Reduction In Case Fatality Rate Research Articles

Does the Implementation of Regulation Affect COVID-19 Transmissibility and Mortality? Lessons Learned from Nganjuk Regency

Background: Coronavirus disease 2019 (COVID-19) as a global pandemic is ineluctable, transmission that originated from a foreign country became the local transmission in Indonesia. As several regional authorities implemented a large-scale social restriction policy to reduce the transmission of COVID-19, the Nganjuk Regency government chose to implement a different strategy with the implementation of Regent Regulation number 28 of 2020 about novel practice in the COVID-19 pandemic situation. Objective: This study aimed to analyze the impact of the implementation of the regulation on COVID-19 transmissibility and mortality at the Nganjuk Regency. Methods: Data were collected from the daily confirmed cases and death of COVID-19 made accessible for the public by the Nganjuk Regency Task Force for COVID-19 and Nganjuk Regency Health Office starting from March 30th to September 20th. Interrupted time series analysis was performed to estimate the impact of the implementation of regent regulation on COVID-19 transmission and mortality parameters. Result: The trend of new confirmed cases and deaths of COVID-19 in the Nganjuk Regency continued to fluctuate before and even after the implementation of regent regulation. It was found that there were reductions in case of fatality rates by -0.002 ± 0.003 (ρ 0.002) on CFR and -0.008 ± 0.008 (ρ 0.007) on eCFR after the regent regulation was implemented but there was no significant reduction on COVID-19 transmissibility parameter. Conclusion: Implementation of regent regulation in Nganjuk Regency significantly affected the reduction of case fatality rate but failed to slow down the COVID-19 transmissibility. Intensive community engagement to comply with the health preventive measures should be considered as an effective preventive strategy to reduce the transmission of COVID-19.

Evolution of human respiratory virus epidemics.

Background: Pathogens are often assumed to evolve towards reduced virulence, but counterexamples abound. Faced with a new pathogen, such as SARS-CoV-2, it is crucial to be able to forecast the case fatality rate (CFR) and the overall disease burden. Considerable effort has been invested towards developing a mathematical framework for predicting virulence evolution. Although many approaches accurately recapitulate complex outcomes, most rely on an assumed trade-off between CFR and infection rate. It is often impractical to empirically validate this constraint for human pathogens. Methods: A compartment model with parameters tuning the degree to which symptomatic individuals are isolated and the duration of immunity is constructed and evaluated at both short timescales and at equilibrium. Results: We reveal kinetic constraints whereby variation of multiple parameters in concert leads to decreased CFR and increased pathogen fitness, whereas independent variation of the parameters decreases pathogen fitness. Smallpox, SARS-CoV-2, and influenza are analyzed as diverse representatives of human respiratory viruses. We show that highly virulent viruses, such as smallpox, are often constrained by the host behavior, whereas moderately virulent viruses, such as SARS-CoV-2, appear to be typically constrained by the relationship between the duration of immunity and CFR. Conclusions: Evolution of human respiratory epidemics appears to be often kinetically constrained and a reduction in CFR should not be assumed. These results agree with previous work demonstrating an increase in virulence for smallpox and further predict that SARS-CoV-2 is likely to continue presenting a substantial disease burden. Herd immunity against SARS-CoV-2 and viruses with similar life history traits might be unachievable without vaccination. However, partial isolation of symptomatic individuals can have a major effect on the epidemic dynamics not only by reducing the number of fatalities in the short term but also by changing the evolutionary trajectory of moderate CFR viruses towards reduced CFR.

Evolution of human respiratory virus epidemics

Background: Pathogens are often assumed to evolve towards reduced virulence, but counterexamples abound. Faced with a new pathogen, such as SARS-CoV-2, it is crucial to be able to forecast the case fatality rate (CFR) and the overall disease burden. Considerable effort has been invested towards developing a mathematical framework for predicting virulence evolution. Although many approaches accurately recapitulate complex outcomes, most rely on an assumed trade-off between CFR and infection rate. It is often impractical to empirically validate this constraint for human pathogens.Methods: A compartment model with parameters tuning the degree to which symptomatic individuals are isolated and the duration of immunity is constructed and evaluated at both short timescales and at equilibrium.Results: We reveal kinetic constraints whereby variation of multiple parameters in concert leads to decreased CFR and increased pathogen fitness, whereas independent variation of the parameters decreases pathogen fitness. Smallpox, SARS-CoV-2, and influenza are analyzed as diverse representatives of human respiratory viruses. We show that highly virulent viruses, such as smallpox, are often constrained by the host behavior, whereas moderately virulent viruses, such as SARS-CoV-2, appear to be typically constrained by the relationship between the duration of immunity and CFR.Conclusions: Evolution of human respiratory epidemics appears to be often kinetically constrained and a reduction in CFR should not be assumed. These results agree with previous work demonstrating an increase in virulence for smallpox and further predict that SARS-CoV-2 is likely to continue presenting a substantial disease burden. Herd immunity against SARS-CoV-2 and viruses with similar life history traits might be unachievable without vaccination. However, partial isolation of symptomatic individuals can have a major effect on the epidemic dynamics not only by reducing the number of fatalities in the short term but also by changing the evolutionary trajectory of moderate CFR viruses towards reduced CFR.

Evolution of human respiratory virus epidemics.

Background: It is often assumed that pathogens evolve towards reduced virulence, but counterexamples abound. Faced with a new pathogen, such as SARS-CoV-2, it is highly desirable to be able to forecast the case fatality rate (CFR) and overall disease burden into the future. Considerable effort has been invested towards the development of a mathematical framework for predicting virulence evolution. Although many approaches accurately recapitulate complex outcomes, most rely on an assumed trade-off between CFR and infection rate. It is often impractical to empirically validate this constraint for human pathogens. Methods: A compartment model with parameters tuning the degree to which symptomatic individuals are isolated and the duration of immunity is constructed and evaluated at both short timescales and at equilibrium (when it exists). Results: We reveal kinetic constraints where the variation of multiple parameters in concert leads to decreased CFR and increased pathogen fitness, whereas independent variation of the parameters decreases pathogen fitness. Smallpox, SARS-CoV-2, and influenza are analyzed as diverse representatives of human respiratory viruses. We show that highly virulent viruses, such as smallpox, are likely often constrained by host behavior, whereas moderately virulent viruses, such as SARS-CoV-2, appear to be typically constrained by the relationship between the duration of immunity and CFR. Conclusions: Evolution of human respiratory epidemics appears to be often kinetically constrained and a reduction in CFR should not be assumed. Our findings imply that, without continued public health intervention, SARS-CoV-2 is likely to continue presenting a substantial disease burden. The existence of a parameter regime admitting endemic equilibrium suggests that herd immunity is unachievable. However, we demonstrate that even partial isolation of symptomatic individuals can have a major effect not only by reducing the number of fatalities in the short term but also by potentially changing the evolutionary trajectory of the virus towards reduced CFR.

Clinical effect and antiviral mechanism of T-705 in treating severe fever with thrombocytopenia syndrome

Severe fever with thrombocytopenia syndrome (SFTS) virus (SFTSV) is an emerging tick-borne virus with high fatality and an expanding endemic. Currently, effective anti-SFTSV intervention remains unavailable. Favipiravir (T-705) was recently reported to show in vitro and in animal model antiviral efficacy against SFTSV. Here, we conducted a single-blind, randomized controlled trial to assess the efficacy and safety of T-705 in treating SFTS (Chinese Clinical Trial Registry website, number ChiCTR1900023350). From May to August 2018, laboratory-confirmed SFTS patients were recruited from a designated hospital and randomly assigned to receive oral T-705 in combination with supportive care or supportive care only. Fatal outcome occurred in 9.5% (7/74) of T-705 treated patients and 18.3% (13/71) of controls (odds ratio, 0.466, 95% CI, 0.174–1.247). Cox regression showed a significant reduction in case fatality rate (CFR) with an adjusted hazard ratio of 0.366 (95% CI, 0.142–0.944). Among the low-viral load subgroup (RT-PCR cycle threshold ≥26), T-705 treatment significantly reduced CFR from 11.5 to 1.6% (P = 0.029), while no between-arm difference was observed in the high-viral load subgroup (RT-PCR cycle threshold <26). The T-705-treated group showed shorter viral clearance, lower incidence of hemorrhagic signs, and faster recovery of laboratory abnormities compared with the controls. The in vitro and animal experiments demonstrated that the antiviral efficacies of T-705 were proportionally induced by SFTSV mutation rates, particularly from two transition mutation types. The mutation analyses on T-705-treated serum samples disclosed a partially consistent mutagenesis pattern as those of the in vitro or animal experiments in reducing the SFTSV viral loads, further supporting the anti-SFTSV effect of T-705, especially for the low-viral loads.

Socioeconomic differences in health-care use and outcomes for stroke and ischaemic heart disease in China during 2009–16: a prospective cohort study of 0·5 million adults

SummaryBackgroundChina initiated major health-care reforms in 2009 aiming to provide universal health care for all by 2020. However, little is known about trends in health-care use and health outcomes across different socioeconomic groups in the past decade.MethodsWe used data from the China Kadoorie Biobank (CKB), a nationwide prospective cohort study of adults aged 30–79 years in 2004–08, in ten regions (five urban, five rural) in China. Individuals who were alive in 2009 were included in the present study. Data for all admissions were obtained by linkage to electronic hospital records from the health insurance system, and to region-specific disease and death registers. Generalised linear models were used to estimate trends in annual hospital admission rates, 28-day case fatality rates, and mean length of stay for stroke, ischaemic heart disease, and any cause in all relevant individuals.Findings512 715 participants were recruited to the CKB between June 25, 2004, and July 15, 2008, 505 995 of whom were still alive on Jan 1, 2009, and contributed to the present study. Among them, we recorded 794 824 hospital admissions (74 313 for stroke, 69 446 for ischaemic heart disease) between 2009 and 2016. After adjustment for demographic, socioeconomic, lifestyle, and morbidity factors, hospitalisation rates increased annually by 3·6% for stroke, 5·4% for ischaemic heart disease, and 4·2% for any cause, between 2009 and 2016. Higher socioeconomic groups had higher hospitalisation rates, but the annual proportional increases were higher in those with lower education or income levels, those enrolled in the urban or rural resident health insurance scheme, and for those in rural areas. Lower socioeconomic groups had higher case fatality rates for stroke and ischaemic heart disease, but greater reductions in case fatality rates than higher socioeconomic groups. By contrast, mean length of stay decreased by around 2% annually for stroke, ischaemic heart disease, and any cause, but decreased to a greater extent in higher than lower socioeconomic groups for stroke and ischaemic heart disease.InterpretationBetween 2009 and 2016, lower socioeconomic groups in China had greater increases in hospital admission rates and greater reductions in case fatality rates for stroke and ischaemic heart disease. Additional strategies are needed to further reduce socioeconomic differences in health-care use and disease outcomes.FundingWellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, China Ministry of Science and Technology, and Chinese National Natural Science Foundation.

ES08.03 The Magnitude of the Benefit

Why do people get screened? The obvious answer is so that cancer can be detected early with a view towards a higher chance of cure with early treatment. Therefore, the critical questions that must be addressed relate to the risk of cancer over time and then, how likely cure will be when screen-detected versus clinically detected. Current approaches to evaluate screening have relied on randomized controlled trials with a view towards demonstrating that a benefit actually exists but are not designed to quantify the magnitude of the benefit. Current trial designs have limited rounds of screening and long-term follow up after screening has stopped. When these parameters change, the results of the trial will also change. Several approaches currently exist to estimate that critical parameter regarding the curability of screen detected lung cancer. This includes modeling approaches which can use data extracted from a variety of sources, they can also be measured directly as was done in the I-ELCAP study which measures directly the reduction in case fatality rate by using long term survival as a measure of cure, and an additional approach would be to screen continuously in the context of a clinical trial and measure the reduction in mortality after several years of screening where the benefit of screening reaches its maximum and becomes equivalent to the reduction in case fatality rate. When applied to lung cancer it can be shown that this benefit is far greater than the 20% so commonly reported and instead is in the 60=80% range for cure. Were this to be fully understood the entire rationale behind requiring shared decision making would be called into question as it was thought that the balance between benefits and harms was so tenuous that shared decision making was necessary. When considering whether a particular type of screening is to be considered beneficial there is also a tendency to compare different types of screening and seeing how many screens are necessary to save a life. Here to, this approach suffers from the same mistake. Each of those screening exams estimates this number based on their own randomized trial and each of these differ in terms of the design parameters, therefore the comparisons are essentially meaningless. benefit, lung cancer screening

Efficacy of World Health Organization guideline in facility-based reduction of mortality in severely malnourished children from low and middle income countries: A systematic review and meta-analysis.

Globally more than 19 million under-five children suffer from severe acute malnutrition (SAM). Data on efficacy of World Health Organization's (WHO's) guideline in reducing SAM mortality are limited. We aimed to assess the efficacy of WHO's facility-based guideline for the reduction of under-five SAM children mortality from low and middle income countries (LMICs). A systematic search of literature published in 1980-2015 was conducted using electronic databases. Additional articles were identified from the reference lists and grey literature. Studies from LMICs where SAM children (0-59 months) were managed in facilities according to WHO's guideline were included. Outcome was reduction in SAM mortality measured by case fatality rate (CFR). The review was reported following the Grading of Recommendations Assessment Development and Evaluation and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline and meta-analyses done using RevMan 5.3®. This review identified nine studies, which demonstrated reductions in SAM mortality. CFR ranged from 8 to 16% where WHO guideline applied. High rates of poverty, malnutrition, severe co-morbid condition, lack of resources and differences in treatment practices played a key role in large CFR variation. Most death occurred within 48 h of admission in Asia, between 4 days and 4 weeks in Africa and in Latin America. CFR was reduced by 41% (odds ratio: 0.59; 95% confidence interval: 0.46-0.76) when WHO guideline were applied. A 45% reduction in CFR was achieved after excluding human immunodeficiency virus positive cases. Dietary management also differed among WHO and conventional management. Children receiving SAM inpatient care as per WHO guideline have reduced CFR compared to conventional treatment.

Reducing maternal deaths in a low resource setting in Nigeria

To assess the impact of the adoption of evidence based guidelines on maternal mortality reduction at Enugu State University Teaching Hospital, Nigeria. A retrospective review of all maternal deaths between 1 st January, 2005 and 31 st December, 2010 was carried out. Evidence based management guidelines for eclampsia and post-partum hemorrhage were adopted. These interventions strategy were carried out from 1 st January, 2008-31 st December, 2010 and the result compared with that before the interventions (2005-2007). Maternal mortality ratio (MMR) and case fatality rates. There were 9150 live births and 59 maternal deaths during the study period, giving an MMR of 645/100 000 live births. Pregnant women who had no antenatal care had almost 10 times higher MMR. There was 43.5% reduction in the MMR with the interventions (488 vs. 864/100 000 live births P = 0.039, odds ratio = 1.77). There was also significant reduction in case fatality rate for both eclampsia (15.8% vs. 2.7%; P = 0.024, odds ratio = 5.84 and Post partum hemorrhage (PPH) (13.6% vs. 2.5% P value = 0.023, odds ratio = 5.5. Obstetric hemorrhage was the most common cause of death (23.73%), followed by the eclampsia. Administration of evidence based intervention is possible in low resource settings and could contribute to a significant reduction in the maternal deaths.

Lethality by pneumonia and factors associated to death

ObjectiveTo describe the case-fatality rate (CFR) and risk factors of death in children with community-acquired acute pneumonia (CAP) in a pediatric university hospital. MethodA longitudinal study was developed with prospective data collected from 1996 to 2011. Patients aged 1 month to 12 years were included in the study. Those who left the hospital against medical orders and those transferred to ICU or other units were excluded. Demographic andclinical-etiological characteristics and the initial treatment were studied. Variables associated to death were determined by bivariate and multivariate analysis using logistic regression. ResultsA total of 871 patients were selected, of whom 11 were excluded; thus 860 children were included in the study. There were 26 deaths, with a CFR of 3%; in 58.7% of these, penicillin G was the initial treatment. Pneumococcus was the most common pathogen (50.4%). From 1996 to 2000, there were 24 deaths (93%), with a CFR of 5.8% (24/413). From 2001 to 2011, the age group of hospitalized patients was older (p = 0.03), and the number of deaths (p = 0.02) and the percentage of disease severity were lower (p = 0.06). Only disease severity remained associated to death in the multivariate analysis (OR = 3.2; 95%CI: 1.2-8.9; p = 0.02). ConclusionWhen the 1996-2000 and 2001-2011 periods were compared, a significant reduction in CFR was observed in the latter, as well as a change in the clinical profile of the pediatric in patients at the institute. These findings may be related to the improvement in the socio-economical status of the population. Penicillin use did not influence CFR.

Sepsis without borders

Sepsis without borders

Vena Cava Filters in Unstable Elderly Patients with Acute Pulmonary Embolism

BackgroundInferior vena cava filters are associated with a reduced in-hospital all-cause case fatality rate of unstable patients with acute pulmonary embolism. Whether vena cava filters are associated with a reduced case fatality rate in adults of all ages with unstable pulmonary embolism, particularly the elderly, has not been determined. MethodsUnstable patients with pulmonary embolism (in shock or ventilator dependent) 1999-2008 were identified from the Nationwide Inpatient Sample. ResultsAmong 21,095 unstable patients with pulmonary embolism who received thrombolytic therapy, in-hospital all-cause case fatality rate was lower in every age group who received a vena cava filter in addition to thrombolytic therapy (P = .0012 to <.0001). Patients aged ≥81 years showed the greatest absolute reduction of case fatality rate with filters (19.3%). Among 50,210 unstable patients who did not receive thrombolytic therapy, case fatality rate also was lower in every age group who received a vena cava filter (all P <.0001). Patients aged ≥81 years with vena cava filters showed the greatest absolute risk reduction of case fatality rate (27.7%). ConclusionVena cava filters are associated with a reduced in-hospital all-cause case fatality rate in unstable adults with pulmonary embolism, irrespective of age.

Vitamin C for preventing and treating tetanus

Tetanus is a severe disease that can be prevented by vaccination. In developing countries vaccination coverage is not always high. Cases still occur also in developed countries, particularly in elderly people owing to their reduced immuno protection. There are about 1 million tetanus cases per year globally. In animal studies, vitamin C has protected against various infections and bacterial toxins. In a study with rats, vitamin C protected against the purified tetanus toxin. To assess the prophylactic and therapeutic effect of vitamin C on tetanus. In May 2013 we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations ); and Ovid EMBASE for this third update. Controlled trials of vitamin C as a prevention or treatment for tetanus, whether or not these were placebo controlled, in any language, published or unpublished. Two review authors independently made inclusion decisions. Both review authors independently extracted data from trial reports and assessed methodological quality. Since one of the cells in a 2 × 2 table had no events, we calculated the odds ratio (OR) and its 95% confidence interval (CI) for case fatality rate by using the Peto-method. Another of the 2 × 2 tables had no empty cells and the inverse-variance method was used to calculate its risk ratio (RR) estimate and 95% CI. We also used the Fisher's exact test to calculate the exact 95% CI for the OR of the 2 × 2 table with the empty cell. One single trial was eligible for inclusion. This non-randomised, unblinded, controlled trial undertaken in Bangladesh involved 117 tetanus patients. Vitamin C at a dosage of 1 g/day was administered intravenously alongside conventional treatment. At recruitment, the participants were stratified into two age groups and the results were reported by age. There was a significant difference in the vitamin C effect between the two age groups (P = 0.01). In the tetanus patients aged 1 to 12 years (n = 62), vitamin C treatment was associated with a 100% reduction in case fatality rate (95% CI from -100% to -94%). In patients aged 13 to 30 years (n = 55), vitamin C treatment was associated with a 45% reduction in case fatality rate (95% CI from -69% to -5%). A single, non-randomised, poorly reported trial of vitamin C as a treatment for tetanus suggests a considerable reduction in mortality. However, concerns about trial quality mean that this result must be interpreted with caution and vitamin C cannot be recommended as a treatment for tetanus on the basis of this evidence. New trials should be carried out to examine the effect of vitamin C on tetanus treatment.

Lethality by pneumonia and factors associated to death

Objectiveto describe the case-fatality rate (CFR) and risk factors of death in children with community-acquired acute pneumonia (CAP) in a pediatric university hospital. Methoda longitudinal study was developed with prospective data collected from 1996 to 2011. Patients aged 1 month to 12 years were included in the study. Those who left the hospital against medical orders and those transferred to ICU or other units were excluded. Demographic and clinical-etiological characteristics and the initial treatment were studied. Variables associated to death were determined by bivariate and multivariate analysis using logistic regression. Resultsa total of 871 patients were selected, of whom 11 were excluded; thus 860 children were included in the study. There were 26 deaths, with a CFR of 3%; in 58.7% of these, penicillin G was the initial treatment. Pneumococcus was the most common pathogen (50.4%). From 1996 to 2000, there were 24 deaths (93%), with a CFR of 5.8% (24/413). From 2001 to 2011, the age group of hospitalized patients was older (p = 0.03), and the number of deaths (p = 0.02) and the percentage of disease severity were lower (p = 0.06). Only disease severity remained associated to death in the multivariate analysis (OR = 3.2; 95%CI: 1.2-8.9; p = 0.02). Conclusionwhen the 1996-2000 and 2001-2011 periods were compared, a significant reduction in CFR was observed in the latter, as well as a change in the clinical profile of the pediatric inpatients at the institute. These findings may be related to the improvement in the socio-economical status of the population. Penicillin use did not influence CFR.

Vena cava filters in hospitalised patients with chronic obstructive pulmonary disease and pulmonary embolism

In view of the high case fatality rates of patients with chronic obstructive pulmonary disease (COPD) who have pulmonary embolism (PE) we speculated that such patients might benefit from vena cava filters. To test this hypothesis we assessed the database of the Nationwide Inpatient Sample. From 1998-2009, 440,370 patients were hospitalised with PE and COPD who were not in shock or ventilator-dependent and did not receive thrombolytic therapy or pulmonary embolectomy. In-hospital all-cause case fatality rate among those with filters was 5,890 of 68,800 (8.6%) (95% confidence interval [CI] = 8.4-8.8) compared with 38,960 of 371,570 (10.5%) (95% CI = 10.4-10.6) (p<0.0001) who did not receive filters. Case fatality rate was age-dependent. Only those who were older than aged 50 years had a lower in-hospital all-cause case fatality rate with filters. Among such patients, absolute risk reduction was 2.1% (95% CI = 1.9-2.3). The greatest reduction of case fatality rate with vena cava filters was shown in patients >aged 80 years, 11,720 of 81,600 (14.4%) compared with 1,570 of 17,220 (9.1%) (p<0.0001). In conclusion, a somewhat lower in-hospital all-cause case fatality rate was shown with vena filters in stable patients with PE >aged 50 years who also had COPD. The benefit was greatest in elderly patients. The benefit in terms of a decreased case fatality rate would seem to outweigh the risks of vena cava filters in such patients.

Trends in case fatality rate in pulmonary embolism according to stability and treatment

PurposeTo determine categories of patients with pulmonary embolism in whom therapy has been reducing or failing to reduce case fatality rate. MethodsPatients with acute pulmonary embolism were assessed from the Nationwide Inpatient Sample, 1999–2008. Trends of case fatality rates were assessed according to whether patients were stable or unstable and according to treatment within these groups. ResultsIn-hospital all-cause case fatality rate among all patients with pulmonary embolism decreased from 16,150 of 136,740 (11.8%) in 1999 to 23,040 of 311,620 (7.4%) in 2008. All-cause case fatality rate decreased 45.0% in stable patients from 14,780 of 133,230 (11.1%) in 1999 to 18,170 of 297,770 (6.1%) in 2008. In unstable patients it decreased only 9.7% from 1,370 of 3,510 (39.0%) in 1999 to 4,870 of 13,850 (35.2%) in 2008. Only 72,230 of 2,110,320 (3.4%) patients with acute pulmonary embolism were unstable. Among unstable patients who received thrombolytic therapy, all-cause mortality did not change from 1999–2008. Among unstable patients treated only with anticoagulants and/or a vena cava filter, all-cause case fatality rate decreased 23.6% from 1,110 of 2,080 (53.4%) in 1999 to 4,290 of 10,530 (40.7%) in 2008, but remained higher than in those treated with thrombolytic agents. Case fatality rates attributable to pulmonary embolism were lower than all-cause case fatality rate, but showed similar trends. ConclusionsThe decreasing all-cause case fatality rate and case fatality rate attributable to pulmonary embolism from 1999–2008 resulted primarily from a decreasing case fatality rate in stable patients. There was no reduction of case fatality rate in unstable patients who received thrombolytic therapy, although case fatality rate was relatively low with thrombolytic therapy plus a vena cava filter. Most unstable patients, however, failed to receive this combination of therapy.

Benefits of using magnesium sulphate (MgSO4) for eclampsia management and maternal mortality reduction: lessons from Kano State in Northern Nigeria

BackgroundDespite clear emphasis through the Millennium Development Goals, the problem of high maternal mortality persists especially within low and middle income countries. Various studies report remarkably high maternal mortality rates in northern Nigeria, where maternal mortality rates exceed 1,000 deaths per 100,000 live births and eclampsia contributes approximately 40% of maternal deaths. Across Nigeria, diazepam is routinely used for the management of eclampsia. Prior to February 2008, diazepam was widely used for the management of eclampsia in Kano State (within northern Nigeria) with case fatality rate being over 20%. While magnesium sulphate (MgSO4) is recognized as the most effective drug for the management of eclampsia; this study aims to compare MgSO4 therapy with diazepam therapy in terms of case fatality rates and costs.FindingsThis retrospective study, including 1045 patients with eclampsia and pre-eclampsia during the years 2008 and 2009, reports a drop in case fatality rates from 20.9% (95% CI: 18.7, 23.2) to 2.3% (95% CI: 1.4, 3.2) among eclampsia patients following the MgSO4 intervention. The study observed no significant difference in the cost of using MgSO4 therapy compared to diazepam therapy.ConclusionsThe study found a remarkable reduction in case fatality rate due to eclampsia in those who received MgSO4 therapy with minimal increase in costs when compared to diazepam therapy. Concerted efforts should be focused on properly introducing MgSO4 into emergency obstetric protocols especially within developing countries to reduce maternal mortality and also impact on health system performance.

MRI in acute myocardial infarction

Although acute myocardial infarction (AMI) is still one of the main causes of high morbidity in Western countries, the rate of mortality has decreased significantly. The main cause of this drop appears to be the decline of the incidence of ST-segment elevation myocardial infarction (STEMI) along with an absolute reduction in case fatality rate once STEMI has occurred. Myocardial ischaemia progresses with the duration of coronary occlusion and the delay in time to reperfusion determines the extent of irreversibile necrosis from subendocarial layers towards the epicardium in accordance with the so-called 'wave-front phenomenon'. Coronary artery recanalization, either by thrombolitic therapy or primary percutaneous intervention, may prevent myocardial cell necrosis increasing salvage of damaged, but still viable, myocardium within the area at risk. Magnetic resonance imaging (MRI) can provide a wide range of clinically useful information in AMI by detecting not only location of transmural necrosis, infarct size and myocardial oedema, but also showing in vivo important microvascular pathophysiological processes associated with AMI in the reperfusion era, such as intramyocardial haemorrhage and no-reflow. The focus of this review will be on the impact of cardiac MRI in the characterization of AMI pathophysiology in vivo in the current reperfusion era, concentrating also on clinical applications and future perspectives for specific therapeutic strategies.

Editorial Hospital care for children in developing countries: getting the evidence where it matters

Medical knowledge is in constant flux: what is done routinely today is considered obsolete tomorrow. In the 1980, children presenting with viral croup to major university hospitals in Germany were treated with cold water nebulisation of the room in the attempt to create a cold, moist atmosphere which would make it easier for the children to breathe, and steroids were despised. Nowadays, the role of steroids is firmly established in the treatment of croup (Russell et al. 2004), and there is little, if any, evidence for the use of cold water nebulisation (Moore & Little 2006). Guidelines only reflect the knowledge of the day, and need to be regularly updated. The WHO Department of Child and Adolescent Health and Development and its predecessors, the ARI and diarrhoeal diseases control programmes, have a long history of developing evidence-based guidelines for clinical conditions affecting children in developing countries, such as pneumonia, neonatal sepsis and diarrhoea. The use of fast breathing as a clinical sign to detect pneumonia was suggested by workers in Papua New Guinea (Shann et al. 1984), and systematic research in other countries led to its adoption as the main sign to base the diagnosis of pneumonia on. Similarly, original guidelines used for identifying sick newborns that require hospital care were refined and simplified in further research (Young Infants Clinical Signs Study Group 2008). Documenting this evidence in a systematic way has become an integral part of guideline development. The quality of care provided in first level hospitals in developing countries has a major impact on the health and lives of millions of children admitted with severe disease each year. Throughout the world, care in these small district hospitals is provided by nurses, paramedical workers and non-specialist doctors. While child survival initiatives have largely focused on community interventions and primary care, large proportions of hospital funding and resources are allocated to tertiary institutions. As a result, most critically ill children are cared for where resources are inadequate, support from central agencies is lacking, there is poor access to information, there is little ongoing professional development or staff training and staff morale is invariably low (Nolan et al. 2001). Formative research on the quality of hospital care in seven countries found as one of the major problems the lack of treatment guidelines in small hospitals. This led to the development of the manual ‘Management of the child with a serious infection or severe malnutrition’, published in 2000 (WHO 2000). The book filled a gap and was much appreciated. However, a survey performed by WHO after publication on useful features and possible improvements of this book brought up several suggestions which led to the development of the ‘Pocket book of hospital care for children’ as the successor of the previous manual (WHO 2005). Apart from several expansions, such as a larger section on neonatal problems, the inclusion of surgical conditions and of HIV, the prominent feature is its pocket size and sturdy binding and cover. This made the pocket book an instantaneous success. David Morley considered it to be one of two essential publications for the district hospital, and made it available through the TALC dissemination network. There have been substantial reductions in case fatality rates where such hospital guidelines have been introduced and when they are accompanied by training, audit or other quality improvement measures. Implementation of guidelines for the management of severe malnutrition (Ahmed et al. 1999; Ashworth et al. 2004), oxygen delivery (Duke et al. 2000a) and neonatal care (Duke et al. 2000b) have reduced case fatality rates in hospitals in several developing countries. Emergency triage and treatment approaches, which are included in the WHO guidelines, are effectively used by nurses to identify and manage seriously ill children in busy outpatient departments in developing countries (Tamburlini et al. 1999; Molyneux 2001). Tropical Medicine and International Health doi:10.1111/j.1365-3156.2009.02390.x

A criterion based audit of the management of obstructed labour in Malawi

To assess and improve the management of obstructed labour in maternity units in Malawi. A criterion based audit of the management of obstructed labour was conducted in 8 hospitals in three districts in Malawi. Management practices were: (a) assessed by a retrospective review of 44 cases notes, and (b) compared with local standards established, by a multidisciplinary team, based on the Malawi Ministry of Health guidelines and World Health Organisation manuals. Gaps in current practice were identified, reasons discussed, and recommendations made and implemented. A re-audit (41 case notes) was conducted 3 months later. There were significant improvements in the attainment of four standards: draining of urinary bladder (70.5 vs. 90.2%; P = 0.022), administration of broad spectrum antibiotics (72.7 vs. 90.2%; P = 0.039), commencement of Caesarean section within 1 hour or delivery of the foetus within 2 h of diagnosis (38.6 vs. 61.0%; P = 0.023), and maintaining an observation chart (45.5 vs. 61.0%; P < 0.001). However, there was no significant change in two standards: securing an intravenous line and hydrating the patient (95.5 vs. 97.6%; P = 0.804), and typing and cross-match of blood (77.3 vs. 63.4%; P = 0.197). There was a reduction in case fatality rate (9.1 vs. 2.4%; P = 0.361) and perinatal mortality (18.8 vs. 12.2%, P = 0.462). Criterion based audit can improve the management of obstructed labour in countries with limited resources.