Mortality Costs Research Articles

DELirium treatment with Transcranial Electrical Stimulation (DELTES): study protocol for a multicentre, randomised, double-blind, sham-controlled trial.

Delirium, a clinical manifestation of acute encephalopathy, is associated with extended hospitalisation, long-term cognitive dysfunction, increased mortality and high healthcare costs. Despite intensive research, there is still no targeted treatment. Delirium is characterised by electroencephalography (EEG) slowing, increased relative delta power and decreased functional connectivity. Recent studies suggest that transcranial alternating current stimulation (tACS) can entrain EEG activity, strengthen connectivity and improve cognitive functioning. Hence, tACS offers a potential treatment for augmenting EEG activity and reducing the duration of delirium. This study aims to evaluate the feasibility and assess the efficacy of tACS in reducing relative delta power. A randomised, double-blind, sham-controlled trial will be conducted across three medical centres in the Netherlands. The study comprises two phases: a pilot phase (n=30) and a main study phase (n=129). Participants are patients aged 50 years and older who are diagnosed with delirium using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision criteria (DSM-5-TR), that persists despite treatment of underlying causes. During the pilot phase, participants will be randomised (1:1) to receive either standardised (10 Hz) tACS or sham tACS. In the main study phase, participants will be randomised to standardised tACS, sham tACS or personalised tACS, in which tACS settings are tailored to the participant. All participants will undergo daily 30 min of (sham) stimulation for up to 14 days or until delirium resolution or hospital discharge. Sixty-four-channel resting-state EEG will be recorded pre- and post the first tACS session, and following the final tACS session. Daily delirium assessments will be acquired using the Intensive Care Delirium Screening Checklist and Delirium Observation Screening Scale. The pilot phase will assess the percentage of completed tACS sessions and increased care requirements post-tACS. The primary outcome variable is change in relative delta EEG power. Secondary outcomes include (1) delirium duration and severity, (2) quantitative EEG measurements, (3) length of hospital stay, (4) cognitive functioning at 3 months post-tACS and (5) tACS treatment burden. Study recruitment started in April 2024 and is ongoing. The study has been approved by the Medical Ethics Committee of the Utrecht University Medical Center and the Institutional Review Boards of all participating centres. Trial results will be disseminated via peer-reviewed publications and conference presentations. NCT06285721.

Assessment of lipid profile and its correlation with ASCVD risk in the general population

Background: Atherosclerotic cardiovascular disease (ASCVD) is a major global health issue with high morbidity, mortality, and healthcare costs, emphasizing the need for effective risk assessment for prevention and management. This study aimed to assess the lipid profile of the general population and establish correlations with their ASCVD risk. Methods: This cross-sectional study was conducted among the general population in India. Participants were invited through advertisements to attend the ASCVD camp for a lipid profile check-up. Results: A total of 1068 participants were included, with a mean age of 52.7 years. The majority of participants were male (69.8%). Approximately 33% of participants had low ASCVD risk, followed by 31.6% with high risk, and 26.7% with intermediate risk. In the high ASCVD risk group, participants aged ≥60 years were significantly higher compared to those in the low risk, borderline risk and intermediate risk groups (P<0.001). The mean total cholesterol and low-density lipoprotein (LDL) were significantly increased in participants with high ASCVD risk compared to intermediate, borderline and low risk (P<0.001 and P=0.001). The mean HDL cholesterol level was significantly lower in male participants compared to female participants (P<0.001). There was a positive correlation between age (r=0.783), total cholesterol (r=0.372) and the ASCVD risk score (P<0.001 for both). There was negative correlation between HDL and ASCVD risk score (r=-124; P<0.001). Conclusion: This study demonstrates a significant association between lipid profiles and ASCVD risk. Age, total cholesterol, and LDL levels are positively correlated with ASCVD risk, while HDL levels show a negative correlation.

Effects of two non-drug interventions on pain and anxiety in the nursing process of burn patients: a literature review with meta-analysis

BackgroundBurns are a global health issue causing significant mortality and high medical costs. Non-pharmacological interventions such as music therapy and virtual reality (VR) therapy have shown potential in alleviating pain and anxiety in burn patients. This study systematically evaluates the impact of these interventions using a network meta-analysis.MethodsA systematic review and network meta-analysis were conducted according to PRISMA 2020 guidelines and registered in PROSPERO (CRD42024566536). Searches in PubMed, Cochrane Library, Web of Science, and Embase up to November 22, 2023, identified randomized controlled trials (RCTs) involving music therapy or VR therapy in burn patients. The Cochrane Risk of Bias Tool (2.0) assessed study quality. Data were analyzed using StataMP-64 software.ResultsSeventeen RCTs with 1,119 burn patients were included. Both music therapy and VR therapy significantly reduced pain and anxiety compared to control groups. Music therapy was more effective for pain reduction (SUCRA: 85.4%), while VR therapy was superior for anxiety relief (SUCRA: 79.5%).ConclusionMusic therapy and VR therapy effectively reduce pain and anxiety in burn patients. Integrating these interventions into burn care can enhance patient outcomes. Further research is needed to confirm these findings and optimize individualized treatment plans.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/, PROSPERO (CRD42024566536).

Burden and economic impact of PM2.5 exposure on Acute Myocardial Infarction in Portugal, 2011-2021

Abstract Background Air pollution, specifically particulate matter with a diameter of 2.5 micrometers (PM2.5), is the primary environmental health risk in Europe. Exposure to PM2.5 increases the risk of cardiovascular diseases, including AMI, resulting in high direct costs associated with in-patient treatment. This study aims to estimate the avoidable and attributable disease and economic burden of AMI due to ambient PM2.5 exposure in Portugal between 2011 and 2021. Methods National databases were used to assess the annual number of hospitalisations and deaths due to AMI between 2011 and 2021. The annual mean costs were calculated using a direct cost analysis (bottom-up micro-costing) to assess the direct economic burden of AMI. In turn, these cases and associated costs were multiplied by the respective morbidity and mortality population attributable fraction (PAF) to estimate the number of hospital admissions and deaths, and their associated costs attributable to ambient PM2.5 exposure. For 2019 and 2021, an alternative scenario of exposure was considered (2021 WHO Air Quality Guidelines), and the avoidable morbidity and mortality costs were determined using the potential impact fraction (PIF). Results Between 2011 and 2021, there were 130,447 hospitalisations and 47,968 deaths due to AMI, with 4.79% and 28.90%, respectively, attributable to ambient PM2.5 exposure. This translates to a direct economic burden of morbidity of more than 44 million euros and mortality of almost 195 million euros. If the proposed scenario guidelines were met, 279 cases and 448 deaths would have been avoided in 2019, resulting in a savings of almost 9.7 million euros. In 2021, 93 cases and 355 deaths would have been avoided, with approximately 4 million euros saved. Conclusions Exposure to ambient PM2.5 significantly contributes to AMI cases and deaths in Portugal, imposing a significant economic burden. These findings highlight the urgent need for measures to improve air quality. Key messages • PM2.5 pollution in Portugal drives AMI cases and fatalities, entailing significant economic costs. • Adhering to WHO air quality guidelines promises substantial reductions in AMI incidence and save millions annually in healthcare expenditure.

Implementing dynamic atrioventricular delay optimization for cardiac resynchronization therapy: an economic analysis in the EU5 countries

Abstract Background Heart failure (HF) poses an escalating public health challenge, contributing significantly to patient morbidity, mortality and healthcare expenditures [1,2]. Cardiac resynchronization therapy (CRT) is a well-established intervention that improves functional capacity and enhances quality of life while mitigating symptoms, hospitalizations, and mortality in HF patients [3]. Nevertheless, the reaction to CRT varies among individuals; some experience positive responses and others show resistance to the therapy, with unfavourable outcomes and increased healthcare costs [4]. The introduction of the dynamic atrioventricular (AV) optimization algorithm aims to enhance CRT response by enabling dynamic optimization of the AV delay [4]. Purpose Despite the strong clinical evidence supporting the effectiveness of dynamic AV optimization algorithm, a comprehensive assessment of its economic implications is still lacking. This study aims to evaluate the economic impact of activating dynamic AV optimization algorithm in patients undergoing CRT treatment across the Big 5 European countries (EU5; France, Germany, Spain, Italy, and the UK). Methods The study examines two scenarios over a 3-year timeframe: a) current scenario, where dynamic AV optimization algorithm activation is limited to a small segment of the population, and b) future scenario, where dynamic AV optimization algorithm activation is progressively expanded per year from 15% to 50%. Treatment efficacy data, measured in terms of HF hospitalization and mortality rates, were sourced from Varma et al. studies [1,4]. Hospitalization and mortality costs were extracted from national DRG tariffs and relevant literature [5–14]. It is important to note that there is no additional cost for algorithm activation if the device is already equipped with it. Results In this hypothetical analysis of 1,000 patients, around 30% undergo CRT implantation compatible with dynamic AV optimization algorithm activation. The treatment cost of patients with the algorithm ON is reduced by -15% compared to patients with the algorithm OFF, considering a weighted average across the EU5 countries (France: -11%, Germany: -16%, Italy: -14%, Spain -17%, UK: -16%), as shown in Table 1. The steady increase in algorithm activation led to an annual expenditure reduction equal to €21,109, calculated on the weighted average across the EU5 countries (France: €15,549, Germany: €33,753, Italy: €13,844, Spain: €20,385, UK: £13,423). When compared to the current scenario, the future scenario saved €36,468 on average across the EU5 countries. Further country-specific cost savings are shown in Table 2. Conclusion The conducted economic analysis gives confidence in dynamic AV optimization algorithm, positioning it as a valuable and economically sustainable asset for enhancing CRT treatment outcomes in patients with HF.

Clinical and financial implications of inpatient and outpatient management strategies for worsening heart failure

Abstract Introduction Hospitalizations for worsening heart failure (HF) represent an enormous public health and financial burden. Accordingly, select centers have developed outpatient worsening HF (WHF) management strategies focused on care in emergency departments (ED), observation units, or intravenous (IV) diuretic clinics. However, broad use of these outpatient strategies and the associated outcomes and healthcare costs remain unclear. Methods Among US Medicare beneficiaries age ≥65 years hospitalized for HF in the Get With The Guidelines Heart Failure registry 2010-2018, we identified patients with a post-discharge non-fatal WHF event. Patients were divided into 4 mutually exclusive groups defined by type of first post-discharge WHF event (HF hospitalization, ED visit with ED discharge, observation unit stay, and outpatient clinic visit with IV diuretics). Following each type of WHF event, mortality, home-time (days alive and out of any healthcare institution), and healthcare costs were compared over the subsequent 12-months. Costs of the initial WHF management strategy were also assessed. Results Among 181,827 patients hospitalized for HF, during the 12-months post-discharge, 83,971 (46.2%) survived with no WHF event, 36,697 (20.2%) died prior to a WHF event, and 61,159 (33.6%) had a WHF event. Of patients with a WHF event, 48,612 were managed with HF hospitalization (79.5%), 8,139 (13.3%) with an ED visit, 1,767 (2.9%) with an observation unit stay, and 2,641 (4.3%) with an outpatient IV diuretic visit. Compared with HF hospitalization, patients with WHF managed in the ED, observation unit, or IV diuretic clinic experienced lower subsequent mortality (Figure 1). Mean 12-month home-time was lowest following HF hospitalization (207 ± 144 days), intermediate following ED (238 ±136 days) and outpatient IV diuretic visits (252 ±128 days), and highest following observation unit stays (277 ± 125 days). For the initial WHF event, median (25th, 75th) total per-patient costs were highest for HF hospitalization and lowest for outpatient IV diuretic visits (Figure 2). Over the 12-months following the WHF event, median total per-patient costs were highest following outpatient IV diuretic visits, intermediate following HF hospitalization and ED stays, and lowest following observation unit stays. Conclusions In a nationwide analysis of older US adults, 1 in 5 episodes of recurrent WHF were exclusively managed as an outpatient within the ED, observation unit, or IV diuretic clinic. High rates of death and substantial reductions in home-time occurred following WHF regardless of inpatient or outpatient management, but were worse following HF hospitalization. Outpatient IV diuretic administration was the least expensive initial management strategy, but was associated with the highest per-patient costs over the subsequent 12 months.

Prevalence of potentially inappropriate medication use in the older population living in Germany

Abstract Background Potentially inappropriate medications (PIM) are medicines for which the risks for adverse events (AEs) usually outweigh the clinical benefits in older adults. PIM is associated with an increased risk of AEs, hospitalizations, mortality and higher health care costs. This analysis presents the prevalence of PIM use and associated factors in people aged 66+ years living in Germany. Methods Data from the nationally representative Study on Health of Older People in Germany (Gesundheit 65+) conducted between 2021-2023 by the Robert Koch Institute, was analyzed. All medicines used, prescribed and over-the-counter (OTC), in the 7 days before the interview were classified into anatomical therapeutic chemical codes. PIM use was identified based on the PRISCUS 2.0 list. Weighted prevalences and associated factors for PIM use are presented. Results 96% of the sample (N = 1,474) took at least 1 medication in the 7 days before the interview. The prevalence of PIM use was 29% (95% CI: 26%-32%), 23% took 1 PIM and 6% 2+. There were no sex differences but a significant increase with age: 23% in the age group 66-74, 33% in the age group 75-84, and 39% in the age group 85 + (29% 1 PIM and 10% 2+). People with a low educational level had a PIM prevalence of 32% compared to 21% in those with a high educational level. Among those reporting having chronic diseases, the PIM prevalence was 34% compared to 19% among those not reporting them. The prevalence of PIM increased with the number of medicines used: 13% in 1-4 medicines, 31% in 5-9 medicines, and 53% in 10+ medicines. The most frequently used PIM in this sample was ginkgo biloba leaf extract (plant-based antidementia drug) followed by diclofenac (non-steroidal anti-inflammatory drug), and then by tricyclic antidepressant drugs (opipramol and amitriptyline). Conclusions PIM use was higher than suggested by prescription data analysis. It was associated with higher age, chronic diseases, polypharmacy and a low educational level. Key messages • PIM use was common, affecting more people with chronic diseases, older age groups and people with a low educational level. • Strategies to promote and monitor appropriate medication use are needed.

Improving Admission Temperature in Infants ≥34 Weeks' Gestation: A Quality Improvement Initiative.

NICU admission for hypothermia is a problem worldwide, with associated morbidity, mortality, and financial costs. Many interventions have been studied for smaller infants, but there has been little focus on infants born ≥34 weeks' gestational age (GA), though most deliveries occur at this gestation. Our primary aim was to improve the proportion of infants ≥34 weeks' GA with normal NICU admission temperature. Secondary outcomes included improvement of the proportion of normal first temperature in all infants ≥34 weeks' GA, independent of NICU admission, and improvement of predefined outcome measures. We completed a root cause analysis, using fishbone and process mapping to determine what factors were contributing to hypothermia. A series of changes were trialed using plan-do-study-act cycles to develop a standard operating procedure, covering both vaginal and cesarean section births. Outcome measures were analyzed using a P-chart as well as traditional statistical tests. We successfully increased the proportion of infants ≥34 weeks' GA with normothermia on NICU admission from 62% to 80% without increasing hyperthermia. In addition, the interventions improved the proportion of delivery room normothermia in all infants born ≥34 weeks' GA and were associated with a decreased need for intravenous therapy for hypoglycemia and the incidence of metabolic acidosis. This quality improvement initiative was successful at improving our institution's rates of normal infant temperature. The methodology used can be applied to other similar centers to improve this common problem.

Biomarker identification and risk assessment of cardiovascular disease based on untargeted metabolomics and machine learning

Cardiovascular disease (CVD) is the leading cause of mortality, disability, and healthcare costs, with a significant impact on the elderly and contributing to premature deaths across various age groups, including those below age 70. Despite decades of transformative discoveries and clinical efforts, the challenges of diagnosis, prevention, and treatment of CVD persist on a massive scale. This study aimed to unravel potential CVD-associated biomarkers and establish a machine learning model for the risk assessment of CVD. Untargeted metabolic assay with ultra-high performance liquid chromatography-tandem mass spectrometry and routine clinical biochemistry test were undertaken on the fasting venous blood specimens from 57 subjects. Four relevant clinical traits and 164 CVD-associated metabolites were identified, especially those related to glycerophospholipid metabolism and biosynthesis of unsaturated fatty acids. The machine learning model achieved from an integrated biomarker panel of palmitic amide, oleic acid, 138-pos (the 138th detected metabolomic feature in positive ion mode), phosphatidylcholine, linoleic acid, age, direct bilirubin, and inorganic phosphate, was able to improve the accuracy of CVD risk assessment up to a high satisfactory value of 0.91. The findings indicate that disorders in the metabolic processes of biological membranes and energy are significantly associated with increased risk of vascular damage in CVD patients. With machine learning methods, the pivotal metabolites and clinical biomarkers offer a promising potential for the efficient risk assessment and diagnosis of CVD.

Average volume-assured pressure support versus fixed pressure support in chronic hypercapnic respiratory failure: a systematic review and meta-analysis

Rationale: Chronic hypercapnic respiratory failure occurs due to alveolar hypoventilation resulting in carbon dioxide retention. This is commonly managed with noninvasive ventilation (NIV) with modalities including fixed pressure support and average volume-assured pressure support (AVAPS). However, there is limited information comparing outcomes with these two modes of ventilator support in the management of chronic hypercapnic respiratory failure. Objective: This review and meta-analysis analyze the outcomes with fixed pressure NIV versus average volume-assured pressure support NIV in managing chronic obstructive pulmonary disease (COPD) with chronic hypercapnic respiratory failure, focusing on patients’ perception of symptom burden and gas exchange based on arterial blood gases. Search methods: PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science databases were searched; the latest search date was December 1, 2023. Inclusion criteria: randomized control trials and crossover studies in English in adults over the age of 19 with the diagnosis of COPD and chronic hypercapnic respiratory failure. Exclusion criteria: patients less than 19 years old, patients with acute exacerbations, and patients with central respiratory failure or neuromuscular disease. Outcomes included blood gas analysis after use of NIV measured in mmHg and patient perception of mental health, symptom burden, and comfort. Results for each outcome were analyzed in RevMan using an inverse variance statistical method with a fixed effect analysis. The final analysis included 7 studies with 252 participants. Results: The patients were 64 ± 9 years old. Baseline pulmonary function testing showed a forced expiratory volume in the first second (FEV1) of 34.6 ± 14.2 % predicted, consistent with severe COPD per GOLD criteria, and a baseline PaCO2 of 55.2 ± 9.2 mmHg. Primary outcomes for ventilation showed no statistical difference between AVAPS and fixed pressure support groups in PaCO2 (Odds Ratio [OR] -1.51; 95% Confidence Interval [CI]: -3.18, 0.16; p=0.08). Patient perceived outcomes were evaluated using several questionnaires, including St. George Respiratory Questionnaire (SGRQ), Short Form 36 Health Survey Questionnaire (SF-36), and Visual Analogue Scale (VAS). Comparable results were not available for all studies, but no statistically significant differences were found when comparing study results. Conclusions: There was little or no clinically significant difference between fixed pressure support and AVAPS in gas exchange. There are inadequate data to draw conclusions about the effect of fixed pressure support compared to AVAPS on patient perceived outcomes, such as comfort and symptom burden. No studies evaluated mortality benefit, cost effectiveness, or hospitalizations. Key words: COPD, chronic hypercapnic respiratory failure, non-invasive ventilation, average volume-assured pressure support ventilation

Nuciferine Alleviates High-Fat Diet- and ApoE-/--Induced Hepatic Steatosis and Ferroptosis in NAFLD Mice via the PPARα Signaling Pathway.

Nonalcoholic fatty liver disease (NAFLD) causes significant global mortality and healthcare costs with no recommended pharmacological intervention for clinical management. Nuciferine (Nuc) is an alkaloid with aromatic rings, abundantly found in Nelumbo nucifera Gaertn. In this study, we explored the protective mechanisms of Nuc against hepatic steatosis and ferroptosis in NAFLD. High-fat diet (HFD) and healthy male ApoE-/- mice were used to induce NAFLD and a hypercholesterolemia model. Nuc was administered to the mice for four consecutive weeks from the ninth week. Various assessments, including histopathology, RNA sequencing, lipid metabolism, and ferroptosis-related protein expression, showed that Nuc alleviated hepatic steatosis and ferroptosis. We further showed that Nuc improves fatty acid accumulation and ferroptosis through the PPARα signaling pathway in mice and RSL3-treated AML-12 cells. The PPARα inhibitor GW6471 blocked Nuc's protective effects, leading to excess accumulation of iron ions. Thus, Nuc may be a potential therapeutic agent for NAFLD.

Unveiling patterns in pediatric appendectomy: A comparative study on healthcare resource capacity and surgical decisions in Brazil.

Appendicitis is the most prevalent surgical emergency in children. This study examined hospital infrastructure, surgical techniques, patient demographics, and hospitalization parameters to assess the provision of safe and adequate care within the Brazilian public healthcare system. Pediatric hospitalizations for acute appendicitis in 2022 were extracted from the Brazilian national database. We included all hospitalizations for patients aged 0-16years with a primary ICD-10 diagnosis of acute appendicitis who underwent an operation. Parameters of interest were the type of surgical approach, mortality, and total cost of hospitalization. Facilities were defined as basic-facility, full-facility, and pediatric according to the level of pediatric resources available. In 2022, there were 29,983 pediatric appendectomies due to acute appendicitis. Of these, 90.2% were open appendectomies. Most occurred in basic-facility general hospitals (53.0%), followed by full-facility (35.2%) and pediatric hospitals (11.8%). Full-facility hospitals had a higher median cost (USD126.3, IQR 99.5-154.4) compared to basic (USD96.8, IQR 87.6-130.1) and pediatric hospitals (USD103.0, IQR 91.9-117.5), though the cost difference between basic and pediatric was not significant (p=0.367). Death was a rare event across all levels of hospital infrastructure and for all types of procedures performed. The majority of hospitalizations for acute appendicitis occurred in hospitals with minimal pediatric infrastructure. Open appendectomies remain the most predominant procedure across all hospital types.

High-cost users after sepsis: a population-based observational cohort study.

High-cost users (HCU) represent important targets for health policy interventions. Sepsis is a life-threatening syndrome that is associated with high morbidity, mortality, and economic costs to the healthcare system. We sought to estimate the effect of sepsis on being a subsequent HCU. Using linked health-administrative databases, we conducted a population-based, propensity score-weighted cohort study of adults who survived a hospitalization in Ontario, Canada between January 2016 and December 2017. Sepsis was identified using a validated algorithm. The primary outcome was being a persistent HCU after hospital discharge (in the top 5% or 1% of total health care spending for 90 consecutive days), and the proportion of follow-up time since discharge as a HCU. We identified 927,057 hospitalized individuals, of whom 79,065 had sepsis. Individuals who had sepsis were more likely to be a top 5% HCU for 90 consecutive days at any time after discharge compared to those without sepsis (OR 2.24; 95% confidence interval [CI] 2.04-2.46) and spent on average 42.3% of their follow up time as a top 5% HCU compared to 28.9% of time among those without sepsis (RR 1.46; 95% CI 1.45-1.48). Individuals with sepsis were more likely to be a top 1% HCU for 90 consecutive days compared to those without sepsis (10% versus 5.1%, OR 2.05 [95% CI 1.99-2.11]), and spent more time as a top 1% HCU (18.5% of time versus 10.8% of time, RR 1.68 [95% CI 1.65-1.70]). The sequelae of sepsis result in higher healthcare costs with important economic implications. After discharge, individuals who experienced sepsis are more likely to be a HCU and spend more time as a HCU compared to individuals who did not experience sepsis during hospitalization.

Development of an Expert-Based Scoring System for Early Identification of Patients with Inborn Errors of Immunity in Primary Care Settings - the PIDCAP Project.

Early diagnosis of inborn errors of immunity (IEIs) has been shown to reduce mortality, morbidity, and healthcare costs. The need for early diagnosis has led to the development of computational tools that trigger earlier clinical suspicion by physicians. Primary care professionals serve as the first line for improving early diagnosis. To this end, a computer-based tool (based on extended Jeffrey Modell Foundation (JMF) Warning Signs) was developed to assist physicians with diagnosis decisions for IEIs in the primary care setting. Two expert-guided scoring systems (one pediatric, one adult) were developed. IEI warning signs were identified and a panel of 36 experts reached a consensus on which signs to include and how they should be weighted. The resulting scoring system was tested against a retrospective registry of patients with confirmed IEI using primary care EHRs. A pilot study to assess the feasibility of implementation in primary care was conducted. The scoring system includes 27 warning signs for pediatric patients and 24 for adults, adding additional clinically relevant criteria established by expert consensus to the JMF Warning Signs. Cytopenias, ≥ 2 systemic infections, recurrent fever and bronchiectasis were the leading warning signs in children, as bronchiectasis, autoimmune diseases, cytopenias, and > 3 pneumonias were in adults. The PIDCAP (Primary Immune Deficiency "Centre d'Atenció Primària" that stands for Primary Care Center in Catalan) tool was implemented in the primary care workstation in a pilot area. The expert-based approach has the potential to lessen under-reporting and minimize diagnostic delays of IEIs. It can be seamlessly integrated into clinical primary care workstations.

A Comprehensive Study on the Distribution of Integrons and Their Gene Cassettes in Clinical Isolates.

Antibiotic resistance is a significant global health concern, leading to increased morbidity, mortality, and health care costs. Integrons are genetic elements that could acquire and express gene cassettes, including those that confer antibiotic resistance. This comprehensive study focused on the distribution of integrons and their gene cassettes in clinical isolates. This study explored the structure and classification of integrons with particular emphasis on Class I, II, III, and IV integrons. It also discussed the role of integrons in antibiotic resistance. The findings of this study contribute to a better understanding of the mechanisms underlying antibiotic resistance and provide valuable insights for developing strategies to combat this public health crisis.

The effect of exercise training in people with pre-dialysis chronic kidney disease: a systematic review with meta-analysis.

Chronic kidney disease (CKD) is a global health issue with high mortality and economic costs. Exercise has potential benefits for pre-dialysis CKD management. This review examines the impact of exercise on CKD patients not on dialysis, focusing on improvement in various health parameters. Findings aim to inform the role of exercise in pre-dialysis CKD care. A systematic search of MEDLINE, EMBASE, the Cochrane Library of Controlled Trials, CINAHL, and SPORTDiscus, up to August 31, 2023, used key terms relating to pre-dialysis CKD and exercise. We pooled randomized controlled trials (RCTs) comparing exercise with usual care and conducted meta-analyses based on a random effects inverse variance model with the effect measure of mean difference. Of 1162 identified studies, 37 RCTs met the inclusion criteria including 1248 participants. Significant improvements were identified for peak VO2, mean difference [MD] (2.66mL/kg/min; 95% confidence interval [CI] 1.48, 3.83; p < 0.00001); the 6-min walk (MD 58.83m; 95% CI 35.26, 82.41; p < 0.00001), timed up and go (standardised mean difference -0.35; 95% CI -0.54, -0.15; p = 0.0006), 2-min step (MD 57.48 steps; 95% CI 27.80, 87.16; p = 0.0001), and sit to stand tests (MD 4.55 repetitions; 95% CI 1.49, 7.60; p = 0.004); short form [SF]-36 general health (MD 4.26; 95% CI 0.04, 8.47; p = 0.05); SF-36 mental component summary (MD 1.84; 95% CI 0.18, 3.51; p = 0.03); estimated glomerular filtration rate (MD 2.19mL/min/1.73 m2; 95% CI 0.97, 3.50; p = 0.001); serum cystatin-C (MD -0.06mg/L; 95% CI -0.11, -0.02; p = 0.004); resting heart rate (MD -1.97 bpm; 95% CI -3.84, -0.11; p = 0.04); triglycerides (MD -12.97mg/dL; 95% CI -17.30, -8.63; p < 0.00001); glycosylated haemoglobin (MD -0.25%; 95% CI -0.50, -0.01; p = 0.04); waist circumference (MD -3.12cm; 95% CI -4.37, -1.86; p < 0.00001); and interleukin-6 (MD -2.24pg/mL; 95% CI -3.87. -0.61; p = 0.007). Analysis revealed improvements in aerobic capacity, functional ability, quality of life, estimated glomerular filtration rate, serum cystatin-C, resting heart rate, waist circumference, triglyceride, glycosylated haemoglobin, and interleukin-6 levels.

Considerations for the application of polygenic scores to clinical care of individuals with substance use disorders.

Substance use disorders (SUDs) are highly prevalent and associated with excess morbidity, mortality, and economic costs. Thus, there is considerable interest in the early identification of individuals who may be more susceptible to developing SUDs and in improving personalized treatment decisions for those who have SUDs. SUDs are known to be influenced by both genetic and environmental factors. Polygenic scores (PGSs) provide a single measure of genetic liability that could be used as a biomarker in predicting disease development, progression, and treatment response. Although PGSs are rapidly being integrated into clinical practice, there is little information to guide clinicians in their responsible use and interpretation. In this Review, we discuss the potential benefits and pitfalls of the use of PGSs in the clinical care of SUDs, highlighting current research. We also provide suggestions for important considerations prior to implementing the clinical use of PGSs and recommend future directions for research.

Health outcomes and economic burden among patients with a COVID-19-associated hospitalization in the United States during the predominance of the XBB and JN.1 omicron lineages

Objective Conduct a comprehensive analysis of the health and economic outcomes of patients with a COVID-19-associated hospitalization in the US during the predominance of the XBB and JN.1 Omicron lineages. Methods This analysis used data from the PINC AI Healthcare Database (PHD) for all patients with a hospital admission date occurring between February 4, 2023, and February 29, 2024 with an ICD-10-CM code U07.1 “COVID-19” in any position. The data were used to estimate the mean and median length of stay (LOS), mean and median hospitalization cost, and proportion of patients that died in the hospital, by age and level of care (normal ward, intensive care [ICU], invasive mechanical ventilation [IMV]). Results LOS, hospitalization costs, and inpatient mortality increased with both the level of care and age. Patients not receiving ICU care had the shortest LOS, lowest inpatient mortality, and lowest hospitalization costs. LOS, hospitalization costs, and inpatient mortality were higher for those receiving ICU care and highest for those receiving IMV in the ICU. Within each level of care (normal ward, ICU without IMV, and ICU with IMV), the LOS, inpatient mortality, and hospitalization cost generally increased with age, indicating that older adults with COVID-19 required a longer recovery period, have a higher likelihood of death, and accrue higher costs. However, the proportion of pediatric patients with an ICU admission and/or IMV usage remained high. Limitations The PHD data may not be representative of all hospitalized patients in the US. Conclusions These findings suggest that COVID-19 continues to have severe and costly consequences in all age groups, but particularly for older adults including long LOS, ICU admission, need for IMV, mortality, and high hospital costs.

Effects of respiratory isolation for tuberculosis to reduce community-based transmission: a systematic review.

Respiratory isolation of people with pulmonary tuberculosis (TB), including after treatment initiation, is used to prevent community-based transmission; yet guidelines on duration are limited and implementation is heterogeneous. This systematic review synthesized evidence on respiratory isolation for TB to inform National TB Coalition of America guidelines. After searching six databases, eight reviewers screened and extracted data in duplicate on effects of respiratory isolation compared to no isolation or masking. Studies were stratified by outcomes: TB infection or disease in contacts, mortality, hospitalization duration, patient and health system costs, and impact on mental health or stigma. We used a convergent integrated approach to synthesize quantitative and qualitative findings and assess limitations. Seventeen studies were included. There were limited data directly comparing isolation to non-isolation interventions, including effects after treatment initiation. One randomized controlled trial suggested treatment in a sanatorium versus at home did not affect TB incidence in contacts. Modelling studies suggest isolation may reduce transmission, but relied on various assumptions, and isolation was implemented alongside other interventions. Descriptive, mixed-methods, and qualitative studies described adverse impacts of isolation on employment, education, food/housing security, and mental health due to transmission fears, stigma and social isolation. Impacts were compounded in marginalized groups including indigenous and incarcerated persons. Data to support current isolation practices, particularly after effective treatment initiation, to reduce TB transmission in communities are limited. Public health guidance should weigh the negative impacts on people with TB against decreased community transmission to make evidence-based decisions about respiratory isolation.

Predictors of non-adherence to an early in-hospital rehabilitation program after surgery for hip fracture in a co-managed orthogeriatric unit

BackgroundHip fracture is a common event in older adults, leading to an increased risk of mortality, disability, and higher healthcare costs. Early in-hospital rehabilitation after surgery within orthogeriatric units may improve outcomes with limited incident complications even in the oldest old. We aimed to determine the prevalence and predictors of non-adherence to early rehabilitation in the orthogeriatric unit of an Italian tertiary hospital and its impact on outcomes and setting at discharge.MethodsRetrospective observational single-centered cohort study. Patients aged ≥ 65 years admitted to the orthogeriatric unit for hip fracture who underwent surgery between April 2019 and October 2020 were considered eligible if able to walk autonomously or with assistance and independent in at least 2 Basic Activities of Daily Living. Along with sociodemographic and geriatric variables, characteristics of surgery and rehabilitation, in-hospital complications and functional outcomes at discharge were collected. The primary outcome was non-adherence to the early in-hospital rehabilitation program.ResultsAmong 283 older patients (mean age 82.7 years, 28.6% male), non-compliance with physical therapy was assessed in 49 cases (17.3%), characterized by worse pre-fracture clinical, cognitive, and functional status and showing worse outcomes in terms of mobilization at discharge. After multivariable analysis, non-adherence was independently associated with the onset of delirium (OR 5.26, 95%CI 2.46–11.26; p < 0.001) or infections after surgery (OR 3.26, 95%CI 1.54–6.89; p < 0.001) and a systolic blood pressure at admission < 120 mmHg (OR 4.52, 95%CI 1.96–10.43, p < 0.001).ConclusionsPre-fracture poor cognitive and functional status, along with lower systolic blood pressure, seem to make some patients more vulnerable to in-hospital complications (mainly delirium and infections) and negatively affect the adherence to physical therapy and, by consequence, clinical outcomes of rehabilitation.