Significant Reduction In In-hospital Mortality Research Articles

Off-pump coronary artery bypass grafting attenuates morbidity and mortality for patients with low and high body mass index

Patients at high and low body mass index have been shown to experience higher morbidity and mortality when undergoing coronary artery bypass grafting. The purpose of this research was to compare outcomes of patients at body mass index extremes who underwent coronary artery bypass grafting with or without cardiopulmonary bypass. A retrospective review of 6801 patients with a body mass index <25 or >35 undergoing isolated, primary coronary artery bypass grafting from 1996 to 2009 at Emory Healthcare Hospitals was performed. Patients were compared by therapy either on-pump coronary artery bypass grafting (n=3210) or off-pump coronary artery bypass grafting (n=3591). Salvage patients or those with concomitant operations were excluded. Comparisons were made using multivariable regression analysis, using a propensity score covariate calculated from 41 preoperative risk factors. A total of 6801 patients, including 4312 with a body mass index <25 (off-pump coronary artery bypass grafting, n=2083; on-pump coronary artery bypass grafting, n=2229) and 2489 with a body mass index >35 (off-pump coronary artery bypass grafting, n=1127; on-pump coronary artery bypass grafting, n=1362) were included for analysis. Society of Thoracic Surgeons predicted risk of mortality was significantly higher for both body mass index strata in patients undergoing off-pump coronary artery bypass grafting (2.8% vs 3.1% for body mass index <25 [P=.043] and 1.7% vs 1.8% for body mass index >35 [P=.049]). For patients with a body mass index <25, multivariable analysis of outcomes showed a significant decrease in in-hospital mortality (adjusted odds ratio, 0.48; 95% confidence interval, 0.28-0.82), stroke (adjusted odds ratio, 0.31; 95% confidence interval, 0.18-0.56), new-onset renal failure (adjusted odds ratio, 0.59; 95% confidence interval, 0.36-0.96), and prolonged ventilation (adjusted odds ratio, 0.50; 95% confidence interval, 0.38-0.64). Long-term survival was unaffected by method of revascularization for either body mass index strata (P > .05). Patients with high and low body mass indices experience reduced morbidity and in-hospital mortality when undergoing off-pump coronary artery bypass grafting. Despite a higher risk profile, patients with a body mass index <25 who underwent off-pump coronary artery bypass grafting experienced a significant reduction in in-hospital mortality.

Intermediate geriatric care in Geneva: A 10-year experience

The ageing of the population generates an increased demand for acute healthcare services in persons aged over 65, who can represent up to half of the patients treated in intensive care units (ICU). However, the number of available ICU beds is limited. Intermediate care units (IntCU), requires less human and technical resources, and has been proposed as an alternative to intensive care in the geriatric population. This article reports a 10-year, single centre experience from Geneva of continuous care and its impact on mortality in a geriatric population. Between 1998–1999 and 2000–2001, after the creation of the IntCU, we observed a significant reduction in in-hospital mortality. Thanks to increased medical and nursing care, IntCUs provide greater security for patients and their family, thereby improving their satisfaction with care.

Outcomes from implementing early goal-directed therapy for severe sepsis and septic shock

The aim of this study was to determine the outcome of patients with severe sepsis and septic shock who did and did not receive early goal-directed therapy (EGDT) in the emergency department (ED). The primary end point was the in-hospital mortality rate. The secondary end points were lengths of stay in the ICU and in hospital. Patients with sepsis who satisfied two of the four systemic inflammatory response criteria and who either had a lactate of greater than 4 mmol/l or a systolic blood pressure of less than 90 mmHg after 20-30 ml/kg of fluid, were included. Patients who had EGDT commenced, and all patients who were admitted to ICU who met EGDT criteria over a 4-year period from 1 January 2006 to 31 December 2009, were studied. One hundred and seventy-four patients with sepsis met the criteria for EGDT. Ninety-seven patients had EGDT commenced in the ED. The mortality rate in the EGDT group was 22.7% compared with 42.9% in the non-EGDT group (P=0.004). The length of stay in ICU was [(median and interquartile range)] 3D(5) versus 4D(8), P value less than 0.0001. There was no difference in the length of in-hospital stay. Initiating EGDT in the ED in patients with severe sepsis and septic shock was associated with a significant reduction in in-hospital mortality and length of stay in ICU.

Acute Coronary Syndrome in Patients with Prior Coronary Artery Bypass Surgery: Observations from a 20-Year Registry in a Middle-Eastern Country

ObjectivesClinical characteristics and trends in the outcome of acute coronary syndrome (ACS) in patients with prior coronary artery bypass graft surgery (CABG) are unclear. The aim of this study was to evaluate clinical characteristics, in-hospital treatment, and outcomes in patients presented with ACS with or without a history of prior CABG over 2 decades.MethodsData were derived from hospital-based study for collected data from 1991 through 2010 of patients hospitalized with ACS in Doha, Qatar. Data were analyzed according to their history of prior CABG. Baseline clinical characteristics, in-hospital treatment, and outcome were compared.ResultsA total 16,750 consecutive patients with ACS were studied, of which 693 (4.1%) had prior CABG. Patients with prior CABG were older (mean 60.5±11 vs. 53±12 years; P = 0.001), more likely to be females and have more cardiovascular risk factors than the non-CABG group. Prior CABG patients had larger infarct size, were less likely to receive reperfusion therapy, early invasive therapy and more likely to receive evidence-based therapies when compared to non-CABG patients. In-hospital mortality and stroke rates were comparable between the 2 groups. Over 2 decades, there was reduction in the in-hospital mortality rates and stroke rates in both groups (CABG, death; 13.2% to 4%, stroke; 1.9% to 0.0%, non-CABG, death; 10% to 3.2%, stroke 1.0% to 0.1%; all, p = 0.001).ConclusionSignificant reduction in-hospital morbidity and mortality among ACS patients with prior CABG over a 20-year period.

Effectiveness and safety of drotrecogin alfa (activated) for severe sepsis: a meta-analysis and metaregression

Drotrecogin alfa (activated) was approved for use in severe sepsis in 2001 on the basis of the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial, but controversies about its effectiveness remain. We aimed to assess effectiveness and safety of use of this drug in the past 10 years and compare them with the original PROWESS results. We searched PubMed, Embase, Ovid, Cochrane Library, Evidence-Based Medicine, and the American College of Physicians Journal Club databases for experimental and analytical studies of drotrecogin alfa (activated) in adults with severe sepsis until Jan 31, 2012. We calculated adjusted risk ratios for effectiveness and safety outcomes with random-effects models. We did a metaregression to assess the effect of severity of illness on the risk of death and the risk of bleeding associated with drotrecogin alfa (activated). We included nine controlled trials (41,401 patients) and 16 single-group studies (5822 patients) in effectiveness analyses and 20 studies (8245 patients) in safety analyses. Hospital mortality was reduced by 18% with drotrecogin alfa (activated) compared with controls (relative risk 0·822, 95% CI 0·779-0·867; p<0·0001; I(2)=40%). This mortality reduction was much the same as was noted in PROWESS (0·851, 0·740-0·979), but smaller than that of patients in PROWESS with high disease severity (0·708, 0·590-0·849). Propensity-adjusted studies also showed a significant mortality reduction with lower heterogeneity (0·844, 0·800-0·891; p<0·0001, I(2)=18%). These findings were not changed by the addition of PROWESS-SHOCK results. Metaregression showed greater benefits of drotrecogin alfa (activated) with increasing control mortality (p=0·01) and more severe disease (p=0·04). Hospital mortality for single-group studies of drotrecogin alfa (activated) was 41% (95% CI 35-48), and was higher than that noted in PROWESS at 31% (27-36; p<0·0001). The serious bleeding rate with drotrecogin alfa (activated) was 5·6% (4·5-6·9), which was higher than the 3·5% (2·5-5·0) noted in PROWESS (p=0·003), but similar to that reported in PROWESS high disease severity (p=0·073). Real-life use of drotrecrogin alfa (activated) was associated with significant reduction in hospital mortality and increased rates of bleeding in patients with severe sepsis. Our effectiveness findings were in line with the PROWESS trial but not with the PROWESS-SHOCK trial. None.

In-hospital hypothermia

Mild therapeutic hypothermia after cardiac arrest has become standard in post-resuscitation care in many hospitals as it is recommended by current guidelines. The last update of guidelines by the European Resuscitation Council on post-cardiac arrest treatment in 2010 recommends hypothermia for every patient after cardiac arrest who remains unconscious after cardiac arrest [1]. In addition to milestone trials [2-4], current published retrospective data from the large Finnish registry showed in a large group of patients a significant reduction of hospital mortality of survivors of out-of-hospital cardiac arrest after implementation of hypothermia [5]. The mild therapeutic hypothermia procedure after cardiac arrest can be divided into three phases: introduction, maintenance and rewarming. The cooling techniques and devices to induce cooling of the cardiac arrest survivor can be separated into three main groups: conventional cooling (no device), non-invasive (surface) systems, and invasive (intravascular) systems (Table ​(Table11). Table 1 Cooling techniques Conventional cooling methods The easiest way to induce hypothermia after cardiac arrest is by using cold saline (for example, 0.9% NaCl solution), crushed ice or ice bags. Kim and colleagues reported the safety and efficacy of the administration of up to 2 litres of 4°C cold saline to the patient after hospital admission [6]. Others published data using 30 ml/kg body weight of saline 0.9% NaCl or Ringer's lactate combined sometimes with ice bags, which led to an acceptable reduction of the temperature [7-10]. Furthermore cold saline as well as other methods like cooling caps and helmets have been evaluated for induction mainly in the preclinical setting [4,11,12]. Kliegel and colleagues pointed out that cold infusion alone is effective for induction but not for tight maintenance of the target temperature [13]. However, in at least one trial the combination of cold saline and ice packs was proven to be effective even to maintain temperature [7]. Focusing on the induction in the in-hospital setting, most authors rank cold saline and crushed ice more as effective adjuvant methods to be combined with a computer-controlled cooling device [10]. The big advantage of cold saline is its availability at almost every place in the hospital if provided and the low costs. Following the data available concerning different amounts of saline administered to the patient, a median amount of 1 to 2 litres of saline seems safe after cardiac arrest. To maintain target temperature with cold saline and ice bags seems to require a high binding of personnel method without a very precise influence on the central body temperature.

034 The effect of thrombus aspiration during primary percutaneous coronary intervention on in-hospital mortality and thrombolysis in myocardial infarction flow grade

BackgroundThrombus aspiration (TA) has been shown to improve Myocardial Blush Grade and ST-segment resolution in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI). However, the...

Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion.

Most clinical practice guidelines recommend restrictive red cell transfusion practices, with the goal of minimising exposure to allogeneic blood. The purpose of this review is to compare clinical outcomes in patients randomised to restrictive versus liberal transfusion thresholds (triggers). To examine the evidence for the effect of transfusion thresholds on the use of allogeneic and/or autologous red cell transfusion, and the evidence for any effect on clinical outcomes. We identified trials by searching; The Cochrane Injuries Group Specialised Register (searched 01 Feb 2011), Cochrane Central Register of Controlled Trials 2011, issue 1 (The Cochrane Library), MEDLINE (Ovid) 1948 to January Week 3 2011, EMBASE (Ovid) 1980 to 2011 (Week 04), ISI Web of Science: Science Citation Index Expanded (1970 to Feb 2011), ISI Web of Science: Conference Proceedings Citation Index- Science (1990 to Feb 2011). We checked reference lists of other published reviews and relevant papers to identify any additional trials. Controlled trials in which patients were randomised to an intervention group or to a control group. Trials were included where intervention groups were assigned on the basis of a clear transfusion 'trigger', described as a haemoglobin (Hb) or haematocrit (Hct) level below which a red blood cell (RBC) transfusion was to be administered. Risk ratios of requiring allogeneic blood transfusion, transfused blood volumes and other clinical outcomes were pooled across trials, using a random effects model. Data extraction and assessment of the risk of bias was performed by two people. Nineteen trials involving a total of 6264 patients were identified, and were similar enough that the results could be combined. Restrictive transfusion strategies reduced the risk of receiving a RBC transfusion by 39% (RR 0.61, 95% CI 0.52 to 0.72). This equates to an average absolute risk reduction (ARR) of 34% (95% CI 24% to 45%). The volume of RBCs transfused was reduced on average by 1.19 units (95% CI 0.53 to 1.85 units). However, heterogeneity between trials was statistically significant (P<0.00001; I(2)≥93%) for these outcomes. Restrictive transfusion strategies did not appear to impact the rate of adverse events compared to liberal transfusion strategies (i.e. mortality, cardiac events, myocardial infarction, stroke, pneumonia and thromboembolism). Restrictive transfusion strategies were associated with a statistically significant reduction in hospital mortality (RR 0.77, 95% CI 0.62-0.95) but not 30 day mortality (RR 0.85, 95% CI 0.70 to 1.03). The use of restrictive transfusion strategies did not reduce functional recovery, hospital or intensive care length of stay. The majority of patients randomised were included in good quality trials, but some items of methodological quality were unclear. There are no trials in patients with acute coronary syndrome. The existing evidence supports the use of restrictive transfusion triggers in most patients including those with pre-existing cardiovascular disease. As there are no trials, the effects of restrictive transfusion triggers in high risk groups such as acute coronary syndrome need to be tested in further large clinical trials. In countries with inadequate screening of donor blood, the data may constitute a stronger basis for avoiding transfusion with allogeneic red cells.

Improving hospital outcomes in patients admitted from residential aged care: results from a controlled trial

residents of aged care are old, frail and frequently require hospital management of intercurrent illness, but hospital outcomes are poor. to identify the impact of an interdisciplinary care model on medical inpatients admitted from residential aged care (RAC). pre-planned subgroup analysis of controlled trial. general medical units of a teaching hospital in Brisbane, Australia. consecutive patients aged over 65 admitted from RAC (n = 189) or the community (n = 815). all admitted general medical patients were allocated by existing cyclical roster to control (usual care) or intervention units (interdisciplinary care consisting of improved allied health staffing, consistent teams, daily team meetings and early discharge planning). Patient characteristics and outcomes of care were compared between RAC and community subgroups. In the RAC subgroup, outcomes were compared between the control and intervention groups. patients admitted from RAC had much higher in-hospital mortality (13 versus 6%) and 6-month mortality (35 versus 17%) than those from community. RAC residents receiving the intervention had a significant reduction in in-hospital mortality (4 versus 22% P < 0.001) sustained at 6 months (28 versus 44% P = 0.02). poor hospital outcomes for RAC residents may reflect prevailing models of inpatient care.

Abstract 140: National Trends in Utilization and Outcomes of Endovascular Treatment in Acute Ischemic Stroke Patients

Background: With the availability of several new devices for mechanical thrombectomy after recent approvals by the Food and Drug Administration, the outcomes of patients undergoing endovascular treatment for acute ischemic stroke are expected to improve in United States. Objective: To evaluate trends in utilization of endovascular treatment and associated rates of death and disability among acute ischemic stroke patients over six years. Methods: We obtained data for patients admitted to hospitals in the United States between 2004 to 2009 with a primary diagnosis of ischemic stroke using a large national database. We determined the rate of utilization of endovascular treatment. Outcomes were classified as minimal disability, moderate to severe disability, and death based on discharge disposition. Results: Of the 670,069 patients with ischemic stroke, 72,342 (10.8%) received intravenous thrombolytic treatment, 18,229 (2.72%) had endovascular thrombolysis. Patients with endovascular treatment comprised 0.35% of ischemic strokes in 2004 vs 4.95% in 2009 (p &lt; 0.001). The estimated number of patients undergoing endovascular treatment increased by 1,519% (362 to 5502) despite a 324% increase in patients receiving intravenous thrombolytic. The rates of intracranial hemorrhage remained unchanged throughout the 6 years. There was no significant difference in all age groups. The interaction between endovascular treatment among all ischemic stroke patients for predicting in-hospital mortality significantly improved (p &lt;0.02). Conclusion: There has been a significant increase in proportion of acute ischemic stroke patients receiving endovascular treatment over the last 6 years with significant reduction in in-hospital mortality.

Trends in primary total hip arthroplasty in Spain from 2001 to 2008: Evaluating changes in demographics, comorbidity, incidence rates, length of stay, costs and mortality

BackgroundHip arthroplasties is one of the most frequent surgical procedures in Spain and are conducted mainly in elderly subjects. We aim to analyze changes in incidence, co-morbidity profile, length of hospital stay (LOHS), costs and in-hospital mortality (IHM) of patients undergoing primary total hip arthroplasty (THA) over an 8-year study period in Spain.MethodsWe selected all surgical admissions in individuals aged ≥40 years who had received a primary THA (ICD-9-CM procedure code 81.51) between 2001 and 2008 from the National Hospital Discharge Database. Age- and sex-specific incidence rates, LOHS, costs and IHM were estimated for each year. Co-morbidity was assessed using the Charlson comorbidity index.Multivariate analysis of time trends was conducted using Poisson regression. Logistic regression models were conducted to analyze IHM.ResultsWe identified a total of 161,791 discharges of patients having undergone THA from 2001 to 2008. Overall crude incidence had increased from 99 to 105 THA per 100.000 inhabitants from 2001 to 2008 (p < 0.001). In 2001, 81% of patients had a Charlson Index of 0, 18.4% of 1-2, and 0.6% > 2 and in 2008, the prevalence of 1-2 or >2 had increased to 20.4% and 1.1% respectively (p < 0.001). The mean LOHS was 13 days in 2001 and decreased to 10.45 days in 2008 (p < 0.001). During the period studied, the mean cost per patient increased from 6,634 to 9,474 Euros. Multivariate analysis shows that from 2001 to 2008 the incidence of THA hospitalizations has significantly increased for both sexes and only men showed a significant reduction in IHM after THA.ConclusionsThe current study provides clear and valid data indicating increased incidence of primary THA in Spain from 2001 to 2008 with concomitant reductions in LOHS, slight reduction IHM, but a significant increase in cost per patient. The health profile of the patient undergoing a THA seems to be worsening in Spain.

Pressure and Volume Limited Ventilation for the Ventilatory Management of Patients with Acute Lung Injury: A Systematic Review and Meta-Analysis

BackgroundAcute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life threatening clinical conditions seen in critically ill patients with diverse underlying illnesses. Lung injury may be perpetuated by ventilation strategies that do not limit lung volumes and airway pressures. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing pressure and volume-limited (PVL) ventilation strategies with more traditional mechanical ventilation in adults with ALI and ARDS.Methods and FindingsWe searched Medline, EMBASE, HEALTHSTAR and CENTRAL, related articles on PubMed™, conference proceedings and bibliographies of identified articles for randomized trials comparing PVL ventilation with traditional approaches to ventilation in critically ill adults with ALI and ARDS. Two reviewers independently selected trials, assessed trial quality, and abstracted data. We identified ten trials (n = 1,749) meeting study inclusion criteria. Tidal volumes achieved in control groups were at the lower end of the traditional range of 10–15 mL/kg. We found a clinically important but borderline statistically significant reduction in hospital mortality with PVL [relative risk (RR) 0.84; 95% CI 0.70, 1.00; p = 0.05]. This reduction in risk was attenuated (RR 0.90; 95% CI 0.74, 1.09, p = 0.27) in a sensitivity analysis which excluded 2 trials that combined PVL with open-lung strategies and stopped early for benefit. We found no effect of PVL on barotrauma; however, use of paralytic agents increased significantly with PVL (RR 1.37; 95% CI, 1.04, 1.82; p = 0.03).ConclusionsThis systematic review suggests that PVL strategies for mechanical ventilation in ALI and ARDS reduce mortality and are associated with increased use of paralytic agents.

Improved Survival with Therapeutic Hypothermia after Cardiac Arrest with Cold Saline and Surfacing Cooling: Keep It Simple

Aim. To evaluate whether the introduction of a therapeutic hypothermia (TH) protocol consisting of cold saline infusion and surface cooling would be effective in targeting mild therapeutic hypothermia (32–34°C). Additionally, to evaluate if TH would improve survival after cardiac arrest. Design. Before-after design. Setting. General Intensive Care Unit (ICU) at an urban general hospital with 470 beds. Patients and Methods. Patients admitted in the ICU after cardiac arrest between 2004 and 2009 were included. Effectiveness of the TH protocol to achieve the targeted temperature was evaluated. Hospital mortality was compared before (October 2004–March 2006) and after (April 2006–September 2009) the protocol implementation. Results. Hundred and thirty patients were included, 75 patients were not submitted to TH (before TH group), and 55 were submitted to TH (TH group). There were no significant differences concerning baseline, ICU, and cardiac arrest characteristics between both groups. There was a significant reduction in hospital mortality from 61% (n = 46) in the before TH group to 40% (n = 22) in the TH group. Conclusion. Our protocol consisting of cold saline infusion and surface cooling might be effective in inducing and maintaining mild therapeutic hypothermia. TH achieved with this protocol was associated with a significant reduction in hospital mortality.

Primary percutaneous coronary intervention and thrombolysis improve survival in patients with ST-elevation myocardial infarction and pre-hospital resuscitation

Background Patients with ST-elevation myocardial infarction (STEMI) surviving pre-hospital resuscitation represent a selected subgroup of patients with a very high adverse event rate. Only few data on the outcome of primary percutaneous coronary intervention (primary PCI) and thrombolysis in such patients are available. Methods We analysed the Maximal Individual Therapy of Acute Myocardial Infarction (MITRA) Plus registry. 1529 survivors of pre-hospital resuscitation with STEMI were included. 593 (38.8%) of those patients did not receive early reperfusion therapy, 793 (51.9%) patients received thrombolysis and 143 (9.4%) patients received primary PCI. Hospital mortality in patients receiving primary PCI or thrombolysis was adjusted for confounding factors with a propensity score analysis. Results Primary PCI as well as thrombolysis in survivors of pre-hospital resuscitation with STEMI were associated with a significant reduction of hospital mortality (OR: 0.29, 95% CI 0.17–0.50; and 0.74, 95% CI 0.54–0.99, respectively), while primary PCI was superior compared to thrombolysis (OR 0.50, 95% CI 0.30–0.84). Conclusion Reperfusion therapy improves mortality of patients with STEMI surviving pre-hospital resuscitation, while primary PCI seems to be more effective than thrombolysis.

Abstract 5605: Significant Reduction of Hospital Mortality of Stemi in Clinical Practice 1994–2008 Through Improvement of Guideline Adherence: Results of MITRAplus and OPTAMI

Background: Data from national and international myocardial infarction registries have identified the gaps between recommendations of guidelines for the management of ST-elevation myocardial infarction (STEMI) and treatment in clinical practice. Participation in continuous STEMI registries with benchmarking reports to the centres might improve implementation of guidelines into practice. Methods: Between 1994 and 2008, 37,876 consecutive patients with STEMI were enrolled into the MI-registries MITRAplus and OPTAMI to document patients’ characteristics, acute treatment and outcome in clinical practice. We examined the impact of guideline adherence for acute treatment of STEMI including reperfusion as well as adjunctive medical treatment on hospital outcome over time in Germany 1994 –2008. Results: From 1994 to 2008, the rate of acute reperfusion therapy in Germany increased from minimal 49% to 90% of consecutive patients with STEMI in 2008 with a significant shift from fibrinolysis to primary PCI. In parallel, the use of adjunctive medical treatment with aspirin, beta-blockers, ACE-inhibitors and clopidogrel was significantly improved over time. This improvement of guideline adherence for the acute treatment of STEMI was associated with a significant reduction of hospital mortality from initially 16.2% in 1994 to 6.2% in 2008. Limitation: In the currently conducted OPTAMI-Registry, 84% of participating centres provide 24h PCI-service. The data from 2006 –2008 therefore reflects the treatment and outcome of STEMI in tertiary centres in Germany, but clearly demonstrates that implementation of current practice guidelines is feasible. Conclusion: The improvements of guideline adherence for the management of STEMI, especially the increased rates of primary PCI as well as acute adjunctive medical treatment were associated with a significant decrease of hospital mortality in clinical practice in Germany.

Gender differences in patients with acute ST-elevation myocardial infarction complicated by cardiogenic shock

The aim of our analysis is to assess gender differences in baseline characteristics, acute therapies, and clinical outcome in patients with acute ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock. The Maximal Individual Therapy of Acute Myocardial Infarction PLUS registry (MITRA PLUS) is a German prospective, multicenter, observational data pool of current treatment of STEMI. STEMI was more often (P < 0.0001) complicated by cardiogenic shock in female patients (12.9%) when compared to male patients (9.3%). This was still true after adjusting for confounding variables (OR 1.19, 95% CI 1.09-1.30). Women with STEMI admitted in a cardiogenic shock were older (P < 0.0001) and had more often concomitant diseases (P < 0.0001). There was no differences in rates of reperfusion therapy (OR 0.92, 95% CI 0.77-1.09). Hospital mortality was 67.7% in female patients, when compared to 57.2% in male patients (P < 0.0001). After adjusting for confounding variables in the multivariate analysis hospital mortality did not differ between men and women (OR 1.16, 95% CI 0.98-1.38). Early reperfusion therapy was associated with a significant reduction of hospital mortality in female patients with STEMI complicated by cardiogenic shock (OR 0.68, 95% CI 0.52-0.90) with primary PCI being more effective than thrombolytic therapy (OR 0.46, 95% CI 0.31-0.68). In women, STEMI was more often complicated by cardiogenic shock when compared to men. However, the use of early reperfusion therapy did not differ between the sexes. Primary PCI was associated with the best outcome in female patients with STEMI complicated by cardiogenic shock and is therefore the therapy of choice.

Electronic Medical Records and Mortality in Trauma Patients

The Electronic Medical Record (EMR) has been proposed as a way to reduce medical errors. It can also be used to document clinician involvement, which may affect outcomes. We sought to determine whether the EMR could be used to improve attending involvement in daily care, enhance surgical revenue, and lower mortality of patients with trauma. In 2004, the Trauma Division adopted a software program (CARE, Miami, FL) for creating an EMR and implemented a weekly report that was distributed to all members of the division and also to Departmental decision makers. Before initiation, explicit instructions were given to all surgeons that daily notes in the EMR were expected and would be followed by weekly reports. Before this, most notes were recorded in the paper chart and were difficult to track. Differences among proportions were determined with z test or chi, where appropriate with significance defined as p < 0.05. With implementation of the EMR, daily and weekly reports were immediately available. Both attending surgeon documented notes and divisional annual revenue increased. A reduction in mortality was also observed. The EMR can be used to change attending surgeon involvement in patient care and procedures. The increase in attending involvement was associated with an increase in revenue. Use of the EMR was associated with a significant reduction in hospital mortality.

High levels of PEEP may improve survival in acute respiratory distress syndrome: A meta-analysis

Positive end-expiratory pressure (PEEP) has been viewed as an essential component of mechanical ventilation in acute respiratory distress syndrome (ARDS) and acute lung injury (ALI). However, clinical trials have not yet convincingly demonstrated that high PEEP levels improve survival. The object of this study was to test a priori hypotheses that a small but clinically important mortality benefit of high PEEP did exist, especially in patients with greater overall severity of illness and differences in PEEP protocols might have affected the study results. Meta-analysis of randomized controlled trials comparing high versus low PEEP in ARDS/ALI. Studies were identified by search of MEDLINE (1950-2008) and other sources. Five studies including 2447 patients were identified. A pooled analysis showed a significant reduction in hospital mortality in favor of high PEEP (RR=0.89; 95% CI, 0.80-0.99; p=0.03). However, significant statistical and clinical heterogeneities such as differences in disease severity and ventilator protocols were found. The differences in PEEP protocols were not associated with differences in mortality rates. A logistic analysis suggested that the beneficial effect of high PEEP was greater in patients with higher ICU severity scores. The statistical and clinical heterogeneities make proper interpretation of the results difficult. However, a small, but significant mortality benefit of high PEEP may exist. In addition, our analysis suggests the effects of high PEEP are greater in patients with higher ICU severity scores.

Effect of Chronic Statin Pretreatment on Hospital Outcome in Patients With Acute Non-ST-Elevation Myocardial Infarction

We sought to investigate the impact of prior statin therapy on in-hospital outcome in patients presenting with acute non-ST-elevation myocardial infarction. We analyzed the data of consecutive patients with non-ST-elevation myocardial infarction who were prospectively enrolled in the German Acute Coronary Syndrome Registry between July 2000 and November 2002. Overall, 6358 patients were included, and we compared the patients who received statins before hospital admission (n = 1247, 19.6%) with those who did not (n = 5111, 80.4%). There was no age difference between the two groups; however, pretreated patients had a higher incidence of prior atherothrombotic events diabetes mellitus and renal insufficiency. The percentage of patients undergoing percutaneous coronary intervention and coronary artery bypass grafting was similar. Infarct size measured by peak creatine kinase level was lower in statin users (238 vs. 283 U/L, P < 0.0001). After adjustment for confounding variables, a significant reduction of in-hospital death could be observed in patients on statins (odds ratio 0.65, 95% confidence interval 0.46-0.90). In clinical practice, pretreatment with statins was associated with smaller myocardial infarction size (peak creatine kinase level) and a significant reduction of hospital mortality. However, the data were obtained from an observational study, and the results need further prospective confirmation.

Comment on: Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy

Sir, I appreciated the recent and very comprehensive guidelines for managing hospital-acquired pneumonia by Masterton et al. Malnutrition can greatly increase pneumonia morbidity and mortality rates in both children and adults. Malnutrition is responsible for an estimated 52% of the 2 million impoverished children who die annually worldwide due to pneumonia. However, the relationship between malnutrition and pneumonia in adults in the developed world is often overlooked. Various studies have reported malnutrition for hospitalized elderly to range from 42% to 91% in the developed world. Several studies have reported that rates of both hospital-acquired pneumonia and nosocomial infections, in general, are significantly higher in malnourished versus well-nourished patients. A study of 578 nursing home elderly reported that rates of both pneumonia infection and antibiotic consumption were significantly higher in residents with low serum zinc levels. Many acutely ill patients require enteral tube feeding, which may present some aspiration risk. A study of 4049 mechanically ventilated patients reported that enteral feeding within 48 h of intubation was associated with a significant reduction in hospital mortality (27.8% versus 34.2%, P 1⁄4 0.0005), even though rates of aspiration pneumonia were increased (12.6% versus 9.5%, P 1⁄4 0.007) when compared with patients who received later enteral feeding. Use of ‘immunonutrition’ enteral formulas containing omega 3 fatty acids and extra levels of glutamine, zinc, copper, selenium and vitamins may reduce the risk of pneumonia among the acutely ill. Meta-analysis of 11 studies reported that the use of such ‘immunonutrition’ formulas was associated with a 46% reduced risk of hospital-acquired pneumonia when compared with standard formulas (P 1⁄4 0.007). A study of 165 mechanically ventilated patients with severe sepsis reported that use of an enteral formula with omega 3 fatty acids and extra vitamins was associated with significantly lower mortality and significantly fewer days on mechanical ventilation when compared with patients on standard formula. Good nutrition can play a major role in preventing and treating hospital-acquired pneumonia. Much more research on the relationship between nutrition and pneumonia should be published and the results incorporated into future pneumonia guidelines.