Greater Severity Of Illness Research Articles

Age and shock severity predict mortality in cardiac intensive care unit patients with and without heart failure.

AimsAge is an important risk factor for mortality among patients with cardiogenic shock and heart failure (HF). We sought to assess the extent to which age modified the performance of the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage for in‐hospital and 1 year mortality in cardiac intensive care unit (CICU) patients with and without HF.Methods and resultsWe retrospectively reviewed unique admissions to the Mayo Clinic CICU during 2007–2015 and stratified patients by age and SCAI shock stage. The association between age and in‐hospital mortality was analysed using multivariable logistic regression, and 1 year mortality was analysed using Cox proportional hazards analysis, both in the entire cohort and among patients with an admission diagnosis of HF or acute coronary syndrome (ACS). The final study population included 10 004 unique patients with a mean age of 67 ± 15 years, including 46.1% with HF and 43.1% with ACS. Older patients more frequently had HF and had more extensive co‐morbidities, higher illness severity, more organ failure, and differential use of critical care therapies. The percentage of patients with SCAI shock stages A, B, C, D, and E were 46%, 30%, 16%, 7%, and 1%, respectively. Patients with HF were older, had greater severity of illness and higher SCAI shock stage, and had higher rates of death at all time points. In‐hospital mortality occurred in 908 (9%) patients, including 549 (12%) patients with HF (61% of all hospital deaths). Age was independently associated with hospital mortality (adjusted odds ratio per 10 years 1.3, 95% confidence interval 1.2–1.4, P < 0.001) and 1 year mortality (adjusted hazard ratio per 10 years 1.2, 95% confidence interval 1.2–1.3, P < 0.001) in the overall cohort. The associations of age with both hospital mortality (adjusted odds ratio 1.6 vs. 1.3 per 10 years older) and 1 year mortality (adjusted hazard ratio 1.5 vs. 1.3 per 10 years older) were higher for patients with ACS compared with patients with HF. Older age was associated with higher adjusted hospital mortality and 1 year mortality in each SCAI shock stage (all P < 0.05). Additive increases in both hospital mortality and 1 year mortality were observed with increasing age and SCAI shock stage.ConclusionsAge is an independent risk factor for mortality that modifies the relationship between the SCAI shock stage and mortality risk in CICU patients, providing robust risk stratification for in‐hospital and 1 year mortality. Although patients with HF had a higher risk of dying, age was more strongly associated with mortality among patients with ACS.

Early Treatment with Human Albumin Solution in Continuous Renal Replacement Patients

Aims: To study the impact of early human albumin solution (HAS) in continuous renal replacement therapy (RRT) patients. Methods: Analysis of Randomized Evaluation of Normal versus Augmented Level (RENAL) RRT trial data. Results: Of 1,464 patients, 500 (34%) received early albumin. These patients had higher illness severity scores, greater use of mechanical ventilation, and 90-day mortality (51 vs. 41%; p < 0.001). However, early albumin carried similar RRT dependence risk among survivors at day 90 (4.9 vs. 5.8%; p = 0.62). On Cox proportional hazards regression, with standardized inverse probability of treatment weighting, early albumin was not associated with increased mortality (hazard ratio [HR]: 1.23, 95% CI: 0.97–1.55; p = 0.09) or recovery to RRT independence (HR: 0.92, 95% CI: 0.78–1.10; p = 0.38). Conclusions: Early albumin was administered to one-third of RENAL trial patients and in those with greater illness severity. Early albumin was not independently associated with mortality risk or rate of recovery to RRT independence.

Predictors of readmission after craniotomy for meningioma resection: a nationwide readmission database analysis.

Meningiomas are the most common benign primary brain tumors. The mainstay of treatment, surgical resection, is often curative. Given the excellent prognosis of these lesions, minimizing perioperative complications is of the utmost importance. With the establishment of the National Readmissions Database (NRD), researchers are now able to identify variables associated with postoperative complications beyond the index admission. In this study, we sought to identify the leading causes for non-elective readmission and variables associated with increased likelihood of readmission at 30 and 90days after discharge following a craniotomy for meningioma resection. Adult inpatients who underwent craniotomy for meningioma resection between 2010 and 2014 were queried from the NRD. All-cause readmissions following craniotomy at 30 and 90days were identified, and a multivariable logistic regression model was used to characterize independent risk factors. Among 26,034 patients who received craniotomy for meningioma resection, 2825 (10.9%) were readmitted at 30days and 3436 (16.1%) were readmitted at 90days. Postoperative wound infection was the most common readmission diagnosis, occurring in 9.32% and 10.2% of 30- and 90-day readmissions respectively. Patient factors associated with increased likelihood of readmission included male gender, greater illness severity, non-routine discharge, index length of hospitalization, and having Medicare or Medicaid insurance. Readmission following craniotomy for meningioma resection occurs at a clinically significant rate. Several patient factors were identified in association with all-cause 30- and 90-day readmissions. Further studies are required to identify means for preventing complications following discharge in these vulnerable patient populations.

Clinical Course and Mortality of Stroke Patients With Coronavirus Disease 2019 in Wuhan, China.

No studies have reported the effect of the coronavirus disease 2019 (COVID-19) epidemic on patients with preexisting stroke. We aim to study the clinical course of COVID-19 patients with preexisting stroke and to investigate death-related risk factors. We consecutively included 651 adult inpatients with COVID-19 from the Central Hospital of Wuhan between January 2 and February 15, 2020. Data on the demography, comorbidities, clinical manifestations, laboratory findings, treatments, complications, and outcomes (ie, discharged or death) of the participants were extracted from electronic medical records and compared between patients with and without preexisting stroke. The association between risk factors and mortality was estimated using a Cox proportional hazards regression model for stroke patients infected with severe acute respiratory syndrome coronavirus 2. Of the 651 patients with COVID-19, 49 with preexisting stroke tended to be elderly, male, had more underlying comorbidities and greater severity of illness, prolonged length of hospital stay, and greater hospitalization expenses than those without preexisting stroke. Cox regression analysis indicated that the patients with stroke had a higher risk of developing critical pneumonia (adjusted hazard ratio, 2.01 [95% CI, 1.27-3.16]) and subsequent mortality (adjusted hazard ratio, 1.73 [95% CI, 1.00-2.98]) than the patients without stroke. Among the 49 stroke patients, older age and higher score of Glasgow Coma Scale or Sequential Organ Failure Assessment were independent risk factors associated with in-hospital mortality. Preexisting stroke patients infected with severe acute respiratory syndrome coronavirus 2 were readily predisposed to death, providing an important message to individuals and health care workers that preventive measures must be implemented to protect and reduce transmission in stroke patients in this COVID-19 crisis.

Intensive care patient survival after limiting life-sustaining treatment-The FINNEOL* national cohort study.

Few studies have examined survival in intensive care unit (ICU) patients after the restriction of life-sustaining treatment (LST). We aimed to analyse independent factors associated with hospital and 12-month survival rates in ICU patients after treatment restrictions. This retrospective observational study examined all patients treated in adult ICUs from 1 January 2016 until 31 December 2016 included in the Finnish ICU Registry. Multivariable logistic regression analysis was performed to explain the effect on survival. Decisions to limit LST were made for 2444 patients (13.7%; 95% CI 13.2-14.2). ICU, hospital, and 12-month survival rates were 71% (95% CI 69-73), 49% (95% CI 47-51), and 24% (95% CI 22-26), respectively. In patients for whom life support was withheld, increased 12-month survival rates were associated with admission from the operating theatre (OR 1.9, 95% CI 1.1-3.4), good pre-hospital physical fitness (OR 4.7, 95% Cl 1.2-16.8) and being housed at home (OR 2.0, 95% Cl 1.4-2.8). Decreased survival rates were associated with admission from a hospital ward (OR 0.67, 95% Cl 0.5-0.9), higher comorbidity (OR 0.6, 95% Cl 0.4-0.9), cancer (OR 0.4, 95%CI 0.2-0.9), greater illness severity (SAPS II; OR 0.98, 95% Cl 0.98-0.99), and higher care intensity (TISS-76; OR 0.93, 95% Cl 0.92-0.95). Survival among ICU patients with limited treatment was higher than expected. Advanced age was not associated with higher mortality, potentially because treatment restrictions may be set more easily for older patients.

COVID-19 and Angiotensin-Converting Enzyme Inhibitor/Angiotensin-Receptor Blocker Therapy

Mackey and colleagues reported a systematic review that found high-certainty evidence that angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers are not associated with greater illness severity in patients with COVID-19. The editorialist discusses the findings and emphasizes that, unless further data show otherwise, clinicians should continue to prescribe these drugs for their standard indications in patients with COVID-19.

Post traumatic stress symptoms, anxiety, and depression in patients after intensive care unit discharge \u2013 a longitudinal cohort study from a LMIC tertiary care centre

BackgroundData on intensive care unit (ICU) related psychiatric morbidity from Low Middle-Income Countries are sparse. We studied the ICU related posttraumatic stress symptoms (PTSS), anxiety, and depression symptoms in a cohort of patients from Eastern India.MethodsWe included adults admitted more than 24 h to a mixed ICU. PTSS, anxiety, and depression symptoms were assessed by telephonic or face to face interviews by using the Impact of Events-r (IES-r) and Hospital anxiety and depression (HADS), respectively, at 0, 7,14, 30, 90 and 180 days from ICU discharge. The loss to follow up was minimal. Demographic, socioeconomic, quality of life (QOL), and critical care related variables were studied.ResultsOf 527 patients, 322 (59.4%) completed 6 months’ follow up. The majority were male (60%), mechanically ventilated > 48 h (59.4%), mean age of 48 (+/− 16), mean acute physiology and chronic health evaluation II (APACHE II) at admission 9.4 (+/− 4.6), median length of stay 3 (2–28 days). The rates of ICU related clinical PTSS was < 1 and < 3% for anxiety/depression at any point of follow up. Data were analyzed by linear mixed (random effects) models. There was a significant drop in all scores and association with repeated measures over time. Poor QOL at discharge from the ICU showed significant association with PTSS, anxiety, and depression (β = − 2.94, − 1.34, − 0.7 respectively) when corrected for gender and education levels. Younger age, greater severity of illness, and prior stressful life experiences predicted worse PTSS (β = − 0.02, 0.08, 3.82, respectively). Benzodiazepines and lower sedation scores (better alertness) predicted lower depression symptoms. (β = − 0.43, 0.37 respectively).ConclusionICU related psychiatric morbidity rates in our population are low compared with reported rates in the literature. Poor QOL at ICU discharge may predict worse long-term mental health outcomes. Further research on the impact of ICU and sociocultural factors on mental health outcomes in patients from different backgrounds is needed. The study was registered at CTRI/2017/07/008959.

Cognitive remediation for inpatients with psychosis: a systematic review and meta-analysis.

Cognitive difficulties are common in people with psychosis and associated with considerable disability. Cognitive remediation (CR) can reduce the burden of cognitive difficulties and improve functioning. While mental health care has predominantly shifted to the community, people with greater illness severity and complexity, and those with poor response to treatment and concomitant greater cognitive difficulties, continue to receive inpatient care. The aim of this study is to review and evaluate the acceptability and efficacy of CR for inpatients with psychosis. A systematic search was used to identify randomized controlled trials of CR for inpatients with psychosis. Demographic and clinical information was extracted by independent raters together with therapy outcomes. Study quality was assessed using the Cochrane Collaboration Risk of Bias Assessment tool. Standardized mean change for cognitive and functional outcomes was calculated using Hedges's g and used to infer therapy effects with meta-analysis. Twenty studies were identified considering 1509 participants. Results from random-effect models suggested that CR was effective in improving processing speed (g = 0.48), memory (g = 0.48) and working memory (g = 0.56). While there was an indication of improvements in the levels of vocational, social and global functioning, these were less reliable. On average, 7% of participants dropped-out of treatment. Studies methodological quality was moderate. CR is an acceptable intervention for inpatients with psychosis and can lead to significant cognitive improvements. Evidence for improvement in functioning requires more robust and converging evidence. Future research should extend the evaluation of inpatient CR to subsequent post-discharge community functioning and further need for care.

Heterogeneity of treatment effect of prophylactic pantoprazole in adult ICU patients: a post hoc analysis of the SUP-ICU trial.

The Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial compared prophylactic pantoprazole with placebo in 3291 adult ICU patients at risk of clinically important gastrointestinal bleeding (CIB). As a predefined subgroup analysis suggested increased 90-day mortality with pantoprazole in the most severely ill patients, we aimed to further explore whether heterogenous treatment effects (HTE) were present. We assessed HTE in subgroups defined according to illness severity by SAPS II quintiles and the total number of risk factors for CIB using Bayesian hierarchical models, and on the continuous scale using Bayesian logistic regression models with interactions. Estimates were presented as posterior probability distributions of odds ratios (ORs), probabilities of different effect sizes, and marginal effects plots. We observed potential HTE for 90-day mortality according to illness severity (median subgroup OR range 0.90-1.09) with higher risk in the most severely ill, but not with different numbers of risk factors (1.00-1.02). We observed potential HTE of pantoprazole for clinically important events (0.86-1.18) and infectious adverse events (0.88-1.27) with higher risk in patients with greater illness severity and in those with more risk factors for CIB. Pantoprazole substantially and consistently reduced the risk of CIB with no indications of HTE (0.53-0.63). In this post hoc analysis of the SUP-ICU trial, we found indications of HTE with increased risks of serious adverse events in patients with greater illness severity or more risk factors for CIB allocated to pantoprazole. These findings are hypothesis-generating and warrant further prospective investigation. CLINICALTRIALS. NCT02467621.

Inflammatory Bowel Disease and Thrombosis: A National Inpatient Sample Study.

Introduction Thrombosis is more common in inflammatory bowel disease (IBD) patients than the general population, but disease-specific correlates of thrombosis remain unclear. Methods We performed a retrospective analysis of discharge data from the National Inpatient Sample between 2009 and 2014, using International Disease Classification codes to identify IBD and non-IBD patients with or without thrombosis. We used NIS-provided discharge-level weights to reflect prevalence estimates. Categoric variables were analyzed by Rao-Scott Chi-square test, continuous variables by weighted simple linear regression, and covariates associated with thrombosis by weighted multivariable logistic regression. Results Thrombosis prevalence in IBD was significantly greater than in non-IBD, 7.52 versus 4.54%, p < 0.0001. IBD patients with thrombosis were older and more likely to be Caucasian than IBD without thrombosis, each p < 0.001. Thrombosis occurred most commonly in the mesenteric vein. Thrombotic risk factors in IBD include surgery, ports, malignancy, dehydration, malnutrition, and steroids at 53.7, 13.2, 13.1, 12.4, 8.9, and 8.2%, respectively. Those with thrombosis had greater severity of illness, 1.42 versus 0.96; length of stay, 7.7 versus 5.5 days; and mortality, 3.8 versus 1.5%; all p < 0.0001. Adjusting for age and comorbidity, odds ratios for predictors of thrombosis included ports, steroids, malnutrition, and malignancy at 1.73, 1.61, 1.34, and 1.13, respectively, while Asian race, 0.61, was protective, each p < 0.001. Conclusion Thrombosis prevalence is 1.7-fold greater in IBD than non-IBD patients. Adjusting for age and comorbidity, the odds ratio for thrombosis in IBD was 73% higher with ports, 61% higher with steroids, 34% with malnutrition, and 13% with malignancy. Whether long-term anticoagulation would benefit the latter is unknown.

Exploration of Treatment-Resistant Schizophrenia Subtypes Based on a Survey of 204 US Psychiatrists.

ObjectiveTo explore and describe potential subgroups within the treatment-resistant schizophrenia (TRS) population, using data from a survey of US psychiatrists.MethodsPsychiatrists completed an online survey of demographic/clinical characteristics and treatment history for two of their patients with TRS. Patients were stratified according to number of suicide attempts, number of hospitalizations, employment status, and TRS onset time frame.ResultsOf the 408 patients with TRS described by psychiatrists, 37.5% had ≥1 suicide attempt, 78.9% had ≥2 hospitalizations, 74.5% were unemployed, 45.0% had TRS onset within 5 years of first treatment (a further 8.0% had TRS from first treatment), and 31.5% had TRS onset after 5 years (15.5% unknown). Patients with ≥1 (vs 0) suicide attempts had statistically significantly more psychiatric (3.6 vs 2.2) and physical (2.2 vs 1.6) comorbidities. Patients with ≥2 (vs ≤1) hospitalizations were statistically significantly more likely to have hallucinations, conceptual disorganization, social withdrawal, and cognitive dysfunction, and had more psychiatric (3.0 vs 1.9) and physical (2.0 vs 1.1) comorbidities. Unemployed (vs employed) patients were statistically significantly more likely to have delusions, hallucinations, blunted affect, social withdrawal, and cognitive dysfunction, and had more psychiatric (2.9 vs 2.3) and physical (2.1 vs 1.2) comorbidities. Patients with TRS onset ≤5 (vs >5) years were statistically significantly younger (35.0 vs 43.7 years), less likely to have hallucinations and social withdrawal, and had fewer psychiatric (2.6 vs 3.3) and physical (1.7 vs 2.3) comorbidities.ConclusionsGreater clinical burden in TRS is associated with greater illness severity and chronicity markers, suggesting a dimensional gradient from non-TRS to mild–moderate and more severe forms of TRS. Time to onset of TRS may have implications for outcomes, with data indicating greater burden in those with late-onset TRS. Accumulation of illness over time may be more important than time to onset.

Schizophrenia polygenic risk score and 20-year course of illness in psychotic disorders

Understanding whether and how the schizophrenia polygenic risk score (SZ PRS) predicts course of illness could improve diagnosis and prognostication in psychotic disorders. We tested whether the SZ PRS predicts symptoms, cognition, illness severity, and diagnostic changes over the 20 years following first admission. The Suffolk County Mental Health Project is an inception cohort study of first-admission patients with psychosis. Patients were assessed six times over 20 years, and 249 provided DNA. Geographically- and demographically-matched never psychotic adults were recruited at year 20, and 205 provided DNA. Symptoms were rated using the Schedule for the Assessment of Positive Symptoms and Schedule for the Assessment of Negative Symptoms. Cognition was evaluated with a comprehensive neuropsychological battery. Illness severity and diagnosis were determined by consensus of study psychiatrists. SZ PRS was significantly higher in first-admission than never psychotic groups. Within the psychosis cohort, the SZ PRS predicted more severe negative symptoms (β = 0.21), greater illness severity (β = 0.28), and worse cognition (β = −0.35), across the follow-up. The SZ PRS was the strongest predictor of diagnostic shifts from affective to non-affective psychosis over the 20 years (AUC = 0.62). The SZ PRS predicts persistent differences in cognition and negative symptoms. The SZ PRS also predicts who among those who appear to have a mood disorder with psychosis at first admission will ultimately be diagnosed with a schizophrenia spectrum disorder. These findings show potential for the SZ PRS to become a tool for diagnosis and treatment planning.

1427. Treatment of Children with Acute Hematogenous Osteomyelitis and Staphylococcus aureus Bacteremia: Impact of Severity of Illness on Antimicrobial Therapy

BackgroundThere is limited evidence-based guidance for the treatment of children with acute hematogenous osteomyelitis (AHO) and concurrent Staphylococcus aureus bacteremia (SAB). Current guidelines emphasize the need for parenteral antibiotics in the setting of SAB, but optimal duration of parenteral therapy in this setting remains unclear. We examined the utility of a Severity of Illness (SOI) score to provide guidance for antimicrobial use in this setting.MethodsWe retrospectively studied children with AHO from 2009–2017, employing a clinical practice algorithm and previously validated SOI to assess the incidence and treatment implications of SAB in AHO. Data collected included demographics, antimicrobial therapy, and response to treatment. Cohorts were categorized according to SOI as follows: mild (0–3); moderate (4–7); and severe (8–10), and compared utilizing one-way ANOVA and Kruskal–Wallis tests for continuous variables, and chi-square test for categorical data.ResultsAmong 466 children diagnosed with AHO, 274 (58.5%) were culture positive for Staphylococcus aureus, with SAB noted in 209 (44.8%) individuals. Among children with SAB, 72, 81, and 56 children had SOI scores classified as mild, moderate, and severe, respectively. There were 41 of 72 (57.7%) children with mild illness who were managed with clindamycin alone, clindamycin followed by β-lactam, or β-lactam alone, compared with 36 of 81 (44.4%) with moderate illness, and 3 of 56 (5.4%) with severe illness. Median parenteral antibiotic durations per SOI cohort were 4.7 days, 10.4 days, and 24.7 days, respectively. Greater SOI was associated with longer hospitalization, prolonged bacteremia, more surgeries, increased vancomycin use, greater number of antibiotic combinations, and longer total duration of antibiotics.ConclusionTreatment of AHO with SAB should be tailored to the severity of illness in the affected child. A “one size fits all” approach may expose children to unnecessarily prolonged parenteral antibiotic courses, as well as suboptimal and potentially toxic regimens. Our study demonstrates the utility of an SOI to help guide antibiotic decisions in the setting of AHO with SAB. Additional studies are needed to further delineate optimal parenteral antibiotic durations in AHO with SAB. Disclosures All authors: No reported disclosures.

Influence of nutritional status on clinical outcomes in hospitalised children

IntroductionPaediatric malnutrition during hospital admission is a prevalent comorbidity, which is estimated around 31.4% in our environment, and could influence the clinical outcomes of paediatric patients. ObjectiveThe aim of this study was to describe the malnutrition risk in hospitalised children using STAMP (Screening Tool for the Assessment of Malnutrition in Paediatrics), and to study its relationship with clinical outcomes. MethodsA single-centre, analytical and prospective study was conducted on children aged 1 month to 15 years hospitalised in a tertiary hospital between October and December 2017. An analysis was made of the clinical data and anthropometric measurements (weight, height, Waterlow weight classification). Patients were classified according to STAMP, which is a validated screening tool used to classify the risk of paediatric malnutrition during hospital admission. Multivariate statistical analysis was used to identify predictive variables of illness severity. ResultsAn analysis was made on a total of 200 patients (55% male), with a median age of 15.8 months (IQR 2.5–42.8), and a median length of stay of 3 days (IQR 1–18 days). Almost half (48.3%) of them had high risk of malnutrition at admission (STAMP ≥4), and 48.2% showed medium risk (STAMP 2–3). A higher STAMP score was associated with longer length of hospital stay (P<.01) and greater severity (P<.01). Multivariable analysis showed that STAMP could be a predictor of illness severity (OR 1.48, 95% CI: 1.18–1.86, P<.01). ConclusionsNearly 50% of hospitalised children have a high risk of malnutrition at admission according to the STAMP screening tool. Risk of malnutrition at admission measured according to STAMP nutritional screening was associated with a longer length of stay and greater severity of illness. It is important to evaluate the risk of malnutrition as this could be related to illness severity.

Incidence, Patient Characteristics, Mode of Drug Delivery, and Outcomes of Septic Shock Patients Treated With Vasopressors in the Arise Trial.

To describe the utilization of vasopressors (VP) in patients enrolled in the Australasian Resuscitation In Sepsis Evaluation (ARISE) trial, and to explore the association between time to VP and 90-day mortality. The primary exposure variable was VP use after arrival in the emergency department (ED). Vasoactive agents considered as VP included: norepinephrine, epinephrine, metaraminol, or vasopressin. Time-to-event analysis, multivariable logistic regression, and propensity-matched treatment effects modeling were used to assess the association between time to VP and 90-day mortality. In total 1,102 of 1,588 patients (69%) in ARISE received VP at any point. The median [interquartile range (IQR)] time from ED presentation to commencing VP was 4.4 [2.7, 7.1] h, and 38% did so prior to central venous access. The median [IQR] volume of intravenous (i.v.) fluid administered prior to commencing VP was 3.1 [2.3, 4.3] L. Increasing age and volume of i.v. fluid therapy were associated with a lower likelihood of commencing VP early (within 4 h of ED presentation), while greater illness severity was associated with a higher likelihood, P < 0.001, respectively. In those who subsequently died within 90 days, the sub-hazard ratio (95% confidence interval) for commencing VP was 1.4 (1.20, 1.68), P < 0.001, adjusted for age, acute physiology and chronic health evaluation II score, study group, inclusion criteria, plasma lactate, i.v. fluid prior to VP, study institution, and site of infection. 50% of the ARISE cohort commenced VP within 4.4 h of ED presentation, and many did so prior to central venous access. Earlier initiation of VP was associated with greater crude and adjusted 90-day mortality.

The Influence of Inpatient Physician Continuity on Hospital Discharge.

Inpatient attending physicians may change during a patient's hospital stay. This study measured the association of attending physician continuity and discharge probability. All patients admitted to general medicine service at a tertiary care teaching hospital in 2015 were included. Attending inpatient physician continuity was measured as the consecutive number of days each patient was treated by the same staff-person. Generalized estimating equation methods were used to model the adjusted association of attending inpatient physician continuity with daily discharge probability. 6301 admissions involving 41 internists, 5134 patients, and 38,242 patient-days were studied. The final model had moderate discrimination (c-statistic = 0.70) but excellent calibration (Hosmer-Lemeshow statistic 11.5, 18 df, p value 0.89). Daily discharge probability decreased significantly with greater severity of illness, higher patient death risk, and longer length of stay, on admission day, for elective admissions, and on the weekend. Discharge likelihood increased significantly with attending inpatient physician continuity; daily discharge probability increased for the average patient from 15.3 to 20.9% when the consecutive number of days the patient was treated by the same attending inpatient physician increased from 1 to 7days. Inpatient attending physician continuity is significantly associated with the likelihood of patient discharge. This finding could be considered if resource utilization is a factor when scheduling attending inpatient physician coverage.

The Evolving Management of Aortic Valve Disease: 5-Year Trends in SAVR, TAVR, and Medical Therapy

Aortic stenosis (AS) and regurgitation (AR) may be treated with surgical aortic valve replacement (SAVR), transcatheter AVR (TAVR), or medical therapy (MT). Data are lacking regarding the usage of SAVR, TAVR, and MT for patients hospitalized with aortic valve disease and the characteristics of the patients and hospitals associated with each therapy. From the Nationwide Readmissions Database, we determined utilization trends for SAVR, TAVR, and MT in patients with aortic valve disease admitted from 2012 to 2016 for valve replacement, heart failure, unstable angina, non-ST-elevation myocardial infarction, or syncope. We also performed multinomial logistic regressions to investigate associations between patient and hospital characteristics and treatment. Among 366,909 patients hospitalized for aortic valve disease, there was a 48.1% annual increase from 2012 through 2016. Overall, 19.9%, 6.7%, and 73.4% of patients received SAVR, TAVR, and MT, respectively. SAVR decreased from 21.9% in 2012 to 18.5% in 2016, whereas TAVR increased from 2.6% to 12.5%, and MT decreased from 75.5% to 69.0%. Older age, female sex, greater severity of illness, more admission diagnoses, not-for-profit hospitals, large hospitals, and urban teaching hospitals were associated with greater use of TAVR. In multivariable analysis, likelihood of TAVR relative to SAVR increased 4.57-fold (95% confidence interval 4.21 to 4.97). TAVR has increased at the expense of both SAVR and MT, a novel finding. However, this increase in TAVR was distributed inequitably, with certain patients more likely to receive TAVR certain hospitals more likely to provide TAVR. With the expected expansion of indications, inequitable access to TAVR must be addressed.

Analysis of risk factors and outcomes in psychiatric inpatients with tardive dyskinesia: A nationwide case-control study

ObjectiveTo analyze comorbidities and outcomes in patients with tardive dyskinesia (TD) during psychiatric inpatient management. MethodsWe conducted a case-control study using the Nationwide Inpatient Sample. It included 77,022 adult inpatient admissions for mood disorders and schizophrenia. Cases had a secondary diagnosis of TD, and controls without TD were matched for age. Multivariable logistic regression was used to generate odds ratio (OR). ResultsMajority of TD patients were older age adults (50–64 years; 40%), and were in nearly equal proportions of men and women. African Americans had two-fold higher odds of TD. TD patients had a higher likelihood for cardio-metabolic comorbidities-obesity (OR 1.61, 95% CI 1.481–1.756), hypertension (OR 1.78, 95% CI 1.635–1.930) and diabetes (OR 1.54, 95% CI 1.414–1.680) compared to controls. They also had 1.5-fold increased risk of comorbid drug abuse. Patients with schizophrenia and bipolar disorder (depressive) had four-fold higher odds of TD. TD patients had about six-fold higher odds of severe morbidity. They had a higher likelihood of extended hospitalization stay by 6.36 days (95% CI 6.174–6.550) and higher cost by $20,415 (95% CI 19537–21293) compared to controls. ConclusionPsychiatric inpatients with TD have greater severity of illness, and those with schizophrenia and bipolar disorders are at highest risk. Presence of TD portends poor hospital outcomes and need for higher acute inpatient care.

Incidence and Prevalence of Delirium Subtypes in an Adult ICU: A Systematic Review and Meta-Analysis.

Use systematic review and meta-analytic methodology to estimate the pooled incidence, prevalence, and proportion of delirium cases for each delirium subtype (hypoactive, hyperactive, and mixed) in an adult ICU population. We conducted a search of the MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, and PsycINFO databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards from database inception until October 22, 2017, with no restrictions. We included original research conducted in adults admitted to any medical, surgical, or speciality ICU that reported incidence or prevalence estimates of delirium according to delirium subtype. Data were extracted on sample size, population demographics, condition information, and reported delirium estimates. Forty-eight studies (27,342 patients; 4,550 with delirium) with an overall pooled prevalence of 31% (95% CI, 24-41; I = 99%) met inclusion criteria. The pooled incidence (n = 18 studies) of delirium subtypes were hyperactive (4% [95% CI, 2-6]; I = 92%]), hypoactive (11% [95% CI, 8-17; I = 97%]), and mixed (7% [95% CI, 4-11; I = 97%]). The pooled prevalence (n = 31 studies) of delirium subtypes were hyperactive (4% [95% CI, 3-6; I = 94%]), hypoactive (17% [95% CI, 13-22; I = 97%]), and mixed (10% [95% CI, 6-16; I = 99%]). The pooled prevalence of hypoactive delirium in study populations with a similarly high severity of illness or mechanically ventilated was higher (severity of illness: 29% [95% CI, 18-46%; I = 95%], 100% mechanically ventilated: 35% [95% CI, 23-55%; I = 93%]) compared with the pooled prevalence of hypoactive delirium. Despite significant heterogeneity between studies, these data show the majority of delirious ICU patients to have hypoactive delirium, a finding with potential monitoring, management, and prognostic implications. The prevalence of hypoactive delirium varies between-study populations and is higher in patients with greater severity of illness.

Differentiation of Deep Venous Thrombosis Among Children With or Without Osteomyelitis.

Children with osteomyelitis are at risk for deep venous thrombosis (DVT). This study evaluates the characteristics of DVT among children to differentiate between those with and without osteomyelitis. Children with DVT of any cause were studied between 2008 and 2016. Children with DVT and osteomyelitis were compared with those with DVT without osteomyelitis. Another comparison cohort included children with osteomyelitis but without DVT. Comorbidities, severity of illness (SOI), and clinical course were compared between cohorts. DVT was identified in 224 children, a prevalence of 2.5 per 10,000 children. Among those with DVT, 28 (12.1%) had osteomyelitis. The DVT rate among 466 children with osteomyelitis was 6.0%. Children with osteomyelitis and DVT had greater SOI (9.1 vs. 2.7), bacteremia rate (82.1% vs. 38.4%), methicillin-resistant Staphylococcus aureus rate (89.3% vs. 21.2%), surgeries per child (2.1 vs. 0.7), and intensive care unit admission rate (67.9% vs. 5.9%) than that of children without DVT (P<0.00001). Of 196 children who had DVT without osteomyelitis, 166 (84.7%) had comorbidities including defined hypercoagulability (27 or 13.8%). Children with DVT due to osteomyelitis were without comorbidities or hypercoagulability (P<0.00001). The rate of pulmonary embolism was similar for children with DVT with or without osteomyelitis (3/28, or 10.7% vs. 18/196, or 9.2%). Children with DVT and osteomyelitis differ substantially from other children with DVT by the absence of comorbidities or post-thrombotic syndrome. They also differ from children with osteomyelitis without DVT by higher SOI, methicillin-resistant S. aureus rate, and occurrence of intensive care. Awareness of for the characteristics of DVT among children with osteomyelitis will reduce delay to diagnostic ultrasound and improve anticoagulation management which must be carefully coordinated given the high rate of surgery of these children. Level II-prognostic, retrospective cohort comparison.