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PubMed1980

Determinants of death in patients with intraabdominal abscess.

To better define determinants of death in patients with intraabdominal abscess, 143 patients from a 5-year hospital experience were reviewed. Abscesses were most commonly results of trauma, spontaneous gastrointestinal perforations, and technical errors. Clinical presentation of abscess was quite variable as were criteria to justify reoperation for drainage. Abscesses occurred most commonly in the subphrenic space, pelvis, or subhepatic space. Complete abdominal exploration was employed most frequently for drainage. Those factors that were associated with a fatal outcome were: organ failure (P < 0.001), lesser sac abscess (P < 0.001), positive blood culture (P < 0.01), recurrent and/or persistent abscess (P < 0.01), multiple abscesses (P pE 0.01), age > 50 years (P < 0.03), and subhepatic abscess (P < 0.03). These data suggest that deaths from abdominal abscess are consequences of ineffective surgical drainage and failure of host defense mechanisms.

Abdomen↗

PubMed1994

Alcohol and mortality. Results from the EPOZ (Epidemiologic Study of Cardiovascular Risk Indicators) follow-up study.

To investigate the association of alcohol intake with mortality from all causes, cardiovascular disease (CVD), cancer and other causes (e.g., accidents, violence, suicide), we performed an analysis of data obtained in a prospective follow-up study conducted in the Netherlands since 1977. Causes of death were defined for a cohort of 1,620 persons (760 men and 860 women) examined in 1977. During the 10-year follow-up period, 123 (7.6%) of the participants died. Frequency of alcohol consumption was obtained separately for wine, beer and liquor by means of a questionnaire. Although no significant association could be established between alcohol consumption and all-cause mortality, all-cause mortality tended to be lower in alcohol consumers compared to abstainers. The age- and sex-adjusted risk estimates of death from CVD were 0.29 (0.11-0.74), 0.46 (0.21-0.96) and 0.32 (0.13-0.77) for subjects with occasional, frequent and daily alcohol use, respectively, compared with those who did not drink at baseline. The mortality risks of never-drinkers and ex-drinkers were similar. A J- or U-shaped relation between alcohol consumption and CVD mortality could not be confirmed in our data but the available information on the amount of alcohol consumed was limited. No significant influence on the risk estimates of death from cancer or other causes was found. However, mortality tended to be higher for those who consumed more alcohol. The protective effect of alcohol intake on CVD mortality found in our data persisted after excluding subjects with cardiovascular or other major diseases at baseline from the analysis.

Adult↗

PubMedDate not supplied

Second Annual Mario S. Verani, MD, Memorial Lecture: Nuclear cardiology, the next 10 years.

The nuclear cardiology of the future will be based on new clinical and biologic targets. It will be driven by modern concepts of molecular and cell biology and molecular genetics. A major effort involves detection of atherosclerosis and vascular vulnerability. Approaches include targeting proliferating smooth muscle cells, angiogenesis, vascular injury, inflammation through a variety of mechanisms, defining cell death and protease activation, and imaging gene expression. Another new clinical target involves imaging stem cells and various progenitor cells. To meet these new objectives, advanced imaging technology is required. This involves the development of micro-single photon emission computed tomography and micro-positron emission tomography systems as well as fusion technology involving radiologic computed tomography imaging together with nuclear imaging. Vascular lesion detection imaging may require intravascular detectors. The future of nuclear cardiology, based on molecular imaging, is extraordinarily exciting. The newly defined biologic targets will allow the answering of many of the key clinical questions that will dominate cardiovascular care in cardiovascular investigation over the next decade.

Animals↗

PubMed2002

Factors affecting surgical outcome in the elderly at Auckland Hospital.

BACKGROUND: The aim of the present study was to define the factors which affect the outcome of major abdominal surgery in elderly patients. METHOD: Data were collected prospectively using the surgical audit on all patients who were 65-years-old or older and had undergone major abdominal surgery at Auckland Hospital between January 1997 and November 2000. Risk factors studied were age, sex, American Society of Anesthesiologists grade, operative duration, timing of surgery (elective, urgent or emergency), surgeon (consultant or registrar) and the presence of the scrubbed consultant in theatre. Surgical outcome (no complications, complications or death) was defined according to the complication stratification and severity score developed by the University of Otago. Direct logistic regression was used to determine the significance of the risk factors. RESULTS: 1141 patients (614 women and 527 men) who underwent 1248 procedures were studied. The factors that affected the mortality were the ASA grade (P = 0.0001) and operative timing (P = 0.0008). The factors that affected the severity of postoperative complications were ASA (P = 0.0001), operative timing (P = 0.0001) and duration (P = 0.0001). CONCLUSIONS: The ASA, timing and duration of surgery were the most significant factors affecting patient outcome. Age had a less important effect. Arranged surgery and short operative duration have a favourable outcome in selected elderly patients. Therefore, the elderly should not be denied indicated major abdominal surgery on basis of age alone.

Abdomen↗

PubMed2005

Feasibility, safety, and preliminary efficacy of a novel ePTFE-covered self-expanding stent in saphenous vein graft lesions: the Symbiot II trial.

Compared with percutaneous interventions in native coronary arteries, revascularization of saphenous vein graft (SVG) lesions is associated with increased rates of immediate and long-term major adverse cardiac events (MACE). The Symbiot II trial was a multicenter prospective study designed to evaluate the feasibility and safety of a novel self-expanding polytetrafluoroethylene (ePTFE)-covered stent in the treatment of de novo and restenotic SVG lesions. The primary endpoint was MACE through 30 days postprocedure. Successful Symbiot stent deployment was achieved in 75 of 77 patients (97.4%) with SVG lesions < or = 35 mm in length (visual assessment). The procedural success rate (defined as < 30% residual stenosis at the target site and no clinical complications) was 83%, and all study device procedures provided grade 3 TIMI flow postprocedure. Within the first 30 days postprocedure, four patients (5.2%) experienced MACE (defined as death, Q-wave or non-Q-wave myocardial infarction, and clinically driven target vessel revascularization), of whom three patients (3.9%) experienced periprocedural non-Q-wave myocardial infarction. No subacute stent thrombosis was observed over the 6-month follow-up period. No relevant luminal loss at the target site (mean, 0.3 +/- 0.9 mm) was observed in the 58 patients (77.3% of enrolled patients) who underwent quantitative coronary angiography at 6 months. The incidences of binary in-stent restenosis, in-segment restenosis, and target vessel failure (defined as acute and late-term MACE through 6 months postprocedure) were low (7.0%, 8.6%, and 14.3%, respectively). The Symbiot self-expanding ePTFE membrane-covered stent was associated with a high procedural success rate (97.4%), low incidences of MACE at 30 days (5.2%) and 6 months (14.3%), suggesting that it is safe and effective in the treatment of SVG disease.

Aged↗

PubMed1986

Long-term follow-up of valvotomy before 1968 for congenital aortic stenosis.

The clinical course of 59 patients who underwent valvotomy for aortic stenosis before 1968 was reviewed. All were older than 1 year at the time of operation. Mean follow-up period was 17.7 years. Forty-six patients are alive; 26 (57%) are 30 to 40 years and 6 (13%) are older. Actuarial analysis indicated that the probability of survival was 94% at 5 years and 77% at 22 years. Thirteen patients died, 7 suddenly. Among the latter, significant obstruction or regurgitation was present in the 4 who underwent catheterization 0.9 to 7.2 years before death, 2 of whom were symptomatic and 2 with progression of a strain pattern on electrocardiogram. Surgery was recommended but declined by the latter 2 patients. Reoperation was carried out in 21 patients (36%), 3 (12%) of whom died. Actuarial analysis revealed the probability of reoperation to increase from 2% at 5 years to 44% at 22 years. Bacterial endocarditis occurred on 4 occasions in 3 patients, 1 of whom died suddenly during treatment. The incidence of endocarditis was 3.8 episodes/1,000 patient-years. Actuarial analysis of serious events, defined as death, reoperation and endocarditis, with the most serious of these and each patient being represented only once, indicated the probability of being free of such an episode to be 92% at 5 years, decreasing to 39% at 22 years. These data emphasize the palliative nature of valvotomy and the meticulous follow-up so necessary in these patients.

Actuarial Analysis↗

PubMed2005

Impact of paracetamol pack size restrictions on poisoning from paracetamol in England and Wales: an observational study.

BACKGROUND: About 500 drug poisoning deaths involving paracetamol (acetaminophen) occur every year in England and Wales. To reduce the number of deaths, regulations were introduced in 1998 to restrict the sale of paracetamol. In this paper, we evaluate the impact of these regulations. METHODS: Mortality data for England and Wales were provided by the Office for National Statistics. Deaths were defined as due to compound paracetamol (paracetamol in combination with another analgesic, a low dose opioid or other ingredients) or paracetamol only, with or without alcohol or other drugs. The Department of Health provided data on all hospital admissions with a primary diagnosis of paracetamol poisoning. RESULTS: Mortality rates for paracetamol only were similar for males and females, and decreased from about 4.5 to 2.8 per million between 1997 and 1999 and again from about 3.1 to 2.2 per million between 2001 and 2002. These falls may be attributable to random variation in the rates. Deaths involving compound paracetamol, which were not subject to the 1998 regulations, remained relatively constant over the study period. There was evidence of a decreasing trend in paracetamol only mortality rates and this followed overall trends for other drug poisoning excluding opioids and drugs of misuse. Hospital admissions due to paracetamol poisoning increased from about 27 000 to 33 000 between 1995/1996 and 1997/1998 and then decreased to 25 000 in 2001/2002. There were almost 50 per cent more admissions for females than males, with the highest admission rates amongst females aged 15-24 years old. CONCLUSIONS: Between 1993 and 2002, mortality rates and hospital admissions due to paracetamol poisoning declined. However, the contribution of the 1998 regulations to this decline is not clear. Paracetamol poisoning continues to be an important public health issue in England and Wales and represents significant workload for the NHS in England.

Acetaminophen↗

PubMed2001

Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial.

CONTEXT: Patients experience the highest rate of death and recurrent ischemic events during the early period after an acute coronary syndrome, but it is not known whether early initiation of treatment with a statin can reduce the occurrence of these early events. OBJECTIVE: To determine whether treatment with atorvastatin, 80 mg/d, initiated 24 to 96 hours after an acute coronary syndrome, reduces death and nonfatal ischemic events. DESIGN AND SETTING: A randomized, double-blind trial conducted from May 1997 to September 1999, with follow-up through 16 weeks at 122 clinical centers in Europe, North America, South Africa, and Australasia. PATIENTS: A total of 3086 adults aged 18 years or older with unstable angina or non-Q-wave acute myocardial infarction. INTERVENTIONS: Patients were stratified by center and randomly assigned to receive treatment with atorvastatin (80 mg/d) or matching placebo between 24 and 96 hours after hospital admission. MAIN OUTCOME MEASURES: Primary end point event defined as death, nonfatal acute myocardial infarction, cardiac arrest with resuscitation, or recurrent symptomatic myocardial ischemia with objective evidence and requiring emergency rehospitalization. RESULTS: A primary end point event occurred in 228 patients (14.8%) in the atorvastatin group and 269 patients (17.4%) in the placebo group (relative risk [RR], 0.84; 95% confidence interval [CI], 0.70-1.00; P =.048). There were no significant differences in risk of death, nonfatal myocardial infarction, or cardiac arrest between the atorvastatin group and the placebo group, although the atorvastatin group had a lower risk of symptomatic ischemia with objective evidence and requiring emergency rehospitalization (6.2% vs 8.4%; RR, 0.74; 95% CI, 0.57-0.95; P =.02). Likewise, there were no significant differences between the atorvastatin group and the placebo group in the incidence of secondary outcomes of coronary revascularization procedures, worsening heart failure, or worsening angina, although there were fewer strokes in the atorvastatin group than in the placebo group (12 vs 24 events; P =.045). In the atorvastatin group, mean low-density lipoprotein cholesterol level declined from 124 mg/dL (3.2 mmol/L) to 72 mg/dL (1.9 mmol/L). Abnormal liver transaminases (>3 times upper limit of normal) were more common in the atorvastatin group than in the placebo group (2.5% vs 0.6%; P<.001). CONCLUSION: For patients with acute coronary syndrome, lipid-lowering therapy with atorvastatin, 80 mg/d, reduces recurrent ischemic events in the first 16 weeks, mostly recurrent symptomatic ischemia requiring rehospitalization.

Aged↗

PubMed2006

Risk factors for heat related death during the August 2003 heat wave in Paris, France, in patients evaluated at the emergency department of the Hôpital Européen Georges Pompidou.

OBJECTIVES: This study sought to determine the risk factors for short term mortality in the victims of the heat wave of August 2003 in France from among patients evaluated in our emergency department (ED). It was hypothesised that age, temperature, and some long term therapies and pre-existing pathologies were factors associated with short term mortality. METHODS: A retrospective analysis of a seven day period. Four experts decided blindly, in pairs, whether a patient had presented with a heat related problem. Inclusion criteria were: core temperature > or =38 degrees C and/or clinical signs of dehydration. Comparisons were made between the survivors and one month non-survivors for 57 different items. Short term mortality was defined as death in the ED or within the first month of the ED visit. RESULTS: Of 841 patients attending the ED in the study period, 165 were included in the study, of which most were elderly women. Thirty one (18.8%) died within one month. Factors associated with short term mortality were: a greater degree of dependent living; more severe clinical condition on admission (higher temperature and heart rate, lower blood pressure, hypoxia, and altered mental status); higher values of blood glucose, troponin, and white blood cell count; lower values of serum protein and prothrombin levels; pre-existing ischaemic cardiomyopathy; pneumonia as associated infection; and previous psychotropic treatment. The total number of survivors at one year was 91. CONCLUSIONS: Although this study is limited because of the small sample size, the results have helped determine factors useful for future identification of patients at greatest risk of death in order to implement a more efficient patient care protocol.

Age Factors↗

PubMed1977

Thermal resistance of Bacillus subtilis var. niger in a closed system.

The heat resistance of Bacillus subtilis var. niger has been measured from 85 to 125 degrees C using moisture levels of percent relative humidity (%RH) less than or equal to 0.001 to 100 in a closed system. Five curves have been presented to characterize the thermal destruction, using thermal death times defined as F values at a given combination of three moisture and temperature conditions. Reductions of 99.99% (4-log10 cycles) of the initial population were estimated for the three moisture conditions. At 110 degrees C, the expected time for a 4-log10 reduction was 1.1 h at %RH = 100, 3.1 h at %RH less than or equal to 0.1 and 54 h at %RH = 10.7. Goodness-of-fit tests to examine the adequacy of three polynomial models failed to indicate a trend. The linear model (from which estimates of D are obtained) was satisfactory for estimating the thermal death times (%RH less than or equal to 0.1) in the plate count range. The estimates based on observed thermal death times and D values for the %RH = 100 diverged so that D values generally gave a more conservative estimate over the temperature range 90 to 125 degrees C. Estimates of ZF and ZL ranged from 32.1 to 58.3 degrees C for the %RH less than or equal to 0.1 and 100. A ZD value of 30.0 was obtained for data observed at %RH less than or equal to 0.1. The ZF results were obtained from plotting observed log times to achieve a 99.99% reduction in the initial population versus temperature. Estimates of ZL and ZD were obtained by using linear estimates of L100 approximately equal to 4D and D values in a similar plot.

Bacillus subtilis↗

PubMed2004

Superiority of the heart failure survival score to peak exercise oxygen consumption in the prediction of outcomes in an independent population referred for heart transplant evaluation.

BACKGROUND: The heart failure survival score (HFSS), a multivariable predictive index that has been shown to predict death or inotrope-dependent transplant in ambulatory patients referred for transplant evaluation has not been independently validated. We sought to independently assess the prognostic ability of the HFSS in a group of patients undergoing transplant evaluation in Italy, and to compare its prognostic value to that of peak exercise oxygen consumption (VO2), the standard tool for risk stratification in most transplant centers. METHODS: Data for the seven variables that constitute the HFSS, including peak VO2, were collected for 107 ambulatory patients referred to the heart transplant center of the University of Turin. Patients were followed prospectively for 997 +/- 32 days, with outcome events defined as death prior to transplant or inotrope-dependent transplant. RESULTS: The discriminative abilities of peak VO2 and the HFSS and their respective risk strata were compared. At univariate Cox regression models, peak VO2 did not successfully predict outcomes, neither when evaluated continuously (p = 0.25) nor when dichotomized at 14 ml/kg/min (p = 0.18). Both the HFSS (p = 0.011) and the HFSS strata (p = 0.008) successfully predicted outcome events. CONCLUSIONS: The HFSS was more accurate than peak VO2 for the prediction of event-free survival, both when evaluated continuously and as risk strata. The HFSS is a valid and widely applicable tool for the identification of patients who, in the absence of contraindications, would benefit from transplantation.

Adult↗

PubMed1987

Pitfalls in diagnosing brain death in infancy.

A 3-year-old child with phenotypic trisomy 18 syndrome survived 26 days after a cardiopulmonary arrest, secondary to an acute viral illness. The child was deeply comatose. No barbiturates, other sedatives, or aminoglycoside antibiotics had been recently administered. The child was normothermic with adequate cardiovascular function. Brain stem function was absent, as assessed by testing of brain stem reflexes. Serial cerebral radionuclide angiograms (CRAG) documented intact cerebral blood flow while electrocerebral silence (ECS) was present on two consecutive EEG recordings within 24 hours. Preservation of intracranial circulation was confirmed by rapid rotational computed tomographic (CT) scans. Cranial CT scans also revealed communicating hydrocephalus, and bilateral basal ganglia hemorrhages. This unusual case illustrates discordance between apparent irreversible loss of cortical function as indicated by electrocerebral silence with preserved cerebral blood flow. The implications of these apparent paradoxical events will be discussed in the context of defining brain death in children.

Brain Death↗

PubMed2003

Use of rapamycin slows progression of cardiac transplantation vasculopathy.

BACKGROUND: Cardiac transplantation vasculopathy is the leading cause of late death in heart transplantation recipients. Rapamycin is an immunosuppressant drug with potent antiproliferative and antimigratory effects. We investigated whether rapamycin could prevent progression of graft vasculopathy in 46 patients (age, 54+/-10 years; 4.3+/-2.3 years after transplantation) with severe disease. METHODS AND RESULTS: At annual cardiac catheterization, patients were randomly assigned to treatment with rapamycin (n=22) versus continued current immunosuppression (n=24). Clinical characteristics including recipient age and sex, underlying cause of congestive heart failure, donor age and sex, and ischemic time were recorded. Cardiac catheterization was graded with the use of a semiquantitative scale and repeated annually. Clinically significant adverse events were defined as death, need for angioplasty or bypass surgery, myocardial infarction, and a >25% worsening of the catheterization score. These events were monitored as primary study end points. Anti-HLA class I and II antibody production and lymphocyte growth assays were measured with each biopsy. Patients selected for rapamycin had azathioprine or mycophenolate mofetil discontinued and were given rapamycin. Outcomes were compared by means of log-rank analysis. There were no significant differences in baseline characteristics. Duration of follow-up was comparable (rapamycin, 689+/-261; control, 630+/-207 days; NS). In the rapamycin group, 3 patients reached primary end points versus 14 patients in the control group (P<0.001). There was no difference in baseline or subsequent anti-HLA class I or II antibody production. CONCLUSIONS: In this patient cohort with cardiac vasculopathy, treatment with rapamycin slowed disease progression probably by its antiproliferative and antimigratory effects.

Arterial Occlusive Diseases↗

PubMed1998

Cerebrospinal fluid pleocytosis and prognosis in invasive meningococcal disease in children.

BACKGROUND: The absence of cerebrospinal fluid (CSF) pleocytosis in invasive meningococcal disease (IMD) has been associated with an increased risk of death. It is unknown whether patients who lack a cellular response to central nervous system (CNS) infection are at the same risk of adverse outcome as patients who lack CNS infection. OBJECTIVES: To determine the frequency of presentation and outcome of three groups of children with IMD: Group 1, children with CSF pleocytosis; Group 2, children without CSF pleocytosis and with negative CSF cultures (bacteremia alone); and Group 3, children without CSF pleocytosis but with positive CSF cultures (CNS infection without CSF pleocytosis). METHODS: We reviewed the medical records of children with IMD at four pediatric referral hospitals between 1985 and 1996. Clinical and laboratory indices and severe adverse outcomes (defined as death or limb loss) were compared in the three groups. Multivariable logistic regression analysis was performed to determine whether CNS infection without CSF pleocytosis was independently associated with adverse outcome in IMD. RESULTS: Three hundred seventy-seven children with IMD were identified. Eighty-six patients were excluded because their CSF analysis either was not done or was unevaluable; of these patients 22 (25.6%) had an adverse outcome. Of the 291 evaluable patients 204 (70.1%) had CSF pleocytosis, 52 (17.9%) had bacteremia alone and 35 (12.0%) had CNS infection without CSF pleocytosis. Patients with CNS infection without CSF pleocytosis had significantly lower white blood cell and platelet counts and more coagulopathy than patients with bacteremia alone (P < or = 0.05) or patients with CSF pleocytosis (P < or = 0.01). The frequency of adverse outcome was 40% for patients with CNS infection without CSF pleocytosis compared with 9.6% for patients with bacteremia alone (P = 0.001) and 3.4% for patients with CSF pleocytosis (P < 0.001). CNS infection without CSF pleocytosis was independently associated with adverse outcome by multivariable logistic regression analysis (P = 0.003). CONCLUSIONS: Approximately 30% of all children with IMD present without CSF pleocytosis. Of these patients those with CNS infection without pleocytosis are at higher risk of adverse outcome than either patients with CSF pleocytosis or patients with bacteremia alone.

Bacteremia↗

PubMed2001

Simultaneous modelling of operative mortality and long-term survival after coronary artery bypass surgery.

Typical analyses of lifetime data treat the time to death or failure as the response variable and use a variety of modelling strategies such as proportional hazards or fully parametric, to investigate the relationship between the response and covariates. In certain circumstances it may be more natural to view the distribution of the response variable as consisting of two or more parts since the survival curve appears segmented. This article addresses such a scenario and we propose a model for simultaneously investigating the effects of covariates over the two segments. The model is an analogue of that proposed by Lambert for zero-inflated Poisson regression. The application is central to the model development and is concerned with survival after coronary artery bypass surgery. Here operative mortality, defined as death within 30 days after surgery, and long-term mortality, are viewed as distinct outcomes. For the application considered, the survivor function displays much steeper descent during the first 30 days after surgery, that is, for operative mortality, than after this period. An investigation of the effects of covariates on operative and long-term mortality after coronary artery bypass surgery illustrates the usefulness of the proposed model.

Age Factors↗

PubMed2004

Critical limb ischaemia as a main cause of death in patients with end-stage renal disease: a single-centre study.

BACKGROUND: Patients with end-stage renal disease (ESRD) have a high overall mortality rate, particularly due to cardiovascular morbidity. In an era of decline in cardiovascular diseases and early cardiovascular intervention, non-cardiac diseases seem to have a larger impact on overall mortality. METHODS: From 1997 to 2003, all incident haemodialysis patients in a single centre were enrolled in this prospective study. Those with clinical signs of vascular disease were examined by coronary or peripheral angiographies. Physicians took the patients' medical histories, examined them and followed them up until the end of the study or death. Causes of death were defined by the physicians. RESULTS: In all, 322 patients were enrolled in the study, 38% of whom were diabetic. At the start of dialysis treatment, 38% had coronary artery disease (CAD), defined as >50% stenosis of at least one coronary artery or as definite myocardial infarction, and 14% had critical ischaemia of at least one limb (CLI). In all patients with foot lesions, CLI was defined angiographically, as evidenced by stenosis or rarefication of distal vessels in the legs. Patients who died (n = 121) [due to cardiac causes (n = 25), complications of CLI (n = 22), stroke (n = 10), cachexia following a long-standing, non-malignant disease (n = 6), malignancy (n = 24), infection not related to CLI (n = 18) and other causes (n = 16)] were older (71+/-10 vs 65+/-13 years), more often male [74/121 (61%)] and often diabetic [56/121 (46%)]. CAD was documented in 82/121 (68%). Five-year survivals in patients with no risk and diabetes without CAD or CLI, CAD and CLI were 74%, 73%, 50% and 10%, respectively. Age, CLI and smoking habits independently increased the risk of death (hazard ratios: 1.052, 4.921 and 2.292, respectively). CONCLUSIONS: These results indicate that CLI with associated complications is not only an indicator of high mortality in patients with ESRD, but is also one of the main causes of death.

Adult↗

PubMed1989

Clinical and ultrasound results after aortic valve replacement: intermediate-term follow-up with the St. Jude Medical prosthesis.

Mortality, morbidity, quality of life, and left ventricular (LV) function were evaluated in 49 patients after aortic valve replacement with the St. Jude prosthesis. Total follow-up was 2577 patient-months; survivors were followed-up for 4 to 7 years by clinical examination and echocardiography. The actuarial survival rate at 6 years was 79.6%, and there were no valve-related deaths. The linearized rates for thromboembolism and hemorrhage were 0.93% and 3.26% per patient-year, respectively. In 34% of the survivors the quality of life was poor. In the first three postoperative months, patients with aortic stenosis (n = 12) had a significant decrease in the muscle cross-sectional area (p less than 0.01) and patients with aortic regurgitation (n = 11) had decreases in both LV end-diastolic diameter (p less than 0.05) and cross-sectional area (p less than 0.001). All of these results were maintained at 5 years without modification of LV systolic function. Despite the good overall results, six patients deteriorated and had major LV dilatation. Multivariate logistic regression analysis identified two independent preoperative variables associated with a poor outcome defined as death of LV dysfunction (p less than 0.05): age and end-diastolic diameter. Thus meticulous follow-up showed a high incidence of hemorrhage and a poor quality of life in many of the survivors. It was concluded that in high-risk patients (age and end-diastolic diameter) surgery should probably be considered earlier.

Aortic Valve↗

PubMed2004

RN education: a matter of degrees.

Until recently, no research had been done to explore the effect of nurse education on patient care. In a study published in JAMA in September 2003, nursing researcher Linda H. Aiken, RN, PhD, led a study to determine the association between the educational levels of hospital RNs and the mortality of surgical patients. The study examined 168 adult acute care hospitals in Pennsylvania reporting a total of 232,342 surgical discharges to the Pennsylvania Health Care Cost Containment Council in 1999. The researchers also surveyed a random sample of 50% of hospital nurses who live in Pennsylvania and were registered with the Pennsylvania Board of Nursing. In all, 10,184 nurses (52% of nurses surveyed) responded. According to the survey results, the average age of respondents was between 40 and 41 years, and between 30% and 31% of respondents had earned a BSN or a higher degree. Hospital nurses who participated in the study had 14.2 years' nursing experience with a mean patient load of 5.7 per day. The researchers examined how the education of hospital nurses affected the death rates of surgical patients within 30 days of admission and death rates within 30 days of admission among patients who experienced complications. The study also took into consideration whether a board-certified surgeon performed the surgery. The types of surgeries examined included general surgery, orthopedic, and vascular procedures. The study found that years of nursing experience don't predict a patient's outcome and that patients cared for in hospitals with a higher proportion of nurses holding a BSN degree or higher have a better chance of postsurgical survival. Specifically, the study stated that "a 10% increase in the proportion of nurses holding a bachelor's degree [in hospitals] was associated with a 5% decrease in both the likelihood of patients dying within 30 days of admission and the odds of failure to rescue." Failure to rescue was defined as "deaths in patients with serious complications." The researchers recognized two limitations to their study: the low (52%) response rate of the nurses surveyed, the examination of hospitals from only one state. The researchers concluded that although these preliminary findings raise concern over nurse education as it relates to patient outcomes, further study of nurses and hospitals nationwide would be required to make these results irrefutable.

Attitude of Health Personnel↗