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Background: The Short Form 36 (SF-36) is a scoring system comprising of 36 items categorized into eight constructs corresponding to patients' health-related quality of life.It has been used extensively in various countries on different sub-populations and used to indicate the health status and help to ascertain the effect of clinical interventions on the particular population. Objective(s): To examine the psychometric properties of the Malay version of SF-36 (Malay SF-36) summated rating scales and validate the scale among post-coronary artery bypass grafting surgery (CABG) patients at the National Heart Institute (IJN), Kuala Lumpur. Method(s): Five hundred and nine post-CABG patients at the IJN, Malaysia completed the questionnaires between 1 July and 31 December 2017. Psychometric tests endorsed by the "International Quality of Life Assessment Project" were utilised. Result(s): The data quality was excellent with a high questionnaire completion rate (100%). As hypothesized, the ordering of item means within scales was clustered. In unison, scaling assumptions were satisfied. Good discriminant validity was shown between subsets of patients with various levels of health status. Notwithstanding, there were probably translation issues of the Physical Functioning scale which showed small ceiling effects. We clearly observed high ceiling and floor effects in both Role Physical and Role Emotional scale most probably attributed to the dichotomous style of their choice of responses. Cronbach alpha values of the eight scales ranged from 0.73 to 0.90, showing good internal consistency reliability. Confirmatory Factor Analysis (CFA) confirmed the 8-factor solution and Composite Reliability revealed internal consistency reliability except for Vitality and Social Functioning. Based on the Average Variance Extracted (AVE), convergent validity was adequate except for two domains. Discriminant Validity is good for the eight constructs as the AVE are generally higher than the corr

Background: The Short Form 36 (SF-36) is a scoring system comprising of 36 items categorized into eight constructs corresponding to patients' health-related quality of life.It has been used extensively in various countries on different sub-populations and used to indicate the health status and help to ascertain the effect of clinical interventions on the particular population. Objective(s): To examine the psychometric properties of the Malay version of SF-36 (Malay SF-36) summated rating scales and validate the scale among post-coronary artery bypass grafting surgery (CABG) patients at the National Heart Institute (IJN), Kuala Lumpur. Method(s): Five hundred and nine post-CABG patients at the IJN, Malaysia completed the questionnaires between 1 July and 31 December 2017. Psychometric tests endorsed by the "International Quality of Life Assessment Project" were utilised. Result(s): The data quality was excellent with a high questionnaire completion rate (100%). As hypothesized, the ordering of item means within scales was clustered. In unison, scaling assumptions were satisfied. Good discriminant validity was shown between subsets of patients with various levels of health status. Notwithstanding, there were probably translation issues of the Physical Functioning scale which showed small ceiling effects. We clearly observed high ceiling and floor effects in both Role Physical and Role Emotional scale most probably attributed to the dichotomous style of their choice of responses. Cronbach alpha values of the eight scales ranged from 0.73 to 0.90, showing good internal consistency reliability. Confirmatory Factor Analysis (CFA) confirmed the 8-factor solution and Composite Reliability revealed internal consistency reliability except for Vitality and Social Functioning. Based on the Average Variance Extracted (AVE), convergent validity was adequate except for two domains. Discriminant Validity is good for the eight constructs as the AVE are generally higher than the corr

Background: The endoscopic endonasal approach to the skull base avoids some of the surgical morbidity associated with a transcranial approach, however it often results in large skull-base defects requiring secure closure. The nasoseptal flap has become the preferred method for closure of such defects but may be associated with its own morbidity. Method(s): A consecutive cohort of patients with skull base pathology with prospectively collected quality of life data using ASBQ and SNOT was analysed. They were grouped into those who received a nasoseptal flap and those who did not. Pre-operative total ASBQ and SNOT scores, and their individual components, were compared to data collected at days 1, 3, and 7; six-weeks; and 3, 6, and 12-months postoperatively. Result(s): Of 158 patients available for analysis, nasoseptal flaps were performed in 52 (33%). Average follow-up (+/-standard deviation) was 8.1 +/- 3.9 months for ASBQ data and 8.2 +/- 3.8 months for SNOT data. In the first post-operative week, nasal symptoms and otalgia were worse in the flap group. At six-weeks and beyond, there was no difference between groups in overall ASBQ or SNOT scores, or in the rate of clinically-significant improvement in SNOT or ASBQ scores or their components. Conclusion(s): In the largest cohort of patients to date, the use of a nasoseptal flap is associated with nasal symptoms and otalgia in the acute post-operative period, but is not associated with any long-term detriment to quality of life after endoscopic skull base surgery.Copyright © 2020 Elsevier Ltd

Background: The endoscopic endonasal approach to the skull base avoids some of the surgical morbidity associated with a transcranial approach, however it often results in large skull-base defects requiring secure closure. The nasoseptal flap has become the preferred method for closure of such defects but may be associated with its own morbidity. Method(s): A consecutive cohort of patients with skull base pathology with prospectively collected quality of life data using ASBQ and SNOT was analysed. They were grouped into those who received a nasoseptal flap and those who did not. Pre-operative total ASBQ and SNOT scores, and their individual components, were compared to data collected at days 1, 3, and 7; six-weeks; and 3, 6, and 12-months postoperatively. Result(s): Of 158 patients available for analysis, nasoseptal flaps were performed in 52 (33%). Average follow-up (+/-standard deviation) was 8.1 +/- 3.9 months for ASBQ data and 8.2 +/- 3.8 months for SNOT data. In the first post-operative week, nasal symptoms and otalgia were worse in the flap group. At six-weeks and beyond, there was no difference between groups in overall ASBQ or SNOT scores, or in the rate of clinically-significant improvement in SNOT or ASBQ scores or their components. Conclusion(s): In the largest cohort of patients to date, the use of a nasoseptal flap is associated with nasal symptoms and otalgia in the acute post-operative period, but is not associated with any long-term detriment to quality of life after endoscopic skull base surgery.Copyright © 2020 Elsevier Ltd

Introduction: Patient specific guides can be a valuable tool in improving the precision of planned femoral neck osteotomies, especially in minimally invasive hip surgery, where bony landmarks are often inaccessible. The aim of our study was to validate the accuracy of a novel patient specific femoral osteotomy guide for THR through a minimally invasive posterior approach, the direct superior approach (DSA). Method(s): As part of our routine preoperative planning 30 patients underwent low dose CT scans of their arthritic hip. 3D printed patient specific femoral neck osteotomy guides were then produced. Intraoperatively, having cleared all soft tissue from the postero-lateral neck of the enlocated hip, the guide was placed and pinned onto the posterolateral femoral neck. The osteotomy was performed using an oscillating saw and the uncemented hip components were implanted as per routine. Postoperatively, the achieved level of the osteotomy at the medial calcar was compared with the planned level of resection using a 3D/2D matching analysis (Mimics X-ray module, Materialise, Belgium). Result(s): A total of 30 patients undergoing uncemented Trinity acetabular and TriFit TS femoral component arthroplasty (Corin, UK) were included in our analysis. All but one of our analysed osteotomies were found to be within 3 mm from the planned height of osteotomy. In one patient the level of osteotomy deviated 5 mm below the planned level of resection. Conclusion(s): Preoperative planning and the use of patient specific osteotomy guides provides an accurate method of performing femoral neck osteotomies in minimally invasive hip arthroplasty using the direct superior approach. Level of Evidence: IV (Case series).Copyright © The Author(s) 2018.

Introduction: Patient specific guides can be a valuable tool in improving the precision of planned femoral neck osteotomies, especially in minimally invasive hip surgery, where bony landmarks are often inaccessible. The aim of our study was to validate the accuracy of a novel patient specific femoral osteotomy guide for THR through a minimally invasive posterior approach, the direct superior approach (DSA). Method(s): As part of our routine preoperative planning 30 patients underwent low dose CT scans of their arthritic hip. 3D printed patient specific femoral neck osteotomy guides were then produced. Intraoperatively, having cleared all soft tissue from the postero-lateral neck of the enlocated hip, the guide was placed and pinned onto the posterolateral femoral neck. The osteotomy was performed using an oscillating saw and the uncemented hip components were implanted as per routine. Postoperatively, the achieved level of the osteotomy at the medial calcar was compared with the planned level of resection using a 3D/2D matching analysis (Mimics X-ray module, Materialise, Belgium). Result(s): A total of 30 patients undergoing uncemented Trinity acetabular and TriFit TS femoral component arthroplasty (Corin, UK) were included in our analysis. All but one of our analysed osteotomies were found to be within 3 mm from the planned height of osteotomy. In one patient the level of osteotomy deviated 5 mm below the planned level of resection. Conclusion(s): Preoperative planning and the use of patient specific osteotomy guides provides an accurate method of performing femoral neck osteotomies in minimally invasive hip arthroplasty using the direct superior approach. Level of Evidence: IV (Case series).Copyright © The Author(s) 2018.

Background Epidemiological studies and randomised clinical trials (RCTs) report disparate findings in relation to omega-3 polyunsaturated fatty acids (n-3 PUFA) benefit for cardiac patients. With RCTs interpretation is potentially confounded by background n-3 PUFA intake. The goal of this pilot, small cohort, pre-surgical supplementation study was to evaluate postoperative atrial fibrillation (AF) and cardiac molecular expression profiles employing two data analysis approaches - by treatment randomisation and by stratification using measured n-3 PUFA. Methods Patients (n = 20) received 3 g/day of fish or placebo oil (FO vs PO) in a double blind randomised protocol prior to elective coronary artery graft and valve surgery. Groups were matched for age, gender, and mean treatment duration (~20 days). Resected atrial myocardium was sampled for assay of viability metabolic markers, and blood obtained for erythrocyte membrane lipid measurement. Results There was substantial overlap of cell membrane n-3 PUFA content across PO and FO groups, and no group treatment effects on AF incidence or myocardial molecular marker levels were detected. In contrast, data stratification using membrane n-3 PUFA content (at 8% total membrane lipid) achieved significant separation of patients (by n-6:n-3 PUFA ratio), a significant differential cardiac expression of the marker peroxisomal proliferator-activated receptor, but no difference in AF incidence. Conclusions This small n-3 PUFA case study demonstrates that the same cohort may yield differing findings when evaluated using randomisation or stratification approaches based on direct molecular measures in cell membranes.Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Background. In a post hoc analysis of the ENIGMA-II trial, we sought to determine whether intraoperative dexamethasone was associated with adverse safety outcomes. Methods. Inverse probability weighting with estimated propensity scores was used to determine the association of dexamethasone administration with postoperative infection, quality of recovery, and adverse safety outcomes for 5499 of the 7112 non-cardiac surgery subjects enrolled in ENIGMA-II. Results. Dexamethasone was administered to 2178 (40%) of the 5499 subjects included in this analysis and was not associated with wound infection [189 (8.7%) vs 275 (8.3%); propensity score-adjusted relative risk (RR) 1.10; 95% confidence interval (CI) 0.89-1.34; P=0.38], severe postoperative nausea and vomiting on day 1 [242 (7.3%) vs 189 (8.7%); propensity score-adjusted RR 1.06; 95% CI 0.86-1.30; P=0.59], quality of recovery score [median 14, interquartile range (IQR) 12-15, vs median 14, IQR 12-16, P=0.10), length of stay in the postanaesthesia care unit [propensity score-adjusted median (IQR) 2.0 (1.3, 2.9) vs 1.9 (1.3, 3.1), P=0.60], or the primary outcome of the main trial. Dexamethasone administration was associated with a decrease in fever on days 1-3 [182 (8.4%) vs 488 (14.7%); RR 0.61; 95% CI 0.5-0.74; P<0.001] and shorter lengths of stay in hospital [propensity score-adjusted median (IQR) 5.0 (2.9, 8.2) vs 5.3 (3.1, 9.1), P<0.001]. Neither diabetes mellitus nor surgical wound contamination status altered these outcomes. Conclusion. Dexamethasone administration to high-risk non-cardiac surgical patients did not increase the risk of postoperative wound infection or other adverse events up to day 30, and appears to be safe in patients either with or without diabetes mellitus. Clinical trial registration. NCT00430989.Copyright © 2017 The Author.

Background Epidemiological studies and randomised clinical trials (RCTs) report disparate findings in relation to omega-3 polyunsaturated fatty acids (n-3 PUFA) benefit for cardiac patients. With RCTs interpretation is potentially confounded by background n-3 PUFA intake. The goal of this pilot, small cohort, pre-surgical supplementation study was to evaluate postoperative atrial fibrillation (AF) and cardiac molecular expression profiles employing two data analysis approaches - by treatment randomisation and by stratification using measured n-3 PUFA. Methods Patients (n = 20) received 3 g/day of fish or placebo oil (FO vs PO) in a double blind randomised protocol prior to elective coronary artery graft and valve surgery. Groups were matched for age, gender, and mean treatment duration (~20 days). Resected atrial myocardium was sampled for assay of viability metabolic markers, and blood obtained for erythrocyte membrane lipid measurement. Results There was substantial overlap of cell membrane n-3 PUFA content across PO and FO groups, and no group treatment effects on AF incidence or myocardial molecular marker levels were detected. In contrast, data stratification using membrane n-3 PUFA content (at 8% total membrane lipid) achieved significant separation of patients (by n-6:n-3 PUFA ratio), a significant differential cardiac expression of the marker peroxisomal proliferator-activated receptor, but no difference in AF incidence. Conclusions This small n-3 PUFA case study demonstrates that the same cohort may yield differing findings when evaluated using randomisation or stratification approaches based on direct molecular measures in cell membranes.Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Background. In a post hoc analysis of the ENIGMA-II trial, we sought to determine whether intraoperative dexamethasone was associated with adverse safety outcomes. Methods. Inverse probability weighting with estimated propensity scores was used to determine the association of dexamethasone administration with postoperative infection, quality of recovery, and adverse safety outcomes for 5499 of the 7112 non-cardiac surgery subjects enrolled in ENIGMA-II. Results. Dexamethasone was administered to 2178 (40%) of the 5499 subjects included in this analysis and was not associated with wound infection [189 (8.7%) vs 275 (8.3%); propensity score-adjusted relative risk (RR) 1.10; 95% confidence interval (CI) 0.89-1.34; P=0.38], severe postoperative nausea and vomiting on day 1 [242 (7.3%) vs 189 (8.7%); propensity score-adjusted RR 1.06; 95% CI 0.86-1.30; P=0.59], quality of recovery score [median 14, interquartile range (IQR) 12-15, vs median 14, IQR 12-16, P=0.10), length of stay in the postanaesthesia care unit [propensity score-adjusted median (IQR) 2.0 (1.3, 2.9) vs 1.9 (1.3, 3.1), P=0.60], or the primary outcome of the main trial. Dexamethasone administration was associated with a decrease in fever on days 1-3 [182 (8.4%) vs 488 (14.7%); RR 0.61; 95% CI 0.5-0.74; P<0.001] and shorter lengths of stay in hospital [propensity score-adjusted median (IQR) 5.0 (2.9, 8.2) vs 5.3 (3.1, 9.1), P<0.001]. Neither diabetes mellitus nor surgical wound contamination status altered these outcomes. Conclusion. Dexamethasone administration to high-risk non-cardiac surgical patients did not increase the risk of postoperative wound infection or other adverse events up to day 30, and appears to be safe in patients either with or without diabetes mellitus. Clinical trial registration. NCT00430989.Copyright © 2017 The Author.

There are limited data on the management of non-tubal ectopic pregnancies (NTEP). We reviewed the management of these cases at a tertiary centre with a dedicated institutional protocol. All cases of confirmed NTEP were retrospectively identified from 2006 to 2014. Records were reviewed for presenting features, mode and success of initial management, preservation of fertility and length of hospital stay. The main outcome measure was the success rate of medical management with methotrexate. The 60 cases identified included 34 cornual, 14 Caesarean section scar, nine cervical and three cervical involving previous Caesarean scar. Primary surgical management was performed in 22 patients. Thirty-eight patients received medical therapy with single or multidose methotrexate. Successful medical management was observed in 33 (87%); however, length of stay was significantly longer compared with surgical patients (mean 14 +/- 12 days versus 5 +/- 2 days, P < 0.01). Hysterectomy was performed in three patients (one surgical group, two medical group). There was one case of methotrexate toxicity with no long-term adverse outcome. Medical management of NTEP is a safe first-line therapy for clinically stable patients desiring preservation of fertility despite a longer period of inpatient monitoring and follow-up.Copyright © 2016

There are limited data on the management of non-tubal ectopic pregnancies (NTEP). We reviewed the management of these cases at a tertiary centre with a dedicated institutional protocol. All cases of confirmed NTEP were retrospectively identified from 2006 to 2014. Records were reviewed for presenting features, mode and success of initial management, preservation of fertility and length of hospital stay. The main outcome measure was the success rate of medical management with methotrexate. The 60 cases identified included 34 cornual, 14 Caesarean section scar, nine cervical and three cervical involving previous Caesarean scar. Primary surgical management was performed in 22 patients. Thirty-eight patients received medical therapy with single or multidose methotrexate. Successful medical management was observed in 33 (87%); however, length of stay was significantly longer compared with surgical patients (mean 14 +/- 12 days versus 5 +/- 2 days, P < 0.01). Hysterectomy was performed in three patients (one surgical group, two medical group). There was one case of methotrexate toxicity with no long-term adverse outcome. Medical management of NTEP is a safe first-line therapy for clinically stable patients desiring preservation of fertility despite a longer period of inpatient monitoring and follow-up.Copyright © 2016

Background. Goal-directed therapy has a secure place in perioperative care. Algorithms are based on Starlings law of the heart, notwithstanding that this does not numerically define volume or heart performance variables. These have been developed based on a Guytonian view of the circulation and are implemented in a computerized decision support system (NavigatorTM). We studied the feasibility and performance of the graphical display of the system in an intervention and a control group of patients undergoing major abdominal surgery. Methods. Patients were randomized to either graphically (intervention) or numerically (control) guided administration of therapy. Goals were set and treatments and concordance with guidance noted, where applicable. Anaesthesia was provided by one of three experienced anaesthetists well acquainted with NavigatorTM. The primary objective was to determine whether the use of graphical display decision support more efficiently enables the achievement of oxygen delivery targets. This was quantitated as percentage time in the target zone and averaged standardized distance from the target centre. Results. The mean percentage time in the target zone was 36.7% for control and 36.5% for intervention. The averaged standardized difference was 1.5 in control and 1.6 in intervention. There was no significant difference in fluid balances. There was a high level of concordance between decision support recommendation and anaesthetist action (84.3%).ConclusionsIn experienced hands, the addition of a graphical display for haemodynamic guidance resulted in a similar time in target and averaged standardized difference. The haemodynamic guidance system should be explored in a comparative study to anaesthesia management without guidance. © 2012 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

Objective: To compare injection site pain of subcutaneous (sc) epoetin beta and darbepoetin alfa in adult patients with chronic kidney disease. Research design and methods: This was a multi-centre, randomised, two-arm, single-blind, cross-over study. Patients were randomised to receive weekly sc darbepoetin alfa 30 mug or weekly sc epoetin beta 6000 IU for 2 weeks and were then crossed over to the alternative treatment for 2 weeks. Injection site pain was assessed using a 10 cm ungraduated visual analogue scale (0 = no pain, 10=worst pain) and a six-point verbal rating scale. Patient preference for treatment was also assessed. Trial registration: http://clinicaltrials.gov/(NCT00377481). Result(s): All randomised patients (N=48) completed the study. The sample comprised 29 chronic kidney disease patients (Stage 3 or Stage 4), 11 peritoneal dialysis patients and 8 renal transplant patients. Patients perceived significantly less pain with epoetin beta than darbepoetin alfa, using the visual analogue scale (relative pain score=2.75, darbepoetin alfa:epoetin beta, 95% Cl: 1.85, 4.07; p<0.0001) and the verbal rating scale (median: 0.5, 95% Cl: 0.5, 1.0 vs. median: 1.5, 95% Cl: 1.0, 2.0; p<0.0001). Epoetin beta was preferred by significantly more patients (65%) than darbepoetin alfa (10%) (p<0.001); 25% of patients reported no preference. Conclusion(s): Limitations included lack of an epoetin alfa comparator and limited blinding (patients were blinded to treatment, however, an unblinded nurse administered treatment). We show that sc injection of epoetin beta is significantly less painful than darbepoetin alfa and patient preference for epoetin beta confirms that the difference is clinically meaningful. © 2008 Informa UK Ltd. All rights reserved.

Introduction: The medical literature has only documented the importace of adverse events in terms of patient outcomes and cost to the health service over the last decade. This review focuses on the incidence, risk factors and prevention on unexpected in-hospital deaths. Discussion(s): The incidence of unexpected in-hospital deaths in the two major retrospective studies was 0.5% and 0.8% of all hospital admissions. A prospective study of surgical patients documented an incidence of nearly 7.1%. The risk factors that have been associated with hospital death include: increasing age; non-elective operative procedure; negligence; human error and unstable bedside observations in the hours prior to death. Although a number of intreventions have been suggested to prevent unexpected in-hospital deaths, very few studies have been performed to determine effectiveness. In a single institution historical control study, the introduction of a Medical Emergency Team was associated with 50% reduction in the casemix adjusted incidence of in-hospital cardiac arrest calls. Conclusion(s): There are a number of studies to suggest that in-hospital deaths are both predictable and preventable. More work is required to determine effective strategies to manage this problem.

Background. Goal-directed therapy has a secure place in perioperative care. Algorithms are based on Starlings law of the heart, notwithstanding that this does not numerically define volume or heart performance variables. These have been developed based on a Guytonian view of the circulation and are implemented in a computerized decision support system (NavigatorTM). We studied the feasibility and performance of the graphical display of the system in an intervention and a control group of patients undergoing major abdominal surgery. Methods. Patients were randomized to either graphically (intervention) or numerically (control) guided administration of therapy. Goals were set and treatments and concordance with guidance noted, where applicable. Anaesthesia was provided by one of three experienced anaesthetists well acquainted with NavigatorTM. The primary objective was to determine whether the use of graphical display decision support more efficiently enables the achievement of oxygen delivery targets. This was quantitated as percentage time in the target zone and averaged standardized distance from the target centre. Results. The mean percentage time in the target zone was 36.7% for control and 36.5% for intervention. The averaged standardized difference was 1.5 in control and 1.6 in intervention. There was no significant difference in fluid balances. There was a high level of concordance between decision support recommendation and anaesthetist action (84.3%).ConclusionsIn experienced hands, the addition of a graphical display for haemodynamic guidance resulted in a similar time in target and averaged standardized difference. The haemodynamic guidance system should be explored in a comparative study to anaesthesia management without guidance. © 2012 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

Objective: To compare injection site pain of subcutaneous (sc) epoetin beta and darbepoetin alfa in adult patients with chronic kidney disease. Research design and methods: This was a multi-centre, randomised, two-arm, single-blind, cross-over study. Patients were randomised to receive weekly sc darbepoetin alfa 30 mug or weekly sc epoetin beta 6000 IU for 2 weeks and were then crossed over to the alternative treatment for 2 weeks. Injection site pain was assessed using a 10 cm ungraduated visual analogue scale (0 = no pain, 10=worst pain) and a six-point verbal rating scale. Patient preference for treatment was also assessed. Trial registration: http://clinicaltrials.gov/(NCT00377481). Result(s): All randomised patients (N=48) completed the study. The sample comprised 29 chronic kidney disease patients (Stage 3 or Stage 4), 11 peritoneal dialysis patients and 8 renal transplant patients. Patients perceived significantly less pain with epoetin beta than darbepoetin alfa, using the visual analogue scale (relative pain score=2.75, darbepoetin alfa:epoetin beta, 95% Cl: 1.85, 4.07; p<0.0001) and the verbal rating scale (median: 0.5, 95% Cl: 0.5, 1.0 vs. median: 1.5, 95% Cl: 1.0, 2.0; p<0.0001). Epoetin beta was preferred by significantly more patients (65%) than darbepoetin alfa (10%) (p<0.001); 25% of patients reported no preference. Conclusion(s): Limitations included lack of an epoetin alfa comparator and limited blinding (patients were blinded to treatment, however, an unblinded nurse administered treatment). We show that sc injection of epoetin beta is significantly less painful than darbepoetin alfa and patient preference for epoetin beta confirms that the difference is clinically meaningful. © 2008 Informa UK Ltd. All rights reserved.

Introduction: The medical literature has only documented the importace of adverse events in terms of patient outcomes and cost to the health service over the last decade. This review focuses on the incidence, risk factors and prevention on unexpected in-hospital deaths. Discussion(s): The incidence of unexpected in-hospital deaths in the two major retrospective studies was 0.5% and 0.8% of all hospital admissions. A prospective study of surgical patients documented an incidence of nearly 7.1%. The risk factors that have been associated with hospital death include: increasing age; non-elective operative procedure; negligence; human error and unstable bedside observations in the hours prior to death. Although a number of intreventions have been suggested to prevent unexpected in-hospital deaths, very few studies have been performed to determine effectiveness. In a single institution historical control study, the introduction of a Medical Emergency Team was associated with 50% reduction in the casemix adjusted incidence of in-hospital cardiac arrest calls. Conclusion(s): There are a number of studies to suggest that in-hospital deaths are both predictable and preventable. More work is required to determine effective strategies to manage this problem.