Background and Purpose-Procedures requiring specific skill sets often have been shown to depend on institutional volume, that is, centers receiving a higher volume observe better outcomes in those patients. This relationship recently has been shown to exist for subarachnoid hemorrhage(SAH) patients in a large study in the United States. We aim to examine this relationship for SAH patients in England, restricting analysis to specialist neurosurgical units. Methods-Aggregate counts of patients with SAH in 25 specialist neuroscience centers in England, from 2005 to 2011, were obtained from the Hospital Episode Statistics database maintained by the National Health Service Information Center. These data were linked with national mortality statistics to obtain counts of deaths. Poisson regression was used to investigate the relationship between institutional caseload of SAH and 6-month mortality from any cause. Six-month mortality rates and mortality ratios were computed. Results-Annual institutional caseload of admissions with SAH was inversely related to 6-month mortality (P=0.009; r 2 =0.26). Each 100-patient increase in annual patient volume was associated with a 24% reduction in mortality (adjusted mortality ratio, 0.76; confidence interval, 0.67-0.87). This relationship was consistent across the entire range of annual institutional caseloads examined (29-367 cases for the lowest and highest volumes seen in a single center in 1 year). Conclusions-Our
Serum albumin is an established predictor of survival in numerous cancers but its prognostic value in central nervous system tumours has not been established. Here we have examined prognostic factors in 685 patients with histologically proven glioblastoma multiforme (GBM), the majority of which (n = 549) had pre-operative serum albumin assayed. Mean serum albumin was 34.7 g/l (SD 5.2). Post-operative survival was significantly less for patients with hypoalbuminaemia (<30 g/l, n = 82) than for patients with normal albumin level (median 2.3 vs. 5.6 months, P < 0.001 Log-rank test). Furthermore, patients with lower normal albumin (30-40 g/l, n = 371) had significantly shorter survival compared against patients with albumin in the upper normal range (40-50 g/l, n = 96; median 5.1 vs. 8.8 months, P < 0.001). Multivariate Cox regression showed the independent predictors of survival were age, debulking surgery, chemoradiotherapy, and serum albumin (Hazard Ratio 0.97 per g/l, P < 0.005). This study suggests pre-operative serum albumin level is a significant predictor of survival in patients with GBM. Further studies are needed to examine the relationship between albumin and other known prognostic factors, and to determine if pre-operative serum albumin is a clinically useful predictor of survival.
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