Days Of Inpatient Care Research Articles

Hypericum perforatum to improve post-operative Pain Outcome after monosegmental Spinal microdiscectomy (HYPOS): a study protocol for a randomised, double-blind, placebo-controlled trial

BackgroundSpinal disc herniation is a frequently occurring degenerative disease of the spine. Many patients undergoing surgery suffer from radicular pain, known as memory pain, beginning from the third post-operative day. This results in the prescription of high-dose opioid medications. In homeopathy, Hypericum perforatum is known as a remedy for unbearable, shooting or jabbing pain especially when neural damage is involved. Reduction of pain after application of H. perforatum has been observed in previous studies. This study is aimed to investigate whether homeopathic H. perforatum in a potentisation of C200 leads to the reduction of post-operative pain and a decrease of pain medication compared to placebo.Methods/designThis is a monocentric, double-blind, randomised placebo-controlled trial conducted at the Department of Neurosurgery at the Community Hospital Herdecke, Germany. One hundred study participants are being recruited from inpatients undergoing elective, monosegmental, lumbar microdiscectomy surgery. Patients are randomly allocated to receive homeopathic treatment or placebo in addition to usual pain management after surgery. The primary clinical outcome is pain reduction after 3 days of inpatient care as measured by pain reduction of subjective pain on a 100-mm Visual Analogue Scale (VAS) at the third post-operative day. Statistical analysis will be carried out by means of a covariance model with adjustment for baseline values and patient expectation for all randomised patients.DiscussionThis study is the first trial of classical homeopathy that will evaluate the efficacy of homeopathic H. perforatum after monosegmental spinal microdiscectomy. We intend to clarify the potential of homoeopathic H. perforatum to reduce surgery-associated pain.Trial registrationGerman Clinical Trials Register, ID: DRKS00007913. Registered on 17 October 2014.EudraCT – Nr: 2013–001383-31.Data sets from the German Clinical Trials Register (DRKS, Deutsches Register Klinischer Studien) are updated every 4 weeks automatically to the International Clinical Trials Registry Platform of World Health Organisation: http://apps.who.int/trialsearch/.ResponsibilitiesSponsor:Witten/Herdecke UniversityAlfred-Herrhausen-Straße 5058,448 WittenDeputy of the sponsor:Dr. Wolfgang Eglmeier (Head of Centre for Clinical Trials Witten/Herdecke)Alfred-Herrhausen-Straße 5058,448 WittenE-mail: wolfgang.eglmeier@uni-wh.dePrincipal investigator:Prof. Dr. med. Wolfram ScharbrodtCommunity Hospital HerdeckeDepartment for NeurosurgeryGerhard-Kienle-Weg 458,313 Herdeckew.scharbrodt@gemeinschaftskrankenhaus.deProject coordination:Christa RaakFaculty for Health (Department for Integrative and Anthroposophic Medicine)University Witten/Herdecke gGmbhGerhard-Kienle-Weg 458,313 Herdeckechrista.raak@uni-wh.deProject manager/data analysis/biometry:Prof. Dr. Thomas OstermannFaculty for Health (Department for Psychology and Psychotherapy)University Witten/Herdecke gGmbhAlfred-Herrhausen-Straße 5058,448 Wittenthomas.ostermann@uni-wh.de

Racial Disparities in End-of-Life Care Planning and Hospital Utilization: A Single Center Retrospective Study

Introduction-Some prior studies suggest patients with hematologic malignancies receive more aggressive end-of-life care when compared to patients with solid tumor malignancies. Hematologic malignancies differ from solid tumors because of the continued potential for cure even in advanced disease, and potential difficulty identifying the terminal portion of a patient's illness. Racial/ethnic minorities are reported to have lower rates of hospice care, advanced directive use, and palliative care utilization. We studied differences in hospital utilization patterns and documentation of advance care planning between solid tumor and hematologic malignancy patients. In the subgroup of patients with hematologic malignancy, we also examined differences in these outcomes associated with racial/ethnic minority status.Methods-We conducted a retrospective cohort study of 9,469 patients with a diagnosis of cancer who received care at University of Washington (UW) Medicine and died between 2010 and 2015. Administrative data were available for the following events during the last 30 days of life: emergency department use, hospitalizations, and intensive care unit (ICU) utilization. We also examined death in a hospital and any documentation of advance directives (AD) in the electronic health record. We regressed each outcome on the binary predictor, adjusting for confounders (taken from a pool of potential confounders: age at death, patient gender, racial/ethnic minority status, level of education, insurance type, attributed facility, and number of Dartmouth Atlas chronic conditions). A variable was considered a confounder if its addition to the bivariate model changed the coefficient for the predictor by at least 10%. Binary outcomes were modeled with logistic regression. For count outcomes, we included only patients who had 1 or more days of the relevant type of care and modeled the remaining cases with negative binomial regression. All estimation was done with restricted maximum likelihood. Statistical significance was p <0.05.Results-In the last 30 days of life, decedents with hematologic cancer were significantly more likely to have aggressive hospital-based care, as measured by receipt of inpatient care, hospitalization for 14 or more days, multiple hospital admissions, and more days of hospital care, once admitted, than were those with solid tumor malignancies. They were also significantly more likely to have received ICU care, and to have spent more time in the ICU, once admitted, in the last 30 days of life. Finally, patients with hematologic malignancies were more likely to have died in a hospital rather than in other locations and more likely to have had documentation of AD in their electronic record. Among patients with hematologic malignancies, racial/ethnic minorities were less likely than white non-Hispanics to have documentation of AD and more likely to have 2+ emergency department visits or 14+ days of inpatient care, and had more days of inpatient care and ICU care, once admitted, in the last 30 days of lifeConclusions-Patients with hematologic malignancies received more aggressive care at the end of life as measured by hospital utilization, despite having more documentation of AD than patients with solid tumor malignancy. Racial/ethnic minorities with hematologic malignancies had lower rates of AD documentation and received even more aggressive care than their white counterparts. Although these are administrative data, they suggest opportunities to improve end-of-life care of patients with hematologic malignancies, particularly racial/ethnic minorities. [Display omitted] DisclosuresLee:Mallinckrodt: Honoraria; Amgen: Other: One-time advisory board member; Bristol-Myers-Squibb: Other: One-time advisory board member; Kadmon: Other: One-time advisory board member.

Does Alcoholism Influence Sexual Functioning?

Background: Alcohol and alcohol use disorder are known to cause sexual dysfunctions. In turn it may aggravate frequency and amount of alcohol consumed. We assessed the prevalence and the correlates of sexual dysfunction in men with Alcohol Dependence Syndrome (ADS) in a tertiary care hospital. Methods: A total fifty Consecutive male subjects were selected on the 3rd day of inpatient care from general hospital psychiatry with a diagnosis of Alcohol Dependence Syndrome with Simple withdrawal Symptoms as per ICD-10 criteria. Co-morbid psychiatric diagnosis was ruled out using SCID – 1. They were assessed for sexual dysfunction using International Index of Erectile Function (IIEF), a 15 item questionnaire. Data analyzed using descriptive and chi square test. Results: The mean age of the study sample was 39.26 (±8) years; The mean age of onset of drinking was 19.1(±6.2) years, and that of dependence was 24(± 6.7) years, duration of alcohol dependence was 15 (±7.7) years, with an average daily consumption of 462 (± 330) ml. Out of 50 patients, 38 (76%) reported to have one or more sexual dysfunction. Sexual desire (78.94%), low intercourse satisfaction (76.31%), followed by low overall satisfaction (57.89%), erectile dysfunction (55.26%) and orgasmic function (31.57%) were reported in that order. Co morbid nicotine dependence was found in 31(62%) of those having sexual dysfunction, and was statistically significant in those with erectile dysfunction and overall satisfaction domain with a p value less than 0.05. however other domains did not correlate. Conclusion: Sexual dysfunction is more prevalent in male patients with ADS. The prevalence of co-morbid nicotine dependence was high among patients with alcohol dependence syndrome. The findings of the current study indicate that it is necessary to routinely evaluate sexual dysfunction in patients with ADS and research should focus on the pathophysiology of sexual dysfunction among ADS.

Risk Factors for Heart Failure and Its Costs Among Children with Complex Congenital Heart Disease in a Medicaid Cohort.

Little research attention has been paid to the occurrence of heart failure (HF) in children with complex congenital heart diseases (CHDs). Herein, we describe the prevalence, risk factors, and costs associated with HF in complex CHD. Patients aged≤17years and diagnosed with a complex CHD on multiple service visits over a 15-year period in the SC Medicaid dataset (1996-2010) were tracked and analyzed. The cohort included 2999 unduplicated patients; 51.0% were male; 34.4% were African American. HF was diagnosed in 7.6%. Single ventricle lesions, genetic syndromes, and ventricular arrhythmia were significantly associated with an increased likelihood of being diagnosed with HF, controlling for development of comorbid pulmonary hypertension. Patients with HF received significantly more subspecialty care, more surgeries, more hospitalizations, more total days of inpatient care, and more emergency department care than those without HF. Patients with significantly higher total care costs paid by Medicaid had HF, more cardiac surgeries, and more specialized mechanical or other support procedures, controlling for diagnosed single ventricle CHD, a genetic syndrome, and number of non-cardiac surgeries. Complex CHD patients with HF incur significantly higher care costs but require multifaceted, intensive supports for management of incident complications and comorbid conditions.

A Group Journey—to Hell and Back

ABSTRACTThe process of a therapy group in an inpatient daycare unit1 became saturated with anger and detachment, ultimately leading to a despairing silence. Based on Ferenczi’s concept of Orpha, I will explain the group silence as indicative of deep trauma and dissociative self-states. I propose that the therapist’s willingness to “hang in” with his group and be part of a seemingly unbearable enactment enhances the possibility for emergence of hope and restoration of positive communication. It is rare in the literature for authors to expose the pitfalls that they and their group members can fall into, leading to despair, shame, and hopelessness. When working in the complex environment of a mental hospital where every level of staff is stressed, therapists often find themselves without support and consultation. My hope is that my colleagues can learn from my challenges, errors, and lessons, as I have.

Cost Analysis and Policy Implications of a Pediatric Palliative Care Program

ContextIn 2010, California launched Partners for Children (PFC), a pediatric palliative care pilot program offering hospice-like services for children eligible for full-scope Medicaid delivered concurrently with curative care, regardless of the child's life expectancy. ObjectivesWe assessed the change from before PFC enrollment to the enrolled period in 1) health care costs per enrollee per month (PEPM), 2) costs by service type and diagnosis category, and 3) health care utilization (days of inpatient care and length of hospital stay). MethodsA pre-post analysis compared enrollees' health care costs and utilization up to 24 months before enrollment with their costs during participation in the pilot, from January 2010 through December 2012. Analyses were conducted using paid Medicaid claims and program enrollment data. ResultsThe average PEPM health care costs of program enrollees decreased by $3331 from before their participation in PFC to the enrolled period, driven by a reduction in inpatient costs of $4897 PEPM. PFC enrollees experienced a nearly 50% reduction in the average number of inpatient days per month, from 4.2 to 2.3. Average length of stay per hospitalization dropped from an average of 16.7 days before enrollment to 6.5 days while in the program. ConclusionThrough the provision of home-based therapeutic services, 24/7 access to medical advice, and enhanced, personally tailored care coordination, PFC demonstrated an effective way to reduce costs for children with life-limiting conditions by moving from costly inpatient care to more coordinated and less expensive outpatient care. PFC's home-based care strategy is a cost-effective model for pediatric palliative care elsewhere.

Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital.

To implement an electronic laboratory utilization management system (laboratory expert system [LES]) to provide safe and effective reductions in unnecessary clinical laboratory testing. The LES is a set of frequency filter subroutines within the Veterans Affairs hospital and laboratory information system that was formulated by an interdisciplinary medical team. Since implementing the LES, total test volume has decreased by a mean of 11.18% per year compared with our pre-LES test volume. This change was not attributable to fluctuations in outpatient visits or inpatient days of care. Laboratory cost savings were estimated at $151,184 and $163,751 for 2012 and 2013, respectively. A significant portion of these cost savings was attributable to reductions in high-volume, large panel testing. No adverse effects on patient care were reported, and mean length of stay for patients remained unchanged. Electronic laboratory utilization systems can effectively reduce unnecessary laboratory testing without compromising patient care.

Comparación de costos y resultados sanitarios de usuarios con neumonia adquirida en comunidad atendidos en domicilio o en hospitalización tradicional: estudio exploratorio de 40 casos

IntroductionEconomic evaluations of health technologies and health interventions are considered in many countries as the fourth barrier for adopting new services or drugs; followed by safety, efficacy and quality. The validity and reliability of the results will depend on the perspective of the study, timeframe of the analysis, discount rate, the model used and the costs involved. ObjectivesThis study aims to assess the cost effectiveness of home care treatment in users with diagnosis of uncomplicated community acquired pneumonia compared with traditional hospitalization at inpatient wards. The hypothesis is that home based care would be more cost effective compared to traditional hospitalization. MethodsThe study perspective was from the health provider. Microcosting was used to determine the costs of both treatment modalities in a sample of 20 users treated with each modality during 2013 at main Hospitals of Coquimbo Region, Chile. ResultsThe main outcome of effectiveness was the number of inpatient care days saved. Additionally, number of infections associated to health care (IAHC) and type of discharge were measured. ConclusionsThe study concludes that there is a better cost effectiveness relationship for the home care modality, with fewer days of treatment, at lower costs and without risk of IAHC. However, further studies are needed in order to achieve accurate results.

The fast-track ultrasound clinic for early diagnosis of giant cell arteritis significantly reduces permanent visual impairment: towards a more effective strategy to improve clinical outcome in giant cell arteritis?

Permanent visual impairment has been reported to occur in up to 19% of GCA patients. The aim of this study was to examine whether implementation of a fast-track approach could reduce the rate of permanent visual impairment and inpatient days of care in GCA patients. A fast-track outpatient GCA clinic (FTC) was implemented in the Department of Rheumatology, Hospital of Southern Norway Trust Kristiansand, Norway in 2012. The patients included in this study were subsequently recruited between March 2010 and October 2014. Routine clinical and laboratory data and number of inpatient days of care were collected. During the observation period, 75 patients were diagnosed with GCA. Among the 75 GCA patients, 32 were evaluated conventionally and 43 in the FTC. In the conventionally approached group, six patients suffered from permanent visual impairment, while in the FTC group only one patient suffered from permanent visual impairment. The relative risk of permanent visual impairment in the GCA patients examined in the FTC was 88% lower compared with the conventionally evaluated group (relative risk 0.12, 95% CI: 0.01, 0.97, P = 0.01). The mean difference in inpatient days of care between patients evaluated conventionally and patients evaluated in the FTC was 3 days (3.6 vs 0.6 days, P < 0.0005). The implementation of the FTC in GCA care appears to significantly reduce the risk of permanent visual impairment and is more cost effective by reducing the need for inpatient care.

Abstract T MP113: Mortality after Gastrointestinal Hemorrhage in Patients taking Dabigatran and Warfarin

Background: Clinical trial data suggest greater likelihood of gastrointestinal (GI) bleeding for patients taking dabigatran 150 mg compared to warfarin, and similar likelihood for patients taking dabigatran 75 mg. Dabigatran-associated GI bleeding is concerning because no antidote exists to reverse the effects of dabigatran, possibly increasing the likelihood of death. Objective: Examine mortality after GI bleeding for patients taking warfarin, dabigatran 150mg, or dabigatran 75mg. Method: We used Medicare inpatient, carrier, and pharmacy claims for beneficiaries age 65 or older with new atrial fibrillation from 11/2010 through 12/2011 who received dabigatran 150mg, dabigatran 75mg, or warfarin. GI bleeds were identified by the primary diagnosis on inpatient claims, and death dates were determined from the CMS enrollment file. Patient demographics, comorbid conditions, and prior health service use were determined from claims incurred during the 12 months prior to the GI bleed. Each patient taking dabigatran 150 mg or 75 mg was matched to a single patient taking warfarin based on patient characteristics at the time of the bleed using an optimal propensity matching algorithm. Results: Of 2,889 GI bleeding events, 2326 (81%), 465 (16%), and 98 (3%) occurred in patients taking warfarin, dabigatran 150 mg, and dabigatran 75 mg, respectively. Compared to patients taking warfarin, patients on dabigatran 150mg were less likely to have renal disease, heart failure, or previous GI bleed, and had fewer previous inpatient days of care. In contrast, patients on dabigatran 75 mg were older and more likely to have renal disease, heart failure, or previous GI bleed compared to patients taking warfarin. The unadjusted 30-day mortality rate was 5.3%, 6.5%, and 8.1% for patients taking warfarin, dabigatran 150 mg, and dabigatran 75 mg and did not differ significantly by anticoagulant type. In the propensity-matched samples, mortality was similar for patients taking dabigatran 150 mg compared to warfarin (6.6% vs. 5.5%; p=0.49), and dabigatran 75 mg compared to warfarin (8.2% vs. 5.1%; p=0.39). Conclusions: Death after GI bleeding does not differ for patients taking dabigatran or warfarin, despite the lack of antidote for dabigatran.

Images of Aerococcus urinae

This is a description of an infection in 73 year old man with multiple comorbidities, with images of Aerococcus urinae from resultant blood cultures, showing their alpha hemolytic and Gram-positive properties. Plain language summary: Aerococcus urinae is a type of bacteria that can lead to infections in the urinary system. This work describes a 73 year old man who had an infection with Aerococcus urinae. Samples of blood and urine were taken from the patient, and when put on blood cells the bacteria weakly changed the color of the blood cells around them. This result is calledalpha hemolysis, and can be seen in Image 1. Adding Gram stain to the bacteria turned them violet, and therefore the bacteria were Gram-positive. This can be seen in microscopy in Image 2. The patient was treated with antibiotics. Aerococcus urinae Aerococcus urinae is a relatively new species of bacteria in clinical and microbiological practice, first reported in 1989 and designated as a separate species in 1992. [1] It can cause urinary tract infections, bacteremia/septicemia and/or endocar ditis. [2] As a urinary tract pathogen, it causes infections predominantly in elderly persons with local or general predisposing conditions. [3] Aerococcus urinae has been estimated to cause approximately 0.31 0.44% of urinary tract infections. [3] Patient case A 73 year old man presented to the emergency department with two days of fatigue, fever and chills. He had a previous history of left arterial cerebral media infarction with expressive aphasia, right side hemiparesis and post-stroke seizures. He suffered from hypertension, atrial fibrillation and aortic stenosis with normal systolic left ventricular function as well asurinary incontinence and prostatic hyperplasia. Wikiversity Journal of Medicine vol. 2, no. 1, March 2015 wijoumed.org | doi: 10.15347/wjm/2015.001 | Last updated: 10 April 2016 In the emergency department he was afebrile and the blood-samples showed a C-reactive protein level of 19 mg/l (normally less than 5 [4] or 6 [5] ) and a leukocyte count of 13.7*10 9 /l (normally less than 9.0 [6] or 10.0 [7] ). The patient was admitted to the hospital for observation, and after one day on the ward he developed chills and was subfebrile with a tympanic body temperature of 37.6°C (normally up to 37.5°C) [8] . Blood and urine samples were taken for culture. Microscopy of the blood samples showed gram-positive cocci. The patient received intravenous cefotaxime. After three days all blood samples and urine samples showed growth of gram-positive catalase-negative cocci Aerococcus urinae (Images 1 and 2). Image 1: Blood agar with alpha hemolytic colonies following culture from the patient's blood samples. Image 2: Micrograph of the bacteria with Gram stain, showing gram-positive cocci. Wikiversity Journal of Medicine vol. 2, no. 1, March 2015 wijoumed.org | doi: 10.15347/wjm/2015.001 | Last updated: 10 April 2016 Confirmation was done with MALDI TOF mass spectrometry. During the seven days of inpatient care, inflammatory parameters did not reach more than 61 mg/l for Creactive protein and 13.7*10 9 /l for leukocyte count. The patient received a cardiac ultrasound due to a systolic murmur, but it did not show any convincing signs of endocarditis. Written consent was obtained from the patient for this publication.

Timing of discharge follow-up for acute pulmonary embolism: retrospective cohort study.

IntroductionHistorically, emergency department (ED) patients with pulmonary embolism (PE) have been admitted for several days of inpatient care. Growing evidence suggests that selected ED patients with PE can be safely discharged home after a short length of stay. However, the optimal timing of follow up is unknown. We hypothesized that higher-risk patients with short length of stay (<24 hours from ED registration) would more commonly receive expedited follow up (≤3 days).MethodsThis retrospective cohort study included adults treated for acute PE in six community EDs. We ascertained the PE Severity Index risk class (for 30-day mortality), facility length of stay, the first follow-up clinician encounter, unscheduled return ED visits ≤3 days, 5-day PE-related readmissions, and 30-day all-cause mortality. Stratifying by risk class, we used multivariable analysis to examine age- and sex-adjusted associations between length of stay and expedited follow up.ResultsThe mean age of our 175 patients was 63.2 (±16.8) years. Overall, 93.1% (n=163) of our cohort received follow up within one week of discharge. Fifty-six patients (32.0%) were sent home within 24 hours and 100 (57.1%) received expedited follow up, often by telephone (67/100). The short and longer length-of-stay groups were comparable in age and sex, but differed in rates of low-risk status (63% vs 37%; p<0.01) and expedited follow up (70% vs 51%; p=0.03). After adjustment, we found that short length of stay was independently associated with expedited follow up in higher-risk patients (adjusted odds ratio [aOR] 3.5; 95% CI [1.0–11.8]; p=0.04), but not in low-risk patients (aOR 2.2; 95% CI [0.8–5.7]; p=0.11). Adverse outcomes were uncommon (<2%) and were not significantly different between the two length-of-stay groups.ConclusionHigher-risk patients with acute PE and short length of stay more commonly received expedited follow up in our community setting than other groups of patients. These practice patterns are associated with low rates of 30-day adverse events.

Compliance as a stable function in the treatment course of bipolar disorder in patients stabilized on olanzapine: results from a 24-month observational study.

Compliance is a key factor in the maintenance treatment of bipolar disorder. This noninterventional study was conducted to explore factors associated with higher levels of compliance in bipolar patients, all treated in routine clinical settings. Bipolar outpatients (Clinical Global Impression of Severity score ≤3) who had been stabilized with olanzapine mono- or combination therapy for ≥4 weeks were enrolled in the study. Compliance to medication was assessed at baseline and after 3, 6, 9, 12, 18, and 24 months by a physician-rated, 4-point categorical scale using the following classification: noncompliant (patients being compliant to treatment schedule less than 20% of the time) and low (20% to 59% of the time), moderate (60% to 79% of the time), and high (≥80% of the time) levels of compliance. Both baseline and post-baseline factors were used in a generalized estimating equations (GEE) model to predict the likelihood of high compliance. Of 891 eligible patients, 657 patients completed the 24-month observation period. High levels of compliance (≥80%) were observed in 67% of patients at baseline, increasing to 80% in study completers. High compliance at baseline was identified as a strong predictor of compliance during study participation (odds ratio (OR) = 6.9, 95% confidence interval (CI) = 5.0 to 9.5, p < 0.001). Factors associated with high compliance during the study (GEE model) included greater life satisfaction (p = 0.002), better insight into illness (p < 0.001), less work impairment (p = 0.007), and fewer days of inpatient care (p = 0.002). Compliance ratings varied by country (p < 0.001) and duration of post-baseline treatment (p = 0.014). In conclusion, a number of clinical, functional, and social factors were identified as predictors of compliance in patients with bipolar disorder. As compliance is crucial for the long-term management of these patients, more attention should be directed towards compliance itself and factors associated with compliance levels in everyday treatment settings.

Etiology and Timing of Readmissions After LVAD Implantation

Background: Patients who undergo left ventricular assist device (LVAD) implantation require very close medical follow-up given their risk for severe complications. Readmission for inpatientmanagement is often required if acute complications develop. Readmissions after LVAD implantation are an important cause of morbidity, and may be a significant personal and financial burden for patients. In this study, we characterized LVAD readmissions by reason for admission, duration of admission, and timing of readmission. Methods: Data were collected for 94 consecutive patients who underwent HeartMate II LVAD implantation at a single center. Five patients were excluded due to death or explantation before discharge after initial implantation. Follow-up was censored at death, transplant, or explantation. Readmissions were classified by reason for admission: cardiac, bleeding, thrombosis, pump malfunction, infection, neurologic, renal, elective, and other. Total days of inpatient care were calculated for each readmission. Time from discharge of initial implantation to time of readmission were calculated for heart failure (HF), GI bleeds (GIB), neurologic, and thrombotic causes for readmission. Results: In the patient cohort of 89 patients who survived to discharge after implantation, there were 239 readmissions, comprising 1765 days of inpatient care. The distribution of readmissions by type is in table 1. Total follow-up time for all patients was 405.4 days. The distribution of initial readmissions for GIB, HF, thrombosis, and neurologic readmissions may be seen in Graph 1. Average total days of follow-up for these patients are as follows: GIB patients were followed for an average of 535.7 days (SE: 77.1), HF patients for an average of 524.2 days (SE: 101.0), neurologic patients for an average of 522.1 days (SE: 101.3), and thrombosis patients for an average of 439.9 days (SE: 120.2). Conclusion: These data demonstrate that cardiac and bleeding readmissions are the predominant reason for readmission after LVAD implantation. Pump malfunction is not a common cause for readmission, but is responsible for a disproportionate fraction of days as inpatient. The timing of readmissions demonstrates that complications typically begin within the first 100 days of the postoperative course of the LVAD implantations. Neurologic readmissions overwhelmingly occur within this period, whereas thrombotic readmissions are less concentrated in this period. Further work to determine how to reduce readmissions in LVAD patients is needed.

Identifying high users of healthcare in British Columbia, Alberta and Manitoba.

This paper describes efforts to identify high users of healthcare in British Columbia, Alberta and Manitoba. British Columbia's Ministry of Health adopted a population segmentation approach that segments the province's population into 14 matrix populations. The approach has been used to inform strategic planning, especially for populations with frailty or chronic conditions. Alberta has pursued a similar but different population segmentation approach. A model capable of allocating healthcare costs to the individual level revealed that 5% of the population consumed approximately 66% of the allocated costs. Additional analysis of this 5% produced seven population profiles that have been used in planning. Manitoba's approach has focused on hospital inpatients and users of emergency departments (EDs). High users of hospitals were defined as the top 5% of users of days of inpatient care. Despite representing only 0.33% of the Manitoba population, this group received 45% of all days of hospital care. Using a threshold of seven or more ED visits annually, 2.2% of all ED patients were defined as frequent users, representing 13.5% of all visits. The paper demonstrates that common themes emerge from the approaches taken in each jurisdiction.

The declining demand for hospital care as a rationale for duty hour reform.

The regulation of duty hours of physicians in training remains among the most hotly debated subjects in medical education. Although recent duty hour reforms have been chiefly motivated by concerns about resident well-being and medical errors attributable to resident fatigue, the debate surrounding duty hour reform has infrequently involved discussion of one of the most important secular changes in hospital care that has affected nearly all developed countries over the last 3 decades: the declining demand for hospital care. For example, in 1980, we show that resident physicians in US teaching hospitals provided, on average, 1,302 inpatient days of care per resident physician compared to 593 inpatient days in 2011, a decline of 54%. This decline in the demand for hospital care by residents provides an under-recognized economic rationale for reducing residency duty hours, a rationale based solely on supply and demand considerations. Work hour reductions and growing requirements for outpatient training can be seen as an appropriate response to the shrinking demand for hospital care across the health-care sector.

Long‐Term Outcome of Home Parenteral Nutrition in Patients With Ultra‐Short Bowel Syndrome

The patients with ultra-short bowel syndrome (U-SBS) have been considered potential candidates for a preemptive/rehabilitative intestinal transplantation owing to the high risk of death from the underlying disease. We hypothesized that children with U-SBS, in the absence of intestinal failure-associated liver disease (IFALD), could also have a good rate of survival on home parenteral nutrition (HPN). A prospective database from the "Bambino Gesù" Artificial Nutrition and Intestinal Failure Program was used to evaluate outcomes and morbidities of consecutive patients with ≤ 10 cm of small bowel enrolled since 2000. Eleven patients were identified with a median bowel length of 7.5 (3-9) cm. Eight patients developed IFALD, which reversed in 7 of them; the IFALD progressively worsened in 1 patient until death. One patient underwent isolated intestinal transplantation and 1 patient is no longer receiving parenteral nutrition (PN) and both are fully enterally fed. The other patients remained at least partially dependent on HPN. The number of days of inpatient care decreased in all of the patients except for the 1 who had repeated episodes of central line infections. The survival of patients with U-SBS receiving HPN was good. Although IFALD was frequent, it had been manageable in most of the patients, but in a single complex case, it led to death. The multidisciplinary management warranted to these patients to approach the school age, to grow, and to maintain the oral intake. Patients with U-SBS are rare, and to better understand their long-term survival, further studies, including more large patient populations, are required.

How effective is the integration of facility and community-based management of severe acute malnutrition in India?

All children admitted to two nutritional rehabilitation centres (NRCs) during 2011-2012 in Madhya Pradesh, India. To determine 1) adherence to in-patient care and follow-up visits, 2) attainment and maintenance of target weight gain, and 3) association with the children's demographic characteristics. A retrospective record review. The 74-day programme included 14 days of in-patient care, with subsequent home-based care and four follow-up visits to the NRC at 15-day intervals. The first three visits were part of the treatment, while the fourth was for assessment of sustained weight gain. Of the 1027 children admitted, 900 (88%) completed in-patient care. Of these, 685 (76%) attended the first three follow-up visits, 482 (70%) of whom gained >15% of their admission weight. Of these, 409 (85%) completed four visits, 314 (77%) of whom were able to sustain their weight gain. Those unable to gain >15% weight by the third visit had a significantly lower proportion of sustained weight gain at the fourth visit. Children aged ⩾6 months had significantly higher odds (OR 4.5, 95%CI 3.1-6.2, P < 0.05) of completing in-patient care. In-patient care combined with community-based follow-up was effective in adherence to follow-up visits; however, there is still room for improvement in attaining and sustaining the target weight.

Vagus nerve stimulation in pediatric patients: Is it really worthwhile?

Vagus nerve stimulation (VNS) seems to be effective in the management of selected cases of pharmacoresistant epilepsy in children. This was a case–control prospective study of children with refractory epilepsy submitted to vagal nerve stimulator implantation and a control group with epilepsy treated with antiepileptic drugs. Patients under 18years of age who underwent clinical or surgical treatment because of pharmacoresistant epilepsy from January 2009 to January 2012 were followed and compared with an age-matched control group at final evaluation. Statistically significant differences were observed considering age at epilepsy onset (VNS group — 1.33±1.45years; controls — 3.23±3.11; p=0.0001), abnormal findings in neurological examination (p=0.01), history of previous ineffective epilepsy surgery (p=0.03), and baseline seizure frequency (p=0.0001). At long-term follow-up, 55.4% of the patients in the VNS group had at least 50% reduction of seizure frequency, with 11.1% of the patients presenting 95% reduction on seizure frequency. Also, a decrease in traumas and hospitalization due to seizures and a subjective improvement in mood and alertness were observed. The control group did not show a significant modification in seizure frequency during the study. In this series, VNS patients evolved with a statistically significant reduction of the number of seizures, a decreased morbidity of the seizures, and the number of days in inpatient care. In accordance with the current literature, VNS has been proven to be an effective alternative in the treatment of pediatric patients with drug-resistant epilepsy.

Predictors of suicidal behaviour in 36,304 individuals sickness absent due to stress-related mental disorders - a Swedish register linkage cohort study

BackgroundStress-related mental disorders (SRMD), which correspond to the diagnostic code F43 in the International Classification of Diseases, version 10, rank among the leading causes of sickness absence in several European countries. Despite the size of this health problem, research on risk factors for severe medical outcomes, like suicidal behavior, is lacking to date. The aim of this study was to investigate predictors of suicide attempt and suicide among sickness absentees with SRMD.MethodsA cohort of 36,304 non-retired individuals, aged 16–64 years on 31.12.2004, with at least one sickness absence spell due to SRMD, initiated in 2005, was followed up with regard to suicide attempt (2006–2009) and suicide (2006–2008). Univariate and multivariate hazard ratios (HR) with 95% confidence intervals (CI) were estimated for a number of predictors.ResultsDuring the follow-up period, 266 individuals attempted suicide and 34 committed suicide. In the multivariate analyses, the following factors increased the risk of suicide attempt: =< 25 years of age, low educational level, lone parenthood, > 1 sickness absence spell, long duration of the first spell of sickness absence due to SRMD (> 180 days), > 4 and > 8 days of inpatient care due to somatic or mental diagnoses (2000–2005), and > 4 and > 1 outpatient visits due to somatic or mental diagnoses (2001–2005), respectively. Hazard ratios ranged from 1.4 to 4.2. Health care due to mental diagnoses and > 1 spell of sickness absence regardless of diagnosis were predictive of suicide.ConclusionsSeveral predictors related to socio-demographics, sickness absence and health-care consumption were identified as risk factors for suicidal behavior. Consideration of these risk factors is of both clinical and public health importance.