The perioperative and long-term risks for living kidney donors are of concern. We have studied donors at the University of Minnesota 20 years or more (mean 23.7) after donation by comparing renal function, blood pressure, and proteinuria in donors with siblings. In 57 donors (mean age 61 [SE 1]), mean serum creatinine is 1.1 (0.01) mg/dl, blood urea nitrogen 17 (0.5) mg/dl, creatinine clearance 82 (2) ml/min, and blood pressure 134 (2)/80 (1) mm Hg. 32% of the donors are taking antihypertensive drugs and 23% have proteinuria. The 65 siblings (mean age 58 [1.3]) do not significantly differ from the donors in any of these variables: 1.1 (0.03) mg/dl, 17 (1.2) mg/dl, 89 (3.3) ml/min, and 130 (3)/80 (1.5) mm Hg, respectively. 44% of the siblings are taking antihypertensives and 22% have proteinuria. To assess perioperative mortality, we surveyed all members of the American Society of Transplant Surgeons about donor mortality at their institutions. We documented 17 perioperative deaths in the USA and Canada after living donation, and estimate mortality to be 0.03%. We conclude that perioperative mortality in the USA and Canada after living-donor nephrectomy is low. In long-term follow-up of our living donors, we found no evidence of progressive renal deterioration or other serious disorders.
Comment In: Lancet. 1992 Nov 28;340(8831):1354-51360068
Restrictions on non-urgent hospital care imposed to control the 2003 Toronto severe acute respiratory syndrome outbreak led to substantial disruptions in hospital clinical practice, admission, and transfer patterns.
We assessed whether there were unintended health consequences to seriously ill hospitalized patients. STUDY DESIGN, SETTING, AND POPULATION: Population-based longitudinal cohort study of patients residing in Toronto or an urban control region with an incident admission for 1 of 7 serious conditions in the 3 years before, or the 4 months during or after restrictions.
Short-term mortality, overall readmissions, cardiac readmissions for acute myocardial infarction patients, serious complications for very low birth weight babies, and quality of care measures, comparing adjusted rates across time periods within regions.
Mortality, readmission, and complication rates did not change for any condition during or after severe acute respiratory syndrome restrictions. Although rates of invasive cardiac procedures for acute myocardial infarction patients decreased 11-37% in Toronto, rates of nonfatal cardiac outcomes did not change.
Restrictions on non-urgent hospital utilization and hospital transfers may be a safe public health strategy to employ to control nosocomial outbreaks or provide hospital surge capacity for up to several months, in large, well-developed healthcare systems with good availability of community-based care.
The level of staffing in hospitals is often lower on weekends than on weekdays, despite a presumably consistent day-to-day burden of disease. It is uncertain whether in-hospital mortality rates among patients with serious conditions differ according to whether they are admitted on a weekend or on a weekday.
We analyzed all acute care admissions from emergency departments in Ontario, Canada, between 1988 and 1997 (a total of 3,789,917 admissions). We compared in-hospital mortality among patients admitted on a weekend with that among patients admitted on a weekday for three prespecified diseases: ruptured abdominal aortic aneurysm (5454 admissions), acute epiglottitis (1139), and pulmonary embolism (11,686) and for three control diseases: myocardial infarction (160,220), intracerebral hemorrhage (10,987), and acute hip fracture (59,670), as well as for the 100 conditions that were the most common causes of death (accounting for 1,820,885 admissions).
Weekend admissions were associated with significantly higher in-hospital mortality rates than were weekday admissions among patients with ruptured abdominal aortic aneurysms (42 percent vs. 36 percent, P
Comment In: N Engl J Med. 2002 May 9;346(19):1500-1; author reply 1500-112001964
Comment In: N Engl J Med. 2001 Aug 30;345(9):692-411547726
Comment In: N Engl J Med. 2002 May 9;346(19):1500-1; author reply 1500-112001963
Comment In: N Engl J Med. 2002 May 9;346(19):1500-1; author reply 1500-112000826
The aims of the study were: (i) to identify trends in the underlying cause-of-death statistics that are due to changes in the coders' selection and coding of causes, and (ii) to identify changes in the coders' documented registration principles that can explain the observed trends in the statistics. 31 Basic Tabulation List categories from the Swedish national cause-of-death register for 1970-1988 were studied. The coders' tendency to register a condition as the underlying cause of death (the underlying cause ratio) was estimated by dividing the occurrence of the condition as underlying cause (the underlying cause rate) with the total registration of the condition (the multiple cause rate). When the development of the underlying cause rate series followed more closely the underlying cause ratio series than the multiple cause rate series, and a corresponding change in the registration rules could be found, the underlying cause rate trend was concluded to be due to changes in the coders' tendency to register the condition. For thirteen categories (fourteen trends), the trends could be explained by changes in the coders' interpretation practice: five upward, four insignificant, and five downward trends. In addition, for three categories the trends could be explained by new explicit ICD-9 rules.
Two hundred and ten patients with verified pulmonary emboli (LE) at autopsy were assessed retrospectively. These patients comprised 13% of all those submitted to autopsy. LE was the primary cause of death, a contributory cause of death or an incidental finding in 35%, 31% and 34%, respectively, of the cases. Two thirds of the lethal cases were not recognized prior to autopsy. LE was preceded by medical conditions and operation with subsequent immobilization in 55% and 22% of the cases, respectively. Out of these, it is estimated that 17% of the medical patients and 56% of the surgical patients would have had a good prognosis if LE had not occurred. If foreign results can be applied to Danish conditions, approximately 1,400 fatal cases of LE should occur in Denmark per annum. This review confirms that the actual Danish figures are of this magnitude, at least, as approximately 1,500 lethal cases must be assumed to occur per annum solely among patients dying in hospital. In 1986, a total of 278 cases of LE were stated as the primary cause of death on the death certificates. Despite the limitations of a retrospective investigation, it is concluded that the vital statistics of the Danish Board of Health underestimate the genuine number of cases. The range of indications for prophylaxis of thrombosis is possibly too narrow. LE should be considered in the differential diagnosis more frequently, particularly in elderly immobilized patients.
OBJECTIVE: Although deep vein thrombosis (DVT) and pulmonary embolism (PE) are manifestations of the same disease, far from all patients develop PE. Our objective was to investigate risk-modifying factors. SETTING, SUBJECTS AND DESIGN: Between 1970 and 1982, 23,796 autopsies, representing 84% of all in-hospital deaths in the Malmö City population, were performed, using a standardized procedure. In a case-control study nested in a population-based cohort of patients with proximal DVT, the relationship between PE and body mass index (BMI), thoracic and abdominal subcutaneous (SC) fat thickness was evaluated. RESULTS: Proximal DVT was found in 15%, of which 58% were women. Mean age in men was 4.5 years lower than in women (P
[Survey of clinical diagnoses and autopsy findings. Autopsy findings and sensitivity, specificity and predictive values for clinical diagnosis during the periods 1 July 1980-30 June 1081 and 1 July 1990-30 June 1993]
The sensitivity, specificity and clinical accuracy of clinical diagnoses were determined and compared for two periods of time: 1.7.1980-30.6.1981 and 1.7.1990-30.6.1993 based on the analysis of 286 and 138 autopsies respectively. The autopsy rate decreased from 82.7% in the first period to 11.2% in the second. The first period shows a generally higher sensitivity and accuracy for positive diagnosis. Both periods reveal the lowest sensitivity for pulmonary embolism and the lowest accuracy for positive clinical diagnosis of pneumonia/bronchopneumonia. For malignancies and arteriosclerotic heart diseases significant discrepancy between the periods was demonstrated using the chi 2-test. The results are influenced by low autopsy rates causing fewer true-positive diagnoses and a declining sensitivity. This type of study is a useful tool for demonstrating changes in the diagnostic procedure. The present investigation demonstrates a need for further analysis of malignancies to explain the simultaneous decrease in sensitivity, specificity and accuracy in spite of an increasing number of malignancies in autopsy findings.
Worldwide, cardiovascular diseases and cancer account for ~40% of deaths. Certain reports have shown a progressive decrease in mortality. Our main objective was to assess mortality trends related to myocardial infarction (MI), heart failure (HF) and pulmonary embolism (PE).
MI, HF and PE were studied as cause of death based on the analysis of death certificates in Canada (C), England and Wales (E), France (F) and Sweden (S). We also used a multiple cause approach. Age-standardized death rates (SDR) were calculated.
The SDR for MI, HF or PE as the underlying cause of death, all decreased during the last decade. The decrease in SDR secondary to MI exceeded that for HF or PE. Concerning multiple cause of death, a greater decrease was also found for MI, compared with HF or PE.
We confirm the beneficial trends in SDR with MI, HF or PE both as underlying or multiple causes in the studied countries. For HF and PE, multiple cause approach seems more accurate to describe the burden of these two pathologies. Our study also suggests that more efforts should be dedicated to HF and PE in order to achieve similar trends than in MI.
To investigate the effect of advances in the prevention and treatment of pulmonary embolism, we examined the rates of death from pulmonary embolism in Canada for 1965-87 and compared them with those for the United States for 1962-84. The direct method of age standardization was used on sex-specific and age-specific death rates, with the 1960 US population as the standard. In both countries the death rates increased then decreased, although the changes in the Canadian rates occurred later and were less pronounced than those in the US rates. Men and elderly people were at higher risk of death from pulmonary embolism than women and younger people. Prevention strategies, possibly including encouraging a more active lifestyle and targetting high-risk groups, may further reduce pulmonary embolism death rates in both countries.
Cites: Ann Surg. 1977 Aug;186(2):149-64329779
Cites: Ann Intern Med. 1977 Dec;87(6):775-81931212