Use Of Pulmonary Artery Catheter Research Articles

Adequate agreement between venous oxygen saturation in right atrium and pulmonary artery in critically ill children*

To determine the agreement between venous oxygen saturation in right atrium (Srao2) and pulmonary artery (Svo2) in critically ill pediatric patients. Retrospective, observational study. Multidisciplinary pediatric intensive care unit from a general university hospital. Thirty critically ill children in whom a pulmonary artery catheter (PAC) was inserted for catecholamine refractory shock (septic and cardiogenic, n = 18) and postoperative management (liver and cardiac transplant, n = 12). Ninety measurements of Srao2 and Svo2 were obtained after placement of PAC and every 6 hrs for the first 12 hrs of pediatric intensive care unit admission. The agreement between Srao2 and Svo2 was determined through Bland and Altman methodology, concordance correlation coefficient, and the frequency of differences between Srao2 and Svo2. The frequency of differences between both saturations was evaluated in three categories: +/-1%-5%, +/-6%-9%, and higher than +/-10%. The first category was the threshold to consider both variables interchangeable. Changes of Srao2 related to clinically significant (>5%) increases and drops of Svo2 were analyzed. Srao2 and Svo2 were not significantly different: median (interquartile range) 83% (75%-86%) and 81% (75%-85%), respectively (p = 0.23). The frequency of differences between Srao2 and Svo2 was +/-1%-5%, 71 (79%); +/-6%-9%, 14 (15.5%); and higher than +/-10%, 5 (5.5%). Bland and Altman analysis showed a 2% bias with a 95% limits of agreement of -6.9% to 10.9%. The concordance correlation coefficient was 0.90. Svo2 increased in 11/90 measurements and Srao2 followed it 82% of the times. Svo2 decreased in 7/90 measurements and Srao2 followed it 100% of the times. The concordance analysis performed allows to conclude that there is an appropriate agreement between Svo2 and Srao2. This finding may become clinically relevant considering the difficulties associated to the use of PAC in children.

The pulmonary artery catheter: In medio virtus

To clarify the role of the pulmonary artery catheter in the intensive care unit. Recent and relevant literature from MEDLINE and authors' personal databases. Studies on pulmonary artery catheter use and use of other monitoring devices in critically ill patients. Based largely on clinical experience and assessment of the relevant published literature and in response to recent articles attacking the pulmonary artery catheter, we propose that the pulmonary artery catheter is still a valuable tool for the hemodynamic monitoring of patients with complex disease processes in whom the information obtained from the pulmonary artery catheter may influence management. We suggest that there is a need to revisit the basics of hemodynamic management and reassess the way in which the pulmonary artery catheter is used, applying three key principles: correct measurement, correct data interpretation, and correct application. The pulmonary artery catheter is still a valuable tool for hemodynamic monitoring when used in selected patients and by physicians adequately trained to correctly interpret and apply the data provided.

High Mortality Without ESCAPE: The Registry of Heart Failure Patients Receiving Pulmonary Artery Catheters Without Randomization

Background In the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE), there was no difference in days alive and out of the hospital for patients with decompensated heart failure randomly assigned to therapy guided by pulmonary artery catheter (PAC) plus clinical assessment versus clinical assessment alone. The external validity of these findings is debated. Methods and Results ESCAPE sites enrolled 439 patients receiving PAC without randomization in a prospective registry. Baseline characteristics, pertinent trial exclusion criteria, reasons for PAC use, hemodynamics, and complications were collected. Survival was determined from the National Death Index and the Alberta Registry. On average, registry patients had lower blood pressure, worse renal function, less neurohormonal antagonist therapy, and higher use of intravenous inotropes compared with trial patients. Although clinical assessment anticipated less volume overload and greater hypoperfusion among the registry population, measured filling pressures were similarly elevated in the registry and trial patients, whereas measured perfusion was slightly higher among registry patients. Registry patients had longer hospitalization (13 vs 6 days, P < .001) and higher 6-month mortality (34% vs 20%, P < .001) than trial patients. Conclusions The decision to use PAC without randomization identified a population with higher disease severity and risk of mortality. This prospective registry highlights the complex context of patient selection for randomized trials.

Pulmonary Artery Catheters

Since 1970, pulmonary artery catheters (PACs) have been used in clinical practice to monitor the hemodynamic status of critically ill and injured patients. This technology was introduced and commercialized without considerable testing to determine safety and efficacy. After years of common clinical use, investigators identified potential increases in mortality associated with PAC use. For the past decade, investigators have studied various patient populations to elucidate the safety and efficacy of the PAC. This article reviews the historical context of PAC use, findings from recent clinical trials intended to determine safety and efficacy, issues with reliability and validity of PAC use, and complications associated with PAC use. Data from recent clinical trials do not support routine use of PACs, and the authors suggest that PAC-guided therapy should be the focus of study in future trials.

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary

TABLE OF CONTENTSPreamble 686Definition of the Problem 688Purpose of These Guidelines 688Methodology and Evidence 689General Approach to the Patient 692History 693Physical Examination and Routine Laboratory Tests 693Multivariable Indices to Predict Preoperative Cardiac Morbidity 694Clinical Assessme

Intraoperative pulmonary embolism and intracardiac thrombosis complicating liver transplantation: a systematic review

Pulmonary embolism (PE) and intracardiac thrombosis (ICT) are rare but potentially lethal complications during orthotopic liver transplantation (OLT). We aimed to review clinical and pathological correlates of PE and ICT in patients undergoing OLT. A systematic review of the literature was conducted using MEDLINE and ISI Web of Science. Seventy-four cases of intraoperative PE and/or ICT were identified; PE alone in 32 patients (43%) and a combination of PE and ICT in 42 patients (57%). Most frequent clinical symptoms included systemic hypotension and concomitant rising pulmonary artery pressure, often leading to complete circulatory collapse. PE and ICT occurred in every stage of the operation and were reported equally in patients with or without the use of venovenous bypass or antifibrinolytics. A large variety of putative risk factors have been suggested in the literature, including the use of pulmonary artery catheters or certain blood products. Nineteen patients underwent urgent thrombectomy or thrombolysis. Overall mortality was 68% (50/74) and 41 patients (82%) died intraoperatively. Mortality was significantly higher in patients with an isolated PE, compared to patients with a combination of PE and ICT (91% and 50%, respectively; P < 0.001). Intraoperative PE and ICT during OLT appear to have multiple etiologies and may occur unexpectedly at any time during the procedure.

Intraoperative pulmonary embolism and intracardiac thrombosis complicating liver transplantation: a systematic review.

Pulmonary embolism (PE) and intracardiac thrombosis (ICT) are rare but potentially lethal complications during orthotopic liver transplantation (OLT). We aimed to review clinical and pathological correlates of PE and ICT in patients undergoing OLT. A systematic review of the literature was conducted using MEDLINE and ISI Web of Science. Seventy-four cases of intraoperative PE and/or ICT were identified; PE alone in 32 patients (43%) and a combination of PE and ICT in 42 patients (57%). Most frequent clinical symptoms included systemic hypotension and concomitant rising pulmonary artery pressure, often leading to complete circulatory collapse. PE and ICT occurred in every stage of the operation and were reported equally in patients with or without the use of venovenous bypass or antifibrinolytics. A large variety of putative risk factors have been suggested in the literature, including the use of pulmonary artery catheters or certain blood products. Nineteen patients underwent urgent thrombectomy or thrombolysis. Overall mortality was 68% (50/74) and 41 patients (82%) died intraoperatively. Mortality was significantly higher in patients with an isolated PE, compared to patients with a combination of PE and ICT (91% and 50%, respectively; P < 0.001). Intraoperative PE and ICT during OLT appear to have multiple etiologies and may occur unexpectedly at any time during the procedure.

Complicaciones graves de tipo mecánico asociadas al catéter de arteria pulmonar en cirugía cardiovascular y torácica

Although the use of pulmonary artery catheters (PACs) in managing critical patients is a subject of debate, they continue to be inserted in many cases and possible complications should be taken into account. Our objective was to review the serious or potentially serious complications associated with PACs in our hospital in the past 15 years. This was a retrospective study of seious mechanical complications of PAC use in patients who underwent vascular, cardiac, and thoracic surgery. The study included the records 7540 patients; 9 cases of serious complications were detected. These complications included 5 cases of pulmonary artery rupture (3 of which resulted in death), 1 perforated internal mammary vein, 1 knotted catheter, 1 bent one, and 1 case of a PAC becoming trapped in the surgical suture. The 0.12% incidence of complications is lower than rates found in the literature. Although these complications are rare, it is necessary to take precautions against their unexcepted appearance by carefully selecting the patients in whom PACs are placed and by paying special attention to the characteristic clinical and radiological signs of complications.

Applying logic to pulmonary artery catheter use

Mansour and colleagues recommend not routinely using the pulmonary artery catheter to guide hemodynamic management in the intensive care unit, because the perceived benefits are largely intangible [1]. Pulmonary artery catheter monitoring of the right ventricular ejection fraction (RVef) and of the right ventricular end-diastolic volume (EDV), however, reflects powerful yet underutilized relationships that assess right ventricular performance. Since the cardiac output equals the product of the RVef, the EDV and the heart rate, one can assess the RVef to EDV relations as direct measures of right ventricular performance. A series of RVef, EDV and heart rate combinations can give the same cardiac output (Figure ​(Figure1);1); monitoring or targeting cardiac output alone ignores this reality. For example, in hypovolemia the EDV is low and the RVef is increased, whereas in right ventricular failure the opposite is true. Furthermore, resuscitation from hypovolemia will increase the EDV and decrease the RVef [2], while reversal of cor pulmonale will decrease the EDV and increase the RVef. Figure 1 Right ventricular ejection fraction, right ventricular end-diastolic volume and heart rate relationship with cardiac output. CO, cardiac output; EDV, right ventricular end-diastolic volume; HR, heart rate; RVef, right ventricular ejection fraction. No monitoring device other than the pulmonary artery catheter can continually assess these variables. These concepts are often used in the cardiac surgery suite, but are rarely codified for diagnosis and management. Monitoring devices can improve outcome only if they are coupled to treatments that improve outcome. Applying the above logic to previously proposed treatment protocols, such as using the mixed venous oxygen saturation [3], may therefore be the first step toward defining pulmonary artery catheter utility [4].

Evaluation of the effect of intensity of care on mortality after traumatic brain injury

To evaluate the effect of age on intensity of care provided to traumatically brain-injured adults and to determine the influence of intensity of care on mortality at discharge and 12 months postinjury, controlling for injury severity. Cohort study using the National Study on the Costs and Outcomes of Trauma (NSCOT) database. Risk ratio and Poisson regression analyses were performed using data weighted according to the population of eligible patients. A total of 18 level 1 and 51 level 2 non-trauma centers located in 14 states in the United States and 1,776 adults aged 25-84 yrs with a diagnosis of traumatic brain injury. Injury severity was determined by the motor component of the Glasgow Coma Scale score, the Injury Severity Score, pupillary reactivity, and presence of midline shift. Factors evaluated as contributing to intensity of care included: admission to the intensive care unit, mechanical ventilation, placement of an intracranial pressure monitor, placement of a jugular bulb catheter, placement of a pulmonary artery catheter, critical care consultation, the number of specialty care consultations, mannitol use, treatment with barbiturate coma, decompressive craniectomy, number of nonneurosurgical procedures performed, the presence of a do-not-resuscitate order, and withdrawal of therapy. Controlling for injury-related factors, sex, and comorbidity, as age increased, the overall likelihood of receiving various interventions decreased. After controlling for injury severity, sex, and comorbidity, factors associated with higher risk of in-hospital death were: being aged 75-84 yrs (relative risk [RR] 1.32, 95% confidence interval [CI] 1.13, 1.55), pulmonary artery catheter use (RR 1.56, 95% CI 1.30, 1.86), intubation (RR 4.17, 95% CI 2.28, 7.61), the presence of a do-not-resuscitate order (RR 3.21, 95% CI 2.21, 4.65), and withdrawal of therapy (RR 2.33, 95% CI 1.69, 3.23). In contrast, a higher number of specialty care consultations (surgical consults: RR 0.63, 95% CI 0.54, 0.74; medical consults: RR 0.87, 95% CI 0.79, 0.95; and other consults: RR 0.43, 95% CI 0.26, 0.69) were associated with decreased risk of death. The results were similar for factors associated with death at 12 months, with the exception that the number of medical consultations was not significant, whereas the number of nonneurosurgical procedures performed was associated with lower risk of death (RR 0.96, 95% CI 0.92, 0.99), as was obtaining critical care consultation services (RR 0.84, 95% CI 0.71, 1.0). There is a lower intensity of care provided to older adults with traumatic brain injury. Although the specific contributions of specialists to patient management are unknown, their consultation was associated with decreased risk of in-hospital death and death within 12 months. It is important that careproviders have an increased awareness of the potential contribution of multidisciplinary clinical decision making to patient outcomes in older traumatically brain-injured patients.

Approach To Swan Ganz Thermodilution Catheter Complications: 6 Years Experience With 2310 Cases

Aim: A pulmonary artery catheter is the most frequent material used during and after cardiac surgery to monitor the patient in the early period because it gives so much information to surgery and anesthesia teams and intensive care staff. To be knotted or fixation with atrium sutures are rare complications seen in 0.1-3%. Material and Method: During 6 years period between 2001 January and 2006 December, totally 2310 pulmonary artery catheterization(PAC) were performed in cardiovascular operation patients. In 3 (%0.1) patients with preoperative pulmonary hypertension and valve disease operation, resistance to removing of PAC was seen. Radiographic images showed that catheters were resisted to displacement because they were knotted near the thermosistor part in two cases. In the third case catheter was fixed at right atrial level. Results: In the first two cases,catheters were pulled with appropriate manuplations and knot became smaller. Compression prevented the morbid hemorrhage and hematoma complications at catheter placement regions.The third case was reoperated because it was thought to be fixed with atrial sutures and open surgery technique showed that the catheter's distal end was fixed between right atrial auricule purse sutures. The first two cases discharged on postop 7th and the third on postop 8th day,with cure. Conclusion: Percutaneous catheterization of vena jugularis interna and vena subclavia needs time and for adequate skill development practice is necessary.Placement and use of PAC carry potential risks that requires immediate management.Developing the information about their complications' treatment can prevent additional morbidity and mortality.

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery WRITING COMMITTEE MEMBERS Lee A. Fleisher, MD, FACC, FAHA, Chair; Joshua A. Beckman, MD, FACC; Kenneth A. Brown, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA; Elliott Chaikof, MD; Kirsten E. Fleischmann, MD, MPH, FACC; William K. Freeman, MD, FACC; James B. Froehlich, MD, MPH, FACC; Edward K. Kasper, MD, FACC; Judy R. Kersten, MD, FACC§; Barbara Riegel, DNSc, RN, FAHA; John F. Robb, MD, FACC ACC/AHA TASK FORCE MEMBERS Sidney C. Smith, Jr, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Vice Chair; Cynthia D. Adams, MSN, PhD, FAHA; Jeffrey L. Anderson, MD, FACC, FAHA; Elliott M. Antman, MD, FACC, FAHA; Christopher E. Buller, MD, FACC; Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; David P. Faxon, MD, FACC, FAHA; Valentin Fuster, MD, PhD, FACC, FAHA; Jonathan L. Halperin, MD, FACC, FAHA; Loren F. Hiratzka, MD, FACC, FAHA; Sharon A. Hunt, MD, FACC, FAHA; Bruce W. Lytle, MD, FACC, FAHA; Rick Nishimura, MD, FACC, FAHA; Joseph P. Ornato, MD, FACC; Richard L. Page, MD, FACC, FAHA; Barbara Riegel, DNSc, RN, FAHA; Lynn G. Tarkington, RN; Clyde W. Yancy, MD, FACC

Trends in the Use of the Pulmonary Artery Catheter in the United States, 1993-2004

Although there is now substantial evidence that pulmonary artery (PA) catheterization does not reduce mortality in critically ill patients, it is unknown whether national utilization has decreased in response. To determine trends in PA catheterization use in the United States. A time trend analysis on national estimates of PA catheterization utilization from 1993-2004 using data from all US states contributing to the Nationwide Inpatient Sample. Hospital admissions for those participants aged 18 years or older were assessed, with primary analysis focused on admissions with a medical diagnosis related group and a secondary analysis focused on surgical admissions. PA catheterization was identified by 5 International Classification of Diseases, Ninth Revision procedure codes describing PA or wedge-pressure monitoring, measurement of mixed venous blood gases, or monitoring of cardiac output by oxygen consumption or other technique. Annual PA catheterization use per 1000 medical admissions. Between 1993 and 2004, PA catheterization use decreased by 65% from 5.66 to 1.99 per 1000 medical admissions (risk ratio [RR], 0.35; 95% confidence interval [CI], 0.29-0.42). Among patients who died during hospitalization, a group whose disease severity may be consistent across time, the relative decline was similar, decreasing from 54.7 to 18.1 per 1000 deaths (RR, 0.33; 95% CI, 0.28-0.38). A significant change in trend occurred following a 1996 study that suggested increased mortality with PA catheterization. The decline in utilization was similar in surgical patients (RR, 0.37; 95% CI, 0.25-0.49). Among common diagnoses associated with PA catheterization, the decline was most prominent for myocardial infarction, which decreased by 81% (RR, 0.19; 95% CI, 0.15-0.23), and least prominent for septicemia, which decreased by 54% (RR, 0.46; 95% CI, 0.38-0.54). Sensitivity analyses suggested findings were not due to artifact of changing procedure coding practice. Use of the PA catheter, previously a hallmark of critical care practice, has decreased in the United States during the last decade, possibly due to growing evidence that this invasive procedure does not reduce mortality.

Use of pulmonary artery catheters in advanced heart failure

Randomized trials have demonstrated that use of the pulmonary artery catheter does not improve outcomes in patients with critical illness. Despite this, pulmonary artery catheters continue to be used, especially in heart failure. This review addresses recent clinical trials evaluating the safety and efficacy of the pulmonary artery catheter. It also offers guidelines on when pulmonary artery catheter use could be considered in patients with advanced heart failure. A meta-analysis demonstrated that use of the pulmonary artery catheter in critically ill patients had no significant impact on morbidity or mortality. In the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial, the addition of the pulmonary artery catheter to careful clinical assessment also had neutral impact. The results of the study are limited, however, by the patient population that was selected for the study, and there still may be a role for the pulmonary artery catheter in advanced heart failure. Based on the results of the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial and the meta-analysis, there is no indication for routine use of pulmonary artery catheters to adjust therapy during hospitalization for decompensation of chronic heart failure. There remain many specific clinical situations in heart failure in which the pulmonary artery catheter may be useful, however.

Internal jugular venous catheter-related bacteremia according to central and posterior accesses

Although there are many studies about central venous catheter-related infection, we have not found any analysis of the incidence of internal jugular venous catheter-related bacteremia associated with different accesses. The objective of this study was to test whether the position of the internal jugular venous catheter, central or posterior, influences the incidence of bacteremia. A cohort study. A 12-bed polyvalent medical-surgical intensive care unit (ICU). Patients admitted to ICU between 1 May 2000 and 30 April 2004 who received one or more internal jugular venous catheters. A total of 1,483 patients were admitted to the polyvalent ICU, of whom 1,311 underwent central venous catheterization. A total of 547 patients received 684 internal jugular venous catheters, 169 by posterior and 515 by central access. There were no significant differences between central and posterior access patients in sex, age, APACHE II (14.1 +/- 5.0 vs. 13.9 +/- 5.2, p = 0.40), diagnosis, order of catheter insertion, use of mechanical ventilation, use of antimicrobials, use of total parenteral nutrition or use of pulmonary artery catheter. We found a higher incidence of internal jugular venous catheter-related bacteremia with central (4.8 per 1000 catheter-day) than with posterior (1.2 per 1000 catheter-day) access (odds ratio 3.9; 95% confidence interval 1.1-infinite; p = 0.03). Posterior access has a lower incidence of internal jugular venous catheter-related bacteremia than central access in non-severely ill patients (according to the low APACHE II score values of the study patients).

Iatrogenic pulmonary artery rupture

Pulmonary artery rupture is probably the most devastating complication associated with the use of the pulmonary artery catheter. This rare but disastrous situation requires a clear intervention plan. The initial presentation of pulmonary artery ruptures may be as obvious as a massive pulmonary hemorrhage or as subtle as a cough associated with minimal hemoptysis, or it may even be totally asymptomatic. A patient presenting any clinical manifestation of pulmonary artery rupture may develop a pulmonary artery false aneurysm, which is the accumulation of blood in an aneurismal sac compressed by lung parenchyma. This condition requires intervention because delayed hemorrhage may occur and recurrence can be massive and fatal. Following an initial episode of suspected pulmonary artery rupture, the patient should undergo immediate radiological investigation. If a diagnosis of pulmonary artery false aneurysm is confirmed, selective angiographic embolization helps reduce morbidity and mortality. The incidence of pulmonary artery ruptures is probably underestimated because many hemoptysis episodes or radiological infiltrations associated with pulmonary artery catheter use are not investigated. Also, the natural evolution of the pulmonary artery false aneurysm is unknown. The incidence of spontaneous healing, bleeding recurrence or asymptomatic persistence is unknown following formation of a pulmonary artery false aneurysm.

Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: A National Trauma Data Bank analysis of 53,312 patients

Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: A National Trauma Data Bank analysis of 53,312 patients

Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: A National Trauma Data Bank analysis of 53,312 patients

Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: A National Trauma Data Bank analysis of 53,312 patients

Lessons from ESCAPE: the PAC may not kill, but when should we consider ‘tailored’ therapy?

This article summarizes the results of the recent ESCAPE trial of the use of pulmonary artery catheter for haemodynamic monitoring and clinical decision making in patients with acute heart failure and proposes several clinical situations not included in the trial, which may be appropriate situations to use such monitoring.

A doença oncológica não deve ser um fator limitante para admissão na UTI de pacientes submetidos a cirurgias de alto risco

Oncologic diseases are conditions that have influence in the treatment offered to affected patients. The aim of this study was to compare hospitalar outcome of oncologic and non oncologic patients submitted to high risk elective surgery. Prospective, observational cohort study realized in an ICU of a tertiary hospital during the period between 04/01/2005 and 07/31/2005. Demographic data, APACHE II and MODS scores and laboratorial and hemodynamic variables were collected and complications like re-intervention need for mechanical ventilation, red blood cell transfusions and pulmonary artery catheter use during the post-operative period were evaluated. All patients were followed until hospital discharge or death. T student and Mann Whitney tests were used to compare numerical variables. Chi-square test was used to compare categorical variables. A p < 0.05 was considered as significant. 119 patients were included in the study. 43 were oncologic and 76 were non-oncologic. 52.9% were female. Mean age was 65.1 ± 14.1 years. Mean APACHE II score was 16.5 ± 5.8 and MODS median was 3 (2-6). Median length of surgery was 5 (3.3-7) hours and ICU and hospital mortality were 10.9% and 25.2%, respectively. Oncologic patients had greater length of hospital stay and length of stay before surgery. These results were statistically significant. Hospital mortality of oncologic patients was not greater than non-oncologic patients (22.4% versus 30.2%, p = 0.32). In this series, oncologic patients submitted to high risk surgery had the same mortality rate as non-onconlogic patients with similar disease severity.