Hospital Mortality Odds Ratio Research Articles

Preoperative Intra-Aortic Balloon Pump in Patients Undergoing Coronary Bypass Surgery: A Systematic Review and Meta-Analysis

To assess the effectiveness of preoperative intra-aortic balloon pump (IABP) placement in high-risk patients undergoing coronary bypass surgery (CABG). The primary outcome was hospital mortality and secondary outcomes were IABP-related complications (bleeding, leg ischemia, aortic dissection). MEDLINE, EMBASE, Cochrane registry of Controlled Trials, and reference lists of relevant articles were searched. We included randomized controlled trials (RCTs), and cohort studies that fulfilled our a priori inclusion criteria. Eligibility decisions, relevance, study validity, and data extraction were performed in duplicate using pre-specified criteria. Meta-analysis was conducted using a random effects model. Ten publications fulfilled our eligibility criteria, of which four were RCTs and six were cohort studies with controls. There were statistical as well as clinical heterogeneity among included studies. A total of 1034 patients received preoperative IABP and 1329 did not receive preoperative IABP. The pooled odds ratio (OR) for hospital mortality in patients treated with preoperative IABP was 0.41 (95% CI, 0.21-0.82, p = 0.01). The number needed to treat was 17. The pooled OR for hospital mortality from randomized trials was 0.18 (95% CI, 0.06-0.57, p = 0.003) and from cohort studies was 0.54 (95% CI, 0.24-1.2, p = 0.13). Overall, 3.7% (13 of 349) of patients who received preoperative IABP developed either limb ischemia or haematoma at the IABP insertion site, and most of these complications improved after discontinuation of IABP. Evidence from this meta-analysis support the use of preoperative IABP in high-risk patients to reduce hospital mortality.

Non-neurologic organ dysfunction in severe traumatic brain injury*

To describe the incidence of non-neurologic organ dysfunction and its association with outcome in patients with severe traumatic brain injury admitted to intensive care. Observational cohort study. Foothills Medical Centre, which is the only neurosurgical service in southern Alberta (population approximately 1.3 million). Patients were 209 consecutive patients with severe traumatic brain injury. None. Non-neurologic organ dysfunction was measured by the maximum modified multiple organ dysfunction score. Organ system failure was defined as a component score of >/=3 on any day during the patient's intensive care unit stay. One hundred and eighty-five patients (89%) developed dysfunction of at least one non-neurologic organ system. Ninety-six organ system failures were identified in 74 patients (35%). Respiratory failure was the most common non-neurologic organ system failure, occurring in 23% of patients, whereas cardiovascular failure occurred in 18%. Eight patients (4%) had failure of the coagulation system. One patient had renal failure, whereas no patient developed hepatic failure. In a multivariate model, non-neurologic organ dysfunction was independently associated with hospital mortality (odds ratio for hospital mortality, 1.63; 95% confidence interval, 1.34, 1.98 for one maximum modified multiple organ dysfunction score point). Non-neurologic organ dysfunction was also independently associated with dichotomized Glasgow Outcome Score, as a measure of neurologic outcome (odds ratio for unfavorable neurologic outcome, 1.53; 95% confidence interval, 1.22, 1.98 for one maximum modified multiple organ dysfunction score point). The timing of the organ dysfunction did not appear to be important in the prediction of outcome. Non-neurologic organ dysfunction is common in patients with severe traumatic brain injury and is independently associated with worse outcome.

Noninvasive positive pressure ventilation in the setting of severe, acute exacerbations of chronic obstructive pulmonary disease: more effective and less expensive.

The use of noninvasive ventilation for patients with acute respiratory failure has become increasingly popular over the last decade. Although the literature provides good evidence for the effectiveness of noninvasive ventilation in addition to standard therapy compared with standard therapy alone in patients with chronic obstructive pulmonary disease (avoiding intubation and improving hospital mortality), the associated costs have not been rigorously measured. Adding noninvasive positive pressure ventilation (NPPV) to standard therapy in the setting of a severe, acute exacerbation of chronic obstructive pulmonary disease (COPD) in patients with respiratory acidosis who are at high risk of requiring endotracheal intubation is both more effective and less expensive. Economic evaluation based on theoretical model. This analysis base case was modeled for a tertiary care, teaching hospital. Carefully selected patients with severe exacerbations of COPD. The two alternative therapies compared were standard therapy (oxygen, bronchodilators, steroids, and antibiotics) and standard therapy plus NPPV. As the hypothesis was dominance, the main outcomes modeled and calculated were costs, mortality rate, and rates of intubation between the two interventions. To determine clinical effectiveness, we used a meta-analysis of randomized trials evaluating the impact of NPPV on hospital survival. A decision tree was constructed and probabilities were applied at each chance node using research evidence and a comprehensive regional database. To provide data for this economic evaluation, MEDLINE literature searches were conducted. Bibliographies of relevant articles were reviewed, as were personal files. To estimate the costs of the alternative therapeutic approaches, eight types of hospitalization days were costed using the London Health Sciences Center costing data. Sensitivity analyses were performed, varying all assumptions made. The meta-analysis yielded an odds ratio for hospital mortality in the NPPV arm, compared with standard therapy, of 0.22 (95% confidence interval, 0.10-0.66). By using baseline case assumptions, we found a cost savings of $3,244 (1996, Canadian), per patient admission, if NPPV were adopted in favor of standard therapy. These findings present a scenario of clear dominance for treatment with NPPV. Sensitivity analyses did not alter the results appreciably. We conclude that from a hospital's perspective, NPPV and standard therapy for carefully selected patients with acute, severe exacerbations of COPD are more effective and less expensive than standard therapy alone.