Progressive Decrease In Mortality Research Articles

The Role of Postoperative Mechanical Ventilation in Neonates with Tracheoesophageal Fistula

Background: Many advances have been made in managing neonates with esophageal atresia/tracheoesophageal fistula (EA/TEF). This resulted in a progressive decrease in mortality as a result of improved neonatal intensive care and neonatal mechanical ventilation; however, this is not the case in developing countries. Objectives: We aimed to evaluate the efficacy of postoperative ventilation in neonates with EA/TEF in Iraq as a developing country. Materials and Methods: It is a prospective study for all neonates with EA and/or TEF admitted to the pediatric intensive care unit (PICU) in Alkhansaa Teaching Hospital between December 2012 to December 2014. Forty operated neonates were randomly divided into two groups according to the record number of presentations (even = G1, odd = G2): Twenty patients (group l) had been assigned to be post-operatively on a ventilator as a routine protocol. While group 2 planned to be extubated in the theater. We evaluated the complications and mortality rates in two groups. Results: For 24 months, 40 neonates with EA/TEF were admitted to PICU; Thirty-two were operated on within 24 hours of life. There were no significant differences between the two groups regarding fetal maturity (p-value 0.490), gender, and weight. The mean period for mechanical ventilation was four days. Six neonates had tube mal-positioning complications, leading to lung collapse, hypoxia, and pneumonia (p-value 0.250). Anastomotic leaks occur in 10 neonates (five in each group) (p-value 0.642), which sometimes leads to sepsis (p-value 0.347). Trachea-malacia was recorded after weaning in 5 intubated patients (p-value 0.078). The mortality rate in G1 was 35%, while in group 2 was 25% (p-value 0.366). Conclusions: Although the study’s sample is small, it is recommended to avoid mechanical ventilation in the postoperative care of neonates with EA and/or TEF.

Biocidal activity of the extracts of Vernonia amygdalina against ticks responsible for livestock diseases

Biocidal activity of Vernonia amygdalina was assessed on Rhipicephalus appendiculatus ticks responsible for livestock diseases in North and South-Kivu provinces. In vitro trials were conducted in the laboratory of Lwiro Research Center for Natural Sciences to determine the lethal dose for different days after ticks contact with extracts. Five different dosages of 1.25, 2.5, 5, 10, 20 g/mL were evaluated. Water was considered as positive control and Batycol as negative control. The phytochemical screening of extracts of Vernonia amygdalina plant shows that this plant contains several substances responsible for acaricidal activity, mainly saponins, terpenoids, steroids and tannins. The experiment shows a mortality rate that varies with the concentration of the extracts; the most fatal is 20 g/mL and decreases with exposure time. The aqueous extracts showed a progressive decrease in mortality compared to ethanol extracts. This is due to the dissolution of the substances responsible for this insecticidal activity. The study recommends the application of aqueous extracts of Vernonia amygdalina in the fight against cattle ticks. Indeed, this is a natural insecticide available and easier to prepare, non-toxic to humans and is rapidly degraded in the environment.

Number of drugs used in secondary cardiovascular prevention and late survival in the population of Valencia Community, Spain

BackgroundDrug treatment for secondary prevention of cardiovascular disease is recommended by guidelines, but it is not always followed in real life. This study wanted to assess the size of this gap and its impact on mortality in subjects after a cardiovascular event (MACE). MethodsPatients with any of MACE in the period from January 1st 2011 to December 31st 2013, and more than one year of follow-up were selected from population of the Valencian Community. Drugs for secondary prevention were antiplatelets, renin-angiotensin system blockers and statins. Assessment of treatment was performed one year after the initial event. Mortality risk was assessed using Cox by the number of drug classes (G0 no medication, G1 one, G2 two and G3 three drugs) adjusted by confounders. ResultsA total of 92,436 patients (62% men, mean age 72 years) of whom 60.5% presented with stroke, 30.6% with myocardial infarction and 8.9% with revascularization were included. Among them, 4.1% were G0, 20.2% G1, 32.9% G2 and 42.7% G3. A progressive decrease in mortality was observed in G1 (HR 0.83, CI 95% 0.73–0.95), G2 (HR 0.70, CI 95% 0.60–0.82) and G3 (HR 0.61, CI95% 0.51–0.74) vs. G0. In diabetic subgroup, significant reduction of risk was observed in the G2 (0.79, CI 95% 0.63–0.98) and G3 (0.72, CI9 5% 0.56–0.95), but not in G1 (0.97, CI 95% 0.80–1.17). ConclusionA gap between guidelines and reality in the use of cardiovascular protecting drugs one year after the initial event still exists and it is largely related with all-cause late mortality.

Arterial hypertension in children after aortic coarctation repair: current challenges for diagnostics and treatment

Coarctation of the aorta is a well-studied congenital heart disease. Our understanding of this congenital heart disease evolves every year from simple obstructive aortic lesions to systemic dysfunction of the cardiovascular system. In the past two decades, there has been a progressive decrease in mortality and early postoperative complications of newborns and infants with aortic coarctation. However, these patients with coarctation of aorta have a high risk of postoperative complications in the long-term period, despite successful correction at an early age. This review will focus on the issues mainly related to blood pressure. Arterial hypertension has been reported to occur in up to 90% of patients, and is considered as the main cause of premature cardiovascular diseases. The development of arterial hypertension in patients after correction of aortic coarctation is likely to be multifactorial and may be associated with the changes in elastic properties of the aorta wall, presence of residual obstruction, changes in the aortic arch geometry, immune-inflammatory disorders and changes in the regulation of renin-angiotensin and baroreceptors. Also described are the prevalence and pathophysiology of arterial hypertension in children who have undergone aortic coarctation repair. Due attention is given to the issues of accurate blood pressure measurement at an early stage of arterial hypertension. Although the patterns for diagnostics of arterial hypertension in adults are well established, we highlight the issues of premature cardiovascular events development in children and describe the techniques, which help provide complementary information for cardiovascular assessment in this group of patients. Received 7 August 2018. Revised 6 December 2018. Accepted 10 December 2018. AcknowledgmentWe would like to express our gratitude to Sergey M. Ivantsov for technical support. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest.

Impact of order set use on outcome of patients with sepsis

In an effort to improve outcome of patients with sepsis, we developed and implemented a disease-specific alert and order set for our computerized physician order entry system. This alert and order set were implemented in 2015. We have produced a progressive decrease in mortality for patients at our hospital with diagnosis of sepsis. We see a significant decrease in mortality for patients who had the sepsis order set used compared to those who did not have the order set used. We recommend use of an order set for patients with sepsis.

Risk factors and biochemical markers in metabolic bone disease of premature newborns

Metabolic bone disease (MBD) of prematurity is a complication of multifactorial aetiology, which has been increasing, due to progressive decrease in mortality of preterm newborns. The aim of the study was to analyze risk factors of severe MBD and its analytical markers. Retrospective study involving preterm infants less than 32 weeks gestational age and/or weight less tan 1,500 g born between january 2012 and december 2014. Comparison was made according to the presence of severe MBD. 139 patients were recruited. Mean value of 25(OH)D3 was 70.68 ± 25.20 nmol/L, being higher in patients born in spring-summer than in autumn-winter (80.94 ± 25.33 vs 61.13 ± 21.07; p = 0.000). Levels of 25(OH)D3 were similar in patients with severe MBD compared with the rest of patients (65.61 ± 26.49 vs 72.07 ± 24.89, P = 0.283). Higher levels of alkaline phosphatase (AP, IU/L ) (1314.19 ± 506.67 vs 476.56 ± 188.85; p = 0.000) were found in these patients. Cutoff point of AP 796.5 IU/L (S 95.2%, specificity 92.4%) was calculated by ROC curve. The risk factors most associated to severe EMO were restricted fetal growth, birth weight, duration of ventilation therapy and parenteral nutrition. AP levels were the best marker of severe MBD development. EMO risk increases with the number of risk factors and lower levels of 25(OH)D3. Levels of 25(OH)D3 higher than 70nmol/L appear to protect from the development of severe MBD, even in patients with multiple risk factors.

Impact of a standardized rapid response system on outcomes in a large healthcare jurisdiction

AimTo assess the impact of a standardized rapid response system (RRS) implemented across a large health care jurisdiction on reducing serious adverse events, hospital mortality and unexpected deaths. MethodWe conducted an interrupted time series (2007–2013) population-based study in the state of New South Wales (NSW), Australia to evaluate the impact of introducing a statewide standardized RRS (the between-the-flags [BTF] system) which employed a five-component intervention strategy. We studied 9,799,081 admissions in all 232 public hospitals in NSW. We studied changes in trends for annual rates of multiple key patient-centered outcomes before and after its introduction. ResultsBefore the BTF system (2007–2009), there was a progressive decrease in mortality, cardiac arrest rates, cardiac arrests related mortality, and failure to rescue rates, but no changes in mortality rate among low mortality diagnostic related group (LMDRGs) patients. After the BTF program (2010–2013), the same trends continued for all outcomes with an overall (2013 vs 2007) 46% reduction in cardiac arrest rates; a 54% reduction in cardiac arrest related mortality rates; a 19% reduction in hospital mortality; a 35% decrease in failure to rescue rates (all Ps<0.001) over seven-years. In addition, there was a new 20% (p<0.001) mortality reduction among LMDRG patients (2013 vs 2007). ConclusionsThe BTF program was associated with continued decrease in the overall cardiac arrests rates, deaths after cardiac arrest, hospital mortality and failure to rescue. In addition, among patients in the LMDRC group, it induced a new and significant post-intervention reduction in mortality which was never reported before.

Does the Obesity Survival Paradox of Dialysis Patients Differ with Age?

Background: The obesity paradox of hemodialysis patients (the association between obesity and survival) could be modified by age. We hypothesize that whereas obesity associates with survival in elderly patients, it behaves as a mortality risk marker in younger individuals. Methods: Retrospective study of 2002-2010 adult incident hemodialysis to analyze the relationship between body mass index (BMI) and annual body weight changes with mortality in different age strata. Results: Included in the study were 6,290 individuals. A progressive decrease in mortality was associated with increasing BMI ranges. Both annual body weight gains and losses were associated with mortality. Similar results were observed in elderly individuals, but in the BMI values of young patients, there were no significant differences in mortality. Conclusion: There is a survival benefit with increasing BMI in patients overall. However, while these results persist in patients >65 years, in young people there are no changes in mortality. Patients with the highest inter-annual variability in weight have an increased risk.

Trends in death attributed to myocardial infarction, heart failure and pulmonary embolism in Europe and Canada over the last decade.

Worldwide, cardiovascular diseases and cancer account for ∼40% of deaths. Certain reports have shown a progressive decrease in mortality. Our main objective was to assess mortality trends related to myocardial infarction (MI), heart failure (HF) and pulmonary embolism (PE). MI, HF and PE were studied as cause of death based on the analysis of death certificates in Canada (C), England and Wales (E), France (F) and Sweden (S). We also used a multiple cause approach. Age-standardized death rates (SDR) were calculated. The SDR for MI, HF or PE as the underlying cause of death, all decreased during the last decade. The decrease in SDR secondary to MI exceeded that for HF or PE. Concerning multiple cause of death, a greater decrease was also found for MI, compared with HF or PE. We confirm the beneficial trends in SDR with MI, HF or PE both as underlying or multiple causes in the studied countries. For HF and PE, multiple cause approach seems more accurate to describe the burden of these two pathologies. Our study also suggests that more efforts should be dedicated to HF and PE in order to achieve similar trends than in MI.

Progressive Decrease in Mortality of Post-Induction Marrow-Ablative Chemotherapy with Autologous Hematopoetic Cell Rescue for Young Children with Newly-Diagnosed Malignant Central Nervous System Tumors: The “Head Start” I-III (HSI-III) Trials, 1991-2009

Progressive Decrease in Mortality of Post-Induction Marrow-Ablative Chemotherapy with Autologous Hematopoetic Cell Rescue for Young Children with Newly-Diagnosed Malignant Central Nervous System Tumors: The “Head Start” I-III (HSI-III) Trials, 1991-2009

Mortalidade por doenças cardiovasculares no Brasil e na região metropolitana de São Paulo: atualização 2011

Cardiovascular diseases (CVD) are the leading causes of death in our population. There was a progressive decrease in mortality due to CVD up to 2005. To update the trends in mortality from cardiovascular diseases in Brazil and in the metropolitan region of São Paulo (MRSP) from 1990 to 2009. Mortality and population data were obtained from the Brazilian Institute of Geography and Statistics and the Ministry of Health. The risk of death was adjusted by the direct method, having as reference the world population in 2000. There was a progressive decrease in the risk of death from ischemic heart disease (IHD) and stroke in Brazil and in the MRSP. From 1990 to 2009, there was a decrease in mortality from IHD and stroke in men and women in Brazil and in the MRSP. There was a greater reduction in mortality from IHD in men in the MRSP than in Brazil (36.24% vs. 23.35%, p <0.001) and in women in the MRSP (44.55% vs. 29.5%; p <0.001). The highest reduction in stroke mortality was observed in men in the MRSP, when compared to Brazil (42.43% vs. 34.9%, p = 0.036) and an equal reduction in women in the MRSP and in Brazil (42.98% vs. 36.15%, p = 0.082). The decrease in mortality was significant for all age groups. We observed a progressive decrease in mortality from CVD, IHD and stroke in Brazil and in the MRSP. In spite of this decrease, we still have high rates of mortality from these diseases.

Thrombolysis and Outcome of Young Stroke Patients Over the Last Decade: Insights From the Nationwide Inpatient Sample

A recent study found a trend toward increasing hospitalizations for acute ischemic stroke (AIS) among young adults, raising concern for this subgroup. In the present study, we evaluated trends of use of thrombolysis and outcome among young adults (19-44 years of age) with AIS using a nationally representative administrative database. Discharge data were obtained from Nationwide Inpatient Sample between 2001 and 2009. Hospitalizations with a discharge diagnosis of AIS for patients 19 to 44 years of age were included. Use of thrombolysis was determined within this subset. The Cochran-Armitage test was used for trend analysis. Thrombolysis in young patients with AIS increased from 354 (1.84%) in 2001 to 1,237 (4.97%) in 2009 (P < .0001). The highest increase was noted at urban teaching hospitals. There was a progressive decrease in mortality in young AIS patients, from 6.81% in 2001 to 5.43% in 2009 (trend P = .027) and significant increase in discharges to rehabilitation (3.42% in 2002 to 12.7% in 2009 [trend P < .0001]). Discharge to other facilities decreased significantly (29.1% in 2001 to 17.8% in 2009 [trend P < .0001]). The rate of intracranial hemorrhage (2.70% in 2001; 2.69% in 2009) did not show any significant change despite the increase in the use of thrombolysis (trend P = .39). The rate of thrombolysis among young patients with AIS increased significantly between 2001 and 2009. A decrease in deaths with increased rehabilitation placements of young patients with AIS was noted over the last decade, suggesting improving outcomes. The lower rate of use of thrombolysis in rural hospitals may be improved with the widespread use of telestroke.

Abstract 2968: Outcomes Of Young Acute Ischemic Stroke Over The Last Decade: Insights From Nationwide Inpatient Sample

Background: The burden of young ischemic stroke has increased over the years. However, outcomes of young patients with acute ischemic stroke (AIS) remain unknown. Over the last decade, with increasing utilization rate of iv tpa, our objective was to evaluate trends in survival and discharge outcomes of young AIS patients in the United States. Methods: Data from the Nationwide Inpatient Sample for the years 2001 through 2009 were reviewed. Hospitalizations with a discharge diagnosis of an acute ischemic stroke (ICD-9 codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 424.01, 434.11, 434.91 and 436) were included. Nationwide estimates of deaths and discharge destination were calculated for each year within the young AIS subset. The Cochrane Armitage test was used to assess trend across the years Results: From 2001 through 2009, there were an estimated 4,917,217 admissions for acute ischemic stroke. Out of that, 204,703 (4.16%) were young patients with AIS. Thrombolysis in young ischemic stroke increased from 354 (1.84% of young AIS) in 2001 to 1237 (4.97%) in 2009 (p&lt;0.0001). There was a progressive decrease in mortality in young AIS patients, from 6.81% in 2001 to 5.43% in 2009 (trend p= 0.027). Discharge to home or home with home health did not show any significant change (trend p= 0.52). Discharge to rehabilitation facilities showed significant increase over the years, 3.42% in 2002 to 12.7% in 2009 (trend p &lt;0.0001). Discharge to other facilities other than rehabilitation showed significant decrease over the years, 29.1% in 2001 to 17.8% in 2009 (trend p&lt;0.0001). Rate of intracranial hemorrhage, 2.70% in 2001 to 2.69% in 2009, did not show any significant change despite increasing use of iv tpa (trend p=0.39). Conclusion: Over the last decade, deaths from AIS among young patients have decreased. The increase in rehabilitation placement and decrease in nursing home discharges suggest improving neurologic outcomes. Modern treatments such as stroke units, thrombolysis, and mechanical thrombectomy may be responsible for the reductions in mortality and morbidity.

Abstract 2801: Improved Outcomes among Patients with Decompressive Hemicraniectomy over the Last Decade: Insights from the Nationwide Inpatient Sample

Background: Hemicraniectomy provides a substantial survival benefit for patients with malignant middle cerebral artery infarcts. Over the last few years, our understanding of patient selection criteria for this potentially life-saving procedure has increased. Little is known about whether hemicraniectomy performance has improved outcomes following the procedure outside of clinical trials. Our objective was to evaluate trends in survival and discharge outcomes of ischemic stroke patients receiving hemicraniectomy in the United States over the last decade. Methods: Data from the Nationwide Inpatient Sample for the years 2001 through 2009 were reviewed. Hospitalizations with a discharge diagnosis of an acute ischemic stroke (ICD-9 codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 424.01, 434.11, 434.91 and 436) were included. Hemicraniectomy utilization was determined using procedure codes 01.2, 01.25 and 02.01. Nationwide estimates of deaths and discharge destination were calculated for each year within the hemicraniectomy subset. The Cochrane Armitage test was used to assess trend across the years. Results: The study included information from 4,917,217 stroke discharges over 9 years. Of these, an estimated 3,447 (0.07%) patients received a hemicraniectomy. There was a progressive decrease in mortality among hemi-craniectomy patients, from 50.1% in 2001 to 26.2% in 2009; trend p=0.016. This survival benefit over the years was primarily seen amongst males (trend p=0.04) and in the younger age group (age &lt;45 years trend p=0.06). Discharges to home (independent or with home care) showed a small decrease in trend over the 9 years. However discharges to rehabilitation facilities and nursing homes have increased over the years ( Figure ). Conclusions: Over the last decade, deaths from hemicraniectomy have decreased. A considerable proportion of survivors are being discharged to rehabilitation facilities and nursing homes. Appropriate patient selection and timing for hemicraniectomy has improved survival outcomes for these patients over the last decade. Data on long term neurologic recovery and patient satisfaction are needed.

Acute Pulmonary Thromboembolism: A Historical Perspective

639 diographic features of acute pulmonary thromboembolism are insensitive and nonspecific. The Westermark sign—oligemia of the lung beyond the occluded vessel—did not live up to early enthusiasm [10]. Similarly, elevation of the ipsilateral hemidiaphragm, enlargement of the proximal pulmonary artery, atelectasis, and pleural effusion are all nonspecific. The most common radiographic findings in the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study were atelectasis and patchy pulmonary opacity [11]. However, the prevalence of these findings in patients who did not have pulmonary thromboembolism was not significantly different. Radionuclide imaging (scintigraphy) became the mainstay of noninvasive imaging but had limitations. A normal ventilation–perfusion scan reliably excluded acute pulmonary thromboembolism, and a high-prob ability scan made this diagnosis with reasonable accuracy. However, a substantial proportion of ventilation–perfusion studies were nondiagnostic [12]. Over the years, the introduction of newer, safer, and quicker investigations has led to a progressive decrease in mortality from acute pulmonary thromboembolism [13]. In the early 1990s, the value of CT in the diagnosis of central pulmonary thromboembolism was documented by Remy-Jardin et al. [14]. CT was 90% sensitive and 96% specific for detection of central and lobar pulmonary thromboembolism, but segmental and subsegmental pulmonary thromboembolism was not assessed. In 1995, Goodman et al. [2] significantly advanced the field by comparing helical CT angiography (CTA) with pulmonary angiography in patients with unresolved suspicion for pulmonary thromboembolism and addressing the issue of segmental and subsegmental pulmonary thromboembolism. Acute Pulmonary Thromboembolism: A Historical Perspective

Continued improvement in survival among HIV-infected individuals with newer forms of highly active antiretroviral therapy

To characterize the temporal changes in mortality and life expectancy among HIV-positive individuals initiating antiretroviral therapy in British Columbia, Canada, from 1993 to 2004. This analysis was restricted to 2238 antiretroviral-naive HIV-positive individuals who started antiretroviral therapy between January 1993 and September 2004. The primary analysis endpoint was all-cause mortality stratified by four time periods: 1993-1995, 1996-1998, 1999-2001, and 2002-2004. Cox proportional hazard models, with associated 95% confidence intervals (CI), were used to estimate the hazard of death. Abridged life tables were constructed to compare life expectancies at the age of 20 years. Product limit estimates of the cumulative mortality rate at 12 months after therapy initiation decreased from 15.8% (+/- 1.6%) in 1993-1995 to 6.1% (+/- 1.1%) in 2002-2004. Life expectancy at the age of 20 years has increased from 9.1 years (+/- 2.3 years) in 1993-1995 to 23.6 years (+/- 4.4 years) in 2002-2004. Subjects in 1993-1995 were more likely to die than those who started therapy in 2002-2004 (hazard ratio 2.78; 95% CI 1.92-3.85). Patients who initiated dual therapy or therapies containing three or more antiretroviral drugs were, respectively, 1.49 (95% CI 1.23-1.82) and 2.56 (95% CI 2.13-3.13) times less likely to die than those who started on monotherapy. A significant and progressive decrease in mortality and increase in life expectancy were observed over the 12-year study period. The increase in life expectancy and decrease in mortality were directly associated with the use of modern forms of HAART.

Heart and Lung Transplantation Pathology: The Padua Experience

Physicians caring for heart and lung transplantation patients utilize routine follow-up biopsies on a prearranged schedule unrelated to the suspicion of a clinical diagnosis of rejection. Of course biopsies are also performed outside the prearranged scheme at any time the clinician is puzzled by clinical suspicion of rejection or infections. Technical considerations are important in handling the biopsies; pathologists who are aware of bias produced by tissue processing are forced to serially section the samples to increase the sensitivity for detection of the pathological processes. During the 20 years since the first Italian cardiac transplantation was performed in our center, 600 patients have been transplanted and monitored with 12,386 endomyocardial biopsies. The overall 5-year mortality was 24.5% and 18.4% in pediatric populations; at 10 years, 34%, and at 19 years, 55%. There was a progressive decrease in mortality from 36.8% in 1985 to 1990 to 12% in the 1996 to 2000. During a decade of experience in lung transplantation from May 1995 to May 2005 ( n = 129), all patients underwent surveillance bronchoscopy including transbronchial biopsy ( n = 722) and bronchoalveolar lavage ( n = 629). The ancillary techniques of immunohistochemistry and molecular analysis have allowed the pathologists to play a pivotal role in the pre- and posttransplant management of patients requiring thoracic organ transplantation.

Acute appendicitis in children under six years

The most common condition in children which requires intra-abdominal surgery is acute appendicitis. 1 With each passing decade the mortality and morbidity of appendicitis has decreased with improvement in diagnotic acumen, safer anesthesia, advances in surgical technic, better pre- and postoperative care, and probably most important the introduction of antibiotics in the 1940's. At the Charity Hospital in New Orleans from 1953 to 1963, in 737 patients under the age of 12 years, Brickman and Leon 2 found a mortality of 0.81 per cent in acute appendicitis. From 1950 to 1960, in 1987 children operated upon for acute appendicitis at the Children's Hospital of Cincinnati 3 the mortality rate was 0.35 per cent. In 1358 cases reviewed by Longino et al. 1 covering the years 1924 to 1957 at the Boston Children's Hospital, there was a 0.07 per cent mortality rate. Despite this progressive decrease in mortality at major medical centers, 284 children died of appendicitis in the United States in 1955. 4 Of these children 102 were less than 5 years old. It is the purpose of this paper to review the experience at the Santa Clara Valley Medical Center in managing appendicitis in children under 6 years, to appraise these methods in terms of mortality and morbidity, and to elucidate the principles of management which contribute to accurate diagnosis and successful treatment.