Episodes Of Hospital Admissions Research Articles

An educational case of toluene intoxication: importance of kidney function and timing in diagnosis.

Metabolic acidosis (MA) is common in daily clinical settings and requires evaluation not only by serum anion gap (AG) but also by urine AG (UAG) and urine osmolal gap (UOG) to investigate potential causes and determine appropriate treatment. Herein, we report an educational case of non-gap (normal AG) MA (pH 7.16, HCO3- 8.4, AG 11.6) with nausea and fatigue. The patient had three episodes of hospital admission with MA in the previous three months. Although serum lactate and ketone levels were negative, the AG levels were notably inconsistent (elevated or not) each time. Nevertheless, the patient was suspected to have toluene intoxication because of low UAG and high UOG levels in the non-gap acidosis phase. Eventually, he was diagnosed with toluene intoxication due to a significantly elevated urinary hippurate level (28.7g/L) despite never admitting to using toluene. Additionally, he had a high AG only in the presence of significant kidney dysfunction, which suggests that the high AG was either due to kidney dysfunction or accumulated hippurate in the blood (when UOG was high). Thus, it should be noted that the use of serum AG alone may lead to incorrect determination of cause(s) of MA when kidney dysfunction coexists, and that UAG and UOG, in addition to AG, are necessary to determine correct diagnosis.

Cost of childhood cancer treatment in Ethiopia.

Despite the recent interest in expanding pediatric oncology units in Ethiopia, reflected in the National Childhood and Adolescent Cancer Control Plan (NCACCP), little is known about the cost of running a pediatric oncology unit and treating childhood cancers. We collected historical cost data and quantity of services provided for the pediatric oncology unit and all other departments in Tikur Anbessa Specialized Hospital (TASH) from 8 July 2018 to 7 July 2019, using a provider perspective and mixed (top-down and bottom-up) costing approaches. Direct costs (human resources, drugs, supplies, medical equipment) of the pediatric oncology unit, costs at other relevant clinical departments, and overhead cost share are summed up to estimate the total annual cost of running the unit. Further, unit costs were estimated at specific childhood cancer levels. The estimated annual total cost of running a pediatric oncology unit was USD 776,060 (equivalent to USD 577 per treated child). The cost of running a pediatric oncology unit per treated child ranged from USD 469 to USD 1,085, on the scenario-based sensitivity analysis. Drugs and supplies, and human resources accounted for 33% and 27% of the total cost, respectively. Outpatient department and inpatient department shared 37% and 63% of the cost, respectively. For the pediatric oncology unit, the cost per OPD visit, cost per bed day, and cost per episode of hospital admission were USD 36.9, 39.9, and 373.3, respectively. The annual cost per treated child ranged from USD 322 to USD 1,313 for the specific childhood cancers. Running a pediatric oncology unit in Ethiopia is likely to be affordable. Further analysis of cost effectiveness, equity, and financial risk protection impacts of investing in childhood cancer programs could better inform the prioritization of childhood cancer control interventions in the Ethiopia Essential Health Service Package.

Clinico-epidemiological profile of children living with HIV/AIDS managed at Heal Africa Hospital, Goma, Democratic Republic of the Congo.

Conflict in the DRC led to a poor health care. HIV/AIDS in children remains one of the leading causes of pediatric morbidity and mortality. This cross-sectional study used a sample size of 238 files and aimed to determine the epidemiological profile of children living with HIV at Heal Hospital in 2015. The age ranged from zero to fifteen, with a mean of 6.1 (±3.9) years. Records of PMTCT were noted in 12%. The mean birth weight was 3(±0.8) kg, most cases (88 percent) had normal vaginal delivery. Many of them (71 percent) were living with at least one parent. The majority of the children (92 percent) were from Goma, and 75 percent were diagnosed at WHO Stage 3. At least one episode of hospital admission was reported in 71 percent. Respiratory tract infections were the most common disease, and they were also the leading cause of death. Based on the CD4, which was the most cost-effective method of monitoring, there was an improvement in immunity at the last visit. This study pointed out the importance of PMTC and early management of children leaving with HIV/AIDS. Outreach would encourage voluntary HIV/AIDS testing for pregnant women in armed conflict zone.

Retrospective case-control study exploring pretransplant predictors for loss of kidney transplant function or death among indigenous kidney transplant recipients.

The factors affecting the outcomes among Indigenous kidney transplant recipients is not fully understood. We conducted a retrospective case control study to identify risk factors beyond those explained by the ANZDATA registry. To identify the risk factors for loss of kidney transplant function or death among Indigenous kidney transplant recipients. Cases were defined as all Indigenous Australian kidney transplant recipients from 1 January 2005 to 31 December 2015 from the major hospitals in the Northern Territory (NT) and South Australia (SA) who experienced graft loss (including patient death) up to 2-years post-transplant. Controls (matched 4:1) were defined as all indigenous kidney transplant recipients during the same period with functioning transplants at 2-years post-transplant operation. Matching was done on gender and diabetes status. Regression analysis adjusted for age was used for comparing cases and controls. There were 17 cases and 68 matched controls. Among cases, the odds ratio for more than one hospital admission episode (compared with ≤1 episode) in the 2-year pretransplant period was 6.2 (95% confidence interval, 1.2-32.5). However, there were no significant differences in the frequency of comorbidities at renal replacement therapy start, cardiovascular intervention pretransplant, pretransplant infection screening, age and gender of the donors, frequency of admission episodes where an infection was documented, the total length of inpatient stay or admission to intensive care unit during pretransplant hospital admission between cases and controls. Early graft loss was associated with a higher frequency of hospital admissions in the 2-years pretransplant period. In contrast, other measured factors in the pretransplant period did not predict these adverse outcomes.

Care processes and outcomes of deprivation across the clinical course of kidney disease: findings from a high-income country with universal healthcare.

No single study contrasts the extent and consequences of inequity of kidney care across the clinical course of kidney disease. This population study of Grampian (UK) followed incident presentations of acute kidney injury (AKI) and incident estimated glomerular filtration rate (eGFR) thresholds of <60, <45 and <30mL/min/1.73m2 in separate cohorts (2011-2021). The key exposure was area-level deprivation (lowest quintile of the Scottish Index of Multiple Deprivation). Outcomes were care processes (monitoring, prescribing, appointments, unscheduled care), long-term mortality and kidney failure. Modelling involved multivariable logistic regression, negative binomial regression and cause-specific Cox models with and without adjustment of comorbidities. There were 41313, 51190, 32171 and 17781 new presentations of AKI and eGFR thresholds <60, <45 and <30 mL/min/1.73m2. A total of 6.1-7.8% of the population was from deprived areas and (versus all others) presented on average 5years younger, with more diabetes and pulmonary and liver disease. Those from deprived areas were more likely to present initially in hospital, less likely to receive community monitoring, less likely to attend appointments and more likely to have an unplanned emergency department or hospital admission episode. Deprivation had the greatest association with long-term kidney failure at the eGFR <60mL/min/1.73m2 threshold {adjusted hazard ratio [HR] 1.48 [95% confidence interval (CI) 1.17-1.87]} and this association decreased with advancing disease severity [HR 1.09 (95% CI 0.93-1.28) at eGFR <30mL/min/1.73m2), with a similar pattern for mortality. Across all analyses the most detrimental associations of deprivation were an eGFR threshold <60mL/min/1.73m2, AKI, males and those <65years of age. Even in a high-income country with universal healthcare, serious and consistent inequities in kidney care exist. The poorer care and outcomes with area-level deprivation were greater earlier in the disease course.

Functional improvement after inpatient rehabilitation in community hospitals following acute hospital care

There are limited studies exploring functional improvement in relation to characteristics of patients who, following acute hospital care, receive inpatient rehabilitation in community hospitals. We evaluated the association of acute hospital admission-related factors with functional improvement on community hospital discharge. We conducted a retrospective cohort study among patients who were transferred to community hospitals within 14-day post-discharge from acute hospital between 2016 and 2018. Modified Barthel Index (MBI) on a 100-point ordinal scale was used to assess functional status on admission to and discharge from the community hospital. We categorised MBI into 6 bands: 0-24, 25-49, 50-74, 75-90, 91-99 and 100. Multivariable logistic regression models were constructed to determine factors associated with categorical improvement in functional status, defined as an increase in at least one MBI band between admission and discharge. A total of 5,641 patients (median age 77 years, interquartile range 69-84; 44.2% men) were included for analysis. After adjusting for potential confounders, factors associated with functional improvement were younger age, a higher MBI on admission, and musculoskeletal diagnosis for the acute hospital admission episode. In contrast, a history of dementia or stroke; lower estimated glomerular filtration rate; abnormal serum albumin or anaemia measured during the acute hospital episode; and diagnoses of stroke, cardiac disease, malignancy, falls or pneumonia; and other chronic respiratory diseases were associated with lower odds of functional improvement. Clinicians may want to take into account the presence of these high-risk factors in their patients when planning rehabilitation programmes, in order to maximise the likelihood of functional improvement.

Effect of macrotroponin on the utility of cardiac troponin I as a prognostic biomarker for long term total and cardiovascular disease mortality.

Macrotroponin is a complex formed between endogenous cardiac troponin autoantibodies and circulating cardiac troponin (cTn). It is a recognised cause of discrepancy between current high sensitivity troponin (hs-cTn) assays; and immunoglobulin-bound (macrotroponin) and unbound cTn can coexist in varying proportions in the acute setting. Increasingly it is considered when laboratory cTn results do not match a patient's clinical picture. However, despite the better understanding of macrotroponin as an analytical interference, its clinical significance remains unclear. The aim of this study was to determine the potential impact of macrotroponin on the use of cTn as a long-term prognostic marker. We repeated cTnI testing after polyethylene glycol (PEG) precipitation on consecutive participants (n=159) with a first elevated cTn above 0.2 μg/L during their hospital admission episode. Because this paper is looking at outcomes in years, the initial data were generated at a time when non-hs-cTn assays were in use. We divided the cohort into two groups based on an exploratory PEG recovery cut-off of <34.6% to indicate the presence of possible macrotroponin and compared the overall and cardiovascular related mortality. The median follow-up time for the overall cohort was 8.35 years (8.32-8.40 interquartile range) with no difference between the two groups. The overall median survival was 8.1 years. Our findings indicate a hazard ratio of 0.54 (0.32-0.91 95% CI) for all-cause mortality and 0.48 (0.24-0.95) for cardiovascular mortality in patients with possible macrotroponin compared to those patients with troponin elevation without evidence of macrotroponin, after adjustment for common cardiovascular disease risk factors. Furthermore, an association was observed between PEG% recovery and all-cause mortality (p<0.05). This study showed that patients with macrotroponin have comparatively favourable long-term all-cause and cardiovascular mortality in a cohort of patients with elevated troponin. We illustrate the importance of recognising cTn results as being a summation of heterogeneous components, including those bound to antibodies, and the potential role of macrotroponin to further improve our interpretation and use of cTn as a biomarker.

S3612 A Clotting and Bleeding Interplay in Ulcerative Colitis

Introduction: Inflammatory bowel disease (IBD) patients are at increased risk of venous thromboembolic (VTE) events. Here we present a case of a patient with ulcerative colitis (UC) with incidental findings of pulmonary embolism (PE) and, further complications on anticoagulation. Case Description/Methods: A 50-year-old female with a past medical history of anxiety and recently diagnosed UC on steroid taper presented to the hospital with complaints of intractable diarrhea, diffuse abdominal discomfort, and worsening fatigue. Lab findings were consistent with previously diagnosed iron deficiency anemia, downtrending C-reactive protein, ESR, negative C.diff, and gastric pathogen panel. A repeat CT abdomen pelvis with contrast showed improving inflammation of the colon, mesalamine was added to steroid regimen . There was an incidental finding of PE in the bilateral segmental arteries without right heart strain, treated with heparin infusion and transitioned to rivaroxaban.Later, patient had two episodes of hospital admission for rectal bleeding complicating the treatment course. Rivaroxaban was resumed after first episode of bleeding, but since the further episode of rectal bleeding required cardiopulmonary resuscitation, anticoagulation was discontinued. During this time for UC, mesalamine was discontinued and infliximab was initiated. She developed another episode of bilateral deep vein thrombosis off anticoagulation, hence IVC filter was placed to avoid new PE and plan to restart anticoagulation after resolution of bleeding was made. Discussion: Patients with IBD are at higher risk ( 2 to 3 fold) of developing the extraintestinal complication of VTE compared to general population with incidence varying from 1.3% to 6.2% and mortality from 8% to 25%. The exact pathophysiology of thrombosis in IBD is not fully understood and is considered to be a complex interplay of inflammation and coagulation, affecting the procoagulant, anticoagulant and fibrinolytic factors of the coagulation cascade. Patients in an acute flare of IBD are associated with highest risk of VTE compared to patients in remission. Patients admitted for IBD flare should be on pharmacological prophylaxis for VTE and can be safely administered for patients with minor hematochezia. Treatment of VTE in IBD patients is the same as patients without IBD, but duration of therapy is not well established. Risk is lower in patients in remission, another important reason for providers to have IBD patients in endoscopic and clinical remission.

Standard management protocol to improve the short-term outcome of biliary atresia.

This study compared the outcomes of patients with biliary atresia (BA) treated according to a standardised protocol with historical patients. This is a single-centred retrospective study of BA patients treated from 1980 to 2016. A standardised treatment protocol was established since 2008 regarding peri-operative management. The outcomes being compared between the two groups (Groups I and II = before and after 2008, respectively) were jaundice clearance (JC), incidence of recurrent cholangitis, hospital admission and native liver survival (NLS). A total of 128 patients were included (Group I = 100, Group II = 28). The overall median follow-up period was 15.3 years (I vs. II = 20.6 years vs. 5.1 years, respectively). There was no significant difference in the JC at the sixth month between the two groups (I vs. II = 60.0 vs. 82.1%, respectively, P = 0.07). The incidence of recurrent cholangitis was similar between the two groups (I vs. II = 39 vs. 35.7%, respectively, P = 0.45), but the median hospital admission episode per patient was non-significantly higher in Group I (I vs. II = 4.2 vs. 2.7, respectively, P = 0.08). There was an improvement in the 1-year NLS rate in Group II (I vs. II = 69.0 vs. 85.7%, respectively, P = 0.05). The introduction of a standardised management protocol has improved the short-term outcome of BA patients, with a better 1-year NLS observed.

Impact of posthospital syndrome on outcomes of elective endovascular repair of abdominal aortic aneurysm

ObjectivePosthospital syndrome (PHS) is an acquired, transient period of health vulnerability after a hospital admission for acute illness. It is characterized by physiologic deconditioning secondary to stressors from disruption in circadian rhythm, depletion of nutritional and physiologic reserve as well as the pain and discomfort associated with hospitalization. PHS is reported as an independent risk factor for readmission and adverse postoperative outcomes. The aim of this study is to investigate whether preoperative hospitalization affects outcomes of elective endovascular repair of abdominal aortic aneurysm (EVAR). MethodsThe Healthcare Cost and Utilization Project State Inpatient Database for California (2009-2011) were queried using International Classification of Disease Codes, Ninth Edition, codes of 441.4 (abdominal aneurysm without mention of rupture), 397.1 (EVAR with graft), and 397.8 (EVAR with branching or fenestrated graft). PHS exposure is defined as any inpatient admission 30 or fewer days before elective EVAR. Primary outcomes are all-cause mortality and overall complications. Secondary outcomes include length of stay (LOS), 30-day readmission, and hospital charge. ResultsA total of 6155 patients were identified. of which 327 patients (5.6%) had more than one episode of hospital admission 30 days or less before elective EVAR. In-hospital mortality was comparable after PHS exposure (P = .09). However, PHS exposure was associated with increased 30-day readmission (9.5% vs 18.4%; P < .001), LOS (3.0 vs 4.5 days; P < .001), and overall complications (14.8% vs 24.5%; P < .001). Risk adjustment was made based on age, sex, race, baseline comorbidities, and reason for preoperative admission. Multivariate logistic regression analysis demonstrated that PHS exposure was a predictor for longer LOS (odds ratio [OR], 2.5; 95% confidence interval [CI], 2.0-3.2; P < .001), higher incidence of 30-day readmission (OR, 2.0; 95% CI, 1.4-2.6; P < .001), and overall complications (OR, 1.7; 95% CI, 1.3-2.2; P < .001). Additional cost associated with increased 30-day readmission attributable to PHS exposure was estimated at $448,302 per 100 cases. ConclusionsPHS is an independent risk-adjusted predictor for increased LOS, 30-day readmission, and overall complications after elective EVAR. Recent hospital admission should be assessed carefully before elective EVAR. Medical optimization with an attempt to delay elective surgery by up to 30 days may help to improve surgical outcomes and decrease unnecessary health care expenditures.

A study of Vitamin D deficiency in patients of sickle cell disease and its association with severity

Background: Both SCD and Vit. D deficiency may cause joint pain. So, Vit. D may have a contributory role in severity of SCD presentation. This study was performed to assess burden of Vitamin D levels and association of vitamin D deficiency with severity of SCD in a tertiary care centre in India.Methods: This was a cross-sectional study, performed for one and half year. All SCD patients &gt;18 years of age were included. Data was analysed to assess the burden of Vitamin D deficiency and to find out any correlation of S. vitamin D level with anemia, jaundice and number of episodes of hospital admissions in patients of SCD.Results: Total 50 patients were included. Multiple joint pain and easy fatigability were the most common symptoms. Most of them had history of jaundice and anaemia in the past, 84% had Vitamin D deficiency. There was significant difference in values of serum total bilirubin, blood urea, SGPT, SGOT, HbF, HbA2 and haemoglobin between the patients with Vitamin D3&lt;30 and vitamin D3≥30 (p&lt;0.05). There was a significant positive correlation of vitamin D3 with haemoglobin (r = 0.889) and a negative correlation with Hb A2 (r= -0.123) and total bilirubin (r= -0.438).Conclusions: Vitamin D3 deficiency is associated with increased morbidity in SCD in terms of joint pain, anemia and jaundice. Routine testing and supplementation of Vitamin D levels in these patients may help to alleviate pain, improve functionality and reduce complications.

Risk factors of infection-associated mortality in children with lupus nephritis in under-resourced areas.

Treatment of lupus nephritis class III, IV and V with immunosuppressive therapy increases patient survival but poses a risk of infection-related mortality. This study was conducted to evaluate risk factors for fatal infection in children with lupus nephritis in under-resourced areas. Medical records of patients, who were admitted to a tertiary-care university-based hospital from January 2002 to July 2018 with the diagnosis of systemic lupus erythematosus, were reviewed. Only patients aged less than 18 years with lupus nephritis and documented infection were included in the study. The primary outcome was infection-associated mortality. The logistic regression model was used to identify independent variables associated with fatal infection. Predicted probabilities of infection-related mortality adjusted for factors significant in multivariate analysis were calculated using marginal effects at representative values. Infection-related deaths occurred in 27 of 179 patients (15.1%). Hospital-acquired infections occurred in 72 of 375 episodes of hospital admissions (19.2%) and 13 hospital-acquired infections (18.1%) resulted in fatal infection. Invasive fungal infections were the leading cause of death (44.4%) and pulmonary infections were the predominant site (55.5%). Haemoglobin levels and glomerular filtration rates were significantly lower in deceased versus surviving patients. Percentages of patients with hospital-acquired infections, invasive fungal infections and pulmonary infections were significantly higher in deceased than surviving patients. Urine protein, the neutrophil-to-lymphocyte ratio, cumulative methylprednisolone dose and daily prednisolone dose were significantly higher in deceased than surviving patients. In multivariate analysis, a neutrophil-to-lymphocyte ratio more than 20, invasive fungal infections and high daily prednisolone dose were independently predictive of fatal infection with adjusted odds ratio of 3.02 (95% confidence interval 1.02-8.97, p = 0.04), 15.08 (95% confidence interval 4.72-48.24, p < 0.001) and 1.03 (95% confidence interval 1.01-1.06, p = 0.04), respectively. A high daily prednisolone dose intensified the impact of invasive fungal infections and high neutrophil-to-lymphocyte ratio on predicted probability of infection-associated mortality. Prevention of invasive fungal infections and minimization of daily prednisolone should be emphasized in routine clinical practice of children with lupus nephritis in under-resourced areas to achieve better survival. Children with lupus nephritis and a high neutrophil-to-lymphocyte ratio should be under cautious surveillance for infection.

1606P - Early palliative care in advanced cancer: Is it really effective?

BackgroundPalliative care units (PCU) have shown an improvement in the quality of life of patients with cancer by reducing overtreatments at the end of life and increasing symptomatic care at home, avoiding unnecessary emergency room visits and decreasing the number of hospital admissions. MethodsA retrospective observational study was conducted, selecting all patients with a first consultation in the Medical Oncology Unit of the Puerta de Hierro University Hospital (HUPdH) between 2014 and 2015 and died before December 31st 2017. Assessment by PCU, number of hospital admissions and re-admissions and most frequent symptoms for admission in the last 6 months of life were reviewed. The main objective was to know if there were differences between those who were valued by PCU or not. ResultsA total of 662 patients were selected. From them, 86 (13%) patients had never been admitted at HUPdH, 312 (47%) had been admitted once, 169 (26%) twice and 95 (14%) three or more times. Before death, 474 (72%) had been valued by PCU and 302 did not received PCU visit before the second hospital admission episode. The three most frequent causes of admission were deterioration of the general condition, infections and uncontrollable pain. In those with an assessment by PCU before the second admission process, there was a significant decrease in the number of readmissions (25% versus 68%). Moreover, in these patients, there was a statistically significant decrease in the number of re-admissions because of the three main causes of admission but also in others, such as dyspnea, neurological worsening, bleeding and nauseas and vomiting. (Table).Table1606PTablePCU: Percentage of patients re-admitted with an assessment by palliative care unit by the time of re-admission; Non PCU: Percentage of patients re-admitted without assessment by palliative care units before re-admissionSymptomPCUNon PCURisk RatioDeterioration of the general condition9%21%RR 0.41, 95% CI 0.27-061, p<0.0001Dyspnea3%13%RR 0.24, 95% CI 0.12-0.45, p<0.0001Neurological worsening2%8%RR 0.25, 95% CI 0.11-0.56, p<0.0001Infections5%24%RR 0.20, 95% CI 0.12-0.32, p<0.0001Uncontrollable pain5%15%RR 0.35, 95% CI 0.21-0.59, p<0.001Nauseas and vomiting2%7%RR 0.32, 95% CI 0.14-0.71, p<0.003Bleeding2%7%RR 0.34, 95% CI 0.15-0.75%, p<0.005 ConclusionsIn our cohort, in patients with an assessment by PCU before the second admission episode, was observed a decrease in number and severity of re-admissions. An optimization of the symptomatic treatment at home implies a decrease in hospital-acquired or nosocomial complications which leads to a reduction in costs and above all, an improvement in the quality life both of patients and their families. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Impact of Post-Hospital Syndrome on Outcomes of Elective Endovascular Repair of Abdominal Aortic Aneurysm

Post-hospital syndrome (PHS) is an acquired, transient period of health vulnerability that follows hospital admission for acute illness. It is characterized by physiologic deconditioning secondary to stressors from disruption in circadian rhythm, depletion of nutritional reserve, and pain or discomfort associated with hospitalization. PHS is reported as an independent risk factor for readmission and adverse postoperative outcomes. The aim of this study was to investigate whether PHS affects outcomes of elective endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm. The Healthcare Cost and Utilization Project State Inpatient Database for California (2009-2011) was queried using International Classification of Diseases, Ninth Revision codes 441.4 (abdominal aneurysm without mention of rupture), 397.1 (EVAR with graft), and 397.8 (EVAR with branching or fenestrated graft). PHS exposure is defined as any inpatient admission ≤30 days before elective EVAR. Primary outcomes are mortality and postoperative complications. Secondary outcomes include length of stay (LOS), 30-day readmission, and hospital charge. A total of 6155 patients were identified, of whom 327 (5.6%) patients had more than one episode of hospital admission ≤30 days before elective EVAR. In-hospital mortality was comparable (P = .09). However, PHS exposure was associated with increased 30-day readmission (9.5% vs 18.4%; P < .001), LOS (3.0 vs 4.5 days; P < .001), and overall complications (14.8% vs 24.5%; P < .001). Risk adjustment was made on the basis of age, sex, race, comorbidities, and reason for preoperative admission. Multivariate regression analysis demonstrated PHS to be a predictor for longer LOS (odds ratio [OR], 2.5; confidence interval [CI], 2.0-3.2; P < .001), 30-day readmission (OR, 2.0; CI 1.4-2.6; P < .001), and overall complications (OR, 1.7; CI, 1.3-2.2; P < .001; Table). Additional cost associated with increased readmission attributable to PHS exposure was estimated at $448,302 per 100 cases (Fig). PHS is an independent predictor for increased LOS, 30-day readmission, and overall complications after elective EVAR. Recent hospital admission should be carefully assessed before elective EVAR. Medical optimization with an attempt to delay elective surgery up to 30 days may help improve outcomes and decrease unnecessary health care expenditure. This could be a potential quality improvement target.TableAdjusted odds ratio (OR) of post-hospital syndrome (PHS) exposure of type of adverse eventsAdjusted OR95% CIP valueHematoma/hemorrhage1.51.1-2.1.022Acute kidney injury1.51.0-2.4.062Any complication1.71.3-2.2<.001Within 30-day readmission2.01.4-2.6<.001Length of hospital stay >3 days2.52.0-3.2<.001CI, Confidence interval.Adjustment made with age, sex, race, comorbid disease severity (Charlson Comorbidity Index), and reason for preoperative admission. Open table in a new tab

Incidence and Characteristics of Adrenal Crisis in Children Younger than 7 Years with 21-Hydroxylase Deficiency: A Nationwide Survey in Japan

Background/Aims: We aimed to evaluate the incidence and characteristics of adrenal crisis in Japanese children with 21-hydroxylase deficiency (21-OHD). Methods: We conducted a retrospective nationwide survey for the councilors of the Japanese Society for Pediatric Endocrinology (JSPE) regarding adrenal crisis in children under 7 years with 21-OHD, admitted to hospitals from 2011 through 2016. We defined adrenal crisis as the acute impairment of general health due to glucocorticoid deficiency with at least two of symptoms, signs, or biochemical abnormalities. Results: The councilors of the JSPE in 83 institutions responded to this survey (response rate, 60.1%). Data analyses of 378 patients with 1,101.4 person-years (PYs) revealed that 67 patients (17.7%) experienced at least 1 episode of hospital admission for adrenal crisis at the median age of 2 years. The incidence of adrenal crisis was calculated as 10.9 per 100 PYs (95% confidence interval [CI] 9.6–12.2). Infections were the most common precipitating factors, while no factor was observed in 12.5%. Hypoglycemia occurred concomitantly in 27.4%. One patient died from severe hypoglycemia, resulting in a mortality rate of 0.09 per 100 PYs (95% CI 0.0–0.2). Conclusion: Adrenal crisis is not rare and can be accompanied by disastrous hypoglycemia in children with 21-OHD.

In-patient Tolvaptan use in SIADH: care audit, therapy observation and outcome analysis

BackgroundIndications for use of tolvaptan in SIADH-associated hyponatraemia remain controversial. We audited our local guidelines for Tolvaptan use in this situation to review treatment implications including drug safety, hospital admission episode analysis (episodes of liver toxicity, CNS myelinolysis, sodium-related re-admission rates), morbidity; mortality and underlying aetiologies.MethodsWe report a retrospective case series analysis of on-going treatment outcomes (case-note review) for 31 patients (age 73.3 ± 10.5 years, 55% females) consecutively treated with Tolvaptan as in-patient for confirmed SIADH with persistent S/Na+ < 125 mmol/L despite removal of reversible causes and 24-48 h fluid restriction, and include longer-term outcome data (re-treatment/readmissions/mortality) for up to 4 years of follow-up. A minimum of 6 months follow-up data were reviewed unless the patient died before that period.ResultsShort-term outcomes were favourable; 94%-achieved treatment targets after a mean of 3.48 ± 2.46 days. There was statistically significant rise in S/Na+ level after Tolvaptan treatment (before treatment: mean sodium 117.8 ± 3.73, 108–121 mmol/L and after treatment: mean sodium 128.7 ± 3.67, 125–135.2 mmol/L, P < .001). Although the target S/Na+ level was >125 mmol/L in fact one third (35%) of the patients achieved a S/Na+ level of >130 mmol/L by the time of hospital discharge. No patient experienced S/Na+ rise >12 mmol/L/24 h, drug-associated liver injury or CNS-myelinolysis. The average length of hospital stay following start of Tolvaptan treatment was 3.2 days. Relapse of hyponatraemia occurred in 26% of the patients, requiring retreatment with Tolvaptan. In all patients where either relapse of hyponatraemia occurred or readmission was necessary, SIADH was associated with malignancy, which was present overall in 60% of the group studied.ConclusionsThis study confirms the safety and efficacy of Tolvaptan in the treatment of SIADH-related significant, symptomatic hyponatraemia when used under specialist guidance and strict monitoring. A sodium level relapsing below the treatment threshold by 1 week after discontinuation is a good indicator of a patient group with re-treatment/longer-term therapy needs, all of whom had underlying malignancy. The criteria set locally in our trust to initiate Tolvaptan use also identifies a group where further investigation for underlying malignancy should be considered.

Pathways after inpatient admission in very advanced age: A Portuguese nationwide study

IntroductionOldest old patients often have complex and multiple medical conditions, which are associated with higher rates of use of healthcare services, and a higher risk of experiencing adverse outcomes, such as mortality. This study investigated (a) the in-hospital mortality rate and predictors in patients aged 80+; (b) the destination patients have after hospital discharge. MethodsNationwide study. All inpatient admissions by individuals aged 80 years and older between 2011 and 2014 in Portugal were considered. Exploratory descriptive analyses of data regarding in-hospital mortality and destination after discharge were performed; multivariate logistic regression analyses were conducted to identify predictors of in-hospital mortality. ResultsA total of 614,807 episodes of hospital admissions were analysed. A mortality rate of 15.4% was observed. In the majority of episodes, patients returned home (78.6%). Increased age, male gender, increased length of stay, unplanned attendance, medical DRG type, increased severity of illness and mortality risk, and comorbidities were significant predictors of in-hospital mortality. DiscussionThis study strengthens the importance of implementing health policies specifically to the oldest old, namely with the promotion of the use of primary care services. That would expectably concur to a better management of the most common medical conditions in this population, and a decrease in hospital unplanned attendances.

Social Risk Factors and Performance Under Medicare's Value-Based Purchasing Programs.

Report to Congress: Social Risk Factors and Performance Under Medicare’s Value-based Purchasing Programs.1 US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. December 21, 2016. ### Policy Context Value-based purchasing (VBP), or pay-for-performance, comprises a growing portion of Medicare payment and the changes in physician payment enacted in the Medicare and Children's Health Insurance Program Reauthorization Act are likely to accelerate these trends even further.2 Simultaneously, there is growing consensus that social risk factors—such as income, race and ethnicity, and community environment—play a major role in health.3–5 Persistent and meaningful gaps exist in health and even in life expectancy based on these factors.6–9 These 2 issues intersect in VBP. If beneficiaries with social risk factors have worse health outcomes because of factors beyond providers’ control, providers could be unfairly disadvantaged under VBP. On the contrary, if beneficiaries with social risk factors have worse health outcomes because the providers serving them provide low-quality care, the financial incentives and accountability of VBP could be an important strategy for improving care and reducing disparities. In 2014, Congress passed the Improving Medicare Postacute Care Transformation Act (IMPACT),10 which required that the Office of the Assistant Secretary for Planning and Evaluation (ASPE) at the US Department of Health and Human Services complete an empirical report addressing the issue of social risk in Medicare’s current VBP programs to assist Congress in further decision making on this issue. The report covered here is the first component of the required work, which was submitted to Congress in December 2016. The ASPE report may have particular salience to cardiovascular clinicians, who practice every day in an environment significantly impacted by VBP. Many current quality measures in inpatient and outpatient VBP programs are cardiovascular in nature; patients …

Do children with neurological disabilities use more inpatient resources: an observational study

BackgroundAdvances in healthcare have improved the survival of children with neurological disabilities (ND). Studies in the US have shown that children with ND use a substantial proportion of resources in children’s hospitals, however, little research has been conducted in the UK. We aimed to test the hypothesis that children with neurological disabilities use more inpatient resources than children without neurological disabilities, and to quantify any significant differences in resource use.MethodsA retrospective observational study was conducted, looking at the number of hospital admissions, total inpatient days and the reason for admissions for paediatric inpatients from January 1st to March 31st 2015. Inpatients were assigned into one of three groups: children without ND, children with one ND, and children with more than one ND.ResultsThe sample population included 942 inpatients (mean age 6y 6mo). Children with at least one ND accounted for 15.3% of the inpatients, 17.7% of total hospital inpatient admission episodes, and 27.8% of the total inpatients days. Neurological disability had a statistically significant effect on total hospital admissions (p < 0.001). Neurological disability also had a statistically significant effect on total inpatient days (p < 0.001). Neurological disability increased the length of inpatient stay across medicine, specialties, and surgery.ConclusionsChildren with ND had more frequent hospital admission episode and longer inpatient stays. We identified a smaller group within this population, with arguably more complex neurological disabilities, children with more than one ND. This group had the highest number of admissions and longest inpatient stays. More frequent hospital admissions and longer inpatient stays may place children with ND at greater risk of the adverse effects of hospitalisations. We recommend further investigations looking at each the effects of the different categories of ND on inpatient resource use, and repeat of this study at a national level and over a longer period of time.

El impacto del cuidador principal en el deterioro funcional y cognitivo del anciano hospitalizado

En la actualidad, existen en Andalucía más de 100.000 personas que sobrepasan los 85 años y dicha progresión va a continuar en el futuro. Paralelamente hay un desplazamiento de cuidados cada vez más complejos, hacia el sistema de cuidados informal, en un momento en el que la contención del gasto, provoca un escaso desarrollo de los servicios de atención sociales y domiciliarios. En este contexto la influencia de las personas que cuidan al anciano, tanto en el domicilio como durante los episodios de ingreso hospitalario, puede ser decisiva en la pérdida de la capacidad funcional y cognitiva del mismo. Nuestro objetivo es analizar la influencia de las distintas personas que ejercen de cuidador principal, en el domicilio y durante los episodios de ingreso hospitalario, en el estado funcional y cognitivo del anciano. Entre los resultados especial mención merece la influencia de la persona que ejerce de cuidador principal sobre el anciano, durante la hospitalización del mismo, observando que las personas acompañadas por su pareja e hijos sufren una menor pérdida funcional durante la hospitalización. Destacamos la novedad de incluir el tipo de cuidador principal en el hospital, como uno de los factores predictores de dependencia posterior en el domicilio y de cambio de domicilio posterior al ingreso.