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PubMed2001

Can generic scores (Pediatric Risk of Mortality and Pediatric Index of Mortality) replace specific scores in predicting the outcome of presumed meningococcal septic shock in children?

OBJECTIVE: To compare, in children with septic shock and purpura, the accuracy in predicting death of two specific scores (the MenOPP bedside clinical [MOC] score of Gedde Dahl and the score of Groupe Francophone de Réanimation Pédiatrique [GFRP]), the C-reactive protein (CRP) level, and the two pediatric generic scores (the Pediatric Risk of Mortality [PRISM] and Pediatric Index of Mortality [PIM] scores). DESIGN: Prospective, population-based study with analysis of previous comparative studies. SETTING: A 14-bed pediatric intensive care unit in a university hospital. PATIENTS: All children admitted consecutively to the pediatric intensive care unit with septic shock and purpura (n = 58, with 16 deaths [27.6%]) from January 1993 to May 2000. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The MOC and GFRP scores and the CRP level were prospectively determined at admission. The PRISM score was prospectively calculated within 24 hrs of admission or at the time of death, and the PIM score was calculated retrospectively between 1993 and 1997 and then prospectively from admission data. The nonparametric estimate of the area under the receiver operating characteristic curves (AUC) was calculated from the raw data using the Wilcoxon-Mann-Whitney two-sample statistic, and the standard error of the AUCs was calculated with DeLong's method. All the scores had an AUC >0.80, the PRISM probability of death having the best one (0.96 +/- 0.02). The PRISM value, which is easier to calculate, had an AUC of 0.95 +/- 0.02. The PRISM score performed significantly better than the PIM score (AUC, 0.83 +/- 0.06; p <.01) and the CRP level (AUC, 0.80 +/- 0.06; p <.01); however, there was no significant difference between the MOC (AUC, 0.91 +/- 0.04) and GFRP scores (AUC, 0.87 +/- 0.05). Analyzing literature and calculating AUCs from original data of previous studies, we observed that the superiority of the PRISM score had never been demonstrated in meningococcal diseases. CONCLUSIONS: The PRISM score performed better than the PIM score, and was not surpassed by specific scores. Thus, we propose its use for outcome prediction in children with septic shock and purpura. However, if the PRISM score is to be used as inclusion criterion for clinical trials, it should be evaluated within a few hours after admission.

Area Under Curve↗
PubMed1977

Preweaning mortality in the pig. The prevalence of various causes of preweaning mortality and the importance of some contributory factors.

The relative importance of the various causes of preweaning mortality in the pig was determined from the results of autopsy and laboratory examinations on 718 animals. Conditions associated with parturition accounted for 25.1% of the losses, while physical factors (33.0%), starvation (12.8%) and septicaemia (10.9%) were the most common causes of death in piglets which were born alive. In contrast enteric diseases, viral infections, genetic conditions and various miscellaneous diseases played a relatively minor part. Some biological factors affected the prevalence of the various causes of death. Most losses from physical factors, starvation and septicaemia occurred during the first 4 days of life, while other infectious conditions were more common in older piglets. Large litters at birth had significantly more deaths associated with parturition and due to physical factors and starvation. Increased losses from physical factors occurred in the litters of gilts and sows of parity 5. The size of the enterprise and the use of farrowing crates combined to influence the extent of losses due to physical factors. A significantly higher mortality occurred in the large piggery in which crates were not used. The large units also had fewer deaths resulting from starvation.

Animal Husbandry↗
PubMed2000

Likely variations in perioperative mortality associated with cardiac surgery: when does high mortality reflect bad practice?

OBJECTIVE: Several methods exist for estimating the risk of perioperative mortality based on preoperative risk factors; graphical methods such as the variable life adjusted display (VLAD) can be used to examine how an individual surgeon's performance for a series of operations fares against what would be expected, given the case mix. This study aimed to devise a method for assessing the natural variation in outcome in order to assist with making judgements about individual performance, in particular whether seemingly poor performance could have occurred by chance. METHOD: The risk scoring system has been derived and validated locally for cardiac surgery. A method is described for calculating the probability that an observed number of deaths occurs within a sequence of operations if perioperative mortality is regarded as a chance event with an expected value derived from the risk score. To illustrate this method, nested prediction intervals are superimposed onto VLAD plots for a series of 393 isolated coronary artery bypass and isolated valve operations performed by a single surgeon. RESULTS: Using the locally derived risk score, the VLAD plot for the individual surgeon shows a net life gain of about 6 over the predicted number of survivors, which is observed to be within the 90% prediction interval. If the Parsonnet scoring system is used instead of the locally derived risk score, the net life gain is considerably overestimated. CONCLUSIONS: The nested prediction intervals are straightforward to generate and can be integrated into a visually informative display. As an indication of the inherent variability in outcome, they have a valuable role in the monitoring of surgical performance.

Clinical Competence↗
PubMed2004

Effect of candesartan on cause-specific mortality in heart failure patients: the Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) program.

BACKGROUND: Patients with heart failure are at increased risk of sudden death and death attributed to progressive pump failure. We assessed the effect of candesartan on cause-specific mortality in patients enrolled in the Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) program. METHODS AND RESULTS: The CHARM program consisted of 3 component trials that enrolled patients with symptomatic heart failure: CHARM-Alternative (n=2028; LVEF<=40% [corrected] and ACE intolerant), CHARM-Added (n=2548; LVEF<=40%, [corrected] already on ACE inhibitors), and CHARM-Preserved (n=3023; LVEF >40%). Patients were randomized to candesartan, titrated to 32 mg QD, or placebo and were followed up for a median of 37.7 months. All deaths were reviewed by a blinded adjudication committee and categorized according to prespecified definitions on the basis of a narrative and source documentation. The number and rate of deaths by cause were calculated for each of the component trials and the overall program. Of all the patients, 8.5% died suddenly, and 6.2% died of progressive heart failure. Candesartan reduced both sudden death (HR 0.85 [0.73 to 0.99], P=0.036) and death from worsening heart failure (HR 0.78 [0.65 to 0.94], P=0.008). These reductions were most apparent in the patients with LVEF<=40% [corrected]. CONCLUSIONS: Candesartan reduced sudden death and death from worsening heart failure in patients with symptomatic heart failure, although this reduction was most apparent in patients with systolic dysfunction.

Aged↗
PubMed2004

Mortality after peripheral bypass surgery: value of a mortality scoring system in evaluating the quality of care.

The objective of this study was to determine the role of a mortality registration in the quality control of patients who died after peripheral bypass surgery. We developed a mortality registration to classify causes of death, to evaluate shortcomings in treatment, and to determine the extent of agreement between pre- and postmortem findings. In a 10-year period, 28 of the 1,022 patients (2.7%) who underwent peripheral arterial reconstruction died. Fifty-three percent of the patients died owing to postoperative complications, most frequently a myocardial infarction. A shortcoming in the medical treatment was observed in only one patient. Forty-three percent of the relatives gave permission for an autopsy. In only two cases, the autopsy report revealed a myocardial infarction that had remained unnoticed during the clinical course. In this selected group of patients undergoing a peripheral bypass operation, the causes of death and the shortcomings in medical care could usually be identified without the help of autopsy data.

Aged↗
PubMedDate not supplied

Hormone replacement therapy in prevention of morbidity and mortality in the older woman. Part IV: HRT and the aging brain, overall mortality, and individual decision-making.

OBJECTIVES: The objective of this four part series is to review for the practicing clinician the extensive and sometimes contradictory literature on the effects of estrogen replacement therapy and hormone replacement therapy (HRT) in the postmenopausal woman. This final article reviews the role of long-term HRT in stroke, Alzheimer's disease (AD), and overall mortality as well as strategies to guide decision-making for the individual patient. DESIGN: Studies reviewed were obtained through Medline searches, examination of citations in the articles reviewed from those searches, interviews with local experts in geriatrics, cardiology, and women's health. CONCLUSIONS: Evidence for benefit from HRT in delaying onset of and preventing AD in aging women is inconclusive. No consistent trend for beneficial or harmful effect of HRT on stroke risk has been demonstrated. HRT does seem to be beneficial in decreasing overall mortality risk, especially in women with coronary heart disease risk factors. The overall health and functioning of the geriatric patient and the presence of co-morbid conditions must be factored into clinical decisions. The decision to initiate HRT is complex, requires thoughtful assessment of net benefit and risk for the individual patient, and should accommodate the individual's personal preferences. Forthcoming results from the Women's Health Initiative HRT trial and observational study will help resolve some of the ambiguities in this decision-making process.

Journal Article↗
PubMed2004

[Annual mortality and morbidity in operating rooms during 2002 and summary of morbidity and mortality between 1999 and 2002 in Japan: a brief review].

The Japanese Society of Anesthesiologists (JSA) conducts an annual survey of life-threatening events in operating rooms (OR) in JSA Certified Training Hospitals (JSACTH) by sending and collecting confidential questionnaires. Etiologies of the incidents were divided into four categories: those totally attributable to anesthetic management (AM), those resulting from preoperative complications (PC), those resulting from intraoperative pathological events (IP) and those related to surgical procedures (SP). IP resulted from coronary ischemia not suspected preoperatively, arrhythmias, pulmonary embolism, and other conditions. Outcomes were judged on the 7th post-operative day. In the year 2002, questionnaires were sent to 844 JSACTHs, and a total of 1,461,020 cases of anesthesia were documented from 773 JSACTHs. Of these, 1,277,045 cases of anesthesia from 712 JSACTHs were available for analysis. Seven hundred thirty nine cardiac arrests (5.79 per 10,000 anesthetics) and 806 deaths (6.31 per 10,000 anesthetics) due to life-threatening events in the OR were reported. The incidence of cardiac arrest and mortality totally attributable to AM was 0.38 and 0.11 per 10,000 anesthetics. These values tended to decrease after 1994, except the mortality totally attributable to AM, which were almost at constant level during recent years. The summary of the study between 1999 and 2002 was as follows. Among 3,855,384 anesthetics, 2,443 cardiac arrests (6.34 per 10,000 anesthetics) and 2,638 deaths (6.85 per 10,000 anesthetics) due to life-threatening events in the OR were reported. PC, SP, IP and AM were responsible for 64.7, 23.9, 9.4, and 1.5% of deaths, respectively. The major cause of PC related deaths was preoperative hemorrhagic shock, followed by cardiovascular diseases such as myocardial ischemia and congestive heart failure. Excessive surgical bleeding comprised 70.2% of SP-related deaths. The major causes of IP-related death were myocardial ischemia, pulmonary embolism, and severe arrhythmias. The incidence of cardiac arrest and death totally attributable to AM was 0.47 and 0.10/10,000 anesthetics, respectively. Among patients with ASA-PS 1(E) and 2(E), AM-related deaths occurred at a rate of 0.04/10,000 anesthetics. Half of AM-induced deaths were caused by airway or ventilatory problems. Other causes of AM-related death were medication accidents and infusion/transfusion accidents. Considerable effort is required to reduce intraoperative life-threatening events caused by human error, hemorrhage, and cardiovascular diseases.

Anesthesiology↗
PubMed1992

The high mortality of gastrointestinal bleeding in HIV-seropositive patients: a multivariate analysis of risk factors and warning signs of mortality in 50 consecutive patients.

The patterns of which human immunodeficiency virus (HIV)-seropositive patients underwent endoscopy for gastrointestinal bleeding at a university hospital were analyzed in 50 consecutive patients admitted from July 1984 through December 1989, and criteria were developed as to which patients are most likely to benefit from endoscopy. Analyzed patient data included the medical records, follow-up until July 1990 obtained by telephone questionnaire in 46 patients, and autopsy findings in the 11 patients undergoing autopsy. Thirty-seven percent of the patients did not undergo endoscopic or radiographic examinations indicated to determine the cause of bleeding. The adequacy of the evaluation was not related to race, intravenous drug abuse, homosexuality, hemophilia, the diagnosis of known AIDS, or being a public patient. In 21 of the 28 cases in which the cause of bleeding was determined, the diagnosed lesions had a specific, effective therapy. The mortality from gastrointestinal bleeding was 39.0%, compared with 8.3% in 48 controls without known HIV infection (p less than 0.001 by Fisher's exact test, odds ratio = 7.0, odds ratio confidence interval = 5.0-9.7). Statistically significant independent predictors of mortality included leukocytosis, concurrent major diseases, intravenous drug abuse, transfusion of 5 or more units of packed erythrocytes, and the presence of a bloody nasogastric aspirate or hematemesis (Wilk's lambda statistic = 0.369, p less than 0.0001). In particular, 10 of 11 patients (89%) with two or more concurrent major diseases died, whereas only three of 24 patients (13%) with no concurrent diseases died during the hospitalization. We conclude a large percentage of HIV-seropositive patients did not undergo a diagnostic evaluation for gastrointestinal bleeding at a university hospital, and there was no discernible rational pattern as to which patients underwent endoscopy. Endoscopy is an important and indicated procedure in HIV-seropositive patients with no or one concomitant major illness. HIV-seropositive patients with gastrointestinal bleeding and two or more concomitant major illnesses have an exceedingly poor prognosis, and are less likely to benefit from invasive diagnostic tests and aggressive therapy.

Acquired Immunodeficiency Syndrome↗
PubMed1988

Cancer mortality and mortality trends in Henan, China, 1974-1985.

Promotion of cancer control programs requires accurate data on cancer incidence and mortality from population-based cancer registries. Currently, there are 12 institutions that register cancer deaths in the respective 12 counties and cities. The data thus obtained show that cancer of the esophagus, stomach, and liver in both sexes and cervical cancer in females are the leading causes of all cancer deaths. During the period of 1974-1985, marked changes have taken place in the Henan province in cancer mortality rates of certain sites. Some description and discussion of these changes are presented in this paper.

Adult↗
PubMed1988

Operative mortality in patients undergoing single valve replacement in teaching institutions--early mortality as a function of resident versus staff surgeon.

Nine hundred sixty-four patients undergoing single valve replacement (SVR) procedures alone or in combination with other cardiac surgical procedures were analyzed prospectively to determine whether the risks of operative mortality (OM) are different when the operation is performed by a resident under direct supervision of an attending surgeon (group I, 49.5%) or by an attending surgeon (group II, 50.5%). The overall OM rate was 8.4% (7.2% for group I and 9.7% for group II, which was not significant). Fifty-eight clinical, angiographic, and hemodynamic variables were analyzed to adjust statistically for differences in patient characteristics in each group. For aortic valve replacement, group II patients had smaller valve area and a higher incidence of three-vessel coronary artery disease, and more patients required resection of an ascending aortic aneurysm, whereas group I patients had higher incidence of peripheral edema and S3 gallop. For mitral valve replacement, more patients in group II had pleural effusion, previous cardiac operations, higher mean pulmonary artery pressures, mitral insufficiency due to coronary artery disease, and were in New York Heart Association (NYHA) functional class 3 and 4, whereas the group I patients had higher incidence of S3 gallop and elevated serum creatinine. Expected OM for each group was derived from a multivariate logistic model. Ratio of observed-to-expected (O/E) OM was calculated to adjust observed OM according to the risk of patients. There was no difference in O/E mortality ratio between the two groups. We conclude that OM probability is not increased when the SVR procedure is performed by residents under direct supervision of attending surgeons when adjusted for patient- and disease-related risk factors. These findings also constitute compelling evidence that patient care does not suffer when resident teaching experience is enhanced in teaching institutions.

Aortic Valve↗
PubMed1985

Texaco mortality study. I. Mortality among refinery, petrochemical, and research workers.

The Texaco mortality study is a retrospective follow-up study of all persons who were employed for at least five years in a refining, petrochemical, or research facility and who worked at some time during the period 1947 through 1977. Of the 19,077 white men in the cohort, 14,609 were alive, 4,024 were known to be dead, and the vital status of the remaining 444 was unknown as of Dec. 31, 1977. The standardized mortality ratio (SMR) of 75 for all causes was significantly low, on the basis of 5,332 expected deaths. Statistically significant deficits also were seen for all major causes of death and for cancer of many sites, including lung, stomach, bladder, and colon. The SMR was greater than 100 for six causes of death: pancreas cancer, brain cancer, leukemia, Hodgkin's disease, other lymphatic cancer, and benign neoplasms. However, none of these increases was statistically significant, and all SMRs except that for benign neoplasms (SMR = 148) were under 119.

Adult↗
PubMed1982

Methodological issues involving the standardized mortality ratio and proportionate mortality ratio in occupational studies.

The algebraic relationship between the standardized mortality ratio (SMR) and the proportionate mortality ratio (PMR) is derived. This relationship clearly shows that the validity of PMR as a risk assessment index depends on the homogeneity of the age-specific overall SMRs and the value of the "average" overall SMR (usually estimated by the age-adjusted overall SMR). Based on actual data from various epidemiologic studies, the adequacy, or lack of it, of using the PMR or the converted SMR is examined. Variations of the PMR method using different bases can be useful. Incomplete death ascertainment, which is a common problem in PMR studies, can lead to biased estimates.

Adult↗
PubMed1982

On a method of mortality analysis incorporating age--year interaction, with application to prostate cancer mortality.

A model used in the analysis of tabular mortality data (or incidence data), in which deaths are classified by age and year of occurrence, is shown to arise from the assumption that effects due to epoch of birth (the cohort effects) act multiplicatively on an underlying hazard function which may change with calendar year. The model disentangles the cohort effects and the effects due to epoch of death (year effects) and age at death (age effects), and incorporates an age--year interaction which has an interpretation in terms of changing the shape of the underlying hazard function. In addition, the derivation of the hazard function suggests meaningful interpretation of certain combinations of the model parameters. As an illustration, application of the model to prostate cancer mortality in England and Wales indicates, among other things, that after allowing the changing cohort effects, the risk for young men has increased relative to that for older men in recent years.

Adult↗
PubMed1995

Lung cancer mortality between 1950 and 1987 after exposure to fractionated moderate-dose-rate ionizing radiation in the Canadian fluoroscopy cohort study and a comparison with lung cancer mortality in the Atomic Bomb survivors study.

Current lung cancer risk estimates after exposure to low-linear energy transfer radiation such as X rays are based on studies of people exposed to such radiation at high dose rates, for example the atomic bomb survivors. Radiobiology and animal experiments suggest that risks from exposure at low to moderate dose rates, for example medical diagnostic procedures, may be over-estimated by such risk models, but data for humans to examine this issue are limited. In this paper we report on lung cancer mortality between 1950 and 1987 in a cohort of 64,172 Canadian tuberculosis patients, of whom 39% were exposed to highly fractionated multiple chest fluoroscopies leading to a mean lung radiation dose of 1.02 Sv received at moderate dose rates. These data have been used to estimate the excess relative risk per sievert of lung cancer mortality, and this is compared directly to estimates derived from 75,991 atomic bomb survivors. Based on 1,178 lung cancer deaths in the fluoroscopy study, there was no evidence of any positive association between risk and dose, with the relative risk at 1 Sv being 1.00 (95% confidence interval 0.94, 1.07), which contrasts with that based on the atomic bomb survivors, 1.60 (1.27, 1.99). The difference in effect between the two studies almost certainly did not arise by chance (P = 0.0001). This study provides strong support from data for humans for a substantial fractionation/dose-rate effect for low-linear energy transfer radiation and lung cancer risk.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1977

[Operative mortality, mortality and late results in bronchial carcinoma].

457 patients with a bronchial carcinoma of the years 1947--1962 are compared with 126 patients of the years 1969--1970 and set up in comparison to the whole clinical material of the years 1960--1975. In the period between 1969 and 1970 radical resections were performed in 20% more patients than in the first period (1947--1962). Older patients were in the last period (1970--1974) more frequent. 8% of all patients in which lobectomy was performed and 5.5% of the patients in which pneumonectomy was performed were older than 70 years of age. Overall mortality has remained unchanged for exploratory thoracotomy (19%), palliative resection (17.5%) and "radical" resection (14%). For simple pneumonectomy the overall mortality went down from 19.2% (1960--1964) to 9.6% (1970-1974) and for simple lobectomy from 14.4% to 3.8%. The five-year survival rate after radical resections was 8% (first period 0%) and after simple resections 26% (26.2%). Patients with stage I epidermoid carcinoma had a five-year survival rate of 46%. Those with stage II (spread to ipsilateral hilar nodes) a five-year survival rate of 14.3% Patients with palliative resections and exploratory thoracotomy died within 16 months.

Aged↗
PubMed1993

[[Perinatal mortality rates in single and multiple births, and the effects of maternal age, birthweight, and other factors on the perinatal mortality rates in Japan]].

"The perinatal mortality rate (PMR) was analyzed using... Vital Statistics for 1950-1991 in Japan. Secular changes in the PMRs were analyzed according to sex and single-multiple births. This paper also investigated the effects of maternal age, birth order, gestational age, and birthweight on the PMR." (SUMMARY IN ENG)

Age Factors↗