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PubMed1998

Prospective validation of a scoring system for predicting neonatal morbidity after acute perinatal asphyxia.

OBJECTIVE: To prospectively validate a previously reported scoring system for identifying the near-term infant at risk for the multiple organ system sequelae of acute perinatal asphyxia. STUDY DESIGN: Prospective observational study. SETTING: Three Denver teaching hospitals, each providing comprehensive obstetric care. SUBJECTS: Newborn infants of 36 weeks or more gestation. INTERVENTION: None. STATISTICAL ANALYSIS: Chi-squared analysis with Fisher's exact test. OUTCOME: Scores consisting of graded abnormalities in fetal heart rate monitoring, umbilical arterial base deficit, and 5-minute Apgar score were calculated by the research nurse after admission of the infant to the nursery (range of possible scores, 0 to 9). A second nurse, blinded to these data, prospectively followed the newborn's hospital course for multiple organ system morbidity. RESULTS: Three thousand two hundred thirty-eight newborns were studied; 366 required neonatal intensive care unit admission. Eleven newborns had a score > or = 6 (mean umbilical artery pH = 6.98, base deficit = 17.1 mEq/L). Morbidities in these 11 newborns included seizures (2), hypoxic-ischemic encephalopathy (5), respiratory distress (9), hypotension (7), renal dysfunction (9), hypoglycemia/hypocalcemia (4), and thrombocytopenia or disseminated intravascular coagulopathy (3). The odds ratio (OR) and 95% confidence interval (CI) for newborns admitted to the neonatal intensive care unit with a score > or = 6 for having multiple organ system morbidity, defined as three or more affected organ systems, was 38.5 (95% CI, 9.2 to 127.8). The scoring system showed a stronger relationship with multiple organ system morbidity than did isolated individual indicators commonly used to identify asphyxia calculated on the same subjects: for those with pH < 7.00, OR 24 (95% CI, 6.4 to 94.1); base deficit > or = 10 mEq/L, OR 4.5 (95% CI, 1.9 to 10.3), and 5-minute Apgar score < or = 3, OR 7.4 (95% CI, 1.3 to 38.1). CONCLUSION: This scoring system, encompassing both immediate intrapartum and postpartum measures and acid-base status proximate to the time of delivery, is useful for rapidly identifying the term and near-term newborn at risk for multiple organ system morbidity after acute perinatal asphyxia.

Acidosis↗
PubMed1999

Prognostic models of thirty-day mortality and morbidity after major pulmonary resection.

BACKGROUND: A part of the prospective, multi-institutional National Veterans Affairs Surgical Quality Improvement Program was developed to predict 30-day mortality and morbidity for patients undergoing a major pulmonary resection. METHODS: Perioperative data were acquired from 194,319 noncardiac surgical operations at 123 Veterans Affairs Medical Centers between October 1, 1991, and August 31, 1995. Current Procedural Terminology code-based analysis was undertaken for major pulmonary resections (lobectomy and pneumonectomy). Preoperative, intraoperative, and outcome variables were collected. The 30-day mortality and morbidity models were developed by means of multivariable stepwise logistic regression with the preoperative and intraoperative variables used as independent predictors of outcome. RESULTS: A total of 3516 patients (mean age 64 9 years) underwent either lobectomy (n = 2949) or pneumonectomy (n = 567). Thirty-day mortality was 4.0% for lobectomy (119/2949) and 11.5% for pneumonectomy (65/567). The preoperative predictors of 30-day mortality were albumin, do not resuscitate status, transfusion of more than 4 units, age, disseminated cancer, impaired sensorium, prothrombin time more than 12 seconds, type of operation, and dyspnea. When the intraoperative variables were considered, intraoperative blood loss was added to the preoperative model. In the presence of these intraoperative variables in the model, do not resuscitate status and prothrombin time more than 12 seconds were only marginally significant. Thirty-day morbidity, defined as the presence of 1 or more of the 21 predefined complications, was 23.8% for lobectomy (703/2949) and 25.7% for pneumonectomy (146/567). In multivariable models, independent preoperative predictors (P <.05) of 30-day morbidity were age, weight loss greater than 10% in the 6 months before surgery, history of chronic obstructive pulmonary disease, transfusion of more than 4 units, albumin, hemiplegia, smoking, and dyspnea. When intraoperative variables were added to the preoperative model, the duration of operation time and intraoperative transfusions were included in the model and albumin became marginally significant. CONCLUSIONS: This analysis identifies independent patient risk factors that are associated with 30-day mortality and morbidity for patients undergoing a major pulmonary resection. This series provides an initial risk-adjustment model for major pulmonary resections. Future refinements will allow comparative assessment of surgical outcomes and quality of care at many institutions.

Adult↗
PubMed1999

Serious maternal morbidity after childbirth: prolonged hospital stays and readmissions.

OBJECTIVE: To determine the frequency of and risk factors for serious morbidity resulting in a prolonged hospital stay or readmission among women enrolled in Tennessee's Medicaid program who delivered live or dead infants in 1991. METHODS: This retrospective cohort study included 33,251 women of white or black ethnicity. Main outcome measures included childbirth-related medical conditions serious enough to result in death, prolonged delivery hospitalization, or readmission within 60 days of delivery. RESULTS: Among 25,810 women with vaginal (78%) and 7441 (22%) women with cesarean deliveries, 2.6% and 8.9%, respectively, had at least one childbirth-related medical condition requiring prolonged delivery hospitalization or readmission, including infection (1.8% and 7.9%), hypertension-related complications (0.7% and 2.0%), or hemorrhage (0.5% and 2.4%). After controlling for other risk factors, maternal age over 32 years was independently associated with increased rate of serious morbidity among women who had vaginal (relative risk [RR] 1.9, 95% confidence interval [CI] 1.4, 2.7) or cesarean deliveries (RR 1.6, 95% CI 1.1, 2.2). Black women had approximately twice the rate of maternal morbidity with vaginal (RR 1.9, 95% CI 1.5, 2.4) or cesarean deliveries (RR 2.3, 95% CI 1.9, 2.9). Primiparous women who had vaginal or cesarean deliveries had a 60% (RR 1.6, 95% CI 1.3, 2.0) and 70% (RR 1.7, 95% CI 1.4, 2.0), respectively, greater risk of serious maternal morbidity than women with 1-3 prior births. CONCLUSION: Predictors of serious maternal morbidity included age over 32 years, black ethnicity, and primiparity.

Adolescent↗
PubMed2001

Laparoscopic surgery for morbid obesity.

Minimally invasive approaches to bariatric surgery offer significant advantages over those of open surgery. The potential of laparoscopic approaches to reduce the morbidity of these operations may exceed that of laparoscopic cholecystecomy and laparoscopic Nissen fundoplication because the access incisions for open bariatric operations have relatively greater potential for harming the morbidly obese patient. Early results of laparoscopic VBG suggest a significant decrease in perioperative morbidity compared to the open approach, with similar weight-loss results. LGB may have the lowest perioperative morbidity and mortality of all current bariatric operations. However, the reoperation rate for device-related complications or failure of the patient to lose sufficient weight appears significant. Long-term esophageal motility also remains questionable for the LGB. It is hoped that the FDA trial will address many of the issues regarding LGB. Results of Lap RYGBP are accumulating and appear promising. The early experience suggests that it is technically feasible and safe in the hands of surgeons who have appropriate training. It is associated with low perioperative morbidity, short hospital stay, and rapid recovery compared to expected results of open RYGBP. Weight loss for Lap RYGBP after 5 years is excellent. It is, however, a technically formidable operation requiring long operating times and a steep learning curve. Early results indicate that technical complications may be greater than those experienced with open RYGBP because of the learning curve. Lap RYGBP is a promising bariatric procedure with potentially significant advantages over open RYGBP. Thus, for patients in the United States, Lap RYGBP may become the preferred weight-reduction procedure. The value of hand-assisted bariatric procedures and laparoscopic malabsorption procedures must await further study.

Anastomosis, Roux-en-Y↗
PubMed1997

Socioeconomic inequalities in morbidity and mortality in western Europe. The EU Working Group on Socioeconomic Inequalities in Health.

BACKGROUND: Previous studies of variation in the magnitude of socioeconomic inequalities in health between countries have methodological drawbacks. We tried to overcome these difficulties in a large study that compared inequalities in morbidity and mortality between different countries in western Europe. METHODS: Data on four indicators of self-reported morbidity by level of education, occupational class, and/or level of income were obtained for 11 countries, and years ranging from 1985 to 1992. Data on total mortality by level of education and/or occupational class were obtained for nine countries for about 1980 to about 1990. We calculated odds ratios or rate ratios to compare a broad lower with a broad upper socioeconomic group. We also calculated an absolute measure for inequalities in mortality, a risk difference, which takes into account differences between countries in average rates of illhealth. FINDINGS: Inequalities in health were found in all countries. Odds ratios for morbidity ranged between about 1.5 and 2.5, and rate ratios for mortality between about 1.3 and 1.7. For men's perceived general health, for instance, inequalities by level of education in Norway were larger than in Switzerland or Spain (odds ratios [95% CI]: 2.57 [2.07-3.18], 1.60 [1.30-1.96], 1.65 [1.44-1.88], respectively). For mortality by occupational class, in men aged 30-44, the rate ratio was highest in Finland (1.76 [1.69-1.83]), although there was no large difference in the size of the inequality in those countries with data. For men aged 45-59, for whom France did have data, this country had the largest inequality (1.71 [1.66-1.77]). In the age-group 45-64, the absolute risk difference ranked Finland second after France (9.8% [9.1-10.4], 11.5% [10.7-12.4]), with Sweden and Norway coming out more favourably than on the basis of rate ratios. In a scatter-plot of average rank scores for morbidity versus mortality. Sweden and Norway had larger relative inequalities in health than most other countries for both measures; France fared badly for mortality but was average for morbidity. INTERPRETATION: Our results challenge conventional views on the between-country pattern of inequalities in health in western European countries.

Adult↗
PubMed1999

Maternal infectious morbidity following multiple courses of betamethasone.

OBJECTIVE: the beneficial effects of antepartum corticosteroids on the reduction of morbidity and mortality in the premature neonate have been amply demonstrated. The NIH consensus statement has, therefore, endorsed their use in women at risk from pre-term delivery between 24 and 34 weeks gestation. Patients at persistent risk of pre-term delivery nay receive multiple weekly courses. However, increased susceptibility to infection is a well-recognized complication of prolonged high-dose steroid therapy. We examined infectious morbidity among women exposed to three or more courses of betamethasone. METHODS AND OUTCOMES MEASURES: thirty-seven patients at risk of pre-term delivery who received three or more courses of betamethasone (median = 6: range 3-10) and 74 normal controls, matched for maternal age, route of delivery, and year of delivery were included in the study. Data on medical care provided to study and control patients between 24 weeks gestation and 6 weeks postpartum were retrieved from centralized medical records. Incidences and types of infections were compared by Chi-square and Fisher's exact test, as appropriate. Only infections diagnosed at least 1 week after betamethasone therapy was initiated were included. Patients with pre-existing conditions predisposing to infectious morbidity were excluded. RESULTS: twenty-four of 37 patients (64.8%) exposed to betamethasone vs. 13 of 74 (17.5%) controls developed infectious diseases (P < 0.001). Symptomatic lower urinary tract infections occurred in 13 of 37 (35.1%) and two of 74 (2.7%) in the study and control groups, respectively (P < 0.001). Serious bacterial infections were found in nine of 37 (24.3%) vs. none of 74 (0%) patients, respectively (P < 0.001). These included sepsis (n=2), pneumonia (n=4), pyelonephritis (n=2), and cholangitis (n=1). Eight of nine serious infections occurred in patients exposed to five or more weekly courses of betamethasone. Postpartum endometritis related to Caesarean delivery was found in five of 37 patients (13.5%) vs. seven of 74 (9.4%), respectively (P=NS). CONCLUSIONS: Three or more courses of antepartum betamethasone in women at risk of pre-term delivery are associated with substantial infectious maternal morbidity. The excess morbidity consisted mainly of bacterial infections, some of which were associated with systemic and potentially life-threatening infections.

Adult↗
PubMed1997

Age-specific education and income gradients in morbidity and mortality in a Canadian province.

While important age-related trends in the use of health care services over the past two decades in Canada have been well described, a comprehensive description of socioeconomic gradients in morbidity and mortality across age cohorts for a representative population has not been accomplished to date in Canada. The objective of this study was to describe age-specific socioeconomic differentials in mortality and morbidity for a representative sample of a single Canadian province. The study sample was formed from the linkage of individual respondent records in the 1986 census to vital statistics records and comprehensive records of health care utilization for a 5% sample of residents of the province of Manitoba. Using two measures of socioeconomic status derived from census responses, attained education and household income, individuals were stratified into age-specific quartile ranks. Based on diagnostic information contained on health care utilization records, the proportion of the sample in treatment during a 12-month observation period was calculated for 15 broadly defined categories of morbidity and tested for differences across socioeconomic quartiles. Mortality was inversely associated with both income and education quartile rank. In the analysis of morbidity, no association between socioeconomic status and treatment prevalence was observed in the majority, no association between socioeconomic status and treatment prevalence was observed in the majority of the 122 age- and disorder-specific strata tested. Of the observed associations, however, negative relationships were dominant, indicating a higher treatment prevalence among individuals of lower attained education or lower household income. Across the age course, negative relationships were most frequently present among young and middle aged adults, those aged 30-64, and were more consistently found for income than for education. The general findings of this study of a representative Canadian population support observations from other developed country settings that socioeconomic differences in relative rates of mortality and morbidity over the life course are greatest in the adult years.

Adolescent↗
PubMed1997

Age- and sex-differentials in morbidity at the start of an epidemiological transition: returns from the 1880 U.S. Census.

This paper uses a new data set, the Public Use file of the 1880 U.S. Census of the Population, to examine national point prevalence rates of adult morbidity over the early phase of the United States epidemiologic transition. These historical data report health status at the individual level and allow the analysis of age and sex differentials in morbidity. Point prevalence rates of morbidity by major cause show that males generally had higher rates of morbidity and long-term disability than females, especially at mid-life and in old age. But large sex differences in the distribution of conditions by major cause occurred over two portions of the life course: in early adulthood and in old age. Age and sex differences in the distribution of adult morbidity reflected the health status divide of the communicable and degenerative conditions.

Adult↗
PubMed1999

Problematizing gender, work and health: the relationship between gender, occupational grade, working conditions and minor morbidity in full-time bank employees.

It is commonly asserted that while women have longer life expectancy than men, they have higher rates of morbidity, particularly for minor and psychological conditions. However, most research on gender and health has taken only limited account of the gendered distribution of social roles. Here we investigate gender differences in morbidity whilst controlling, as far as possible, for one major role, namely participation in paid employment. There is substantial segregation of the labour market by gender; men and women typically work different hours in different occupations which involve varying conditions and differing rewards and costs. Here, we examine men and women working full-time for the same employer. This paper reports on a postal survey of employees (1112 men and 1064 women) of a large British bank. It addresses three main questions: do gender differences in minor morbidity remain if we compare men and women who are employed in similar circumstances (same industry and employer)? What is the relative importance of gender, grade of employment within the organisation, perceived working conditions and orientation to gender roles for minor morbidity? Finally, are these factors related to health differentially for men and women? There were statistically significant gender differences amongst these full-time employees in recent experience of malaise symptoms, but not in physical symptoms or GHQ scores. Controlling for other factors did not reduce the gender differences in malaise scores and produced a weak, but significant, gender difference in GHQ scores. However, gender explained only a small proportion of variance, particularly in comparison with working conditions. Generally similar relationships between experience of work and occupational grade and morbidity were observed for men and women. Throughout the paper, we attempt to problematize gender, recognising that there are similarities between women and men and diversity amongst women and amongst men. However, we conclude that the gendered nature of much of adult life, including paid work, continues to shape the experiences and health of men and women at the end of the twentieth century.

Adult↗
PubMed1999

Do measures of self-reported morbidity bias the estimation of the determinants of health care utilisation?

Most national surveys of health care utilisation capture only self-reported measures of morbidity. If self-reported morbidity is measured with error, then the results of applied work may be misleading. In this paper we propose a model of the relationship between morbidity and health service utilisation which allows for reporting errors and simultaneity. Errors in self-reported morbidity are expressed as a function of person-specific reporting thresholds and recent contact with health services, arising because of better self-evaluation of current health status or a desire to justify consumption of a publicly-provided good. We demonstrate the bias in ignoring the potential problems of reporting errors and simultaneity for a variety of special cases, but in the general case the biases are of ambiguous sign. The empirical nature of these biases is investigated using limiting long-standing illness (LLI) and recent contact with a General Practitioner (GP) in two waves of The UK Health and Lifestyle Survey. Biomedical measures of functioning are used as objective indicators of health status. We find evidence of substantial and significant differences between individuals in reporting thresholds and some evidence that the reporting of LLI may depend on recent visits to a GP. Adjustments for these biases significantly increase the estimated effect of morbidity on utilisation.

Adult↗
PubMed2003

A comparison of the neonatal morbidity of second twins to that of a low-risk population.

OBJECTIVE: To assess the neonatal morbidity of second twins. STUDY DESIGN: Cohort study in a department of perinatalogy. The neonatal morbidity of second twins was compared to that of a low-risk population: singletons in the cephalic presentation delivered vaginally. RESULTS: Five hundred fifty-nine second twins and 18,061 vaginally delivered singletons in the cephalic presentation were studied. Of 452 (81%) second twins delivered vaginally, 310 (69%) were extracted using obstetrical maneuvers: internal version and breech extraction, breech extraction alone, or assisted breech delivery if the breech was already engaged. Before 33 weeks of gestation, there was no significant difference between the neonatal morbidity of the vaginally delivered second twins and the vaginally delivered singletons in the cephalic presentation. After 33 weeks of gestation, only the 1-min Apgar score <7 and the rate of intubation at birth were significantly higher in the second twins. Whatever the gestational age, there was no significant difference between the neonatal morbidity of the vaginally delivered second twins and that of the second twins born by cesarean section before labor. At comparable gestational ages, there was no significant difference between the death rate of the vaginally delivered second twins and that in the reference population. CONCLUSION: The neonatal morbidity of second twins was comparable to that of a low-risk population. Immediate management of the vaginally delivered second twins was, however, more intensive than that of vaginally delivered singletons in the cephalic presentation. It, therefore, requires appropriate equipment in a suitable obstetric-pediatric setting.

Birth Order↗
PubMed1997

Centenarians prove the compression of morbidity hypothesis, but what about the rest of us who are genetically less fortunate?

For those who believe that the longer people live into old age, the longer they will live with chronic disability (the expansion of morbidity hypothesis), the current increase in average life expectancy that we are experiencing portends an even greater increase in health care costs and morbidity associated with old age. On the other hand, other scholars assert that if medical science is able to facilitate people's living to an age near or at the maximum lifespan (by curing or markedly delaying illnesses that cause premature mortality), we should observe a compression of morbidity near the end of life. Our experience in the New England Centenarian Study indicates that compression of morbidity does occur among centenarians. Demographic selection or selective survival produces a cohort of successfully aging individuals at very old age as those with illnesses that cause premature mortality are weeded out of the aging population. Unfortunately, the majority of us who are weeded out by the early to mid-eighties (the average life expectancy), succumb to illnesses that are likely to lead to an expansion of morbidity as medical science and healthier lifestyles facilitate longer life expectancies.

Activities of Daily Living↗
PubMed2004

[Obstetrical complications of morbid obesity].

OBJECTIVE: To determine whether morbidly obese women have an increased risk of pregnancy complications and adverse perinatal outcome. METHODS: In a retrospective study, 2472 women with morbid obesity, defined as a body mass index (BMI) more than 40 were compared with normal weight women (BMI 20-25). Fisher and Student tests were used for statistical analysis. RESULTS: In the group of morbidly obese mothers (BMI greater than 40) as compared with the normal weight mothers, there was an increased risk of the following outcomes: gravidic hypertension (7.7 vs 0.5%; p<0.05). preeclampsia (11.5 vs 2%; p<0.05), gestational diabetes (15.4 vs 1.8%; p<0.05), cesarean delivery (50 vs 15.4%; p<0.05), and macrosomia (42.3 vs 10.3%; p<0.05). However, we noted a lower rate of prematurity in the obese group (0 vs 11%). Even when morbidly obese women with preexisting diabetes and chronic hypertension were excluded from the analysis, significant differences in the perinatal outcomes still persisted. CONCLUSION: Morbid obesity appears to be an independent risk factor for perinatal and gestational complications.

Adult↗
PubMed2002

Diabetes mellitus increases short-term mortality and morbidity in patients undergoing coronary artery bypass graft surgery.

OBJECTIVES: The aim of this study was to determine the impact of diabetes mellitus (DM) on short-term mortality and morbidity in patients undergoing coronary artery bypass surgery (CABG). BACKGROUND: Diabetes mellitus is present in approximately 20% to 30% of patients undergoing CABG, and the impact of diabetes on short-term outcome is unclear. METHODS: We performed a retrospective cohort study in 434 hospitals from North America. The study population included 146,786 patients undergoing CABG during 1997: 41,663 patients with DM and 105,123 without DM. The primary outcome was 30-day mortality. Secondary outcomes were in-hospital morbidity, infections and composite outcomes of mortality or morbidity and mortality or infection. RESULTS: The 30-day mortality was 3.7% in patients with DM and 2.7% in those without DM; the unadjusted odds ratio was 1.40 (95% confidence interval [CI], 1.31 to 1.49). After adjusting for other baseline risk factors, the overall adjusted odds ratio for diabetics was 1.23 (95% CI, 1.15 to 1.32). Patients treated with oral hypoglycemic medications had adjusted odds ratio 1.13; 95% CI, 1.04 to 1.23, whereas those on insulin had an adjusted odds ratio 1.39; 95% CI, 1.27 to 1.52. Morbidity, infections and the composite outcomes occurred more commonly in diabetic patients and were associated with an adjusted risk about 35% higher in diabetics than nondiabetics, particularly among insulin-treated diabetics (adjusted risk between 1.5 to 1.61). CONCLUSIONS: Diabetes mellitus is an important risk factor for mortality and morbidity among those undergoing CABG. Research is needed to determine if good control of glucose levels during the perioperative time period improves outcome.

Aged↗
PubMed1996

Liver transplantation in the morbidly obese.

STUDY OBJECTIVE: To test the hypothesis that morbid obesity implies increased difficulty of liver transplantation and increased risk of adverse outcome. DESIGN: Retrospective review of medical records of 40 morbidly obese patients using a control cohort of patients transplanted just before and after the obese patients. SETTING: University medical center. PATIENTS: All morbidly obese patients who underwent liver transplantation over a 52-month period were included. Forty adult patients met criterion for morbid obesity with body mass index greater than 30 kg/m2. Records for 61 time-matched controls were reviewed. MEASUREMENTS AND MAIN RESULTS: Demographic, intraoperative, and postoperative data were collected including preoperative diagnoses, laboratory and pulmonary function tests, intraoperative transfusion requirements and length of surgery postoperative complications, and survival. Data were analyzed using Student's t-tests, and Chi-square analyses as appropriate, with significance considered a p-value less than 0.05. Obese patients were more hypoxemic than controls prior to surgery (PaO2, 82.9 +/- 3.5 vs. 93.0 +/- 3.0 mmHg), were more likely to be diabetic, and had higher creatinine levels (3.0 +/- 0.6 vs. 1.7 +/- 0.2 mg/dl). Despite this evidence of multi organ dysfunction, intraoperative and postoperative pulmonary and cardiac complications did not differ between groups. Though more obese patients had prior cholecystectomy, length of surgery and intraoperative transfusion requirements were not different between groups. Obese patients did not have an increased incidence of reoperation for wound problems, and lengths of intensive care unit and hospital stays did not differ between groups. Graft and patient survival were similar in obese and nonobese liver transplant recipients. CONCLUSION: Morbid obesity alone does not predispose to increased complications or decreased survival after liver transplantation.

Adult↗
PubMed1997

Reducing asthma morbidity in the community: the effect of a targeted nurse-run asthma clinic in an English general practice.

Although most primary health care teams in the U.K. now offer proactive care for patients with asthma, there is relatively little published evidence showing the effectiveness of such innovations. This may be due in part to lack of targeting of extra care towards those most in need. Therefore, to demonstrate the benefits of targeted nurse-run asthma clinic care in a seven-partner general practice in a mixed urban and rural area of North Lincolnshire in the east of England, a cohort of 173 patients, with asthma selected predominantly by having high morbidity in a postal survey, completed 12 months follow-up in a nurse-run asthma clinic. A longitudinal comparison was conducted in terms of: changes in morbidity index category, inhaler technique score, knowledge score, use of inhaled steroids, use of salmeterol, method of administration of beta(2)-agonist medication and frequent use of peak flow meters. The number with high morbidity fell from 123 (71.1%) at the initial consultation to 14 (8.1%) at the 12-month review. Those with full marks on inhaler technique rose from 28 (16.2%) to 142 (82.1%), and with full marks on asthma knowledge rose from 7 (4.0%) to 98 (56.6%). The numbers of patients using inhaled steroids and salmeterol rose from 127 (73.4%) to 171 (98.9%) and from 5 (2.9%) to 35 (20.2%), respectively. The preferred inhaler device for beta(2)-bronchodilator medication changed from metered dose aerosol to dry powder. Regular use of peak flow meters in 157 subjects aged 5 years and over rose from 43 (27.4%) to 116 (73.9%). These data clearly demonstrate the benefits of targeted proactive nurse-run asthma care in terms of reduced morbidity for patients. The authors recommend the morbidity index targeting concept to other primary health care teams.

Adolescent↗
PubMed2002

Preoperative prediction of early mortality and morbidity in coronary bypass surgery.

OBJECTIVE: A scoring system to predict early mortality and morbidity in CABG, distinguishing low and high risk patients. METHODS: 563 patients (1998) served as development dataset, 969 patients as validation set. Univariate and logistic regression analysis was used to identify risk factors. RESULTS: Gender, hypertension, pulmonary disease, reoperation, age, operative status and left-ventricular function were predictive variables for early mortality. The area under the ROC curve was 0.81. We identified a low risk, mortality of 1.8% and a high-risk group, mortality of 13.4%. Diabetes, hypertension, kidney and lung disease, reoperation, operative status and left ventricular function were predictive variables for morbidity. The area under the ROC curve was 0.73. We identified a low risk, morbidity of 17%, and a high-risk group, morbidity of 41%. CONCLUSION: This scoring system is a simple system identifying a low and high-risk group for morbidity and early mortality.

Aged↗
PubMed2003

Effects of preoperative chemoradiotherapy on postsurgical morbidity and mortality in cT3-4 +/- cM1lymph cancer of the oesophagus and gastro-oesophageal junction.

OBJECTIVE: Very few studies have examined post-operative morbidity after resection of oesophageal carcinoma, especially in patients treated with induction chemo- and radiotherapy for locally advanced stages. This study assessed the effects of induction chemoradiotherapy on post-operative course after resection of locally advanced oesophageal carcinoma (cT3-4 + cM1lymph). METHODS: Induction therapy consisted of 5-fluorouracil days 1-5 and days 21-25, cisplatin day 1 + day 21 and concomitant radiotherapy 18-20 fractions of 2Gy (total dose 36-40Gy). Induction chemoradiotherapy was completed in 109 patients. Surgery was performed in 90 patients (operability: 90/109 = 83%): 85 patients underwent resection with curative intent (resectability: 85/109 = 78%), bypass operation was performed in five patients. Nineteen patients could not be operated on. Results were compared to a matched group of pT3M1LYM/pT4 patients (n = 86) who underwent primary surgery in the same period. RESULTS: Resection was complete (R0) in 68 patients (68/90 = 76%). Mean duration of surgery was 428 min (range: 240-690). Peroperative complications were haemorrhage in three patients (3/90 = 3.3%), tracheobronchial perforation in three patients (3/90 = 3.3%). Median total hospital stay was 20.5 days (range: 8-355). Mean duration of intubation was 7 days (range: 1-190); 67 patients (67/90 = 74.4%) were intubated for less than 24 h. Non-tumour related hospital mortality after resection was 8.3% (7/84 patients). Mortality after two-field lymphadenectomy was 5.2 versus 11.7% after three-field lymphadenectomy. After primary surgery (n = 86) overall mortality was 2.3% (P = 0.015) and nil after two- and three-field lymphadenectomy (P = 0.011). Medical morbidity consisted of pneumonia in 43 patients (43/90 = 48%), atelectasis in ten patients (10/90 = 11%), dysrhythmia in 21 patients (21/90 = 23%), sepsis in 11 patients (11/90 = 12%) and adult respiratory distress syndrome in ten patients (10/90 = 11%). Surgical morbidity included pleural effusion in 16 patients (16/90 = 18%), tracheal fistula in two patients (2/90 = 2%), chylothorax in two patients (2/90 = 2%) and acute pancreatitis in one patient (1/90 = 1%). Ten patients (10/90 = 11%) had a radiologically confirmed anastomotic leak; however only in four out of them with clinical manifestation; treatment was conservative in all four patients. Major morbidity occurred in 27 patients (27/90 = 30%). Overall rate of morbidity was significantly higher after three-field lymphadenectomy (85%) as compared to two-field lymphadenectomy (68.7%; P = 0.023). CONCLUSIONS: Chemoradiotherapy followed by resection of cT3-4 +/- cM1lymph oesophageal carcinoma is feasible with acceptable mortality. Mortality, however, seems to be significantly higher when compared to a group of pT3M1LYM/pT4 patients who underwent primary surgery (8.3 versus 2.3%; P = 0.015) in the same period in our department.

Adenocarcinoma↗