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A Look at Subarachnoid Hemorrhage Mortality

A Look at Subarachnoid Hemorrhage Mortality

Published data show that more than 30,000 Americans suffer from subarachnoid hemorrhage (SAH), a devastating acute neurological disease, each year. Mortality risk factors for SAH include poor clinical grade at presentation, older age, aneurysm rebleeding, large aneurysm size, and cerebral infarction from vasospasm. “There have been significant advances in the medical and surgical management of SAH as mortality rates have improved over the past 20 years,” says Stephan A. Mayer, MD, FCCM. “However, SAH continues to be a major cause of premature mortality.” Studies indicate that SAH accounts for 27 % of all stroke-related potential years of life lost before the age of 65. For a study published Critical Care, Dr. Mayer and colleagues sought to re-evaluate the causes and mechanisms of in-hospital mortality after SAH. They studied 1,200 consecutive SAH patients who were prospectively enrolled in the Columbia University SAH Outcomes Project between July 1996 and January 2009. “We found that the in-hospital mortality for SAH was about 18% overall,” Dr. Mayer says. The largest mortality percentages were seen among patients who had a Hunt-Hess grade of 4 (24%) or 5 (71%). Common Causes The most common primary causes of death from SAH or neurological devastation leading to withdrawal of support were direct effects of: The primary hemorrhage: 55 % Aneurysm rebleeding: 17% Medical complications: 15%. Brain death was declared in 42% of patients who had died in the study. About one-half of patients had do-not-resuscitate orders at the time of cardiac death and 8% died despite full support. The study also identified several admission predictors of mortality among patients with SAH. These included age, loss of consciousness at ictus,...
An Update on Fibromuscular Dysplasia

An Update on Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) has been defined as a non-atherosclerotic, non-inflammatory vascular disease that can result in arterial stenosis, occlusions, aneurysms, or dissections. Although the cause of FMD and its prevalence in the general population are unknown, research has shown that it has been reported in virtually every arterial bed. Most commonly, FMD affects the renal and extracranial carotid and vertebral arteries. When the renal artery is involved, the most frequent finding is hypertension. Carotid or vertebral artery FMD may lead to dizziness, pulsatile tinnitus, transient ischemic attack (TIA), or stroke. According to Jeffrey W. Olin, DO, FACC, FAHA, there is an average delay of 4 to 9 years from the time of the first symptom or sign to a diagnosis of FMD. “Many consider this disease rare, but in reality, the diagnosis is often overlooked,” he says. “Thus, it’s not considered in a differential diagnosis. In addition, FMD is poorly understood by many healthcare providers. Many of the signs and symptoms are non-specific, which in turn can lead clinicians down the wrong diagnostic pathway.” He notes that a delayed diagnosis can impair quality of life and result in poor outcomes. In 2014, the American Heart Association (AHA) released a scientific statement on FMD that addressed the state of the science and critical unanswered questions. “Over the last several years, we have learned that FMD is more common than previously thought,” says Dr. Olin, who chaired the AHA writing committee that developed the scientific statement. “FMD is frequently being discovered incidentally while imaging is performed for other reasons in asymptomatic patients without classic risk factors for atherosclerosis. The clinical manifestations...
Surgical Readmissions and Quality of Care

Surgical Readmissions and Quality of Care

Throughout the United States, reducing the rates of hospital readmissions has become a top priority, as evidenced by CMS planning to include surgical procedures in the expansion of the penalty program. “The hospital readmissions reduction program is predicated on the notion that decreasing the frequency with which patients return to hospitals can improve care and lower costs,” says Thomas C. Tsai, MD, MPH. “However, using medical readmission rates as a measure of hospital quality has been controversial.” Hospitals vary substantially in their medical readmission rates, but these data generally do not correlate with the measures that are often used to identify high-quality hospitals, such as mortality. This raises the question of whether or not medical readmission rates actually measure hospital quality or if they instead reflect other factors that are unrelated to hospital care. The relationship between readmission rates and surgical care may be different than that of medical readmissions. Most patients undergo non-urgent major surgery when they’re clinically stable. As a result, surgical readmissions are more likely to result from complications of care received during index hospitalizations. “Clinicians have relatively little information on the types of hospitals that perform well or poorly with regard to surgical readmission rates,” says Dr. Tsai, “but we hypothesized that hospitals excelling in surgical care would generally have fewer readmissions.” A Comprehensive Analysis In a study published in the New England Journal of Medicine, Dr. Tsai and colleagues sought to determine the patterns of surgical readmissions among Medicare patients across a set of major procedures in a national sample of hospitals. The study team combined information from Medicare claims, the American Hospital Association...
Analyzing Operative Outcomes for Proximal Aortic Replacement

Analyzing Operative Outcomes for Proximal Aortic Replacement

Morbidity and mortality from proximal aortic replacement remain high when compared with other surgical procedures, but research indicates that patient outcomes have improved over the last 30 years. Much of this has been attributed to advances in operative approaches, perioperative care, and increased surveillance. For patients undergoing these procedures, better character­izing outcomes and determin­ing predictors of mortality and major morbidity are important for clinicians managing this patient population. In the Journal of the American College of Cardiology, G. Chad Hughes, MD, and colleagues had an analysis published that looked at operative outcomes for ascending aorta and arch replacement on a national scale. The study also reviewed risk factors for postoperative mortality and major morbidity. “Our study provides a broad overview of the current practices and outcomes for proximal aortic replacement in North America,” says Dr. Hughes. “With more than 45,000 patients from the Society of Thoracic Surgeons Database involved in our analysis, we have the largest cohort of proximal aortic replacements that have been reported to date.”   Examining Outcomes for Proximal Aortic Replacement In the study by Dr. Hughes and colleagues, roughly 60% of proximal aortic replacement cases were elective, 20% were urgent, and 20% were emergent. From 2004 to 2009, the number of centers that reported performing aortic replacement, as well as the overall number of patients treated, increased dramatically, although the average number of patients treated per center remained relatively constant. In 2004, 285 centers in North America treated 2,121 patients. In 2008, there were 806 centers that treated 11,033 patients. “Outcomes were excellent for elective proximal aortic replacement but sharply deteriorated when the procedure was...
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