DISEASES AND DEATHS—A Summary of Data from the Los Angeles County General Hospital, 1918 to 1948—Part I

Classification of the 2,557,035 diagnoses made in 1,168,139 different patients at the Los Angeles County General Hospital in the period 1918-48 has been compiled according to the new International List of Causes of Diseases and Death. Similar tabulation of the 377,776 diagnoses made in the 112,409 patients who died while in the hospital reflects the fatality rates associated with these diagnoses. Striking differences are shown in the incidence and fatality rates in the various conditions and great changes have occurred in both during this time. Defects and sources of error in these data are recognized, but they offer a wealth of valuable material for further study and interpretation.     

Diseases and deaths; a statistical survey of 40,130 autopsies at the Los Angeles County General Hospital, 1918 to 1948. II

The 215,468 diagnoses recorded in 40,130 autopsies on patients treated at the Los Angeles County General Hospital during the 30 years between 1918 and 1948 were reviewed and tabulated. The primary causes of death as determined by the pathologists in these cases were recorded and the incidence of death from each disease in relation to the number of cases in which each occurred was computed. The age, sex and race distribution of patients examined postmortem and the incidence and fatality rates from various pathological conditions changed greatly during the period, owing to many factors, among them changes in elements of the population served by the hospital, an increasing incidence of older patients, and medical triumph over some formerly formidable diseases.     

DISEASES AND DEATHS—A Statistical Survey of 40,130 Autopsies at the Los Angeles County General Hospital, 1918 to 1948—Part II

The 215,468 diagnoses recorded in 40,130 autopsies on patients treated at the Los Angeles County General Hospital during the 30 years between 1918 and 1948 were reviewed and tabulated. The primary causes of death as determined by the pathologists in these cases were recorded and the incidence of death from each disease in relation to the number of cases in which each occurred was computed. The age, sex and race distribution of patients examined postmortem and the incidence and fatality rates from various pathological conditions changed greatly during the period, owing to many factors, among them changes in elements of the population served by the hospital, an increasing incidence of older patients, and medical triumph over some formerly formidable diseases.     

Mortality Related to Acute Illness and Injury in Rural Uganda: Task Shifting to Improve Outcomes

Background

Due to the dual critical shortages of acute care and healthcare workers in resource-limited settings, many people suffer or die from conditions that could be easily treated if existing resources were used in a more timely and effective manner. In order to address this preventable morbidity and mortality, a novel emergency midlevel provider training program was developed in rural Uganda. This is the first study that assesses this unique application of a task-shifting model to acute care by evaluating the outcomes of 10,105 patients.

Methods

Nurses participated in a two-year training program to become midlevel providers called Emergency Care Practitioners at a rural district hospital. This is a retrospective analysis of the Emergency Department’s quality assurance database, including three-day follow-up data. Case fatality rates (CFRs) are reported as the percentage of cases with a specific diagnosis that died within three days of their Emergency Department visit.

Findings

Overall, three-day mortality was 2.0%. The most common diagnoses of patients who died were malaria (n=60), pneumonia (n=51), malnutrition (n=21), and trauma (n=18). Overall and under-five CFRs were as follows: malaria, 2.0% and 1.9%; pneumonia, 5.5% and 4.1%; and trauma, 1.2% and 1.6%. Malnutrition-related fatality (all cases <18 years old) was 6.5% overall and 6.8% for under-fives.

Interpretation

This study describes the outcomes of emergency patients treated by midlevel providers in a resource-limited setting. Our fatality rates are lower than previously published regional rates. These findings suggest this model of task-shifting can be successfully applied to acute care in order to address the shortage of emergency care services in similar settings as part of an integrated approach to health systems strengthening.     

Teesside coronary survey: an epidemiological study of acute attacks of myocardial infarction.

A 12-month epidemiological survey of attacks of acute myocardial infarction was carried out in a large urban population. The incidence and mortality at all ages and in both sexes were examined. Altogether, 1938 attacks were diagnosed--an overall incidence of 4-89 per 1000 population. The 28-day fatality rate was 50-5%. A third of the patients were treated at home and these patients had a lower fatality rate than those in hospital, a difference that could not be attributed to age, sex, or severity of attack. Half of the deaths that were witnessed occurred suddenly and a further 21% occurred within the next two hours. The median time to patients coming under care was about three hours. As used at present, coronary care units are unlikely to improve fatality rates. Future advances in treatment must take place outside hospital and will require re-education of the public and the general practitioner.     

Trial of early nifedipine in acute myocardial infarction: the Trent study.

Over 30 months 9292 consecutive patients admitted to nine coronary care units with suspected myocardial infarction were considered for admission to a randomised double blind study comparing the effect on mortality of nifedipine 10 mg four times a day with that of placebo. Among the 4801 patients excluded from the study the overall one month fatality rate was 18.2% and the one month fatality rate in those with definite myocardial infarction 26.8%. A total of 4491 patients fulfilled the entry criteria and were randomly allocated to nifedipine or placebo immediately after assessment in the coronary care unit. Roughly 64% of patients in both treatment groups sustained an acute myocardial infarction. The overall one month fatality rates were 6.3% in the placebo treated group and 6.7% in the nifedipine treated group. Most of the deaths occurred in patients with an in hospital diagnosis of myocardial infarction, and their one month fatality rates were 9.3% for the placebo group and 10.2% for the nifedipine group. These differences were not statistically significant. Subgroup analysis also did not suggest any particular group of patients with suspected acute myocardial infarction who might benefit from early nifedipine treatment in the dose studied.     

TUBERCULOSIS—Recent Trends in Infection,Disease and Deaths in California

Although fewer patients with tuberculosis are reported in a far advanced stage of the disease than ever before, the proportion of persons dying of tuberculosis whose disease had not previously been diagnosed appears to be increasing. The average length of sanatorium treatment, and the intramural case fatality rates have not shown much decrease. Tuberculosis mortality rates fall during economic depressions and rise with business booms. Epidemics of influenza do not always increase tuberculosis death rates. Common claims to the contrary are not sustained by recent California data.     

Tuberculosis; recent trends in infection,disease and deaths in California

Although fewer patients with tuberculosis are reported in a far advanced stage of the disease than ever before, the proportion of persons dying of tuberculosis whose disease had not previously been diagnosed appears to be increasing. The average length of sanatorium treatment, and the intramural case fatality rates have not shown much decrease. Tuberculosis mortality rates fall during economic depressions and rise with business booms. Epidemics of influenza do not always increase tuberculosis death rates. Common claims to the contrary are not sustained by recent California data.     

Benefits of using magnesium sulphate (MgSO4) for eclampsia management and maternal mortality reduction: lessons from Kano State in northern Nigeria

ABSTRACT: BACKGROUND: Despite clear emphasis through the Millennium Development Goals, the problem of high maternal mortality persists especially within low and middle income countries. Various studies report remarkably high maternal mortality rates in northern Nigeria, where maternal mortality rates exceed 1,000 deaths per 100,000 live births and eclampsia contributes approximately 40% of maternal deaths. Across Nigeria, diazepam is routinely used for the management of eclampsia. Prior to February 2008, diazepam was widely used for the management of eclampsia in Kano state (within northern Nigeria) with case fatality rate being over 20%. While magnesium sulphate (MgSO4) is recognized as the most effective drug for the management of eclampsia; this study aims to compare MgSO4 therapy with diazepam therapy in terms of case fatality rates and costs. FINDINGS: This retrospective study, including 1045 patients with eclampsia and pre-eclampsia during the years 2008 and 2009, reports a drop in case fatality rates from 20.9% (95% CI: 18.7, 23.2) to 2.3% (95% CI: 1.4, 3.2) among eclampsia patients following the MgSO4 intervention. The study observed no significant difference in the cost of using MgSO4 therapy compared to diazepam therapy. CONCLUSIONS: The study found a remarkable reduction in case fatality rate due to eclampsia in those who received MgSO4 therapy with minimal increase in costs when compared to diazepam therapy. Concerted efforts should be focused on properly introducing MgSO4 into emergency obstetric protocols especially within developing countries to reduce maternal mortality and also impact on health system performance.     

Ebola and Marburg viruses: pathogenesis and development of countermeasures

Ebola and Marburg viruses, family Filoviridae, are among the best known examples of emerging and re-emerging pathogens. Although outbreaks have been sporadic and geographically restricted to areas of Central Africa, the hemorrhagic fevers caused by these viruses are remarkably severe and are associated with high case fatality rates often exceeding 80 percent. In addition to humans, these viruses have decimated populations of wild apes in Central Africa. Currently, there are no vaccines or effective therapies available for human use. Progress in understanding the geneses of the pathophysiological changes that make filoviral infections of humans so destructive has been slow, primarily because these viruses require special containment for safe research. However, an increasing understanding of the molecular mechanisms of filoviral pathogenesis, facilitated by the development of new tools to elucidate critical regulatory elements in the viral life cycle, is providing new targets that can be exploited for therapeutic interventions. In addition, substantial progress has been made in developing recombinant vaccines against these viruses.     

Measures of early postoperative mortality: beyond hospital fatality rates.

OBJECTIVE--To quantify the short term risk of postoperative mortality in ways which take account of deaths after discharge and the background risks of death in patients who come to operation. DESIGN--Analysis of linked abstracts of hospital admission records and death certificates for common operations. SETTING--Six health districts in the Oxford region. SUBJECTS--Records of 223,529 operations performed in 1980-6. MAIN OUTCOME MEASURES--In hospital fatality rates, case fatality rates, and standardised mortality ratios at selected time periods during the year after operation and the ratio of early (< 30 days) to late (90-364 days after operation) fatality rates. RESULTS--Fatality rates throughout the year after operations performed after emergency admissions were generally higher than those for similar operations performed after elective admissions and higher than expected from population rates. Examples were prostatectomy, hip arthroplasty, inguinal herniorrhaphy, and cholecystectomy. Common elective operations such as inguinal herniorrhaphy and cataract operations showed no early peak in mortality, but others did. These included transurethral prostatectomy (ratio of early to late mortality 2.0; 95% confidence interval 1.3 to 2.6), hysterectomy (3.2; 1.5 to 6.6), hip arthroplasty (3.8; 2.5 to 5.4), and cholecystectomy (6.9; 4.3 to 11.1). CONCLUSIONS--Temporal profiles of death rates in the year after operation show which operations have early peaks in mortality and which do not. Emergency and elective operations have very different profiles and should be analysed separately. For elective operations for conditions which pose no immediate threat to life the ratio of early to later fatality rates provides a measure of increase in mortality after operation while allowing for the background risk of death in the patient groups.     

Effect of Temperature on Hospital Admissions for Myocardial Infarction in a Subarctic Area

In a study of the effect of mean daily temperature on the admission and fatality rates of 771 patients with myocardial infarction the admission rate was found to be significantly higher on cold (temperature below 0°C.) than on warm (temperature above 0°C.) days. The fatality rate was almost equal in cold and warm weather. Thus the seasonal fluctuation in the admission rate of patients with myocardial infarction is probably due to a direct effect of environmental temperature.     

Response to Huso and Erickson's comments on novel scavenger removal trials

Trials involving volitionally placed carcasses are often used to estimate the portion of the collision-caused fatality population that is undetected by periodic fatality searches at wind turbines. Huso and Erickson criticized our paper reporting on a comparison of carcass persistence rates between what we termed conventional versus novel approaches to these trials. In our novel approach, we measured carcass persistence rates by placing only 1–2 fresh carcasses per week, instead of the typical 10 or more carcasses at a time, often using found carcasses of unknown time since death. Huso and Erickson directed most of their critique to this novel aspect of our approach, although the novelty of our approach also included the use of event-triggered camera traps, which we used to record exact times of removals and to identify vertebrate scavenger species responsible for the removals. In our replies to Huso and Erickson's major criticisms, we acknowledge flaws in our field methods for arriving at fatality rate estimates, but we also point out the larger flaws in the methods used by Huso and Erickson, especially in their use of mean days to removal as a measure of carcass persistence. We conclude by introducing a more appropriate detection trial, which combines searcher detection and scavenger removal trials, and integrates this detection trial into periodic fatality monitoring. © 2013 The Wildlife Society.     

Phylogenetic clustering of 4 prevalent virulence genes in <Emphasis Type="Italic">Orientia tsutsugamushi</Emphasis> isolates from human patients

The pathogenicity of microbes is involved in many kinds of virulence genes. The relationships between these virulence genes and strains are not clear in Orientia tsutsugamushi yet. In this study, we confirmed the presence of the virulence genes and classified into O. tsutsugamushi isolates using phylogenetic analysis of the virulence genes. We also compared the fatality rates of every isolate via an infection experiment in BALB/c mice using the O. tsutsugamushi isolates, Deajeon03-01, Wonju03-01, and Muju03-01. Moreover, we compared the phylogenetic analysis, in basis with 56 kDa protein sequence which determined from serotype, and virulence genes of O. tsutsugamushi. Our results showed remarkably different fatality rates between Deajeon03-01 and Muju03-01, which are both Boryong strains of O. tsutsugamushi. Also, clustering analyses including these two isolates gave slightly different results depending on whether they were clustered based on virulence genes or on the 56 kDa protein sequences. Consequently, we conclude that fatality rates in O. tsutsugamushi are correlated with differences in both serotypes and virulence genes. We identified some variations within the virulence genes dnaA, virB8, tolR, and trxA among the isolates.     

Percutaneous needle biopsy of the lung.

A total of 160 percutaneous needle biopsies of pulmonary lesions were performed in 149 patients. Cytological and bacteriological examination of the biopsy material yielded clinically useful information in 87% of these patients. False-negative diagnoses were made in 6%, but there were no false-positive diagnoses. In most patients the biopsy obviated the need for a diagnostic thoracotomy. The principal complication of the procedure was pneumothorax, which occurred in 24% of patients; the pneumothorax, however, was usually very small and only two of these patients required treatment with a pleural drain. There were no deaths in the series. It is concluded that percutaneous needle biopsy is an effective and relatively safe method of obtaining diagnostic material from a pulmonary lesion.     

Ten years of respiratory cytopathology at Duke University Medical Center. II. The cytopathologic diagnosis of lung cancer during the years 1970 to 1974, with a comparison between cytopathology and histopathology in the typing of lung cancer

In 1975 Duke University Medical Center, a retrospective and prospective survey of respiratory cytopathologic specimens was undertaken for the ten-year period 1970 to 1979. The purpose of this study was to document the role of cytopathology in the diagnosis of lung cancer at this institution. This paper presents the results of the cytopathologic and histopathologic typing of cases of lung cancer seen at Duke University Medical Center from 1970 to 1974. During this period, 9,892 cytologic specimens from the lower respiratory tract were processed. Cytopathologic diagnoses of cancer with tissue confirmation were made on 483 specimens from 232 patients. Because original cytologic diagnoses, but not histopathologic diagnoses, had been made in conformity with a modified WHO classification of lung neoplasms, all histopathologic material was reviewed and reclassified when necessary. This was carried out by one of the authors (E.H.B.) as a blind review without benefit of knowledge of either preexisting cytopathologic or histopathologic diagnoses. Twenty-six patients were excluded from the current study because of lack of satisfactory histologic material. In 94 patients classified by histopathology as having squamous cell carcinoma, 76.4% of the positive cytologic specimens were also called squamous cell carcinoma; 18.6% were interpreted as large cell undifferentiated carcinoma. In 39 patients classified by tissue as having large cell undifferentiated carcinoma, the cytology agreed in 42.4% of the positive specimens. For the 29 patients thought histologically to have small cell undifferentiated carcinoma, the same diagnosis was rendered in 95.5% of the cytologically positive specimens from these patients. For the adenocarcinoma group of 43 patients, a cytopathologic diagnosis of adenocarcinoma was made in 67.8% of the positive specimens.     

The ASCUS : SIL ratio and the reference laboratory pathologist

The atypical squamous cells of undetermined significance (ASCUS) : squamous intraepithelial lesion (SIL) ratio was proposed to monitor laboratory use of the ASCUS diagnosis. This study addresses problems associated with comparing pathologists by this means. An intuitive example showed the ASCUS : SIL ratio depends on the prevalence of smears from patients who actually have SIL. In this study of 2000 cervical smears, each of five pathologists made 400 diagnoses. Differences among proportions of SIL diagnoses were statistically significant; differences among proportions of ASCUS diagnoses were not. Had an ASCUS : SIL ratio upper limit of 3.0 been used, two pathologists would have been misidentified as having high ASCUS diagnosis rates. Unlike the situation for laboratories, potential variability in SIL prevalence requires caution in the use of this ratio in assessing pathologists. An alternative measure that is independent of prevalence, the ASCUS : SIL odds ratio, is posited.     

外科急腹症48例临床诊疗分析

目的:探讨外科急腹症的早期诊断与治疗,以便总结经验,提高治愈率,降低致残率与病死率。方法:回顾性分析48例外科急腹症诊治的临床资料。结果:急诊手术40例,经严密观察后手术8例,术后并发症11例,治愈44例,死亡4例。结论:外科急腹症的诊断应结合病史,体征及辅助检查等综合判断。对其早期确诊与及时处置和手术治疗是降低病死率的关键。     

A Survey of Newborn Intensive Care Centers in California

Newborn intensive care has come of age in California. Twenty-one newborn intensive care centers and 11 community level units are now approved by Crippled Children Services in California. In 1973 there were more than 6,863 patients admitted to the 20 centers surveyed, over half requiring transport from referring hospitals. This paper provides information on the distribution, admission and occupancy rates, length of stay, costs and admission diagnoses for these high risk infants.     

Mortality and Case Fatality Due to Visceral Leishmaniasis in Brazil: A Nationwide Analysis of Epidemiology,Trends and Spatial Patterns

Background

Visceral leishmaniasis (VL) is a significant public health problem in Brazil and several regions of the world. This study investigated the magnitude, temporal trends and spatial distribution of mortality related to VL in Brazil.

Methods

We performed a study based on secondary data obtained from the Brazilian Mortality Information System. We included all deaths in Brazil from 2000 to 2011, in which VL was recorded as cause of death. We present epidemiological characteristics, trend analysis of mortality and case fatality rates by joinpoint regression models, and spatial analysis using municipalities as geographical units of analysis.

Results

In the study period, 12,491,280 deaths were recorded in Brazil. VL was mentioned in 3,322 (0.03%) deaths. Average annual age-adjusted mortality rate was 0.15 deaths per 100,000 inhabitants and case fatality rate 8.1%. Highest mortality rates were observed in males (0.19 deaths/100,000 inhabitants), <1 year-olds (1.03 deaths/100,000 inhabitants) and residents in Northeast region (0.30 deaths/100,000 inhabitants). Highest case fatality rates were observed in males (8.8%), ≥70 year-olds (43.8%) and residents in South region (17.7%). Mortality and case fatality rates showed a significant increase in Brazil over the period, with different patterns between regions: increasing mortality rates in the North (Annual Percent Change – APC: 9.4%; 95% confidence interval – CI: 5.3 to 13.6), and Southeast (APC: 8.1%; 95% CI: 2.6 to 13.9); and increasing case fatality rates in the Northeast (APC: 4.0%; 95% CI: 0.8 to 7.4). Spatial analysis identified a major cluster of high mortality encompassing a wide geographic range in North and Northeast Brazil.

Conclusions

Despite ongoing control strategies, mortality related to VL in Brazil is increasing. Mortality and case fatality vary considerably between regions, and surveillance and control measures should be prioritized in high-risk clusters. Early diagnosis and treatment are fundamental strategies for reducing case fatality of VL in Brazil.