Multiple Hospital Admissions Research Articles

Cardiomyopathy - Football

HISTROTY: A 19-year-old division one college football player presented to his team physician with shortness of breath two days prior. Complained of chest pain the night before, which increased with mild exertion. Also complained of a cough and mild rhinorrhea. No fever or chills. Denied a history of asthma although his sister has asthma. PHYSICAL EXAMINATION: Awake, alert and oriented X 3. No cervical lymphadenopathy. Tympanic membranes were within normal limits. Lungs had limited air movement. Peak flow was 425 (predicted 604). DIFFERENTIAL DIAGNOSIS: Asthma Bronchitis Upper respiratory tract infection CLINICAL COURSE: The patient was given albuterol with no relief. Returned the following day with coughing up brown/red mucous and left sided chest pain. He was then given azithromycin. Chest radiographs the following day did not reveal any cardiopulmonary abnormalities. The following week, he still complained of Sob and cough. Given triamcinolone inhaled and cefuroxime. Taken to community ER few days later where he was diagnosed with dilated cardiomegaly. After discharge, he returned the following day with expressive aphasia and was diagnosed with TIA. Started on metropolol, warfarin, lisinopril and aspirin. He has since had multiple ER visits and hospital admissions for shortness of breath, pancreatitis and chest pain. TESTS AND RESULTS: Chest X-Ray -Cardiomegaly MRA Neck -No stenosis MRI Brain -Acute cortical based infarction with left middle cerebral artery distribution Trans-thoracic Echocardiogram -Pulmonary Hypertension -Ejection fraction = 13.6% Cardiac MRI -Marked cardiomegaly of both left and right side of the heart and global hypokinesia. FINAL WORKING DIAGNOSIS: Viral Cardiomyopathy TREATMENT AND OUTCOMES: The patient had a ventricular assistance device placed as well as a dual-chamber defibrillator. He withdrew from the football team but continues to work out with them. He took approximately 8 months of medical leave from college but is now back attending classes. He is currently awaiting a cardiac transplant.

Attenuation of ECG voltage in cirrhotic patients

Two patients with cirrhosis (CIR), ascites (ASC), and peripheral oedema (PEROD) are presented. They were followed for many years, had multiple hospital admissions and clinic evaluations, had repeated laboratory testing, and many ECGs recorded. As their condition worsened, they developed attenuation of the ECG voltage (ATTECGV), which was more pronounced during intervals of increased fluid overload. Attenuation of the ECG voltage was decreased at times of successful diuresis and amelioration of PEROD, while abdominal paracenteses for ASC did not have any influence on the ATTECGV, suggesting that ATTECGV in patients with CIR is due to the associated PEROD, and not to ASC.

Frail older people's experiences and use of health and social care services

To highlight older people's experiences and expectations of services and the consequences for service provision, service development and research. A large amount of resources have been invested in providing services for frail older people who experienced multiple hospital admissions. However, their own views are under-reported. Semi-structured interviews with frail older people were conducted in four Scottish Health Board areas to explore the context of emergency admissions and the use of extramural services. Frail older people are high users of services but claim that services are not responsive to their main concerns: meeting individual needs, maximizing independence and helping to live fulfilled lives. Services not catering for these needs are often cancelled or left in abeyance. The same people who are targeted by care services are reluctant to engage with them. Care providers need to adopt older people's priorities to provide them with responsive patient-centred care.

Crianças hospitalizadas com Fibrose Cística: percepções sobre as múltiplas hospitalizações

As crianças com fibrose cística (FC) geralmente são hospitalizadas inúmeras vezes ao longo de suas vidas. Este estudo objetiva conhecer as percepções destas crianças em relação às múltiplas hospitalizações, bem como identificar o que percebem sobre o tratamento e os cuidados recebidos. Trata-se de um estudo descritivo com abordagem qualitativa. Os sujeitos são sete crianças portadoras de FC, entre 6 e 11 anos. Os dados são coletados em uma unidade pediátrica de um hospital geral, através de uma entrevista focalizada, pouco estruturada, e analisados pelo método da análise compreensiva. Os resultados deste estudo demonstram que as crianças prezam muito sua liberdade, que durante a hospitalização fica restringida, o que pode ser amenizado através da nossa escuta, compreensão e atenção.

Hernia de Morgagni: Reporte de un caso

SUMMARY Morgagni hernia is an uncommon form of congenital diaphragmatic hernia. It is usually diagnosed during childhood but occasionally, it is discovered during adulthood. We report a 77 years old female with a Morgagni diaphragmatic hernia. The patient did not have a history of trauma and had multiple hospital admissions due to respiratory problems, managed as pneumonias. A chest CAT scan established the diagnosis and the patient was operated using a trans abdominal approach, with good results.

Plasma von Willebrand factor and soluble E-selectin levels in stable outpatients with systolic heart failure: The Frederiksberg heart failure study

Background Endothelial dysfunction is a well-established aspect of the pathophysiology of patients with systolic heart failure. We have previously reported that patients who have had multiple current or previous hospital admissions for decompensated heart failure have consistently shown abnormal levels of plasma von Willebrand factor (vWf, an index of endothelial damage/dysfunction) and soluble E-selectin (E-sel, an index of endothelial activation), as well as other indices of endothelial pertubation. Methods To investigate if endothelial abnormalities extend to CHF outpatients who have only been recently diagnosed or have relatively mild or few, stable symptoms (at baseline), given the better prognosis in these patients, we performed a cross-sectional analysis of CHF patients, where vWf and E-sel levels (as indices of endothelial perturbation) were measured (ELISA) and related to left ventricular ejection fraction (LVEF), exercise capacity (6-min walk test) and N-terminal pro-Brain Natiuretic Peptide (NT-proBNP). Results There were no statistically significant differences in vWf and E-sel levels amongst patients with systolic heart failure compared to controls. Plasma NT-proBNP levels in patients with CHF were significantly elevated compared to controls ( p < 0.0001). Among the patients with CHF, higher NT-proBNP levels correlated with poorer LVEF [Spearman r = − 0.244, p < 0.004] and shorter 6-min walk distance [Spearman r = − 0.226, p = 0.045] but not NYHA class. Plasma vWf or E-sel levels did not correlate with LVEF, 6-min walk test or NYHA class. NT-proBNP levels correlated weakly with E-sel [Spearman r = − 0.211, p = 0.015] but not vWf. Conclusion The present observation suggests that stable CHF outpatients with few symptoms may in fact have less severe endothelial pertubation, as reflected by plasma indices such as vWf and E-selectin. There was limited association of endothelial indices to LVEF, exercise capacity, NYHA class and NT-proBNP levels.

Fatores de risco para readmissão hospitalar de crianças e adolescentes asmáticos

To determine the influence that hospital admission of suckling infants with asthma has on their risk for future admissions for the same cause. A retrospective study was conducted, in which the charts of 202 patients, all less than fifteen years of age, were evaluated. All of the patients had been treated as outpatients in a pediatric pulmonology clinic and had been admitted to the hospital on one or more occasions. A multivariate analysis was conducted in order to evaluate the risk factors associated with multiple hospitalizations. Virtually all of the patients evaluated were hospitalized a second time within 18 months of the first hospitalization. Among the patients first hospitalized at = 12 months of age, the second admission occurred sooner than did that recorded for those first hospitalized at > 12 months of age (p = 0.001). The risk factors found to be associated with multiple hospital admissions were as follows: age at first admission = 12 months (odds ratio: 2.55; 95% confidence interval: 1.18-5.48); age at first admission between 13 and 24 months (odds ratio: 3.54; 95% confidence interval: 1.31-9.63); and severity of asthma symptoms (odds ratio: 3.86; 95% confidence interval: 2.02-7.40). After the first hospitalization, children with asthma should be closely monitored, since the risk of subsequent admissions is elevated in the first months following discharge, especially among those of less than two years of age. Health care facilities should be organized to confront this problem appropriately and should dispense prophylactic medication more freely.

&lt;![CDATA[&lt;B&gt;Risk factors for multiple hospital admissions among children and adolescents with asthma&lt;/B&gt;]]&gt;

&lt;![CDATA[&lt;B&gt;Risk factors for multiple hospital admissions among children and adolescents with asthma&lt;/B&gt;]]&gt;

Endoscopic Band Ligation of Gastric Arteriovenous Malformations in a Patient with Hereditary Hemorrhagic Telangiectasia

A 45-year-old man with hereditary hemorrhagic telangiectasia (HHT) was referred for symptomatic anemia related to recurrent brisk GI blood loss form documented arteriovenous malformations (AVMs). Prior upper endoscopy disclosed multiple gastric AVMs. Previous treatment modalities included argon plasma coagulation (APC), heater probe/injection therapy, and endovascular embolization on multiple occasions. Despite this, the patient continued to have episodes of GI blood loss requiring multiple hospital admissions and transfusions. Ultimately, the patient underwent repeat upper endoscopy showing two ulcerated AVMs, one in the cardia and one in the high body. Due to recurrent bleeding and failure of previous treatments, a decision was made to treat the two lesions using band ligation. The procedure was performed in the standard fashion and the patient was discharged from the endoscopy center on the same day. Repeat upper endoscopies at one week, one month, and six months showed obliteration of the AVMs with complete healing and scar formation. In a period of six months follow up, the patient had no further bleeding. Endoscopic band ligation is a routine procedure performed both for variceal and non-variceal upper gastrointestinal tract (GI) hemorrhage. There is no consensus as to the best treatment option for non-variceal, non-ulcer upper GI hemorrhage. Only a few reports have been published pertaining specifically to the treatment of arteriovenous malformations using band ligation. Band ligation provides effective hemostasis in non-variceal upper GI hemorrhage. Furthermore, band ligation should be considered for AVMs that are refractory to traditional therapeutic options such as APC and angiographic embolization. [figure 1]Figure 1

Identifying patients at high risk of emergency hospital admissions: a logistic regression analysis.

To use routine data to identify patients at high risk of future emergency hospital admissions. Descriptive analysis of inpatient hospital episode statistics. Predictive model developed using multiple logistic regression. National Health Service hospital trusts in England. All patients with an emergency admission to an NHS hospital between 1 April 2000 and 31 March 2001. 'High-impact users' were defined as patients who had at least one emergency inpatient admission and who then went on to have at least two further emergency hospital admissions in the 12 months following the start date of that index admission. 2,895,234 patients were admitted as emergencies in 2000/2001, of whom 147,725 (5.1%) did not survive their first spell. Of the 2,747,509 surviving patients, 269,686 (9.8%) subsequently had at least two or more emergency admissions within 365 days of the index date of admission. A further 236,779 (8.6%) died during this period. Risk factors for becoming a high-impact user included the number of emergencies in the 36 months before index spell, comorbidity, age, an admission for an ambulatory care sensitive condition, ethnicity, area-level socioeconomic data, local admission rates, the number of episodes in the index spell, sex and the source of admission. The predictive model based on all emergency admissions produced a receiver operating characteristic curve score of 0.72. Routine hospital episode statistics can be used to identify patients who are at high risk of suffering future multiple emergency hospital admissions. The potential cost savings in preventing a proportion of these subsequent admissions need to be compared with the costs of case management of these patients.

Identifying patients at high risk of emergency hospital admissions: a logistic regression analysis

To use routine data to identify patients at high risk of future emergency hospital admissions. Descriptive analysis of inpatient hospital episode statistics. Predictive model developed using multiple logistic regression. National Health Service hospital trusts in England. All patients with an emergency admission to an NHS hospital between 1 April 2000 and 31 March 2001. 'High-impact users' were defined as patients who had at least one emergency inpatient admission and who then went on to have at least two further emergency hospital admissions in the 12 months following the start date of that index admission. 2,895,234 patients were admitted as emergencies in 2000/2001, of whom 147,725 (5.1%) did not survive their first spell. Of the 2,747,509 surviving patients, 269,686 (9.8%) subsequently had at least two or more emergency admissions within 365 days of the index date of admission. A further 236,779 (8.6%) died during this period. Risk factors for becoming a high-impact user included the number of emergencies in the 36 months before index spell, comorbidity, age, an admission for an ambulatory care sensitive condition, ethnicity, area-level socioeconomic data, local admission rates, the number of episodes in the index spell, sex and the source of admission. The predictive model based on all emergency admissions produced a receiver operating characteristic curve score of 0.72. Routine hospital episode statistics can be used to identify patients who are at high risk of suffering future multiple emergency hospital admissions. The potential cost savings in preventing a proportion of these subsequent admissions need to be compared with the costs of case management of these patients.

Impact of a Heart Failure Disease Management Program on Hospitalization

Introduction: Heart failure (HF) is a significant healthcare issue and is expected to become more problematic as the American population ages. The purpose of the present investigation is to examine the impact of a disease management program on hospital admissions in patients with HF. Methods: Two hundred and eighty two subjects diagnosed with HF were included in this analysis. One hundred and fifty-eight subjects (86 male/71 female) were enrolled in a HF disease management program. This program included HF education as well as an outpatient clinic and a tele-management system. The tele-management system monitored weight and self reported signs and symptoms. When weight and/or symptoms were outside of pre-set limits, the HF treatment plan was readjusted. The remaining 124 subject (71 male/53 female) received usual care consisting of management by their personal physician. Subjects were tracked for hospital admissions for seven months. Results: The following unpaired t-test and chi-square results at baseline are reported disease management vs. standard care. Age (75.0 ± 12.8 years vs. 74.1 ± 13.2 years), baseline ejection fraction (41.2 ± 15.7% vs. 37.8 ± 17.0%) and baseline brain natriuretic peptide (943.8 ± 1086.8 pg/ml vs. 1139.4 ± 955.8 pg/ml) were not significantly different (p > 0.10). The number of subjects prescribed an ACE inhibitor (52.5% vs. 64.5%) at baseline was significantly higher (p = 0.008) in the usual care group. The number of subjects prescribed a beta blocker (64.2% vs. 73.4%) and diuretic (79.1% vs. 82.3%) was not significantly different (p > 0.05) between groups. During the tracking period, 20 subjects in the disease management group and 53 subjects in the usual care group were hospitalized. Five subjects in the disease management group (3.2%) and 17 subjects in the usual care group (13.7%) required multiple hospital admissions. Univariate Cox regression analysis revealed the usual care group had a significantly higher risk for hospitalization during the tracking period (Hazard ratio: 4.0, 95% confidence interval: 2.4–6.7, p < 0.001). Conclusions: The results of the present study indicate a HF disease management program significantly reduces the number of hospitalizations in the short-term. These results may be particularly novel considering the mean age of both groups was over 70. Additional research examining disease management programs in the HF population is warranted.

Inflow Stenoses in Dysfunctional Hemodialysis Access Fistulae and Grafts

The aim of the study is to prospectively determine the incidence of inflow stenoses in dysfunctional hemodialysis access arteriovenous fistulae (AVFs) and grafts (AVGs). Contrast-enhanced magnetic resonance angiography (CE-MRA) was performed of 66 dysfunctional AVFs and 35 AVGs in 56 men and 45 women (mean age, 62 years; age range, 31 to 86 years). Complete inflow (from the subclavian artery), shunt region, and complete outflow (including subclavian vein) were shown at CE-MRA. In addition to standard digital subtraction angiography (DSA) of the shunt region and outflow, DSA of the complete inflow was obtained through access catheterization of all cases in which CE-MRA showed an inflow stenosis. Vascular stenosis is defined as greater than 50% decrease in luminal diameter compared with an uninvolved vascular segment located adjacent to the stenosis. Endovascular intervention of stenoses was performed in connection with DSA. CE-MRA showed 19 arterial stenoses in 14 patients (14%). DSA confirmed 18 of these lesions in 13 patients and showed no additional inflow lesions. Of the 13 patients, 7 patients had arterial stenoses only and 6 patients had accompanying stenoses in the shunt region and/or outflow. Referral criteria for the 13 patients to undergo access evaluation had been decreased flow rates (9 patients), steal symptoms (2 patients), and insufficient access maturation (2 patients). Access flow of the 9 patients with a low-flow access improved from 477 +/- 74 mL/min to 825 +/- 199 mL/min after angioplasty. One patient with steal symptoms became symptom free after angioplasty. Endovascular intervention in 3 patients proved to be unsuccessful. Inflow stenoses are not uncommon in dysfunctional hemodialysis access shunts. We suggest that radiological evaluation comprise assessment of the complete arterial inflow.

Query

My uncle died last week. He had been ill for years, but started his death spiral this past year with multiple hospital admissions as morbid markers by the mortal roadside. He had three kids. One became a teacher, another a chemist, and the youngest followed in his father's footsteps and entered the

Citalopram Treatment for Inappropriate Sexual Behavior in a Cognitively Impaired Patient

Citalopram Treatment for Inappropriate Sexual Behavior in a Cognitively Impaired Patient

Colonic Duplication: Diagnostic Dilemma

Colonic duplication is a rare congenital anomaly which presents as a diagnostic and therapeutic challenge. We report a 5-year-old boy with colonic duplication who required multiple hospital admissions, multiple diagnostic tests, and evaluation by various clinical specialists before the diagnosis was made intraoperatively. He was known to have left renal hypoplasia, low spinal abnormalities, hypoplasia of the left hemipelvis, and mild hypoplasia of the left lower limb, all of which were considered to be a variant of caudal regression syndrome.

Fluphenazine-Induced Neuroleptic Malignant Syndrome in a Schizophrenic Patient

To report a case of neuroleptic malignant syndrome (NMS) associated with fluphenazine in a schizophrenic patient and review the literature related to this condition. A 21-year-old African American male with schizophrenia came to our medical intensive care unit from the crisis intervention unit (CIU). He was hyperthermic (oral temperature 40.6 degrees C), diaphoretic, tachycardic (heart rate 140 beats/min), and tachypneic (respiratory rate 22 breaths/min), with severe muscle rigidity and shaking tremors. He had an extensive psychiatric history significant for schizophrenia and multiple past hospital admissions, starting at age 14 years. Two days prior to admission to the CIU, he had been given 25 mg of fluphenazine decanoate injection intramuscularly in addition to his regular psychotropic regimen of thioridazine and haloperidol after reportedly making several verbal threats and displaying aggressive behavior toward the personnel at the group home where he resided. Laboratory studies showed elevated creatine kinase, aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase levels, as well as azotemia, hyperphosphatemia, hypocalcemia, and leukocytosis. NMS is a rare but potentially fatal reaction associated with neuroleptic drugs. It occurs in approximately 0.07-2.2% of patients treated with neuroleptics. Risk factors include previous episodes, dehydration, agitation, polypharmacy, and the rate and route of neuroleptic administration. An objective causality assessment revealed that fluphenazine was the probable cause of NMS in this patient. There was no reaction associated with thioridazine and/or haloperidol. Clinicians need to be aware of this drug-induced condition and the potential increased risk associated with concurrent use of multiple psychotropics.

Hemoptise fictícia na síndrome de Munchhausen: uma entidade a ser considerada no diagnóstico diferencial

A síndrome de Munchhausen resulta de um distúrbio psiquiátrico, no qual os pacientes conscientemente procuram demonstrar sinais e sintomas de doenças orgânicas graves. Foram encontrados na literatura 23 casos de hemoptise fictícia associada à síndrome de Munchhausen, dois com o mesmo mecanismo aqui descrito. Relata-se o caso de um paciente com diversas admissões hospitalares recentes por escarros sangüíneos, que resultavam em exaustivas investigações diagnósticas inconclusivas. Insistentemente questionado, confessou que aspirava o próprio sangue com uma seringa, armazenando-o na cavidade oral, e eliminando-o para forjar a hemoptise. A síndrome de Munchhausen deve ser considerada em pacientes com hemoptise de etiologia obscura.

Acute Abdomen Secondary to Ascaris lumbricoides Infestation of the Small Bowel

Ascariasis is a helminthic infection commonly found in tropical climates. It often propagates in communities of low socioeconomic status secondary to contamination of the soil and water supply with human feces. We present a case report of a 42-year-old Asian-Indian female presenting with a long-standing history of severe recurrent postprandial epigastric pain, requiring multiple hospital admissions. Ultrasound, computed tomography (CT), and nuclear biliary scan were negative. She underwent esophagogastroduodenoscopy that suggested ischemia. Magnetic resonance angiography (MRA) and mesenteric angiography were inconclusive. As conservative treatment had been unsuccessful, a small bowel series was performed. The radiographs demonstrated characteristic findings of Ascaris lumbricoides infestation. Although the prevalence, diagnosis, and subsequent treatment of an acute abdomen secondary to Ascaris lumbricoides infestation is commonly seen in developing countries, clinicians in developed countries may not consider this entity when faced with a patient with similar symptoms. We frequently care for immigrants from developing countries and our own citizens who visit the countries where ascariasis is endemic. Therefore, heightened awareness of Ascaris lumbricoides infection (ALI) presenting as an acute abdomen is necessary. The diagnosis requires an experienced radiologist and knowledge by the clinician of treatment options and of when a surgeon should be involved.

Mold sensitization is common amongst patients with severe asthma requiring multiple hospital admissions

BackgroundMultiple studies have linked fungal exposure to asthma, but the link to severe asthma is controversial. We studied the relationship between asthma severity and immediate type hypersensitivity to mold (fungal) and non-mold allergens in 181 asthmatic subjects.MethodsWe recruited asthma patients aged 16 to 60 years at a University hospital and a nearby General Practice. Patients were categorized according to the lifetime number of hospital admissions for asthma (82 never admitted, 53 one admission, 46 multiple admissions). All subjects had allergy skin prick tests performed for 5 mold allergens (Aspergillus, Alternaria, Cladosporium, Penicillium and Candida) and 4 other common inhalant allergens (D. pteronyssinus, Grass Pollen, Cat and Dog).ResultsSkin reactivity to all allergens was commonest in the group with multiple admissions. This trend was strongest for mold allergens and dog allergen and weakest for D. pteronyssinus. 76% of patients with multiple admissions had at least one positive mold skin test compared with 16%-19% of other asthma patients; (Chi squared p < 0.0001). Multiple mold reactions were also much commoner in the group with multiple admissions (50% V 5% and 6%; p < 0.0001). The number of asthma admissions was related to the number and size of positive mold skin allergy tests (Spearman Correlation Coefficient r = 0.60, p < 0.0001) and less strongly correlated to the number and size of non-mold allergy tests (r = 0.34, p = 0.0005). Hospital admissions for asthma patients aged 16–40 were commonest during the mold spore season (July to October) whereas admissions of patients aged above 40 peaked in November-February (Chi Squared, p < 0.02).ConclusionThese findings support previous suggestions that mold sensitization may be associated with severe asthma attacks requiring hospital admission.