Median Number Of Hospital Days Research Articles

Consequence of Dysphagia in the Hospitalized Patient

To determine if comorbid dysphagia in all hospitalized patients has the potential to prolong hospital stay and increase morbidity. Dysphagia is increasingly prevalent with age and comorbid medical conditions. Our research group has previously shown that dysphagia is a bad prognostic indicator in patients with stroke. Analysis of national database. The National Hospital Discharge Survey (NHDS), 2005-2006, was evaluated for presence of dysphagia and the most common comorbid medical conditions. Patient demographics, associated disease, length of hospital stay, morbidity and mortality were also evaluated. There were over 77 million estimated hospital admissions in the period evaluated, of which 271,983 were associated with dysphagia. Dysphagia was most commonly associated with fluid or electrolyte disorder, esophageal disease, stroke, aspiration pneumonia, urinary tract infection, and congestive heart failure. The median number of hospitalization days for all patients with dysphagia was 4.04 compared with 2.40 days for those patients without dysphagia. Mortality increased substantially in patients with dysphagia associated with rehabilitation, intervertebral disk disorders, and heart diseases. Dysphagia has a significant impact on hospital length of stay and is a bad prognostic indicator. Early recognition of dysphagia and intervention in the hospitalized patient is advised to reduce morbidity and length of hospital stay.

Phase I Study of Temozolomide and Cisplatin in Patients with Acute Leukemia.

We previously demonstrated that temozolomide has significant activity in patients with acute leukemia (Seiter K, et al JCO 2002). Cisplatin can increase the activity of temozolomide through depletion of MGMT, the enzyme that rescues cells from temozolomide toxicity. We performed a phase I study of temozolomide in 17 patients with relapsed or refractory acute leukemia. Median age: 53 (range 26–73); M/F: 9/8; Dx: AML: 12, ALL: 3, biphenotypic: 2; median # of prior regimens: 2 (range 1–7); duration of 1st remission: primary refractory: 8 patients, 1–6 months: 3 patients, 7–12 months: 4 patients, greater than 1 yr: 2 patients; cytogenetics: good: 2, intermediate: 11, poor: 4; prior AHD: 6 patients; Cisplatin (50–100 mg/m2) was given on day 1; temozolomide (200 mg/m2/d for 5–7 days) was administered daily beginning 4 hours after cisplatin. Cisplatin was administered in the inpatient setting. Twenty-one cycles were administered. To date, no dose limiting toxicity has been observed. The median number of hospital days was 10 (range 2–37). Neutropenic fever occurred in 11/21 cycles. Other grade 3 non-hematologic toxicity included orthostatic hypotension, syncope, and constipation in one patient each, and elevated bilirubin in 2 patients. Four patients had grade 2 elevations of creatinine that resolved with hydration. Other grade 1/2 non-hematologic toxicity included fatigue, nausea/vomiting, constipation, bradycardia, diarrhea, hypokalemia and hypomagnesemia. The median number of RBC transfusions was 3U (range 0–8); the median number of platelet transfusions was 3 (range 0–12). No complete remissions were seen. However significant antileukemic activity was seen: the median pretreatment WBC was 3.2 (range 0.3–78.3); the median nadir WBC was 0.4 (range 0.1–9.6). Four patients had a significant reduction in bone marrow blasts: 40 to 22%, 87 to 38%, 69 to 3%, and 87 to 5%, respectively. The three latter patients were treated at the highest dose level. Cisplatin and temozolomide was well tolerated. We are continuing to accrue patients at the highest dose level to further assess efficacy.

Clinical Outcome of IgM Amyloidosis (AL) Following Stem Cell Transplantation.

Introduction: The association of amyloidosis with immunoglobulin light chain disorders is well recognized. It is less commonly appreciated that amyloidosis can be associated with IgM monoclonal gammopathies. One of the available therapies for treating amyloidosis is stem cell transplantation. It is unknown whether the clinical outcomes in patients with IgM amyloidosis differs from those patients with light chain amyloidosis.Patients: Among 242 amyloidosis patients receiving stem cell transplants 10 (4%) had an IgM monoclonal protein. Eight were Mλ. One was biclonal Mλ Mκ and one was biclonal Mκ Gλ. The age range was 56 to 71, median 64 years. Seven were men. The monoclonal protein ranged in size from 0.1 to 2.3 g/dL (median 1.2 g/dL). Patients were transplanted from 2 to 8 months (median 4 months) following histologic diagnosis of amyloid. The median time from the recognition of the IgM monoclonal protein to the diagnosis of amyloid was 1.3 months, but 2 patients, both of whom had overt Waldenström's macroglobulinemia, were diagnosed 45 and 115 months respectively before amyloidosis developed. Of the cohort of 10, 3 fulfilled the criteria for symptomatic Waldenström's macroglobulinemia.Results: Amyloid syndromes were recognized in the kidney, heart, peripheral nerve and liver in 8, 3, 3 and 1 patient, respectively. Of the 3 peripheral neuropathy patients one also had autonomic failure. Seven of the 8 renal amyloid patients were confirmed with a renal biopsy. Their urinary protein loss ranged from 0.1 to 9.5 g/24h with a median of 4.7 g/24h. Six of the 10 patients had single organ involvement, 3 had 2 organ involvement and 1 had 3 organ involvement. All 3 Waldenström's patients had prior exposure to cytotoxic chemotherapy. Amyloid deposits were seen in the bone marrow, fat and lymph node in 6, 5 and 1 patient, respectively. Patients underwent from 1 to 7 (median 3) apheresis with a median CD34 yield of 4.5 x 106/kg. Conditioning was Melphalan at 140 and 200 mg/m2 in 2 and 8 patients respectively. Neutrophil engraftment 500/μL occurred between day 11 and 30 (median 14) and for platelets 20,000/μL between day 11 and 406 (median day 16). The median number of hospitalization days ranged from 0 to 32 (median 12). Nine of the 10 patients fulfilled criteria for a hematologic response and to date 3 of these 9 have also achieved an organ response, including normalization of urinary protein loss in 2 nephrotic patients and a greater than 50% reduction in urinary protein loss in the third. None of the patients with amyloid neuropathy responded. One of the patients with cardiac amyloid showed echocardiographic evidence of improvement. At this time 8 survive and 2 died; 1 a treatment-related death (day +40) and 1 of relapse post transplant with progressive amyloid at 45 months. The median follow-up of surviving patients is 29 months.Conclusion: The outcomes in patients with IgM amyloidosis following transplantation do not appear to be different from those with immunoglobulin light chain amyloidosis. There is no suggestion that the response rates are lower or that alternate conditioning schemes such as BEAM should be considered.

Post-Transplantation Cyclophosphamide (Cy) Reduces Graft Rejection and Graft-Versus-Host Disease (GVHD) after Non-Myeloablative, Partially HLA-Mismatched (Haploidentical) Bone Marrow Transplantation (BMT).

In animal models of haploidentical BMT, a properly timed high dose of Cy post-BMT selectively eliminates host-versus-graft and graft-versus-host reactive T cells, thereby preventing graft rejection and reducing GVHD. To test the activity of post-BMT Cy in humans, 56 patients (median age 48 years) with advanced hematologic malignancies received Cy 50 mg/kg IV, either once (on day 3; n=20) or twice (on days 3 and 4; n=36) after non-myeloablative conditioning and haploidentical BMT (“mini-haploBMT”). Diagnoses included AML (n=18), MDS (n=8), ALL (n=3), CML (n=4), CMMoL (n=3), CLL (n=3), multiple myeloma (MM; n=3), Hodgkin's disease (HD; n=5), non-Hodgkin's lymphoma (NHL; n=8), and paroxysmal nocturnal hemoglobinuria (PNH; n=1). Most patients had advanced disease or failed a previous autologous transplant. All were conditioned as outpatients with fludarabine (30 mg/m2 IV q d, days −6 to −2), Cy (14.5 mg/kg IV on days −6, −5), and total body irradiation (200 cGy on day −1), transplanted with non-T cell-depleted marrow, and treated with G-CSF, FK-506 and mycophenolate mofetil beginning the day after the last dose of Cy. Median number of hospitalizations in the first 60 days after BMT was 1 (range, 0–3), and the median number of hospital days was 4 (range, 1–53). Neutrophil engraftment (>500/mm3) after one or two days of post-BMT Cy occurred at a median of 15 versus 17 days after BMT, respectively (p=.36), and platelet counts >20,000/mm3 without transfusion were achieved at a median of 31 and 31 days, respectively (p=.78). Graft rejection, which in all cases was followed by recovery of autologous hematopoiesis, occurred in 5/18 (28%) versus 4/35 (11%) evaluable patients receiving one versus two doses of post-transplant Cy, respectively (p=.24). Full donor hematopoietic chimerism in the peripheral blood on day 60 was seen in 10/13 versus 25/31 engrafting patients who received one versus two doses of post-BMT Cy; with two exceptions, mixed chimerism was an immediate harbinger of relapse. Compared to patients receiving a single dose of post-BMT Cy, those receiving two doses had significantly less Grade II–IV (43% vs. 78%; p=.01) and Grade III–IV acute GVHD (20% vs. 53%; p=.006) by day 200 after BMT. Death from GVHD occurred in 5/13 evaluable patients receiving one dose versus 2/28 evaluable patients receiving 2 doses of post-BMT Cy. This latter group also had a non-significantly lower incidence of non-relapse mortality at 100 days (4% vs. 15%, p=.13) and at 1 year (23% vs. 35%; p=.37). At a median follow-up of 172 days (range, 32–1440 days), 21 patients remain alive without disease progression, including all 3 patients with chronic phase CML and the patient with PNH. In summary, mini-haploBMT with 2 doses of post-transplantation Cy resulted in full donor chimerism without severe GVHD in 23/36 patients (64%). Its toxicity profile compares favorably to matched sibling BMT. Moreover, in a very high-risk patient group, the early event-free survival is encouraging.

Continuous intraperitoneal insulin infusion in patients with 'brittle' diabetes: favourable effects on glycaemic control and hospital stay.

To evaluate the effects of continuous intraperitoneal insulin infusion (CIPII) using implantable pumps on glycaemic control and duration of hospital stay in poorly controlled 'brittle' Dutch diabetes patients, and to assess their current quality of life. Thirty-three patients were included. Glycaemic control was retrospectively assessed with HbA(1c) levels acquired before implantation, 1 year later and at long-term follow up of 58 months. Duration of hospital stay the year before and the year following first implantation was extracted from hospital records. Determinants of long-term glycaemic response were sought. Self-report questionnaires were administered at 58 months follow-up only, to assess current psychopathology and quality of life. Mean HbA(1c) decreased from 10.0 +/- 2.3% to 9.0 +/- 1.8% (P = 0.039) 1 year after implantation and stabilized at 9.0 +/- 1.6% (P = 0.023) during long-term follow-up. Median number of hospital days in the 20 patients suffering from hospital admission before implantation decreased from 45 the year before implantation to 13 the year after (P = 0.005). Patients with a higher baseline HbA(1c) showed a larger long-term response (P < 0.001). Relatively low levels for quality of life were found, as well as a higher than expected number of patients with psychiatric symptoms. CIPII proved effective in complex patients with a history of poor control and hospital admission. Despite a substantial long-term improvement in glycaemic control and diminished hospital stay, normal levels of glycaemic control and quality of life were not attained.

Treatment of infants with reactive syphilis serology, New Jersey: 1992 to 1996.

Diagnosis of congenital syphilis is problematic: infants with congenital syphilis are often asymptomatic, and signs in symptomatic infants are frequently subtle and nonspecific. Furthermore, there are no readily available diagnostic tests that provide a definitive diagnosis. Previously, the diagnosis of congenital syphilis was based on a complex set of clinical and laboratory criteria, and only infants with clinically apparent illness or laboratory findings indicating congenital syphilis were classified as cases and reported to health departments and the Centers for Disease Control and Prevention (CDC). To systematize diagnosis and case-reporting, the CDC developed a standardized surveillance case definition in 1988. This case definition includes symptomatic infants as well as asymptomatic infants of mothers with untreated or inadequately treated syphilis during pregnancy. It is intended to be highly sensitive to better estimate the burden of disease in the community. Treatment guidelines for congenital syphilis are intentionally conservative and err on the side of overtreatment so that all potentially infected infants are treated. The congenital syphilis surveillance case definition is compatible with the American Academy of Pediatrics (AAP) and CDC treatment guidelines; thus, the number of infants identified and reported to state health departments and the CDC should reflect the number of infants treated. Hundreds of infants with reactive serologic tests for syphilis (STS) are reported each year to the New Jersey Department of Health and Senior Services (NJDHSS). The majority of these infants do not meet the case definition for congenital syphilis, and most are treated although treatment guidelines indicate that treatment is not necessary. To determine whether infants with reactive STS in New Jersey are being treated according to the AAP treatment guidelines. Medical records of newborns with reactive STS reported to NJDHSS between July 1, 1992, and June 30, 1996, were reviewed to determine status of infection and compliance with the AAP treatment guidelines. The 1995 NJDHSS Uniform Billing and Hospital Discharge Data was used to estimate the mean cost of hospitalization per day for infants with the diagnosis of congenital syphilis. Results. During the study period, 1669 newborns with reactive STS were reported to the NJDHSS Sexually Transmitted Disease Program. Medical record review was completed for 1480 infants (88%). Infants were classified by CDC surveillance criteria as follows: 0 confirmed cases; 515 (35%) presumptive cases; 16 (1%) syphilitic stillbirths; and 949 (64%) cases that did not meet the definition for congenital syphilis. Of the 512 presumptive cases that survived the immediate perinatal period, 478 (93%) were treated with antibiotics and 459 (90%) were treated according to the AAP treatment guidelines. Only 27 infants (6%) were treated with a single intramuscular dose of benzathine penicillin. Thirty-four infants (7%) were not treated; instead, their physicians chose to follow them clinically and serologically. All of those treated were asymptomatic, and most were born to mothers with a history of adequate treatment before or during pregnancy, but who were without serologic follow-up. Of the 949 infants that did not meet the case definition, 329 infants (35%) were not treated and 620 (65%) were treated with antibiotics. The 508 (82%) infants treated with antibiotics were treated with intravenous or intramuscular antibiotics for 10 days; only 62 (10%) were treated with a singular intramuscular dose of benzathine penicillin. According to NJDHSS Uniform Billing Hospital Discharge Data, 267 infants weighing >/= 2500 g were discharged with a diagnosis of congenital syphilis in 1995. The median number of hospital days for these infants was 10, and the mean cost of hospitalization per day was $1010. Sources of payment of hospital charges for most infants were public in

Bicycle-related Injuries Among Preschool Children

Study objective: To describe the circumstances, severity, and outcome of bicycle-related injuries among hospitalized children younger than 5 years and to compare injuries in young children (<5 years) and older children (5 to 14 years). Methods: We studied a case series of children (0 to 14 years) with bicycle-related injuries requiring hospital admission reported to the National Pediatric Trauma Registry (NPTR) between January 1986 and June 1996. Results: Bicycle-related injuries were reported for 4,041 patients; 219 (5%) involved children younger than 5 years. Two young children and 124 older children (3%) wore bicycle helmets. Young children were less likely than older ones to be injured in the street (46% versus 81%, P<.001) and were more likely to be injured at home in the driveway or yard (39% versus 9%, P<.001). Interaction with a motor vehicle contributed to injuries in 31% of young children and 47% of older children (P<.001). Forty-five percent of young children and 56% of older children sustained head injuries (P<.002). The fractions of children in each age group with facial trauma, abdominal or thoracic injury, and fractures were similar. Pediatric Trauma Scores, Glasgow Coma Scale scores, operating room use rates, and median number of hospital days were similar for both age groups. Rehabilitation or extended care was required by 1% of young children and 2% of older children. Two deaths occurred among young children (1%); 2% of older children died. Conclusion: Of patients with bicycle-related injuries reported to the NPTR, a minority are young children, but they have injuries similar in severity and outcome to those of older children. Because young children sustain severe injuries, including head trauma, helmets are indicated for them, as well as for older children. [Powell EC, Tanz RR, DiScala C: Bicycle-related injuries among preschool children. Ann Emerg Med September 1997;30:260-265.]

Risk factors for hospital utilization in chronic dialysis patients. Southeastern Kidney Council (Network 6).

It is not known if the risk factors for hospital utilization are similar to the risk factors for mortality in chronic dialysis patients. The risk factors associated with hospital days per year of patient risk were identified in a subset of patients in Network 6 (the states of North Carolina, South Carolina, and Georgia) who began dialysis in 1989. The demographic characteristics of this cohort of 1572 patients included a mean (+/- SD) age of 57.4 +/- 15.0 yr; 63.7% of the patients were African American, 52.4% were female, and 33.0% had diabetes mellitus as the primary cause of ESRD. The median number of hospital days per year of patient risk was 8.8, with 25th and 75th quartiles of 3.9 and 20.1, respectively. By using multiple regression analysis, the strongest predictors of the number of hospital days per year of patient risk included low serum albumin level (P = 0.0001), decreased activity level (P = 0.0006), diabetes mellitus as the primary cause of ESRD (P = 0.002), peripheral vascular disease (P = 0.004), white race (P = 0.01), increasing age (P = 0.03), the absence of hypertension (P = 0.03), and the presence of angina (P = 0.03), smoking (P = 0.03), and congestive heart failure (P = 0.045). These risk factors are similar to those reported for an increased risk of mortality in dialysis patients and some of them, such as smoking, are modifiable and may be amenable to interventional strategies.