Mortality in-hospital

Acute renal failure secondary to ischemia-reperfusion or nephro-toxins represents a major cause of morbidity and mortality in hospitalized patients, particularly in the intensive care unit setting. The proximal tubule region of the nephron suffers the most damage in acute renal injury and is therefore the target site of therapeutic interventions. While several experimental therapies have been attempted to prevent or hasten recovery from acute renal injury,... 

Obialo Cl, Crowell AK, Okonofua EC. Acute renal failure mortality in hospitalized African Americans age and gender considerations. J Natl Med Assoc 2002 94(3) 127-134. 

With evidence that monitoring BNP can be helpful in stratifying disease severity, whether treatments that lower BNP result in decreased morbidity and mortality has to be considered, and multicenter studies are imderway to address this question. The initial data from smaller trials and pilot studies look promising. A pilot study examined BNP in patients admitted with decompensated CHF and treated with the current standard of care. BNP was monitored regularly during hospitalization (hut bhnded to physicians) and correlated with the following endpoints mortality in hospital. 

Pappas, PG, Rex JH, Lee J, et al. A prospective observational smdy of candidemia Epidemiology, therapy, and influences on mortality in hospitalized adult and pediatric patients. Clin Infect Dis 2003 37 634-643. 

It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle, because the actual mortality in hospitals, especially in those of large crowded cities, is very much higher than any calculation founded on the mortality ofthe same class of diseases amongst patients treated out of hospital would lead us to expect. 

There are several other examples in which berberine is combined with other substances to potentiate its antibacterial activity. Flavones, chrysosplenol-D, and chrysoplenetm from Artemisia annua L. (Asteraceae), which possess very weak antibacterial action by themselves, produce potent combinations with berberine resulting in very effective inhibition of Staphylococcus aureus growth. The combination of amphotericin B and berberine can reduce by approximately 75 % the amphotericin B dose in the treatment of candidiasis in mice, implying that berberine indeed has synergy with amphotericin B against C. albicans [104]. Another example is methicillin-resistant Staphylococcus aureus (MRSA) bacteria, which are responsible for substantial morbidity and mortality in hospitals. According to Yu et al., berberine is able to restore the effectiveness of / -lactam antibiotics... 

Pasquel FJ, Spiegelman R, McCauley M, Smiley D, Umpierrez D, Johnson R, Rhee M, Gatcliffe C, Lin E, Umpierrez E, Peng L, Umpierrez GE. Hyperglycemia during total parenteral nutrition an important marker of poor outcome and mortality in hospitalized patients. Diabetes Care 2010 33(4) 739 1. 

Main ML, Ryan AC, Davis TE, Albano MP, Kusnetzky LL, Hibberd M. Acute mortality in hospitalized patients undergoing echocardiography with and without an ultrasound contrast agent (multicenter registry results in 4,300,966 consecutive patients). Am J Cardiol 2008 102 1742-6. 

Ahmed A et al (2006) Digoxin and reductionin mortality and hospitalization in heart failure a comprehensive post hoc analysis of the DIG trial. Eur Heart J 27 178-186... 

Heuschmann PU, Berger K, Misselwitz B, Hermanek P, Leffmann C, Adelmann M, Buecker-Nott HI, Rother J, Neundoerfer B, Kolominsky-Rabas PL. Frequency of thrombolytic therapy in patients with acute ischemic stroke and the risk of in-hospital mortality The German Stroke Registers Study Group. Stroke. 2003 34 1106-1113. 

Bateman BT, Schumacher HC, Boden-Albala B, Berman ME, Mohr JP, Sacco RL, Pile-Spellman J. Eactors associated with in-hospital mortality after administration of thrombolysis in acute ischemic stroke patients An analysis of the nationwide inpatient sample 1999 to 2002. Stroke. 2006 37 440-446. 

In rodent stroke models, statin pretreatment has been shown to reduce infarct volumes and improve outcomes. Similarly, several clinical studies have shown that prior statin use reduced the severity of acute ischemic stroke and myocardial infarction. Recent studies indicate that beneftt can be achieved even when treatment is initiated after the onset of symptoms. In rodents, atorvastatin and simvastatin have been shown to reduce the growth of ischemic lesions, enhance functional outcome, and induce brain plasticity when administered after stroke onset. A retrospective analysis of the population-based Northern Manhattan Stroke Study (NOMASS) showed that patients using lipid-lowering agents at the time of ischemic stroke have a lower incidence of in-hospital stroke progression and reduced 90-day mortality rates. Retrospective analysis of data of the phase III citicoline trial showed... 

There is growing evidence of a link between renal disease and HF.8 Renal insufficiency is present in one-third of HF patients and is associated with a worse prognosis. In hospitalized HF patients, the presence of renal insufficiency is associated with longer lengths of stay, increased in-hospital morbidity and mortality, and detrimental neurohormonal alterations. Conversely, renal dysfunction is a common complication of HF or results from its treatment. Renal failure is also a common cause for HF decompensation. 

In patients with ST-segment elevation (STE) ACS, in-hospital death rates are approximately 7% for patients who are treated with fibrinolytics and 16% for patients who do not receive reperfusion therapy. In patients with non-ST-segment elevation (NSTE) MI, in-hospital mortality is less than 5%. In-hospital and 1-year mortality rates are higher for women and elderly patients. In the first year following MI, 38% of women and 25% of men will die, most from recurrent infarction.1 At 1 year, rates of mortality and reinfarction are similar between STE and NSTE MI. 

Initiation of prophylactic antibiotics is recommended during acute variceal bleeding this is typically done with an oral fluoroquinolone (e.g., ciprofloxacin 500 mg twice daily x 7 days) or an IV third-generation cephalosporin. Prophylactic antibiotic therapy reduces in-hospital infections and mortality in patients hospitalized for variceal bleeding.44... 

Maintaining adequate nutritional status, especially during periods of illness and metabolic stress, is an important part of patient care. Malnutrition in hospitalized patients is associated with significant complications, including increased infection risk, poor wound healing, prolonged hospital stay, and increased mortality, especially in surgical and critically ill patients.1 Specialized nutrition support refers to the administration of nutrients via the oral, enteral, or parenteral route for therapeutic purposes.1 Parenteral nutrition (PN), also... 

There is overwhelming clinical trial evidence that certain /J-blockers slow disease progression, decrease hospitalizations, and reduce mortality in patients with HF. 

Octreotide, 0.1 mg subcutaneously every 8 hours, may decrease sepsis, length of hospital stay, and perhaps mortality in patients with severe AP, but there are insufficient data to support its routine use in treating AP. 

Horne R and Weinman J (1999) Patients beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res 47(6) 555-567 Kannisto V, Lauritsen J, Thatcher AR et al. (1994) Reductions in mortality at advanced age several decades of evidence from 27 countries. Population and development review 20(4) 793-810 Lazarou J, Pomeranz BH, Corey PN (1998) Incidence of adverse drug reactions in hospitalized patients a meta- analysis of prospective studies. JAMA 279(15) 1200-1205 LeSage J (1991) Polypharmacy in geriatric patients. Nurs Clin North Am 26(2) 273-290 Pitkala KH, Strandberg TE, Tilvis RS (2001) Is it possible to reduce polypharmacy in the elderly ... 

Several of the individual problems and risks increasing and cumulating the risk for morbidity and mortality in the elderly are presented in this book. Each of them is presented in more detail elsewhere. Special attention should be given to patients with severe diseases, polypharmacy, high-alert medications, several prescribers, several acute hospital admissions, and low compliance. It is important to understand that the problems and risks are interconnected. One problem lead to another in a cascade, where the net benefit to harm relation, might be negative. 

Classen D.C., Pestotnik, S.L., Evans, R.S., Lloyd, J.F., Burke, J.P. (1997) Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. The Journal of the American Medical Association, 277 (4), 301-306. 

PTCA offered a different strategy to obtain vessel patency. Success rates were greater than 90% with low rates of bleeding and mortality [41, 42]. This was seen with both low in-hospital and 6 month mortality and reinfarction rate compared to thrombolysis (5.1% versus 12% p = 0.02 and 8.5% versus 16.8% p = 0.02, respectively) [43]. While there was no immediate benefit on ejection fraction, a similar study comparing PTCA with streptokinase showed a significant improvement in LVEF at the time of discharge with early PTCA (51 11 versus 45 12 = 0.004) [44]. 

Obstacles remained as PTCA was not universally available and often associated with considerable time delay, especially in off peak hours. In the National Registry of Myocardial Infarction-2 (NRMI-2 >27,000 patients), total ischemia time (symptom onset to balloon inflation) was 3.9 h with onset to hospital arrival 1.6 h [45]. Unadjusted in-hospital mortality was higher in patients treated later. Door to balloon time > 2 h was related to in-hospital death (41-62% adjusted odds increase) and centers who treat >3 STEMIs/month had improved in-hospital mortality compared to less experienced facilities (Figs. 5.4 and 5.5). Lastly, similar to trials of unstable angina, PTCA was plagued by high restenosis rates... 

Fig. 5.4 NRMI database of door to balloon time as indicator of in-hospital mortality...

Fig. 5.5 In-hospital mortality compared with hospital volume in the NRMI database. Cannon JAMA, Volume 283(22). June 14, 2000. 2941-2947...

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