Days Of Initial Hospitalization Research Articles

Optimal timing of surgery for patients with infective endocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Background Infective endocarditis (IE) is a disease associated with high risk of morbidity and mortality. Recent literature suggests that surgery during index hospitalization may be performed safely without increased risk of adverse clinical outcomes. However, risk associated with specific surgical timing during index hospitalization remains unclear. Purpose The purpose of this meta-analysis is to assess the association of early surgery with mortality in patients with IE. Methods We performed a literature search for studies reporting an association between early surgery and study endpoints. The primary endpoint was in-hospital mortality. The secondary endpoint was long-term mortality. Early surgery was defined as surgery within 14 days of admission. The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. Results A total of 15 studies with 2491 participants (900 with early surgery vs 1591 with delayed surgery) were included. The mean duration of follow-up was 33 months (ranging between 6 to 66 months). Early surgery was not associated with increased risk of in-hospital or long-term mortality compared to delayed surgery (OR 1.08, 95% CI 0.80, 1.46; P=0.63; OR 1.12, 95% CI 0.68, 1.86; P=0.65). Heterogeneity was low: Chi2 = 7.85, I2 = 0%. Subgroup analysis by time to surgery demonstrated that early surgery was not associated with increased risk of in-hospital mortality for surgeries performed within 2 days, 7 days, or 14 days of hospitalization (OR 0.87, 95% CI 0.58, 1.32; P=0.51; OR 1.06, 95% CI 0.78, 1.43; P=0.72; OR 0.51, 95% CI 0.21, 1.23; P=0.13). Heterogeneity was low: Chi2 = 4.84, I2 = 0%. Conclusions Early surgery performed within 14 days of initial hospitalization is not associated with increased risk of in-hospital mortality or long-term mortality compared to delayed surgery.

Association of early surgery and post-operative complications in patients with infective endocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Background Infective endocarditis (IE) is a disease associated with high risk of morbidity and mortality. Recent literature suggests that surgery during index hospitalization may be performed safely without increased risk of mortality. However, the risk of post-operative complications remains unclear. Purpose The purpose of this meta-analysis is to assess the association of early surgery with post-operative complications as compared to delayed surgery in patients with IE. Methods We performed a literature search for studies reporting an association between early surgery and study endpoints. The primary endpoint was post-operative neurological complications. The secondary endpoints were post-operative systemic embolic events, recurrence of IE, and need for reoperation. Early surgery was defined as surgery within 14 days of admission. The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. Results A total of 11 studies with 1857 participants (634 with early surgery vs 1223 with delayed surgery) were included. The mean duration of follow-up was 39 months (ranging between 6 to 66 months). Early surgery compared to delayed surgery was not associated with increased risk of post-operative neurological complications (OR 1.01, 95% CI 0.55, 1.85; P=0.98). Heterogeneity was low: Chi2 = 2.93, I2 = 0%. Early surgery compared to delayed surgery was not associated with increased risk for post-operative systemic embolic events, recurrence of IE, or need for reoperation (OR 0.98, 95% CI 0.6, 1.61; p=0.94; OR 1.66, 95% CI 0.83, 3.33; p=0.15; OR 2.18, 95% CI 0.41, 11.69; p=0.36). Conclusions Early surgery performed within 14 days of initial hospitalization is not associated with increased risk of post-operative complications compared to delayed surgery.

Evaluation of Pulse Rate, Oxygen Saturation, and Respiratory Effort after Different Types of Feeding Methods in Preterm Newborns.

Background During the initial days of hospitalization, preterm newborns are given combinations of breastfeeding, spoon/paladai feeding, and/or gavage feeding. Each method of feeding may have a different effect on vital parameters. Objective To study changes in vital parameters in relation to different feeding methods and postmenstrual age (PMA) in preterm newborns. Study Design. This prospective observational study was carried out at a tertiary care neonatal unit. Participants. Physiologically stable preterm newborns with PMA less than 37 weeks on full enteral feeds were included in the study. Intervention. None. Outcomes. Respiratory rate (RR), pulse rate (PR), oxygen saturation (SPO2), nasal flaring, and lower chest indrawing were monitored before and up to 3 h after the breastfeeding/spoon (paladai) feeding/gavage feeding or their combinations. These vital parameters were assessed in relation to the feeding methods and PMA groups using ANOVA. Results A total of 383 records were analyzed from 110 newborns. No infant developed chest indrawing or nasal flaring after any feeding method. During the 3 h period of monitoring, vital parameters changed significantly except in the gavage feeding group. The mean PR did not change, but the mean RR and SPO2 changed significantly at different PMA. Conclusion Vital parameters changed after different types of feeding methods and at different PMA. A further multicentric prospective study is needed to understand the effect of different feeding methods and PMA on vital parameters.

Trends in the national early warning score are associated with subsequent mortality – A prospective three-centre observational study with 11,331 general ward patients

AimTo investigate whether trends in the NEWS values are associated with patient mortality in general ward patients. MethodsA one-year prospective observational study in three hospitals in Finland. All data on patients’ NEWS values during the first three days of general ward admissions were collected. The linear regression model was used to investigate the association of the NEWS trajectories with subsequent mortality. We used three outcome measures: 4–7-day, 4–14-day and 4–21-day mortality rates after the 0–3 days of initial hospitalization, respectively. ResultsThe study cohort consisted of 11,331 general ward patients. The non-survivors had higher initial NEWS score values in all outcome categories (all p < 0.001). The non-survivors had a rising trajectory in their NEWS values in all the outcome categories, whereas the survivors had a downward trajectory in their NEWS values in all outcome categories (data presented as first- and third-day’s median values): an increase from 5.0 to 6.0 vs. a decrease from 1.5 to 1.0 (4–7-day non-survivors vs. survivors), an increase from 4.0 to 5.0 vs. a decrease from 1.5 to 1.0 (4–14-day non-survivors vs. survivors) and an increase from 4.0 to 5.0 vs. a decrease from 1.5 to 1.0 (4–21-day non-survivors vs. survivors). In the linear regression model, these differences in trends were statistically significant in all the outcome categories (p < 0.05). ConclusionThe NEWS score trajectory during the first three days of general ward admission is associated with patient outcome. Further studies are warranted to determine specific thresholds for clinically relevant changes in the NEWS trajectories.

Characteristics and Economic Burden of Hospitalized Elderly Patients (&gt; 65 Years) Due to Community-Acquired Pneumonia

Objective : The prevalence hospitalization of elderly patients due to community acquired pneumonia (CAP) is high and increases the hospital cost. Characteristics and economic burden of hospitalized elderly patients (>65years) due to CAP were analyzed. Materials and Methods : We performed a retrospective analysis of the 180 patients who were hospitalized with pneumonia between 01.01.2015-15.11.2017. Patients older than 65 years old and hospitalized for CAP were followed up for up to 30 days from initial hospitalization for mortality and the patients who were discharged were followed up to 90 days of initial hospitalization. Hospital costs were analyzed. Results : 115(60%) patients were older than 65. 82.4% of the patients received oxygen therapy and 27.8% of them received noninvasive mechanical support. 16.5% of the patients needed intensive care support. PSI was increased with age(p=0.021). Thirty-day mortality was related with older age(p=0.048). Total treatment costs were increased with high PSI (p=0.003). Increased PSI and total cost were significantly associated with mortality (p=0.000). Thirty-day mortality was related with older age(p=0.048), but age was not related with 60-day and 90-day mortality (p=0.244, p=0.469). 30-day mortality was high in patients with COPD and malignancy (p=0.038, p=0.040). No associations were found between total hospital cost and additional diseases (p>0.05). Conclusion : CAP is a common cause of hospitalization in elderly patients. Older patients had more severe CAP which caused high mortality and high treatment costs; so it is important to identify elderly patients with risk factors for early adequate treatment.

In-hospital predictors of 60-day readmission in COVID-19 patients

Abstract Introduction Preventing hospital readmissions can improve a patient's quality of life and decrease healthcare costs. While prior work has focused on pre-existing comorbidities to predict COVID-19 readmissions, the prognostic role of in-hospital data and complications has been less studied. Methods Data was collected on adult patients diagnosed with COVID-19 and admitted to a multicenter hospital system in Illinois between March and November 2020. Our cohort consisted of COVID-19 hospitalization survivors excluding those discharged to hospice care. Major adverse events (MAEs) were defined as venous thromboembolism (VTE), myocardial injury (troponin greater than upper limit of normal), stroke, new requirement for renal replacement therapy (RRT), life-threatening arrhythmia, or acute heart failure exacerbation. The primary outcome was readmission within 60 days of initial hospitalization. Results From the 1406 survivors of the index hospitalization, 223 (15.9%) patients were readmitted within 60 days. Those readmitted were older and more likely to have underlying comorbidities including atrial fibrillation, coronary artery disease, and hypertension (Table 1). Length of stay between the readmission and non-readmission groups was trending towards statistical significance (10.52 days vs 8.95 days, p=0.053). Those with one or more MAE during their index hospitalization, when adjusted for age and body mass index, were at an increased risk of readmission (adjusted odds ratio [aOR] 1.90, p&amp;lt;0.01). Readmitted patients were more likely to have VTE during their index hospitalization than those not readmitted (7.2% vs 3.7%, p&amp;lt;0.05). The incidence of new RRT (4.9% vs 2.5%, p=0.083) and myocardial injury (3.6% vs 1.5%, p=0.067) between the groups was also trending towards statistical significance (Table 1). No statistical difference was present between the other individual MAEs; however, this is limited by small sample sizes of certain MAEs. Of the 322 patients with echocardiography during the index admission, 82 (25.5%) were readmitted. In this cohort, left ventricular ejection fraction (LVEF) that was reduced (LVEF &amp;lt;50%) or hyperdynamic (LVEF &amp;gt;65%) was not a statistically significant predictor of readmission (Figure 1). Lastly, discharge disposition was predictive of readmission as those being sent to acute rehab (OR 2.04, p&amp;lt;0.01), long-term acute care (OR 2.58, p&amp;lt;0.01), or skilled nursing facility (OR 2.67, p&amp;lt;0.001) were at higher risk compared to those who were discharged to home (Figure 1). Conclusion In this cohort, the occurrence of any MAE during index COVID-19 hospitalization, particularly VTE, RRT, and myocardial injury, can be used to predict 60-day readmission. Furthermore, discharge disposition, but not LVEF, demonstrated prognostic value in our cohort. Identifying high risk patients prior to discharge helps health care providers focus resources on patients most likely to be readmitted. Funding Acknowledgement Type of funding sources: None.

Bilateral facial palsy in cerebral venous sinus thrombosis – An uncommon association

Background: Cranial nerve palsy in cerebral venous sinus thrombosis (CVST) is not a very common presentation, its pathophysiology is not well understood. Case Description: We report a 27 year old young man with CVST having protein-S deficiency & hyperhomocystinemia, who during his initial days of hospitalization developed bilateral facial palsy. With conservative treatment of CVST, complete recovery of facial palsy occurred with recanalization of transverse sinus. Conclusions: Facial palsy in this patient was probably caused by transient neurapraxia in the intracranial segment of the nerve. It may be hypothesised that elevated venous transmural pressure in the nerve’s satellite vein, which belongs to the affected drainage territory of the transverse sinus, might have caused venous blood-brain barrier dysfunction in the intrinsic vascular system of the nerve, with leakage of fluids and ions into the endoneurial space and thus an increase in interstitial resistance causing conduction defects.

Evidence of bromethalin toxicosis in feral San Francisco "Telegraph Hill" conures.

During 2018, four free-ranging conures, from a naturalized flock in San Francisco, presented with a characteristic set of neurologic signs that had been reported in other individuals from this flock. The cause of morbidity or mortality in historic cases has not been identified. From these four subjects, fresh feces were collected during their initial days of hospitalization and submitted to the University of Georgia Infectious Diseases Laboratory and Center for Applied Isotope Studies for bromethalin and desmethyl-bromethalin quantitation. Using High Performance Liquid Chromatography, the laboratory detected bromethalin, a non-anticoagulant, single-dose rodenticide, in fecal samples from three subjects; half of these samples were also positive for desmethyl-bromethalin, bromethalin’s active metabolite. In three subjects that died, the UGA laboratory screened brain and liver samples and found bromethalin in all samples; desmethyl-bromethalin was detected in all but one brain sample, which was below the detection limit. Our findings suggest the conures are more resistant to bromethalin than are other species in which bromethalin has been studied, and/or that the conures may be ingesting the toxin at a sublethal dose. More data is needed to better assess the long-term effects of bromethalin on animals exposed at the subacute/chronic levels, and also to better understand the compartmentalization of bromethalin and desmethyl-bromethalin in a wider variety of species.

Eighteen years of clinical experience with a modification of the Bentall button technique for total root replacement.

We retrospectively reviewed our experience with the modified Bentall procedure and evaluated the short- and long-term results over a period of 18 years. Between 1999 and 2017, 89 patients with a mean age of 57.3±13.9 years underwent the modified Bentall operation with a slight modification for the correction of aortic root disease. The operative mortality was 1.1% while the overall early mortality rate, defined as death within 30 days of initial hospitalization, was 2.2% (2/89). Logistic regression analysis revealed that increased Euroscore and aortic cross-clamp times were associated with greater likelihood for complications. The overall survival rates for the 89 patients (including deaths occurred at the initial hospitalization) were 93.0% (SE =3.0%) at 6 months, 93.0% (SE =3.0%) at 1 year, 89% (SE =5.0%) at 5 years and 73.0% (SE =5.0%) at 10, 15 and 18 years. Multiple Cox regression analysis for survival identified that increased aortic cross-clamp time, increased age, having a concomitant cardiac procedure and increased NYHA Class were associated with greater hazard. Left ventricular remodeling was assessed by means of echocardiography preoperatively and 1, 3, 6 and 12 months postoperatively. According to our experience, the Bentall procedure is a safe procedure, provides optimal long-term survival and can still be regarded as the gold standard procedure for aortic root replacement.

Economic Benefit of Early Inhospital Diagnosis and Treatment Initiation of Eculizumab in aHUS

BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is a rare, genetic, potentially life-threatening disease often requiring hospital or intensive care unit (ICU) admission. Previously outcomes were poor with 56% of adults progressing to end-stage renal disease or death within one year of disease onset, regardless of plasma exchange/plasma infusion. Eculizumab (Soliris®, Alexion Pharmaceuticals, Inc., New Haven, CT, USA), a monoclonal antibody directed against complement C5, is the only approved treatment for aHUS. It has demonstrated significant improvement in clinical outcomes, including rescue or preservation of renal function, particularly with early initiation. However, difficulty in the differential diagnosis of aHUS has contributed to significant delays in instituting effective therapy. We hypothesize that patients initiating treatment on Day 8 of their hospital stay or later [late initiators (LI)] consume more inpatient resources and have greater hospital costs compared to those that initiate therapy earlier [early initiators (EI)].OBJECTIVE: To evaluate the impact of early versus late initiation of eculizumab treatment for patients with aHUS admitted to a hospital.METHODS: Patients with an inpatient hospitalization in the Premier Perspective® Hospital Database (Oct 2011 - March 2016) with a diagnosis code for hemolytic uremic syndrome (HUS) and/or thrombotic microangiopathy (TMA) (International Classification of Diseases, Clinical Modification 9th Revision [ICD-9-CM]: 283.11 or 10th Revision [ICD-9-CM]: D59.3 and ICD-9-CM 446.6/ICD-10-CM M31.1, respectively), and evidence of eculizumab use for aHUS during the hospitalization were included. Patients who had eculizumab use in the hospital outpatient setting within the preceding 6 months were excluded from the analysis. Patients were further validated as aHUS by an expert clinician prior to inclusion in the analysis. EI were defined as having received eculizumab within 7 days of admission; LI received eculizumab on Day 8 or later. Cutoff at 8 days was chosen due to time it takes in general to receive results of an ADAMTS13 activity test, which is used to distinguish between thrombotic thrombocytopenic purpura and other TMAs. The primary outcome measures were discharge status, days in intensive care unit (ICU), time from initiation to discharge, readmission rates, dialysis use, and total hospital costs. Multivariable regression (logit and log-linear gamma) models were fit to the data to control for potential confounding variables like patient demographics and comorbid conditions.RESULTS: A total of 150 (67.6%) LI and 72 (32.4%) EI were identified. Patient characteristics and descriptive statistics of the cohorts are shown in the Table. LI were older and a lower proportion were <18 years of age. While a similar proportion of patients were admitted to ICU, LI spent longer in the ICU. Although the number of days to live discharge from eculizumab initiation was similar between groups, the total hospital length of stay (LOS) for LI was much greater versus EI. Significantly more LI than EI received dialysis and were readmitted within 90 days of initial hospitalization. Multivariable regression analyses demonstrated significant differences in dialysis use and hospital costs in the LI versus EI groups. LI had 3.2 (OR 1.4, 7.3) times the odds of receiving dialysis during hospitalization (versus EI) and had estimated total hospital costs (least squares mean) that were $17,781 higher ($103,557 versus $85,776).CONCLUSIONS: Late initiation of eculizumab in patients with aHUS results in greater resource utilization and higher hospital costs than those for early initiators of treatment. This suggests that processes should be implemented to expedite results of required lab tests such as ADAMTS13 activity test, for rapid differential diagnosis of aHUS to institute timely and appropriate treatment.This study was funded by Alexion Pharmaceuticals Inc. [Display omitted] DisclosuresDonato:Alexion Pharmaceuticals Inc: Employment, Equity Ownership. Ryan:2CTI Clinical Trial and Consulting: Consultancy, Other: I am an employee of 2CTI Clinical Trial and Consulting Services Inc. who is a consultant for Alexion. Irish:2CTI Clinical Trial and Consulting Services: Consultancy, Other: During this study, I was an employee of 2CTI Clinical Trial and Consulting Services Inc. who is a consultant for Alexion. Gasteyger:Alexion Pharma GmbH: Employment, Equity Ownership. L'Italien:Alexion Pharmaceuticals, Inc.: Equity Ownership, Other: Former employee and current stockholder of Alexion Pharmaceuticals, Inc. . Laurence:Alexion Pharmaceuticals Inc: Consultancy.

Using Claims Data to Examine Hospital Readmission Risk in Patients With Schizophrenia and Comorbid Marijuana Use Disorders

Few epidemiologic studies have examined marijuana use disorder and repeated hospitalizations related to schizophrenia. To address this gap, this study examines time to readmission by indicators for recent marijuana use disorder in the presence of alcohol use disorder (AUD) and other drug use disorder. Our sample consisted of 4,349 patients with a primary diagnosis of schizophrenia spectrum disorder (SSD) in 2005 in individually linked California Health Care Cost and Utilization Project (CA HCUP) data. Readmissions were assessed from 2005 to 2011. Predictors for readmission were examined using a stratified, recurrent-event, Cox proportional hazards model. Sensitivity analyses were conducted on patients readmitted in 2010 or 2011. We found that having marijuana use disorder or AUD alone within 90 days of initial hospitalization was associated with longer times until first readmission. A lower risk of readmission for those with recent marijuana use disorder persisted through the fifth readmission (hazard ratio [HR] = 0.92, 95% CI [0.85, 0.99]) but was not significant in the sixth or greater readmission nor in sensitivity analyses. SSD patients with recent other drug use disorder had an increased risk for a second to fifth readmission (HR = 1.13, 95% CI [1.06, 1.20]). Those with recent AUD had an increased risk for a sixth or greater readmission (HR = 1.15, 95% CI [1.07, 1.23]). Both of these results remained significant in the sensitivity analysis. We found that AUD and other drug use disorder increase readmission risk in patients with SSD after a first hospitalization, whereas marijuana use disorder does not appear to be associated with an increased risk for readmission.

Multimorbidity and the Risk of All-Cause 30-Day Readmission in the Setting of Multidisciplinary Management of Chronic Heart Failure: A Retrospective Analysis of 830 Hospitalized Patients in Australia.

Multimorbidity has an adverse effect on health outcomes in hospitalized individuals with chronic heart failure (CHF), but the modulating effect of multidisciplinary management is unknown. The aim of this study was to test the hypothesis that increasing morbidity would independently predict an increasing risk of 30-day readmission despite multidisciplinary management of CHF. We studied patients hospitalized for any reason with heart failure receiving nurse-led, postdischarge multidisciplinary management. We profiled a matrix of expected comorbidities involving the most common coexisting conditions associated with CHF and examined the relationship between multimorbidity and 30-day all-cause readmission. A total of 830 patients (mean age 73 ± 13 years and 65% men) were assessed. Multimorbidity was common, with an average of 6.6 ± 2.4 comorbid conditions with sex-based differences in prevalence of 4 of 10 conditions. Within 30 days of initial hospitalization, 216 of 830 (26%) patients were readmitted for any reason. Greater multimorbidity was associated with increasing readmission (4%-44% for those with 0-1 to 8-9 morbid conditions; adjusted odds ratio, 1.25; 95% confidence interval, 1.13-1.38) for each additional condition. Three distinct classes of patient emerged: class 1-diabetes, metabolic, and mood disorders; class 2-renal impairment; and class 3-low with relatively fewer comorbid conditions. Classes 1 and 2 had higher 30-day readmission than class 3 did (adjusted P < .01 for both comparisons). These data affirm that multimorbidity is common in adult CHF inpatients and in potentially distinct patterns linked to outcome. Overall, greater multimorbidity is associated with a higher risk of 30-day all-cause readmission despite high-quality multidisciplinary management. More innovative approaches to target-specific clusters of multimorbidity are required to improve health outcomes in affected individuals.

Assessment of Severity of Alcoholic Hepatitis Episode: Comparison of Discriminant Function, MELD, and Glasgow Alcoholic Hepatitis Scores

Introduction: Alcoholic hepatitis (AH) is a distinct syndrome among patients with chronic and active alcohol abuse and has a potential for 30-40% mortality at 1 month among patients with severe disease. Various scores have been developed to assess the disease severity, however, none is an ideal score. We performed this study with an aim to compare discriminant function (DF), model for end-stage disease (MELD), and Glasgow alcoholic hepatitis score (GAHS) on their accuracy in assessing the severity of AH as determined by in-hospital and 30-day mortality. Methods: Medical charts were reviewed for patients admitted to 1 tertiary care hospital (2004-2013) with a discharge diagnosis of AH (ICD-9 code 571.1). Patients meeting criteria for AH diagnosis and with total bilirubin >5 mg/dL formed the study population. Chi-squareD and t-tests were used for comparing categorical and continuous variables, respectively. Multivariate logistic regression models were built to compare DF, MELD, and GAHS in predicting in-hospital (IHM) and 30-day mortality. Results: A total of 105 AH patients (mean age 48±10 years, 66% males, 81% white, 56% underlying cirrhosis) were reviewed. Average (mean±SD) DF, MELD, and GAHS were 54±32, 25±10, and 8±2, respectively. About 79% patients had severe AH with DF ≥32 and/or hepatic encephalopathy (HE). A total of 52 (50%) received treatment with steroids (n=29), pentoxifylline (13), or both (n=10). A total of 17 (16%) had infections with sepsis in 11 and SBP in 7 (1 with sepsis). A total of 51 (49%) died within 30 days of initial hospitalization with 26 (25%) dying during the hospitalization with an average hospital stay of about 15 days. Non-survivors compared to 79 surviving the hospitalization differed for age (51±10 vs. 47±11 years, P=0.07), HE (100% vs. 32%, P<0.0001), white cell count (16±10 vs. 12±8, P=0.02), DF (68±27 vs. 50±33, P=0.01), MELD (30±8 vs. 24±10, P=0.006), and GAHS (9±1 vs. 8±2, P=0.003). On logistic regression analysis adjusting for age, sex, underlying cirrhosis, treatment, accuracy of DF, MELD, and GAHS were similar in predicting IHM with c statistic of 0.728, 0.726, and 0.729, respectively. The scores were also similar in predicting 30-day mortality. For independently predicting the IHM and 30-day mortality, GAHS was superior to DF and MELD with OR (95% CI) of 0.68 (0.47-0.98) vs. 0.99 (0.97-1.001) vs. 0.95 (0.9-0.99) and 0.69 (0.5-0.92) vs.0.99 (0.97-0.999) vs. 0.94 (0.9-0.99), respectively. Conclusion: Discriminant function, MELD score, and GAHS are similar in predicting in-hospital and 30-day mortality in alcoholic hepatitis patients. Studies are needed to refine and improve the existing scores in predicting severity of alcoholic hepatitis.

30-Day Readmission After Admission for Alcoholic Hepatitis: Prevalence and Impact on Outcome

Introduction: Alcoholic hepatitis (AH) is potentially lethal disease among alcoholic liver disease patients. Data are scanty on discharge criteria among patients admitted with severe AH. We performed this retrospective study to examine 30-day readmission rates and identify their predictors and impact on outcome. Methods: Medical charts of patients admitted (2006-2013) with discharge diagnosis of AH (ICD-9 code 571.1) were reviewed to identify patients meeting criteria for AH diagnosis and total bilirubin >5 mg/dL. Patients surviving initial hospitalization were reviewed for readmission within 30-days of discharge. Chisquare and t-tests were used for comparing categorical and continuous variables respectively. Multivariate logistic regression and Cox proportion hazard regression models were built to examine predictors of 30-day readmission and of 1 year mortality respectively. Results: Of 116 AH patients (mean age 46 years, 66% male, 52% with underlying cirrhosis, mean MELD 27±11, and mean discriminant function [DF] 62±37), 76 survived hospitalization. Of these, 14 (18%) were readmitted within 30-days with reason of admission as liver related in 10 patients. Readmitted compared to 62 not readmitted within 30-days differed for receiving steroids (21 vs. 38%; p=0.036) with other baseline characteristics at the initial hospitalization being similar including social support, length of hospital stay, and insurance status. Total bilirubin was higher at discharge among readmitted patients (24±20 vs. 13±10; p=0.004) with a trend for higher DF (67±43 vs. 47±27; p=0.06). Proportion of patients discharged to home was similar (77 vs. 79%; p=0.6) with a trend for more frequent clinic follow-up within 30-days among readmitted patients (100 vs. 52%; p=0.067). After controlling for treatment received, readmission rate was 40% higher with 3 point increase in discharge bilirubin with odds ratio (95% confidence interval [CI]) of 1.4 (1.03-1.9). On median follow-up of 2 months among readmitted and 6 months among not requiring readmission, 1 year survival was lower among readmitted patients (37 vs. 82%; p=0.001). After controlling for underlying cirrhosis, initial DF, treatment, and discharge bilirubin, readmission within 30-d was associated with about 4-fold increased mortality: 3.99 (1.5-10.6). Other predictor was presence of underlying cirrhosis: 3.2 (1.2-9.0). Conclusion: Readmission within 30 days of initial hospitalization for AH is a significant event and is associated with a high mortality at 1 year. Discharge bilirubin is an independent predictor of readmission. Prospective large studies are needed to define discharge criteria and safe total bilirubin levels to avoid readmission as a basis for developing guidelines for discharging patients admitted with severe alcoholic hepatitis.

A comprehensive, longitudinal description of the in-hospital and post-discharge clinical, laboratory, and neurohormonal course of patients with heart failure who die or are re-hospitalized within 90 days: analysis from the EVEREST trial

Hospitalization for worsening chronic heart failure results in high post-discharge mortality, morbidity, and cost. However, thorough characterization, soon after discharge of patients with early post-discharge events has not been previously performed. The objectives of this study were to describe the baseline, in-hospital, and post-discharge clinical, laboratory, and neurohormonal profiles of patients hospitalized for worsening heart failure with reduced ejection fraction (EF) who die or are re-admitted for cardiovascular (CV) causes within 90 days of initial hospitalization. Retrospective analysis of 4,133 patients hospitalized for worsening heart failure with EF ≤40% in the Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study with Tolvaptan (EVEREST) trial, which randomized patients to tolvaptan or placebo, both in addition to standard therapy. Clinical and laboratory parameters were obtained within 48h of admission, during hospitalization, and post-discharge weeks 1, 4, 8, and every 8weeks thereafter for a median of 9.9months. Patients with events within 90days were compared with those with later/no events. All-cause mortality (ACM) and CV re-hospitalization were independently adjudicated. Within 90days of admission, 395 patients (9.6%) died and 801 patients (19.4%) were re-hospitalized for CV causes. Significant baseline and longitudinal differences were seen between groups with early versus later (>90days) or no events at 12months post-randomization. Post-discharge outcomes were similar in the tolvaptan and placebo groups. Patients with early post-discharge events experienced clinically significant worsening in signs and symptoms, laboratory values, and neurohormonal parameters soon after discharge. Identifying these abnormalities may facilitate efforts to reduce post-discharge mortality and re-hospitalization.

CHRONIC DIARRHEA IN AN ELDERLY MAN

CHRONIC DIARRHEA IN AN ELDERLY MAN

Predictors of inhospital mortality and re-hospitalization in older adults with community-acquired pneumonia: a prospective cohort study

BackgroundA better understanding of potentially modifiable predictors of in-hospital mortality and re-admission to the hospital following discharge may help to improve management of community-acquired pneumonia in older adults. We aimed to assess the associations of potentially modifiable factors with mortality and re-hospitalization in older adults hospitalized with community-acquired pneumonia.MethodsA prospective cohort study was conducted from July 2003 to April 2005 in two Canadian cities. Patients aged 65 years or older hospitalized for community-acquired pneumonia were followed up for up to 30 days from initial hospitalization for mortality and these patients who were discharged alive within 30 days of initial hospitalization were followed up to 90 days of initial hospitalization for re-hospitalization. Separate logistic regression analyses were performed identify the predictors of mortality and re-hospitalization.ResultsOf 717 enrolled patients hospitalized for community-acquired pneumonia, 49 (6.8%) died within 30 days of hospital admission. Among these patients, 526 were discharged alive within 30 days of hospitalization of whom 58 (11.2%) were re-hospitalized within 90 days of initial hospitalization. History of hip fracture (odds ratio (OR) = 4.00, 95% confidence interval (CI) = (1.46, 10.96), P = .007), chronic obstructive pulmonary disease (OR = 2.31, 95% CI = (1.18, 4.50), P = .014), cerebrovascular disease (OR = 2.11, 95% CI = (1.03, 4.31), P = .040) were associated with mortality. Male sex (OR = 2.35, 95% CI = (1.13, 4.85), P = .022) was associated with re-hospitalization while vitamin E supplementation was protective (OR = 0.37 (0.16, 0.90), P = .028). Lower socioeconomic status, prior influenza and pneumococcal vaccinations, appropriate antibiotic prescription upon admission, and lower nutrition risk were not significantly associated with mortality or re-hospitalization.ConclusionChronic comorbidities appear to be the most important predictors of death and re-hospitalization in older adults hospitalized with community-acquired pneumonia while vitamin E supplementation was protective.

Increased serum ferritin levels in patients with Crimean-Congo hemorrhagic fever: can it be a new severity criterion?

Serum ferritin is one of the markers indicating hemophagocytosis that may have a role in the pathogenesis of Crimean-Congo hemorrhagic fever (CCHF). This study was designed to determine any correlation between serum ferritin and routine diagnostic laboratory markers of CCHF, and to investigate the relationship between serum ferritin levels and disease severity. Sixty-six patients with CCHF admitted to the hospital during the spring and summer months of 2006 and 2007 were included in the study. Serum ferritin levels were measured in sera obtained during the initial days of hospitalization. Data from 53 patients showing decreasing platelet counts over the first three days were used for further analysis and these patients were divided into two groups according to disease severity: group A included severe cases with lowest platelet counts < or =20x10(9)/l and group B included mild cases with lowest platelet counts >20x10(9)/l. Forty patients (60.6%) were male (mean age 43+/-17 years). Three patients died, thus the fatality rate was 4.5%. Fifty-one patients (77.3%) had abnormal serum ferritin levels, with levels above 500 ng/ml in 62.1%. There was a significant negative correlation between ferritin levels and concordant platelet counts (p<0.001; r=-0.416) and ferritin was also found to be positively correlated with aspartate aminotransferase (p<0.001; r=0.625), alanine aminotransferase (p<0.001; r=0.479), and lactate dehydrogenase (p<0.001; r=0.684). Group A had higher ferritin levels than group B (p < 0.001). Receiver operating characteristic analysis revealed that a ferritin level of > or =1862ng/ml had a sensitivity of 87.5% and a specificity of 83.8% in differentiating severe cases from mild ones. Increased serum ferritin levels may suggest a significant role of hemophagocytosis in the pathogenesis of CCHF and may be a useful marker for diagnosis, disease activity, and prognosis.

Comparison of methotrexate- versus sirolimus-containing graft-versus-host disease prophylaxis regimens after myeloablative stem cell transplantation

Background: Graft-versus-host disease (GvHD) is a serious complication after allogeneic hematopoietic stem cell transplantation (HSCT). Methotrexate in combination with a calcineurin inhibitor (CM) is considered standard GvHD prophylaxis. Studies suggest that sirolimus in combination with a calcineurin inhibitor (SC) is effective in preventing GvHD and minimizing transplant-related morbidity and mortality. We sought to compare costs and clinical outcomes between the two different GvHD regimens. Method: A total of 159 patients with hematological diseases underwent myeloablative HLA-matched HSCT at the Dana-Farber Cancer Institute between June 2000 and December 2004 using Cytoxan and TBI conditioning. GvHD prophylaxis was either CM (n=97) or SC (n=62). Inpatient costs for the first transplant year of 94 CM and 47 SC recipients were obtained. Multivariate analyses were conducted including baseline factors: GvHD prophylaxis, patient age, sex matching, donor type, CMV serological status, disease status, stem cell source, and year of transplantation. In addition, for the cost analysis a full model was examined considering both baseline and post-transplant events [neutrophil engraftment, grade II to IV aGvHD, veno-occlusive disease, idiopathic pneumonia/diffuse alveolar hemorrhage, infection, severe organ toxicity, and in-hospital death]. Results: CM recipients were more likely to have unrelated donors, BM grafts, and to be transplanted in earlier years than SC recipients. Univariate and multivariate comparisons of outcomes, costs and days of initial hospitalization are presented in Table 1. The SC regimen was associated with faster engraftment, less acute GvHD and better DFS and OS. Days of initial hospitalization and costs were lower for SC in the univariate model but not the multivariate model. Use of an unrelated donor was the only significant predictor of high costs considering baseline factors. In contrast, in the full model, grade II to IV aGvHD, late engraftment, and in-hospital death were the significant factors associated with high costs. Conclusion: Both OS and DFS in the SC group were higher in the multivariate analysis, probably due to early engraftment and reduced incidence of grade II to IV aGvHD seen in SC group. However, we could not detect the impact of GvHD prophylaxis on inpatient costs for the first transplant year. The SC regimen is a promising alternative to CM and larger multi-center randomized trial is planned through the NIH-funded Clinical Trials Network. | | Univariate analysis | Multivariate analysis | |:-----------------------------------------------------:| ------------------- | --------------------- | ------- | | Variables | CM | SC | P-value | HR (Ratio*) (CM vs SC) | P-value | | Median age, yrs [range] | 40 [18–58] | 43 [18–65] | 0.28 | - | - | | Neutrophil engraftment, median [range] | 17 [10–35] | 13 [8–17] | <0.0001 | 0.21 | <0.0001 | | Cumulative incidence of grade II–IV aGvHD at 100 d | 37±5 | 18±5 | 0.01 | 2.61 | 0.02 | | Cumulative incidence of extensive cGvHD at 1 y | 24±5 | 22±6 | 0.75 | 1.70 | 0.21 | | Disease-free survival at 1 y | 52±5 | 71±6 | 0.0051 | 2.50 | 0.0044 | | Overall survival at 1 y | 53±5 | 72±6 | 0.01 | 1.61 | 0.01 | | Inpatient costs during the first post-transplant year | $110,081 | $101,697 | 0.03 | 1.14* | 0.30 | | Days of initial hospitalization | 33 | 27 | 0.0008 | 0.99* | 0.91 | Table 1

Comparison of Methotrexate- Versus Sirolimus- Containing Graft-Versus-Host Disease Prophylaxis Regimens after Myeloablative Stem Cell Transplantation.

Background:Graft-versus-host disease (GvHD) is a serious complication after allogeneic hematopoietic stem cell transplantation (HSCT). Methotrexate in combination with a calcineurin inhibitor (CM) is considered standard GvHD prophylaxis. Studies suggest that sirolimus in combination with a calcineurin inhibitor (SC) is effective in preventing GvHD and minimizing transplant-related morbidity and mortality. We sought to compare costs and clinical outcomes between the two different GvHD regimens.Method:A total of 159 patients with hematological diseases underwent myeloablative HLA-matched HSCT at the Dana-Farber Cancer Institute between June 2000 and December 2004 using Cytoxan and TBI conditioning. GvHD prophylaxis was either CM (n=97) or SC (n=62). Inpatient costs for the first transplant year of 94 CM and 47 SC recipients were obtained. Multivariate analyses were conducted including baseline factors: GvHD prophylaxis, patient age, sex matching, donor type, CMV serological status, disease status, stem cell source, and year of transplantation. In addition, for the cost analysis a full model was examined considering both baseline and post-transplant events [neutrophil engraftment, grade II to IV aGvHD, veno-occlusive disease, idiopathic pneumonia/diffuse alveolar hemorrhage, infection, severe organ toxicity, and in-hospital death].Results:CM recipients were more likely to have unrelated donors, BM grafts, and to be transplanted in earlier years than SC recipients. Univariate and multivariate comparisons of outcomes, costs and days of initial hospitalization are presented in Table 1. The SC regimen was associated with faster engraftment, less acute GvHD and better DFS and OS. Days of initial hospitalization and costs were lower for SC in the univariate model but not the multivariate model. Use of an unrelated donor was the only significant predictor of high costs considering baseline factors. In contrast, in the full model, grade II to IV aGvHD, late engraftment, and in-hospital death were the significant factors associated with high costs.Conclusion:Both OS and DFS in the SC group were higher in the multivariate analysis, probably due to early engraftment and reduced incidence of grade II to IV aGvHD seen in SC group. However, we could not detect the impact of GvHD prophylaxis on inpatient costs for the first transplant year. The SC regimen is a promising alternative to CM and larger multi-center randomized trial is planned through the NIH-funded Clinical Trials Network.Table 1Univariate analysisMultivariate analysisVariablesCMSCP-valueHR (Ratio*) (CM vs SC)P-valueMedian age, yrs [range]40 [18–58]43 [18–65]0.28--Neutrophil engraftment, median [range]17 [10–35]13 [8–17]<0.00010.21<0.0001Cumulative incidence of grade II–IV aGvHD at 100 d37±518±50.012.610.02Cumulative incidence of extensive cGvHD at 1 y24±522±60.751.700.21Disease-free survival at 1 y52±571±60.00512.500.0044Overall survival at 1 y53±572±60.011.610.01Inpatient costs during the first post-transplant year$110,081$101,6970.031.14*0.30Days of initial hospitalization33270.00080.99*0.91