Open-heart surgery in elderly patients.

Between March 1975 and March 1980, 50 patients aged 70 to 78 years underwent open-heart surgery at the Montreal Heart Institute. Coronary bypass was performed in 23 patients, valve replacement in 16 and combined coronary and valve surgery in 11. There were four early deaths, all due to cardiac causes. Early postoperative complications occurred in 58% of the patients. There were seven late deaths, five in the valve replacement groups and two in the isolated coronary bypass group. The cumulative survival rate 5 years after surgery was estimated at 76%. While 82% of the survivors were in functional class III or IV before surgery, 90% were in class I or II when last seen, after an average postoperative follow-up of 3 years. Nonfatal late complications occurred in eight of the survivors, one of whom suffered a major hemorrhage due to anticoagulant therapy. Thus, open-heart operations can be offered to the elderly, with a low risk of operative death. The late clinical improvement, with a return to a normal lifestyle, justifies a surgical approach for patients in otherwise good general condition.     

CEREBRAL COMPLICATIONS INCURRED DURING PREGNANCY AND THE PUERPERIUM

In a statistical study of maternal mortality cases in Franklin County, Ohio, with a total of 170 deaths in a ten-year period (1948-1957), there were 36 fatal cases with cerebral complications of various types. Intracranial hemorrhage was the cause of death in 17 cases; subarachnoid hemorrhage in eight; intracerebral hemorrhage in eight and subdural hemorrhage in one case. There were nine cases of intracranial tumor with fatality. In a miscellaneous group of ten “cerebral deaths” infectious processes were the cause in eight cases, including tuberculous meningitis, purulent meningitis, brain abscess, acute (cerebromedullary) poliomyelitis, “viral” encephalitis, toxoplasmosis and tetanus.In a smaller clinical (nonfatal) group with cerebral complications occurring during pregnancy and the puerperium, two patients with subarachnoid hemorrhages made spontaneous recovery. A diagnosis of intracerebral hemorrhage was made in three instances, in two of which operation was done and evacuation of blood clots was accomplished. One patient recovered spontaneously from a minimal hemorrhage.Five other persons had cerebral thrombosis, three in the third month of pregnancy and two in the immediate puerperium. All recovered, with some residual deficits.Three patients with intracranial tumor were successfully treated surgically but with disappointing results ultimately (one case each of cerebellar medulloblastoma, cerebral astrocytoma and supratentorial meningioma).Only when the obstetrician, neurologist and the neurosurgeon are fully aware of the signs, symptoms, and many times the rapid course of these cerebral complications of pregnancy, can there be any material lowering of the morbidity and mortality. Emphasis should be placed on the early investigation of all neurological complaints during pregnancy and the puerperium, with immediate institution of an aggressive diagnostic and therapeutic regimen.     

Deaths from cerebrovascular diseases correlated to month of birth: elevated risk of death from subarachnoid hemorrhage among summer-born

It has been suggested that maternal nutrition, and fetal and infant growth have an important effect on the risk of cardiovascular disease in adult life. We investigated the population-based distribution of deaths from cerebrovascular diseases (ICD9 codes 430, 431, or 434) in Japan in 1986–1994 as a function of birth month, by examining death-certificate records. For a total of 853 981 people born in the years 1900–1959, the distribution of the number of deaths according to the month of birth was compared with the distribution expected from the monthly numbers of all births for each sex and for the corresponding birth decade. For those born between 1920 and 1949, there were significant discrepancies between the actual numbers of deaths from subarachnoid hemorrhage (ICD9 430) and the numbers expected, and these differences were related to the month of birth. Those born in summer, June–September, consistently had an elevated risk of death, particularly men, where the excess risk was 8%–23%. This tendency was also observed, less distinctly but significantly, for deaths from intracerebral hemorrhage (ICD9 431), but was not observed for those dying from occlusion of the cerebral arteries (ICD9 434). The observation that the risk of dying from subarachnoid hemorrhage was more than 10% higher among those born in the summer implies that at least one in ten deaths from subarachnoid hemorrhage has its origin at a perinatal stage. Although variations in hypertension in later life, which could possibly be ”programmed” during the intra-uterine stages, could be an explanation for this observation, the disease-specific nature of the observation suggests the involvement of aneurysm formation, which is a predominant cause of subarachnoid hemorrhage. Received: 22 October 1999 / Revised: 8 May 2000 / Accepted: 10 May 2000     

中国肝细胞癌患者TACE术后死亡原因分析(英文)

目的:通过探讨中国肝细胞癌患者肝动脉化疗栓塞术(TACE)术后并发症及死亡原因,来提高临床治疗效果,并积累治疗经验。方法:通过联合检索CBM及CNKI上从1994年1月到2008年9月的关于中国肝细胞癌患者行TACE术后出现并发症的相关文章,分析总结肝细胞癌患者TACE术后死亡的原因及特点。结果:中国肝细胞癌患者TACE术后并发症较为危重,致死率较高,死亡原因有84%是肝功能衰竭、上消化道出血及肝癌破裂出血,且死亡病例发生在术后1月内的占78.7%,因此大多是早期死亡。结论:中国肝细胞患者TACE术后死亡原因主要是肝功能衰竭、上消化道出血及肝癌破裂出血,且术后死亡常为早期死亡,因此TACE术后严重并发症可直接影响患者的预后情况,我们需要提高对TACE术选择时机的重视程度,规范介入治疗手段和流程,尽量避免和减少严重并发症的发生。     

Reproductive mortality.

The transfer from traditional to modern methods of contraception in recent decades has been accompanied by a transfer of deaths from complications of pregnancy to deaths from complications of the modern contraceptive methods. In 1975, for example, it is estimated that there were more deaths at ages 25-44 years in England and Wales from adverse effects of oral contraceptive use than from all complications of pregnancy, delivery, and the puerperium combined. Thus maternal mortality is no longer an adequate indicator of the deaths associated with reproduction in the community. An alternative measure, the reproductive mortality rate should be used, which includes deaths from complications of contraceptive use as well as those from complications of pregnancy or abortion. The reproductive mortality rate in England and Wales seems to have declined continuously since 1950 for women aged 25-34. But after 1960 it increased for women aged 35-44, because of the higher mortality associated with oral contraceptive use in this age group.     

MATERNAL AND PERINATAL DEATHS IN CALIFORNIA

In a 29-month period, 151 of 373 deaths of California women occurring during or within 90 days of termination of pregnancy were studied jointly by the California Medical Association and the California State Department of Public Health. Twenty-two per cent of the deaths reviewed were considered unavoidable. In 74 per cent, one or more avoidable factors were identified. Avoidable factors could not be identified in 4 per cent of the cases.Thirty-three per cent of the cases considered to have avoidable factors were attributed to be solely the responsibility of the attending physician. Inadequate hospital facilities were held responsible in less than 1 per cent of deaths, while responsibility in 26 per cent of the deaths was laid directly to patient error or refusal. In 40 per cent of the avoidable deaths, more than one avoidable factor was identified.Nonobstetric conditions accounted for the greatest proportion of the deaths, followed by hemorrhage, toxemia of pregnancy, sepsis, abortion and ectopic pregnancy.The findings of this study compare closely with those of similar studies in other states, including Minnesota and Massachusetts.     

The Warren Shunt in Treating Bleeding Esophageal Varices

In patients who have impaired hepatic reserve, the Warren shunt has been proposed as an effective operation because it decompresses the esophageal varices without disturbing portal perfusion of the liver. However, early reports of high operative mortality and technical difficulties have impeded acceptance of the procedure.The operation was done in a series of 17 patients. All patients in whom elective variceal decompression with a patent splenic vein was required and without clinical ascites were candidates for this operation. Follow-up ranged from 2 to 48 months. Six patients had alcoholic cirrhosis, two had primary biliary cirrhosis and seven had postnecrotic cirrhosis; in two the cause of the liver disease was unknown. Five patients were categorized as Child''s class A, nine as class B and three as class C. No intraoperative or early postoperative deaths owing to hemorrhage occurred. However, there was one death two weeks postoperatively from pulmonary sepsis and one death five weeks postoperatively due to antigen-positive hepatitis. Two patients died from hepatic failure six weeks and five months after operation, respectively; in the first of these, chronic active hepatitis was diagnosed at the time of operation. In one patient hemorrhage recurred and transfusion was required. Although ascites, which eventually resolved, developed in eight patients after operation, the results in 76 percent of patients have been good without new episodes of hemorrhage or encephalopathy. We conclude that the Warren shunt is a safe and effective elective operation for the treatment of patients in whom hemorrhage from esophageal varices has occurred.     

OPERATING ROOM DEATHS—An Analysis of Mortality in a Veterans Administration Hospital Over a Ten-Year Period

A study of operating room and recovery room deaths which occurred during a ten-year period from 1948 through 1957 at one hospital revealed that there were 59 deaths associated with 57,132 surgical procedures.Factors which directly influenced the rate of operating room and recovery room death were the age of the patient and the length of operating time. Seventy-five per cent of the deaths occurred in cases in which the operation took longer than one hour. Combined anesthesia techniques may have indirectly contributed to death in some cases.Complications of operation requiring another surgical procedure sometimes occur. In this series, reoperation proved to be more hazardous in terms of mortality rate than did single operations. This is not surprising for most complications occur in the poorer risk patients.The operating room death rate steadily increased during the ten-year period studied. This increasing death rate can largely be attributed to the more intricate operations which are being done on poorer risk patients. The use of the curariform drugs had no influence on the increasing death rate.     

Operating room deaths; an analysis of mortality in a Veterans Administration hospital over a ten-year period

A study of operating room and recovery room deaths which occurred during a ten-year period from 1948 through 1957 at one hospital revealed that there were 59 deaths associated with 57,132 surgical procedures. Factors which directly influenced the rate of operating room and recovery room death were the age of the patient and the length of operating time. Seventy-five per cent of the deaths occurred in cases in which the operation took longer than one hour. Combined anesthesia techniques may have indirectly contributed to death in some cases. Complications of operation requiring another surgical procedure sometimes occur. In this series, reoperation proved to be more hazardous in terms of mortality rate than did single operations. This is not surprising for most complications occur in the poorer risk patients. The operating room death rate steadily increased during the ten-year period studied. This increasing death rate can largely be attributed to the more intricate operations which are being done on poorer risk patients. The use of the curariform drugs had no influence on the increasing death rate.     

High risk maternal factors related to fetal wastage in rural Bangladesh

An analysis of the relationship between fetal mortality (early fetal death and stillbirth), pregnancy order, maternal age, and previous fetal deaths in a rural Bangladesh population characterized by high fertility and mortality and the virtual absence of obstetric and other medical care indicates that early fetal wastage and stillbirth are higher among pregnancy orders 1 and 6, or higher than among orders 2 and 3, with the increased risk particularly apparent among those pregnancies following 2 or more previous fetal deaths. The data consist of the 21,144 pregnancies that occurred to the women in Matlab, Bangladesh, 1966-1969. By a multiple regression technique allowing for pregnancy order and previous fetal deaths, adjustments were made for age of the mother, and after allowances were made for previous fetal deaths, adjustments were made for pregnancy order. Results show the fewest fetal deaths in 2nd and 3rd pregnancies, and most at the highest parities. 10% of all pregnancy terminations 1966-1969 were registered as fetal deaths. Women in the higher pregnancy orders who have not experienced previous fetal deaths or only 1 fetal death have only a slight increase in the risk of fetal death compared to women in pregnancy orders 2 and 3. It is concluded that the virtual absence of medical care facilities is responsible for the large numbers of fetal deaths due to complications of gestation, delivery, and environmental influences. It also results in a higher maternal mortality of women with pregnancy complications related to fetal deaths. This absence of obstetric care and the high maternal mortality in this population may allow only women without reproductive impairments to reach the higher pregnancy orders.     

In-hospital cerebrovascular complications following orthotopic liver transplantation: A retrospective study

Background

Cerebrovascular complications are severe events following orthotopic liver transplantation (OLT). This study aimed to observe the clinical and neuroimaging features and possible risk factors of in-hospital cerebrovascular complications in the patients who underwent OLT.

Patients and methods

We retrospectively reviewed 337 consecutive patients who underwent 358 OLTs. Cerebrovascular complications were determined by clinical and neuroimaging manifestations, and the possible risk factors were analyzed in the patients with intracranial hemorrhage.

Results

Ten of 337 (3.0%) patients developed in-hospital cerebrovascular complications (8 cases experienced intracranial hemorrhage and 2 cases had cerebral infarction), and 6 of them died. The clinical presentations were similar to common stroke, but with rapid deterioration at early stage. The hematomas on brain CT scan were massive, irregular, multifocal and diffuse, and most of them were located at brain lobes and might enlarge or rebleed. Infarcts presented lacunar and multifocal lesions in basal gangliar but with possible hemorrhagic transformation. The patients with intracranial hemorrhage had older age and a more frequency of systemic infection than non-intracranial hemorrhage patients. (P = 0.011 and 0.029, respectively).

Conclusion

Posttransplant cerebrovascular complications have severe impact on outcome of the patients who received OLT. Older age and systemic infection may be the possible risk factors of in-hospital intracranial hemorrhage following OLT.     

An analysis of maternal deaths in British Columbia: 1963 to 1970

There were 132 maternal deaths in British Columbia in the years 1963 to 1970. The mean maternal mortality rate for these eight years was 0.317. Sixty of these deaths (45.5%) were due to direct obstetrical causes. Indirect and nonrelated deaths accounted for 21.2 and 33.3% of the total, respectively. The most common causes of direct obstetrical deaths were hemorrhage, infection and vascular accidents, in that order; pre-eclampsia ranked a distant fourth. Ninety-five percent of direct obstetrical deaths were probably avoidable. Approximately 27% of all direct obstetrical deaths were abortion-related. Hemorrhage continues to be a major problem, in particular among the native Indian women of the province.If further reduction in maternal mortality is to be achieved, obstetrical hemorrhage must be better managed and deaths due to abortions reduced. Future studies should reveal if the liberalized abortion laws will assist in the realization of the latter goal.     

Controlled investigation of deaths from asthma in hospitals in the North East Thames region.

One hundred and thirty deaths definitely or potentially due to asthma occurring in hospitals in the North East Thames region over one year were identified from death certificates and Hospital Activity Analysis records. Thirty five of these deaths were considered after independent assessment to have been directly due to asthma. Control patients who left hospital alive after acute asthma attacks were selected and matched with cases for sex, age, and hospital. Management was compared in the two groups. Inadequate monitoring, including failure to monitor arterial blood gas values, and inadequate use of nebulised beta agonists occurred significantly more often in fatal cases. Use of sedation, inadequate treatment with steroids, exposure to potentially toxic doses of aminophylline, and inadequate clinical assessment were more common in cases than controls, but not significantly so. Failure to institute artificial ventilation contributed to seven deaths. Assessors considered important defects in management to have occurred in 83% (29/35) of the cases and 40% (14/35) of the controls. Nevertheless, most of the hospital deaths (19/35) were considered not to have been preventable. Eight other deaths in the region were attributed to the complications of asthma or its treatment. Three of these were associated with gastrointestinal bleeding and one with perforation of a duodenal ulcer. Before considering policies aimed at speeding admission to hospital of patients with acute attacks of asthma it is crucial that the general standard of hospital care offered to all patients with asthma should be improved.     

The Impact of COVID-19 On Comorbidities: A Review Of Recent Updates For Combating It

Coronavirus disease is caused by the SARS-CoV-2 virus. The virus first appeared in Wuhan (China) in December 2019 and has spread globally. Till now, it affected 269 million people with 5.3 million deaths in 224 countries and territories. With the emergence of variants like Omicron, the COVID-19 cases grew exponentially, with thousands of deaths. The general symptoms of COVID-19 include fever, sore throat, cough, lung infections, and, in severe cases, acute respiratory distress syndrome, sepsis, and death. SARS-CoV-2 predominantly affects the lung, but it can also affect other organs such as the brain, heart, and gastrointestinal system. It is observed that 75 % of hospitalized COVID-19 patients have at least one COVID-19 associated comorbidity. The most common reported comorbidities are hypertension, NDs, diabetes, cancer, endothelial dysfunction, and CVDs. Moreover, older and pre-existing polypharmacy patients have worsened COVID-19 associated complications. SARS-CoV-2 also results in the hypercoagulability issues like gangrene, stroke, pulmonary embolism, and other associated complications. This review aims to provide the latest information on the impact of the COVID-19 on pre-existing comorbidities such as CVDs, NDs, COPD, and other complications. This review will help us to understand the current scenario of COVID-19 and comorbidities; thus, it will play an important role in the management and decision-making efforts to tackle such complications.     

Mortality in achondroplasia.

Standardized mortality ratios (SMRs) were determined for a historical cohort of achondroplastic individuals identified through the Medical Genetics Clinics of the University of Texas Health Science Center at Houston and Johns Hopkins Hospital, Baltimore. Mortality was increased at all ages, with an overall SMR of 2.27 (95% confidence interval 1.7-3.0). Sudden death accounted for the excess deaths in those less than 4 years of age, and brain-stem compression was identified as the cause in half of these deaths. Central nervous system and respiratory causes were not significantly increased but accounted for half of the deaths in those 5-24 years of age. SMRs were not significantly increased for those greater than 34 years of age. However, deaths attributed to cardiovascular causes were increased in the 25-54-year-old age group, accounting for 10 of 17 deaths. The overall cardiovascular SMR was 5.2 (95% confidence interval 2.5-9.6). Within this group, severe disability resulting from marked spinal canal stenosis was present in a majority of individuals and may have been a contributing factor in these deaths. This study suggests that the bony abnormalities associated with achondroplasia--i.e., foramen magnum and spinal canal stenosis--may have a significant effect on mortality at all ages but particularly in children. Efforts to minimize these complications are recommended.     

Birth order,gestational age,and risk of delivery related perinatal death in twins: retrospective cohort study

ObjectiveTo determine whether twins born second are at increased risk of perinatal death because of complications during labour and delivery.DesignRetrospective cohort study.SettingScotland, 1992 and 1997.ParticipantsAll twin births at or after 24 weeks'' gestation, excluding twin pairs in which either twin died before labour or delivery or died during or after labour and delivery because of congenital abnormality, non-immune hydrops, or twin to twin transfusion syndrome.ResultsOverall, delivery related perinatal deaths were recorded for 23 first twins only and 23 second twins only of 1438 twin pairs born before 36 weeks (preterm) by means other than planned caesarean section (P>0.99). No deaths of first twins and nine deaths of second twins (P=0.004) were recorded among the 2436 twin pairs born at or after 36 weeks (term). Discordance between first and second twins differed significantly in preterm and term births (P=0.007). Seven of nine deaths of second twins at term were due to anoxia during the birth (2.9 (95% confidence interval 1.2 to 5.9) per 1000); five of these deaths were associated with mechanical problems with the second delivery following vaginal delivery of the first twin. No deaths were recorded among 454 second twins delivered at term by planned caesarean section.ConclusionsSecond twins born at term are at higher risk than first twins of death due to complications of delivery. Previous studies may not have shown an increased risk because of inadequate categorisation of deaths, lack of statistical power, inappropriate analyses, and pooling of data about preterm births and term births.

What is already known on this topic

It is difficult to assess the wellbeing of second twins during labourDeliveries of second twins are at increased risk of mechanical problems, such as cord prolapse and malpresentation, after vaginal delivery of first twinsIncreased risks of perinatal death in second twins have not been shown, but the methods of these studies were flawed

What this study adds

Second twins delivered at term are at increased risk of delivery related perinatal deathsIntrapartum anoxia caused 75% of these deaths in second twins, and most of these resulted from mechanical problems after vaginal delivery of first twinsPlanned caesarean section of twins at term may prevent perinatal deaths     

Tuberculous Enteritis

Tuberculous enteritis occurs in about 2 percent of patients with pulmonary tuberculosis. Although it is uncommon in the United States, tuberculous enteritis should be considered in any patient with active pulmonary tuberculosis and abdominal complaints.Eight cases of T. enteritis have been treated at Harbor General Hospital in the last 25 years. Associated pulmonary disease was shown radiologically to be present in seven of eight patients. Findings on contrast studies of the gastrointestinal tract showed disease in six of six patients examined.In five patients, surgical operation was required for diagnosis or complications. Resection of diseased bowel with primary anastomosis was done in five patients. Although medical therapy is the mainstay in the treatment of both pulmonary and intestinal tuberculosis, one staged resection of diseased bowel with primary anastomosis is the procedure of choice for complications such as obstruction, hemorrhage or perforation.     

Maternal Mortality in British Columbia: A Study of 145 Deaths from 1955 to 1962

Between 1955 and 1962, 145 maternal deaths were reported in the Province of British Columbia. One hundred of them were due to obstetrical causes. Of these deaths, hemorrhage was by far the commonest cause (40 cases), followed in frequency by vascular accidents (23 cases), infections (17 cases), toxemia (10 cases), anesthetic deaths (five cases), and other causes (five cases). Significant avoidable factors were noted in 80%. Indirect obstetrical deaths accounted for 29 cases, or 20% of all maternal mortalities. The most frequently encountered causes of indirect obstetrical deaths were cardiac (nine cases) and vascular accidents (six cases). Avoidable factors were considered to be present in 19 of the 29, an incidence of 65%.When all deaths were considered together, 72% were felt to have significant avoidable factors when judged against an academic standard. It was also apparent that some 40% to 50% of deaths were intimately involved with social factors.     

Neurosurgical complications of anticoagulant therapy

Ten cases of subdural hematoma and one case of spinal epidural hematoma encountered in patients who were receiving anticoagulant therapy are discussed.This surprisingly large number of complications was observed within three years in a single hospital and represents 36.6% of all chronic and subacute subdural hematomas seen during the same period. The cases are analyzed and the conclusion reached that the causal relationship between anticoagulant therapy and hemorrhage cannot be denied.Suggestions are made as to how to decrease the danger of such complications.     

CIRRHOSIS OF THE LIVER—Clinical Course in 2,377 Patients at San Francisco General Hospital

The records of 2,377 patients with Laennec''s cirrhosis were reviewed for the period 1947-1957. The chief presenting symptom was ascites in 46 per cent, bleeding in 23 per cent, coma in 18 per cent, jaundice in 9 per cent, and both jaundice and ascites in 4 per cent. Nearly half of the patients died during the period under study—one-third from hepatic failure, one-third from gastrointestinal bleeding, and one-third from other causes, most of which were related to alcoholism.Massive gastrointestinal bleeding occurred in 21 per cent of the patients at some time in their clinical course, and in the 10 per cent of these in whom ulcer was demonstrated, one-fifth died as a result of the hemorrhage. Of those presumed to be bleeding from esophageal varices, 64 per cent died at the first hemorrhage and 10 per cent at subsequent hemorrhages; 85 per cent of all those who bled from varices were dead at the end of one year, and 91 per cent were dead at the end of three years.The survival curve of a group of patients who bled once and were good operative risks but had received no operative treatment was compared to the survival curve for entire group who survived the first hemorrhage. The three-year survival in the good risk group was 47 per cent; for the group as a whole it was 30 per cent. The difference in mortality rate was primarily due to an increased number of deaths from hepatic failure in the combined group, whereas 60 per cent of the good risk group died of recurrent gastrointestinal hemorrhage.As 86 per cent of those who were to die of gastrointestinal bleeding did so at the first hemorrhage, it was concluded that any decided improvement in the salvage rate achievable by operation must come from some means of diagnostic forecast of the likelihood of bleeding, with resort to prophylactic operation in such cases.