Primary Reason For Admission Research Articles

Weekend Hospital Admission, Acute Kidney Injury, and Mortality

Admission to the hospital on weekends is associated with increased mortality for several acute illnesses. We investigated whether patients admitted on a weekend with acute kidney injury (AKI) were more likely to die than those admitted on a weekday. Using the Nationwide Inpatient Sample, a large database of admissions to acute care, nonfederal hospitals in the United States, we identified 963,730 admissions with a diagnosis of AKI between 2003 and 2006. Of these, 214,962 admissions (22%) designated AKI as the primary reason for admission (45,203 on a weekend and 169,759 on a weekday). We used logistic regression models to examine the adjusted odds of in-hospital mortality associated with weekend versus weekday admission. Compared with admission on a weekday, patients admitted with a primary diagnosis of AKI on a weekend had a higher odds of death [adjusted odds ratio (OR) 1.07, 95% confidence interval (CI) 1.02 to 1.12]. The risk for death with admission on a weekend for AKI was more pronounced in smaller hospitals (adjusted OR 1.17, 95% CI 1.03 to 1.33) compared with larger hospitals (adjusted OR 1.07, 95% CI 1.01 to 1.13). Increased mortality was also associated with weekend admission among patients with AKI as a secondary diagnosis across a spectrum of co-existing medical diagnoses. In conclusion, among patients hospitalized with AKI, weekend admission is associated with a higher risk for death compared with admission on a weekday.

Early severe morbidity and resource utilization in South African adults on antiretroviral therapy

BackgroundHigh rates of mortality and morbidity have been described in sub-Saharan African patients within the first few months of starting highly active antiretroviral therapy (HAART). There is limited data on the causes of early morbidity on HAART and the associated resource utilization.MethodsA cross-sectional study was conducted of medical admissions at a secondary-level hospital in Cape Town, South Africa. Patients on HAART were identified from a register and HIV-infected patients not on HAART were matched by gender, month of admission, and age group to correspond with the first admission of each case. Primary reasons for admission were determined by chart review. Direct health care costs were determined from the provider's perspective.ResultsThere were 53 in the HAART group with 70 admissions and 53 in the no-HAART group with 60 admissions. The median duration of HAART was 1 month (interquartile range 1-3 months). Median baseline CD4 count in the HAART group was 57 × 106 cells/L (IQR 15-115). The primary reasons for admission in the HAART group were more likely to be due to adverse drug reactions and less likely to be due to AIDS events than the no-HAART group (34% versus 7%; p < 0.001 and 39% versus 63%; p = 0.005 respectively). Immune reconstitution inflammatory syndrome was the primary reason for admission in 10% of the HAART group. Lengths of hospital stay per admission and inpatient survival were not significantly different between the two groups. Five of the 15 deaths in the HAART group were due to IRIS or adverse drug reactions. Median costs per admission of diagnostic and therapeutic services (laboratory investigations, radiology, intravenous fluids and blood, and non-ART medications) were higher in the HAART group compared with the no-HAART group (US$190 versus US$111; p = 0.001), but the more expensive non-curative costs (overhead, capital, and clinical staff) were not significantly different (US$1199 versus US$1128; p = 0.525).ConclusionsCauses of early morbidity are different and more complex in HIV-infected patients on HAART. This results in greater resource utilization of diagnostic and therapeutic services.

高齢者死亡症例の死因分析

The Juntendo Tokyo Koto Geriatric Medical Center (JTKGMC) is a community hospital catering for the health care needs of senior citizens, and 37.5% (120 beds) of its beds are psychiatric beds mostly for those with cognitive impairment. The purpose of this study was to analyze cause of death in a hospital like ours with its particular case mix. All patients who passed away in our hospital between June 1st 2002 and November 30th 2007 were surveyed with regard to their age distribution and causes of death were analyzed and compared with available national statistics. The over 65 age group accounted for 93.5% of the total and consisted of 815 patients, including 461 men (56.6%) and 354 women (43.4%). The most common cause of death was malignant neoplasm, followed by pneumonia, cardiovascular diseases, cerebrovascular accidents, and renal failure. Among those who died from the primary disease diagnosed on admission, malignancy was most common (288 cases, 61.3%), followed by pneumonia, cerebrovascular accidents, cardiovascular diseases and renal failure. As for those who died from non-primary diagnosis on admission (patients dying due to any condition, not the direct reason of their admission), pneumonia was the most common diagnosis on admission (95 cases, 27.5%), followed by cardiovascular diseases, malignant neoplasm, sepsis and renal failure. In the general wards, above half of those who died due to the primary cause of admission was malignant neoplasm. On the other hand, 1/4 of those who died from causes other than the primary diagnosis on admission was pneumonia. In the mental health wards the most common cause of death due to the primary diagnosis was malignant neoplasm, followed by dementia of Alzheimer's type. The most common cause of death other than the primary reason for admission was pneumonia. More non-primary diagnosis deaths occurred in the mental health wards than in the general wards. In our hospital, malignancy and pneumonia were the most common causes of death, rather than cerebrovascular or cardiovascular diseases, but otherwise, the ranking order of the causes of death was very similar to those in other areas of Japan. Causes of the both in our hospital were closely linked with the high incidence of in-hospital mortality in Japan, accounting for 80% of all deaths. Although the case mix of our in-patients is influenced by a particular distribution of health care institutions and nursing care facilities in our catchment area for secondary care, the study demonstrated that our geriatric service responds to the needs of a wide spectrum of indications suffered by elderly citizens at the end of their life.

TEACH: Trial of Education And Compliance in Heart dysfunction chronic disease and heart failure (HF) as an increasing problem

In this manuscript we outline the development of a randomized control trial. Introduction Heart failure (HF) is one of the leading causes of hospitalization in North America. While great advances have been made in the treatment of this disease, many factors limit the effectiveness of treatment. The objective of this Trial of Education And Compliance in Heart failure patients (TEACH) was to measure in patients with heart failure who were hospitalized and then discharged into the community, the impact of a comprehensive outpatient educational intervention on: 1) a composite endpoint of mortality, readmissions and visits to the emergency room for all causes, 2) the impact of the intervention on health-related quality of life, 3) the impact of the intervention on compliance to medication and 4) the economic impact of providing such an intervention to patients. Research design This was a prospective cluster randomized controlled clinical trial in patients who were admitted to hospital with a diagnosis of heart failure (HF). Patients were stratified by reason for admission to hospital. Stratum 1 included patients whose primary reason for admission was HF and stratum 2 included patients whose primary reason for hospital admission was not HF. Hypothesis HF patients who receive an enhanced educational intervention from their community pharmacist will 1) have an absolute risk reduction in the number of events of 20%, 2) be more compliant, 3) will demonstrate less health-related quality of life (HRQoL) impairment as measured by disease-specific and generic HRQoL instruments and 4) will lower costs/Quality Adjusted Life Years (QALY) due to fewer total events per patient. Outcomes Outcomes were collected every 3 months from baseline to the end of 1 year. Events were tracked using a comprehensive database that we developed and validated. In order to measure compliance we used electronic measures known as Track Caps (MEMS). We also used pharmacy refill data that was provided to us from all community pharmacies the patient used. This data was analyzed and interpreted using a validated formula developed by Steiner et al. (1996).

The Burden of Atrial Fibrillation in Unselected Acute Medical Admissions

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is of increasing prevalence. The presence of AF complicates the management of patients presenting as medical emergencies. To assess the prevalence of AF and current investigation and management strategies in unselected acute medical admissions. Prospective survey of all acute medical admissions over 22 days. Stobhill Hospital--district general hospital in north Glasgow. Five hundred and seven consecutive acute medical admissions. Of the 507 patients, 47 (9.3%) had AF. AF was a new diagnosis in five patients (11.0%). The most common presenting features were dyspnoea and chest pain. The principal underlying medical conditions were hypertension and ischaemic heart disease. AF was the primary reason for admission in six patients (12.8%) and a documented reason for admission in 11 patients (23.4%). Thyroid function tests were or had previously been performed in 45 patients (95.7%). Twenty-four patients (51.1%) underwent echocardiography or had done so previously. Twenty-two patients (46.8%) received anticoagulation with warfarin. Ten patients (21.3%) should have received warfarin by standard guidelines but did not. No patient received warfarin inappropriately. Rate control was used in 40 patients (85.1%). Rhythm control was attempted in four patients (8.5%). AF is common amongst emergency admissions to district general hospitals and has significant resource implications. Improvements are needed both in the use of echocardiography and in the administration of anticoagulant therapy.

Trends in Heart Failure Hospitalization Rate and Outcome in the United States

Background: Therapies for heart failure known to reduce admission rates are increasingly used; however, recent trends in U.S. hospitalization rates are unclear. Methods: We used data from the National Hospital Discharge Survey from 2000 to 2004, a random sample of all discharges from non-federal hospitals. There were 51,670 hospitalizations with heart failure as the primary reason for admission. Rates of admission per age group were calculated using U.S. census data. Trends in in-hospital survival, length of stay, and comorbidity were determined.

Pro/con debate: Octreotide has an important role in the treatment of gastrointestinal bleeding of unknown origin?

Whether it is the primary reason for admission or a complication of critical illness, upper gastrointestinal bleeding is commonly encountered in the intensive care unit. In this setting, in the absence of endoscopy, intensivists generally provide supportive care (transfusion of blood products) and acid suppression (such as proton pump inhibitors). More recently, octreotide (a somatostatin analogue) has been used in such patients. However, its precise role in patients with upper gastrointestinal bleeding is not necessarily clear and the drug is associated with significant costs. In this issue of Critical Care, two expert teams debate the merits of using octreotide in non-variceal upper gastrointestinal bleeding.

Profile of the malnourished patient

To characterize malnutrition in a nonspecific group of newly admitted hospital patients. A prospective, descriptive study aiming to identify typical symptoms of malnutrition in a heterogeneous population of newly admitted patients to the wards of internal medicine. The wards of internal medicine of the VU University Medical Center. A total of 106 patients were included in the study, 70 patients underwent the full interview. Next to nutritional status, the sociodemographics, underlying disease, estimated care complexity, care situation before admission, journey through the care system, nutritional intervention and nutritional follow-up after discharge were described for each patient. Of 70 patients 24 (34%) were malnourished. Malnourished patients suffered two chronic diseases vs one for well-nourished patients (P = 0.05). They also had a higher estimated care complexity (P = 0.035) and a trend towards longer length of hospital stay (P = 0.09). Malnourished patients did not differ from well-nourished patients in age, sex, partner status and care received at home. In all, 54% of the malnourished patients were identified correctly by the medical staff. The reasons for admission to the hospital were diverse in only four out of 24 patients malnutrition was the primary reason for admission. Discharge letters to the general practitioner (GP) contained only fragmentary information about the patients' nutritional status. At 3 months after discharge, most of the GPs were scarcely aware of any nutritional problems of their patients. Malnutrition is difficult to recognize in a nonspecific hospital population. Patients do not present with unique symptoms indicating malnutrition. To be able to correctly identify all malnourished patients, screening of the nutritional status of all newly admitted patients seems to be necessary.

Trends in Complete Blood Count Values During Acute Painful Episodes in Children With Sickle Cell Disease

Complete blood count (CBC) values are monitored as crude indicators of the hemolytic and inflammatory processes that accompany an acute painful episode in children with sickle cell disease. As part of a larger study that examined the pain experience and pain management of hospitalized children during painful vaso-occlusive episodes, the authors examined trends in CBC values and determined whether there were relationships between these values and pain intensity scores. Children, 5 to 19 years of age, with sickle cell disease whose primary reason for admission was vasoocclusive pain were recruited for participation in the study. Once every evening from the day of admission until the day of discharge, they were asked to rate their worst and least pain using the numeric rating scale of the African American Oucher pain scale. Complete blood count values were obtained from the hospital information system on a daily basis. Parallel changes in CBC values and pain intensity scores were evident within the first 48 hours of hospitalization. However, although the inflammatory and hemolytic processes were resolving, pain persisted at moderate levels throughout the course of hospitalization.

Nosocomial Infections in Neurosurgical Intensive Care Units in the United States

BACKGROUND: Nosocomial infections (NIs) in intensive care unit (ICU) patients result in increased mortality, morbidity, and cost. However, little is known about the epidemiology of NIs in neurosurgical ICU (NSU) patients. METHODS: Data on NIs in NSU patients in hospitals participating in the National Nosocomial Infections Surveillance (NNIS) system from 1995 to 2001 were analyzed. A NSU is a patient-care area with neurosurgery as primary reason for admission or care by a neurosurgeon after head or spinal trauma. The pooled mean NI rate was calculated per patient and patient days spent in the NSU. Device utilization is the days each device was used (device days) divided by patient days. Device-associated infection rates were calculated for pneumonia, urinary tract infection (UTI), and bloodstream infection (BSI) and compared to those of surgical ICUs. RESULTS: Among 93,327 patients monitored for 334,217 patient days, 5,484 (5.9%) developed 7231 NIs. The most common NIs were pneumonia (30.8%) and UTI (30.4%). BSI (11.9%), lower respiratory infections (6.6%), surgical site infections (4.4%), and central nervous system infections (4.3%) also occurred. Meningitis or ventriculitis occurred in 43.8% of surgical site infections. Staphylococcus aureus was the most common pathogen in pneumonia and lower respiratory tract infections, whereas Escherichia coli was most common for UTI and coagulase-negative staphylococci was for BSI. Of 2225 pneumonias, 83.6% were ventilator-associated. Of 2,198 UTIs, 95.7% were catheter-associated. Of 860 BSI, 81.1% were central line–associated. In comparison with use in surgical ICUs, device utilization per patient day was lower for all three devices: central lines (0.46 for NSU, 0.65 for surgical), urinary catheters (0.80 for NSU, 0.84 for surgical), and ventilators (0.37 for NSU, 0.46 for surgical). Pooled mean device-associated infection rates per 1,000 device days were 4.6 for BSI (5.2 for surgical), 7.3 for UTI (5.1 for surgical), and 13.6 for pneumonias (9.9 for surgical). CONCLUSIONS: Nosocomial infections are relatively common in neurosurgical patients. Most of these infections were device-associated UTI and pneumonia.

A Geriatric Day Hospital: Who Improves the Most?

This study compared the changes in some bio-psychosocial variables (functional independence, nutritional risk, pain, balance and walking, grip strength, general well-being, psychiatric profile, perception of social support, leisure satisfaction, and caregivers' feeling of burden) in four categories of clients during their program at a geriatric day hospital (GDH). The study also evaluated whether or not improvements, if any, were maintained 3 months after discharge. One-hundred-and-fifty-one people, categorized by primary reason for admission, were assessed at the GDH with reliable and valid tools, at admission and at discharge. Three months after discharge, they were reassessed with the same tools. Overall, two categories of clients, stroke / neurological diseases and musculoskeletal disorders / amputations, improved the most. For the gait disorders and falls group, only the functional independence score improved, but not at a clinically significant level. Finally, clients in the cognitive function disorders / psychopathologies group improved the most on their well-being scores and caregivers' burden decreased the most. All gains were maintained up to 3 months after discharge, except for leisure satisfaction. With the exception of clients who attended the GDH because of gait disorders and falls, the improvements and maintenance achieved in each category occurred in the domains where improvement had been hoped for, because of the particular disabilities in question and because of the nature of the GDH services offered.

Energy expenditure in 100 ventilated, critically ill children: improving the accuracy of predictive equations.

The purpose of this study was to evaluate current methods of predicting energy requirements and to develop and validate new equations derived from energy expenditure measurements of ventilated, critically ill children. Prospective, observational, sequential study. Pediatric intensive care unit. A total of 100 ventilated, critically ill children who fit the criteria of energy expenditure measurement. Additional patients (n = 25) were included in the validation study. An indirect calorimeter was used to measure energy expenditure for a period of 30 mins. The mean measured energy expenditure was 185+/-51 kJ/kg per day. Predicted energy expenditure from standard equations was compared with measured energy expenditure by using the Bland and Altman "methods comparison procedure," and poor precision and accuracy were observed. Patient variables were collected at the time of measurement, and multiple regression analysis was performed to determine the independent contribution of each variable to measure energy expenditure. New predictive equations were formulated and validated with additional energy expenditure measurements. Patient variables that did not correlate significantly with energy expenditure were gender, Pediatric Risk of Mortality score, and commencement of nutritional support. An equation was derived from patient variables (age, weight, weight for age Z score, body temperature, number of days after intensive care admission, and primary reason for admission) that correlated significantly (r2 = .898) with measured energy expenditure. A second, simplified equation (energy expenditure kJ/day = ¿17 x age [months]¿ + ¿48 x weight [kg]¿ + ¿292 x body temperature degrees C¿ - 9,677) was produced (r2 = .867). Validation found no significant difference between measured and predicted energy expenditure by the new equations; however, the equations did not predict accurately for patients <2 months of age. The new equations provide a more accurate alternative to current predictive methods in assessing energy requirements of ventilated, critically ill children.

Respiratory morbidity of hospitalized children with Trisomy 21.

To review the respiratory morbidity in children with Trisomy 21 admitted to a teaching hospital. A retrospective chart review of 232 admissions to John Hunter Children's Hospital during a 6.5-year period (1991-98). The primary outcome measures included: (i) primary reason for admission, (ii) concomitant respiratory pathology, (iii) admission to the Intensive Care Unit (ICU), (iv) length of stay and (v) costs of admission. Fifty-four per cent of admissions were primarily for respiratory tract pathology, dominated by pneumonia, bronchiolitis and croup. Admission to the ICU was required for 10% of admissions, most commonly for pneumonia (10/23). Congenital heart disease (CHD) was present in 33% of patients. The median length of stay and cost of admission for a child with Trisomy 21 (without CHD) with common respiratory conditions such as bronchiolitis, asthma or pneumonia was two to three times greater than in patients without Trisomy 21. Lower respiratory pathology is most common cause for acute hospital admission in children with Trisomy 21. The presence of CHD did not influence admission rates to hospital. However, patients with CHD had longer lengths of stay, appeared to have more severe illness, were more likely to require admission to an ICU and were more likely to require ventilatory support.

Prognostic performance and customization of the SAPS II: results of a multicenter Austrian study. Simplified Acute Physiology Score.

To evaluate the prognostic performance of the original Simplified Acute Physiology Score (SAPS) II in Austrian intensive care patients and to evaluate the impact of customization. Analysis of the database of a multicenter study. Nine adult medical, surgical, and mixed intensive care units (ICUs) in Austria. A total of 1733 patients consecutively admitted to the ICUs. The database included admission data, SAPS II, length of stay, and hospital mortality. The Hosmer-Lemeshow goodness-of-fit test for the SAPS II showed a lack of uniformity of fit (H = 89.1, 10 df, p < 0.0001; C = 91.8, 10 df, p < 0.0001). Subgroup analysis showed good performance in patients with cardiovascular (medical and surgical) diseases as the primary reasons for admission. A new predictive equation was derived by means of the logistic regression. Goodness-of-fit was excellent for the customized model (SAPS IIAM) (H = 11.2, 9 df, p = 0.33, C = 11.6, 9 df, p = 0.24). The mean standardized mortality ratio (SMR) changed from 0.81 +/- 0.26 to 0.93 +/- 0.29 with customization. SAPS II was not well calibrated when applied to all patients. However, it performed well for patients with cardiovascular diseases as the primary reason for admission and may thus be applied to these patients. Standardized mortality ratios that are calculated from scoring systems without known calibration must be viewed with skepticism.

Bicycle riding and oral/maxillofacial trauma in young children

To investigate the frequency of oral/maxillofacial injuries in children who have had a bicycle incident and to relate this to the wearing of a protective helmet. Part of a larger prospective study in which self-administered questionnaires were completed by each child with bicycle-related injuries and their parents or caregivers. Two tertiary-referral children's hospitals (between 1 April 1991 and 30 June 1992) and three general hospitals (between 1 August 1991 and 30 June 1992) in Brisbane. 813 children aged under 15 years who presented to the accident and emergency departments with bicycle-related injuries. There were 321 children (39.5%) who sustained oral/maxillofacial injuries. Of 1355 injuries, 340 (25.1%) were to the facial region. Of the 153 children admitted to hospital for bicycle-related injuries, 94 (61.4%) had oral/maxillofacial injury as the primary reason for admission (including those with a reduced level of consciousness). Of the 66 children with a reduced level of consciousness, 53 had concomitant facial injuries. The most common oral/maxillofacial injuries were facial abrasions, cuts and lacerations (50.3%); soft tissue injuries to the mouth (30.9%); and dentoalveolar trauma (9.7%). Over half of these children were wearing bicycle helmets. Of the 15 facial fractures (mandibular, nasal, and zygomatico-orbital), 10 were in children wearing helmets. Oral/maxillofacial injuries are frequent among child bicycle riders, even for those who wear Australian Standards-approved bicycle helmets. Bicycle helmets need design modifications (e.g., lightweight chin protectors) to more adequately protect the face and jaw.

A Study of the Relationship between the Patterns of Planned Activity and Incidents of Deliberate Self-Harm within a Regional Secure Unit

Within a 77-bed Regional Secure Unit, there has been an increase in the number of patients admitted who deliberately do themselves harm, although this Is generally not the primary reason for admission. During this 9-month study, 307 incidents of self-harm were recorded on the clinic's information system; a subgroup of seven patients was responsible for 77.5% of these incidents. Whilst there is a perception among rehabilitation staff that activity has a role in reducing the incidence of deliberate self-harm, this study Identifies no correlation between the patterns of structured activity and the patterns of deliberate self-harm. This does not suggest, however, that occupational therapy is ineffective with this client group, particularly given the potentially addictive nature of deliberate self-harm behaviour even after problem resolution. The study identifies areas for further research, focusing on qualitative rather than quantitative study.

Management Errors Leading to Unnecessary Hospitalization for Kerion

Tinea capitis is a common problem in the inner city, outpatient population. It is known that some children were being admitted for treatment of the kerion type of tinea capitis. The purpose of this study was to determine why these children were being admitted and whether hospitalization was justified. A retrospective study of all children hospitalized at Children's Hospital of Wisconsin between January 1990 and December 1992 with the diagnosis of tinea capitis was performed. Twenty-nine children who were hospitalized with tinea capitis were identified. In 10 cases, tinea capitis was the primary reason for admission, in 19 patients it was a secondary diagnosis. All of the patients with a primary diagnosis of tinea capitis were presumed to have a secondary bacterial infection of the kerion; however, this was not verified by the workup of any patient. Numerous deviations from optimal treatment were noted in both groups of patients. Although tinea capitis had been correctly diagnosed before admission in seven primary tinea capitis patients, only two of these patients received oral griseofulvin. The patients in whom tinea capitis was a secondary diagnosis also had a number of therapeutic deficiencies including failure to prescribe griseofulvin (16%), failure to administer griseofulvin with a fatty food or meal (58%), and failure to prescribe a sporicidal shampoo (63%). Although all patients were assumed to have a secondary bacterial infection, this could not be documented. With the possible exception of one patient all the symptoms described by the patients could be explained by the highly inflammatory nature of a kerion. A better understanding of the degree of inflammation that may accompany a kerion, as well as its proper treatment, may prevent unnecessary hospitalization of children.

Pediatric intensive care: factors that influence outcome.

Four hundred sixty-one consecutive admissions to the Pediatric Intensive Care Unit (PICU) were evaluated using the Therapeutic Intervention Scoring System (TISS). Patients requiring an increased level of care, defined as TISS points greater than or equal to 10, accounted for 75% of patient days in the ICU. Within this group, the primary reason for admission to the ICU was congenital heart disease, trauma, malignancy, respiratory failure, and sepsis. Survival was inversely related to TISS points, through TISS itself could not differentiate between survivors and nonsurvivors. The mortality rates for children who had a congenital malformation, a cardiac arrest before admission, or who developed acute failure secondary to other disease processes were significantly increased. Comparison of critically ill children and adults using TISS showed mortality rates that were similar. Assuming that the cost of intensive care is related to both seriousness of illness (assessed by TISS) and length of hospitalization, in this pediatric population the cost of hospitalization was not disproportionately high for nonsurvivors compared to survivors. Reduction in mortality rates in a PICU population will be dependent on factors largely uncontrollable buy ICU practitioners. This will come about by reduction in the numbers of congenital malformations and the prevention of childhood trauma.

Secondary hypertension in a medical ward.

The prevalence of secondary hypertension was evaluated by investigating 400 consecutive patients with arterial hypertension in a medical ward. They were classified into four groups according to the case history. Group A: 104 subjects with therapy-resistant hypertension, group B: 247 patients who had another concomitant disease as the primary reason for admission, group C: 34 patients referred to the ward for basic investigation due to recently diagnosed hypertension, group D: 15 patients with unwanted hypertension was 15.5% in the entire series, and 14.4%, 18.6%, 2.9% and 0% in groups A - D, respectively. Ten patients (2.5%) were operated on, nine of them from group A and one from group B. The findings demonstrate the importance of a careful examination of patients with therapy-resistant hypertension, since they might include subjects whose hypertension can be treated by surgery.

Medical audit in neonatal care.

A system of medical audit on a neonatal unit based on the primary reason for admission may be used alongside the more conventional type of audit of mortality and morbidity by birthweight and gestation using a diagnostic classification of disease. The method provides a more accurate description of all babies admitted to a neonatal unit and thus a more comprehensive measure of work undertaken.