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Two-decade-long trends (1975-1997) in the incidence, hospitalization, and long-term death rates associated with complete heart block complicating acute myocardial infarction: A community-wide perspective

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AMERICAN HEART JOURNAL 2003年第3期145卷 500-507页

作者： Spencer, FA Jabbour, S Lessard, D Yarzebski, J Ravid, S Zaleskas, V Hyder, M Gore, JM Goldberg, RJ Univ Massachusetts Sch Med Dept Med Div Cardiovasc Med Worcester MA 01655 USA Lown Cardiovasc Res Fdn Brookline MA USA

Background The purpose of this community-wide study was to describe a >2-decade-long experience (1975-97) in the incidence and death rates associated with complete heart block (CHB) in patients with acute myocardial infarction (AMI). Limited population-based: data exist describing recent, and changes with time therein, incidence and case-fatality rates associated with CHB complicating AMI. Methods We conducted an observational study of 9082 metropolitan Worcester, Mass, residents (1990 census 437,000) hospitalized with validated AMI in all greater Worcester hospitals during 11 1-year periods between 1975 and 1997. Results Overall, CHB developed in 5.0 % of patients with AMI. The incidence rates of CHB declined in the periods studied (6.0% in 1975/78 vs 3.1 % in 1997). Declines in the occurrence of CHB were noted in patients with anterior or inferior/posterior MI. These trends remained after adjustment for other factors that might affect the risk of CHB. Patients in whom CHB developed experienced significantly higher hospital death rates than patients in whom CHB did not develop (46.8% vs.14.6%). However, improving trends in the hospital survival rate of patients with CHB were observed between 1975/78 (47.4% surviving) and 1997 (61.3% surviving). Patients in whom CHB developed during hospitalization were not at increased risk for dying after hospital discharge. Conclusions our findings indicate that the incidence of CHB complicating AMI has declined with time. The hospital prognosis of patients in whom CHB developed has improved, but these patients remain at an increased risk of hospital mortality. The long-term prognosis of patients with inferior MI and CHB is similar to that of patients in whom CHB did not develop. Patients with anterior MI and CHB may beat an increased risk of long-term mortality.

关键词：急性病共病现象心脏传导阻滞/诊断心脏传导阻滞/流行病学心脏传导阻滞/死亡率医院死亡率/发展趋势住院/统计学和数值数据住院/发展趋势发病率纵向研究马萨诸塞/流行病学死亡率/发展趋势心肌梗死/诊断心肌梗死/流行病学存活率分析老年人女(雌)性人类男(雄)性

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Comparing hierarchical modeling with traditional logistics regression analysis among patients hospitalized with acute myocardial infarction: Should we be analyzing cardiovascular outcomes data differently?

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AMERICAN HEART JOURNAL 2003年第1期145卷 27-35页

作者： Austin, PC Tu, JV Alter, DA Inst Clin Evaluat Sci Toronto ON M4N 3M5 Canada Schulich Heart Ctr Div Cardiol Toronto ON Canada Univ Toronto Dept Publ Hlth Sci Toronto ON Canada Sunnybrook & Womens Coll Hlth Sci Ctr Div Gen Internal Med Toronto ON Canada Clin Epidemiol & Hlth Care Res Program Toronto ON Canada

Background Data. in health research are frequently structured, hierarchically. For example, data, may consist of patients treated by physicians who in turn practice in hospitals. Traditional statistical techniques ignore the possible correlation of outcomes within a given practice or hospital. Furthermore, imputing characteristics measured at higher levels of, the hierarchy to the patient-level artificially inflates the amount of available information on the effect of higher-level characteristics on outcomes. Methods Conventional logistic regression models and multilevel logistic regression models were fit to a cross-sectional cohort of patients hospitalized with a diagnosis of acute myocardial infarction. The statistical significance of the effect of patient, physician, and hospital characteristics on patient outcomes was compared between the 2 modeling strategies. Results The 2 analytic strategies agreed well on the effect of patient characteristics on outcomes. According to the traditional analysis, teaching status was statistically significantly associated with 5 of the 9 outcomes, whereas the multilevel models did not find a statistically significant association between teaching status and any patient outcomes. Similarly, the traditional and multilevel models disagreed on the statistical significance of the effect of being treated at a revascularization hospital and 3 patient outcomes. Conclusions in comparing the resultant models, we see that false inferences can be drawn by ignoring the structure of the data. Conventional logistic regression tended to increase the statistical significance for. the effects of variables measured at the hospital-level compared to the level of significance indicated by the multilevel model.

关键词：年龄分布队列研究住院/统计学和数值数据 Logistic模型模型统计学多元分析心肌梗死/死亡率心肌梗死/治疗安大略/流行病学疾病严重程度指数性别分布存活率治疗结果成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Evaluation of the pediatric risk of admission score in a pediatric emergency department

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ANNALS OF EMERGENCY MEDICINE 2003年第5期41卷 630-638页

作者： Gravel, J Gouin, S Amre, D Bergeron, S Lacroix, J Univ Montreal Hop St Justine Dept Pediat Div Emergency Med Montreal PQ H3T 1C5 Canada Univ Montreal Hop St Justine Dept Pediat Res Inst Montreal PQ H3T 1C5 Canada Univ Montreal Hop St Justine Dept Pediat Div Intens Care Montreal PQ H3T 1C5 Canada

Study objectives: The pediatric risk of admission (PRISA) score was developed to predict the risk for hospitalization for pediatric emergency department patients. We sought to evaluate prospectively the predictive value of the PRISA score with respect to the risk for hospitalization in a pediatric ED. Methods: A prospective cohort study was conducted in a pediatric tertiary center ED. From November 1, 2000, to October 31, 2001, 3 periods of 8 hours each were randomly chosen monthly. During these periods, all patients triaged to the ED were evaluated. Data collection was performed by an investigator uninvolved in the patients' treatment. Data were recorded before the decision regarding hospitalization was made. Odds ratios for the risk of hospitalization related to individual criteria and PRISA scores were calculated. Discrimination and calibration of the score were assessed. Results: During the study periods, 1,930 patients were evaluated. Among these, 203 hospitalizations were observed, and the PRISA score predicted 235. The goodness-of-fit test demonstrated that the score had good predictive ability (chi(2) =28.15;P=38). Receiver operating characteristic curve analysis confirmed the latter findings (area under the curve 0.79 [95% confidence interval 0.72 to 0.86]). Some individual criteria of the score did not significantly predict risk for admission. Conclusion: The PRISA score is a good predictor of the risk for hospitalization in a pediatric ED. It seems more accurate for the sicker patients. Some variables of the score could be deleted or modified to optimize its accuracy.

关键词：卡方分布急诊室医院/统计学和数值数据住院/统计学和数值数据医院儿科/统计学和数值数据 Logistic模型病人入院/统计学和数值数据试验预期值前瞻性研究魁北克 ROC曲线危险性评估疾病严重程度指数青少年成年人儿童儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性

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How many emergency department visits are there?

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ANNALS OF EMERGENCY MEDICINE 2003年第3期41卷 319-321页

作者： Wears, RL Univ Florida Hlth Sci Ctr Dept Emergency Med Jacksonville FL 32209 USA

[ Ann Emerg Med. 2003;41:319-321.]

关键词：门诊医疗/统计学和数值数据数据收集/方法急诊室医院/利用住院/统计学和数值数据病人接受卫生保健的程度/统计学和数值数据美国/流行病学利用情况审核/方法人类

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New national surveillance system for hemodialysis-associated infections: Initial results

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AMERICAN JOURNAL OF INFECTION CONTROL 2002年第5期30卷 288-295页

作者： Tokars, JI Miller, ER Stein, G Ctr Dis Control & Prevent Div Healthcare Qual Promot Dialysis Surveillance Network Atlanta GA 30333 USA

Background: Hemodialysis patients have frequent infections, especially of the vascular access site, and often harbor antimicrobial-resistant pathogens. Therefore a voluntary national system was created to monitor and prevent infections in these patients. Methods: From October 1999 to May 2001, participating centers recorded the number of chronic hemodialysis outpatients that were treated (denominator), Several outcome events, including infections of the vascular access site, were monitored, Data were reported on paper forms or via an Internet-based data entry and analysis system. Results: Among 109 participating centers, the vascular access infection rate per 100 patient-months was 3.2 overall and varied markedly by type of vascular access: 0.56 for native arteriovenous fistulas, 1.36 for synthetic arteriovenous grafts, 8.42 for cuffed catheters, and 11.98 for noncuffed catheters. Among 76 dialysis centers reporting at least 200 patient-months of data, 11 had a significantly low and 14 a significantly high rate of vascular access infection. Conclusion: Initial results from the first national project to monitor infections in patients undergoing hemodialysis indicate that vascular access infections were common and that risk varied substantially among different vascular access types and different dialysis centers. These results can be used for quality improvement at individual centers and to help evaluate the efficacy of specific infection control measures.

关键词：门诊医疗设施/统计学和数值数据菌血症/流行病学菌血症/传播细菌/分离和提纯细菌/致病力数据收集设备污染住院/统计学和数值数据人群监测肾透析/仪器和设备美国/流行病学人类

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A randomized clinical trial comparing oral ondansetron with placebo in children with vomiting from acute gastroenteritis

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ANNALS OF EMERGENCY MEDICINE 2002年第4期39卷 397-403页

作者： Ramsook, C Sahagun-Carreon, I Kozinetz, CA Moro-Sutherland, D Wendy Fitzwilliam Pediat Hosp Sect Pediat Emergency Med Mt Hope Trinidad Tobago Texas Childrens Hosp Baylor Coll Med Dept Pediat Sect Emergency Med Houston TX 77030 USA Texas Childrens Hosp Baylor Coll Med Dept Pediat Sect Acad Gen Pediat Houston TX 77030 USA

Study objective: Vomiting in children suffering from acute gastroenteritis interferes with the oral rehydration process and equally frustrates parents and health care providers. Adjuncts such as promethazine and metoclopramide are less than optimally effective and are associated with side effects. Ondansetron, a 5-HT3 receptor antagonist marketed as Zofran, is a safe and effective antiemetic used extensively in oncology and postoperative patients. We evaluate the effect of the antiemetic ondansetron versus placebo on the clinical outcome of patients with vomiting from gastroenteritis in a pediatric emergency department. Methods: This was a randomized, prospective, double-blind clinical trial in a university-affiliated children's hospital ED, Children between the ages of 6 months and 12 years who had vomited at least 5 times during the preceding 24 hours were randomized to receive either oral ondansetron or a taste- and color-matched placebo. Oral rehydration was commenced 15 minutes later at 5 mL/min per standard oral rehydration protocols. Patients were discharged after they voided and continued standard oral rehydration at home with the introduction of a bananas, rice, applesauce, and toast (BRAT) diet after the first 24 hours, Any patient requiring admission was considered a treatment failure, and no further doses were given. Discharged patients were given 5 additional doses to be used every 8 hours, and they were contacted by telephone 24 and 48 hours after discharge to record the number of episodes of vomiting and diarrhea. The parents were also required to complete a diary of the same information, which was mailed to the investigators for confirmation of the telephone data. Results: One hundred forty-five patients were enrolled, of whom 51% (n=74) were randomized to ondansetron. At baseline, age distribution, sex, and severity of illness did not differ between the ondansetron and placebo groups. During the observation period in the ED, the median number of epi

关键词：急性病/治疗投药口服腹泻/并发症双盲法补液疗法/统计学和数值数据胃肠炎/并发症住院/统计学和数值数据昂丹司琼/投药和剂量前瞻性研究治疗结果呕吐/药物疗法呕吐/病因学儿童儿童学龄前女(雌)性人类婴儿男(雄)性

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Correlates and outcomes of preserved left ventricular systolic function among older adults hospitalized with heart failure

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AMERICAN HEART JOURNAL 2002年第2期144卷 365-372页

作者： Ahmed, A Roseman, JM Duxbury, AS Allman, RM DeLong, JF Univ Birmingham Div Gerontol & Geriatr Med Dept Med Birmingham AL 35294 USA Univ Birmingham Dept Epidemiol & Publ Hlth Birmingham AL USA Univ Birmingham Ctr Aging Birmingham AL USA Univ Birmingham Ctr Outcomes & Effectiveness Educ & Res Birmingham AL USA VA Med Ctr Heart Failure Clin Birmingham AL USA VA Med Ctr Sect Geriatr Birmingham AL USA VA Med Ctr Geriatr Res Educ & Clin Ctr Birmingham AL USA Alabama Qual Assurance Fdn Birmingham AL USA

Background Heart failure (HF) in older adults is often associated with preserved left ventricular systolic function (LVSF). The objective of this retrospective follow-up study was, to determine the correlates and outcomes of preserved LVSF among older adults hospitalized with HF. Methods We studied older Medicare beneficiaries hospitalized with HF (n = 1091) who had documented LVSF evaluation (n = 438). LVSF was defined as preserved if left ventricular ejection fraction was greater than or equal to 40%. The Fisher exact test and the Student t test were used to compare baseline characteristics between patients with preserved versus those with impaired LVSF. Multivariate logistic regression analysis was used to determine the correlates of preserved LVSF. Cox proportional hazards analyses were used to determine the associations between LVSF and both 4-year mortality rates and 6-month readmission rates and the associations between angiotensin-converting enzyme (ACE) inhibitor use and 4-year mortality rates, separately, in patients with preserved and impaired LVSF. Results Of the 438 patients, 200 (46%) had preserved LVSF. Women were more likely to have preserved LVSF (odds ratio [OR] = 2.44, 95% Cl 1.57-3.81) than men. Preserved LVSF was associated with lower 4-year mortality rates (adjusted hazards ratio [HR] = 0.67, 95% Cl 0.52-0.86) but not with 6-month readmission rates (adjusted HR = 0.66, 95% Cl 0.41-1.09). The use of ACE inhibitors was associated with lower 4-year mortality,rates in patients with impaired LVSF (adjusted HR = 0.61, 95% Cl 0.43-0.86) but not in those with preserved LVSF (HR = 0.96, 95% Cl 0.65-1.42). Conclusions Among older adults hospitalized with HF, preserved LVSF was common among women and was associated with significantly higher morbidity and mortality rates, which were unaffected by treatment with ACE inhibitors.

关键词：非洲大陆世系人群血管紧张素转换酶抑制药/治疗应用共病现象住院/统计学和数值数据 Medicare/统计学和数值数据患病率比例危险度模型性别分布存活率治疗结果美国/流行病学心室功能障碍左/流行病学老年人老年人 80以上女(雌)性人类男(雄)性

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Spectrum of heart failure in older patients: Results from the National Heart Failure project

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AMERICAN HEART JOURNAL 2002年第3期143卷 412-417页

作者： Havranek, EP Masoudi, FA Westfall, KA Wolfe, P Ordin, DL Krumholz, HM Denver Hlth Med Ctr 0960 Denver CO 80220 USA Colorado Fdn Med Care Aurora CO USA Univ Colorado Hlth Sci Ctr Denver CO USA Hlth Care Financing Adm Boston MA USA Yale Univ Sch Med New Haven CT USA

Background The elderly make up the majority of patients with heart failure (HF), but information on this segment of the HF population is lacking because clinical trials typically enroll younger patients and population-based studies lack clinical detail. We sought to describe a contemporary national sample of elderly patients with HF and to examine the sample for age-related trends in clinical characteristics. Methods We studied the charts of 800 Medicare patients per state who were hospitalized with a principal diagnosis of HF between April 1998 and March 1999. There were 34,587 patients in the sample after exclusion of patients who were <65 years old, repeat discharges, discharges to another acute care facility or against medical advice, or receiving long-term hemodialysis. Results Comorbidity was common. About one third of patients had chronic obstructive pulmonary disease, about 40% had diabetes, more than half had coronary heart disease, and more than half had a history of hypertension, but comorbidity rates declined with age, Left ventricular ejection fraction was <40% in only 50.4% of patients in whom it was assessed. Associated laboratory abnormalities were relatively constant across the age spectrum, but renal insufficiency was more common with advancing age. The likelihood that patients were in long-term care facilities before admission rose quite steeply with age. Conclusions Elderly patients with HF are a heterogeneous group and appear to differ substantially from patients enrolled in clinical trials. Evidence-based guidance for treatment in the context of multiple comorbid conditions, poor renal function, HF with preserved left ventricular systolic function, and residence in long-term care facilities is urgently needed.

关键词：共病现象冠心病/流行病学糖尿病/流行病学住院/统计学和数值数据高血压/流行病学 Medicare 病人出院/统计学和数值数据病人遴选肺疾病慢性阻塞性/流行病学每搏输出量美国/流行病学老年人老年人 80以上女(雌)性人类男(雄)性

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Choice of clinical outcomes in randomized trials of heart failure therapies: Disease-specific or overall outcomes?

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AMERICAN HEART JOURNAL 2002年第1期143卷 22-28页

作者： Yusuf, S Negassa, A McMaster Univ Div Cardiol Hamilton ON L8S 4L8 Canada Hamilton Hlth Sci Corp Prevent Cardiol & Therapeut Program Hamilton ON Canada

Background There are different views regarding the appropriateness of using cause-specific events or all events as the primary outcome of clinical trials. Methods This is a methodologic essay in which we discuss the pros and cons of the 2 approaches and provide illustrative examples. Results Our preference is the use of cause-specific outcomes (as long as they can be classified with reasonable reproducibility and without bias) because they are more likely to be sensitive to change, less likely to lead to spurious conclusions by random variations in categories of outcomes that are unlikely to be affected by treatment, and relatively free from confounding. Overall benefit-risk ratios can be derived by examining the impact of treatment on various categories of outcomes and then developing 6 general judgment. Such an approach will also allow judgments to be made regarding generalizability of results across various groups of patients who are at differing risks for an event. Conclusions In general, cause-specific outcomes sensitive to the effects of a treatment are to be preferred as the principal outcome in trials of heart failure, as long as they are biologically sensible and can be classified without bias. Other outcomes, not expected to be affected, should also be reported separately.

关键词：偏倚(流行病学) 心排血量低/死亡率心排血量低/治疗死亡原因猝死心脏/病因学住院/统计学和数值数据预后危险性评估敏感性与特异性治疗结果人类

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An emergency department observation unit protocol for acute-onset atrial fibrillation is feasible

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ANNALS OF EMERGENCY MEDICINE 2002年第4期39卷 374-381页

作者： Koenig, BO Ross, MA Jackson, RE William Beaumont Hosp Dept Emergency Med Royal Oak MI 48072 USA Wayne State Univ Sch Med Dept Emergency Med Detroit MI USA

Study objective: We sought to describe the feasibility of an emergency department observation unit (EDOU) treatment protocol for the management of uncomplicated acute-onset atrial fibrillation (AAF). Methods: This descriptive case series took place at a major suburban, university-affiliated teaching hospital. Patients were prospectively enrolled in an EDOU treatment protocol if they had uncomplicated AAF that failed initial ED attempts to convert to sinus rhythm. In the EDOU, patients underwent ECG monitoring, serial creatine kianse MB measurements, and further rate control with optional electrical cardioversion. Primary outcomes measured were EDOU rate of conversion to sinus rhythm, rate of discharge home, length of stay, positive diagnostic outcomes, complications of AAF, and 7-day return visits. Results: Sixty-seven patients were studied. Patients were symptomatic for a median of 4.0 hours, had mean initial ED pulse rates of 137+/-23 beats/min, and spent 4.7+/-2.2 hours in the ED before transfer to the EDOU, While in the EDOU, 55 (82%) patients converted to sinus rhythm. Five (7%) patients were admitted because of positive test results: 2 for myocardial infarction, 2 for fever, and 1 for ventricular tachycardia. Twelve (18%) patients remained in atrial fibrillation, with 9 admitted and 3 discharged, Overall, 81% of patients were discharged in 11.8+/-7.0 hours, and 19% were admitted after 17.6+/-9.5 hours of observation. Three discharged patients returned within 7 days, 2 for uncomplicated recurrent AAF and 1 for chest pain subsequently found to be noncardiac in origin, There were no major complications attributable to the EDOU protocol, Conclusion: Selected patients with AAF for whom initial ED management fails can subsequently be managed in an EDOU with a high short-term conversion and discharge rate.

关键词：急性病/治疗抗心律失常药/治疗应用心房颤动/治疗临床方案电抗休克/统计学和数值数据急诊室医院/组织和管理急诊处理/方法可行性研究随访研究住院/统计学和数值数据密执安/流行病学观察结果与过程评价(卫生保健) 前瞻性研究成年人老年人女(雌)性人类男(雄)性中年人

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