Over-all Hospital Mortality Research Articles

Hospital mortality of blunt abdominal aortic injury (BAAI): a systematic review and meta-analysis

BackgroundStudies on the mortality of blunt abdominal aortic injury (BAAI) are rare and have yielded inconsistent results. In the present study, we aimed to quantitatively analyse the retrieved data to more accurately determine the hospital mortality of BAAI.MethodsThe Excerpta Medica Database, PubMed, Web of Science and Cochrane Library databases were searched to identify relevant publications without date restrictions. The overall hospital mortality (OHM) of BAAI patients was set as the primary outcome measure. English publications with data that met the selection criteria were included. The quality of all included studies was assessed by the Joanna Briggs Institute checklist and the American Agency for Health Care Quality and Research’s cross-sectional study quality evaluation items. After data extraction, a meta-analysis of the Freeman–Tukey double arcsine transformation of data was performed using the Metaprop command in Stata 16 software. Heterogeneity was assessed and reported as a percentage using the I2 index value and as a P value using the Cochrane Q test. Various methods were used to determine the sources of heterogeneity and to analyse the sensitivity of the computation model.ResultsOf the 2147 references screened, 5 studies that involved 1593 patients met the selection criteria and were included. There were no low-quality references after assessment. One study that only included 16 juvenile BAAI patients was excluded from the meta-analysis of the primary outcome measure due to high heterogeneity. Due to the low heterogeneity (I2 = 47.6%, P = 0.126 for Q test) that was observed after using the random effects model, the fixed model was subsequently used to pool the effect sizes of the remaining four studies, thus yielding an OHM of 28.8% [95% confidence interval (CI) 26.5–31.1%]. The stability of the model was verified by sensitivity analysis, and Egger’s test (P = 0.339) indicated a low level of publication bias. In addition, we also performed meta-analyses and obtained a pooled hospital mortality of operation (13.5%, 95% CI 8.0–20.0%), a pooled hospital mortality of non-operation (28.4%, 95% CI 25.9–31.0%), and a pooled rate of aortic rupture (12.2%, 95% CI 7.0–18.5%) of BAAI.ConclusionsThe present study indicated that BAAI has an OHM of 28.8%, indicating that this disease deserves more attention and research.

Outcome of very preterm infants delivered outside tertiary perinatal centers in China: a multi-center cohort study.

BackgroundTo describe the incidence of outborns among very preterm infants (VPIs, <32 weeks of gestation) in Chinese perinatal centers and to examine the association of outborn status with adverse outcomes.MethodsA cohort study enrolling all VPIs admitted to 18 perinatal centers in China from May 1st, 2015 to April 30th, 2018. Neonatal outcomes including rates of discharge against medical advice (DAMA), in-hospital mortality, overall mortality, severe intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL), sepsis, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC) and severe retinopathy of prematurity (ROP) were compared between outborn and inborn infants. A multivariate logistic regression model was used to estimate the independent association of outborn status with neonatal outcomes.ResultsAmong 12,014 VPIs, 1,991 (16.6%) infants were outborn. Outborn infants had lower Apgar scores and higher illness severity score on admission. Mothers of outborn infants were less likely to receive antenatal steroids, prenatal care and caesarean section. The incidence of DAMA (18.0% vs. 12.5%, P<0.001), overall mortality (19.9% vs. 15.8%, P<0.001) and severe brain injury (10.8% vs. 9.1%, P=0.024) of outborn infants were significantly higher than inborn infants. Outborn status was independently associated with increased risks of DAMA (aOR, 1.6; 95% CI: 1.4–1.8), overall-hospital mortality (aOR, 1.3; 95% CI: 1.1–1.5) and severe IVH/PVL (aOR, 1.2; 95% CI: 1.0–1.5).ConclusionsThe incidence of outborn VPIs was high in China. Outborn infants were more likely to be delivered in an uncontrolled situation and were at significantly higher risk of neonatal mortality and severe brain injury compared with inborn infants. Quality improvement efforts are needed to facilitate in-utero transfer of high-risk pregnancies to tertiary centers.

Surgical treatment of aortic dissection in 60 patients.

During the years 1964-82 a total of 60 patients underwent surgery for aortic dissection. Forty of them were males, with a mean age of 48.8 years (22 to 69) and 20 were females, with a mean age of 49.0 years (31 to 65). Forty-five patients were operated in an acute stage of aortic dissection and 15 patients in a chronic stage of this disease. The mortality rate of patients operated on for acute dissections was 51.1% and of patients with a chronic dissection 13.3%, the over-all hospital mortality rate being 41.7%. Cardiac and haemorrhagic complications were the commonest cause of death. Among the 35 operative survivors, there were seven late deaths (11.7%); 4 patients died of cardiovascular causes. The mean follow-up time was 6.1 years (2.7 to 13.4). Twenty-six long-term survivors were re-examined in the hospital.

Early and late results of aortoplasty with a left subclavian flap for coarctation of the aorta in infancy

Between February, 1969, and December, 1976, 45 consecutive infants younger than 6 months old underwent aortoplasty with a subclavian flap for the relief of coarctation of the aorta. All infants had persistence of the ductus arteriosus, and 58 percent had associated intracardiac anomalies. The over-all hospital mortality rate was 24 percent, nad no deaths occurred in infants with coarctation associated with patent ductus arteriosus only. All the deaths were in the group of patients under 2 months of age who had associated intracardiac defects. Follow-up over a 7 year period shows no clinical, hemodynamic, or angiographic evidence of recoarctation in any of the survivors.

Cardiopulmonary bypass in infants under four months of age

Thirty infants under 4 months of age who had cardiac surgery with standard cardiopulmonary bypass were reviewed in order to assess the results and applicability of cardiopulmonary bypass in these very young infants. Their major diagnoses were as follows (deaths in parentheses): transposition of the great vessels (TGA), 9 cases (5); aortic stenosis, 5 cases (2); double-outlet right ventricle, 3 cases (3); total anomalous pulmonary venous drainage, 3 cases (one); ventricular septal defect (VSD), 3 cases (0); tetralogy of Fallot, 2 cases (one); pulmonary stenosis, 2 cases (one); atrial septal defect (ASD) with primary pulmonary hypertension, one case (one), VSD and ASD, one case (0); and dextrocardia and common atrioventricular canal, one case (0). The over-all hospital mortality rate was 46.6 per cent (14 deaths). Two deaths in the transposition group resulted from attempts to explore or close a patent ductus arteriosus (PDA). These cases might have been better managed by surface cooling and limited cardiopulmonary bypass. One case of postoperative hemorrhage and cardiac tamponade might have been partially related to the use of cardiopulmonary bypass. Four deaths were due to uncorrectable lesions, two each were related to technical errors and improper choice of operations, and one each was related to irreversible preoperative deterioration, advanced primary pulmonary hypertension, and intractable arrhythmia. Thus the deaths directly related to the use of cardiopulmonary bypass are infrequent. Standard cardiopulmonary bypass, in conjunction with mild-to-moderate hypothermia, is applicable even in small infants and gives satisfactory exposure in most routine operations. No imposition of a significant time limit is advantageous on a surgical teaching service. The so-called Kyoto technique may afford better exposure in repairs of TGA and total anomalous pulmonary venous drainage and may also facilitate concomitant repair of associated extracardiac shunts.

Congenital aortic stenosis: Experience with 43 patients

Between September, 1967, and January, 1975, 43 patients underwent intracardiac repair for congenital aortic stenosis at the Buffalo Children's Hospital. The patients ranged in age from 2 days to 24 years, 6 of them being below one year of age. Valvular aortic stenosis was found in 21 cases (4 infants [Group I-A] and 17 older patients [Group I-B]), discrete subaortic membranous diaphragm in 11 (Group II); diffuse subvalvular muscular obstruction in 3 (Group III), supravalvular stenosis in 4 (Group IV), and multiple-level obstruction in 4 (2 infants [Group V-A] and 2 older patients [Group V-B]). Preoperatively, 58 per cent of the patients were symptomatic and 67 per cent had abnormal electrocardiograms. Associated congenital cardiac defects were found in 28 per cent of the cases. The over-all hospital mortality rate was 9 per cent (3 patients in Group I-A and one in Group V-A), with no deaths occurring in patients older than 3 months of age at the time of operation. Two late deaths occurred (Groups I-B and V-B). A complete heart block developed in one patient (Group III). The average intraoperative peak systolic left ventricular-aortic gradient decreased in all groups after repair but progressively increased in the late hemodynamic studies obtained in symptomatic patients. Six patients were reoperated upon for recurrent obstruction. Late results were evaluated on the basis of symptoms, electrocardiographic findings, valve function, and hemodynamic data. They showed excellent or satisfactory results in 59 per cent of the patients in Group I-B, in 45 per cent in Group II, in 66 per cent in Group III, and in 25 per cent in Group I-V. Results were fair or poor in Groups, I-A, V-A, and V-B. In children and adolescents, effective relief of the obstruction and of the symptoms can be obtained with minimal operative risk and minimal morbidity. In symptomatic infants, despite the high operative mortality rate, surgical intervention is indicated because of the poor prognosis.

Intracardiac repair of tetralogy of Fallot: Five-year review of 403 patients

During the 5 year period 1969 to 1973, 403 patients underwent intracardiac repair of tetralogy of Fallot. The patients ranged in age from 3 months to 41 years. Before operation, 86 per cent were cyanotic and 14 per cent were acyanotic. Forty-nine per cent had had at least one palliative procedure before total correction. Mahor associated anomalies included atrial septal defect in 24 per cent, patent ductus arteriosus in 2.5 per cent, coronary anomalies in 4 per cent, and left superior vena cava in 4.5 per cent. Seven per cent of the patients had pulmonary atresia. Pulmonary valvotomy was performed in 111 patients and complete excision of the pulmonary valve in 151. Patch graft reconstruction of the right ventricular outflow tract was performed in 57 per cent of the patients. In 11 patients a conduit was used to connect the right ventricle to the pulmonary artery. The over-all hospital mortality rate was 9.5 per cent, with the lowest rate (3.5 per cent) in the age group 6 to 10 years and the highest in the infant and adult groups (16.5 and 14.5 per cent, respectively). Three known late deaths occurred. A residual ventricular septal defect (VSD) was found in 3 per cent of the patients and an aneurysm of the pericardial patch in the right ventricular outflow tract developed in 7 patients. Intracardiac repair of the tetralogy of Fallot can be performed with reasonable risk and low morbidity. In our experience the optimal age for elective surgery is between 6 and 10 years.

Manual coronary endarterectomy: Clinical experience in 315 patients

From July, 1970, to December, 1973, manual endarterectomies were performed on 330 coronary arteries in 315 patients. The procedures were performed on either an elective or nonelective basis. The over-all hospital mortality rate was 1.27 per cent. Postoperative myocardial infarction occurred in 4.8 per cent of these patients. Postoperative catheterization was performed on 186 endarterectomized arteries; the average time of postoperative catheterization was 13.1 months after surgery. The over-all patency rate was 76.3 per cent. This experience suggests that endarterectomy is a safe and useful adjunct to saphenous vein bypass grafting procedures when used in a restricted fashion as detailed in this presentation.

The profile and surgical management of mitral stenosis in young patients

Mitral stenosis in the younger age groups in India is a unique condition characterized by a short duration and a rapid progression of symptoms. The majority of patients with this lesion develop pulmonary hypertension at an accelerated pace, and about one third have associated congestive failure and functional tricuspid regurgitation. Five hundred consecutive patients with this condition were treated surgically, 493 with a closed valvotomy. The over-all hospital mortality rate of 5.8 per cent was related to the severity of the preoperative functional status. In the last 150 cases, the figure dropped to 2 per cent. Assessment during the first 5 years after surgery revealed an excellent functional status in 85 per cent. The incidence of restenosis was only 3.4 per cent in the first 5 year period and 11 per cent in a subsequent 6 to 10 year follow-up period. Twenty of the 21 subjects with restenosis had an excellent functional result following closed transventricular valvotomy, and this status has been maintained during the follow-up period. To our knowledge, there are no other reports of long-term follow-up data in young patients undergoing surgical treatment for mitral stenosis.

Operative risk in coronary revascularization of patients with ventricular dysfunction

The initial sixteen month experience in patients undergoing simple revascularization of coronary arteries shows that 81 per cent of these patients were either Class III or Class IV on the basis of the New York Heart Association scale preoperatively; 57 per cent had some degree of ventricular dysfunction on left ventricular cineangiography, 50 per cent had elevated left ventricular graft dysfunction at rest, and 57 per cent had elevation post angiography. The hospital mortality was 1.6 per cent in the first 252 patients, and 2 per cent of the patients had a definite perioperative myocardial infarction and a further 6 per cent had a possible myocardial infarction. The total number of patients operated on between January 1971 and March 1974 now exceeds 1,000 with a total over-all hospital mortality of ten patients or 1 per cent. We believe that mortality and morbidity are essentially unchanged and that the flow study instances of myocardial infarction, pericarditis, and arrhythmia are representative of our over-all experience. Whenever significant valvular disease or ventricular aneurysm is associated with occlusive coronary artery disease, we believe that revascularization is necessary to achieve lower mortality and that ventricular dysfunction per se in patients undergoing revascularization is only a relative contraindication to revascularization.

Direct coronary artery surgery for coronary artery occlusive disease

Surgical revascularization of the myocardium for coronary artery occlusive disease has gained great impetus over the past five years with the advent of successful methods of direct surgical reconstruction of the coronary arteries. Seventy-five patients underwent direct coronary artery surgery for ischemic heart disease over the past two and a half years. The indication for coronary arterial revascularization was angina in forty-eight patients, congestive heart failure in twenty-four patients, and recurrent myocardial infarction in three patients. In this group of seventy-five patients there were 105 aortocoronary saphenous vein bypass grafts, five internal mammary-coronary artery bypass grafts, and thirty-five distal endarterectomies combined with aortocoronary vein bypass grafts. Direct coronary artery surgery was combined with resection of a left ventricular aneurysm in seven patients and with aortic valve replacement in three. A single coronary artery was reconstructed in twenty-seven cases and two of the three major coronary arteries were reconstructed in thirty-nine cases. There were nine hospital deaths, yielding an over-all hospital mortality of 12 per cent. Four of the nine deaths occurred in the seven patients undergoing both direct coronary artery reconstruction and left ventricular aneurysmectomy. All seven of these patients with severe angina and cardiac failure represented end-stage coronary artery disease. The operative mortality for patients with angina alone was 10 per cent, and for patients with cardiac failure and angina, 17 per cent. The results of direct coronary artery surgery have been most encouraging with sixty-six per cent of this group of seventy-five experiencing good or excellent results. Eighty per cent of patients with angina have had good or excellent results. Ten patients have been restudied by cardiac catheterization and coronary angiography at periods of six months to one year postoperatively. Clinical results have correlated well with the angiographic findings of the status of patency of the arterial reconstruction.

Hospital registration in patients with acute myocardial infarction

Registration of 278 patients admitted to the Royal Melbourne Hospital during a six-month period with definite or suspected acute myocardial infarction has been achieved. One hundred and ninety-nine patients were admitted to general ward beds, while 79 patients were admitted to a two-bed coronary care unit. For the purpose of analysis, registered patients were placed in one of the six diagnostic classes recommended by the World Health Organization. A comparison of the patients admitted to hospital ward beds and to the coronary care unit emphasized the basic difference in the two groups of patients. The coronary care unit patients were younger, they had a higher incidence of cardiogenic shock on admission, and there was a higher mortality rate among those patients admitted to the unit within six hours of the onset of their severe pain. The over-all hospital mortality rate was 24 per cent in the patients admitted to the ward beds and to the coronary care unit. The register provides a background of information on which the effectiveness of the management of patients with acute myocardial infarction can be assessed.

Closed mitral commissurotomy: Recent results in 291 cases

Early and late results for 291 patients undergoing closed mitral commissurotomy, usually with transventricular dilator, between July 1, 1960, and July 1, 1964, are presented. The over-all hospital mortality rate was 3.4 per cent (1.5% for patients with no previous mitral valve surgery). Over-all incidence of operative or postoperative arterial embolism was 2.4 per cent (5% in patients with a history of arterial embolism). Causes of hospital deaths are listed. Within the period of follow-up, results of surgery were good in 86 per cent of patients traced. When the valve was immobile or significantly incompetent or when an optimal initial opening was not obtained at operation, the results were less good. In proper circumstances, good palliation at a low risk usually can be achieved by a closed operation.

Surgical Repair of the Partial Form of Persistent Common Atrioventricular Canal, with Special Reference to the Problem of Mitral Valve Incompetence

A total of 131 patients with the partial form of common atrioventricular canal were operated on between March, 1955 and January, 1964. The over-all hospital mortality rate was 3.8%; no deaths occurred in patients who had no or only mild incompetence of the mitral valve. Permanent heart block has not occurred in the last 93 cases. Results have been good in general, although there is evidence of residual mitral valve incompetence in many patients. In the few who had severe incompetence at the mitral valve before repair, the results have been considerably less satisfactory than in the group as a whole; therefore, further work is needed on this aspect of the problem.

Surgical aspects of heart disease in infants under the age of two years

The natural history of cardiovascular disease in infants is now reasonably well documented. Poor results with many severe lesions under medical management have necessitated an early active surgical attempt to restore physiologic balance entirely or in part to save or prolong life. Early diagnosis, observation and intensive medical treatment are imperative to assess progress of the infant and success of cardiac compensation. Nevertheless, delay in recommending surgery may jeopardize the chances of successful surgery of a favorable correctable lesion. One hundred forty-one infants under two years of age have received surgical treatment. The over-all hospital mortality has been 21 per cent (thirty patients). In twenty-one infants with coarctation, a good result was obtained in 77 per cent. Only one death occurred in fifteen patients when no associated intracardiac lesion was present. With patent ductus arteriosus, all but two of the thirty-nine infants with the isolated lesion survived with a good result. However, the presence of an additional lesion increased the mortality to two of sixteen additional infants; one death occurring early and the second four months after operation. Cardiac failure was the main cause of death. Pulmonary valvular stenosis still presents a problem in infants. Whatever technical method is employed, either transventricular or transarterial valvotomy, the myocardium needs full protection during manipulation, and the maintenance of a good aortic pressure and coronary blood flow are essential. The favorable results of Blalock-Taussig anastomosis for severe tetralogy of Fallot have been rewarding and open correction in infants appears inadvisable. A 4 per cent mortality occurred in this series of twenty-five infants. Pulmonary arterial banding in six cases has given beneficial results in 67 per cent. This series is small but the palliation obtained is dramatic, enabling the infants to grow to a state in which open direct closure of the intracardiac defects will be more successful. Our experience with transposition and atresias has been very limited, but the value of palliative procedures is again emphasized. Open heart procedures using extracorporeal circulation have been used in only seven instances. The over-all results of palliative procedures in infants are so much better that we believe our indications for cardiopulmonary bypass in infants are few at this time; however, with improvement in bypass technics, more infants will be operated upon successfully.

A STUDY IN GERIATRIC ANAESTHESIA. FRACTURED NECK OF THE FEMUR.

Two hundred and twelve consecutive hip fractures have been reviewed. There were no anaesthetic deaths in this series and only three patients died within 24 hours of the end of anaesthesia, but from causes not directly related to the anaesthetic management. With an over-all hospital mortality of slightly under 9 per cent this is not a dangerous operation, bearing in mind the frequently very advanced age of these patients and associated major diseases of the cardiorespiratory system. In terms of functional recovery, hip-pinning seems to be a more satisfactory operation than arthroplasty, even in this series where patients for arthroplasty were selected because of their good general condition and the anticipation of good functional recovery. Although almost 60 per cent of patients left the hospital still in wheelchairs after a stay frequently of many weeks, the large majority of them eventually became ambulatory, many of them without support. Of those who did not become fully ambulatory, there were certainly a few who had not been so before the accident and, therefore, they had been restored really to the preoperative status quo. Obviously no more can be expected from the operation. Perhaps the most significant finding in this study has been the poor survival in patients operated upon as emergencies, and thus the realization of the benefits of an adequate all-round preparation to improve the general status as much as possible. This, despite the fact that early mobilization of these patients is obviously desirable to prevent cardiovascular and thrombotic complications. On balance, there is no doubt that the risk of an increased incidence of these postoperative complications must be borne for the sake of adequate preparation and the reduction in over-all mortality figures. Although not infrequently many days were spent to improve the general condition of the patient as much as could reasonably be expected, spot checks of blood gases pre- and post-operatively have shown that most of these patients are in a state of at least compensated metabolic acidosis. No conclusions are being drawn from these findings at the present time since an inadequate number of patients has been studied. This project is now under way and comparisons will be made with geriatric patients who are not acutely ill, in order to determine a baseline for the aged. Our clinical results have convinced us that it is unnecessary in the large majority of cases to use endotracheal intubation in the anaesthetic management of hip-pinnings, provided a perfect airway can be maintained. This permits a much lighter level of anaesthesia and the surgical stimulation is sufficient to ensure adequate respiratory exchange. These patients should be awake within minutes of the completion of the operation. Results from regional anaesthesia are not superior to those following general anaesthetic techniques, so that it is hardly justified to inflict on these patients the discomfort of positioning for spinal or epidural puncture. The actual choice of anaesthetic agent is of secondary importance as compared with meticulous management. The postoperative period is characterized by the relatively frequent occurrence of pulmonary emboli, many of which are fatal. Routine prophylactic anticoagulant therapy has not been used in our series. Better results could be obtained if this complication could be prevented effectively. Other complications must be minimized by continuous and intensive postoperative management and supervision.