Trends In Case Fatality Rates Research Articles

A chronological review of COVID-19 case fatality rate and its secular trend and investigation of all-cause mortality and hospitalization during the Delta and Omicron waves in the United States: a retrospective cohort study.

Coronavirus disease 2019 (COVID-19) has caused more than 690 million deaths worldwide. Different results concerning the death rates of the Delta and Omicron variants have been recorded. We aimed to assess the secular trend of case fatality rate (CFR), identify risk factors associated with mortality following COVID-19 diagnosis, and investigate the risks of mortality and hospitalization during Delta and Omicron waves in the United States. This study assessed 2,857,925 individuals diagnosed with COVID-19 in the United States from January 2020, to June 2022. The inclusion criterion was the presence of COVID-19 diagnostic codes in electronic medical record or a positive laboratory test of the SARS-CoV-2. Statistical analysis was bifurcated into two components, longitudinal analysis and comparative analysis. To assess the discrepancies in hospitalization and mortality rates for COVID-19, we identified the prevailing periods for the Delta and Omicron variants. Longitudinal analysis demonstrated four sharp surges in the number of deaths and CFR. The CFR was persistently higher in males and older age. The CFR of Black and White remained higher than Asians since January 2022. In comparative analysis, the adjusted hazard ratios for all-cause mortality and hospitalization were higher in Delta wave compared to the Omicron wave. Risk of all-cause mortality was found to be greater 14-30 days after a COVID-19 diagnosis, while the likelihood of hospitalization was higher in the first 14 days following a COVID-19 diagnosis in Delta wave compared with Omicron wave. Kaplan-Meier analysis revealed the cumulative probability of mortality was approximately 2-fold on day 30 in Delta than in Omicron cases (log-rank p < 0.001). The mortality risk ratio between the Delta and Omicron variants was 1.671 (95% Cl 1.615-1.729, log-rank p < 0.001). Delta also had a significantly increased mortality risk over Omicron in all age groups. The CFR of people aged above 80 years was extremely high as 17.33%. Male sex and age seemed to be strong and independent risk factors of mortality in COVID-19. The Delta variant appears to cause more hospitalization and death than the Omicron variant.

Analysis of early neonatal case fatality rate among newborns with congenital hydrocephalus, a 2000-2014 multi-country registry-based study.

Congenital hydrocephalus (CH) comprises a heterogeneous group of birth anomalies with a wide-ranging prevalence across geographic regions and registry type. The aim of the present study was to analyze the early neonatal case fatality rate (CFR) and total birth prevalence of newborns diagnosed with CH. Data were provided by 25 registries from four continents participating in the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR) on births ascertained between 2000 and 2014. Two CH rates were calculated using a Poisson distribution: early neonatal CFR (death within 7 days) per 100 liveborn CH cases (CFR) and total birth prevalence rate (BPR) per 10,000 births (including live births and stillbirths) (BPR). Heterogeneity between registries was calculated using a meta-analysis approach with random effects. Temporal trends in CFR and BPR within registries were evaluated through Poisson regression modeling. A total of 13,112 CH cases among 19,293,280 total births were analyzed. The early neonatal CFR was 5.9 per 100 liveborn cases, 95% confidence interval (CI): 5.4-6.8. The CFR among syndromic cases was 2.7 times (95% CI: 2.2-3.3) higher than among non-syndromic cases (10.4% [95% CI: 9.3-11.7] and 4.4% [95% CI: 3.7-5.2], respectively). The total BPR was 6.8 per 10,000 births (95% CI: 6.7-6.9). Stratified by elective termination of pregnancy for fetal anomalies (ETOPFA), region and system, higher CFR were observed alongside higher BPR rates. The early neonatal CFR and total BPR did not show temporal variation, with the exception of a CFR decrease in one registry. Findings of early neonatal CFR and total BPR were highly heterogeneous among registries participating in ICBDSR. Most registries with higher CFR also had higher BPR. Differences were attributable to type of registry (hospital-based vs. population-based), ETOPFA (allowed yes or no) and geographical regions. These findings contribute to the understanding of regional differences of CH occurrence and early neonatal deaths.

Abstract 13165: Increasing Incidence Rates and High Case Fatality Rates for Acute Myocardial Infarction in the Caribbean Island of Barbados

Introduction: The Caribbean sub-region has the highest rates of cardiovascular disease in the Region of the Americas. We present data from one of the few population-based registries in the region - the Barbados National Registry for NCDs (BNR). We describe trends in incidence and case fatality rates for acute myocardial infarction(MI) in the high income small island developing state of Barbados. Hypothesis: Myocardial infarction age-standardized incidence rates (ASIRs) are increasing. Methods: Data from the BNR were collected prospectively from charts of patients diagnosed with acute myocardial infarction from all private and public hospitals for the period 2010-2019. Out-of-hospital deaths and in-hospital deaths within 24 hours, were identified through the national vital registration department. Cases are defined in accordance with the Universal Definition of Myocardial Infarctions published by the American Heart Association. Population estimates were obtained from the United Nation World Population Prospects. We calculated incidence rates by sex, age-standardized to the World Health Organization 2000 population and assessed trends in case fatality rates for those admitted to hospital. Results: For the period 2010-2019, 4065 cases of as myocardial infarction (MI) were registered by BNR. Numbers of cases ranged from 294 in 2011 to 547 in 2019. The 3-year average for 2014 - 2016 is 391 cases versus 499 cases for 2017 - 2019 - a 28% increase in new cases. ASIRs increased from 67 per 100,000 (95%UI 59 to 75) in 2011 to 123 per 100,000 (95%UI 113 to 135) in 2019. ASIRs were consistently higher in men ranging from 83 per 100,00 (95% UI 71 - 98) to 120 (95% UI 106 to 136) while rates in women ranged from 43 per 100,000 95% CI (35 - 53) to 83 per 100,000 (73 - 95). The in-hospital case fatality rate (CFR) was 25% in 2019, ranging from 15% in 2011 to 31% in 2014. Overall, CFR was higher in women (24%) versus men (19%) and this was true in 9/10 years. Conclusions: Despite its status as a high income country, ASIRs for MIs in Barbados are increasing while case fatality rates are more than twice as high as rates found in developed countries.

Statistical models in trends of COVID-19 case fatality rates, India: a secondary data analysis

Background: The COVID-19 is potentially severe acute respiratory infectious disease, increasing day by day. Hence, to control of COVID-19 cases and deaths due to, study has been under taken with an objective to establish the models of trends in COVID-19 Case Fatality Rates for states of India, so that containment performance is assessed taking model as reference level. Materials and methods: The state-wise data from Kaggle website were used to study the levels and trends in Case Fatality Rate per 100 cases (Cured + Deaths) using Modified Logistic Regression Model, using SPSS-22 and Microsoft Office-10. The model is useful, where; deaths due to COVID-19 were more than one. Results: Himachal Pradesh was the best in controlling the disease, as per COVID-19 Active Cases and Case Fatality Rate. In Himachal Pradesh, COVID-19 stabilized by 45 days of presence of the disease, while, in Kerala by 100 days. Furthermore, the decline in COVID-19 in Himachal Pradesh was steadier and smoother as compared to comparable state Kerala. The worst group of states in controlling the COVID-19 Case Fatality Rate in poorest to better order was Maharashtra followed by Delhi, Rajasthan, Uttar Pradesh and Bihar, along with wide fluctuation in Active Cases and Case Fatality Rates. Conclusion: The worst affected state by COVID-19 was Maharashtra followed by Delhi, Rajasthan etc., reasons may be large movements of daily wagers/ temporary workers. Hence, the containment of COVID-19 is expected to be achieved by restriction in public movement and unrest in communities.

Trends in case-fatality rates of COVID-19 in the World, between 2019 - 2020

Introduction: CoV infections can potentially cause from a simple cold to a severe respiratory syndrome, such as the Severe Acute Respiratory Syndrome and the Middle East Respiratory Syndrome (MERS-CoV). The COVID-19 created a new reality for global healthcare models. Objetive: To evaluate trends in case fatality rates of COVID-19 in the World. Methods: We conducted a population based time-series study using public and official data of cases and deaths from COVID-19 in Argentina, Australia, Brazil, Chile, China, Colombia, France, Germany, India, Iran, Italy, Japan, Mexico, Morocco, New Zealand, Nigeria, Peru, Saudi Arabia, South Africa, South Korea, Spain, Switzerland, United Kingdom, United States and Russian, between December, 2019 and August, 2020. Data were based on reports from European Centre for Disease Prevention and Control. COVID-19 was defined by the International Classification of Diseases, 10th revision (U07.1). A Prais-Winsten regression model was performed and the Daily Percentage Change (DPC) calculated determine rates as increasing, decreasing or flat. Results: During the study period, trends in case-fatality rates in the world were flat (DPC = 0.3; CI 95% [-0.2: 0.7]; p = 0.225). In Africa, Morocco had decreasing trends (DPC = -1.1; CI 95% [-1.5: -0.7]; p &lt; 0.001), whereas it were increasing in South Africa (p &lt; 0.05) and flat in Nigeria (p &gt; 0.05). In the Americas, Argentina showed a decreasing trend in case-fatality rates (DPC = -0.6; CI 95% [-1.1: -0.2]; p = 0.005), the U.S. had flat trends (p &gt; 0.05) and all other American countries had increasing trends (p &lt; 0.05). In Asia, Iran had decreasing trends (DPC = -1.5; CI 95% [-2.6 : -0.2]; p = 0.019); China and Saudi Arabia showed increasing trends (p &lt; 0.05), while in India, Japan and South Korea they were flat (p &gt; 0.05). European countries had mostly increasing trends (p &lt; 0.05): Germany, Italy, Spain, the UK and Russia; France and Switzerland had flat trends (p &gt; 0.05). Finally, in Oceania, trends in case-fatality rates were flat in Australia (p &gt; 0.05) and increasing in New Zealand (p &lt; 0.05). Conclusion: Trends in case-fatality rates of COVID-19 in the World were flat between December, 31 and August, 31. Argentina, Iran and Morocco were the only countries with decreasing trends. On the other hand, South Africa, Brazil, Canada, Chile, Colombia, Mexico, Peru, China, Saudi Arabia, Germany, Spain, United Kingdom, Russian and New Zealand had increasing trends in case-fatality rate. All the other countries analyzed had flat trends. Based on case-fatality rate data, our study supports that COVID-19 pandemic is still in progress worldwide.

Trend of case fatality rate during first 30 days of COVID-19 epidemic; the example of Iran

Introduction: One of the unusual aspects in coronavirus disease 2019 (COVID-19) pandemic is changing case fatality rate (CFR) in different time series. Many researchers are trying to find the reasons of this variability. Objectives: This study aimed to present a model for a 30-day trend of CFR in any infectious disease epidemic using the example of COVID-19 in Iran. Patients and Methods: As a case study, we tried to use statistical mining of scientific databases. A descriptive approach with quantitative tools was conducted. The World Health Organization (WHO) database was used to access daily reports of CFR. Funnel plot and Z score were used to study and graph the trend. Results: During this period of time, a total of 20610 cases were confirmed based on real-time polymerase chain reaction (PCR). Among them, 1556 individuals died. Therefore, CFR was calculated as 7.549% (95% confidence intervals 7.189%-7.910%). This frequency was considered as the pooled frequency. Daily CFR with 95% CI was compared with the pooled frequency. Conclusion: In our case, the epidemic was started from high CFR due to low number of cases and testing only highly suspicious individuals. Then, the CFR was reduced due to increased number of patients and improvement in screening. Finally, CFR went back to its moderate rate due to the addition of the death numbers related to the cases of previous days.

World one-hundred days after COVID-19 outbreak: Incidence, case fatality rate, and trend.

BACKGROUND:The prevalence of viral diseases is on the rise and has caused many problems for public health. COVID-19 is a new viral outbreak in the world. This study aimed to investigate the trends of incidence and case fatality rate (CFR) of COVID-19 in the world by April 30, 2020.METHODS:This was a descriptive-analytical study. We investigated the number of cases and deaths in 35 selected countries and regions of the WHO that had at least 10,000 cases by the time of the study. In addition, the incidence and CFR of COVID-19 were investigated. Finally, time trends of the number of cases, deaths, and CFR were investigated using ordinary least squares regression models.RESULTS:The total number of confirmed cases of COVID-19 was 3,090,184. The European region had the highest number of COVID-19 patients (1,434,649 [46.43%]). Ukraine with 10,406 and the USA with 1,003,974 cases have reported the lowest and highest confirmed cases, respectively. In addition, the European region and the African region with 157.13 and 2.50 patients per 100,000 population had the highest and the lowest incidence rate, respectively. India (2.44) and Spain (455.69) had the lowest and the highest incidence rate per 100,000 population, respectively. In the world, 217,759 deaths have happened, of which 135,961 (62.44%) were reported in the European region. Furthermore, the USA had the highest number of deaths (52,428) due to COVID-19. CFR was 7.05% in the world, which ranged from 3.74% in the African region and 9.48% in the European region. The number of patients and deaths due to COVID-19 had increasing trends in all countries, and the trend of CFR just for Iran and Ukraine was negative.CONCLUSION:The countries had different trends in the morbidity and mortality of COVID-19. However, regarding the increasing trend of the disease in the world, it will be more important to rely on public prevention strategies. It is necessary to apply and continue public health policies at national and global levels till the control of the disease.

Old subjects with sepsis in the emergency department: trend analysis of case fatality rate

BackgroundThe burden of sepsis represents a global health care problem. We aimed to assess the case fatality rate (CFR) and its predictors in subjects with sepsis admitted to a general Italian hospital from 2009 to 2016, stratified by risk score.MethodsWe performed a retrospective analysis of all sepsis-related hospitalizations after Emergency Department (ED) visit in a public Italian hospital in an 8-year period. A risk score to predict CFR was computed by logistic regression analysis of selected variables in a training set (2009–2012), and then confirmed in the whole study population. A trend analysis of CFR during the study period was performed dividing patient as high-risk (upper tertile of risk score) or low-risk.ResultsTwo thousand four hundred ninety-two subjects were included. Over time the incidental admission rate (no. of sepsis-related admissions per 100 total admissions) increased from 4.1% (2009–2010) to 5.4% (2015–2016); P < 0.001, accompanied by a reduced CFR (from 38.0 to 18.4%; P < 0.001). A group of 10 variables (admission to intensive care unit, cardio-vascular dysfunction, HIV infection, diabetes, age ≥ 80 years, respiratory diseases, number of organ dysfunction, digestive diseases, dementia and cancer) were selected by the logistic model to predict CFR with good accuracy: AUC 0.873 [0.009]. Along the years CFR decreased from 31.8% (2009–2010) to 25.0% (2015–2016); P = 0.007. The relative proportion of subjects ≥80 years (overall, 52.9% of cases) and classified as high-risk did not change along the years. CFR decreased only in low-risk subjects (from 13.3 to 5.2%; P < 0.001), and particularly in those aged ≥80 (from 18.2 to 6.6%; P = 0.003), but not in high-risk individuals (from 69.9 to 64.2%; P = 0.713).ConclusionBetween 2009 and 2016 the incidence of sepsis-related hospitalization increased in a general Italian hospital, with a downward trend in CFR, only limited to low-risk patients and particularly to subjects ≥80 years.

Firearm assault in Philadelphia, 2005–2014: a comparison of police and trauma registry data

BackgroundFirearm injury is a major public health burden in the USA. Absent a single, reliable data source, researchers have attempted to describe firearm injury epidemiology using trauma registry data. To...

Trends of case-fatality rate by acute coronary syndrome in Portugal: Impact of a fast track to the coronary unit.

IntroductionEfforts were made to improve management of coronary disease as the fast-track system to the Coronary Unit. We aim to analyse case-fatality rates by acute coronary syndrome in Portugal from 2000 to 2016, mainly the impact of the fast-track system and the proportion of patients that activate the fast-track system.MethodsWe analysed monthly acute coronary syndrome case-fatality before and after the implementation of the fast-track system in 2007. Impact of the system was assessed through regression models for interrupted time-series. We calculated annual proportion of fast-track system admissions.ResultsAfter 2007 case-fatality by acute coronary syndrome decreased (β=−1.27, p-value < 0.01). The estimates obtained for ST Elevation Myocardial Infarction suggest a reduction of nearly 86 monthly deaths prevented after 2007. The highest percentage of patients admitted through the fast-track system was 35%.ConclusionsOur results suggest fast-track system may have contributed to a decline in acute coronary syndrome case-fatality. However, more than half of patients were not admitted through the system. This should encourage health authorities to make efforts to ensure compliance.

Global dengue death before and after the new World Health Organization 2009 case classification: A systematic review and meta-regression analysis

BackgroundSince the introduction of 2009 WHO dengue case classification, no literature was found regarding its effect on dengue death. This study was to evaluate the effect of 2009 WHO dengue case classification towards dengue case fatality rate. MethodsVarious databases were used to search relevant articles since 1995. Studies included were cohort and cross-sectional studies, all patients with dengue infection and must report the number of death or case fatality rate. The Joanna Briggs Institute appraisal checklist was used to evaluate the risk of bias of the full-texts. The studies were grouped according to the classification adopted: WHO 1997 and WHO 2009. Meta-regression was employed using a logistic transformation (log-odds) of the case fatality rate. The result of the meta-regression was the adjusted case fatality rate and odds ratio on the explanatory variables. ResultsA total of 77 studies were included in the meta-regression analysis. The case fatality rate for all studies combined was 1.14% with 95% confidence interval (CI) of 0.82–1.58%. The combined (unadjusted) case fatality rate for 69 studies which adopted WHO 1997 dengue case classification was 1.09% with 95% CI of 0.77–1.55%; and for eight studies with WHO 2009 was 1.62% with 95% CI of 0.64–4.02%. The unadjusted and adjusted odds ratio of case fatality using WHO 2009 dengue case classification was 1.49 (95% CI: 0.52, 4.24) and 0.83 (95% CI: 0.26, 2.63) respectively, compared to WHO 1997 dengue case classification. There was an apparent increase in trend of case fatality rate from the year 1992–2016. Neither was statistically significant. ConclusionsThe WHO 2009 dengue case classification might have no effect towards the case fatality rate although the adjusted results indicated a lower case fatality rate. Future studies are required for an update in the meta-regression analysis to confirm the findings.

Score for the Survival Probability in Metastasis Breast Cancer: A Nomogram-Based Risk Assessment Model.

PurposeSurvival of metastatic breast cancer (MBC) patient remains unknown and varies greatly from person to person. Thus, we aimed to construct a nomogram to quantify the survival probability of patients with MBC.Materials and MethodsWe had included 793 MBC patients and calculated trends of case fatality rate by Kaplan-Meier method and joinpoint regression. Six hundred thirty-four patients with MBC between January 2004 and July 2011 and 159 patients with MBC between August 2011 and July 2013 were assigned to training cohort and internal validation cohort, respectively. We constructed the nomogram based on the results of univariable and multivariable Cox regression analyses in the training cohort and validated the nomogram in the validation cohort. Concordance index and calibration curves were used to assess the effectiveness of nomogram.ResultsCase fatality rate of MBC was increasing (annual percentage change [APC], 21.6; 95% confidence interval [CI], 1.0 to 46.3; p < 0.05) in the first 18 months and then decreased (APC, -4.5; 95% CI, -8.2 to -0.7; p < 0.05). Metastasis-free interval, age, metastasis location, and hormone receptor status were independent prognostic factors and were included in the nomogram, which had a concordance index of 0.69 in the training cohort and 0.67 in the validation cohort. Calibration curves indicated good consistency between the two cohorts at 1 and 3 years.ConclusionIn conclusion, the fatality risk of MBC was increasing and reached the summit between 13th and 18th month after the detection of MBC. We have developed and validated a nomogram to predict the 1- and 3-year survival probability in MBC.

Pediatric Traumatic Brain Injury: a 5-year descriptive study from the National Trauma Center in Qatar

BackgroundThe epidemiologic characteristics and outcomes of pediatric traumatic brain injury (pTBI) have not been adequately documented from the rapidly developing countries in the Arab Middle East. We aimed to describe the hospital-based epidemiologic characteristics, injury mechanisms, clinical presentation, and outcomes of pTBI and analyze key characteristics and determinant of pTBI that could help to make recommendations for policies to improve their care.MethodsWe conducted a retrospective observational study in a level 1 trauma center (2010–2014) for all pTBI patients. Data were analyzed and compared according to different patient age groups.ResultsOut of 945 traumatic brain injury patients, 167 (17.7%) were ≤ 18 years old with a mean age of 10.6 ± 5.9 and 81% were males. The rate of pTBI varied from 5 to 14 cases per 100,000 children per year. The most affected group was teenagers (15–18 years; 40%) followed by infants/toddlers (≤ 4 years; 23%). Motor vehicle crash (MVC; 47.3%) was the most frequent mechanism of injury followed by falls (21.6%). MVC accounted for a high proportion of pTBI among teenagers (77.3%) and adolescents (10–14 years; 48.3%). Fall was a common cause of pTBI for infants/toddlers (51.3%) and 5–9 years old group (30.3%). The proportion of brain contusion was significantly higher in adolescents (61.5%) and teenagers (58.6%). Teenagers had higher mean Injury Severity Scoring of 24.2 ± 9.8 and lower median (range) Glasgow Coma Scale of 3 (3–15) (P = 0.001 for all). The median ventilatory days and intensive care unit and hospital length of stay were significantly prolonged in the teenage group. Also, pTBI in teenage group showed higher association with pneumonia (46.4%) and sepsis (17.3%) than other age groups (P = 0.01). The overall mortality rate was 13% (n = 22); 11 died within the first 24 h, 7 died between the second and seventh day and 4 died one week post-admission. Among MVC victims, a decreasing trend of case fatality rate (CFR) was observed with age; teenagers had the highest CFR (85.7) followed by adolescents (75.0), young children (33.3), and infants/toddlers (12.5).ConclusionsThis local experience to describe the burden of pTBI could be a basis to adopt and form an efficient, tailored strategy for safety in the pediatric population.

A study to evaluate the functioning of Special Care Newborn Unit (SNCU) established at a District Hospital

The Neonatal mortality rate in India is high and stagnant. Special Care Newborn Units (SCNUs) have been set up to provide quality level II newborn-care services in several district hospitals to meet this challenge. The units are located in some districts where the burden of neonatal deaths is high, and access to special newborn care is poor. A cross-sectional survey was conducted to assess the availability of human resources, equipment, and quality care. Descriptive statistics were used for analyzing the inputs (resources) and outcomes (morbidity and mortality). The rate of mortality among admitted neonates was taken as the key outcome variable to assess the performance of the units. Chi-square test was used for analyzing the trend of case-fatality rate over a period of first year of operationalization of SNCU as the base. The Average Neonatal Mortality Rate reduced from 1.29% before the start of SNCU in 2012 to 0.845% after 1 year of start of SNCU in Rajouri district during 2013-14 study periods. Proportional mortality due to sepsis and low birth weight (LBW) declined significantly over a period of one year (LBW <2.5 kg). The major reasons for admission and the major causes of deaths were birth asphyxia, sepsis, and LBW/prematurity. Repair and maintenance of equipment were a major concern. It is possible to set up and manage quality SCNUs and improve the survival of newborns with LBW and sepsis in developing countries, although several challenges relating to human resources, maintenance of equipment, and maintenance of asepsis remain.

Deaths, late deaths, and role of infecting dose in Ebola virus disease in Sierra Leone: retrospective cohort study

Objectives To assess the frequency of fatal recrudescence from Ebola virus disease after discharge from treatment centres, and explore the influence of infecting dose on case fatality rates.Design Retrospective cohort...

Mortality and its risk factors in Malawian children admitted to hospital with clinical pneumonia, 2001-12: a retrospective observational study.

Few studies have reported long-term data on mortality rates for children admitted to hospital with pneumonia in Africa. We examined trends in case fatality rates for all-cause clinical pneumonia and its risk factors in Malawian children between 2001 and 2012. Individual patient data for children (<5 years) with clinical pneumonia who were admitted to hospitals participating in Malawi's Child Lung Health Programme between 2001 and 2012 were recorded prospectively on a standardised medical form. We analysed trends in pneumonia mortality and children's clinical characteristics, and we estimated the association of risk factors with case fatality for children younger than 2 months, 2-11 months of age, and 12-59 months of age using separate multivariable mixed effects logistic regression models. Between November, 2012, and May, 2013, we retrospectively collected all available hard copies of yellow forms from 40 of 41 participating hospitals. We examined 113 154 pneumonia cases, 104 932 (92·7%) of whom had mortality data and 6903 of whom died, and calculated an overall case fatality rate of 6·6% (95% CI 6·4-6·7). The case fatality rate significantly decreased between 2001 (15·2% [13·4-17·1]) and 2012 (4·5% [4·1-4·9]; ptrend<0·0001). Univariable analyses indicated that the decrease in case fatality rate was consistent across most subgroups. In multivariable analyses, the risk factors significantly associated with increased odds of mortality were female sex, young age, very severe pneumonia, clinically suspected Pneumocystis jirovecii infection, moderate or severe underweight, severe acute malnutrition, disease duration of more than 21 days, and referral from a health centre. Increasing year between 2001 and 2012 and increasing age (in months) were associated with reduced odds of mortality. Fast breathing was associated with reduced odds of mortality in children 2-11 months of age. However, case fatality rate in 2012 remained high for children with very severe pneumonia (11·8%), severe undernutrition (15·4%), severe acute malnutrition (34·8%), and symptom duration of more than 21 days (9·0%). Pneumonia mortality and its risk factors have steadily improved in the past decade in Malawi; however, mortality remains high in specific subgroups. Improvements in hospital care may have reduced case fatality rates though a lack of sufficient data on quality of care indicators and the potential of socioeconomic and other improvements outside the hospital precludes adequate assessment of why case-fatality rates fell. Results from this study emphasise the importance of effective national systems for data collection. Further work combining this with data on trends in the incidence of pneumonia in the community are needed to estimate trends in the overall risk of mortality from pneumonia in children in Malawi. Bill & Melinda Gates Foundation.

Cardiovascular case fatality in rheumatoid arthritis is decreasing; first prospective analysis of a current low disease activity rheumatoid arthritis cohort and review of the literature.

BackgroundPrevious studies found increased case fatality after myocardial infarction and more frequent sudden death in RA patients compared to non-RA subjects. The RA associated CV risk might be explained by the combined effects of chronic systemic inflammation and increased lifestyle associated cardiovascular risk factors, and modified by the use of medication such as non steroidal anti-inflammatory drugs, corticosteroids and disease modifying anti-rheumatic drugs. Trends in case fatality rate in RA after the introduction of potent anti-inflammatory biologic therapies and treat-to-target treatment strategies aiming at remission are not known. This study was performed to examine the cardiovascular fatality rate in current low disease activity RA, and to evaluate trends in RA associated CV case fatality over time.MethodsProspective study to determine the incidence of fatal and nonfatal CV events in 480 RA patients included in the ACT-CVD cohort between February 2009 and December 2011. Patients with prior CV disease were excluded. Cox regression analysis was performed to determine CV event risk and contributing risk factors over time. The results of the cohort analysis were put into the context of a review of the literature to evaluate trends in RA associated CV fatality rate over time.ResultsThe study included 480 RA patients, 72.3% female with median disease duration of 4.2 years, 72.1% being in clinical remission (Disease Activity Score in 28 joints). During a mean follow up of 2.9 years 29 patients (6%) experienced a first CV event, 2 fatal and 27 non-fatal, corresponding to a 6.9% case fatality rate. Comparison with previous studies in cohorts with successive enrolment periods shows a trend towards a decrease in CV case fatality in RA from 52.9% in 1998 to 6.9% in our study.ConclusionCV case fatality in current low disease activity RA is importantly lower than in previous studies, and a trend towards decreasing CV fatality in RA is suggested.

Administrative Databases and Trends in In-Hospital Deaths in Pulmonary Embolism

T he recent article by Tsai et al 1 highlights the trends in in-hospital deaths among hospitalizations with pulmonary embolism. Using the National Hospital Discharge Survey, they report a decreasing trend in case fatality rate between the years 2001 and 2008. Our group also recently investigated the outcomes of acute pulmonary embolism from the Nationwide Inpatient Sample, the largest all-payer inpatient care database in the United States, between the periods 2000 and 2008. Although we were looking at the differences in outcomes between weekend and weekday hospitalizations for patients admitted with a primary diagnosis of pulmonary embolism, we noted a significant trend in declining inpatient mortality. We used data from all patients coded with primary diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 415.11 and 415.19. These ICD9-CM codes have been validated before, with a positive predictive value of 95%. We think that the similar results from these 2 reports from different large databases reflect the importance of using administrative databases to examine trends in outcomes for common medical conditions. They represent timely, “real-world” analyses of questions that may be too difficult to address using prospective randomized methods or extensive retrospective medical chart reviews. Use of large databases provides an important analytical resource as we embark on improving national health care efficacy in the current challenging environment.

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.

Trends in Case-Fatality Rates in Hospitalized Nontraumatic Subarachnoid Hemorrhage

Subarachnoid hemorrhage accounts for 2% to 5% of all strokes and is associated with high morbidity and mortality rates. Reports in the literature show that case-fatality rates vary with time and according to geographical area. The objective of the study was to evaluate the case-fatality rates in subarachnoid hemorrhage at 1 and 6 months and to determine trends in these rates over 22 years using a population-based registry. The Dijon Stroke Registry has enabled us to perform a comprehensive analysis of subarachnoid hemorrhage diagnosed in a population of >150 000 inhabitants hospitalized between 1985 and 2006 in the Dijon University Hospital, which has both a neurosurgery unit and a neuroradiology unit. Diagnosis was based on clinical and neuroimaging features and, when necessary, on lumbar puncture. Case-fatality rates for hospitalized subarachnoid hemorrhages at 1 and 6 months were 15.59% (95% confidence interval [CI], 9.37-25.34) and 16.84% (95% CI, 10.33-26.78), respectively. From 1985 to 1995, case-fatality rates for SAH at 1 and 6 months were 17.1% (95% CI, 8.1-34.2) and 17.7% (95% CI, 9.6-31.3), whereas from 1996 to 2006, they were 20.2% (95% CI, 10.2-37.8) and 19.7% (95% CI, 11.1-33.6), respectively. Case-fatality rates for hospitalized subarachnoid hemorrhages in this population-based study remained stable over 22 years, suggesting that this stroke subtype is still a very severe disease despite early management. Most deaths occurred during the first 30 days. Further work is necessary to evaluate levels of prehospital case-fatality in our population-based registry.