Lower Admission Rates Research Articles

Proteinuria is associated with worse outcomes in babies born to mothers with preeclampsia: A retrospective cohort study at a tertiary referral hospital in Brazil.

To evaluate whether the presence of proteinuria, although no longer mandatory in the revised diagnostic criteria, results in worse maternal and fetal outcomes in preeclampsia (PE). A retrospective cohort study was conducted, analyzing data from pregnant patients diagnosed with PE between January 2015 and December 2019 at a tertiary care center in Brazil. Ethical approval was obtained, and the patient records were reviewed to assess maternal and perinatal outcomes based on the revised diagnostic criteria by the College of Obstetricians and Gynecologists, focusing on the presence or absence of proteinuria. The study included 816 pregnant patients with PE, of whom 685 (83.9%) were diagnosed based on proteinuria. The revised criteria, which include indicators of organ damage, identified an additional 131 cases (16.4%). Analysis showed no significant differences in maternal outcomes between proteinuria and non-proteinuria groups, including intensive care unit (ICU) admission, acute pulmonary edema (APE), HELLP syndrome, eclampsia, or C-section rates. However, babies born to mothers with proteinuria PE experienced worse outcomes, including fetal growth restriction, low birth weight, ICU admission, and higher rates of preterm birth. Relative risk analysis demonstrated a high risk of babies being born with low birth weight, ICU admission, and being born preterm and very preterm in cases where proteinuria was present in mothers with PE. The presence of proteinuria is associated with significantly worse outcomes in babies born to mothers with preeclampsia, while no significant differences were observed in maternal outcomes.

Fractional-Order Mathematical Modeling of Methicillin- Resistant Staphylococcus aureus Transmission in Hospitals

This article investigates the environmental contamination and antibiotic exposure effect on the transmission dynamics of the Methicillin-Resistant Staphylococcus aureus (MRSA) model in hospitals using the fractional Adams–Bashforth–Moulton Method (ABMM). This epidemic model simulates the dynamics of patient populations, bacterial contamination, and healthcare worker safety under varying conditions. This model provides critical insights into the interactions between hospital practices, environmental factors, and infection dynamics, demonstrating the importance of symmetry in balancing hospital admission and discharge rates to manage infection spread effectively. The analysis extends to the impact of environmental bacterial density and hospital admission rates on patient colonization. Increasing admission rates introduce more susceptible patients, exacerbating infection spread when bacterial density is high. Conversely, lower admission rates and bacterial density result in a more controlled infection environment. The model further investigates how varying discharge rates influence colonization dynamics, highlighting that effective discharge practices can mitigate infection spread, especially in high-bacterial density scenarios. It must be noted that this model is studied fractionally for the first time. Overall, this model provides critical insights into the interactions between hospital practices, environmental factors, and infection dynamics, offering valuable guidance for infection control strategies and hospital policy formulation. By adjusting fractional order constant (σ) values and analyzing different scenarios, this research aids in understanding and managing bacterial infections in healthcare settings. The proposed method is able to provide the results presented in the figures within this study considering the influence of many factors.

Effect of continuity of team midwifery care on maternal and neonatal outcomes: a quasi-experimental study in Iran

Midwife-led continuity of care models have been linked to better clinical outcomes in certain developed countries. However, there is a paucity of research on these models in developing nations. This quasi-experimental study was conducted on primiparous women who referred to one private midwifery center and two public hospitals in Ahvaz, Iran to evaluate the effect of team midwifery care on maternal and neonatal outcomes of pregnant women in Iran. Two hundred women were allocated either into the experimental (n = 100) or control (n = 100) groups. Women in the experimental group, received team midwifery care, while women in the control group, received routine care. Data were collected using a demographic questionnaire, Mackey questionnaire, and a checklist. Women in the team midwifery care group experienced significantly higher rates of normal vaginal birth and exclusive breastfeeding compared to women in the control group. No statistically significant difference was observed between the two groups in terms of the rate of induction of labor and postpartum hemorrhage. The duration of labor was longer in the team midwifery care compared to the control group. Women in the team midwifery care group had a significantly higher rate of exclusive breastfeeding at six weeks postpartum compared to the control group (80 vs. 61%, p = 0.001). After excluding women with ruptured membranes and prolonged pregnancies, neonates in the intervention group had significantly higher first- and fifth-minute Apgar scores (p < 0.0001), and a lower rate of admission to intensive care unit in the intervention group compared to the control group (1 vs. 9%, p = 0.04). Also, women in the team midwifery group had skin-to-skin contact significantly earlier than those in the control group (33.87 ± 66.26 min vs. 111.98 ± 247.31 min, p = 0.578). Given the positive impact of continuous team midwifery care on maternal and neonatal outcomes, its implementation in maternity care systems, particularly in countries like Iran with high cesarean section rates, is strongly recommended.

Effect of climate on emergency department admissions for renal colic: a comparative analysis of sedentary and non-sedentary lifestyles.

To investigate the impact of climate and seasonal variations on emergency department (ED) admissions for renal colic, while specifically comparing the differences between individuals with sedentary and non-sedentary lifestyles. A retrospective, single center study was conducted. Between the years 2017- 2020, medical records of patients admitted to the ED with renal colic, found to harbor ureteric stones on CT scans, were examined. Data on patients' occupational activities was collected through telephone questionnaires. Patients were categorized into two groups: sedentary and active. Precise weather data was obtained from the Israeli Meteorological Service website. The monthly average daily maximum temperatures were calculated. In the final sample of 560 participants, 285 were in the sedentary group, and 275 were in the active group. The study population consisted of 78.1% males and 21.9% females, with consistent gender ratios in both occupational groups. Prevalence of uric acid stones was higher in the sedentary group (p < 0.05). While there was a slight increase in admissions during the summer, seasonal distribution did not significantly differ among occupational groups. The study found no significant differences in admissions across different temperature ranges. Both groups exhibited a pattern of increased referrals during the summer and reduced referrals in the colder winter months. The baseline data revealed notable differences between the sedentary and active groups, particularly in the prevalence of uric acid stones. Climate factors, including temperature and seasonal variations, had limited impact on ED admissions for renal colic in patients with kidney stones, irrespective of their sedentary or active lifestyles. Both groups exhibited similar admission patterns, with a higher rate of admissions during the summer and a lower rate of admissions during the winter.

The Use of Telepsychiatry Services in Emergency Settings: Scoping Review.

Telepsychiatry (TP), a live video meeting, has been implemented in many contexts and settings. It has a distinct advantage in the psychiatric emergency department (ED) setting, as it expedites expert assessments for psychiatric patients. However, limited knowledge exits for TP's effectiveness in the ED setting, as well as the process of implementing TP in this setting. This scoping review aimed to review the existing evidence for the administrative and clinical outcomes for TP in the ED setting and to identify the barriers and facilitators to implementing TP in this setting. The scoping review was conducted according to the guidelines for the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Three electronic databases were examined: PubMed, Embase, and Web of Science. The databases were searched from January 2013 to April 2023 for papers and their bibliography. A total of 2816 potentially relevant papers were retrieved from the initial search. Studies were screened and selected independently by 2 authors. A total of 11 articles were included. Ten papers reported on administrative and clinical outcomes of TP use in the ED setting and 1 on the barriers and facilitators of its implementation. TP is used in urban and rural areas and for settings with and with no on-site psychiatric services. Evidence shows that TP reduced waiting time for psychiatric evaluation, but in some studies, it was associated with prolonged total length of stay in the ED compared with in-person evaluation. Findings indicate lower admission rates in patients assessed with TP in the ED. Limited data were reported for TP costs, its use for involuntary commitment evaluations, and its use for particular subgroups of patients (eg, those with a particular diagnosis). A single paper examined TP implementation process in the ED, which explored the barriers and facilitators for implementation among patients and staff in a rural setting. Based on the extant studies, TP seems to be generally feasible and acceptable to key stakeholders. However, this review detected a gap in the literature regarding TP's effectiveness and implementation process in the ED setting. Specific attention should be paid to the examination of this service for specific groups of patients, as well as its use to enable assessments for possible involuntary commitment.

Ambulatory teclistamab administration in patients with relapsed/refractory multiple myeloma.

11146 Background: Teclistamab (Tec) is the first B-Cell Maturation antigen (BCMA)xCD3 bispecific antibody FDA approved for the treatment of relapsed or refractory multiple myeloma (RRMM) in patients who have received ≥4 prior lines of therapy. The phase 1-2 MajesTec-1 study raised concerns for cytokine release syndrome (CRS)/immune effector cell-associated neurotoxicity syndrome (ICANS). 48-hour inpatient observation is recommended for step-up dosing, which imposes financial and logistical burdens. We report our institutional experience with ambulatory Tec administration. Methods: Our inpatient/outpatient (IPOP) hybrid nursing unit is staffed with specialized nurses, advanced practice providers, and attending physicians. Our patients treated in IPOP must live within 1 hour of the hospital and have a 24-hour caregiver. Patients were treated with the recommended step-up dosing schedule. CRS grading and ICE scoring were performed daily. Both CRS and ICANS were graded according to the ASTCT grading systems. We collected toxicities until the second full treatment dose, at which point hospitalization is no longer recommended. Results: In total, 25 patients were treated with Tec between January 2023 to December 2023. The median age was 70 years old (range 59-89), with a median of 6 prior lines of therapy. One patient was dialysis dependent prior to starting Tec. All patients were triple class refractory. Thirteen patients (52%) received prior bone marrow transplant. One (4%) patient received prior anti-BCMA CAR-T therapy. Seventeen patients (68%) required admission during the Tec ramp-up period. CRS was observed in 15 (60 %) patients, all of which were grade I/II events. Fourteen of these patients were hospitalized for CRS. They were admitted for median number of 2 hospital days (range 1-6). Tocilizumab was administered for Grade 2 CRS in 3 patients (12%). ICANS was reported in 4 (16%) patients. Two of those patients developed Grade 2 ICANS which completely resolved with dexamethasone. The median number of admitted hospital days for these patients was 3 days (range 2-49). Neutropenia with ANC &lt; 500 was seen in only 1 (4%) patient. Grade 3/4 infections were seen in 3 (12%) patients during the ramp-up period. Conclusions: Tec administration through an inpatient/outpatient hybrid model is safe and feasible. CRS was common but low grade and short lived. ICANS was observed, but remained low grade and may be attributable to our older patient population. As our center gained experience with the Tec management, we noticed lower rates of admission for low grade CRS. Lower incidences of infections and neutropenia demonstrate that these complications emerge in the months after starting therapy. Future studies will help identify patients who are higher risk for CRS and ICANS during ramp-up treatment and may pave the way for prophylactic interventions and outpatient administration.

COVID-19 Admission Rates and Changes in Care Quality in US Hospitals

Unprecedented increases in hospital occupancy rates during COVID-19 surges in 2020 caused concern over hospital care quality for patients without COVID-19. To examine changes in hospital nonsurgical care quality for patients without COVID-19 during periods of high and low COVID-19 admissions. This cross-sectional study used data from the 2019 and 2020 Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project State Inpatient Databases. Data were obtained for all nonfederal, acute care hospitals in 36 states with admissions in 2019 and 2020, and patients without a diagnosis of COVID-19 or pneumonia who were at risk for selected quality indicators were included. The data analysis was performed between January 1, 2023, and March 15, 2024. Each hospital and week in 2020 was categorized based on the number of COVID-19 admissions per 100 beds: less than 1.0, 1.0 to 4.9, 5.0 to 9.9, 10.0 to 14.9, and 15.0 or greater. The main outcomes were rates of adverse outcomes for selected quality indicators, including pressure ulcers and in-hospital mortality for acute myocardial infarction, heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and percutaneous coronary intervention. Changes in 2020 compared with 2019 were calculated for each level of the weekly COVID-19 admission rate, adjusting for case-mix and hospital-month fixed effects. Changes during weeks with high COVID-19 admissions (≥15 per 100 beds) were compared with changes during weeks with low COVID-19 admissions (<1 per 100 beds). The analysis included 19 111 629 discharges (50.3% female; mean [SD] age, 63.0 [18.0] years) from 3283 hospitals in 36 states. In weeks 18 to 48 of 2020, 35 851 hospital-weeks (36.7%) had low COVID-19 admission rates, and 8094 (8.3%) had high rates. Quality indicators for patients without COVID-19 significantly worsened in 2020 during weeks with high vs low COVID-19 admissions. Pressure ulcer rates increased by 0.09 per 1000 admissions (95% CI, 0.01-0.17 per 1000 admissions; relative change, 24.3%), heart failure mortality increased by 0.40 per 100 admissions (95% CI, 0.18-0.63 per 100 admissions; relative change, 21.1%), hip fracture mortality increased by 0.40 per 100 admissions (95% CI, 0.04-0.77 per 100 admissions; relative change, 29.4%), and a weighted mean of mortality for the selected indicators increased by 0.30 per 100 admissions (95% CI, 0.14-0.45 per 100 admissions; relative change, 10.6%). In this cross-sectional study, COVID-19 surges were associated with declines in hospital quality, highlighting the importance of identifying and implementing strategies to maintain care quality during periods of high hospital use.

The Association between Race and Extended Length of Stay in Low-energy Proximal Humerus Fractures in Elderly Patients.

Proximal humerus fractures (PHFs) are one of the most common fractures among patients aged 65 years and older, commonly due to low-energy mechanisms. It is essential to identify drivers of increased healthcare utilization in geriatric PHF patients and bring awareness to any disparities in care. Here, we identify factors associated with the likelihood of inpatient admission and prolonged hospital stay among patients aged 65 years and older who sustain PHF due to falls. A national database was used to identify patients aged 65 years and older who suffered proximal humeral fractures due to a fall. Patient factors were analyzed for association with the likelihood of admission and odds of prolonged stay (≥5 days). In the study period, 75,385 PHF patients who met our inclusion criteria presented to the emergency department and 14,118 (18.7%) were admitted. Black race was significantly associated with decreased odds of admission ( P < 0.001) and increased likelihood of prolonged stay ( P = 0.007) compared with White patients. Patients aged 75 to 84 and 85+ were both more likely to be admitted ( P < 0.001) and experienced a prolonged hospital stay ( P = 0.015). Patients undergoing surgical intervention with reverse total shoulder arthroplasty were associated with admission and prolonged length of stay ( P < 0.001). Hospitals in Midwestern ( P < 0.001) and Western ( P < 0.001) regions exhibited lower rates of admission and Northeastern hospitals were associated with prolonged stays ( P = 0.001). Finally, trauma and nonmetropolitan ( P < 0.001) centers were associated with admission. Our study highlights the notable influence of age and race on the likelihood of hospital admission and prolonged hospital stay. Specifically, Black patients exhibited prolonged hospital stay, which has been associated with lower-quality care, warranting additional exploration. Understanding these demographic and hospital-related factors is essential for optimizing resource allocation and reducing healthcare disparities in the care of PHF patients, especially as the population ages and the incidence of PHF continues to rise.

A 6-year Retrospective Study on the Clinical Profile and Outcomes of Postrenal Transplant Patients in the Emergency Department

Abstract Background: Kidney transplantation is widely recognized as the primary treatment for those with end-stage renal disease. Our goal was to provide an overview of the clinical characteristics of postrenal transplant patients (commercial vs. noncommercial) seeking care in the emergency department (ED). Methodology: The study was conducted at a leading Omani ED from 2015 to 2021; this study included all postrenal transplant patients. Various variables were categorized, coded, and analyzed. Results: A total of 55 postrenal transplant patients were included in our study. Of these, 60.0% were male (n = 33). Among the participants, 14.5% (n = 8) had undergone noncommercial renal transplants, whereas the remaining 85.5% (n = 47) had undergone commercial renal transplants. Among noncommercial postrenal transplant patients, the most common reasons for ED visits were fever (5), gastrointestinal symptoms (4), and cardiac symptoms (3). They also presented with pain at the surgical site (2) and urological symptoms such as dysuria and hematuria (2). In contrast, the most frequent clinical presentations among commercial postrenal transplant patients were cardiac symptoms (13) and pain at the surgical site (13), followed by fever (12). Noncommercial renal transplant patients had a high discharge rate of 62.5% (5) and a low admission rate of 37.5% (3). On the other hand, commercial renal transplant patients necessitated a high admission rate of 59.6% (28) and a low discharge rate of 40.4% (19). Conclusion: The majority of patients had received commercial kidney transplants, and the most common complaints upon their presentation to the ED were cardiac symptoms and pain at the surgical site. Patients undergoing commercial transplants had higher rates of admission.

Hospital readmissions after robotic hepatectomy for neoplastic disease: Analysis of risk factors, survival, and economical impact. A logistical regression and propensity score matched study

BackgroundAs the first comprehensive investigation into hospital readmissions following robotic hepatectomy for neoplastic disease, this study aims to fill a critical knowledge gap by evaluating risk factors associated with readmission and their impact on survival and the financial burden. MethodsThe study analyzed a database of robotic hepatectomy patients, comparing readmitted and non-readmitted individuals post-operatively using 1:1 propensity score matching. Statistical methods included Chi-square, Mann-Whitney U, T-test, binomial logistic regression, and Kaplan-Meier analysis. ResultsAmong 244 patients, 44 were readmitted within 90 days. Risk factors included hypertension (p ​= ​0.01), increased Child-Pugh score (p ​< ​0.01), and R1 margin status (p ​= ​0.05). Neoadjuvant chemotherapy correlated with lower readmission risk (p ​= ​0.045). Readmissions didn't significantly impact five-year survival (p ​= ​0.42) but increased fixed indirect hospital costs (p ​< ​0.01). ConclusionsReadmission post-robotic hepatectomy correlates with hypertension, higher Child-Pugh scores, and R1 margins. The use of neoadjuvant chemotherapy was associated with a lower admission rate due to less diffuse liver disease in these patients. While not affecting survival, readmissions elevate healthcare costs.

A Study of Cycle Analysis and Turbine Design for Obtaining Small-Scaled Power from the Organic Rankine Cycle Using R245fa

The organic Rankine cycle (ORC) has been widely applied to convert the renewable energy to the electric power. Some previous studies focused to find what kind of refrigerant would be a best working fluid for the ORC. In this study, R245fa was chosen as the working fluid, and the cycle analysis was conducted when the small scaled output power less than 30kW was required. In addition, properties of the working fluid on the cycle were predicted when the turbine output power was controlled by the mass flowrate. The configuration of the turbine was the radial-type turbine and the supersonic nozzles were applied as stator. So, the turbine was operated in partial admission. The turbine efficiency as well as the optimum velocity ratio was considered in the cycle analysis with the low partial admission rate. The computed results show that the partial admission rate was more important factor on the system efficiency than the temperature at the evaporator.

Utilisation of and factors associated with non-COVID-19 healthcare services in public facilities amongst cross-border migrants in Thailand, 2019–2022

BackgroundIt is believed that the COVID-19 pandemic might disrupt routine healthcare services. A vulnerable group such as cross-border migrants is of critical concern if the pandemic affects their service utilisation. In this study, we aim to explore the impact of COVID-19 and other related factors on non-COVID-19 service amongst cross-border migrants in Thailand.MethodsWe conducted an ecological time-series cross-sectional analysis using secondary data from 2019 to 2022, focusing on insured and non-insured migrants in a unit of a provincial monthly quarter. We obtained data on registered migrants from the Ministry of Labour and inpatient visits from the Ministry of Public Health (MOPH). Our analysis involved descriptive statistics and a random-effects negative binomial regression, considering variables such as COVID-19 cases, number of hospital beds, registered regions, and COVID-19 waves. We assessed inpatient utilisation number and rate as our primary outcomes.ResultsThe admission numbers for insured and non-insured migrants in all regions increased 1.3–2.1 times after 2019 despite a decrease in the numbers of registered migrants. The utilisation of services for selected communicable and non-communicable diseases and obstetric conditions remained consistent throughout 2019–2022. The admission numbers and rates were not associated with an increase in COVID-19 incidence cases but significantly enlarged as time passed by compared to the pre-COVID-19 period (44.5–77.0% for insured migrants and 15.0–26.4% for non-insured migrants). Greater Bangkok saw the lowest admission rate amongst insured migrants, reflected by the incidence rate ratio of 5.7–27.5 relative to other regions.ConclusionThe admission numbers and rates for non-COVID-19 healthcare services remained stable regardless of COVID-19 incidence. The later pandemic waves (Delta and Omicron variants) were related to an increase in admission numbers and rates, possibly due to disruptions in outpatient care, leading to more severe cases seeking hospitalisation. Lower admission rates in Greater Bangkok may be linked to the fragmentation of the primary care network in major cities and the disintegration of service utilisation data between private facilities and the MOPH. Future research should explore migrant healthcare-seeking behaviour at an individual level, using both quantitative and qualitative methods for deeper insights.

Intensive care following in-hospital cardiac arrest / periarrest calls—experience from one Scottish hospital

BackgroundIn-hospital cardiac arrest/periarrest is a recognised trigger for consideration of admission to the intensive care unit (ICU). We aimed to investigate the rates of ICU admission following in-hospital cardiac arrest/periarrest, evaluate the outcomes of such patients and assess whether anticipatory care planning had taken place prior to the adult resuscitation team being called.MethodsAnalysis of all referrals to the ICU page-holder within our district general hospital is between 1st November 2018 and 31st May 2019. From this, the frequency of adult resuscitation team calls was determined. Case notes were then reviewed to determine details of the events, patient outcomes and the use of anticipatory care planning tools on wards.ResultsOf the 506 referrals to the ICU page-holder, 141 (27.9%) were adult resuscitation team calls (114 periarrests and 27 cardiac arrests). Twelve patients were excluded due to health records being unavailable. Admission rates to ICU were low — 17.4% for cardiac arrests (4/23 patients), 5.7% (6/106) following periarrest. The primary reason for not admitting to ICU was patients being “too well” at the time of review (78/129 — 60.5%). Prior to adult resuscitation team call, treatment escalation plans had been completed in 27.9% (36/129) with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms present in 15.5% of cases (20/129). Four cardiac arrest calls were made in the presence of a valid DNACPR form, frequently due to a lack of awareness of the patient’s resuscitation status.ConclusionsThis study highlights the significant workload for the ICU page-holder brought about by adult resuscitation team calls. There is a low admission rate from these calls, and, at the time of resuscitation team call, anticipatory planning is frequently either incomplete or poorly communicated. Addressing these issues requires a collaborative approach between ICU and non-ICU physicians and highlights the need for larger studies to develop scoring systems to aid objective admission decision-making.

Risk factors analysis and multidisciplinary team first-aid simulation training for umbilical cord prolapse can improve neonatal outcomes

Objective In the present study, we sought to identify risk factors for umbilical cord prolapse (UCP) and adapt the multidisciplinary team (MDT) first-aid simulation training for UCP patients. We evaluated the usefulness of the MDT first-aid simulation by comparing delivery outcomes for UCP patients before and after its implementation. Material and methods A retrospective review was conducted on 149 UCP cases (48 overt and 101 occult) and 298 control deliveries that occurred at the Third Affiliated Hospital of Sun Yat-sen University from January 1998 to December 2022. Patient data were compared between the groups. One-way analysis of variance (ANOVA) was used for means comparison, and the chi-square test was used for categorical data. Univariate and multivariate logistic regression analyses were performed to identify factors significantly associated with UCP. Results Overt UCP was strongly associated with all adverse delivery outcomes. Both univariate and multivariate analyses identified multiparity, breech presentation, polyhydramnios, and low birth weight as independent risk factors for overt UCP (all odds ratios [OR] > 1; all p < 0.05). Preterm labor and abnormal placental cord insertion were identified as independent risk factors for occult UCP (all OR > 1; all p < 0.05). After 2014, when obstetrical staff received MDT first-aid simulation training, patients with overt UCP experienced shorter decision-to-delivery intervals due to more timely cesarean sections. They also had higher Apgar scores at 1, 5, and 10 min, and lower admission rates to the neonatal intensive care unit compared to patients before 2014 (all p < 0.05). Conclusion MDT first-aid simulation training for overt UCP can improve neonatal outcomes. However, medical simulation training efforts should initially focus on the early identification of risk factors for both overt and occult UCP.

Same-day discharge after elective open arterial surgery

ObjectiveTo evaluate the feasibility of same-day discharge (SDD) after open peripheral arterial surgery (OAS) in a veteran population. MethodsThis is a single-center, retrospective study. Starting September 2021, veterans who underwent elective OAS were selectively chosen for planned SDD. Eligible procedures included popliteal artery aneurysm repair, common femoral/superficial femoral/popliteal artery endarterectomy ± concurrent endovascular intervention, bypass graft revision, femoral-femoral bypass, and axillofemoral bypass. All patients who underwent eligible procedures were compared across three eras based on the primary location of postoperative admission: intensive care unit era (ICUE, September 2016-December 2018), inpatient ward era (WARDE, January 2019-August 2021), and SDD era (SDDE, September 2021-December 2022). Demographics, comorbidities, indication for procedures, operative times, complications, readmissions, and length of stay (LOS) were analyzed. ResultsNinety-nine male patients underwent eligible procedures during the 6-year study period (ICUE: 32, WARDE; 41, and SDDE: 26). ICUE had higher rates of tobacco use (P = .04) with no differences in age or other comorbidities between the eras. Indications were claudication, bypass graft stenosis, popliteal aneurysm, ischemic rest pain, and tissue loss. Twenty patients were selected for SDD, and 18 were successfully discharged same day. Operative times were not significantly different between the eras. SDDE patients were more likely to undergo monitored anesthesia care (P = .04). The mean LOS was significantly lower in SDDE (0.54 days, P < .001) compared with WARDE (2.9 days) and ICUE (2.8 days). The mean ICU LOS was lower in SDDE (0.2 days, P <.001) compared with ICUE (1.1 days). There was no difference in postoperative complications (P = .30), reoperation (P = .51), or readmission rates (P = .35). ConclusionsSDD is safe and feasible after elective OAS in a veteran population with a low unplanned admission rate.

Baseline presentation of atypical anorexia nervosa in Singaporean adolescents: a retrospective cohort study

BackgroundWhile atypical anorexia nervosa (AAN) has been found to present with significant physical and psychological complications, the presentation of AAN has not been described in a multi-ethnic Singaporean population.MethodsThis retrospective cohort analysis aimed to characterize the baseline presentation of adolescents with anorexia nervosa (AN) (N = 317) and AAN (N = 141) in a Singaporean cohort that presented to a specialist paediatric eating disorder program between January 2010 and October 2020 for assessment.ResultsIn patients with AAN, there were increased proportions of males (16% vs. 7%) and of Malay ethnicity (11% vs. 4%) compared to AN. Compared to adolescents with AN, adolescents with AAN had lower rates of admission (61% vs. 81%), bradycardia (45% vs. 75%), and hypotension (7% vs. 21%) but had a higher rate of syncope (13% vs. 7%). Likewise, adolescents with AAN had higher rates of self-harm and drug overdose (14% vs. 1.5%) requiring admission, more purging (45.1% vs. 14.8%) and more shape concerns.ConclusionHighlighting the severity of the illness, Singaporean adolescents with AAN presented with physical complications of malnutrition and had more severe eating disorder psychopathology and a higher frequency of other psychological comorbidities than did adolescents with AN.

COVID-19 Admission Rates and Changes in US Hospital Inpatient and Intensive Care Unit Occupancy

The COVID-19 pandemic had unprecedented effects on hospital occupancy, with consequences for hospital operations and patient care. Previous studies of occupancy during COVID-19 have been limited to small samples of hospitals. To measure the association between COVID-19 admission rates and hospital occupancy in different US areas and at different time periods during 2020. This cross-sectional study used data from the Healthcare Cost and Utilization Project State Inpatient Databases (2019-2020) for patients in nonfederal acute care hospitals in 45 US states, including the District of Columbia. Data analysis was performed between September 1, 2022, and April 30, 2023. Each hospital and week in 2020 was categorized based on the number of COVID-19 admissions per 100 beds (<1 [low], 1-4.9, 5-9.9, 10-14.9, or ≥15 [high]). The main outcomes were inpatient and intensive care unit (ICU) occupancy. We used regression analysis to estimate the average change in occupancy for each hospital-week in 2020 relative to the same hospital week in 2019. This study included 3960 hospitals and 54 355 916 admissions. Of the admissions in the 40 states used for race and ethnicity analyses, 15.7% were for Black patients, 12.9% were for Hispanic patients, 62.5% were for White patients, and 7.2% were for patients of other race or ethnicity; 1.7% of patients were missing these data. Weekly COVID-19 admission rates in 2020 were less than 4 per 100 beds for 63.9% of hospital-weeks and at least 10 in only 15.9% of hospital-weeks. Inpatient occupancy decreased by 12.7% (95% CI, 12.1% to 13.4%) during weeks with low COVID-19 admission rates and increased by 7.9% (95% CI, 6.8% to 9.0%) during weeks with high COVID-19 admission rates. Intensive care unit occupancy rates increased by 67.8% (95% CI, 60.5% to 75.3%) during weeks with high COVID-19 admissions. Increases in ICU occupancy were greatest when weighted to reflect the experience of Hispanic patients. Changes in occupancy were most pronounced early in the pandemic. During weeks with high COVID-19 admissions, occupancy decreased for many service lines, with occupancy by surgical patients declining by 43.1% (95% CI, 38.6% to 47.2%) early in the pandemic. In this cross-sectional study of US hospital discharges in 45 states in 2020, hospital occupancy decreased during weeks with low COVID-19 admissions and increased during weeks with high COVID-19 admissions, with the largest changes occurring early in the pandemic. These findings suggest that surges in COVID-19 strained ICUs and were associated with large decreases in the number of surgical patients. These occupancy fluctuations may have affected quality of care and hospital finances.

Emergency Department Utilization for Heavy Menstrual Bleeding (2016-2020): An Opportunity to Improve Care

Introduction: Heavy Menstrual Bleeding (HMB) is one of the most common indications for ambulatory gynecological visits amongst reproductive aged women. It can have significant physical, social, emotional, and economic impact. Two thirds of women who report HMB develop anemia. While the outpatient setting may represent the optimal setting for management of this condition, it is known that many patients are treated in the emergency room or inpatient setting. We sought to evaluate Emergency Department (ED) utilization and the associated health care charges of patients who present to the ED with HMB. We hypothesized that marginalized groups are more likely to use the ED for HMB and are more likely to be admitted for this condition. Methods: The Nationwide Emergency Department Sample (NEDS) Database of the Health Cost and Utilization Project (HCUP, Rockville, MD) was queried for all visits with primary ICD-10 diagnosis codes of N92.0 (Excessive and Frequent Menstruation with Regular Cycle) or N92.4 (Excessive bleeding in the premenopausal period) among females 21-50 years of age. Variables assessed included age, hospital type, medical insurance, household income quartile, visit charges, disposition, and race. Race data were only available for 2019 and 2020. Z-test and Chi-square analyses were performed to compare counts and proportions across groups and years. All analyses were performed using SAS 9.4 (Cary, NC). Results: Between 2016 and 2020, 195,499 emergency room visits with a primary diagnosis of HMB were identified out of 164,441,890 total ED visits (0.12% of visits). The patient mean (SD) age was 33.7 (0.1) years. Total ED visits per year for HMB declined from 42,462 in 2016 to 33,718 in 2020. Self-pay represents a disproportionately high share of admissions. Approximately 6% of patients who presented to the ED with HMB were admitted which was stable from 2016-2020. Patients age 21-25 years represented the highest proportion of ED visits for HMB with 21.5% versus 12.2% among those ages 46-50 years. However, patients age 46-50 years accounted for 24.6% of admissions versus 6.3% of admissions for those aged 21-25 years. Patients 46-50 years had the highest admission rate (13.2%) versus 1.9% for ages 21-25 years. HMB related charges were over $150,000,000 per year, with a median charge per visit of over $3,000. For the two years for which race data were available, White women (WW) represented 41.2% of HMB visits versus 50.6% of all other diagnoses visits; Black women (BW) represented 28.6% of HMB ED visits versus 25.6% of all other diagnoses, and Hispanic women (HW) 22.1% of HMB ED visits versus 17.2% of all other diagnoses. Of the patients that were admitted for HMB, 31% were White versus 51% of all other diagnoses admissions, 33% were Black compared to 23% of all other diagnoses admissions, and 28% were Hispanic versus 18% of all other diagnoses admissions. Admission rates were higher for Black/Hispanic/Asian-Pacific Islanders (7.6%, 8.2%, 9.1%) vs. WW (4.9%). Percentage of ED visits for HMB for BW and HW were 29% and 22% respectively which compared to 25.6% and 17.2% of visits for all other diagnoses. Conclusion: ED visits with HMB as a primary diagnosis represent a small percent of visits overall and are decreasing. However, Black and Hispanic patients make up a disproportionate percentage of HMB patients. In addition, there is an inverse relationship with respect to age between ED visits and admissions. Younger adults ages 21-25 years make up the highest percentage of ED visits by age, but they are the least likely to be admitted with an admission rate of 1.9% suggesting an opportunity to better leverage an outpatient visit setting for this demographic. This analysis serves as a first step to understand ED utilization for HMB, and suggest potential disparities in ED utilization and/or admissions for HMB by age and race. Given the overall low admission rate, there may be an opportunity to improve outpatient services for HMB in younger women and in Black and Hispanic women.

Biologic Assessment of RBC Biology and Neutrophil Activation: Correlation with Sickle Cell Disease Activity

Sickle cell disease (SCD) has pleiomorphic effects on affected individuals, most typically including both hemolysis and vaso-occlusive events (VOE). However, previous reports have suggested that these two paradigmatic presentations of SCD represent two poles of a spectrum of disease activity, so that patients with the highest frequency of VOEs are at one end, and patients with high hemolytic rates and organ damage, such as nephropathy and pulmonary hypertension, are at the other end. We performed an observational study of erythroid (RBC) factors, neutrophil activation, and clinical parameters, including vaso-occlusion event (VOE) frequency, in order to determine which factors were related to each other and to either hemolytic rate or VOE frequency. 115 patients in steady state, at least 3 weeks after last VOE, with either HbSS, HbSß +/0 thalassemia, or HbS/HPFH, were enrolled from 10/20/2020 - 10/25/2022. Erythrocytes and plasma were isolated from whole blood and analyzed for RBC deformability, intracellular RBC [ATP], RBC phosphatidylserine exposure, and plasma matrix metallopeptidase 9 (MMP9), a product of neutrophil activation and degranulation. A subset of samples were examined for RBC reactive oxygen species (ROS) content and adhesivity to laminin with and without stimulation by epinephrine. Clinical data collected included complete blood count parameters, LDH, total bilirubin, reticulocyte (retic) counts, and health care utilization for VOE in the preceding year. Deformability was measured as maximal elongation index (EImax) at Pa=30 by laser optical rotational red cell analyzer (Lorrca). RBC ROS was quantitated using 2′,7′-dichlorofluorescein and expressed as nM/mg Hb. MMP9 was measured by commercial ELISA assay. We found (N=102 with complete data) that EImax was directly proportional to total [Hb] (P&amp;lt;0.0001), irrespective of gender. Higher EImax was also associated with lower parameters of hemolysis (P = &amp;lt;0.0001, 0.0002, 0.0004, and &amp;lt;0.0001 for total LDH, total bilirubin, absolute retic count, and % retics, respectively). Higher HbF levels were associated with greater deformability (P&amp;lt;0.0001), and RBC deformability was inversely associated with PS exposure (P&amp;lt;0.0001) and RBC ROS content (P=0.0484, N=23). Surprisingly, however, greater deformability was not associated with higher RBC ATP content or lower health care utilization for VOE, while there was only a trend toward an inverse association with plasma MMP9 (P=0.0771). Interestingly, we also found that RBC [ATP] was lower in the RBCs of patients with higher total Hb, while it was higher in individuals with higher retic counts, suggesting that more long-lived RBCs have diminished [ATP], despite the fact that both [ATP] and total Hb have been reported to rise substantially after treatment with pyruvate kinase activators etavopivat and mitapivat. Higher ATP was also not significantly associated with a decrease in RBC adhesivity. Of note, higher HbF levels were significantly associated with lower hospital admissions for VOE (P=0.0053), although not with frequency of out-patient health care utilization for VOE (ED and day hospital visits). HbF levels also showed a trend toward inverse association with plasma MMP9 (P=0.0613). These results may help explain why therapeutic agents that increase total Hb by shifting the oxygen dissociation curve, thereby reducing sickling and hemolysis, appear to have little or no effect on VOE rate. Similarly, senicapoc, which also reduces hemolysis, although by a different mechanism, failed to lessen VOE frequency. We conclude that RBC deformability, PS exposure, and RBC ROS are markers associated with the hemolytic subphenotype but not with the somewhat overlapping but divergent adhesiveness and frequent VOE subphenotype. Anti-adhesive agents (crizanlizumab, rivipansel, sevuparin) have thus far failed to yield marked improvements in VOE frequency, but our results suggest that, in order to decrease the frequency of VOEs, it is not sufficient to reduce sickling and hemolysis. On the other hand, higher HbF levels were associated with lower admission rates for VOE and a trend toward lower levels of neutrophil activation. This suggests that higher HbF, beyond its ability to reduce sickling, also alters other biological characteristics of SS RBCs and is accompanied by reduction in the inflammatory nature of SCD, thereby contributing to a decrease in VOE frequency.

Investigating the association between characteristics of local crisis care systems and service use in an English national survey.

In England, a range of mental health crisis care models and approaches to organising crisis care systems have been implemented, but characteristics associated with their effectiveness are poorly understood. To (a) develop a typology of catchment area mental health crisis care systems and (b) investigate how crisis care service models and system characteristics relate to psychiatric hospital admissions and detentions. Crisis systems data were obtained from a 2019 English national survey. Latent class analyses were conducted to identify discernible typologies, and mixed-effects negative binomial regression models were fitted to explore associations between crisis care models and admissions and detention rates, obtained from nationally reported data. No clear typology of catchment area crisis care systems emerged. Regression models suggested that provision of a crisis telephone service within the local crisis system was associated with a 11.6% lower admissions rate and 15.3% lower detention rate. Provision of a crisis cafe was associated with a 7.8% lower admission rates. The provision of a crisis assessment team separate from the crisis resolution and home treatment service was associated with a 12.8% higher admission rate. The configuration of crisis care systems varies considerably in England, but we could not derive a typology that convincingly categorised crisis care systems. Our results suggest that a crisis phone line and a crisis cafe may be associated with lower admission rates. However, our findings suggest crisis assessment teams, separate from home treatment teams, may not be associated with reductions in admission and detentions.