Mortality within hospital after resuscitation from ventricular fibrillation outside hospital

OBJECTIVE

To determine factors related to mortality within hospital after successful resuscitation from ventricular fibrillation outside hospital by a mobile coronary care unit manned by a physician.

DESIGN

Retrospective review of records of patients resuscitated and admitted to hospital between 1 January 1966 and 31 December 1987.

SETTING

Mobile coronary care unit, coronary care unit, and cardiology department.

PATIENTS

281 patients (227 male), aged 14-82 (mean 58) successfully resuscitated from ventricular fibrillation outside hospital of whom 182 (65%) developed ventricular fibrillation before the arrival of the mobile coronary care unit. The aetiology of ventricular fibrillation was acute myocardial infarction in 194 patients (69%), ischaemic heart disease without infarction in 71 (25%), and other or unknown in 16 (6%).

MAIN OUTCOME MEASURES

Death within hospital.

RESULTS

There were 91 deaths in hospital (32%). Factors on univariate analysis significantly associated with increased mortality were patient age > or = 60 years, previous myocardial infarction or cerebrovascular disease, prior digoxin or diuretic treatment, collapse without prior chest pain or with pain lasting 30 minutes or less, defibrillation delayed by > or = 5 min, > or = four shocks required to correct ventricular fibrillation, left ventricular failure or pulmonary oedema and cardiogenic shock after successful defibrillation, and coma on admission to hospital. On multivariate analysis the most important factors (in rank order) were cardiogenic shock after defibrillation, coma on admission to hospital, age > or = 60 years and the requirement for four or more shocks to correct ventricular fibrillation.

CONCLUSIONS

The in-hospital mortality of patients resuscitated from ventricular fibrillation outside hospital was related to patient characteristics before the cardiac arrest and to the immediate haemodynamic and neurological status after correction of ventricular fibrillation as well as to factors at the resuscitation itself. The in-hospital mortality of this study compares favourably with the results obtained by units staffed by paramedical workers and emergency medical technicians, although 35% (99/281) of the patients had ventricular fibrillation after the arrival of the mobile unit and defibrillation was thus rapid.

Disparity between influenza vaccination rates and risks for influenza-associated hospital discharge and death in Manitoba in 1982-1983

OBJECTIVE

To determine, in a defined population, the percentage of persons who were discharged from a hospital or died of influenza-associated respiratory conditions who had a health care contact during the preceding vaccination season and to determine the relation between risk status for influenza-associated hospitalization and death and influenza vaccination rates.

DESIGN

An observational study using linked-record analysis of medical claims data.

SETTING AND PATIENTS

A probability sample of 100,000 noninstitutionalized adults living in Manitoba in 1982 to 1983.

MEASUREMENTS

Analysis of medical claims for influenza vaccination and hospital discharges and deaths for influenza-associated respiratory conditions during the 1982-83 influenza vaccination season and influenza outbreak period.

RESULTS

For the population as a whole, 50% to 60% of elderly persons (greater than or equal to 65 years of age) and 30% to 40% of younger persons had one or more health care contacts during the influenza vaccination season but fewer than 10% of all persons had been discharged from a hospital. In contrast, for elderly persons hospitalized with respiratory conditions during the influenza outbreak period, approximately 80% had at least one health care contact during the vaccination season. Among the elderly, 39% to 46% of all those discharged for influenza-associated respiratory conditions and 62% to 67% of those who died had been discharged from hospital during the previous vaccination season. Persons discharged with high-risk conditions during the vaccination season were at greater risk for hospitalization with influenza-associated respiratory conditions but were less likely to be vaccinated than were those at lower risk.

CONCLUSIONS

Most persons who were hospitalized with influenza-associated respiratory conditions had contact with health care providers during the preceding influenza vaccination season. Among elderly patients, previous hospital care was common, especially among those who died. The disparity between influenza vaccination rates and risks for influenza-associated hospital discharge and death supports a strategy of hospital-based influenza vaccination.

Differences in trauma care among pediatric and nonpediatric trauma centers

To characterize pediatric trauma care, state trauma registry data from all designated trauma centers in Pennsylvania were divided into three categories, that from: (1) pediatric centers, (2) urban nonpediatric centers, (3) and rural nonpediatric centers. From October 1, 1986 through September 30, 1989 (3 years), 4,615 patients less than 15 years old were admitted to 28 trauma centers in Pennsylvania. Nonpediatric centers cared for the majority of children (2,734, 59.2%), but the average number of children treated per nonpediatric institution (105.1 per year) was far fewer than the average treated in the pediatric centers (940.5). Pediatric trauma centers in the state treated a younger population (6.4 +/- 4.2 years, mean +/- SD) compared with urban and rural nonpediatric centers (8.4 +/- 4.2 and 8.1 +/- 4.3 years, respectively; P less than .05). Pediatric centers received proportionately more children by transfer (56.2%), victims of falls (34.6%), pedestrian injuries (16.8%), and head and neck injuries (41.8%, all P less than .05). Nonpediatric centers received children directly from the scene of injury more frequently than transferred from other hospitals. The male:female sex ratio in urban nonpediatric centers was significantly higher (70.1%, P less than .05) than in the other two groups. Rural nonpediatric centers cared for a higher proportion of motor vehicle passengers (28.5%) and patients classified as "other" in the state registry, a category to which bicycle injuries are assigned (28.2%, P less than .05). Mortality was highest in rural nonpediatric centers (6.2%). The death rate in pediatric centers and urban nonpediatric centers were similar (4.1%) and significantly lower (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of severity measurement approaches

Hospital mortality statistics derived from administrative data may not adjust adequately for patient risk on admission. Using clinical data collected from the medical record, this study compared the ability of six models to predict in-hospital death, including one model based on administrative data (age, sex, and principal and secondary diagnoses), one on admission MedisGroups score, and one on an approximation of the Acute Physiology Score (APS) from the revised Acute Physiology and Chronic Health Evaluation (APACHE II), as well as three empirically derived models. The database from 24 hospitals included 16,855 cases involving five medical conditions, with an overall in-hospital mortality rate of 15.6%. The administrative data model fit least well (R-squared values ranged from 1.9-5.5% across the five conditions). Admission MedisGroups score and the proxy APS score did better, with R-squared values ranging from 4.9% to 25.9%. Two empirical models based on small subsets of explanatory variables performed best (R-squared values ranged from 18.5-29.9%). The preceding models had the same relative performances after cross-validation using split samples. However, the high R-squared values produced by the full empirical models (using 40 or more explanatory variables) were not preserved when they were cross-validated. Most of the predictive clinical findings were general physiologic measures that were similar across conditions; only a fifth of predictors were condition-specific. Therefore, an efficient approach to risk-adjusting in-hospital mortality figures may involve adding a small subset of condition-specific clinical variables to a core group of acute physiologic variables. The best predictive models employ condition-specific weighting of even the generic clinical findings.

Infantile hypertrophic pyloric stenosis in Ghana

In a retrospective study of 84 Ghanaian infants with hypertrophic pyloric stenosis seen over a 15-year period between 1974 and 1988, the male/female incidence ratio was 9:1. First-born infants constituted 23.8% of the patient population. The incidence of associated congenital anomalies and jaundice were 10.7% and 3.6% respectively. About 33.3% of the infants started vomiting within the first week of life. The peak-age of presentation and diagnosis was between the second and sixth weeks of life. The operative mortality was 3.6%.

Improved thrombolysis in acute myocardial infarction with front-loaded administration of alteplase: results of the rt-PA-APSAC patency study (TAPS)

Thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) and anisoylated plasminogen streptokinase activator (APSAC) in myocardial infarction has been proved to reduce mortality. A new front-loaded infusion regimen of 100 mg of rt-PA with an initial bolus dose of 15 mg followed by an infusion of 50 mg over 30 min and 35 mg over 60 min has been reported to yield higher patency rates than those achieved with standard regimens of thrombolytic treatment. The effects of this front-loaded administration of rt-PA versus those obtained with APSAC on early patency and reocclusion of infarct-related coronary arteries were investigated in a randomized multicenter trial in 421 patients with acute myocardial infarction. Coronary angiography 90 min after the start of treatment revealed a patent infarct-related artery (Thrombolysis in Myocardial Infarction [TIMI] grade 2 or 3) in 84.4% of 199 patients given rt-PA versus 70.3% of 202 patients given APSAC (p = 0.0007). Early reocclusion within 24 to 48 h was documented in 10.3% of 174 patients given rt-PA versus 2.5% of 163 patients given APSAC. Late reocclusion within 21 days was observed in 2.6% of 152 patients given rt-PA versus 6.3% of 159 patients given APSAC. There were 5 in-hospital deaths (2.4%) in the rt-PA group and 17 deaths (8.1%) in the APSAC group (p = 0.0095). The reinfarction rate was 3.8% and 4.8%, respectively. Peak serum creatine kinase and left ventricular ejection fraction at follow-up angiography were essentially identical in both treatment groups. There were more bleeding complications after APSAC (45% vs. 31%, p = 0.0019).(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of left ventricular function on outcome of patients treated with implantable defibrillators

BACKGROUND

The outcomes of patients treated with implantable defibrillators were compared between patients with left ventricular ejection fraction greater than or equal to 30% and less than 30%.

METHODS AND RESULTS

Of 68 consecutive patients treated with implantable defibrillators, 40 patients (group 1) had left ventricular ejection fraction greater than or equal to 30%, and 28 patients (group 2) had left ventricular ejection fraction less than 30%. Sudden death, surgical mortality, nonsudden arrhythmia-related death (death within 24 hours after an arrhythmic event despite initial termination of the arrhythmia by the implantable defibrillator), total arrhythmia-related death (including sudden death, surgical death, and nonsudden arrhythmia-related death), and total cardiac death were compared between the two groups. Surgical mortality was 4.4% (0% in group 1, 11% in group 2). During the follow-up of 31 +/- 27 months, actuarial survival rates free of events were 97%, 97%, and 97% in group 1 and 96%, 91%, and 82% in group 2 at 12, 24, and 36 months, respectively, for sudden death (p = NS); 97%, 97%, and 97% in group 1 and 85%, 81%, and 72% in group 2 at 12, 24, and 36 months, respectively, for sudden death and surgical mortality (p less than 0.05); 97%, 97%, and 97% in group 1 and 82%, 78%, and 70% in group 2 at 12, 24, and 36 months, respectively, for total arrhythmia-related death (p less than 0.05); and 95%, 95%, and 95% in group 1 and 82%, 69%, and 57% in group 2 at 12, 24, and 36 months, respectively, for total cardiac death (p less than 0.05). Four (57%) of seven nonsudden cardiac deaths during the initial 36-month follow-up period were causally related to arrhythmia (three surgical deaths and one arrhythmia-related nonsudden death).

CONCLUSIONS

The outcome of patients treated with implantable defibrillators is strongly influenced by the degree of left ventricular dysfunction. In group 1 patients, surgical mortality, sudden death, and total cardiac death are rare. In group 2, sudden death rate may not be markedly different from that of group 1 patients. However, the risk of therapy (surgical mortality) is high. Many nonsudden cardiac deaths are causally related to arrhythmia (surgical mortality or nonsudden arrhythmia-related death). Therefore, the survival rate free of total arrhythmia-related death is significantly lower in group 2 (70% versus 97% in group 1 at 3 years). Further studies are needed to determine the roles of defibrillator therapy and other therapies in various clinical settings.

Multiple valve operation for advanced valvular heart disease: results and risk factors in 513 patients

To assess the results and incremental risk factors affecting outcome after multiple-valve operation in the early blood cardioplegia era of cardiac surgery, follow-up data (mean +/- SD 3.1 +/- 2 years) were obtained on 97% of 513 patients (mean age +/- SD 58.8 +/- 10.5 years) who underwent a multiple-valve procedure between June 1976 and August 1985. Preoperatively 41% of patients were in New York Heart Association functional class III and 54% in class IV. Three groups accounted for 98.6% of the patients: 57.7% had an aortic and mitral valve procedure, 29% had a mitral and tricuspid valve procedure and 11.9% had a triple-valve procedure. The overall hospital mortality rate was 12.5% and overall 5-year survival rate was 67.1%. Hazard function analysis for all deaths revealed systolic pulmonary artery pressure (p less than 0.0001), age (p = 0.005), triple valve procedure (p less than 0.005), concomitant coronary bypass operation (p less than 0.005) and prior cardiac surgery (p less than 0.002) as the significant incremental risk factors predicting decreased survival in the early hazard phase; diabetes (p less than 0.005) predicted decreased survival in the late hazard phase. Postoperatively the condition of 80% of the patients improved to functional class I or II; only 0.6% remained in functional class IV. The 5-year rate of freedom from late combined valve-related morbidity was 81.7% and that of freedom from late combined valve-related morbidity and mortality was 71.7%. These results demonstrate excellent clinical improvement and late survival after multiple valve operation in patients with advanced valvular heart disease, justifying aggressive surgical therapy in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic cholecystectomy. A prospective study of outcome in 100 unselected patients

OBJECTIVE

To describe the outcome of laparoscopic (percutaneous) cholecystectomy in the management of gallbladder stones.

PATIENTS AND METHODS

One hundred unselected consecutive patients referred for cholecystectomy, or admitted as emergencies with complicated gallbladder disease. Ten patients had acute cholecystitis, three had empyema, three had gallstone pancreatitis, and 11 had a history of recent jaundice. Common bile duct stones were dealt with by endoscopic sphincterotomy.

OUTCOME MEASURES

Intraoperative and postoperative complications, 30-day mortality rate, duration of hospital stay, and length of postoperative disability.

RESULTS

Three patients were excluded and underwent open cholecystectomy. Laparoscopic cholecystectomy was attempted in the remaining 97, and successfully completed in 87; 10 were converted to open cholecystectomy. There were no significant intraoperative complications. Two patients had a postoperative haemorrhage and one had a transient bile leak; none required reoperation. There was one death from myocardial infarction 12 days after operation. Minor complications occurred in 12 patients. Mean operating time was 88 minutes. The average length of hospital stay was 72 hours, and most patients returned to normal activities after seven days.

CONCLUSIONS

Laparoscopic cholecystectomy offers an outcome comparable to standard cholecystectomy and is applicable to 90% of patients requiring removal of the gallbladder. Laparoscopic cholecystectomy has significant advantages over open cholecystectomy in terms of reduced postoperative pain and disability.

Transient ischaemia refractory to conventional medical treatment in unstable angina: angiographic correlates and prognostic implications

Complex stenosis morphology is frequently seen in patients with unstable angina. However, its relation to transient myocardial ischaemia and clinical outcome has not been adequately elucidated. We studied 86 patients admitted to the Coronary Care Unit for unstable angina; all patients underwent ECG Holter monitoring during the first 2-4 days, while receiving intensive triple drug treatment. Coronary angiography and subsequent analysis of the ischaemia-related artery were performed within 12 days of admission. Patients were grouped according to their angiographic features: 45 showed complex coronary morphology (CM: 29 eccentric stenosis with irregular borders or overhanging edges; 16 intracoronary thrombus), 11 had documented coronary spasm as well as moderate atherosclerosis (CS), seven had left main coronary artery disease, and the remaining 23 patients showed regular and smooth morphology of coronary stenosis (RM). At admission, transient myocardial ischaemia (TMI) was greater in patients with CM (85 +/- 60 min .24 h-1) than in those with RM or CS (33 +/- 26 min .24 h-1; P less than 0.005). After 3 days of full medical treatment TMI decreased in all groups, but 34/45 patients with CM and 9/34 with RM or CS still showed residual ischaemia (greater than 0 min .24 h-1): 76% vs 26%, P less than 0.02. Follow-up was obtained at hospital discharge and after 1 year in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Does oxytocin augmentation increase perinatal risk in primigravid labor?

To assess the influence of high-dose oxytocin augmentation of spontaneous labor, a consecutive series of 30,874 primigravid term deliveries were analyzed for adverse perinatal outcome. In spite of a longer mean duration of labor, the frequencies of asphyxial perinatal death, neonatal seizures, and abnormal neonatal neurologic behavior were not significantly increased in 14,119 (45%) oxytocin-treated patients. There was no case of uterine rupture in any primigravid labor during the study. These results from 13 years of clinical practice provide reassurance about maternal and fetal safety if oxytocin is used as part of a protocol of active management to correct dystocia when spontaneous primigravid labor with vertex presentation fails to progress.

Surgical repair of coarctation of the aorta in infants under one year of age. Long-term results in 146 patients comparing subclavian flap angioplasty and modified end-to-end anastomosis

Between July 1976 and February 1991, 146 consecutive infants underwent surgical repair of coarctation of the aorta. Age at operation varied from 2 days to 11 months (median 1 month). Ninety-two (63%) were less than 2 months. Isolated coarctation was present in 65 patients (group 1), associated ventricular septal defect in 49 patients (group 2) and complex anomalies in 32 patients (group 3). The majority (65%) were in a critical condition and 45 patients (31%) were artificially ventilated. Subclavian flap angioplasty was performed in 39 patients and resection and end to end anastomosis in 107 patients. Neither hospital mortality was significantly different between subclavian flap angioplasty (15%) and end-to-end anastomosis (18%) nor was the postoperative hypertension. Actuarial survival at 10 years were 100% for group 1, 94% for group 2, and 62% for group 3. Seventeen patients had recurrent coarctation. No significant difference was found in terms of types of repair or age at operation. As no major advantage in terms of mortality and morbidity to either technique was found, we recommend resection and end-to-end anastomosis. This technique not only relieves the obstruction whatever the level is but also eliminates the ductal tissue, preserves the subclavian artery and avoids the use of prosthetic material.

Predicting mortality and length of stay of geriatric patients in an acute care general hospital

Three-hundred-eight geriatric patients (mean age = 76.7 yr, range = 70-94 yr) consecutively admitted to an acute care general hospital were followed up to identify the predictors of in-hospital mortality and long stay. Sociodemographic, medical, and functional data were collected within 24 hours from admission and their correlation with the outcomes assessed by logistic regression analysis. The following variables were shown to be independent predictors of death: use of more than 6 drugs (odds ratio = 3.04, confidence limits = 1.05-8.76); abnormal Mini-Mental State score (o.r. = 1.72, c.l. = 1.05-1.83); low ADL score (o.r. = 2.4, c.l. = 1.07-5.56). Extended stay was significantly and independently predicted by polypharmacy (o.r. = 1.94, c.l. = 1.18-3.2) and comorbidity (o.r. = 2.06, c.l. = 1.24-3.38). The mortality rates of patients with cognitive impairment and polypharmacy with or without functional impairment were 40% and 22%, respectively. The proposed method allows identification of high-risk geriatric inpatients by a simple medical and functional assessment on admission.

Heart transplantation in neonates and in children

Between May 1988 and July 1991, 28 neonates and children underwent orthotopic heart transplantation at Children's Memorial Hospital in Chicago. Indications for heart transplantation were hypoplastic left heart syndrome (10), dilated cardiomyopathy (13), aortic stenosis with endocardial fibroelastosis (1), complex D-transposition of the great arteries after Senning repair (1), L-transposition of the great arteries with single ventricle after shunt (1), cor biloculare, pulmonary atresia, and situs inversus after Fontan (1), and chronic rejection after heart transplantation for hypoplastic left heart syndrome (1). The age at time of transplantation ranged from 2 days to 17 years (mean, 5.3 +/- 6.1 years). Early deaths were from intraoperative donor right ventricular failure (2) and acute rejection after a second transplant procedure at 21 days (1), for an in-hospital mortality rate of 10.7%. Immunosuppression was with cyclosporine, azathioprine, and prednisone, with an attempt to discontinue the prednisone in neonates at age 6 months as guided by endomyocardial biopsy. Rejection episodes were treated with methylprednisolone pulse (34) or with OKT3 (4). Endomyocardial biopsy (in patients older than 6 months) was used extensively, and acute rejection was diagnosed in 29 of 301 biopsies. Three late deaths occurred (mean follow-up, 16.3 +/- 11.8 months): one of acute rejection at 13 months, one of viral pneumonia at 7 months, and one of intraabdominal sepsis as a complication of peritoneal dialysis at 5 months. Actuarial survival at 2 years is 77% +/- 9% (standard error of the estimate). Heart transplantation for neonates and for children can be performed with acceptable operative mortality. Intermediate results with triple therapy immunosuppression and an intensive rejection surveillance regimen relying on endomyocardial biopsy are encouraging.

Audit of critical care: aims, uses, costs and limitations of a Canadian system

We describe an audit system used in our Medical/Surgical Intensive Care Unit (ICU) during 1989-90. The system emphasizes the integration of data acquisition (database function) with the analysis and use of data (decision function). Resource input (human and technological) included patient demographics, diagnoses, complications, procedures, severity of illness (Apache II), therapeutic interventions (TISS), and nursing workload (GRASP and TISS). The output was assessed by survival, length of stay and ability to return home. The annual operating cost for 277 admissions (249 patients) to this ICU was $7,333. The implementation costs were $58,261 including program development and computer purchases. Non-survivors of ICU and hospital had higher Apache II scores on admission (P less than 0.0001) and longer ICU length of stay (P less than 0.05) than survivors. The nursing workload (both TISS and GRASP) on the day of admission and the last day in ICU were greater in non-survivors (P less than 0.0001) than survivors. Limitations of this audit system included the delay (6-9 mos) from ICU admission until data entry, the large number of diagnostic groups in the ICD.9.CM classification, and lack of a documented cause/effect relationship between interventions and complications. This audit system was more useful for utilization management than for quality assurance purposes.

Continuous positive airway pressure by face mask or mechanical ventilation in patients with human immunodeficiency virus infection and severe Pneumocystis carinii pneumonia

We reviewed the records of 44 patients with AIDS who had 45 episodes of severe Pneumocystis carinii pneumonia (PCP). While 9 patients required intubation and mechanical ventilation (MV) on admission, continuous positive airway pressure (CPAP) by face mask was the initial measure in 36 episodes. There were 25 patients managed with CPAP alone, 23 of whom survived. Among the reasons for delayed intubation and MV (11 patients) was that treatment failure was strongly associated with non-survival, since all 6 such patients died. The in-hospital mortality for severe PCP in this study was 33% overall, and reached 65% for mechanically ventilated patients. The 1-year survival was 43% (95% confidence interval, 28%-58%). These data confirm the improved prognosis for patients with AIDS and severe PCP, and suggest that mask CPAP may be an adequate mean of ventilatory support in this setting.

[Repeat myocardial revascularization]

Eighty-two consecutive patients undergoing reoperation for coronary revascularization from January 1980 to November 1990 were reviewed to determine early and late results and predictors of survival. Seventy patients were male and 12 female; age ranged from 36 to 75 years (mean 56.4 +/- 8.1). All were symptomatic for angina. The mean interval between first and second operation was 62.8 +/- 47.8 months (range 1 to 220 months). Angiographic indications for reoperation were: graft failure (34.1%), progression of atherosclerosis in the native coronary circulation (6.1%) and combination of the two (59.8%). Mean ejection fraction was 45.9 +/- 10.2 (range 11 to 67). Surgical indication was elective in 79.3%, urgent in 14.6% and emergent in 6.1%; 199 grafts were performed (2.4 +/- 1 grafts/patient). Hospital mortality was 6.1% (5 cases). Late mortality was 5.2% (4 cases). Actuarial survival rate (including hospital mortality) was 87.9% at 3, 5 and 10 years. Multivariate analysis identified left main stenosis (p = 0.00001), family history of coronary disease (p = 0.003), urgent/emergency operation (p = 0.015) as predictors of increased in-hospital mortality; postoperative myocardial infarction (p = 0.002) and preoperative heart failure (p = 0.01) as predictors of increased late mortality. Follow-up of in-hospital survivors (mean interval 42.7 +/- 25.8 months, range 3 to 120 months) documented 27 cardiac major events (other than death) in 24 patients (32.9%). Actuarial rates of freedom from major cardiac events were 70%, 52.9% and 48.1% at 3, 5 and 10 years respectively. Multivariate analysis identified preoperative ejection fraction (p = 0.01) as predictor of recurrence of angina and preoperative heart failure (p = 0.02) as predictor of occurrence of cardiac major events.

Protein-energy malnutrition in elderly medical patients

STUDY OBJECTIVE

To evaluate (1) the prevalence of protein-energy malnutrition in elderly patients; (2) the changes in nutritional status during the hospital stay; and (3) (main objective) the relationship between simple nutritional parameters and short-term in-hospital mortality.

DESIGN

Prospective time series at admission and on the 15th day of hospitalization.

SETTING

Medical care unit in a teaching hospital.

PARTICIPANTS

Consecutive sample of 324 hospitalized patients greater than or equal to 70 years (86.4% of eligible patients). Norms of measurements were obtained from a referred sample of healthy control subjects (26 males and 36 females).

MAIN OUTCOME MEASURES

Mid-arm circumference, triceps skinfold thickness, serum albumin, prealbumin, and retinol-binding protein levels were measured in patients at admission and on the 15th day.

RESULTS

(1) Prevalence of PEM was 30% in male and 41% in female patients. (2) Both mid-arm circumference and serum albumin level decreased over the first 15 days of hospital stay (53 patients, paired t test, P less than 0.05). Triceps skinfold thickness did not change. (3) A step-wise discriminant-function analysis determined the utility of the parameters at admission as predictors of in-hospital mortality before the 15th day. Mid-arm circumference, triceps skinfold thickness, albumin, and prealbumin levels, as well as age, are predictors of in-hospital mortality, with 73% sensitivity, 69% specificity, and 70% of correctly classified patients of both sexes.

CONCLUSIONS

Parameters used are predictors for short-term in-hospital mortality of elderly patients hospitalized in an acute medical unit. The lean body mass is preferentially mobilized for energy during hospitalization.

Epidemiology of pediatric trauma: importance of population-based statistics

To determine the validity of using hospital-based pediatric trauma registry data to draw specific inferences with regard to regional pediatric trauma system design, we compared statistical data on the incidence and mortality of pediatric and adult injuries and burns calculated by the New York State Department of Health, based on legally mandated reports of injury deaths and hospital discharges for 1989. During this year, some 488 children, aged 0 to 14 years, died as a result of injuries, a rate of 13.8 per 100,000 annually, of whom 408 (11.6/100,000) died as a result of traumatic injuries or burns, a population-based rate 20% of that observed in adults. During the same period, 16,402 children were hospitalized for treatment of traumatic injuries and burns, a rate of 465 per 100,000 annually, a population-based rate 56% of that observed in adults; and of this number, some 90 children died, yielding an in-hospital mortality "rate" (ie, case fatality ratio) of 0.55%, and a population-based rate of 2.6 per 100,000 annually. Thus, 9.0 of the 11.6 per 100,000 children who died in New York State in 1989 as a result of traumatic injuries and burns were not admitted to the hospital and, therefore, were unknown to the statewide hospital reporting system.(ABSTRACT TRUNCATED AT 250 WORDS)

Medicare use in the last ninety days of life

The introduction of Medicare's prospective payment system (PPS) has led to changes in the way hospitals are being used. This article examines concomitant changes in the use of Medicare-covered services during the last 90 days of life, using data on more than 34,000 Medicare beneficiaries who died during the years 1982-1986. We focus on questions pertaining to changes in practice patterns that include location of death, hospital utilization, use of other covered services, and spending. We find that use of hospitals and other health services by Medicare beneficiaries during the last 90 days of life changed markedly over this period, which included the introduction of PPS in late 1983. The percentage of deaths occurring in hospitals decreased sharply from 1982 to 1986, especially in PPS states relative to waivered states; this effect seems primarily due to reductions in length of stay rather than reduced admission rates, which did not change significantly. Use of home care, durable medical equipment (DME), and physicians' office services also increased sharply during the last 90 days of life, but with no consistent evidence that the introduction of PPS was associated with these changes or with the level or mix of Medicare expenditures for these patients. Medicare spending in this period of life rose at the same rate as medical care price inflation, and about 75 percent of reimbursements continued to be hospital payments, despite the utilization changes.

[Acute aortic dissections. Hospital outcome of 186 cases]

PURPOSE

To determine in hospital outcome acute aortic dissection patients.

METHODS

We revised 186 consecutive cases (up to 14 days of dissection), in a period of 6 years. The patients were divided according to Daily's classification (types A and B).

RESULTS

Type A--127 cases: a) 75 were surgically treated (37 died); b) 2 were medically treated (both died); c) 39 died before the definitive treatment could be initiated; d) 11 died misdiagnosed or undiagnosed. The total mortality was 70.0%. Type B--59 cases: a) 11 complicated cases were surgically treated (6 died); b) 40 were medically treated (8 died); c) 7 died before the definitive treatment could be initiated; d) one died misdiagnosed. The total mortality was 37.25%. In summary, 41.4% of the patients survived. 28.4% died despite the definitive treatment, 24.7% died before the definitive treatment could be initiated and 6.4% died without the correct diagnosis.

CONCLUSION

The acute aortic dissection is a dramatic situation, mainly type A. In this type of dissection many patients (41%) died misdiagnosed, undiagnosed or without enough time to surgical therapy. So, an earlier diagnosis and treatment are imperative.

Long-term survival of emergency department patients with acute chest pain

To evaluate the long-term prognosis of patients with acute chest pain, prospective clinical data and long-term follow-up data (mean 30.1 +/- 9.4 months) were collected for 1,956 patients who presented to the emergency department of an urban teaching hospital with this chief complaint. During follow-up of the 1,915 patients who were discharged alive from the emergency department or hospital, there were 113 (6%) cardiovascular deaths. No differences were detected in the post-discharge cardiovascular survival rates after 3 years of experience with patients who were discharged from the emergency department with a known prior diagnosis of angina or myocardial infarction (89%) and patients who had been admitted and found to have acute myocardial infarction (85%), angina (87%), or other cardiovascular diagnoses (87%). Patients who were discharged from either the hospital or the emergency department without cardiovascular diagnoses had an excellent prognosis. Multivariate Cox regression analysis identified 5 independent correlates of cardiovascular mortality after discharge: age, prior history of coronary disease, ischemic changes on the emergency department electrocardiogram, congestive heart failure and cardiogenic shock. These findings indicate that the postdischarge cardiovascular mortality of patients with chest pain who are discharged from the emergency department with a known history of coronary disease is similar to that of admitted patients with angina or myocardial infarction. These data suggest that the same types of prognostic evaluation strategies that have been developed for admitted patients with ischemic heart disease should also be considered when such patients present to the emergency department but are not admitted.

Patterns of referral and recovery in women and men undergoing coronary artery bypass grafting

This study compares women and men undergoing coronary artery bypass grafting. Factors before and after coronary surgery were examined to identify variables related to mortality and morbidity. The study population included 465 women and 465 men matched for age (mean age 64.2 years) who underwent first time isolated coronary artery bypass grafting between 1983 and 1988. There were higher incidences of systemic hypertension, diabetes mellitus, postmyocardial infarction angina, thyroid gland disease, arthritis (p less than 0.001 for all), acute myocardial infarction (p = 0.03), congestive heart failure (p = 0.03), and emergency surgery (p = 0.02) in women, whereas more men had peptic ulcer disease (p less than 0.001). The in-hospital death rate was not significantly different (women 4.3% vs men 3.7%). For all subjects, emergency surgery (p less than 0.001), significant left main narrowing (p less than 0.05) and renal disease (p less than 0.001) were related to death, whereas history of myocardial infarction (p less than 0.05) and diabetes (p less than 0.05) were related to death only in men. Age and body surface area were not related to death. After surgery men had a higher incidence of atrial arrhythmia (p less than 0.001), and women had a higher incidence of congestive heart failure (p less than 0.001). Although women did not have a higher mortality rate, the data suggest that women and men do not share all the same predictors of mortality after surgery.

A survey of medical quality assurance programs in Ontario hospitals

OBJECTIVE

To determine the prevalence and types of medical quality assurance practices in Ontario hospitals.

DESIGN

Survey.

SETTING

All teaching, community, chronic care, rehabilitation and psychiatric hospitals that were members of the Ontario Hospital Association as of May 1990.

PARTICIPANTS

The person deemed by the chief executive officer of each hospital to be most responsible for medical administration.

INTERVENTION

A questionnaire to obtain information on each hospital's use of criteria audit, indicators inventory, occurrence screening and reporting, and utilization review and management (URM) activities.

OUTCOME MEASURES

Prevalence of the use of the quality assurance activities, the people responsible for the activities and the relative success of the URM program in modifying physicians' performance.

RESULTS

Of the 245 member hospitals participants from 179 (73%) responded. Criteria audits were performed in 136 (76%), indicators inventory in 43 (24%), occurrence screening in 44 (25%), occurrence reporting in 61 (34%) and URM in 123 (69%). In-hospital deaths were reviewed in 157 (88%) of the hospitals. In all, 87 (55%) of the respondents from hospitals that had a URM program or were developing one indicated that their program was successful in modifying physicians' practices, and 29 (18%) reported that it was not successful; 26 (16%) stated that the effect was still unknown, and 16 (10%) did not respond. Seventy (40%) stated that results of tissue reviews were reported at least 10 times per year and 94 (83%) that medical record reviews were reported at least as often. The differences in the prevalence of the quality assurance activities between the hospitals were not found to be significant.

CONCLUSIONS

Many Ontario hospitals are conducting a wide variety of quality assurance activities. Further study is required to determine whether the differences in prevalence of these activities between hospitals would be significant in a larger, perhaps national, sample. Strategies are needed to ensure universal involvement and participation in the improvement of the quality of care and the assessment of the cost-effectiveness of health care treatments. Recommendations to achieve these objectives are suggested.

Is age an independent predictor of early and late mortality in patients with acute myocardial infarction?

PURPOSE

To determine whether advancing age is an independent predictor of increased mortality following acute myocardial infarction or simply a marker for more extensive cardiac disease, a higher prevalence of comorbid conditions, and/or differences in therapeutic approach.

PATIENTS

A total of 261 consecutive patients with documented acute myocardial infarction admitted to a university teaching hospital during a 1-year interval.

METHODS

Seventy-four variables were analyzed to determine univariate predictors of inhospital and 1-year post-discharge mortality. Multiple linear regression models were constructed to determine independent predictors of early and late mortality after adjusting for baseline and therapeutic differences between younger and older patients.

RESULTS

Compared with patients less than 70 years (n = 124), patients greater than or equal to 70 years (n = 137) were more likely (all p less than 0.05) to be female and have a prior history of ischemic heart disease. New York Heart Association functional class and Killip class on admission were higher in older patients, as were the admission serum creatinine and blood urea nitrogen levels. Serum albumin and peak creatine kinase levels were lower in older patients, but older patients were more likely to exhibit left ventricular hypertrophy or atrioventricular block on the initial electrocardiogram. Finally, younger patients were three times as likely to receive a thrombolytic agent and 66% more likely to receive intravenous beta-blockade than older patients, and younger patients were also more likely to receive heparin and intravenous nitroglycerin. Hospital mortality was 5.6% in patients less than 70 years versus 16.1% in patients greater than or equal to 70 years (p = 0.013). After adjusting for baseline and therapeutic differences, independent predictors of hospital mortality were systolic blood pressure on admission (inverse correlation, p = 0.0095), beta-blocker therapy (inverse correlation, p = 0.01), age (p = 0.014), peak creatine kinase level (p = 0.015), and Killip class (p = 0.035). Among hospital survivors, 1-year post discharge mortality was 6.8% in patients less than 70 years versus 19.1% in those greater than or equal to 70 years (p = 0.001). Independent predictors of post-discharge mortality after adjusting for age-related baseline and therapeutic differences were admission heart rate (p = 0.0004), age (p = 0.011), left ventricular ejection fraction (inverse correlation, p = 0.012), initial non-Q-wave myocardial infarction (p = 0.026), and the blood urea nitrogen level (p = 0.036).

CONCLUSION

After adjusting for multiple baseline and therapeutic differences between older and younger patients, age per se remains a strong independent predictor of both inhospital and 1-year post-discharge mortality rates in patients with acute myocardial infarction.

Hospital and posthospital survival in patients mechanically ventilated for more than 29 days

Experience with prolonged mechanical ventilation has improved over recent years. Retrospective analysis of the records of 104 patients older than 16 years of age who were mechanically ventilated for more than 29 days over a 29-month period from May 1986 to October 1988 revealed the following findings. The mean patient age was 66.3 +/- 15.7 years (SD). The mean number of in-hospital ventilator days was 59.9 +/- 36.7 days (range, 29 to 247 days). The mean number of days of oral or nasal endotracheal intubation prior to tracheostomy (96 patients) was 21.5 +/- 14.2 days. The mean length of hospital stay for the 104 patients was 79.9 +/- 45.4 days. The majority of the 104 patients (82.6 percent) were surgical patients. Nine patients left the hospital receiving extended mechanical ventilation. Mortality was highest in multiple organ system failure and lowest among the trauma patients. The total days of mechanical ventilation did not appear to be related to mortality if patients older than 16 years survived for seven days. Postdischarge survival of the 53 of 60 patients who survived and whom we were able to contact was 67 percent at one year and 56 percent at three years.

Neonatal anatomic repair of transposition of the great arteries and ventricular septal defect

From January 1985 to March 1992, 64 consecutive neonates with transposition of the great arteries (TGA) and ventricular septal defect (VSD) underwent an arterial switch operation and VSD closure. The mean age at operation was 18.5 +/- 12 days and the mean weight was 3.3 kg. Seventeen patients had an associated aortic coarctation, of whom 15 underwent single-stage repair through median sternotomy. Coronary artery distribution was: type A: 45 patients; type B: 2; type D: 11 and type E: 6 patients. The location of the VSD was perimembranous in 42 patients, trabecular in 13, infundibular in 5, and 4 presented with the Taussig Bing heart anomaly. The hospital mortality was 9.3% (n = 6). There were four late deaths (one TGA-VSD and three TGA-VSD and coarctation). Nine patients required reoperation. The mean follow-up of all survivors was 36 +/- 19 months. They were in NYHA class I without medication. Six patients developed mild-to-moderate aortic insufficiency. The actuarial survival and freedom from reoperation at 5 years were 81.06% and 84.6%, respectively. We conclude that neonatal anatomic repair of TGA and VSD offers good medium-term results and avoids iterative operations.

Evaluation and treatment of secondary tricuspid insufficiency

To define the role of functional tricuspid insufficiency and right ventricular (RV) failure in patients with mitral disease, the data of 121 patients with secondary tricuspid insufficiency that underwent mitral valve replacement (MVR) from January 1982 to December 1987 were analyzed. The mitral hemodynamic lesion was: stenosis in 41 patients (33.9%); insufficiency in 11 (9.1%) and mixed stenosis and insufficiency in 69 (57.0%). NYHA functional class was: II in 4 patients (3.3%), III in 78 (64.5%) and IV in 39 (32.2%). In 100 cases (group 1) with tricuspid insufficiency defined as moderate or severe, a De Vega annuloplasty was performed while in 21 (group 2) with mild tricuspid insufficiency, no tricuspid surgical procedure was performed. Hospital deaths occurred in 17 of 121 patients [14% (CL 10.8-17.0)]. There was no significant difference in hospital mortality between group 1 and group 2 (15% vs 9.5%; P = 0.75). Incremental risk factors for hospital mortality as determined by multivariate analysis, include: cardiothoracic ratio (P = 0.0016), total aortic cross-clamp time (P = 0.006), associated cardiac disease (P = 0.0209) and emergency operations (P = 0.0318). Mean follow-up of surviving patients was 50.1 +/- 28.1 months. Late deaths occurred in 16 patients [15.4% (CL 11.7-18.7)]. The actuarial survival rate was 85.6% and 73.8% at 5 and 9 years, respectively. Nine patients [8.6% (CL 5.9-11.3)] required reoperation. There was no significant difference between group 1 and group 2 in the rate of late cardiac related deaths (5.9% vs 5.3%, P = 0.66) and of tricuspid reoperations (4.7% vs 5.3%, P = 0.62).(ABSTRACT TRUNCATED AT 250 WORDS)

Quality of life after myocardial revascularization. Effect of increasing age

The effect of increasing age on quality of life, survival, and risk of reoperation was studied in 2479 patients followed up prospectively 2 to 20 years after myocardial revascularization. Quality of life was determined from annual questionnaires, which we used to calculate a health status index from the patient's symptomatic status and subjective response to the operation, which was graded between zero and 1.00 (asymptomatic). Four age groups were studied: age 49 years or less (AG40), 50 to 59 years (AG50), 60 to 69 years (AG60), and 70 years or older (AG70). Associated problems (left ventricular aneurysm, valve disease, acute myocardial infarction) necessitating treatment were present in 17% (61/361) of AG40 patients, 19% (165 of 859) of AG50 patients, 23% (213/927) of AG60 patients, and 31% (102/332) of AG70 patients. The hospital mortality rate was higher in older patients undergoing combined procedures but not in patients undergoing coronary bypass grafts only. Probability of survival and health status indexes were calculated excluding patients with valve disease and cardiogenic shock. Probability of survival was significantly better (p less than 0.001 by the Wilcoxon test) in patients less than age 60 than in those 60 years or older, but in patients with an ejection fraction greater than or equal to 0.40, probability of survival at 12 years was 0.64 (age less than 60) versus 0.62 (age greater than or equal to 60). The actuarial risk of reoperation, calculated as the difference between probability of survival and probability of survival without reoperation, progressively increased in younger patients but not in patients aged 60 years or older. At 15 years, the reoperation rates were 26% (AG40), 14% (AG50), 5% (AG60), and 7% (AG70). Mean health status index for years 1 to 5 was 0.85 in AG40 patients, 0.84 in AG50 patients, 0.89 in AG60 patients, and 0.90 in AG70 patients; for years 6 to 10, 0.81, 0.80, 0.86, and 0.89; and for years 11 to 15, 0.77, 0.78, 0.84, and 0.84, respectively. Thus quality of life after myocardial revascularization is better, improvement lasts longer, and reoperation rate is less in patients aged 60 years or older.

Volume-outcome relationships and in-hospital mortality: the effect of changes in volume over time

This study examines whether patient outcomes are affected by changes in volume over time within hospitals and whether such effects are consistent with cross-sectional results previously reported in the literature. Investigating the existence of volume-outcome relationships longitudinally for specific groups of patients relates directly to the policy issue of whether, and how, specific inpatient services should be regionalized. The analysis uses up to 8 years of observations from a national sample of nearly 500 community hospitals. Outcomes are measured as inhospital mortality adjusted for case severity. Instrumental variables techniques are used to test and control for the possibility of selective referral. The results suggest that higher volume leads to better outcomes for certain groups of patients. Among the groups studied here, increases in volume lowered adjusted mortality rates for acute myocardial infarction, hernia repair, and respiratory distress syndrome in neonates; correlations were observed between volume and outcome for coronary artery bypass grafts, which seemed to be due primarily to referral patterns; and, no significant findings were found for hip replacements. In general, the effects of volume on outcome appear to be larger when estimated from longitudinal, rather than cross-sectional, data.

Measuring stroke in the population: quality of routine statistics in comparison with a population-based stroke registry

The validity of routine stroke data (official mortality statistics and hospital discharge registries) and a population-based MONICA stroke registry was assessed in a population of 309,806 25- to 74-year-old people in Sweden. The 'true' number of strokes in the population was estimated by screening for non-stroke diagnoses in death certificates and hospital discharge records and by a period of intensified search for otherwise unrecognized non-hospitalized stroke cases. Applying strict stroke criteria, the proportion of false-positive diagnoses was 10% and false-negative 17% in official mortality statistics. Among patients discharged alive from hospital, there were 32% false-positive and 6% false-negative stroke diagnoses. In the MONICA registry, the proportion of false-negative cases was 6% in fatal cases and 4% in non-fatal cases. Diagnostic information for subtyping stroke improved over time in non-fatal cases but remained essentially unchanged in fatal cases. We conclude that official mortality statistics give a reasonably good estimate of fatal stroke cases in Sweden, whereas hospital discharge records reflect poorly the incidence of stroke in the population. The overall quality of the population-based MONICA registry is good, although 4% of all strokes are missed. The proportion of unspecified stroke is substantial and changes over time; this makes longitudinal studies of stroke subtype difficult.

Dynamic cardiomyoplasty for long-term cardiac assist

The principle of cardiomyoplasty is long-term electrostimulation of a latissimus dorsi muscle (LDM) wrapped around the failing heart. Technically, this procedure consists of placing the left LDM flap around the heart via a window created by partial resection of the 2nd or 3rd rib, and subsequent muscle electrostimulation in synchrony with ventricular systole. The aim of cardiomyoplasty is to support ventricular function in ischemic or dilated cardiomyopathies, or to partially replace the ventricular myocardium after large aneurysm or tumor resections. Our clinical experience at Broussais Hospital involves 44 patients. The functional class and quality of life improved after cardiomyoplasty. Improvement of the ventricular performance and limitation of cardiac dilatation were demonstrated over the long-term. The actuarial survival at 6 years was 71%. Risk factors influencing perioperative mortality were: age > 65 years, associated surgical procedures, pulmonary vascular hypertension, and patients hemodynamically unstable or on inotropic drug support. Preoperative risk factors influencing the long-term mortality were: permanent NYHA functional class 4, cardiothoracic ratio > 0.60, LV ejection fraction < 15%, bi-ventricular heart failure, and atrial fibrillation. Cardiomyoplasty does not preclude the use of future orthotopic heart transplantation.

Coordinate-based mapping--a new method in health services research

The Finnish national hospital discharge registers from 1985 and 1988 have been analysed by the National Board of Health. Results are provided for all the 21 Finnish hospital districts and central communal organizations. The small area variation phenomenon in hospital utilization cannot be explained by demographic or epidemiological factors. Rather, the variations seem to be largely due to organizational factors. The project aims to develop a data processing system capable of handling information on one million patients rapidly and economically, and show the results in an intelligible form as a table with standard headers or as a map illustration. Maps are superior to traditional statistical tables in demonstrating regional variations in health care utilization and in mortality. Maps based on small administrative units are useful for many purposes. These maps are, however, relatively 'noisy' due to substantial random variation. Coordinate-based mapping is a method to overcome some of these difficulties. It is based on linking hospital discharge and mortality data with exact address data. The method allows mapping independent of administrative boundaries. Several examples of coordinate-based maps are given. The method is used in Finland for annual analysis of hospital use.

Long-term prognosis of patients with paroxysmal atrial fibrillation complicating acute myocardial infarction. SPRINT Study Group

The aim of the study was to assess the relationship between paroxysmal atrial fibrillation during acute myocardial infarction and the long-term prognosis of patients after acute myocardial infarction. The incidence of paroxysmal atrial fibrillation among 5803 consecutive hospitalized patients was 9.9% (557/5803). Incidence rose with increasing age (less than or equal to 59 years, 4.2%), (60-69 years, 10.5%), (greater than or equal to 70 years, 16.0%) and was slightly (but not significantly) higher in women (11.0%) than in men (9.6%). The presence of congestive heart failure and mean age represented two major discriminants between patients with paroxysmal atrial fibrillation (70% and 68.6 years) in comparison with their counterparts (35% and 62.3% years). Hospital mortality was significantly higher (25.5%) in patients with paroxysmal atrial fibrillation than in those without (16.2%). However, the effect of paroxysmal atrial fibrillation disappeared when other factors influencing the short term prognosis (i.e. heart failure) were taken into account by a multivariate logistic regression analysis. The covariate adjusted relative odds of in-hospital mortality then fell to 0.82. The 1- and 5-year mortality rates were 18.6% and 43.3% in patients with paroxysmal atrial fibrillation as compared to 8.2% and 25.4% (P less than 0.001), respectively, in patients free of paroxysmal atrial fibrillation. Using a proportional hazards analysis of mortality through the first quarter of 1988 (average follow-up time, 5.5 years) the net risk of dying among patients with paroxysmal atrial fibrillation complicating the acute myocardial infarction is estimated at 1.28 (90% confidence interval, 1.12-1.46) relative to counterparts free of the complication.(ABSTRACT TRUNCATED AT 250 WORDS)

Morbidity and mortality in the Special Care Baby Unit of New Mulago Hospital, Kampala

The morbidity and mortality of admissions to the Special Care Baby Unit at New Mulago Hospital, Kampala are described for 1598 infants seen during the 12-month period of 1989. The overall neonatal mortality rate on the Unit was 18.0%, which has shown only slight improvement during the period 1984-1989. The major causes of death were, in descending order of frequency: birth asphyxia, respiratory distress syndrome, aspiration syndromes, very low birthweight, infection, anaemia and congenital malformations. Birth asphyxia was the most common cause of death in infants weighing over 2500 g while respiratory distress syndrome predominated among deaths below 2500 g. Birth injuries and transient tachypnoea of the newborn were also common reasons for admission. Difficulties of caring for infants requiring special care in a developing country are emphasized. These include inadequate equipment and supplies, poor investigative facilities and scarcity of well trained personnel. The situation is further aggravated by low morale among health workers due to poor working conditions.

Analysis of Deaths in Patients with an Implantable Cardioverter Defibrillator

The cause of death and clinical characteristics of 26 patients that died after implantable cardioverter defibrillator placement were reviewed and compared to the 145 patients still living after a mean follow-up of 17 months. Operative mortality was 4% (7/171) and resulted from postoperative ventricular arrhythmias (four patients), heart failure (two patients), and respiratory failure (one patient). Operative mortality was significantly higher (1.7% vs 9.6%, P less than 0.05) following concomitant surgical procedures. Total late mortality was 11% (18/171). Thirteen deaths (75%) occurred in-hospital from progressive deterioration of left ventricular function (nine patients), arrhythmia (two patients), and noncardiac causes (two patients). Outpatient mortality was 3.5% (6/171) and resulted from presumed sudden cardiac death in five of six patients; two of the five had devices that were inactive, one had high defibrillation thresholds, and two had suspected bradyarrhythmic deaths. One postoperative death and one late in-hospital death were also considered sudden cardiac deaths for a total of seven patients with defibrillation system failures. By multivariant analysis, preoperative clinical characteristics associated with a worse prognosis following defibrillator implantation were identified: presentation as ventricular tachycardia (P less than 0.02), induction of sustained monomorphic ventricular tachycardia (P less than 0.05), poor left ventricular performance (P less than 0.01), poor functional status (P less than 0.001), and the use of diuretics (P less than 0.01). Frequent device discharges (P less than 0.001) and concomitant antitachycardia pacing systems (P less than 0.001) were markers for greater arrhythmia recurrence and were potent predictors of a worse prognosis and particularly sudden death.

Clinical Outcome of Acute Myocardial Infarction in Patients on Treatment with Beta-Blockers or Calcium Antagonists

To assess the effects of current treatments with beta-blockers or calcium antagonists on the clinical outcome of acute myocardial infarction (MI), enzymatically estimated infarct sizes, circulatory arrests from ventricular tachyarrhythmias, ventricular tachycardia (VT)/ventricular fibrillation (VF), and in-hospital mortality were analyzed retrospectively from 7,922 citizens of Malmö, Sweden, hospitalized due to a first MI between 1973 and 1987. Of these patients, 296 were on treatment with calcium antagonists, 393 on treatment with a beta 1-selective beta-blocker, 482 with a nonselective beta-blocker, and 95 on combined treatment with beta-blockers and calcium antagonists at the time of admission to hospital. In a set of multivariate analyses including several clinical characteristics, patients on treatment with a nonselective beta-blocker had a significantly lower peak aspartate aminotransferase (ASAT; difference -0.70 mukat/l, 95% CL: -1.24 to -0.16), whereas no significant relations between peak ASAT and treatment with cardioselective beta-blockers or calcium antagonists were found. Treatment with cardioselective beta-blockers or calcium antagonists, in contrast to treatment with a nonselective beta-blocker, were significant predictors of the occurrence of circulatory arrests from VT/VF. The relative risk of VT/VF in patients on cardioselective beta-blockers was 1.51 (95% CI: 1.12-2.03), and in patients on calcium antagonists 1.44 (95% CI: 1.03-2.02). None of the treatments were significantly associated with in-hospital mortality. In patients on beta-blockers or calcium antagonists when suffering their first MI, nonselective beta-blockade may reduce infarct size. Treatment with beta-blockers or calcium antagonists identified patients with an increased risk of circulatory arrests from VT/VF, but neither of the treatments were significantly associated with in-hospital mortality. We suggest that only minor differences exist between the effects of chronic treatment with beta-blockers and calcium antagonists on the outcome of an acute MI.

Clinical experience with the zero-pressure-fixed Medtronic Intact bioprosthetic valve

The Medtronic Intact porcine valve bioprosthesis was inserted in 219 patients between 1983 and 1990. Mean patient age was 52 years and mean follow up 33.3 months. There was only one example of structural valve degeneration at 25 months, giving an actuarial freedom of 99% at 6 years. Reoperation was performed in 7 patients. Freedom from reoperation was 93% at 6 years, from infective endocarditis 96%, from thrombo-embolism 91% and from valve-related complications 86%. Doppler echocardiography revealed non-significant incompetence in 8 instances and mild leaflet thickening of 5 valves. Valve gradients and areas were unchanged between two Doppler studies 2 years apart of valves in the mitral position, and were reduced in valves in the aortic position from 17 +/- 5.2 mmHg to 13 +/- 2.8 mmHg (P = 0.02). These medium-term results are considered very encouraging. The theoretical considerations underlying the use of zero-pressure glutaraldehyde fixation, which is the technique used for the Intact valve, are detailed elsewhere in this issue [1]. The Intact valve is treated with toluidine blue as a calcium-retarding agent and is mounted on a Dacron-covered acetyl copolymer (Celcon) stent with flexible posts. The normal profile of the porcine aortic valve is maintained.

Preoperative prediction of mortality following surgery for esophageal cancer

Ninety-five patients with thoracic esophageal cancer who had undergone radical esophagectomies through right thoracotomies from 1986 to 1989 were statistically analyzed semi-quantitatively to identify the risk factors predicting "operative (within 45 days of operation) or hospital death." Age, pulmonary function (%VC or %FEV1.0), cardiac function (EKG or Master test), renal function (Ccr), hepatic function (R15'ICG), diabetes mellitus (75 OGTT), extent of tumor invasion to the adventitia, and the type of operative procedure were each scored according to severity; 0 (no risk), 1, 2, or 3 (high risk). Patients with no severe postoperative complications had an accumulated score of less than 8 and comprised Group I, while those suffering an an "operative death" had a total score of 8 or more, and comprised Group II. Group III included those suffering a "hospital death." There was a significant difference between Group I and Group II (p < 0.005), but not between Group I and Group III. "Operative deaths" could be preoperatively predicted from the risk factors. However, "hospital deaths" could not be predicted, since they resulted mainly from recurrences of the cancer. In cases with scores of 8 or more the operative procedure should be changed to a simpler one for an improved prognosis.

Hemodynamic changes after resection of thoracic duct for en bloc resection of esophageal cancer

An en bloc resection of esophageal cancer is one of the most radical forms of esophagectomy, and includes the resection of the thoracic duct, but a relatively high hospital mortality rate has been reported. There is very little knowledge on the pathophysiological changes after resection of the thoracic duct. We examined 24 patients who underwent en bloc resection. Some patients developed severe tachycardia or shock postoperatively which subsided after a massive infusion of plasma. Analysis of the fluid balance revealed that much more fluid was necessary during surgery and the postoperative 24 h than in patients treated by a standard esophagectomy. Postoperative lymphangiography or CT revealed abnormal collateral lymphatics around the kidneys or in the pelvic cavity. This suggests the development of the lymphaticovenous shunts, which differed depending on the anatomy of each patient. One patient with chronic hepatitis developed uncontrollable ascites. These are important findings which can hopefully reduce the high rate of hospital death after this operation.

Mortality and recurrences during eight years following stroke

A total of 388 patients, of mean age 73 years, with acute cerebrovascular disease (CVD) evaluated in a non-intensive Stroke Unit, and a sample of 209 age- and sex-matched similarly acutely admitted patients with surgical diseases were followed up for 5-8 years. The CVD patients had a 21-day hospital mortality of 13%, and 66% mortality during the entire study period, compared to 2% and 48%, respectively, in controls. Old age had only a minor effect on the initial mortality. However, long-term mortality increased markedly with age. The initial mortality in 120 stroke recurrences was 50%. In CVD patients heart diseases were common causes of death, and circulatory diseases were most predominant of all (86%), with an accumulation during the first months after the occurrence of the initial CVD event. These figures clearly show that stroke patients constitute a group with high risk of stroke recurrence and death. Despite declining figures for stroke mortality, and most probably also for case fatality rate after first stroke episodes, much work remains to be done within the field of secondary prevention after stroke.

[Measurement of mortality as the effect of hospital intervention at an internal medicine service]

The mortality measurement by the effect of hospital mediation is little known. The aim of the present study was to evaluate the mortality rate in a Internal Medicine Service of a Regional Hospital and to know there are the mortality risk factors, that might have influenced by hospital mediation. 870 patients were analyzed during a period of one year. The risk factors were classified in three groups: to the individual, to the hospital admission and we compared there with the calculation of the Odds Ratio (OR) and its 95% confidence intervals (95% CI) by a bivariate and multivariate analysis. The mortality rate was about 10.2% (CI: 8.2 +/- 12.2). Age older 70 years, the re-enter and the diagnostic of Cerebral Infarct were the individual factors associated with a higher risk. The insertion of nasogastric catheters and the use of diuretics were the only hospital-related factors that were correlated with mortality. The hospital infection and the heart complication were also the risk factors of death. These findings suggest there are risk factors to report with mortality risk. That could be used to evaluate the clinical resolution in order to reduce the hospital mortality.

[Clinical characteristics of pulmonary edema in patients with unstable angina]

To elucidate the clinical characteristics of pulmonary edema in unstable angina, 120 patients with unstable angina who admitted to the hospital within 6 hours after the onset of chest pain were studied. The criteria for the diagnosis of pulmonary edema included interstitial pulmonary edema and diffuse alveolar edema. Pulmonary edema was present in 24 patients. In these patients, the duration of chest pain was relatively longer, and the incidences of diabetes mellitus, emergency coronary revascularization and multiple-vessel coronary artery disease were higher than in those without pulmonary edema. In addition, in-hospital mortality rate in patients with pulmonary edema was higher than in those without it (21 vs 1%, p < 0.001), which is probably due to a large area of myocardial ischemia. For these patients, therefore, early diagnosis and appropriate therapy to save viable segments of the myocardium are mandatory.

The changing pattern of fetal death, 1961-1988

The aim of this study was to assess any changes in cause-specific fetal death rates in the nonreferred population of a tertiary care unit. The fetal death rate (per 1000 births) among 88,651 births diminished from 11.5 in the 1960s to 5.1 in the 1980s. Fetal death due to intrapartum asphyxia and Rh isoimmunization has almost disappeared. Toxemia and diabetes continue to make similar and small contributions to fetal death rates. There has been a significant decline in unexplained antepartum fetal deaths and in those caused by fetal growth retardation, but no significant change in the death rate due to intrauterine infection or abruptio placentae. During the 1960s, the risk of fetal death was increased in women with hypertension, diabetes, or a history of stillbirth; during the 1980s, only women with a history of insulin-dependent diabetes were at risk. Improved application of current knowledge may help decrease the fetal death rate caused by fetal growth retardation. Reduction in deaths due to abruptio placentae, intrauterine infections, or lethal malformations, as well as unexplained antepartum deaths, appears to depend on better understanding of the etiology of these disorders.

Elective total hip replacement: incidence, emergency readmission rate, and postoperative mortality

OBJECTIVES

To report the incidence of elective total hip replacement and postoperative mortality, emergency readmission rates, and the demographic factors associated with these rates in a large defined population.

DESIGN

Analysis of linked, routine abstracts of hospital inpatient records and death certificates.

SETTING

10 hospitals in six districts in Oxford Regional Health Authority covered by the Oxford record linkage study.

SUBJECTS

Records for 11,607 total hip replacements performed electively in 1976-85.

MAIN OUTCOME MEASURES

Incidence of operation, postoperative mortality, relative mortality ratios, and incidence of emergency readmission.

RESULTS

NHS operation rates increased over time from 43 to 58 operations/100,000 population. Variation in operation rates between districts reduced over time. Operation rates were on average 25% higher in women than men. There were 93 deaths (11/1000 operations) within 90 days of the operation and 208 emergency readmissions (28/1000 operations) within 28 days of discharge. Postoperative mortality and emergency readmission rates increased with age. No significant trend with time was found. Mortality in the 90 days after the operation was 2.5-fold higher (1.9 to 3.0) than in the rest of the first postoperative year. This represented an estimated excess of 6.5 (4.2 to 8.8) early postoperative deaths/1000 operations. Most deaths were ascribed to cardiovascular events. Thromboembolic disease was the commonest reason for emergency readmission.

CONCLUSIONS

The pronounced increase in operations in districts with initially low rates suggests a trend towards greater equity in the local provision of NHS hip arthroplasty. The early postoperative clusters of deaths attributed to cardiovascular disease and of readmissions for thromboembolic disease suggest that there is scope for investigating ways of reducing the incidence of major adverse postoperative events.