Risk Of Serious Morbidity Research Articles

Pregnancies in women with diabetic nephropathy: long-term outcome for mother and child

In order to improve the basis upon which to advise women with diabetic nephropathy about pregnancy, we studied the effect of diabetic nephropathy on the course of pregnancy, perinatal out-come, infant development and long-term outcome of the mothers. All pregnancies of women with diabetic nephropathy (defined as proteinuria >400 mg/day (n=26), creatinine clearance <80 ml/min and hypertension in the first trimester (n=10)) followed at our centre from 1982 to 1992 were identified (34 White class F and 2 White class T) and the women and their children re-examined in the spring 1993. From the first to the third trimester the percentage of women with proteinuria over 3 g/day increased from 14 to 53% and those treated with anti-hypertensive medication from 53 to 97%. There were no intrauterine or perinatal deaths, but one child died suddenly 4 weeks postpartum. Of 36 new-borns (gestational week at birth 36(3), birth weight 2384(834) g)), 11 were born before week 34 and 8 had respiratory distress syndrome. Renal function in the first trimester, diastolic blood pressure in the third trimester and an HbA1c above normal were predictive of gestational age at delivery and low birth weight (stepwise regression analysis). At follow-up of the children (n=35, age 4.5 (0.4–10) years) the majority (n=27) were normally developed but seven had psychomotor retardation (four of them major). One child had a severe motor retardation due to a congenital anomaly. At follow up, 21 of the 29 mothers had preserved renal function (creatinine 1.3 (0.8–4.3) mg/dl and 8 had developed end stage renal disease and required dialysis (2 of whom were White class T) within 3 (1–9) years postpartum. Of those, 4 women (3 White F and 1 White T) had died. Pregnancy did not seem to specifically accelerate the rate of decline of renal function. In women with diabetic nephropathy perinatal mortality can be prevented but perinatal and long-term infant morbidity remains elevated. Women with severely impaired renal function before pregnancy are at risk for serious morbidity when their children are still young. Improvement might be made if all women were to receive specialized care and counselling before, throughout and after pregnancy.

Mortality in immune thrombocytopenic purpura: report of seven cases and consideration of prognostic indicators.

ITP (immune thrombocytopenic purpura) is generally considered a benign disease. Despite what may be severe thrombocytopenia, most patients with ITP do not suffer significant bleeding episodes. Mortality is rare, and the majority of cases are managed successfully with conventional treatments. For patients who maintain a platelet count of > 20,000/microliters, aggressive immunosuppressive therapy is usually unwarranted. There are some patients with ITP who are at increased risk of serious morbidity and mortality from their disease. Fatal cases of ITP are rarely mentioned in published reports. In this study we review the incidence of mortality and describe the deaths of seven patients with ITP, with the aim of identifying and improving management of high-risk cases. Based on our review of the literature and analysis of cases at our institution, fatal cases of ITP fall into three groups: death from intracranial hemorrhage with severe thrombocytopenia, death after splenectomy, and death due to infection after cytotoxic treatments. Patients who appear to carry increased risk include: 1) older patients; 2) chronic, refractory patients with a history of hemorrhage; and 3) patients with concomitant bleeding diatheses such as uremia and hemophilia.

Aggressive treatment of acute myocardial infarction Management options for various settings

Multiple lifesaving options are currently available for treatment of acute myocardial infarction as a medical emergency. Serial electrocardiography and continuous ST-segment monitoring, urgent echocardiography, rapid enzyme analysis, and cardiac catheterization may all assist in the accurate and early diagnosis of acute myocardial infarction. Both intravenous thrombolytic therapy and direct infarct percutaneous transluminal coronary angioplasty are of benefit in early treatment. The choice of therapy depends on the individual patient and the hospital capabilities. Adjunctive pharmacologic therapies can be easily administered in the community hospital setting and should be considered for every patient with suspected acute myocardial infarction. The risk of serious morbidity and hospital death in these patients has not been eliminated, and a more aggressive approach to diagnosis and treatment is sorely needed.

Morbidity and Duration of ICU Stay After Cardiac Surgery

Although risk factors for mortality after cardiac surgery have been identified, there is no widely applicable method for readily determining risk of postoperative morbidity based on preoperative severity of illness. The goal of this study was to develop a model for stratifying the risk of serious morbidity after adult cardiac surgery using readily available and objective clinical data. After univariate analysis of risk factors in 3,156 operations, 11 variables were identified as important predictors by logistic regression (LR) analysis and used to construct an additive model to calculate the probability of serious morbidity. Reliable correlation was found between a simplified additive model for clinical use and the LR model. The clinical and logistic models were then tested prospectively in 394 patients and demonstrated a pattern of increasing morbidity with ascending scores similar to that predicted by the reference group. Increasing clinical risk score was also associated with a greater frequency of individual complications as well as prolongation of ICU stay. This study demonstrates that it is feasible to design a simple method to stratify the risk of serious morbidity after adult cardiac surgery. With further prospective multicenter refinement and testing, such a model is likely to be useful for adjusting severity of illness when reporting outcome statistics as well as planning resource utilization. (Chest 1992; 102:36–44)

Gamete intrafallopian transfer with spinal anesthesia

To investigate the feasibility of performing GIFT under spinal anesthesia administered through a thin (27-gauge) needle.Prospectively studied case series.A tertiary care center staffed by a 260 physician multispecialty group.Twenty-seven consecutive fertility patients underwent 28 laparoscopic GIFT procedures, electing to receive spinal anesthesia administered through a thin (27-gauge) needle.Laparoscopic GIFT and thin-needle spinal anesthesia.Assessment of anesthetic complications and reproductive outcome.Satisfactory anesthesia was obtained in 27 of the 28 cases (96%). One patient required additional general anesthesia because of failed spinal anesthesia. All patients were discharged from the hospital on the day of surgery and no postdural headache, persistent back pain, meningitis, or neurological deficit was reported on a 7-day follow-up. Of the 12 clinical pregnancies (43%), 9 ongoing/delivered pregnancies occurred (32%). Six patients had livebirths, and three patients have ongoing second or third trimester pregnancies; there were three spontaneous abortions.Spinal anesthesia administered through a 27-gauge needle is an attractive option for laparoscopic GIFT. The risk of serious morbidity because of an anesthetic-related complications may be reduced, and the oocytes are not exposed to the potentially deleterious effects of the drugs associated with general anesthesia.

Morbidity and Duration of ICU Stay after Cardiac Surgery: A Model for Preoperative Risk Assessment

Although risk factors for mortality after cardiac surgery have been identified, there is no widely applicable method for readily determining risk of postoperative morbidity based on preoperative severity of illness. The goal of this study was to develop a model for stratifying the risk of serious morbidity after adult cardiac surgery using readily available and objective clinical data. After univariate analysis of risk factors in 3,156 operations, 11 variables were identified as important predictors by logistic regression (LR) analysis and used to construct an additive model to calculate the probability of serious morbidity. Reliable correlation was found between a simplified additive model for clinical use and the LR model. The clinical and logistic models were then tested prospectively in 394 patients and demonstrated a pattern of increasing morbidity with ascending scores similar to that predicted by the reference group. Increasing clinical risk score was also associated with a greater frequency of individual complications as well as prolongation of ICU stay. This study demonstrates that it is feasible to design a simple method to stratify the risk of serious morbidity after adult cardiac surgery. With further prospective multicenter refinement and testing, such a model is likely to be useful for adjusting severity of illness when reporting outcome statistics as well as planning resource utilization.

Foodborne Disease Outbreaks in Nursing Homes, 1975 Through 1987

--To describe the epidemiology of foodborne disease outbreaks in nursing homes and to identify where preventive efforts might be focused. --Reports by state and local health departments of foodborne disease outbreaks occurring from January 1, 1975, through December 31, 1987. --Foodborne disease outbreaks reported to the Centers for Disease Control, Atlanta, Ga, on standard investigation forms. --Each foodborne disease outbreak report was examined by an epidemiologist or statistician. Outbreaks were considered to have a known pathogen if confirmed by laboratory tests, and a known vehicle when an epidemiologic investigation implicated a specific food item. --From 1975 through 1987, 26 states reported 115 outbreaks of foodborne disease in nursing homes, causing illness in 4944 persons and death in 51. These outbreaks represented 2% of all reported foodborne disease outbreaks and 19% of outbreak-associated deaths in this period. Of 52 outbreaks with a known cause, Salmonella was the most frequently reported pathogen, accounting for 52% of outbreaks and 81% of deaths. Salmonella enteritidis outbreaks accounted for 56% of the Salmonella-associated deaths since 1981. The implicated food vehicles in S enteritidis outbreaks were made with eggs or prepared with equipment contaminated with eggs. Staphylococcal foodborne disease was the next most commonly identified cause, accounting for 23% of outbreaks. --Since the elderly are at high risk for serious morbidity from foodborne disease, nursing homes should practice careful food handling, preparation, and storage procedures; provide education for food handlers; and have active infection control programs to rapidly detect and control outbreaks of foodborne disease.

Trends in Fertility and Infant and Maternal Health—United States, 1980-1988

Infants born to teenaged mothers and to unmarried mothers are particularly at risk for low birth weight (LBW), which in turn increases their risk for serious morbidity, permanent disability, and death. In the United States, data from birth certificates are the primary source for monitoring trends in reproductive patterns and maternal and infant health. This report uses information from U.S. birth certificates for 1980 and for 1985-1988 to characterize trends in fertility among teenagers (aged 15-19 years) and unmarried women, use of prenatal care, and the incidence of LBW.

Risk of serious morbidity associated with hydralazine versus methyldopa treatment in hypertensive patients

The medical records of patients presenting to the Hammersmith Hospital hypertension clinic between 1971 and 1981 were examined to determine presenting clinical data, treatment regimes, and both cardiovascular and non cardiovascular mortality and morbidity. When compared with 1004 patients receiving treatment other than hydralazine 310 patients on hydralazine had a significantly higher risk of developing renal disease (RR = 2.71) in men, and severe weight loss in women (RR = 3.06). Renal disease risk also tended to be high in women on hydralazine (RR = 1.95) compared with all other treatments, but this was not statistically significant and could be explained by poorer renal function and significantly higher untreated blood pressure in the hydralazine treated group at presentation. The 422 patients who were treated with methyldopa but not hydralazine had similar risk factors for cardiovascular disease compared with a group of 167 who received hydralazine but not methyldopa. Comparisons of event rates failed to find significant differences in morbidity or mortality between these two groups. The age adjusted male mortality was 14/1000 patient years on hydralazine and 12/1000 on methyldopa and 13/1000 and 6/1000 years for women respectively. There was no evidence of an increased risk of either renal disease (RR = 0.3 in men, RR = 0.3 in women) on hydralazine or weight loss (RR = 0.7 in men, RR = 1.6 in women), with similar presenting data. Systemic lupus erythematosus was a rare complication (2 of 314) of treatment with hydralazine.

Symptomatic Care of Patients With Amyotrophic Lateral Sclerosis

Until a definitive treatment is found for amyotrophic lateral sclerosis, there will continue to be a need to provide symptomatic care. Experience with caring for a large number of patients has proved that symptomatic therapy can be based on rational principles. Treatment should be limited to procedures that are simple and low-cost, with low risk of serious morbidity. When all remedies fail, the physician can still provide a comforting presence and foster a dignified death.