Dominic C. Marshall

The association between the neutrophil-to-lymphocyte ratio and mortality in critical illness: an observational cohort study.

IntroductionThe neutrophil-to-lymphocyte ratio (NLR) is a biological marker that has been shown to be associated with outcomes in patients with a number of different malignancies. The objective of this study was to assess the relationship between NLR and mortality in a population of adult critically ill patients.MethodsWe performed an observational cohort study of unselected intensive care unit (ICU) patients based on records in a large clinical database. We computed individual patient NLR and categorized patients by quartile of this ratio. The association of NLR quartiles and 28-day mortality was assessed using multivariable logistic regression. Secondary outcomes included mortality in the ICU, in-hospital mortality and 1-year mortality. An a priori subgroup analysis of patients with versus without sepsis was performed to assess any differences in the relationship between the NLR and outcomes in these cohorts.ResultsA total of 5,056 patients were included. Their 28-day mortality rate was 19%. The median age of the cohort was 65 years, and 47% were female. The median NLR for the entire cohort was 8.9 (interquartile range, 4.99 to 16.21). Following multivariable adjustments, there was a stepwise increase in mortality with increasing quartiles of NLR (first quartile: reference category; second quartile odds ratio (OR) = 1.32; 95% confidence interval (CI), 1.03 to 1.71; third quartile OR = 1.43; 95% CI, 1.12 to 1.83; 4th quartile OR = 1.71; 95% CI, 1.35 to 2.16). A similar stepwise relationship was identified in the subgroup of patients who presented without sepsis. The NLR was not associated with 28-day mortality in patients with sepsis. Increasing quartile of NLR was statistically significantly associated with secondary outcome.ConclusionThe NLR is associated with outcomes in unselected critically ill patients. In patients with sepsis, there was no statistically significant relationship between NLR and mortality. Further investigation is required to increase understanding of the pathophysiology of this relationship and to validate these findings with data collected prospectively.

Trends in Mortality From Ischemic Heart Disease and Cerebrovascular Disease in Europe: 1980 to 2009.

Background— Trends in cardiovascular mortality across Europe demonstrate significant geographical variation, and an understanding of these trends has a central role in global public health. Methods and Results— Ischemic heart disease and cerebrovascular disease age-standardized death rates (as per International Classification of Diseases, ninth and tenth revisions) were collated from the World Health Organization mortality database for member states of the European Union. Trends were characterized by using Joinpoint regression analysis. An overall trend for reduction in ischemic heart disease mortality was observed, most pronounced in Western Europe (>60% for the Netherlands, United Kingdom, and Ireland) for both sexes from 1980 to 2009. Eastern European states, Romania, Croatia, and Slovakia, had modest mortality reductions. Most recently (2009), Lithuania had the highest mortality for males and females (318.1/100 000 and 166.1/100 000, respectively), followed by Latvia and Slovakia. France had the lowest mortality: 39.8/100 000 for males and 14.7/100 000 for females. Analysis of cerebrovascular disease mortality revealed that Austria had the largest reduction for both sexes (76.8% males, 76.5% females) from 1980 to 2009. The smallest improvement over this period was seen in Lithuania, Poland, and Cyprus (–5% to +20% approximately). France has the lowest present-day cerebrovascular disease mortality for both males and females (23.9/100 000 and 17.3/100 000, respectively). Conclusions— There is a growing disparity in cardiovascular mortality between Western and Eastern Europe, for which diverse explanations are discussed. The need for population-wide health promotion and primary prevention policies is emphasized.

A “datathon” model to support cross-disciplinary collaboration

A “datathon” model combines complementary knowledge and skills to formulate inquiries and drive research that addresses information gaps faced by clinicians. In recent years, there has been a growing focus on the unreliability of published biomedical and clinical research. To introduce effective new scientific contributors to the culture of health care, we propose a “datathon” or “hackathon” model in which participants with disparate, but potentially synergistic and complementary, knowledge and skills effectively combine to address questions faced by clinicians. The continuous peer review intrinsically provided by follow-up datathons, which take up prior uncompleted projects, might produce more reliable research, either by providing a different perspective on the study design and methodology or by replication of prior analyses.

Trends in UK regional cancer mortality 1991–2007

Background:Until 1990, there was an upward trend in mortality from breast, lung, prostate, and colon cancers in the United Kingdom. With improvements in cancer treatment there has, in general, been a fall in mortality over the last 20 years. We evaluate regional cancer mortality trends in the United Kingdom between 1991 and 2007.Methods:We analysed mortality trends for breast, lung, prostate, and colon cancers using data obtained from the EUREG cancer database. We have described changes in age-standardised rates (using European standard population) per 100 000 for cancer mortality and generated trends in mortality for the 11 regions using Joinpoint regression.Results:Across all regions in the United Kingdom there was a downward trend in mortality for the four most common cancers in males and females. Overall, deaths from colon cancer decreased most rapidly and deaths from prostate cancer decreased at the slowest rate. Similar downward trends in mortality were observed across all regions of the United Kingdom with the data for lung cancer exhibiting the greatest variation.Conclusions:Mortality from the four most common cancers decreased across all regions of the United Kingdom; however, the rate of decline varied between cancer type and in some instances by region.

Trends in mortality from idiopathic pulmonary fibrosis in the European Union: an observational study of the WHO mortality database from 2001–2013

Idiopathic pulmonary fibrosis (IPF) is the most common of the idiopathic interstitial pneumonias and is characterised by progressive accumulation of scar tissue in the lungs. The objective of this study was to describe the current mortality rates due to IPF in Europe, based on the World Health Organization (WHO) mortality database. We used country-level data for IPF mortality, identified in the WHO mortality database using International Classification of Diseases 10th Edition (ICD-10) codes, for the period 2001–2013. Joinpoint analysis was performed to describe trends throughout the observation period. The median mortality was 3.75 per 100 000 (interquartile range (IQR) 1.37–5.30) and 1.50 per 100 000 (IQR 0.65–2.02) for males and females, respectively. IPF mortality increased in the majority of the European Union (EU) countries with the exceptions of Denmark, Croatia, Austria and Romania. There was a significant disparity in rates across Europe, in the range 0.41–12.1 per 100 000 for men and 0.24–5.63 per 100 000 for women. The most notable increases were observed in the United Kingdom and Finland. Rates were also substantially higher in males, with sex disparity increasing across the period. The reported IPF mortality appears to be increasing across the EU; however, there is substantial variation in mortality trends and overall reported mortality rates between countries. Reported IPF mortality is increasing across the EU with substantial variations between EU countries http://ow.ly/tpIO30h3hZK

Bridging the Health Data Divide

Fundamental quality, safety, and cost problems have not been resolved by the increasing digitization of health care. This digitization has progressed alongside the presence of a persistent divide between clinicians, the domain experts, and the technical experts, such as data scientists. The disconnect between clinicians and data scientists translates into a waste of research and health care resources, slow uptake of innovations, and poorer outcomes than are desirable and achievable. The divide can be narrowed by creating a culture of collaboration between these two disciplines, exemplified by events such as datathons. However, in order to more fully and meaningfully bridge the divide, the infrastructure of medical education, publication, and funding processes must evolve to support and enhance a learning health care system.

The Association between sodium fluctuations and mortality in surgical patients requiring intensive care

Purpose Serum sodium derangement is the most common electrolyte disturbance among patients admitted to intensive care. This study aims to validate the association between dysnatremia and serum sodium fluctuation with mortality in surgical intensive care patients. Method We performed a retrospective analysis of the Medical Information Mart for Intensive Care II database. Dysnatremia was defined as a sodium concentration outside physiologic range (135‐145 mmol/L) and subjects were categorized by severity of dysnatremia and sodium fluctuation. Univariate and multivariable logistic regressions were used to test for associations between sodium fluctuations and mortality. Results We identified 8600 subjects, 39% of whom were female, with a median age of 66 years for analysis. Subjects with dysnatremia were more likely to be dead at 28 days (17% vs 7%; P < .001). There was a significant association between sodium fluctuation and mortality at 28 days (adjusted odds ratio per 1 mmol/L change, 1.10 [95% confidence interval, 1.08‐1.12; P < .001]), even in patients who remained normotremic during their intensive care unit stay (1.12 [95% confidence interval, 1.09‐1.16; P < .001]) Conclusions This observational study validates previous findings of an association between serum sodium fluctuations and mortality in surgical intensive care patients. This association was also present in subjects who remained normonatremic throughout their intensive care unit admission. HighlightsDysnatremia is common and is associated with increased risk of mortality in postoperative patients requiring intensive care.There is a significant association between sodium fluctuation and 28‐day mortality, even in patients who remained normotremic throughout their ICU stay.Subjects with dysnatremia were more likely to be dead at 28 days.Severity of dysnatremia was associated with 28‐day mortality.

Viable funding options for the National Health Service in England

Established in 1948, the National Health Service (NHS) in England was founded on the principles of universal coverage and a service free at the point of use. These principles are under threat with a funding crisis and a lack of clear political will to find a long term solution. This article reviews and explores three categories of options, looking forward, for delivery of more sustainable services. First, is for no additional funding, in which case patient expectations and the breadth of services offered would need to change. Second, is for additional public funding. Options include increased taxation, the formation of a hypothecated tax, amendment of current pension funding and or localized funding strategies. Third, is for additional private funds, including charges for utilisation, prescriptions or via incentivisation of private health insurance. These latter avenues however remain largely unpalatable and have noteworthy disadvantages.

A systematic analysis of UK cancer research funding by gender of primary investigator

Objectives To categorically describe cancer research funding in the UK by gender of primary investigator (PIs). Design Systematic analysis of all open-access data. Methods Data about public and philanthropic cancer research funding awarded to UK institutions between 2000 and 2013 were obtained from several sources. Fold differences were used to compare total investment, award number, mean and median award value between male and female PIs. Mann-Whitney U tests were performed to determine statistically significant associations between PI gender and median grant value. Results Of the studies included in our analysis, 2890 (69%) grants with a total value of £1.82 billion (78%) were awarded to male PIs compared with 1296 (31%) grants with a total value of £512 million (22%) awarded to female PIs. Male PIs received 1.3 times the median award value of their female counterparts (P<0.001). These apparent absolute and relative differences largely persisted regardless of subanalyses. Conclusions We demonstrate substantial differences in cancer research investment awarded by gender. Female PIs clearly and consistently receive less funding than their male counterparts in terms of total investment, the number of funded awards, mean funding awarded and median funding awarded.

Systematic review of methods for quantifying teamwork in the operating theatre: Methods for quantifying teamwork in the operating theatre

Teamwork in the operating theatre is becoming increasingly recognized as a major factor in clinical outcomes. Many tools have been developed to measure teamwork. Most fall into two categories: self‐assessment by theatre staff and assessment by observers. A critical and comparative analysis of the validity and reliability of these tools is lacking.