.03 years; Crow's Index=0.92). The St Cross Parish encompassed a fairly large area of the city characterized by varying ecological conditions. Among infants and young children from the three studied populations a high frequency of deaths due to infectious diseases, diarrhoeas, dysenteries and tuberculosis were observed. Differences in the mortality of children from Catholic and Lutheran families in 19th century Poznań resulted from ecological conditions, among which water played the most important role, rather than from religious differences.

Death Ideas, Suicidal Thoughts, and Plans Among Nursing Home Residents

Recent studies have shown that suicides are at least as frequent among Nursing Home (NH) residents as they are among older people in the general population. The objective of the present study was to evaluate the prevalence of death- and/or suicidal feelings, thoughts, and plans and any attempted suicides in a random, unselected sample (N=288) of individuals aged 65-years-and-over, living in NHs located in the Veneto Region (the Italian North-East). One hundred seventy-two participants were surveyed with a response rate of 59.7%. Five sample questions were asked to investigate the presence of death- and suicidal thoughts, plans and behaviors in different time periods. Among the NH residents, 30.8% admitted having had death or suicidal thoughts or plans during the month prior to the interview. The oldest-old residents (85+y) more frequently reported death-suicide ideation. This high frequency of death and/or suicidal feelings and thoughts among older NH residents should be carefully considered when planning and implementing health care programs in these facilities.

Frequency and clinical impact of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage

The authors sought to determine frequency, risk factors, and impact on outcome of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage (SAH). The authors prospectively studied 580 patients with SAH admitted to their center between July 1996 and May 2002. Delayed cerebral ischemia (DCI) from vasospasm was defined as 1) a new focal neurological deficit or decrease in level of consciousness, 2) a new infarct revealed by follow-up CT imaging, or both, after excluding causes other than vasospasm. Outcome at 3 months was assessed using the modified Rankin Scale. Delayed cerebral ischemia occurred in 121 (21%) of 580 patients. Of those with DCI, 36% (44 patients) experienced neurological deterioration without a corresponding infarct, 42% (51 patients) developed an infarct in conjunction with neurological deterioration, and 21% (26 patients) had a new infarct on CT without concurrent neurological deterioration. In a multivariate analysis, risk factors for asymptomatic DCI included coma on admission, placement of an external ventricular drain, and smaller volumes of SAH (all p < or = 0.03). Patients with asymptomatic DCI were less likely to be treated with vasopressor agents than those with symptomatic DCI (64 vs 86%, p = 0.01). After adjusting for clinical grade, age, and aneurysm size, the authors found that there was a higher frequency of death or moderate-to-severe disability at 3 months (modified Rankin Scale Score 4-6) in patients with asymptomatic DCI than in patients with symptomatic DCI (73 vs 40%, adjusted odds ratio 3.9, 95% confidence interval 1.3-12.0, p = 0.017). Approximately 20% of episodes of DCI after SAH are characterized by cerebral infarction in the absence of clinical symptoms. Asymptomatic DCI is particularly common in comatose patients and is associated with poor outcome. Strategies directed at diagnosing and preventing asymptomatic infarction from vasospasm in patients with poor-grade SAH are needed.

Tacrolimus/Methotrexate (MTX) Versus Cyclosprorine/MTX for Graft-Versus-Host Disease (GVHD) Prophylaxis in Patients with Severe Aplastic Anemia (SAA) Who Received Marrow Transplantation from Unrelated Donors: Results of a Matched Pair Analysis.

Acute and chronic GVHD contribute to much of the morbidity and mortality associated with unrelated bone marrow transplantation (UBMT). Effective prevention of these complications is crucial for the success of UBMT. Cyclosporine(CSA) was introduced for the prophylaxis of GVHD and has been shown to be effective; similar findings have been shown for tacrolimus. However, there are no comparative studies between tacrolimus/MTX and CSA/MTX in patients with SAA who undergo UBMT. We compared tacrolimus/MTX with CSA/MTX in patients with SAA who received UBMT using a matched-pair analysis. Patients with acquired SAA who received UBMT between July 1997 and December 2002 through the Japan Marrow Donor Program were eligible for analysis. Recipients of UBMT were divided into two cohorts for comparison: those who received tacrolimus/MTX and those who received CSA/MTX. Because our previous studies identified that recipient age and conditioning regimen are the most important variables associated with treatment failure, we selected pairs of patients treated with either tacrolimus/MTX or CSA/MTX by matching these variables. We were able to identify 47 pairs that could be matched exactly for the recipient age and conditioning regimens. There was an imbalance of HLA-A, -B, and -DRB1 antigen mismatches, with 18 mismatched pairs in the tacrolimus group and 7 in the CSA group (p=0.005). Other variables were comparable between the two groups. Engraftment took place in 46 patients (98%) in the tacrolimus group and 43 patients (92%) in the CSA group. The median time to neutrophil recovery was the same in the two groups (tacrolimus group: 18.0 days, CSA group: 17.5 days). The cumulative incidence of grade 2 to 4 acute GVHD was 28.9% in the tacrolimus group and 32.6% in the CSA group (p=0.56). The estimate of chronic GVHD occurrence was 13.3% for the tacrolimus group and 36.0% for the CSA group (p=0.10). 8 patients died of transplantation related toxicities in the tacrolimus group and 22 patients in the CSA group (p=0.002). There was a higher frequency of deaths from thrombomicroangiopathy in the CSA group than in the tacrolimus group (6 vs 0: p=0.03). The 4-year survival rate was 82% for patients in the tacrolimus group and 52% for patients in the CSA group (p=0.001). Although a disadvantage existed in terms of HLA disparity in the tacrolimus group, there was no difference in the incidence of acute and chronic GVHD between the two groups. The present study shows the superiority of tacrolimus/MTX over CSA/MTX in overall survival because of lower incidence of regimen-related toxic deaths.