No description available.

As multiple trauma is ubiquitous, affects predominantly young people and is attended by a high mortality, it seemed a fruitful area for study in an effort to reduce morbidity and mortality. One of the main problems in trauma research has been accurate description of the severity of injury and associating severity with subsequent outcome. While a number of scoring systems have been proposed the Injury Severity Score has been the most widely adopted and validated. The Injury Severity score was adopted with a number of other systems of scoring infection and other complications in a retrospective study of multiple trauma patients admitted to an Intensive Therapy Unit. This study revealed an unexpected increased in mortality in the latter two years of the study period which was not associated with an increase in injury severity as assessed by the ISS nor by any other change in patient characteristics which might explain this finding. Eventually it was noted that the introduction of a hypnotic drug etomidate for use in sedation of ventilated patients seemed to be associated with the increased mortality. Clinical evidence suggested that etomidate might inhibit adrenocortical function and an experimental study indeed confirmed that etomidate had a direct effect on adrenal steroidogenesis such that cortisol and aldosterone production were completely suppressed. Following analysis of the retrospective clinical study etomidate was withdrawn from use in our unit. Analysis of mortality rates both for trauma patients and the general patient population indicated a reversion to the rate which pertained prior to introduction of etomidate. The results of retrospective and prospective clinical studies strongly implied that the administration of etomidate was associated with an increased mortality among trauma patients. The experimental study based on clinical observations clearly demonstrated that etomidate infusion was a potent inhibitor of adrenal steroidogenesis. It seems highly likely that the detrimental effect of etomidate was mediated by its direct inhibitory effect on the production of cortisol and aldosterone by the adrenal gland. Subsequent clinical and experimental studies from other authors tend to confirm these findings.

No description available.

Sepsis causes major health care problems in the United States, resulting in long hospitalizations, complications, and even patient death. Lack of nursing knowledge regarding sepsis signs and symptoms is a significant problem at a hospital in the northeast. Local hospital data showed a high patient mortality rate for patients diagnosed with sepsis. The purpose of this project was to develop an educational module on sepsis for intensive care nurses. The educational module was developed using current sepsis evidence-based guidelines. The practice-focused question for the project asked whether an educational module on sepsis would increase the intensive care nurse's knowledge on sepsis recognition and treatment guidelines. The adult learning theory was used as a conceptual model to guide project development. After development, the educational module was evaluated by a panel of 8 experts, including a nurse educator, infection control nurse, a charge nurse, a staff nurse, and an infectious disease physician. Program content evaluations included a 10-question pretest/posttest questionnaire completed by each panel member. Program content was modified based on pretest/posttest results. Results of the panel evaluation indicated agreement that the sepsis module content would benefit nurses on sepsis recognition and management for patients. Improving nursing knowledge on sepsis can provide a positive social change to improve patient outcomes, including mortality rates and complications from sepsis.

When faced with death counts strati ed by age, analysts often calculate a crude mortality rate (CMR) as a single summary measure. This is done by simply dividing total death counts by total population counts. However, the crude mortality rate is not appropriate for comparing different populations due to the significant impact of age on mortality and the possibility of having different age structures for different populations. While a set of age-adjustment methods seeks to collapse age-specific mortality rates into a single measure that is free from the confounding effect of age structure, we focus on one of these methods called "direct age-standardization" method which summarizes and compares age-specific mortality rates by adopting a reference population. While qualitative insights in relation to age-standardization are often discussed, we seek to approximate age-standardized mortality rate of a population based on the corresponding CMR and the 90th quantile of its population distribution. This approximation is most useful when age-specific mortality data is unavailable. In addition, we provide quantitative insights related to age-standardization. We derive our model based on mathematical insights drawn from the explication of exact calculations and validate our model by using empirical data for a large number of countries under a large number of circumstances. We also extend the application of our approximation model to other age-standardized mortality indicators such as cause-specific mortality rate and potential years of life lost. In the second part of the thesis, we consider the formulation of a general risk management procedure, where risk needs to be measured and further mitigated. The formulation admits an optimization representation and requires as input the distributional information about the underlying risk factors. Unfortunately, for most risk factors it is known to be difficult to identify their distribution in full details, and more problematically the risk management procedure can be prone to errors in the input distribution. In particular, one of the most important distribution information is the covariance hat captures the spread and correlation among risk factors. We study the issue of covariance uncertainty in the problem of mitigating tail risk and by admitting an uncertainty set of covariance of risk factors, we propose a robust optimization model which minimizes risk for the worst scenario especially when data is insufficient and the number of risk factors is large. We will then transform our model into a computationally solvable one and test the model using real-world data.

Magister Scientiae - MSc / Although the under-five mortality rate in Malawi has been declining since 1960, it still remains one of the highest in the world. In order to appropriately target interventions to achieve substantial reductions in deaths among children under the age of five years in Malawi, there is an ongoing need for better knowledge of the proportion of cause-specific under-five mortality in the country. The aim of this study was to estimate the direct contribution of HIV/AIDS to the observed level of under-five mortality in Malawi during the period 2000 to 2004. / South Africa

This thesis is missing page 168. The other copies do not have this page. -Digitization Centre / The Canadian Health Insurance program has been in place for quite some time now and it has always been said that Canadians have some of the best healthcare in the world. Canadian healthcare is very well known throughout the world because every Canadian citizen has the right to healthcare without having to pay for it. The benefits of this program are quite well known but some benefits one might think would result, just might not be there. This paper looks at whether the inception of Canadian Health Insurance has had an effect on the mortality rates of Canadians. Through a statistical analysis, this paper shows that there is no evidence that the Canadian Health Insurance program has had an effect on Canadian aggregate mortality rates. This paper shows that Canadian mortality rates follow a trend to that of the United States. To say Canadians have a similar trend in mortality rate to the United States is perhaps surprising since Canadians are supposed to have a far superior healthcare system. / Thesis / Master of Science (MS)

Yes / IMPORTANCE Patients undergoing emergency laparotomy have high mortality, but few studies exist to improve outcomes for these patients. OBJECTIVE To assess whether a collaborative approach to implement a 6-point care bundle is associated with reduction in mortality and length of stay and improvement in the delivery of standards of care across a group of hospitals. DESIGN, SETTING, AND PARTICIPANTS The Emergency Laparotomy Collaborative (ELC) was a UK-based prospective quality improvement study of the implementation of a care bundle provided to patients requiring emergency laparotomy between October 1, 2015, and September 30, 2017. Participants were 28 National Health Service hospitals and emergency surgical patients who were treated at these hospitals and whose data were entered into the National Emergency Laparotomy Audit (NELA) database. Post-ELC implementation outcomes were compared with baseline data from July 1, 2014, to September 30, 2015. Data entry and collection were performed through the NELA. INTERVENTIONS A 6-point, evidence-based care bundle was used. The bundle included prompt measurement of blood lactate levels, early review and treatment for sepsis, transfer to the operating room within defined time goals after the decision to operate, use of goal-directed fluid therapy, postoperative admission to an intensive care unit, and multidisciplinary involvement of senior clinicians in the decision and delivery of perioperative care. Change management and leadership coaching were provided to ELC leadership teams. MAIN OUTCOME AND MEASURES Primary outcomes were in-hospital mortality, both crude and Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) risk-adjusted, and length of stay. Secondary outcomes were the changes after implementation of the separate metrics in the care bundle. RESULTS A total of 28 hospitals participated in the ELC and completed the project. The baseline group included 5562 patients (2937 female [52.8%] and a mean [range] age of 65.3 [18.0-114.0] years), whereas the post-ELC group had 9247 patients (4911 female [53.1%] and a mean [range] age of 65.0 [18.0-99.0] years). Unadjusted mortality rate decreased from 9.8% at baseline to 8.3% in year 2 of the project, and so did risk-adjusted mortality from a baseline of 5.3% to 4.5% post-ELC. Mean length of stay decreased from 20.1 days during year 1 to 18.9 days during year 2. Significant changes in 5 of the 6 metrics in the care bundle were achieved. CONCLUSIONS AND RELEVANCE A collaborative approach using a quality improvement methodology and a care bundle appeared to be effective in reducing mortality and length of stay in emergency laparotomy, suggesting that hospitals should adopt such an approach to see better patient outcomes and care delivery performance. / This study was funded by The Health Foundation, United Kingdom, as part of a Scaling Up Award.

La réduction de la mortalité maternelle et infantile est universellement acceptée comme un objectif du millénaire pour le développement. L'aide étrangère est un des moyens utilisés pour l'atteindre. Cependant, malgré les succès, à l'échelle microéconomique, de certains programmes de santé financés par les aides étrangères, l'efficacité globale de ces aides demeure inconnue. Plusieurs travaux ont traité de l'efficacité de l'aides sur la croissance économique, mais peu d'entre eux concernent le secteur de la santé. Le but de cette thèse, est précisément d'évaluer l'efficacité des aides étrangères sur des indicateurs de santé à l'échelle macroéconomique. On va essayer d'explorer l'impact des aides étrangères octroyées par des bailleurs privés et publics sur l'état de santé telle que la mortalité infantile, maternelle et des adultes dans les pays en développement. La thèse examine l'affectation des aides étrangères au secteur de la santé, à travers trois documents de travail à soumettre à publication. / The reduction of child and maternal mortality is universally accepted as a millennium development goal (MDG). Foreign aid for health is one of the means implemented to reach it. However, even if many successes of health aid activities have been underlined at the microeconomic level, the effectiveness of health aid in general remains unknown. In spite of many macroeconomic works on aid effectiveness on economic growth, only little deals with its effectiveness in health. The purpose of this thesis is precisely to assess the effectiveness of foreign aid in improving health measurements, at the macroeconomic level. I tried to explore the impact of health aid disbursed by the donors through the government and private sector on health outcomes like child, maternal and adult mortality rates in developing economies. The thesis examines the issue of foreign aid earmarked for health sector using a three-paper format. The three chapters of this thesis can be read independently.

<p>Although the under-five mortality rate in Malawi has been declining since 1960, it still remains one of the highest in the world. In order to appropriately target interventions to achieve substantial reductions in deaths among children under the age of five years in Malawi, there is an ongoing need for better knowledge of the proportion of cause-specific under-five mortality in the country. The aim of this study was to estimate the direct contribution of HIV/AIDS to the observed level of under-five mortality in Malawi during the period 2000 to 2004.</p>