Many stroke patients on ‘clot-busting’ tPA may not need long stays in ICU

A Johns Hopkins study of patients with ischemic stroke suggests that many of those who receive prompt hospital treatment with “clot-busting” tissue plasminogen activator (tPA) therapy can avoid lengthy, restrictive monitoring in an intensive care unit (ICU).The study challenges the long-standing protocol that calls for intensive monitoring, mostly done in ICUs, for the first 24 hours after tPA infusion to catch bleeding in the brain, a side effect seen in 6 percent of patients treated with the medication.Results show that a relatively simple measure of stroke severity can accurately single out which patients need ICU monitoring and which can be managed outside of a critical care setting in the hospital.”What we saw in this preliminary study was that, after the initial hour-long infusion of tPA, if an intensive care need had not developed, the chance of needing ICU monitoring — including a symptomatic ‘bleed’ — was extremely low for a large majority of patients, namely those with milder strokes,” says Victor Urrutia, M.D., medical director of the Comprehensive Stroke Center at The Johns Hopkins Hospital and head of the research team.Ischemic stroke, caused by a clot in a blood vessel that cuts off blood flow to the brain, is the most common form of stroke and the second leading cause of death for those over 60. In the United States, an estimated 795,000 people suffer a stroke each year. So far, tPA is the only FDA-approved treatment for acute stroke.In a report on the study published online in the journal PLOS ONE, the Johns Hopkins team analyzed data from 153 stroke patients admitted to the emergency departments of The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center between 2010 and 2013. After taking into account differences in age, sex, race, hypertension, diabetes, atrial fibrillation, kidney function, blood clotting status, use of statin drugs and other health factors, the team says that what emerged as the best predictor of the need for intensive care was a patient’s score on the National Institutes of Health (NIH) Stroke Scale, a trusted measure of stroke severity. The scale is a proven tool administered at the bedside involving 15 measures and observations, including level of consciousness, language ability, eye movements, vision strength, coordination and sensory loss. Scores range from zero to 42, with mild strokes typically registering 10 or lower. The average score for the Johns Hopkins patient group was 9.8.”What we learned is that the majority of our patients with mild strokes required no critical care, and that we are using scarce, specialized resources for intensive monitoring rather than for intensive care,” says Urrutia, an assistant professor of neurology.”If our upcoming, prospective study verifies what we’ve found about those who don’t need to be in the ICU, our patients will benefit, and we will also reduce costs of care.”Urrutia emphasized that critical care is clearly needed for tPa-linked bleeding, stroke-related brain swelling and critical abnormalities in blood pressure or blood sugar.But, he says, “For patients with an NIH Stroke Scale score of less than 10 without a need for transfer to the ICU after the first hour, the risk of a problem occurring later that needed ICU attention was only about 1 percent.”In the follow-up study, which is scheduled to begin this spring, consenting patients with a low stroke scale score and no other apparent need for intensive care will enter a stroke unit with a less rigorous monitoring schedule and increased family visiting time.Patients in the non-ICU setting will be less physically restricted and subjected to fewer sleep interruptions, lowering the risk of ICU-associated delirium and psychological distress. “We expect benefits to extend to the hospital as well, freeing up the ICU staff and beds for sicker patients,” says Urrutia.The financial benefits of the change in protocol could be significant, Urrutia adds. “Present monitoring for patients with tPA is very costly,” he says.

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Fewer than half of women attend recommended doctors visits after childbirth

Medical associations widely recommend that women visit their obstetricians and primary care doctors shortly after giving birth, but slightly fewer than half make or keep those postpartum appointments, according to a study by Johns Hopkins researchers.The researchers found that women with pregnancy complications were more likely to see a doctor post-delivery, but overall, visit rates were low.”Women need to understand the importance of a six-week visit to the obstetrician — not only to address concerns and healing after delivery, but also to follow up on possible future health risks, review the pregnancy and make the transition to primary care,” says Wendy Bennett, M.D., assistant professor of medicine and the lead researcher for the study, described online last week in the Journal of General Internal Medicine. “Women with pregnancy complications are at higher risk for some chronic diseases, such as diabetes, high blood pressure and heart disease, and these visits are an opportunity to assess risks and refer to primary care providers to work on long-term preventive care.”Physician groups, such as the American College of Obstetrics and Gynecology, recommend women with complications like high blood pressure during pregnancy or gestational diabetes not only visit their obstetricians six weeks after a birth, but that they also see their primary care doctors within a year.For the study, the researchers collected data from one commercial health insurance plan and multiple Medicaid insurance plans in Maryland. The aims were to determine different predictors of receiving post-delivery primary and obstetric care in women with and without pregnancy complications, including gestational or pregestational diabetes mellitus and hypertensive disorders, such as preeclampsia. Women with these conditions are much more likely to develop long-term health problems, such as type 2 diabetes and cardiovascular disease.Among women with tax-supported Medicaid insurance, 56.6 percent of those with a complicated pregnancy and 51.7 percent of those without a complicated pregnancy visited a primary care doctor within a year. Among women with commercial health insurance, 60 percent of those with a complicated pregnancy and 49.6 percent of those without a complicated pregnancy did so.White patients, older patients and patients with depression or preeclampsia were also more likely to visit their primary care doctor.Of the women on Medicaid, 65 percent of those with complicated pregnancies and 61.5 percent of those without complicated pregnancies had a postpartum obstetric visit within three months. Numbers were slightly lower for those with commercial insurance, at 50.8 percent of those with complicated pregnancies and 44.6 percent of those without complicated pregnancies.Bennett says providers need to develop creative ways to improve attendance at postpartum visits. A pilot project at Johns Hopkins Bayview Medical Center, for example, involves combined “mommy-baby” visits, she says. If the baby’s checkup is included in the mother’s visit, the mother may be more likely to keep the appointment, and thus would receive important education about improving health behaviors and the need for primary care follow-up. Other options are home visits and collaborations with day care centers, community centers and churches to make visits and health promotional activities more convenient.Bennett says more work is also needed by hospitals and physicians to coordinate future appointments, or to arrange transportation or child care if needed.”Pregnancy is a teachable moment — many women are very motivated to make healthier lifestyle choices to keep themselves and their babies healthy. After a birth, we need to keep them motivated,” she says.Bennett and her team say their findings add to evidence that access to health care alone — having insurance and a physician — is not enough to assure proper care. …

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Out-of-hospital cardiac arrest survival just 7 percent

Sep. 1, 2013 — Survival for out-of-hospital cardiac arrest is just 7%, according to research presented at ESC Congress 2013 by Professor Xavier Jouven and Dr Wulfran Bougouin from France.Professor Jouven said: “Sudden cardiac death (SCD) is an important public health problem, accounting for more than 400,000 deaths every year. The main cause is ventricular tachyarrhythmias which are often triggered by acute ischaemic events that can occur in persons with or without known heart disease. The survival rate from cardiac arrest has remained low over the last 40 years despite major investment and the epidemiology of SCD in Western Europe is unclear.” The Paris Sudden Death Expertise Centre (SDEC) Registry is a population based registry using multiple sources to collect every case of cardiac arrest in Greater Paris (population 6.6 million) according to the Utstein Style.1 Cases are continuously recorded (within hours of occurrence) and standardised follow-up is initiated on admission to the intensive care unit. Incidence, prognostic factors and outcomes are recorded.The results reported today reveal the 2 year experience of the SDEC Registry. From May 2011 to December 2012, 3,670 sudden cardiac arrests, with resuscitation attempted, occurred. Most cases occurred at home (72%) with bystanders in 81% of cases, performing cardiopulmonary resuscitation (CPR) in only 42% of cases. Among those cases only 34% of patients were admitted alive at hospital and 7% were discharged alive.Professor Jouven said: “The majority of sudden cardiac deaths occur outside hospital so specific programmes are needed in the community. Friends and relatives of people at risk of SCD should learn CPR and attend regular training to keep their skills up-to-date.” Therapeutic hypothermia and early coronary reperfusion were both significantly associated with survival (p<0.001) but these procedures were used in just 58% of patients admitted to hospital. Professor Jouven said: “These interventions markedly improve survival yet are given to just over half of patients. …

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Diets of pregnant women contain harmful, hidden toxins

Aug. 7, 2013 — Pregnant women regularly consume food and beverages containing toxins believed to pose potential risks to developing fetuses, according to researchers at the University of California in Riverside and San Diego, suggesting that health care providers must do more to counsel their patients about the dangers of hidden toxins in the food supply.In a peer-reviewed study published in the July issue of Nutrition Journal — “Consumption habits of pregnant women and implications for developmental biology: a survey of predominantly Hispanic women in California” — a team of psychologists from UC Riverside and UC San Diego found that the diets of pregnant Hispanic women included tuna, salmon, canned foods, tap water, caffeine, alcohol and over-the-counter medications that contain substances known to cause birth defects.The study is unique in that it highlights the unseen dangers of consuming toxins in food and beverages that are not typically thought of as unhealthy for a fetus, said Sarah Santiago, a Ph.D. student in psychology at UCR and the paper’s lead author. It also contributes to the body of literature aimed at assessing dietary habits of both Hispanic and non-Hispanic pregnant women.”Unlike alcohol and nicotine, which carry a certain stigma along with surgeon general warnings on the packaging, tuna, canned foods, caffeine, and a handful of other foods and beverages with associated developmental effects are not typically thought of as unsafe,” Santiago explained. “Hopefully, this study will encourage health care providers to keep pregnant women well informed as to the possible dangers of unhealthy consumption habits.”The research team — Santiago; Kelly Huffman, assistant professor of psychology at UC Riverside; and UCSD undergraduate student Grace Park — surveyed 200 pregnant or recently pregnant women at a private medical group in Downey, Calif., between December 2011 and December 2012. The women ranged in age from 18 to about 40, with Hispanic women accounting for 87 percent of the group. Nearly all had a high school degree, and about one-fourth had a college or post-graduate degree. More than two-thirds had an annual income of $50,000 or less.Using a food questionnaire, participants reported how often and when during their pregnancy they ate certain foods, drank certain beverages, and ingested prescription and over-the-counter medications. Nearly all of the women reported eating meat while pregnant, with about three-quarters of them eating fish, typically tuna, tilapia and salmon. All reported eating fresh fruit, but fewer than one-third ate the recommended amount of more than one serving a day. …

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Most ward nurses say time pressures force them to ‘ration’ care

July 29, 2013 — Most ward nurses say they are forced to ration care, and not do or complete certain aspects of it — including adequate monitoring of patients — because they don’t have enough time, indicates research published online in BMJ Quality & Safety.The lower the nurse headcount, the greater the risk, the study shows, prompting the researchers to suggest that hospitals could use episodes of missed care as an early warning sign that nurse staffing levels are too low to provide safe, high quality care.They base their findings on a survey of almost 3000 registered nurses working in 401 general medical/surgical wards in 46 acute care NHS hospitals across England between January and September 2010.The questions, which covered five different domains, were designed to gauge the prevalence of missed care — care that nurses deemed necessary, but which they were unable to do or complete because of insufficient time.Thirteen different aspects of nursing care were included in the survey, ranging from adequate patient monitoring, through to adequate documentation of care, and pain management.The researchers wanted to find out if there was any association between nurse staffing levels and the number of these episodes, and whether these were linked to overall perceptions of the quality of nursing care and patient safety in a ward.So they asked nurses to rate the quality of care on their ward, and to indicate how many patients needed assistance with routine activities and frequent monitoring. The researchers also assessed the quality of the working environment using a validated scoring system — the Practice Environment Scale (PES).The results showed that 86% of the 2917 respondents said that at least one of the 13 care activities on their last shift had been needed, but not done, because of lack of time. On average, nurses were unable to do or complete four activities.The most commonly rationed of these were comforting and talking to patients, reported by 66% of participating nurses; educating patients (52%); and developing or updating care plans (47%).Pain management and treatment/procedures were the activities least likely to be missed, reported as not being done by only 7% and 11%, respectively.Higher numbers of patients requiring assistance with routine daily living or frequent monitoring were linked to higher numbers of missed care activities.Staffing levels varied considerably across wards, but the average number of patients per nurse was 7.8 on day shifts and 10.9 at night.The fewer patients a nurse looked after, the less likely was care to be missed or rationed, and the lower was the volume of these episodes. Staffing levels were significantly associated with rationing eight of the 13 care activities.Nurses looking after the most (in excess of 11) patients were twice as likely to say they rationed patient monitoring as those looking after the fewest (six or fewer). Adequate documentation and comforting/talking with patients also suffered the most.Staffing levels of healthcare assistants had no bearing on rationing of care. But the quality of the work environment did, with the average number of care activities significantly lower (2.82) in the best than in the worst (5.61).Around eight care activities were left undone on wards nurses rated as “failing” on patient safety, compared with around 2.5 on wards rated as “excellent.””Our findings raise difficult questions for hospitals in a climate where many are looking to reduce — not increase — their expenditure on nurse staffing,” comment the authors, who go on to say that hospitals would have to reduce the number of patients to seven or fewer per registered nurse to significantly reduce the amount of care left undone.But they suggest: “Hospitals could use a nurse-rated assessment of “missed care” as an early warning measure to identify wards with inadequate nurse staffing.”

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Researchers develop system that uses a big data approach to personalized healthcare

July 25, 2013 — University of Notre Dame researchers have developed a computer-aided method that uses electronic medical records to offer the promise of rapid advances toward personalized health care, disease management and wellness.Notre Dame computer science associate professor Nitesh V. Chawla and his doctoral student, Darcy A. Davis, developed the system called Collaborative Assessment and Recommendation Engine (CARE) for personalized disease risk predictions and well-being.”The potential for ‘personalizing’ health care from a disease prevention, disease management and therapeutics perspective is increasing,” Chawla said. “Health care informatics and advanced analytics, or data science, may contribute to this shift from population-based evidence for health care decision-making to the fusion of population- and individual-based evidence in health care. The key question is how to leverage health population data to drive patient-centered health care.”At the heart of CARE is a novel collaborative filtering method that captures patient similarities and produces personalized disease risk profiles for individuals. Using what is known as Big Data science, the system generates predictions focused on other diseases that are based on Big Data from similar patients.”In its most conservative use, the CARE rankings can provide reminders for conditions that busy doctors may have overlooked,” Chawla said. “Utilized to its full potential, CARE can be used to explore broader disease histories, suggest previously unconsidered concerns and facilitate discussion about early testing and prevention, as well as wellness strategies that may ring a more familiar bell with an individual and are essentially doable.”We believe that our work can lead to reduced re-admission rates, improved quality of care ratings and can demonstrate meaningful use, impact personal and population health, and push forward the discussion and impact on the patient-centered paradigm.”Chawla points out that the core premise of CARE is centered on patient empowerment and patient engagement.”Imagine visiting your physician’s office with a list of concerns and questions,” he said. “What if you could walk out of the office with a personalized assessment of your health, along with a list of personalized and important lifestyle change recommendations based on your predicted health risks? What if your physician was afforded a limitless experience to gauge the impact of your disease toward developing other diseases in the future? What if you could find out that there are other patients similar to you not only with respect to major symptoms, but also with respect to rare issues that have puzzled your doctor? …

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US physicians put patients’ best interests above concerns about health care costs

July 23, 2013 — A new study of attitudes about health care costs reveals that an overwhelming majority of U.S. physicians feel a responsibility to address costs, but prioritize their obligations to patients’ best interests over cost concerns. Results of the random survey of 2,500 U.S. physicians are published in this week’s Journal of the American Medical Association (JAMA).”Physicians feel stuck in a difficult position,” says lead author Jon Tilburt, M.D., Mayo Clinic’s Biomedical Ethics Program and Center for the Science of Health Care Delivery. “Despite their sense of responsibility to address health care costs, physicians consistently express a commitment to the best interests of patients even when it is expensive. Given this finding, we recommend that cost-containment strategies aimed at physician behavior should focus on innovations that not only promote savings but also preserve physicians’ commitment to individual patients.”Survey highlights include:* The vast majority (85 percent) agreed that “trying to contain costs is the responsibility of every physician.”* Most (76 percent) reported being aware of the costs of tests or treatments they recommend.* Nearly 80 percent endorsed prioritizing patients’ best interests over issues of cost.* Most ascribed “major responsibility” for reducing health care costs to trial lawyers, health insurance companies, and pharmaceutical and device manufacturers. In contrast, most (59 percent) thought practicing physicians were only “somewhat responsible.”Researchers also assessed physicians’ attitudes about strategies to constrain health care spending.Major findings include:* Most expressed enthusiasm for cost-containment initiatives aimed at improving the quality and efficiency of care, and favored improving conditions for making decisions based upon cumulative medical evidence. For example, 69 percent were very enthusiastic about promoting chronic disease care coordination, and 63 percent were very enthusiastic about limiting corporate influence on physician behavior.* Physicians’ opinions were mixed on making payment changes to control costs. For example, 65 percent were not enthusiastic about paying a network of practices a fixed, bundled payment for managing all care for a defined population, and 70 percent were not enthusiastic about eliminating fee-for-service payment models.”We found that physicians’ degree of enthusiasm for various cost-containment strategies was associated with practice setting and compensation structure,” says Dr. Tilburt. …

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Reduced brain volume in kids with low birth-weight tied to academic struggles

June 10, 2013 — An analysis of recent data from magnetic resonance imaging (MRI) of 97 adolescents who were part of study begun with very low birth weight babies born in 1982-1986 in a Cleveland neonatal intensive care unit has tied smaller brain volumes to poor academic achievement.More than half of the babies that weighed less than 1.66 pounds and more than 30 percent of those less than 3.31 pounds at birth later had academic deficits. (Less than 1.66 pounds is considered extremely low birth weight; less than 3.31 pounds is labeled very low birth weight.) Lower birth weight was associated to smaller brain volumes in some of these children, and smaller brain volume, in turn, was tied to academic deficits.Researchers also found that 65.6 percent of very low birth weight and 41.2 percent of extremely preterm children had experienced academic achievement similar to normal weight peers.The research team — led by Caron A.C. Clark, a scientist in the Department of Psychology and Child and Family Center at the University of Oregon — detected an overall reduced volume of mid-brain structures, the caudate and corpus callosum, which are involved in connectivity, executive attention and motor control.The findings, based a logistic regression analyses of the MRIs done approximately five years ago, were published in the May issue of the journal Neuropsychology. The longitudinal study originally was launched in the 1980s with a grant from the National Institute of Child Health and Human Development (National Institutes of Health, grant HD 26554) to H. Gerry Taylor of Case Western University, who was the senior author and principal investigator on the new paper.”Our new study shows that pre-term births do not necessarily mean academic difficulties are ahead,” Clark said. “We had this group of children that did have academic difficulties, but there were a lot of kids in this data set who didn’t and, in fact, displayed the same trajectories as their normal birth-weight peers.”Academic progress of the 201 original participants had been assessed early in their school years, again four years later and then annually until they were almost 17 years old. “We had the opportunity to explore this very rich data set,” Clark said. “There are very few studies that follow this population of children over time, where their trajectories of growth at school are tracked. We were interested in seeing how development unfolds over time.”The findings, Clark added, provide new insights but also raise questions such as why some low-birth-weight babies develop normally and others do not? “It is very difficult to pick up which kids will need the most intensive interventions really early, which we know can be really important.”The findings also provide a snapshot of children of very low birth weights who were born in NICU 30 years ago. …

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Obese patients trust diet advice from overweight physicians more than normal weight physicians

June 4, 2013 — When it comes to taking diet advice from a physician — size matters. This is according to a new study led by a team of researchers at the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins University School of Medicine who examined the impact of primary care physician BMI (body mass index) on their patients’ trust and perceptions of weight-related stigma. They found that overweight and obese patients trust weight-related counseling from overweight physicians more than normal weight physicians and patients seeing an obese primary care physician were more likely to perceive weight-related stigma.The results are featured online in the June 2013 issue of Preventive Medicine.”With respect to overall trust, our results suggest that overweight and obese patients trust their primary care physicians, regardless of their body weight,” said Sara Bleich, PhD, associate professor with the Bloomberg School’s Department of Health Policy and Management. “However, with respect to trust in weight-related advice, we found that patients more strongly trusted diet advice from overweight primary care physicians as compared to normal BMI primary care physicians. In addition, we found that patient perceptions of weight-related stigma increased with physician BMI. Patients seeing obese primary care physicians, as compared to normal BMI physicians, were significantly more likely to report feeling judged because of their weight.”Using a national cross-section survey of 600 overweight and obese patients, researchers examined overall trust and trust in weight-related counseling from their primary care physicians. Overall trust was assessed by asking, “Using any number from 0 to 10, where 0 means that you do not trust this doctor at all and 10 means that you trust this doctor completely, what number would you use to rate how much you trust this doctor?” While, trust in weight-related advice was assessed by the survey question: “How much do you trust the advice from this doctor about how to control your weight; improve your diet or increase your physical activity, a great deal; a good amount; only some or very little?” Bleich and colleagues conducted multivariate regression analyses to determine whether trust or perceived stigma differed by physician BMI.”While weight-related stigma has been documented among health professionals for decades, as well as lower physician respect towards patients with a higher BMI, our finding that weight-related stigma increases with physician BMI was quite surprising,” notes Bleich. “Recent changes to obesity coverage among the publicly insured makes understanding primary care physicians’ barriers to providing effective obesity care critical. Existing research suggests that primary care physicians face numerous challenges to providing optimal obesity care which include knowledge deficits, negative attitudes and structural barriers. Future research should further examine the impact of physician BMI on obesity care. …

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New discovery permits rapid diagnosis and treatment of sepsis

May 30, 2013 — Despite numerous advances in treating infections and disease, effective treatments for sepsis remain elusive. A new discovery published in the June 2013 issue of The FASEB Journal not only could help health care providers predict who is more and less likely to develop sepsis, but it also opens the doors to new therapies that actually address the root cause of the problem, rather than just managing the symptoms. This also has the potential to benefit patients suffering from influenza and other viral infections, as well as chronic inflammatory diseases such as periodontal disease, rheumatoid arthritis, inflammatory bowel disease and chronic obstructive pulmonary disease.


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“Addressing infectious and inflammatory complications early and effectively in burn and trauma patients remains a significant unmet clinical need,” said Daniel Irimia, M.D., Ph.D., a researcher involved in the work from the BioMEMS Resource Center and the Department of Surgery at Shriners Hospital for Children in Boston, MA. “This need is augmented by the difficulties of diagnosing infections early and the upsurge in frequency of multi-drug resistant bacteria.”

To make this discovery, Irimia and colleagues studied two groups of rats with burn injuries and septic complications by designing a microfluidic assay to precisely measure the movement of isolated neutrophils. They found that the ability of neutrophils to move becomes progressively worse during the first week after the injury, and that a known compound, called resolvin D2, can restore neutrophil movement. Using neutrophil measurements as a guide, researchers optimized the parameters of the treatment, and as a result all treated animals survived, while all untreated animals died. This study suggests that measuring neutrophil motility could become a useful biomarker for the actual risk for septic complications in patients. Rather than relying on statistical data for each disease and patient group, measuring neutrophil movement could help personalize treatments for individual patients, resulting in better outcomes.

“Reports of patients contracting deadly secondary infections while in the ICU continue to increase,” said Gerald Weissmann, M.D., Editor-in-Chief of The FASEB Journal, “but doctors have to find out what’s wrong, and find it out quickly. This research should lead to faster diagnosis and better treatments for burns and sepsis. It’s an important step on the way to new therapeutics.”

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The above story is reprinted from materials provided by Federation of American Societies for Experimental Biology, via EurekAlert!, a service of AAAS.

Note: Materials may be edited for content and length. For further information, please contact the source cited above.


Journal Reference:

  1. T. Kurihara, C. N. Jones, Y.-M. Yu, A. J. Fischman, S. Watada, R. G. Tompkins, S. P. Fagan, D. Irimia. Resolvin D2 restores neutrophil directionality and improves survival after burns. The FASEB Journal, 2013; 27 (6): 2270 DOI: 10.1096/fj.12-219519

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Operative death rates higher at weekend, warn researchers

May 29, 2013 — There is a higher risk of death for patients who have elective surgery later in the week and at the weekend, compared with those earlier in the week, a new paper suggests

Previous research has suggested a significantly higher risk of death if admitted as an emergency patient at the weekend compared with a weekday. Plus, other papers have described the “weekend effect.”

Researchers offer two potential explanations for this: poorer quality of care at the weekend (which can be attributed to staffing levels and / or less senior / experienced staff) and patients who are admitted or operated on at the weekend being more severely ill.

In this, the first study to focus on day of elective surgery to report a ‘weekday effect’, researchers from Imperial College London investigate death rates for planned admissions by day of the week of procedure, hypothesising that if there is a quality of care issue at weekends, higher death rates would be seen.

National hospital administrative data were used, linked with death certificates. Information was used on patients’ age, gender, source of admission and diagnoses. Mortality outcome was defined as any death occurring within 30 days of the index procedure.

The researchers focussed their study on five higher-risk major surgical procedure groups: excision of esophagus and / or stomach; excision of colon and / or rectum; coronary artery bypass graft; repair of abdominal aortic aneurysm and excision of lung.

There were 4,133,346 elective inpatient surgical procedures with 27,582 deaths within 30 days of the date of procedure during 2008/2009 to 2010/2011. 4.5% of this surgery was performed at the weekend.

Weekend patients tended to have fewer diseases, fewer admissions, longer waiting time and lower-risk surgery.

The overall risk of 30-day death for patients undergoing elective surgery increased with each day of the week the procedure was performed (by an odds ratio factor of 1.09 per day from Monday). Compared with Monday, the risk of death was significantly higher if procedures were carried out on a Friday. There were also significant differences in the observed rates of death for each day of the week, compared with Monday, for all procedures.

The 30-day mortality rates (for the five selected major survival procedures) per 1000 admissions were: 35 for excision of esophagus and/or stomach; 24 for excision of colon and/or rectum; 20 for coronary artery bypass graft; 34 for repair of abdominal aortic aneurysm and 20 for excision of lung. All procedures, apart from repair of abdominal aortic aneurysm, had statistically significant trends towards higher mortality at the end of the working week and weekends compared with Monday.

The findings suggest that the weekend effect might be more pronounced for patients with more diseases and for patients with three or more previous admissions, than for patients with none.

The researchers say that their analysis confirms their hypothesis that there is a ‘weekday effect’ on mortality for patients undergoing elective surgery. They say that serious complications are more likely to occur within the first 48 hours post-operatively and a failure to rescue the patient may be due to well-known issues relating to reduced, and / or locum, staffing and poorer availability of services.

They conclude that without more information related to surgical care processes, including the organisation of services / staffing, it remains unclear if the estimated risks can be entirely attributed to differences in quality of care and provision needs to be made for adequate services to support these patients and ensure the best outcome.

In an accompanying editorial, doctors from the Mount Sinai Hospital in Toronto say that reassuringly, the “weekend effect” is not due to reduced staffing levels. They say the paper’s findings do however beg the question, what makes these patients different? Doctors Kwan and Bell question whether there are any differences between “surgeons who operate or the surgical teams who work at weekends and those who work in the week.” They conclude the scheduling of elective procedures can be controlled but ask whether we are willing to “sacrifice the safe provision of care for shorter procedural wait times and length of stay.”

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