Lower Hospital Admission Rates Research Articles

#1647 Clinical insights into incremental hemodialysis: a retrospective analysis of patient persistence and outcomes

Abstract Background and Aims Incremental haemodialysis has been proposed as an alternative to standard thrice-weekly haemodialysis for incident patients with significant residual kidney function. Definition is not unique, but it is mostly intended as twice weekly dialysis. Its diffusion is not known since there are no public registers in Europe, but it is adopted in some dialysis facilities, while in others is not, with geographical differences. In our centre incremental haemodialysis in adopted for some patients, based on the clinical judgement, without a strict protocol. We retrospectively analysed clinical outcomes of the incident patients of the last 36 months, to understand which patients may benefit more from this approach, how long it is viable and the clinical outcomes. Method Retrospective observational analysis of incident patients of the last 36 months, without serious rapidly evolving disease. Focus was on persistence in twice-weekly dialysis, nutritional parameters, residual kidney function, hospital admissions and economic considerations. 36 patients started haemodialysis with a 2-times per week schedule while 13 with full dose dialysis. At baseline, there were no significant differences on age, sex, serum albumin or vascular access. 5 patients in full dose group were anuric for bilateral nephrectomy or rapidly progressive kidney disease, while all patients in incremental group had significant residual kidney function (average creatinine clearance: 7.1 ml/min). Results During the follow up period, 19/36 patients’ weekly dialysis sessions were incremented to three after a median time of 280 days, and 17/36 were still on 2-dialysis with a median follow-up time of 228 days. The reason for transition to three dialysis per week was residual kidney function loss except for a case of pericarditis. Persistence in incremental dialysis was >80% at 6 months and 44% at 1 year (Fig. 1a). We observed a significantly reduced persistence in patients with low ultrafiltration at 2nd month of dialysis (<1.7% of weight per session – 1 kg for a 60 kg patient-) and a reduced persistence with pre-dialysis systolic blood pressure <150 mmHg at 2nd month (Fig. 1b-c). Persistence was not different in more frail patients (elderly, dialyzed with a central venous line or with lower baseline albumin). Serum albumin increase was higher in patients in incremental haemodialysis at 6 months, with a borderline statistically significant difference, and similar at 1 year (Fig. 2a-b). The average weight was stable in both groups (Fig. 2). Hospital admissions were lower in the incremental group, and number of days of hospitalization per 1000 patients’ days were lower (24 vs 41 days). Thanks to the incremental approach, about 1600 dialysis sessions were avoided for the patients included in the analysis, with significant reduction of economic impact for the public healthcare and the possibility to treat more patients. Data was insufficient to make conclusions on kidney function preservation. Conclusion Incremental approach is valid in our experience. These data give useful information on how long we can expect patients to persist in 2-weekly dialysis and on which patients might benefit more and longer of this approach. The patients with better volume control, which reflect in adequate blood pressure control and low ultrafiltration rate, show a significantly longer persistence in incremental dialysis. The approach is valid also for frail patients. We also found better albumin and lower hospital admission rates that could be related with a reduced health-care exposition and better overall patients’ well-being, with adequate uremic symptoms control. The reduction on the hospital admissions has been already observed, while the albumin better rise is a new finding and should be confirmed in a randomized or at least larger study. Waiting for the results of the on-going randomized clinical trials, incremental haemodialysis might be the new standard-of-care for a subset incident haemodialysis patients.

The efficacy of lamotrigine in bipolar disorder: A systematic review and meta-analysis.

To provide up-to-date clinical guidance on the efficacy of lamotrigine in bipolar disorder (BD). Eligible studies were identified during a systematic literature search according to PRISMA-guidelines. We included randomized controlled trials (RCTs) and cohort studies that quantitatively assessed lamotrigine's efficacy in BD. We divided the included studies into three groups: 1. acute treatment of depression, 2. acute treatment of mania and hypomania, and 3. maintenance treatment. Analyses were stratified by control group (placebo vs active comparator) and treatment strategy (monotherapy vs add-on treatment). We included 20 RCTs (n = 1166 lamotrigine users) and 20 cohort studies (n = 11,141 lamotrigine users). Twenty-four of these studies were included in meta-analyses. During depressive episodes, greater decreases in depressive symptomatology were associated with initiation of lamotrigine as add-on treatment than with placebo (SMD -0.30 [95% CI = -0.51, -0.10], df = 3, p = 0.004). Decreases in depressive symptomatology did not differ significantly between lamotrigine and the active comparator (SMD -0.28 [95% CI = -1.06, 0.50], df = 3, p = 0.488). As a maintenance treatment, lamotrigine was associated with a significantly lower relapse/recurrence rate than placebo (risk ratio (RR) 0.84 [95% CI = 0.71, 0.99], df = 2, p = 0.037). Relapse/recurrence rates did not differ significantly between lamotrigine and lithium (RR 1.06 [95% CI = 0.89, 1.25], df = 2, p = 0.513). A qualitative assessment of high-quality register-based studies found that lamotrigine was associated with lower hospital admission rates than other commonly used treatment regimes. There is substantial evidence for the efficacy of lamotrigine in BD, specifically as add-on treatment during acute depressive episodes and as maintenance treatment for preventing relapse and recurrence.

Impact of the geriatric emergency medicine specialist intervention on final emergency department disposition.

The Geriatric Emergency Medicine Specialist (GEMS) pilot program is an innovative approach that utilizes geriatric-trained advanced practice providers to facilitate geriatric assessments and care planning for older adults in the emergency department (ED). The objective of this study was to explore the effect of GEMS on the use of observation status and final ED disposition. This was a retrospective study under a target trial emulation framework. Geriatric patients (65+ years old) who presented to two ED sites within a large regional healthcare system between December 2020 and December 2022 were included. The primary outcome was final ED disposition (discharge, hospital inpatient admission, or hospital observation admission). Secondary outcomes included ED observation and ED length of stay. Non-GEMS patients were propensity score matched 5:1 to GEMS patients. Doubly robust regression was used to estimate the odds ratios and 95% confidence intervals of inpatient admission, discharge, hospital observation admission, ED observation admission, and estimate the mean ED length of stay. A total of 427 of 43,064 total patients (1.0%) received a GEMS intervention during the study period. Our analysis included 2,302 geriatric ED patients (410 GEMS, 1,892 non-GEMS) after propensity score matching. Hospital admission rates were 34.1% for GEMS compared to 56.4% for conventional treatment. GEMS patients had decreased odds of inpatient admission (OR: 0.41, 95 CI: 0.34-0.51, p < 0.001), increased odds of discharge (OR: 1.19 95 CI: 1.00-1.42, p = 0.047), hospital observation admission (OR: 2.97, 95 CI: 2.35-3.75, p < 0.001), ED observation admission (OR: 4.84 95 CI: 3.67-6.38, p < 0.001), and had a longer average ED length of stay (170 min, 95 CI: 84.6-256, p < 0.001) compared to non-GEMS patients. Patients seen by GEMS during their ED visit were associated with higher rates of hospital discharge and lower rates of hospital admissions.

Enhancing patient outcomes: Integrating electronic cardiology consultation in primary care for cancer patients.

The prevalence of cancer patients with concomitant cardiovascular (CV) disease is on the rise due to improved cancer prognoses. The aim of this study is to evaluate the long-term outcomes of cancer patients referred to a cardiology department (CD) via primary care using e-consultation. We analysed data from cancer patients with prior referrals to a CD between 2010 and 2021 (n = 6889) and compared two care models: traditional in-person consultations and e-consultations. In e-consultation model, cardiologists reviewed electronic health records (e-consultation) to determine whether the demand could be addressed remotely or necessitated an in-person consultation. We used an interrupted time series regression model to assess outcomes during the two periods: (1) time to cardiology consultation, (2) rates of all-cause and CV related hospital admissions and (3) rates of all-cause and CV-related mortality within the first year after the initial consultation or e-consultation at the CD. Introduction of e-consultation for cancer patients referred to cardiology care led to a 51.8% reduction (95%CI: 51.7%-51.9%) in waiting times. Furthermore, we observed decreased 1-year incidence rates, with incidence rate ratios (iRRs) [IC95%] of .75 [.73-.77] for CV-related hospitalizations, .43 [.42-.44] for all-cause hospitalizations, and .87 [.86-.88] for all-cause mortality. Compared to traditional in-person consultations, an outpatient care program incorporating e-consultation for cancer patients significantly reduced waiting times for cardiology care and demonstrated safety, associated with lower rates of hospital admissions.

Impact of Geriatric Consult Evaluations on Hospital Admission Rates for Older Adults.

We examined the impact of a geriatric consult program in the emergency department (ED) and an ED observation geriatric care unit (GCU) setting on hospital admission rates for older ED patients. We performed a retrospective case control study from June 1-August 31, 2019 (pre-program) to September 24, 2019-January 31, 2020 (post-program). Post-program geriatric consults were readily available in the ED and required in the GCU setting. Hospital admission rates (outcome) are reported for patients who received a geriatric consult evaluation (intervention). We analyzed probability of admission using a mixed-effects logistic regression model that included age, gender, recent ED visit, Charlson Comorbidity Index, referral to ED observation, and geriatric consult evaluation as predictor variables. A total of 9,663 geriatric ED encounters occurred, 4,042 pre-program and 5,621 post-program. Overall, ED admission rates for geriatric patients were similar pre- and post-program (44.8% vs 43.9%, P = 0.39). Of 243 geriatric consults, 149 (61.3%) occurred in the GCU. Overall admission rates post-program for patients receiving geriatric intervention were significantly lower compared to pre-program (23.4% vs 44.9%, P < 0.001). Post-program GCU hospital admission rates were significantly lower than pre-program ED observation unit admission rates (14/149, 9.4%, vs 111/477, 23.3%, P < 0.001). In the logistic regression model, admissions post-program were lower when a geriatric consult evaluation occurred (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.41-0.83). Hospital admissions for older ED observation patients were also significantly decreased when a geriatric consult was obtained (GCU vs pre-program ED observation unit; OR 0.27, 95% CI 0.14-0.50). Geriatric consult evaluations were associated with significantly lower rates of hospital admission and persisted when controlled for age, gender, comorbidities, and ED observation unit placement. This model may allow healthcare systems to decrease potentially avoidable hospital admission rates in older ED patients.

A universal electronic consultation programme at the cardiology department after general practitioner referrals improves healthcare outcomes in patients with health failure

Abstract Background Electronic consultation (e-Consult) is an emerging health care innovation developed to address excess wait times for specialist care by enabling primary care physicians (PCPs) to obtain a specialist consultant’s expert opinion in a timely manner 1. A recent wait time report in England showed that in the first 7 months of 2017, 89.4% of patients waited up to 18 weeks to see a specialist. This result failed to meet their standard of 92% of patients waiting no more than 18 weeks for their consult 2. e-Consult services were shown to be effective in terms of providing faster access to specialist’s advice, with short response times (from 1 to 6 days) of the participating specialists and resulting in substantial avoidance of face-to-face referral visits 3. The recent ESC HF guideline made a "may be considered" recommendation for the use of home-based telemonitoring, according on a meta-analysis published in 2017 4,5. Nevertheless, never has been evaluated the impact on access to care and clinical outcomes of a clinician-to-clinician e-consult program as a first step for all the PCPs referrals to cardiologist in heart failure patients. Purpose We aimed to assess in patients with heart failure (HF) the clinical impact of the implementation of an outpatient care model that includes an initial e-consultation (from 2013 to 2021) and to compare it with a one-time in-person consultation model (from 2010 to 2012) for all the primary care physicians’ referrals to a cardiology department. Methods We selected 6,859 HF patients who visited the cardiology service at least once between 2010 and 2021: 4,851 were attended in e-consultation and 2,008 in one-time in-person consultations. Using an interrupted time series regression model, we analysed the impact of incorporating e-consultation into the health care model (started in 2013), and evaluated the elapsed time to cardiology care, cardiovascular (CV) and HF hospital admissions, and HF, CV and all-cause mortality. Results The interrupted time series regression model showed that the introduction of e-consultation substantially decreased waiting times to cardiology care (8.6 [8.7] vs 55.4 [79.9] days, p&amp;lt;0.001). and a reduction in the need for visits to the emergency department 1-year after e-consultation compared with the previous period (HR [IC95%]: 0.07 [0.05-0.08]). After e-consultation implantation, hospital admissions were reduced (RRi [IC95%]: 0,867 [0,875-0,838] for HF, 0,838 [0,825-0,856] for CV and 0,639 [0,635-0,651] all-cause), figure 1; and lower mortality (RRi [IC95%]: 0,981 [0,977-0,983] due to HF, 0,977 [0,970-0,980] for CV and 0,985 [0,984-0,985] for all-cause), figure 2. These results were maintained during the COVID-19 pandemic. Conclusion In HF patients, an outpatient care program that includes an e-consultation significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year.Figure 1Figure 2

Impact of a clinician-to-clinician electronic consultation in heart failure patients with previous hospital admissions.

To evaluate the impact of an outpatient care management programme that includes a clinician-to-clinician e-consultation on delay time in care, hospital admissions, and mortality in a high-risk group of patients with heart failure (HF) and previous episodes of HF hospitalization (HFH). We selected 6444 HF patients who visited the cardiology service at least once between 2010 and 2021. Of these, 4851 were attended in e-consult, and 2230 had previous HFH. Using an interrupted time series regression model, we analysed the impact of incorporating e-consult into the healthcare model in the group of patients with HFH and evaluated the elapsed time to cardiology care, HF, cardiovascular (CV), and all-cause hospital admissions and mortality, calculating the incidence relative risk (iRR). In the group of patients with HFH, the introduction of e-consult substantially decreased waiting times to cardiology care (8.6 [8.7] vs. 55.4 [79.9] days, P < 0.001). In that group of patients, after e-consult implantation, hospital admissions for HF were reduced (iRR [95%CI]: 0.837 [0.840-0.833]), 0.900 [0.862-0.949] for CV and 0.699 [0.678-0.726] for all-cause hospitalizations. There was also lower mortality (iRR [95%CI]: 0.715 [0.657-0.798] due to HF, 0.737 [0.764-0.706] for CV and 0.687 [0.652-0.718] for all-cause). The improved outcomes after e-consultation implementation were significantly higher in the group of patients with previous HFH. In patients with HFH, an outpatient care programme that includes an e-consult significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year.

Adolescent track and field injuries presenting to US emergency departments

ABSTRACT Objectives Track and field (T&F) is a highly popular sport for adolescents. The diversity of running, jumping, and throwing events within the sport can result in unique injury patterns for adolescent track and field participants. The purpose of this study was to estimate injury risk in adolescent T&F and describe the types of injuries resulting in ED visits, classified by T&F events. Methods Emergency department (ED) data from the National Electronic Injury Surveillance System were obtained for a 20-year period from 2000 through 2019. Cases involving 14- to 18-year-olds participating in T&F were classified by sex, case severity, involved body region, and the T&F event patients were engaged in at the time of their injury. National estimates and Injury rates were calculated using national high school T&F participation data. Longitudinal trends in ED visits were measured using linear regression. Rate ratios (RRs) were used to compare the risk and severity of ED visits by sex. Results 8,060 track and field related ED encounters were observed, representing an estimated 272,227 encounters nationally over the 20-year study period. The rate of ED encounters increased significantly over the study period (p < 0.001). Adolescent females exhibited a higher rate of ED encounters (RR: 1.23, 95% CI: 1.22-1.24), but a lower rate of hospital admissions (RR: 0.68, 95% CI: 0.64-0.73) compared to males. The lower extremity was the most commonly injured body region for most T&F events, but this differed for sprinting, high jumping, shot put, and javelin events. Most T&F events resulted in unique injury patterns characteristic of their athletic demands. Conclusions There was an increasing trend of ED visits from adolescent T&F participants throughout the 20-year study period with different injury patterns observed by sex and T&F event discipline.

Reducing hospital admissions in patients with malignant pleural effusion: a quality improvement study

BackgroundMalignant pleural effusions (MPE) can cause severe dyspnoea leading to greater than 125 000 hospitalisations per year and cost greater than US$5 billion per year in the USA. Timely insertion...

Endoscopic failure for foreign body ingestion and food bolus impaction in the upper gastrointestinal tract: an updated analysis in a European tertiary care hospital.

Harmfulness of foreign body ingestion and food bolus impaction (FBIs) varies according to geographical area, population, habits, and diet. Therefore, studies may not draw generalizable conclusions. Furthermore, data regarding FBIs management in Europe are limited and outdated. This study aimed to analyze the endoscopic management and outcomes of FBIs in an Italian tertiary care hospital to identify risk factors for endoscopic failure. We retrospectively reviewed patients who underwent upper gastrointestinal endoscopy for FBIs between 2007 and 2017. Baseline, clinical, FBIs, and endoscopic characteristics and outcomes were collected and reported using descriptive statistics and logistic regression analyses. Of the 381 endoscopies for FBIs, 288 (75.5%) were emergent endoscopy and 135 (35,4%) included underlying upper gastrointestinal conditions. The study population included 44 pediatric patients (11.5%), 54 prisoners (15.8%), and 283 adults (74.2%). The most common type and location of FBIs were food boluses (52.9%) and upper esophagus (36.5%), respectively. While eight patients (2.1%) developed major adverse events requiring hospital admission, the remainder (97.9%) were discharged after observation. No mortality occurred. Endoscopic success was achieved in 263 of 286 (91.9%) verified FBIs endoscopies. Endoscopic failure (8.04%) was associated with age, bone, disk battery, intentional ingestion, razor blade, prisoners, and stomach in the univariate analysis. Multivariate logistic regression revealed that intentional ingestion was associated with endoscopic failure (odds ratio: 7.31; 95% confidence interval = 2.06-25.99; P = 0.002). Endoscopy for FBIs is safe and successful, with low hospital admission rate in children, prisoners, and adults. Intentional ingestion is a risk factor of endoscopic failure.

Impact of prior SARS-COV-2 infection and vaccination on COVID-19 hospital admission and mortality amongst nursing home residents.

Nursing home residents (NHRs) have experienced disproportionately high risk of severe outcomes due to COVID-19 infection. We investigated the impact of COVID-19 vaccinations and previous SARS-CoV-2 episodes in preventing hospitalization and mortality in NHRs. Retrospective study of a cohort of all NHRs in our area who were alive at the start of the vaccination campaign. The first three doses of SARS-CoV-2 vaccine and prior COVID-19 infections were registered. The main outcomes were hospital admission and mortality during each follow up. Random effects time-varying Cox models adjusted for age, sex, and comorbidities were fitted to estimate hazard ratios (HRs) according to vaccination status. COVID-19 hospitalization and death rates for unvaccinated NHRs were respectively 2.39 and 1.42 per 10,000 person-days, falling after administration of the second dose (0.37 and 0.34) and rising with the third dose (1.08 and 0.8). Rates were much lower amongst people who had previously had COVID-19. Adjusted HRs indicated a significant decrease in hospital admission amongst those with a two- and three-dose status; those who had had a previous COVID-19 infection had even lower hospital admission rates. Death rates decreased as NHRs received two and three doses, and the probability of death was much lower among those who had previously had the infection. The effectiveness of current vaccines against severe COVID-19 disease in NHRs remains high and SARS-CoV-2 episodes prior to vaccination entail a major reduction in hospitalization and mortality rates. The protection conferred by vaccines appears to decline in the following months. ClinicalTrials.gov Identifier: NCT04463706.

Gender differences on healthcare accessibility and outcomes of a electronic inter-clinician consultation program at the cardiology department in a Galician Health Area.

To assess the longer-term results (hospital admissions and mortality) in women versus men referred to a cardiology department from primary care using an e-consultation in our outpatient care program. We selected 61,306 patients (30,312 women and 30,994 men) who visited the cardiology service at least once between 2010 and 2021: 69,1% (19,997 women and 20,462 men) were attended in e-consultation (from 2013 to 2021) and 30,9% (8,920 women and 9,136 men) in in-person consultations (from 2010 to 2012) without gender differences in the proportion of patients attended in each period. Using an interrupted time series regression model, we analysed the impact of incorporating e-consultation into the health care model and evaluated the elapsed time to cardiology care, heart failure (HF), cardiovascular (CV), and all-cause hospital admissions and mortality during the one-year after cardiology consultation. The introduction of e-consultation substantially decreased waiting times to cardiology care; during the in-person consultation period, the mean delay for cardiology care was 57.9 (24.8) days in men and 55.8 (22.8) days in women. During the e-consultation period, the waiting time to cardiology care was markedly reduced to 9.41 (4.02) days in men and 9.46 (4.18) in women. After e-consultation implantation, there was a significant reduction in the 1-year rate of hospital admissions and mortality, both in women and men iRR [IC95%]: 0.95 [0.93-0.96] for HF, 0.90 [0.89-0.91] for CV, and 0.70 [0.69-0.71] for all-cause hospitalization; and 0.93 [0.92-0.95] for HF, 0.86 [0.86-0.87] for CV, and 0.88 [0.87-0.89] for all-cause mortality in women; and 0.91 [0.89-0.92] for HF, 0.90 [0.89-0.91] for CV and 0.72 [0.71-0.73] for all-cause hospitalization; and 0.96 [0.93-0.97] for HF, 0.87 [95%CI: 0.86-0.87] for CV, and 0.87 [0.86-0.87] for all-cause mortality, in men. Compared with the in-person consultation period, an outpatient care program that includes an e-consultation significantly reduced waiting time to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year, without significative gender differences.

The impact of trimester of COVID-19 infection on pregnancy outcomes after recovery.

Many physiological adaptations occur during pregnancy. It is not currently known how timing of COVID-19 infection impacts pregnancy. We hypothesize that maternal and neonatal outcomes are different if COVID-19 infection occurs in different trimesters of pregnancy. This retrospective cohort study was conducted from 3/2020 to 6/2022. Pregnant patients with a positive COVID-19 infection more than 10days before delivery (COVID-recovered) were identified and grouped by trimester of infection. Demographics and maternal, obstetric, and neonatal outcomes were analyzed. ANOVA, Wilcoxon rank-sum test, Pearson's chi-squared test, and Fisher's exact test were used to compare continuous and categorical data. A total of 298 COVID-recovered pregnant patients were identified. Of those, 48 (16 %) were infected in the 1st trimester, 123 (41 %) in the 2nd, and 127 (43 %) in the 3rd. There were no significant demographic differences between the study groups. Vaccination status was similar. Hospital admission rate and the need for oxygen therapy while infected were significantly higher in patients with 2nd or 3rd trimester infection (18 % & 20 % vs. 2 % and 13 % & 14 % vs. 0 %, respectively). Rates of preterm birth (PTB) and extreme PTB were higher in the 1st trimester infection group. Infants born to mothers infected in the 2nd trimester had more neonatal sepsis workups (22 % vs. 12 % & 7 %). Other outcomes were similar between groups. First trimester COVID-recovered patients were more likely to have a preterm birth despite having lower rates of hospital admission and oxygen supplementation while infected than patients who recovered from a 2nd or 3rd trimester infection.

Pregnancy Outcomes Before and After the Emergence of the SARS-CoV-2 B.1.1.529 (Omicron) Variant [ID: 1365953

INTRODUCTION: Starting December 15, 2021, the SARS-CoV-2 B.1.1.529 (Omicron) variant became the predominant strain in the United States. Preliminary data suggest that the Omicron variant causes less severe COVID-19 than earlier variants. We hypothesize that adverse maternal and neonatal outcomes are less likely if infection occurred during the Omicron epoch compared to pre-Omicron. METHODS: This IRB-approved retrospective cohort study was conducted at a major university health system in Maryland from March 2020 to May 2022. We identified patients who were SARS-CoV-2 positive before and after December 15, 2021. Demographics and maternal, obstetric, and neonatal outcomes were collected and compared. Wilcoxon rank-sum and Fisher’s exact tests were used to compare continuous and categorical data, respectively. Adjusted odds ratios (aORs) were calculated using vaccination status. RESULTS: A total of 742 SARS-CoV-2–positive pregnant patients were identified. Of those, 548 (74%) tested positive pre-Omicron and 194 (26%) tested positive during the Omicron wave. Tobacco and illicit drug use were higher among patients in the Omicron epoch. Patients were also older and more likely to have received at least one vaccine dose (3% versus 35%, P&lt;.001). Omicron epoch patients had less severe disease as evidenced by higher rates of asymptomatic infection (72% versus 44%) as well as lower rates of hospital admission due to COVID-19, supplemental oxygenation, and intensive care unit (ICU) admission. However, the odds of ICU admission were not significantly decreased in Omicron epoch patients after adjusting for vaccination (aOR 0.15, 95% CI 0.02–1.14). The odds of preeclampsia and preterm birth less than 34 weeks were lower in Omicron epoch patients after adjusting for vaccination (aOR, 0.61 and 0.38, respectively). Neonatal outcomes were not statistically different between the two groups. CONCLUSION: Pregnant patients infected with SARS-CoV-2 during the Omicron epoch have a less severe disease course than those infected pre-Omicron. Lower ICU admissions during the Omicron epoch may be due to higher vaccination rates.

The Effect of Trimester of COVID-19 Infection on Pregnancy Outcomes After Recovery [ID: 1365996

INTRODUCTION: Many physiological, immune, and respiratory adaptations occur during pregnancy. Data have emerged that COVID-19 infection affects placental function, raising concerns about obstetric morbidity. It is not currently known how timing of COVID-19 infection affects pregnancy. We hypothesize that maternal and neonatal outcomes are different if COVID-19 infection occurs in different trimesters of pregnancy. METHODS: This IRB-approved retrospective cohort study was conducted at a single center from March 2020 to June 2022. Pregnant patients with a positive COVID-19 infection more than 10 days before delivery (COVID-recovered) were identified and grouped by trimester of infection. Demographics and maternal infection, obstetric, and neonatal outcomes were collected. Wilcoxon rank-sum and Fisher’s exact tests were used to compare continuous and categorical data, respectively. To account for multiple comparisons, a significant P value was set at .01. RESULTS: Two hundred ninety-eight COVID-recovered pregnant patients were identified. Of those, 48 (16%) were infected in the first trimester, 123 (41%) in the second trimester, and 127 (43%) in the third trimester. There were no significant demographic differences between the study groups. Vaccination status was similar. Hospital admission rate and the need for oxygen therapy while infected were significantly higher in patients with second- or third-trimester infection (18% and 20% versus 2% and 13% and 14% versus 0%, respectively). Rates of preterm birth (PTB) less than 37 weeks (33% versus 19% and 12%, P=.006) and extreme PTB (19% versus 5%, P&lt;.001) were higher in the first-trimester infection group. Infants born to mothers infected in the second trimester had more neonatal sepsis workups (22% versus 12% and 7%, P=.008). Other maternal, obstetric, and neonatal outcomes were similar between groups. CONCLUSION: First-trimester COVID-recovered patients were more likely to have preterm birth despite having lower rates of hospital admission and oxygen supplementation while infected than patients who recovered from a second- or third-trimester infection.

Coordination of Pharmaceutical Care in Dialysis Patients Is Associated With Lower Hospital Admission Rates

Coordination of Pharmaceutical Care in Dialysis Patients Is Associated With Lower Hospital Admission Rates

PB1998: WEEKLY OPPOSED TO BI-WEEKLY BORTEZOMIB AS PART OF INDUCTION CHEMOTHERAPY IN NEWLY DIAGNOSED MULTIPLE MYELOMA IS BETTER TOLERATED AND EQUALLY EFFICIENT: REAL-WORLD DATA FROM A RETROSPECTIVE AUDIT

Background: The VTD (Bortezomib, Thalidomide, Dexamethasone) triplet chemotherapy regime is frequently used as induction chemotherapy in newly diagnosed multiple myeloma prior to autologous stem cell transplant. The manufacturer’s protocol recommends a twice-weekly dosing schedule. Adverse effects are common, most notably neuropathy and cytopenias. These can be disabling and are often permanent, with significant impacts on quality of life. This limits drug tolerance with management confined to dose reduction or discontinuation. A once-weekly dosing schedule has been widely adopted, but to date, no clinical trials have been conducted to compare the efficacy and side effect profile of this dosing frequency in transplant-eligible myeloma. Aims: In order to investigate prescribing practice locally, we conducted a retrospective audit in Leicester Royal Infirmary, a tertiary Haematology centre in the UK. Primary outcomes were response to induction therapy, and the development of neuropathy (peripheral or autonomic) or serious adverse events occurring whilst on VTD. Secondary outcomes included cumulative Bortezomib dose, number of Bortezomib cycles and Thalidomide tolerance. Methods: Real-world data was collected consecutively from all patients treated in the intensive treatment arm with VTD as first-line chemotherapy between January 2015 and November 2020. Patient received Bortezomib 1.3mg/m2 subcutaneously on days 1,4,8 and 11 of a 21-day cycle (bi-weekly) or days 1,8,15 and 22 of a 35-day cycle (weekly). The trust protocol was altered in December 2020, increasing the bi-weekly regime to a 28-day cycle Results: We demonstrate a trend of lower incidence of neuropathy, both peripheral and autonomic, with the weekly regime (PN≥2: weekly 8.7% bi-weekly 19.6% AN: weekly 8.7% bi-weekly 26.5%). There was also a trend of fewer serious adverse events with lower rates of hospital admissions due to infection (weekly 33.3% bi-weekly 47.8%). Patients on the weekly regime received more VTD cycles and a higher cumulative dose (p=0.044). The initial therapeutic response between the two regimes were similar (weekly: ORR 87% ≥VGPR 78.3%, bi-weekly: ORR 86.3% ≥VGPR 60.8%). Preliminary data from patients treated with bi-weekly Bortezomib in a 28-day cycle shows lower rates of peripheral neuropathy compared to the 21-day cycle. Image:Summary/Conclusion: Here we demonstrate that weekly Bortezomib is better tolerated with equal efficacy in terms of initial therapeutic response. We believe that delivery of Bortezomib through a weekly regime facilitates patients being able to maintain on Bortezomib longer and receive higher cumulative doses. This may have important implications in those later deemed unsuitable or transplantation and for future treatment as intolerance or refractoriness limits the ability to obtain Bortezomib in further treatment lines. Preliminary data shows the cycle length may also be important in determining the risk of side of side effects and we intent to continue to monitor patients treated with this regime.

Symptom prevalence, duration, and risk of hospital admission in individuals infected with SARS-CoV-2 during periods of omicron and delta variant dominance: a prospective observational study from the ZOE COVID Study

SummaryBackgroundThe SARS-CoV-2 variant of concern, omicron, appears to be less severe than delta. We aim to quantify the differences in symptom prevalence, risk of hospital admission, and symptom duration among the vaccinated population.MethodsIn this prospective longitudinal observational study, we collected data from participants who were self-reporting test results and symptoms in the ZOE COVID app (previously known as the COVID Symptoms Study App). Eligible participants were aged 16–99 years, based in the UK, with a body-mass index between 15 and 55 kg/m2, had received at least two doses of any SARS-CoV-2 vaccine, were symptomatic, and logged a positive symptomatic PCR or lateral flow result for SARS-CoV-2 during the study period. The primary outcome was the likelihood of developing a given symptom (of the 32 monitored in the app) or hospital admission within 7 days before or after the positive test in participants infected during omicron prevalence compared with those infected during delta prevalence.FindingsBetween June 1, 2021, and Jan 17, 2022, we identified 63 002 participants who tested positive for SARS-CoV-2 and reported symptoms in the ZOE app. These patients were matched 1:1 for age, sex, and vaccination dose, across two periods (June 1 to Nov 27, 2021, delta prevalent at >70%; n=4990, and Dec 20, 2021, to Jan 17, 2022, omicron prevalent at >70%; n=4990). Loss of smell was less common in participants infected during omicron prevalence than during delta prevalence (16·7% vs 52·7%, odds ratio [OR] 0·17; 95% CI 0·16–0·19, p<0·001). Sore throat was more common during omicron prevalence than during delta prevalence (70·5% vs 60·8%, 1·55; 1·43–1·69, p<0·001). There was a lower rate of hospital admission during omicron prevalence than during delta prevalence (1·9% vs 2·6%, OR 0·75; 95% CI 0·57–0·98, p=0·03).InterpretationThe prevalence of symptoms that characterise an omicron infection differs from those of the delta SARS-CoV-2 variant, apparently with less involvement of the lower respiratory tract and reduced probability of hospital admission. Our data indicate a shorter period of illness and potentially of infectiousness which should impact work–health policies and public health advice.FundingWellcome Trust, ZOE, National Institute for Health Research, Chronic Disease Research Foundation, National Institutes of Health, and Medical Research Council

English language proficiency and hospital admissions via the emergency department by aged care residents in Australia: A mixed-methods investigation.

Residents of Residential Age Care Facilities (RACFs) have particularly high rates of Emergency Department (ED) visits, with up to 55% being potentially avoidable (e.g. not resulting in a hospital admission). This is concerning as ED visits by RACF residents are associated with negative outcomes including longer hospital stays, iatrogenic illness, complications and mortality. Limited English proficiency (LEP) has significant negative impacts on the healthcare quality and outcomes for older people but has not been studied as a factor in ED visits from RACFs. This study aimed to examine if RACF residents with LEP have a lower rate of hospital admission via the ED compared to non-LEP controls and identify any associated factors. We hypothesised that LEP-related communication difficulties would reduce the ability to manage minor health issues in the RACF, leading to a lower proportion of LEP ED transfers being admitted. We used a parallel mixed-methods design, comprising a quantitative matched cohort study of ED visit data from two Local Hospital Networks (LHNs) in South-East Melbourne, Australia and secondary thematic analysis of 25 interviews with LEP residents, family carers and staff from two RACFs in the same region. We found no differences in the proportion of hospital ED transfers that led to admission (LHN1, 87.1% LEP, 85.6% non-LEP controls, p=0.57; LHN2, 76.0% LEP, 76.9% non-LEP controls, p=0.41) and no direct qualitative evidence suggesting that resident LEP affected decisions to transfer residents to ED, despite communication difficulties being reported during the transfer process. These results may be due to the high level of family carer involvement in residents' care identified in the qualitative study. However, additional research using different measures of LEP is recommended to further explore a broader range of cultural and linguistic factors in both rates of ED presentations and the decision-making processes underpinning resident transfers to ED.

Proportion and characteristics of young people in a first-episode psychosis clinic who first attended an at-risk mental state service or other specialist youth mental health service

BackgroundServices for young people identified as having an ‘at-risk mental state’ (ARMS) aim to prevent transition to first-episode psychosis (FEP), in addition, early intervention services for other mental health disorders have also been developed. The aim of the current study was to determine the proportion of young people attending a specialist FEP service who had been referred via other early intervention clinics, including an ARMS clinic, and compare the characteristics to those who presented directly to the FEP service. MethodsWe included young people diagnosed with FEP who received treatment at Orygen between 01.01.2012 and 31.12.2016. We examined rates of direct entry to the First Episode Psychosis service and rates from other early intervention services, specifically ARMS, personality disorders, mood disorders and a primary care youth mental health service clinics. Results1138 young people were diagnosed with a FEP, of whom 13.7% first attended an ARMS clinic and a further 7.6% attended other youth mental health services. Individuals who first presented to an ARMS clinic were more likely to be female, younger, and less likely to be migrants or use substances. Rates of both voluntary and involuntary hospital admissions were significantly reduced for young people who transitioned from the ARMS clinic, the personality disorder clinic or the primary care service compared to those who presented directly with FEP. ConclusionsA significant proportion of young people with FEP initially attended another specialist youth mental health service, and importantly, they had much lower rates of hospital admission at the time of transition to FEP.