In-hospital Therapy Research Articles

Hospital-Acquired Infection Is the Strongest Predictor of In-hospital Mortality in Patients With Alcoholic Hepatitis

Introduction: Alcoholic hepatitis (AH) is a clinical syndrome associated with high mortality and utilization of resources. We performed this study to evaluate predictors of in-hospital mortality (IHM) among AH patients. Methods: A retrospective chart review was done on patients discharged from our hospital with a diagnosis of AH. Patients who met a well characterized definition of AH (serum bilirubin > 3 mg/dL, AST to ALT ratio of > 1.5, recent heavy alcohol use, and absence of other causes of liver disease) were included in the study. Chi-square and t-tests were used to compare categorical and continuous variables. Multivariate logistic regression was used to evaluate the impact of several variables on IHM. Results: 105 patients with AH (median age 46yrs, 56% male, 74% white, 57% with cirrhosis, MELD score 23) were included in the study. Complications present on admission included acute kidney injury (AKI) (44%), encephalopathy (29%), infection (24%), and gastrointestinal bleeding (17%). Complications that developed during the hospitalization included AKI (48%) with 8% requiring dialysis, infection (15%), encephalopathy (12%), and gastrointestinal bleeding (5%). 67 patients (64%) received treatment for AH including steroids (n=33), pentoxifylline (21), or both (n=13).15 patients (14%) died during hospitalization. Compared to those that survived hospitalization, patients with IHM had a higher incidence of AKI on admission (73 vs. 39%, P=0.013), in-hospital AKI (73 vs. 20%, P < 0.0001), in-hospital encephalopathy(40 vs. 8%, P=0.0005), in-hospital infection (47 vs. 10% P=0.0003), pentoxifylline use (60 vs. 28%, P=0.014), and in-hospital renal replacement therapy (33 vs. 3%, P < 0.0001). They were also more likely to meet SIRS criteria (73 vs. 46%, P=0.046) and have a higher admission MELD score (32 vs. 23, P=0.0003). The use of prophylactic antibiotics was similar among patients with IHM and those who survived hospitalization (33 vs. 29%, P=0.73). On multivariate logistic regression, hospital-acquired infection was the single most important predictor for IHM (OR 15, 2.3-99, P=0.005). Prophylactic antibiotic use (OR 1.04, 0.14-8.1, P=0.96) and admission MELD score (OR 1.07, 0.98-1.17, P=0.13) were not predictive of IHM. Conclusion: Patients with AH have high in-hospital mortality and hospital acquired infection appears to be the strongest predictor of IHM. Prophylactic antibiotic use does not affect IHM and so clinicians should be vigilant to reduce the risk of infection and treat appropriately if there is evidence of an infection.

Past, present, and future of acute heart failure clinical trials-a high-risk population in search of a strategy.

Past, present, and future of acute heart failure clinical trials-a high-risk population in search of a strategy.

Levetiracetam in toxic seizures

Background/Objectives: The use of levetiracetam (LEV) in the management of drug-induced seizures has not been systematically investigated. Repetitive and continuous seizures that do not respond to benzodiazepines require second line therapy. Levetiracetam has a unique receptor binding site, rapid absorption, no known cardiac effects at therapeutic doses, and is theoretically a good candidate for use in drug-induced seizures. We evaluate the safety of LEV and its association with seizure cessation in this retrospective chart review of patients who received LEV as a control agent in drug-induced seizures.Methods: We identified the medical records of patients presenting to an urban, level 1 trauma center between 1 January 2010 and 31 May 2015 by ICD-9 codes based on the following: (1) a poisoning diagnosis, (2) a seizure diagnosis, and (3) administration of LEV. We included patients with a drug-induced seizure based on history, electroencephalogram results, blood alcohol concentrations, urine drug screens, and adequate documentation. We excluded patients with alcohol withdrawal, anoxic brain injury, subtherapeutic concentrations of other antiepileptics, hypoglycemia, and pseudoseizures. Primary outcomes of interest included cessation of active seizures or the prevention of seizure recurrence. We assessed safety by the presence or absence of adverse drug effects (ADE) attributed to the administration of LEV.Results: Thirty-four patients met inclusion and exclusion criteria. Half of the study cohort (17) presented with generalized tonic-clonic seizures (TCS); half (17) presented in generalized convulsive status epilepticus (GCSE). Six patients in GCSE received LEV during their seizures; 2 also received fosphenytoin. One improved immediately following LEV administration, and the remaining 5 had seizure control. Eleven GCSE patients (65%) remained seizure free after LEV therapy. The patients with TCS (17) received LEV after seizure(s) control. Sixteen (94%) were seizure-free during their hospital course. We found no adverse drug effects. In total, 27 of 34 patients (79%) had a return to baseline neurological and physical health. Six had long-term sequelae; none of which are known LEV side-effects. We identified 46 toxic substances and 22 known seizurogenic agents (48%). The median length of stay was 3.7 days (0.4–96), and the median duration of in-hospital LEV therapy was 1.6 days (0–49).Conclusions: Levetiracetam used as a second-line agent was associated with control of drug-induced seizures and prevention of seizure recurrence without obvious adverse effects. A prospective study is needed to confirm these results.

Concepts for Prehospital and Initial In-hospital Therapy of Status Epilepticus

AbstractStatus epilepticus is a major neurological emergency requiring immediate anticonvulsive treatment. Rapid and sufficient treatment is essential for optimizing outcome and reducing mortality. Here, we give an overview on concepts for acute prehospital and initial in-hospital treatment of status epilepticus. Options for initial therapy in settings without intensive care monitoring are presented in detail.

Decreased risk of knee buckling with adductor canal block versus femoral nerve block in total knee arthroplasty: a retrospective cohort study.

BackgroundFemoral nerve (FNB) and adductor canal blocks (ACB) are used in the setting of total knee arthroplasty (TKA), but neither has been demonstrated to be clearly superior. Although dynamometer studies have shown ACBs spare perioperative quadriceps function when compared to FNBs, ACBs have been widely adopted in orthopaedic surgery without significant evidence that they decrease the risk of perioperative falls.MethodsAll patients who received single-shot FNB (129 patients) or ACB (150 patients) at our institution for unilateral primary TKA from April 2014 to September 2015 were retrospectively reviewed for perioperative falls or near-falls during physical therapy and inpatient care.ResultsThere were significantly more “near-falls” with documented episodes of knee buckling in the FNB group (17 vs 3, P = .0004). These patients’ first buckling episode occurred at an average of 21.1 hours postoperatively (standard deviation 5.83, range 13.83-41.15). There were no significant differences in pain scores between the 2 groups at any of the time periods measured; however, patients in the FNB group consumed significantly fewer opioids on postoperative day 1 than the ACB group (59 morphine equivalents vs 73, P = .004).ConclusionsA significantly higher rate of near-falls with knee buckling during in-hospital physical therapy was discovered in the FNB group. With increasing numbers of TKAs being performed on a “fast-track” discharge model, these results must be seriously considered, particularly in patients planning to go home the same day, to reduce the risk of postoperative falls. These data support the recent clinical data trend favoring ACB over FNB in orthopaedic surgery.

Fluid Therapy Management in Hospitalized Patients: Results From a Cross-sectional Study

PurposeIntravenous (IV) fluid therapy is widely used in hospitalized patients. It has been internationally studied in surgical patients, but little attention to date has been dedicated to medical patients within the Italian context. The aims of the present study were to describe the prevalence of fluid therapy and associated factors among Italian patients admitted to medical and surgical units, describe the methods used to manage fluid therapy, and analyze the monitoring of patients by clinical staff. MethodsIn this cross-sectional study of 7 hospitals in northern Italy, data on individual and monitoring variables were collected, and their associations with in-hospital fluid therapy were analyzed by using logistic regression analysis. Patients aged ≥18 years who were admitted to medical and surgical units were included. Patients who received at least 500 mL of continuous fluids were included in the fluid therapy group. FindingsIn total, 785 (median age, 72 years; women, 52%) patients were included in the study, and 293 (37.3%) received fluid therapy. Maintenance was the most frequent reason for prescribing IV fluid therapy (59%). The mean (SD) volume delivered was 1177 (624) mL/d, and the highest volume was infused for replacement therapy (1660 [931] mL/d). The mean volume infused was 19.55 (13) mL/kg/d. The most commonly used fluid solutions were 0.9% sodium chloride (65.7%) and balanced crystalloid without glucose (32.9%). The proportion of patients assessed for urine output (52.6% vs 36.8%; P < 0.001), serum electrolyte concentrations (74.4% vs 65.0%; P = 0.005), and renal function (70.0% vs 58.7%; P = 0.002) was significantly higher in patients who did receive fluid therapy versus those who did not. In contrast, the use of weight and fluid assessments was not significantly different between the 2 groups (P = 0.216 and 0.256, respectively). Patients admitted for gastrointestinal disorders (odds ratio [OR], 3.5 [95% CI, 1.8–7.05) and for fluid/electrolyte imbalances (OR, 3.35 [95% CI, 1.06–10.52) were more likely to receive fluids. However, the likelihood of receiving fluids was lower for patients admitted to a surgical unit (OR, 0.36 [95% CI, 0.22–0.59]) and with cardiovascular diseases (OR, 0.37 [95% CI, 0.17–0.79). ImplicationsOnly one third of the study patients received fluid therapy. Crystalloid fluids, are the fluids of choice for maintaining plasma volume. During fluid therapy, measurement of the serum electrolyte concentrations, renal function, and urine output was largely used while weight and fluid balance were rarely assessed.

Cross-sectional imaging of complicated urinary infections affecting the lower tract and male genital organs.

Complicated urinary tract infections (C-UTIs) are those associated with structural or functional genitourinary abnormalities or with conditions that impair the host defence mechanisms, leading to an increased risk of acquiring infection or failing therapy. C-UTIs occur in patients with risk factors such as neurogenic dysfunction, bladder outlet obstruction, obstructive uropathy, bladder catheterisation, urologic instrumentation or indwelling stent, urinary tract post-surgical modifications, chemotherapy- or radiation-induced damage, renal impairment, diabetes and immunodeficiency.Multidetector CT and MRI allow comprehensive investigation of C-UTIs and systemic infection from an unknown source. Based upon personal experience at a tertiary care hospital focused on the treatment of infectious illnesses, this pictorial essay reviews with examples the clinical features and cross-sectional imaging findings of C-UTIs affecting the lower urinary tract and male genital organs. The disorders presented include acute infectious cystitis, bladder mural abscesses, infections of the prostate and seminal vesicles, acute urethritis and related perineal abscesses, funiculitis, epididymo-orchitis and scrotal abscesses. Emphasis is placed on the possible differential diagnoses of lower C-UTIs.The aim is to provide radiologists greater familiarity with these potentially severe disorders which frequently require intensive in-hospital antibiotic therapy, percutaneous drainage or surgery.Teaching Points• Complicated urinary tract infections occur in patients with structural or functional risk factors.• CT and MRI comprehensively investigate complicated urinary infections and sepsis from unknown sources.• Infections of the urinary bladder, prostate, seminal vesicles, urethra and scrotum are presented.• Emphasis is placed on differential diagnoses of complicated lower urogenital infections.• Unsuspected urinary infections may be detected on CT performed for other clinical reasons.

Российский регистр острого коронарного синдрома «РЕКОРД-3». Характеристика пациентов и лечение до выписки из стационара

RECORD-3 recruited pts with suspected ACS consecutively hospitalized in participating hospitals (n=47, 55% "invasive") during 1 month. Number of included pts was 2370 (39% women, mean age 64.6 years), 72% were admitted to invasive hospitals, 37% had ST-elevation ACS (STEACS). Median "onset of symptoms - first medical contact" time was 3.4 (1.0-16.8) hours, "first medical contact - hospital admission" time - 1.5 (1.0-3.1) hours. Cardiac troponin was determined in 76% of pts. Coronary angiography was carried out in 70 and 46% of pts with STE and non-STE ACS, respectively. (16% of all patients hospitalized in "noninvasive" cetnters were transferred for angiography to invasive ones). Primary percutaneous coronary intervention (PCI) was performed in 39% of patients with STEACS (in 65% of them with "door to pPCI" time less or equal 90 min). Thrombolytic therapy (TLT) was administered to 32% of pts (in half of them prehospitally). Overall reperfusion therapy received 68% of pts. Among non-STEACS pts rate of PCI was 20% (1/3 of procedures within 2, 1/3 - >2-24hours). Inhospital antiplatelet therapy (APT) included aspirin (88%), clopidogrel (71%), ticagrelor (14%); 86% of pts received dual APT. Other medications were: unfractionated heparin (UFH, 47% [81% subcutaneously]), enoxaparin (13%), fondaparinux (10%), angiotensin converting enzyme inhibitors/sartans (81%), -adrenoblockers (84%), statins (87%). Mortality during hospitalization (median 10 days) was 10% in STE, and 5% in non-STE ACS. Inhospital management of RECORD-3 population was characterized by relatively low rates of pPCI, reperfusion therapy in STEACS, urgent PCI in non-STEACS. Preponderance of UFG including its subcutaneous use is of note. Use of other standard therapies appears satisfactory.

Use of CPAP in patients with obstructive sleep apnea admitted to the general ward: effect on length of stay and readmission rate.

Obstructive sleep apnea (OSA) has been associated with multiple cardiovascular comorbidities. Despite increased awareness of OSA and its treatments, the management of OSA in the hospital setting remains below expectations. We retrospectively reviewed the demographics, clinical characteristics, and hospital course on 413 consecutive patients with a history of OSA on domiciliary CPAP therapy admitted to the general medical ward and analyzed the prevalence of CPAP use and its effect on length of stay (LOS), 30-day readmission rate, and time-to-readmission in our tertiary care teaching hospital. Of the 413 study participants, 264 (64.0%) patients were receiving CPAP during their hospital admission. Patients who were receiving CPAP therapy during their hospitalization had a significantly higher body mass index (BMI) (41.4 vs. 36.8kg/m(2), p<0.001) and were more likely to be African-American (p=0.01) and have congestive heart failure (CHF) (42.0 vs. 31.0%, p=0.038) peripheral vascular disease (PVD) (26.0 vs. 15.0%, p=0.013), and uncomplicated diabetes mellitus (p=0.001) than those who were not. CPAP therapy in the hospital setting did not affect LOS (4.7 vs. 4.0days, p=0.291), readmission rate (11.0% for both groups), or time-to-readmission (20.8 vs. 22.3days, p=0.762). The majority of patients who are on domiciliary CPAP therapy were receiving CPAP therapy while admitted to the general medical ward of a tertiary care academic hospital. Presence of comorbid conditions such as obesity and certain cardiovascular diseases may have increased the likelihood of prescribing CPAP therapy while in the hospital. In-hospital CPAP therapy did not appear to significantly influence short-term outcomes such as hospital LOS, readmission rate, or time-to-readmission.

Abstract TP316: Appraising the Quality of Patient Care in Hospitalization for Transient Ischemic Attack

Introduction: The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services (CMS) hospital-acquired conditions (HACs) are federally implemented quality metrics. The necessity of hospitalization for transient ischemic attack (TIA) remains controversial. Here, we report the incidence, risk factors, and in-hospital outcomes associated with HACs and PSIs in this population. Methods: The Nationwide Inpatient Sample (2002-2011) was queried for all records coded as primary diagnoses of TIA. The impact of demographics, insurance status, comorbidities, and in-hospital procedures on the occurrence of PSIs and HACs and the effect of these events on length of stay (LOS), hospital costs, and mortality was examined in bivariate and multivariate analyses. Results: A total of 52,969 PSIs and 21,612 HACs were identified among 2,117,247 TIA hospitalizations. The most frequent PSIs were pressure ulcers (1,173 per 100,000 patients), deep vein thrombosis (376 per 100,000 patients), and respiratory failure (329 per 100,000 patients) while the most frequent HACs were falls/trauma (942 per 100,000 patients), poor glycemic control (33 per 100,000 patients), and stage III/IV pressure ulcers (31 per 100,000 patients). In adjusted analyses, age 85+ (odds ratios [ORs]: 3.81, 1.50), Medicare (ORs: 1.62, 1.37), Medicaid (ORs: 2.01, 1.34), and 3+ comorbidities (ORs: 2.83, 1.30) were independent predictors of PSI or HAC occurrence, respectively (all p&lt;0.0001). Adjusted risk factors of PSI occurrence included: black race (OR: 1.21), in-hospital ischemic stroke (OR: 1.97), thrombolytic therapy (OR: 2.54), coronary angioplasty (OR: 1.81), and coronary artery bypass graft (OR: 7.18) (all p&lt;0.0001). PSI or HAC in TIA patients independently predicted prolonged LOS, increased total costs, and adverse discharges (all p&lt;0.0001). In TIA patients suffering a PSI or HAC, odds of mortality were increased by factors of 30.1 and 4.08, respectively (all p&lt;0.0001). Conclusion: Among TIA hospitalizations, patient age, race, payer status, pre-existing comorbidity, hospital characteristics, and procedural management significantly impact the occurrence of PSIs and HACs, further affecting patient outcomes.

Abstract WP144: Predictors of In-hospital Speech Therapy Referral in Aphasic Acute Ischemic Stroke Patients Within a Population

Background: Aphasia is a major cause of disability following ischemic stroke (IS). We sought to determine clinical characteristics of patients with aphasia that are associated with speech therapy evaluation (STE) in the acute setting within a large, biracial population. Methods: Adult IS patients in 2010 in the Greater Cincinnati/Northern KY region (population 1.3 million) were ascertained from all local hospitals via ICD-9 codes 430-436, using retrospective chart review. Aphasia was defined by symptoms or examination documented in the medical record. Demented patients were excluded. Logistic regression was used to determine associations between STE and clinical characteristics. We ran our model twice, including and excluding patients who died in-hospital or shifted to comfort/hospice care. Age and NIHSS were evaluated for potential nonlinear effects using spline functions. Results: In 2010, there were 1997 non-demented IS subjects, with 21% black, 54% female, and mean age of 68 (SD 15) years. Of these, 728 (36%) presented with aphasia, of whom 514 (71%) were assessed by ST. Age, race, gender, and academic hospital were not significantly associated with STE. In-hospital death and hospice referral were negative predictors (OR 0.12 and OR 0.19; both p&lt;0.01); excluding these 202, 463 (79%) of the remainder were assessed. Factors predictive of STE in both models were stroke/neurology consult (OR 2.56 (95% CI 1.55, 4.21), p&lt;0.01), dysarthria (OR 2.34 (1.46, 3.75), p&lt;0.01), and NIHSS. NIHSS had a non-linear relationship, with moderate strokes most likely to be evaluated and mild and severe strokes less likely (Figure). Discussion: Of non-moribund IS patients presenting with aphasia, 1 in 5 did not receive STE during acute hospitalization. While moderate stroke patients had a high rate of STE, mild and severe strokes showed a bias towards less consultation. Our results suggest that limited ST resources are not always directed at those with potentially the greatest need.

Pre- and in-hospital antithrombotic management patterns and in-hospital outcomes in patients with acute coronary syndrome: data from the Turkish arm of the EPICOR study.

Objective:To evaluate the acute phase (pre- and in-hospital) antithrombotic management patterns (AMPs) and in-hospital outcomes for patients hospitalized with an acute coronary syndrome (ACS).Methods:In total, 1034 patients [514 patients with ST-segment elevation myocardial infarction (STEMI) and 520 with unstable angina/non-STEMI (UA/NSTEMI)] hospitalized for ACS within 24 h of symptom onset were included in this multicenter prospective registry study conducted at 34 hospitals across Turkey. Patient characteristics, index event description, pre- and in-hospital AMPs, and clinical outcomes were evaluated.Results:Majority (89.1%) of patients did not receive pre-hospital treatment. Overall 87.9% patients with STEMI and 55.6% patients with NSTEMI underwent percutaneous coronary intervention and dual antiplatelet therapy (DAPT) was based mainly on acetylsalicylic acid (ASA) and clopidogrel during hospitalization (99.8% and 98.2%, respectively). DAPT use at discharge was 98.4% and 86.8%, respectively. The percentage of patients with STEMI who received pre-hospital care, in-hospital cardiac catheterization, and pre and/or in-hospital triple antiplatelet therapy was higher than that of patients with UA/NSTEMI. In addition, higher rate of in-hospital hemorrhagic (2.3% vs. 0.8%) and cardiac ischemic (1.2% vs. 0.4% for MI and 1.6% vs. 0.8% for recurrent ischemia) complications and earlier induction of pre and/or in-hospital antiplatelet therapy and cardiac catheterization were also noted in patients with STEMI than in those with UA/NSTEMI.Conclusion:Our findings revealed in-hospital and at-discharge management to be mainly based on DAPT in patients with ACS. Interventional strategies were used in the majority of patients with STEMI, while the usage and timing of immediate pre-hospital ECG from symptom onset should be improved in these patients.

Outcomes after stroke in patients receiving adjuvant therapy with traditional Chinese medicine: A nationwide matched interventional cohort study

Ethnopharmacological relevanceThe use of traditional Chinese medicine (TCM) was high in stroke patients but limited information was available on whether TCM is effective on post-stroke outcomes. The aim of this study is to compare the outcomes of stroke patients with and without receiving adjuvant TCM therapy. Materials and methodsUsing Taiwan's National Health Insurance Research Database, we conducted a nationwide cohort study and selected hospitalized stroke patients receiving routine care with (n=1734) and without (n=1734) in-hospital adjuvant TCM therapy by propensity score matching procedures. The adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of poststroke complications and mortality associated with in-hospital adjuvant TCM therapy were calculated. The use of medical resource was also compared between stroke patients with and without adjuvant TCM therapy. ResultsCompared with hospitalized stroke patients receiving routine care alone, hospitalized stroke patients receiving routine care and adjuvant TCM therapy exhibited decreased risks of urinary tract infection (HR 0.82, 95% CI 0.68-1.00), pneumonia (HR 0.60, 95% CI 0.47-0.76), epilepsy (HR 0.67, 95% CI 0.49-0.96), gastrointestinal hemorrhage (HR 0.68, 95% CI 0.47-0.98), and mortality (HR 0.37, 95% CI 0.19-0.70) within 3 months after stroke admission. The corresponding 6-month HRs for urinary tract infection, pneumonia, gastrointestinal hemorrhage, and mortality were 0.83, 0.63, 0.64, and 0.40, respectively. Less use and expenditure of hospitalization were found in those received adjuvant TCM therapy. ConclusionsHospitalized stroke patients who received routine care and adjuvant TCM therapy exhibited reduced adverse outcomes after admission within a 6-month follow-up period.

Adjuvant use of antibiotics with corticosteroids in inflammatory bowel disease exacerbations requiring hospitalisation: a retrospective cohort study and meta‐analysis

Patients hospitalised with an exacerbation of inflammatory bowel disease (IBD) often receive antibiotics in addition to intravenous steroids. However, their efficacy in this setting is unclear. To ascertain if the addition of antibiotics to intravenous steroids modifies short and long-term clinical outcomes. Our study included IBD patients hospitalised between 2009 and 2014 who received intravenous (IV) steroids with or without adjuvant antibiotics. Outcomes of interest included length of stay (LOS), need for medical and surgical rescue therapy during the hospitalisation, and at 90 and 365 days. A meta-analysis of previously published randomised trials was additionally performed. A total of 354 patients were included [145 ulcerative colitis (UC); 209 Crohn's disease (CD)]. In CD, combination of IV steroids and antibiotics did not change need for in-hospital medical rescue therapy, surgery or hospitalisations at 1 year but was associated with greater LOS (6.1 vs. 4.6 days, P = 0.02). In UC, patients receiving antibiotics were less likely to require in-hospital medical rescue therapy [odds ratio (OR): 0.42, 95% confidence interval (CI): 0.19-0.93] but experienced no statistically significant differences in LOS, in-hospital surgery, re-hospitalisations or surgery by 1 year. A meta-analysis of three relevant randomised trials demonstrated no difference in clinical improvement with antibiotics over placebo (OR: 1.08, 95% CI: 0.50-2.32). The addition of antibiotics to intravenous steroids for treatment of IBD exacerbations was associated with a reduced need for in-hospital medical rescue therapy in ulcerative colitis without significant long-term benefit, and did not affect short- or long-term outcomes in Crohn's disease.

Influence of Comorbid Risk Factors and Prehospital Medications on Patients With Heart Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

SESSION TITLE: Advances in Cardiac Disease SESSION TYPE: Original Investigation Slide PRESENTED ON: Monday, October 26, 2015 at 04:30 PM - 05:30 PM PURPOSE: Heart failure (HF) often worsens clinical outcomes in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) despite appropriate in-hospital therapy. METHODS: This is a 5-year retrospective study on patients admitted with AECOPD. Patients were divided in left (LHF) vs right (RHF) vs biventricular HF (BiHF). Pre-morbid conditions such as obstructive sleep apnea (OSA), coronary artery disease (CAD) and use of pre-hospital angiotensin-converting-enzyme inhibitor (ACE-i)/angiotensin-receptor blocker (ARB), beta-blockers (BB) and 3-hydroxy-3-methylglutaryl CoA reductase inhibitors (statins) was analyzed. Outcomes included need and duration of non-invasive ventilation (NIV) and mechanical ventilation (MV), intensive care unit (ICU) length of stay (LOS) and total LOS (days). The data was assessed using chi-square test and Fisher's exact test. Two-tailed p-value <0.05 was considered statistically significant. RESULTS: A total of 735 patients met our inclusion criteria and were included in this study. HF was noted in 419 (57.0%) patients - LHF 165 (39.4%), RHF 154 (36.8%) and BiHF 100 (23.8%) (Mean left ventricular ejection fraction 52.4±15%). OSA increased ICU LOS in BiHF (5.1±0.4 vs 1.6±0.6, p=0.003), LHF (4.2±0.3 vs 2.6±0.5, p=0.03), RHF (4.3±0.6 vs 2.6±0.3, p=0.007) and no HF (5.6±0.6 vs 3.2±0.2, p<0.0001). MV days were increased in CAD+BiHF (9.5±1.5 vs 5.4±0.6, p=0.005), CAD+LHF (4.6±0.6 vs 2.6±0.5, p=0.01), OSA+LHF (4.4±0.5 vs 0.9±0.5, p=0.004) and OSA+no HF (6.2±1.0 vs 2.8±0.3, p<0.0001). Pre-hospital BB use decreased (a) MV in LHF (17.5% vs 5.6%); (b) MV days in BiHF (6.9±0.6 vs 2.0±0.9) and no HF (4.9±0.7 vs 2.7±0.3); (c) ICU LOS in LHF (5.3±0.5 vs 3.3±0.3), BiHF (5.2±0.4 vs 2.1±0.6) and no HF (5.1±0.5 vs 3.2±0.3); and (d) total LOS in LHF (7.1±0.7 vs 5.3±0.4) and no HF (6.0±0.5 vs. 4.8±0.2) (all p<0.05). In LHF, statins reduced NIV use (41.9% vs 26.6%, p=0.03), MV days (4.6±0.6 vs 2.5±0.5, p=0.01) and ICU LOS (4.4±0.4 vs 3.3±0.4, p=0.04). ACE-i/ARB reduced MV days and ICU LOS for BiHF (7.7±0.8 vs 3.4±0.7; 6.0±0.5 vs 3.0±0.4) and RHF (3.3±0.6 vs 1.4±0.5; 3.6±0.4 vs 2.5±0.3) (all p<0.05). CONCLUSIONS: In this hypothesis-generating study on patients with AECOPD, pre-hospital cardiac medications predict better outcomes in concomitant HF. CAD with coexisting LHF/BiHF portends a worse prognosis while OSA is associated with worse outcomes independent of HF. CLINICAL IMPLICATIONS: Pre-hospital factors influence outcomes in AECOPD patients with HF and merit further study in prospective trials. DISCLOSURE: The following authors have nothing to disclose: Saraschandra Vallabhajosyula, Pranathi Sundaragiri, Anas Ahmed, Hamza Rayes, Toufik Mahfood Haddad, Haitam Buaisha, Anila Khan, Gene Pershwitz, Muhammad Sarfraz Nawaz, Dustin McCann, Christopher Wichman, Mark Holmberg, Lee Morrow No Product/Research Disclosure Information

Adherence to statin treatment following a myocardial infarction: an Italian population-based survey.

BackgroundStatins are standard therapies after myocardial infarction (MI) in the general population. In the current study, we assessed adherence to statin treatment by patients after an MI in Italy, and estimated the effect of in-hospital statin therapy on persistence in treatment during a 2-year follow-up.Patients and methodsThis was a retrospective cohort observation study of patients who experienced their MI between January 1, 2004 and December 31, 2005. Patients to enroll were identified by a diagnosis of MI at discharge from hospital. Previous drug therapies and hospital admissions for cardiovascular reasons in the 12 months before hospitalization for MI, statin treatment and lipid levels during hospitalization, indication for statin treatment at hospital discharge, and adherence to statin treatment in the following 24 months using an integrated analysis of administrative databases and hospital case records were evaluated. Also, factors associated either positively or negatively with consistent acute and long-term use of this efficacy-proven therapy were evaluated.ResultsWe identified 3,369 patients: 28.5% of patients had not been consistently treated with statins during their hospital stay for MI, and 36.2% of patients did not receive a statin prescription at hospital discharge. Of the 2,629 patients persistent with treatment during the follow-up, only 1,431 had an adherence to statins >80%. Either during the hospitalization or during the follow-up, the use of statins was negatively associated with older age and the presence of diabetes and chronic kidney disease. Lipid levels were significantly higher in treated than in untreated patients, but did not contribute to adherence to treatment. An important factor in long-term adherence to statin treatment was a statin prescription at the time of hospital discharge.ConclusionSince the statin undertreatment rate in routine care is still high, physicians need to increase the awareness of patients regarding the implications of discontinuation and/or underuse of their medications and encourage higher adherence.

PP.22.20

Objective: Systemic congestion is the known main cause of hospital readmissions of patients with acute decompensated heart failure (ADHF). The aim of the study was to evaluate changes of hydration status assessed by clinical criteria and bioimpedance vector analysis (BIVA). Design and method: In 48 patients admitted with ADHF (56% male, 67.1 ± 11.6 years (M ± SD), arterial hypertension 94%, ischemic heart disease 85%, myocardial infarction 45%, atrial fibrillation 66%, diabetes mellitus 54%, known chronic kidney disease 29%, left ventricular ejection fraction (EF) 46 ± 9%) hydration status was assessed and graded according ESC 2010 Scientific statement and by BIVA using resistance (R) and reactance (Xc), standardized by height (h). Mann-Whitney and Wilkoxon tests were performed. P < 0.05 was considered statistically significant. Results: 45 (94%) patients discharged with clinical improvement (patients lost weight, reduced edema, had improvement in dyspnea and NYHA functional class (p < 0.05)). Only 28 (58%) patients attained compensation assessed by BIVA. In spite of failure of attainment BIVA compensation in 42% of patients R/h and Xc/h significantly increased in both groups (meaning decrease of overhydration severity): from 235 ± 46 to 298 ± 55 Om/m and from 18 ± 8 to 24 ± 8 Om/m in patients with BIVA compensation (p < 0.001), from 225 ± 54 to 284 ± 56 Om/m and from 17 ± 7 to 23 ± 5 Om/m in patients without BIVA compensation (p < 0.001). Patients with versus without compensation by BIVA had lower baseline distance attained during a 6-minute walk (6MWD) (133 ± 65 vs 170 ± 42 meters, p < 0.05), EF (42 ± 9 vs 49 ± 8%, p < 0.05), more pronounced edema (2.3 ± 0.7 vs 2.0 ± 0.5 points, p < 0.05). Patients did not differ by baseline BIVA parameters or outpatient therapy. Patients with versus without compensation by BIVA had higher rate of in-hospital therapy with beta-blockers (100 vs 75%, p = 0.006), higher dose of i/v loop diuretics (p = 0.02), lower rate of thiazide diuretics (18 vs 50%, p = 0.03) and longer duration of hospitalization (17.4 ± 2.9 vs 13.4 ± 2.6 days, p < 0.001). Conclusions: 42% of patients admitted with ADHF discharged with subclinical congestion according BIVA assessment. Higher severity of clinical hyperhydration, worse baseline functional status as well as non-optimal regime of medical therapy may be associated with failure to attain BIVA compensation.

Role of Systemic Inflammation and Monocyte Activation in Acutely‐Decompensated Cardiorenal Syndrome Patients

Background A role for enteric endotoxin translocation has been postulated for heart-failure condition. In acutely decompensated cardiorenal syndrome (Ronco type 1 or type 3), the role of systemic inflammation remains unclear. Methods: Blood samples from 15 consecutively hospitalized cardiorenal syndrome (CRS) patients without pneumonia or urinary-tract infection were analyzed at admission and before hospital discharge. Methods included flow-cytometry analysis of monocyte function in terms of activation (CD14+/CD16+; CD14-/CD16+). Results were displayed as medians (per group) with standard deviation. ANOVA or Kruskal-Wallis test was performed, where applicable. Differences were considered as significant, if p<0.05. Results: Baseline parameters of renal and cardiac function were displayed in the Table. CRS Patients Hemodialysis Patients Hypertensive Patients p Age (years) 71.9 ± 9.1 71.3 ± 8.6 60.5 ± 13.7 <0.01 LVEF (%) 39.9 ± 15.7 54.0 ± 11.4 81.5 ± 4.9 <0.001 Creatinine (µmol/l) 270.0 ± 142.7 583.0 ± 248.7 67.0 ± 14.0 <0.0001 Urea (mmol/l) 22.4 ± 11.0 15.5 ± 5.3 3.5 ± 1.0 <0.0001 Brain-natriuretic peptide (ng/ml) 854.0 ± 1081.0 328.0 ± 299.8 21.5 ± 59.6 <0.0001 C-reactive protein (mg/dl) 36.9 ± 34.0 9.5 ± 13.2 1.9 ± 3.1 <0.001 Lipopolysaccharide-binding protein (ng/ml) 11.7 ± 7.9 10.4 ± 4.5 5.8 ± 1.6 =0.001 Procalcitonin (ng/ml) 0,2 ± 2.0 0.5 ± 1.0 0.0 ± 0.04 <0.0001 Interleukin-6 (pg/ml) 15.0 ± 23.6 14.6 ± 12.1 1.8 ± 1.5 <0.0001 Albumin (mg/dl) 34.0 ± 6.5 32.0 ± 4.1 41.0 ± 2.6 <0.0001 CD14+/CD16+ Monocytes 6.9 ± 2.7 7.9 ± 3.0 5.1 ± 2.3 =0.07 CD14-/CD16+ Monocytes 7.3 ± 5.8 9.5 ± 3.8 6.2 ± 2.8 ns Flow-cytometry analysis showed a tendency toward monocyte activation (CD14+/CD16+) both in CRS and hemodialysis patients. Individual comparisons between CRS/hypertensive patients and hemodialysis/hypertensive patients were significantly different. By discharge, one CRS patient died. No CRS patient required renal replacement therapy. Surviving CRS patients showed a normalization of urea (p<0.01), interleukin-6 tended to improve by discharge (p=0.01). Other prespecified parameters (Table) did not change by discharge. Conclusion Based on intergroup-comparisons, there is a higher degree of systemic inflammation in both CRS and hemodialysis patients than in hypertensive control patients. In CRS, systemic inflammation is hardly affected by current in-hospital therapy. More specific targets for therapy need to be identified to improve both systemic inflammation and outcome in CRS.

Abstract T P262: Lower Thrombolysis Rates in Women with Acute Ischemic Stroke in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study - The NINDS Stroke Prevention Intervention Research Program

Background: Higher prevalence of stroke in women and sex-specific disparities in stroke care are reported. We sought to determine sex-specific differences in stroke performance metrics in a large quality improvement registry of Florida and Puerto Rico based on Get With The Guidelines-Stroke (GWTG-S). Methods: 38,684 (49% women) acute ischemic stroke patients were included from 63 sites (54 FL; 9 PR) from 2010 to 2013. Logistic regression was used to evaluate sex-specific differences in defect-free care (IV tPA therapy, in-hospital antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy, statin medication at discharge, smoking cessation counseling) adjusting for age and race-ethnicity. Results: As compared to men, women were older (73±15 vs. 69±14 years; p&lt;0.0001), less likely Hispanic (17% vs. 18%; p=0.0001), with lower age- and race-ethnic-adjusted rates of hypertension (34% vs. 37%; p=0.0009) and smoking (13% vs. 21%; p&lt;0.0001), but higher rates of atrial fibrillation (18% vs. 16%; p=0.02). Overall, 9% of patients received thrombolysis. Women were less likely to receive thrombolysis (OR 0.92, 95% CI 0.86-0.99) and less likely to have door-to-needle time &lt;1 hour (OR 0.84, 95% CI 0.73-0.97). Overall, defect-free care was 75% in women and 76% in men (lower early antithrombotic therapy [OR 0.86, 95% CI 0.77-0.96], less antithrombotic at discharge [OR 0.87, 95% CI 0.77-0.99], less statin therapy at discharge [OR 0.81, 95% CI 0.74-0.88] and less smoking cessation counseling [OR 0.74, 95% CI 0.56-0.98]). Defect- free care improved over the study period; it was significantly lower in women vs. men in 2010 (58.2% vs. 60.7%, p=0.005), but similar in 2013 (90.2% vs 90.0%; p=0.64). Conclusions: Women eligible to receive IV tPA for acute ischemic stroke were less likely to be treated and received less defect-free care compared to men, but these measures improved over time. These findings suggest that the adoption of GWTG-S quality improvement program helps reduce sex disparities in quality of care for acute ischemic stroke patients.

Abstract W P283: Race-Ethnic Stroke Disparities in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study - The NINDS Stroke Prevention Intervention Research Program

Background: Race-ethnic disparities in stroke care can contribute to inequality in stroke outcomes. We sought to determine the disparities in stroke performance metrics by race-ethnicity in a voluntary stroke registry of Florida and Puerto Rico Get With The Guidelines-Stroke (GWTG-S) data. Methods: Sixty-three sites who had enrolled in the FL-PR Stroke Registry (54 FL; 9 PR) recorded 38,684 ischemic stroke cases from 2010 to 2013. Generalized linear regression models were used to evaluate race-ethnic differences in 7 pre-defined acute stroke performance measures and defect-free care (IV tPA treatment, in-hospital antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy, statin medication at discharge, and smoking cessation counseling), adjusting for age and region (FL vs. PR). Results: Of acute ischemic stroke cases, 63% were non-Hispanic White (NHW), 18% NH-Black (NHB), and 17% Hispanic. The mean age was 71±14 years. NHW were older (73±14), followed by Hispanics (70±14), and NHB (63±14); p&lt;0.0001. Defect-free care was better among NHB (78%) and NHW (76%) than in Hispanics (68%), p&lt;0.0001. Defect-free care improved over time and the race-ethnic disparity decreased (2010: NHW 61%, NHB 64%, Hispanic 46%, p&lt;0.0001; 2013: 91%, 91%, 86%, p=0.47 respectively). NHW were most likely to receive IV tPA treatment (arrived by 2 hours and treated by 3 hours; 88%) and early antithrombotic treatment (96%). Hispanics were least likely to receive DVT prophylaxis (76%), anticoagulation (92%), statins (89%), and smoking cessation counseling (93%). Conclusions: Race-ethnic disparities in acute stroke care are evident yet decreasing, coinciding with improvements in quality of care over time in Florida and Puerto Rico hospitals participating in GWTG-S. Special stroke quality improvement programs to target areas where performance is less than expected and minimize race-ethnic disparities are necessary to improve stroke care for all Americans.