Multiple Hospital Research Articles

Nomogram model for predicting medication adherence in patients with various mental disorders based on the Dryad database

ObjectiveTreatment compliance among psychiatric patients is related to disease outcomes. How to assess patient compliance remains a concern. Here, we established a predictive model for medication compliance in patients with...

Measuring hospital antibiotic consumption in EU/EEA countries: comparison of different metrics, 2017 to 2021.

BackgroundAntibiotic resistance poses a considerable public health threat, with data-driven stewardship a main prevention measure. While quantifying antibiotic consumption is a key component of antibiotic stewardship programmes, the choice of denominator for calculating this metric can impact comparative analyses and trend evaluations substantially, influencing targeted stewardship interventions.AimWe aim to evaluate how using hospital sector-specific antibiotic consumption rate denominators at country level impacts country rankings and trends, addressing the limitations of the commonly used 'defined daily doses (DDD) per 1,000 inhabitants per day' metric.MethodsHospital antibiotic consumption data from ESAC-Net and denominator data from Eurostat ('inhabitants,' 'bed-days' and 'discharges') for 2017-2021 were used to calculate hospital antibiotic consumption rates for 24 reporting European Union/ European Economic Area (EU/EEA) countries. Countries were ranked by their consumption rates and trends were analysed to assess the effects of using different denominators.ResultsCountry rankings and 5-year trend analyses varied depending on the denominator used. Antibiotic consumption rates were more similar when using hospital activity-based denominators 'bed-days' and 'discharges' compared with the population-based 'inhabitants' denominator. Differences in country rankings and trends were also seen among rates derived using 'bed-days' and 'discharges'.ConclusionThe study underscores the importance of using hospital activity-based denominators such as 'bed-days' and 'discharges' when evaluating hospital antibiotic consumption. ESAC-Net's historical reliance on only 'DDD per 1,000 inhabitants per day' is challenged, advocating for the use of multiple hospital activity-based denominators. Corresponding hospital activity denominators for ESAC-Net data will more effectively inform national hospital antibiotic stewardship interventions.

Efficacy and safety of CalliSpheres drug-eluting bead bronchial arterial infusion chemoembolization vs. bland embolization in advanced lung cancer with hemoptysis: A multicenter retrospective study.

Massive hemoptysis is a life-threatening complication in patients with advanced primary lung cancer, and effective, safe treatments are crucial. This study aimed to investigate the efficacy and safety of CalliSpheres drug-eluting bead bronchial arterial infusion chemoembolization (DEB-BACE) for managing this condition. A retrospective analysis included 144 patients with advanced primary lung cancer and massive hemoptysis treated at multiple hospitals from January 2019 to January 2023. Patients undergoing bronchial artery embolization were divided into two groups: the observation group (n=76) received CalliSpheres DEB-BACE with epirubicin, and the control group (n=68) received 8spheres blank embolization. Both groups achieved successful hemostasis, with no statistically significant difference in success rates (observation group: 88.16%, control group: 86.76%). However, the observation group had a significantly longer median duration without hemoptysis (96 days vs. 50 days). Two months post-therapy, the observation group showed higher objective response rates (82.89% vs. 38.24%) and disease control rates (92.11% vs. 66.18%) compared to the control group. Adverse reactions were manageable and similar between groups, with no serious complications observed. By January 31, 2024, the observation group had significantly longer median overall survival (11 months vs. 7 months). The DEB-BACE treatment demonstrates safety and efficacy in managing massive hemoptysis in patients with advanced lung cancer. However, the superiority of this approach over bland embolization remains to be established through well-designed prospective studies. Future research is anticipated to provide a definitive comparison and further validate the role of DEB-BACE in clinical practice.

An Electronic Medical Record-Based Prognostic Model for Inpatient Falls: Development and Internal-External Cross-Validation.

Effective fall prevention interventions in hospitals require appropriate allocation of resources early in admission. To address this, fall risk prediction tools and models have been developed with the aim to provide fall prevention strategies to patients at high risk. However, fall risk assessment tools have typically been inaccurate for prediction, ineffective in prevention, and time-consuming to complete. Accurate, dynamic, individualized estimates of fall risk for admitted patients using routinely recorded data may assist in prioritizing fall prevention efforts. The objective of this study was to develop and validate an accurate and dynamic prognostic model for inpatient falls among a cohort of patients using routinely recorded electronic medical record data. We used routinely recorded data from 5 Australian hospitals to develop and internally-externally validate a prediction model for inpatient falls using a Cox proportional hazards model with time-varying covariates. The study cohort included patients admitted during 2018-2021 to any ward, with no age restriction. Predictors used in the model included admission-related administrative data, length of stay, and number of previous falls during the admission (updated every 12 hours up to 14 days after admission). Model calibration was assessed using Poisson regression and discrimination using the area under the time-dependent receiver operating characteristic curve. There were 1,107,556 inpatient admissions, 6004 falls, and 5341 unique fallers. The area under the time-dependent receiver operating characteristic curve was 0.899 (95% CI 0.88-0.91) at 24 hours after admission and declined throughout admission (eg, 0.765, 95% CI 0.75-0.78 on the seventh day after admission). Site-dependent overestimation and underestimation of risk was observed on the calibration plots. Using a large dataset from multiple hospitals and robust methods to model development and validation, we developed a prognostic model for inpatient falls. It had high discrimination, suggesting the model has the potential for operationalization in clinical decision support for prioritizing inpatients for fall prevention. Performance was site dependent, and model recalibration may lead to improved performance.

BN SO29 - Overinvestigation and unnecessary surgery for Gallbladder Polyps: An audit of compliance with ESGAR guidelines

Abstract Background Incidental gallbladder polyps are increasingly reported on abdominal ultrasound and have a theoretical association with increased risk of gallbladder cancer. Most gallbladder polyps are actually gallstones and there is little evidence for any survival benefit or reduced rates of gallbladder cancer in patients under ultrasound surveillance. ESGAR guidelines attempt to standardize and rationalize surveillance protocols, balancing the risks of missed early cancers versus the costs of surveillance investigations. This audit aims to assess the investigation and management of gallbladder polyps as per ESGAR guidelines at a single NHS trust. Method An audit was conducted at a single NHS Trust in England. Searches were conducted on the electronic patient record for patients coded for K82.8 (Gallbladder pathology: other) from 01/01/2022 to 31/12/2023. Patient records were examined for radiological imaging confirming diagnosis of gallbladder polyp. Data was analysed using Microsoft excel and compared with the 2021 ESGAR guidance on management of gallbladder polyps. Results 97 patients were included. All polyps were diagnosed with abdominal ultrasound. Patients had, on average, two ultrasounds. 51% were seen in outpatients clinic. 35 patients (36%) underwent laparoscopic cholecystectomy (including all patients with a polyp >10mm). Histology confirmed diagnosis of cholecystitis (69%), pseudopolyp (9%), gallbladder polyp (6%) and IPMN (3%). 74% (26/35) of patients that underwent cholecystectomy had biliary symptoms and 77% (20/26) had cholecystitis confirmed by histology. Despite having biliary symptoms at first assessment, 47% of polyp patients went on to have two ultrasounds and two clinic appointments. Conclusion The study confirms that the majority of ultrasound detected polyps are not neoplastic, and patients undergo multiple hospital visits, incurring significant non-therapeutic costs. Adherence to ESGAR guidelines is inconsistent. In the symptomatic cohort, however, a low threshold for laparoscopic cholecystectomy should be considered given the high likelihood of underlying stones.

Abstract 4135095: Outcomes of Atrial Fibrillation Patients with Thrombocytopenia: Insights From a Nationwide Database

Background: While anticoagulation is crucial for atrial fibrillation (AF) patients to prevent ischemic events, those with thrombocytopenia have a potential increased risk of bleeding. This study examines the outcomes of hospitalized AF patients with thrombocytopenia. Methods: The National Inpatient Sample (NIS) from 2016-2020 was analyzed to identify adult patients with AF and thrombocytopenia (using the proper ICD-10 codes). Multivariate logistic and regression analyses were performed after adjusting for multiple patient and hospital confounders to compare outcomes between patients with and without thrombocytopenia. The primary outcome was all-cause inpatient mortality. Secondary outcomes included major bleeding (defined as gastrointestinal, intracranial, pulmonary, or unspecified bleeding), hypovolemic shock, packed red blood cell (pRBC) transfusion, ischemic stroke, length of stay (LOS), and total charges. Results: Among 2,016,244 AF admissions, 75,545 patients (3.75%) had thrombocytopenia. Thrombocytopenia was associated with increased inpatient mortality (adjusted odds ratio [aOR] 2.47, 95% CI 2.21-2.77, p < 0.001). Thrombocytopenia was also associated with increased risk of major bleeding (aOR 1.99, 95% CI 1.8-2.19, p < 0.001), hypovolemic shock (aOR 3.11, 95% CI 2.29-4.24, p < 0.001), pRBC transfusion (aOR 3.07, 95% CI 2.8-3.37, p < 0.001). There was no significant difference in ischemic stroke risk (aOR 0.67, 95% CI 0.37-1.21, p < 0.19) but thrombocytopenia was associated with longer LOS (aMD 1.5 days, 95% CI 1.41-1.59, p < 0.001) and higher total charges (aMD $16,508, 95% CI 14,805-18,211, p < 0.001). Conclusions: Thrombocytopenia in hospitalized AF patients is associated with increased mortality, bleeding risk, and healthcare costs, with no clear impact on ischemic stroke. These findings highlight the need for careful risk-benefit assessment and individualized management strategies for this vulnerable patient population.

Abstract 4118341: Outcomes of Heart Failure with Preserved Ejection Fraction Patients With Concurrent Opioid Use: Insights From the National Inpatient Sample

Background: Opioid use has increased significantly in the past few decades, impacting cardiac and non-cardiac patients. As heart failure with preserved ejection fraction (HFpEF) comprises half of all heart failure cases, understanding its management and effect on outcomes is crucial. This study aims to evaluate the outcomes of chronic opioid therapy on HFpEF patients. Methods: Studying the National Inpatient Sample (2016-2020), we identified adult HFpEF patients using the appropriate ICD-10 codes -after excluding patients with end-stage renal disease (ESRD)- and compared outcomes between chronic opioid users and non-users. Multivariate logistic and linear regression analyses were performed, adjusting for multiple patient and hospital confounders. The primary outcome was all-cause in-hospital mortality while secondary outcomes included acute kidney injury/hemodialysis (AKI/HD), cardiogenic shock, cardiac arrest, mechanical ventilation, length of stay, and total charges. Results: Among 1,557,344 HFpEF patients, 21,655 (1.4%) were on opioids chronically. Inpatient mortality was not significantly different between patients who were on opioids and those who were not. (adjusted odds ratio [aOR] 1.01, 95% CI 0.85 - 1.2, p=0.89). There was a non-significant increased risk of cardiogenic shock (aOR 1.14, 95% CI 0.87 - 1.5, p=0.35) and cardiac arrest (aOR 1.05, 95% CI 0.8 - 1.36, p=0.74) in patients on chronic opioids. Chronic opioids were associated with increased risk of AKI/HD (aOR 1.12, 95% CI 1.04 - 1.2, p=0.002) and mechanical ventilation (aOR 1.29, 95% CI 1.16 - 1.43, p< 0.001). Opioid use was also associated with longer hospital stay (adjusted MD [aMD] 1.07 days, 95% CI 0.75 - 1.39, p<0.001) and a non-significant increase in total charges (aMD $2,593, 95% CI -$2,044 - $7,229, p=0.27). Conclusions: While chronic opioid use in hospitalized HFpEF patients did not significantly impact in-hospital mortality, it was associated with increased risk of other adverse events and longer hospital stay. Further research is needed to understand the impact of chronic opioid use on HFpEF patients.

Lemierre Syndrome Associated with Streptococcus constellatus and Atypical Vascular Involvement: A Case Report and Review of the Literature

Background: Lemierre syndrome is a rare and life-threatening disease. It is characterized by septic thrombophlebitis of the internal jugular vein, historically associated with Fusobacterium necrophorum infection. However, atypical cases and associations with other organisms have been reported. Methods: Here, we describe a challenging case of Lemierre syndrome in a 71-year-old woman caused by Streptococcus constellatus and review the related literature. Case: The patient experienced multiple hospital admissions due to misdiagnoses and developed thrombosis involving the internal jugular vein and transverse sinus bilaterally, pulmonary complications including the formation of a pseudoaneurysm, and occipital abscess. She presented with headaches, neck pain, and blindness. Prolonged antibiotic therapy was administered, leading to gradual improvement of symptoms, with partial resolution of blindness. Prophylaxis with intramuscular penicillin was prescribed at discharge. Conclusions: Our case underscores the importance of considering Lemierre syndrome in patients who present with multiple thrombotic events affecting the intracranial circulation and/or jugular veins, particularly in those already receiving anticoagulation therapy or with no identifiable cause for thrombosis, even in the absence of sore throat or fever.

Commercial insurers' market power and hospital prices in Medicaid managed care.

To examine the relationship between insurers' commercial market power and negotiated prices in Medicaid Managed Care (MMC) plans for hospital care. MMC prices from hospital-disclosed price transparency data as of July 2023 compiled by Turquoise Health, insurance enrollment information from the 2021 Clarivate InterStudy enrollment data. Log-transformed linear regression with hospital and procedure fixed effects estimating the within-hospital MMC price variation as a function of insurers' commercial market share quartile and MMC market share for 15 common outpatient hospital services. A total of 39,049 MMC price samples measured at hospital-procedure-MMC insurer level are merged with county-insurer level market share data. Around 25% of price variation in MMC plans are driven by within-hospital factors. Compared with MMC insurers from the lowest commercial market share quartile (<0.8%), those from the highest commercial market share quartile (>17%) are associated with negotiating 4.6% (95% confidence interval: [2.8%-6.4%], p < 0.001) lower MMC prices for outpatient hospital care, including 3.6% (p < 0.05) for medical/surgical procedures, 3.6% (p < 0.01) for radiology, and 6.7% (p < 0.001) for emergency department visits. MMC insurers with substantial commercial market share negotiate lower MMC prices for multiple outpatient hospital services.

Evaluating Supply Chain Network Models for Third Party Logistics Operated Supply-Processing-Distribution in Thai Hospitals: An AHP-Fuzzy TOPSIS Approach

Background: This study introduces a novel supply chain management (SCM) model tailored for the hospital industry in Thailand. The model emphasises the integration of third-party logistics (3PL) providers to streamline supply-processing-distribution (SPD) functions. By outsourcing non-core activities like SPD to 3PL providers, hospitals can enhance their operational efficiency, allowing healthcare professionals to focus on core tasks and ultimately improving service delivery. Methods: This research employed a dual methodology, combining an analytic hierarchy process (AHP) with a Fuzzy Technique for Order of Preference by Similarity to Ideal Solution (Fuzzy TOPSIS). These approaches evaluated various SCM models based on multiple hospital logistics performance attributes. Results: The AHP results highlighted on-time delivery, patient safety, utilisation rate, and emergency procurement as critical criteria for selecting the optimal model. Fuzzy TOPSIS analysis identified the SCIII: W-G-H model as the most suitable for implementation in Thai hospitals. This model incorporates a centralised warehouse for negotiation leverage, a Group Purchasing Organisation (GPO) for cost efficiency, and regional SPD hubs for effective inventory management and rapid responses to demand fluctuations or emergencies. Conclusions: Adopting this SCM model is expected to significantly enhance supply chain performance, reduce operational costs, and improve the quality and safety of patient care in Thai hospitals.

Emergency psychiatric care for children and adolescents: factors associated with multiple visits and hospital admissions.

Given the increased demand for mental health resources in the child and adolescent population, this study aims to describe the emergency psychiatric care of the children and adolescents and to explore factors associated with multiple visits and hospital admissions. All patients < 18 years of age who visited the psychiatric ED(ED) of a University Hospital in Madrid, Spain, during 2022 were included. Data were collected by the attending psychiatrist upon first 2022 ED visit (index visit) and during any ED revisit. Electronic health records of all included patients were revised to contrast information and complete missing data. Logistic regressions and correlation analyses were used to explore factors associated with multiple ED visits and hospitalisations. N = 397 patients were included. Factors associated with multiple ED visits were: being LGTBQ+, having eating problems, substance use, consulting for psychosis upon first visit, having a history of suicidal behaviour, previous mental health service use or previous hospitalisations, having two or more psychiatric diagnoses, and being diagnosed of eating disorders or depression. Factors associated with hospitalisation include female gender, older age, LGTBQ+, family conflicts, first or second-generation migrants, history of abuse, eating problems, drug use, history of suicidal behaviour, previous mental health service use or previous hospitalisations, psychiatric comorbidity, and eating disorders diagnosis. Identifying predictors that lead to different clinical pathways and use of mental health services can improve clinical outcomes and resource use.

The nutrition profile and utility of banana puree as a liquid thickener for medically complex infants with dysphagia.

Dysphagia among infants, particularly high-risk and preterm neonates, poses feeding challenges that can impact multiple systemic outcomes and delay hospital discharge. Limited therapeutic options for approved thickening agents for human milk and infant formula necessitate the exploration of alternatives, including banana puree. This study investigated the feasibility of using banana puree as a thickening agent for hospitalized infants with dysphagia. The International Dysphagia Diet Standardisation Initiative (IDDSI) flow test determined optimal volumes of banana puree mixed with infant formulas or human milk to achieve desired liquid thickness levels. Nutrition analysis considered potassium intake and calories from carbohydrates to assess dietary composition. Banana puree effectively achieved IDDSI Levels 1-3, with varying volumes required based on milk types and caloric concentrations. The nutrition analysis revealed the importance of restricting banana puree to 15% of feeding volumes to avoid exceeding recommended potassium levels while promoting appropriate nutrition. Banana puree represents a promising option for thickening feeds in infants with dysphagia, facilitating safe oral feeding opportunities, accelerating the introduction of oral feeding, and, potentially, improving long-term outcomes. Further research is warranted to explore its impact on feeding progression, hospital stays, growth, patient outcomes, and feeding-related behaviors compared with traditional thickening agents.

P38 Lupus enteritis as a first presentation of systemic lupus erythematosus in a previously well patient: a very rare occurrence

Abstract Introduction Lupus enteritis is an anecdotally rare condition (with no formal estimates of incidence) which can pose a diagnostic challenge, especially when presenting without other lupus-related symptoms and signs. Here, we present an unusual case where lupus enteritis was the first manifestation of systemic lupus erythematosus (SLE). Case description A 65-year-old South Asian female presented with a 6-month history of intermittent nausea, vomiting and abdominal pain, with the only systemic feature being worsening fatigue. She had no connective tissue disease features, previous miscarriage or venous thromboembolism (VTE). Over six months, she had multiple hospitalisations in different hospitals with recurrent attacks of episodic abdominal pain and vomiting, associated with migratory and reversible intestinal inflammation on serial imaging. Initial investigations revealed lymphopenia (0.99x109/L) and hypoalbuminaemia (25 g/L). During a two-month admission at our centre, she underwent detailed gastrointestinal investigations, including four abdomino-pelvic CT scans during transient episodes of pain and vomiting, showing diffuse wall thickening affecting different parts of the gastrointestinal tract at different times. Following discussion at specialist radiology and inflammatory bowel disease multidisciplinary meetings, these CT scans and an MRI small bowel study were confirmed to demonstrate a transient, migratory, reversible pattern of bowel inflammation affecting the ileum, jejunum and colon at different time points; there were no clinical, endoscopic, histological or imaging features of inflammatory bowel disease. Gastro-duodenal biopsies were normal and negative for amyloidosis and tuberculosis. Colonic biopsies excluded inflammation. C1 esterase inhibitory deficiency was excluded. A vasculitis screen was negative, but immunology was positive for anti-nuclear and anti-chromatin antibodies, with positive crithidia, but normal dsDNA. C3 was normal, but C4 was low at 0.04 g/L. Urinalysis showed significant albuminuria (413.8 mg/mmol). Following multidisciplinary discussion between gastroenterology, clinical immunology and rheumatology, a diagnosis of SLE was made, with an initial presentation of lupus enteritis. She received a tapering dose of corticosteroids and hydroxychloroquine. The patient suffered from a right-sided multi-segmental pulmonary embolus with infarction, but this was felt to be due to her nephrotic syndrome (negative anti-cardiolipin and β2-glycoprotein antibodies). Renal biopsy revealed class I lupus nephritis with podocytopathy. The patient was duly commenced on tacrolimus as a steroid-sparing agent. Discussion Lupus enteritis is a rare, poorly-defined condition, with only small amounts evidence regarding treatment and management in the literature, although a narrative review of 58 papers has recently been published. However, the average time between diagnosis of SLE and presentation with lupus enteritis is around 44 months, meaning that isolated enteritis as a first presentation of SLE is extremely rare. Only two out of 150 patients reviewed by Janssens et al (from a single tertiary lupus centre) presented with enteritis prior to a diagnosis of SLE. Lupus enteritis is potentially serious if left untreated, and can lead to life-threatening complications such as intestinal necrosis and/or perforation. This rare presentation highlights the importance of considering lupus enteritis in the differential in any patient presenting with non-specific gastrointestinal symptoms and a migratory pattern of intestinal inflammation on radiological investigations. This can enable prompt diagnosis and timely management. Key learning points • Lupus enteritis can be a first presentation of SLE without any other classical manifestations. • Lupus enteritis is extremely rare, but can be life-threatening if not identified and rapidly treated. • Radiology can demonstrate transient, migratory bowel inflammation on serial imaging.

Patients' knowledge about renal secondary effects of anti-tumoral drugs and renal protection measures.

Onco-nephrology is an emerging subspecialty aiming to better understand and prevent renal events in cancer patients. We assessed patients' knowledge about (1) oncological/hematological treatments induced renal toxicity and (2) kidney protective measures. Adult patients receiving systemic anti-tumor treatments in multiple day hospital units in France answered a self-administered questionnaire about their knowledge and expectations related to treatment-associated renal toxicity. In total, 621 questionnaires were collected in 8 units from November 2021 to January 2022. Among respondents, 84.5% were treated for a solid tumor. Overall, 34.3% (n = 208) patients reported they had some knowledge about potential renal adverse events related to their anticancer treatment, and 38.5% (n = 234) about kidney protection measures. Their referring oncologist or hematologist represented the commonest source of knowledge (67.8%). Sufficient hydration was cited as a kidney protection measure by 93.2% (n = 218) of patients declaring some knowledge about renal toxicity; prevention of nausea/vomiting by 52.6% (n = 123). Consumption of still and alkaline water was chosen by respectively 64.4% (n = 400) and 16.8% (n = 104) of participants to correct dehydration. A majority of patients expressed strong interest for receiving more information about renal toxicity and prevention: median Likert scale score was 10/10 (Q1-Q3, 5-10), with online resources mentioned as the most desired source of information. One-third of patients declared they had some knowledge about potential renal toxicity of their oncologic treatment and the ways to prevent them, especially regarding hydration. However, a majority expressed interest for dedicated information, which conducted to the elaboration of free online educational sheets for patients.

The association between composite measures of social vulnerability and PICU admission for status asthmaticus.

Current knowledge of the impact of socioeconomic factors on the risk of admission to the pediatric intensive care unit (PICU) for asthma is limited. Using composite measures of social vulnerability-Social Vulnerability Index (SVI) and Child Opportunity Index (COI) 2.0-we compared patients admitted for status asthmaticus to the PICU and pediatric ward at Children's Hospital Los Angeles (CHLA). We hypothesized patients with a high SVI and low COI are at higher risk for PICU admission. Patients were identified using ICD-10 codes for asthma. Primary outcome was admission to PICU versus ward for status asthmaticus. Patient-registered residential street addresses were geocoded and spatially joined to SVI and COI 2.0 data at the census tract level. Univariate and regression analyses using the patient's SVI, COI 2.0, and admission location were conducted. From January 2017 to March 2022, there were 2458 admissions matched to addresses from 1983 distinct patients. The overall median SVI for all patients was 0.86 (IQR 0.6, 0.9). Overall median COI was 25.0 (IQR 10, 50). There was no difference in SVI or COI for admission to the PICU versus the ward. However, children requiring multiple hospital admissions for asthma were associated with higher SVI and lower COI. Children admitted to CHLA for asthma had an elevated SVI and low COI. There was no difference between admission locations based on SVI or COI scores. This indicates we care for children at increased socioeconomic risk, but this did not increase PICU use for asthma.

BlaGES-producing ST654 comprises a quarter of all carbapenem-resistant Pseudomonas aeruginosa in blood isolates from 15 hospitals.

Carbapenem-resistant Pseudomonas aeruginosa (CRPA) are of major clinical concern. We analyzed 85 P. aeruginosa blood isolates non-susceptible to carbapenems collected during 2021-2023 from 15 medical centers in Israel. We aimed to determine the prevalence of high-risk clones, examine clonality, test antibiotic susceptibility, and assess the presence of acquired resistance genes, including carbapenemases. Whole-genome sequencing was performed using Illumina sequencing technology. Susceptibly was determined using the broth microdilution method. In the entire sample, 43.5% were high-risk clones. A main clade (27.1% of isolates) found in multiple hospitals comprised 19 isolates belonging to the high-risk ST654 clone and four closely related isolates. The isolates in this main clade harbored a broad set of resistance genes, including GES-type genes, and 91% had a mutated outer membrane protein (OprD). Isolates in the main clade were uniformly tobramycin (TOB) resistant and 83% were ceftolozane/tazobactam resistant. In the entire sample, we found high resistance to most antipseudomonal agents, including new beta-lactam/beta-lactamase inhibitor combinations. No uniform susceptibility to an antipseudomonal agent was found. Carbapenemases were carried by 9.4% of isolates (5.9% blaGES-5 and 3.5% blaNDM-1) and oprD was mutated in 67% of isolates. Thus, the epidemiology of CRPA is explained by a combination of clonal expansion of a dominant high-risk clade and sporadic occurrence of mutated strains. Our findings highlight the importance of susceptibility testing using a wide panel of antibiotics when CRPA is detected. Prevention measures tracking and controlling emerging high-risk clades and clones are crucial to limit the spread of CRPA.

The effect of intraoperative midazolam on postoperative delirium in older surgical patients: a prospective, multicentre cohort study.

Midazolam is a short-acting benzodiazepine frequently used in the perioperative setting. This study aimed to investigate the potential impact of intraoperative midazolam on postoperative delirium (POD) in older patients undergoing non-cardiac surgery. This study included patients aged ≥ 65 years who received general anaesthesia between April 2020 and April 2022 in multiple hospitals across China. POD occurring within 7 days was assessed using the 3-minute Diagnostic Interview for Confusion Assessment Method (3D-CAM). Univariable and multivariable logistic regression models based on the random effects were used to determine the association between midazolam administration and the occurrence of POD, presented as risk ratio (RR) and 95% confidence intervals (CI). Kaplan-Meier cumulative incidence curve was plotted to compare the distribution of time to POD onset between patients who received midazolam and those who did not. Subgroup analyses based on specific populations were performed to explore the relationship between midazolam and POD. In all, 5,663 patients were included, of whom 723 (12.8%) developed POD. Univariate and multivariable logistic regression analyses based on random effects of different hospitals showed no significant association between midazolam medication and POD among older population (unadjusted RR=0.96, 95% CI: 0.90-1.30, P=0.38; adjusted RR=1.09, 95% CI: 0.91-1.33, P=0.35). Kaplan-Meier curve showed no difference in the distribution of time to POD onset (Hazard ratio [HR]=1.02, 95%CI: 0.88-1.18, P=0.82). The results of subgroup analyses found that intraoperative midazolam treatment was not associated with POD in the specific subgroups of patients. Intraoperative administration of midazolam may not be associated with an increased risk of POD in older patients undergoing non-cardiac surgery.

A point-of-care testing strip based on a rationally designed antigen and antibody for fast and reliable Diquat poisoning detection: Ready for clinical application

AbstractDiquat (DQ) is a nonselective quick-acting herbicide, which can directly contaminate humans and the environment during improper use and production. The early diagnosis of DQ poisoning allows for patients to receive timely treatment. Here, a novel monoclonal antibody was screened based on the rational design and synthesis of a DQ hapten and complete antigen. With the custom-designed anti-DQ antibody, we developed a stable and specific immunochromatographic strip to recognize DQ within 10 ∼ 15 min in various biological samples. The test strips could recognize DQ at concentrations as low as 20 ng/mL and be read by the naked eye, reaching the detection level of liquid chromatography-mass spectrometry. Moreover, quantitative methods involving the use of immunochromatographic strips and ELISA were developed to continuously monitor DQ concentrations. DQ and paraquat (PQ) joint test strips were developed to simultaneously measure DQ and PQ. Notably, the clinical performance of the proposed test strips was evaluated in multiple hospitals and public health agencies. Taken together, our study provides the first clinical DQ-targeted colloidal gold immunochromatographic test strips with excellent performance, which are expected to be useful for clinical practice, environmental monitoring, food safety and scientific research.

Risk Profiles of Avoidable and Unavoidable Hospitalizations: a Swedish population-based study

Abstract Background Older adults frequently experience multiple hospitalizations, owing to their complex health and social needs. This study aims to comprehensively characterize the risk factors associated with avoidable and unavoidable hospitalization among older adults. Specific emphasis is placed on avoidable/unavoidable hospitalization originating from chronic or acute causes. Methods Data on 3,166 individuals aged ≥60 years were obtained from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K), linked to the Swedish National Patient Register. Multistate models were used to investigate the risk profiles of participants experiencing their first and recurrent hospitalizations over 15 years. The Swedish National Board of Health and Welfare criteria were used to define avoidable/unavoidable hospitalizations. Results Women had a lower hazard of avoidable hospitalizations for chronic conditions as well as unavoidable hospitalizations (HR range 0.46-0.84). However, receiving informal care was associated with 88% increased hazard of avoidable hospitalizations due to chronic causes (95%CI 1.18-2.99), while receiving formal care was associated with 44% increasing hazard of avoidable hospitalization due to acute causes (95%CI1.04-1.98). Factors such as slow walking speed, multimorbidity, and polypharmacy were associated with a high risk of avoidable hospitalizations due to both acute (HR range1.27-3.03) and chronic (HR range1.63-2.54) causes. Conclusions Both clinical and functional factors have emerged as key predictors of avoidable hospitalization, underscoring the importance of comprehensive risk assessment and proactive healthcare management strategies to reduce the burden of hospital utilization in older adults. Key messages • Targeted interventions are essential to improve healthcare outcomes among older adults at risk of avoidable hospitalizations due to chronic and acute conditions. • The study identified predictors such as slow walking speed, multimorbidity, and polypharmacy, underscoring the need for comprehensive risk assessment to prevent avoidable hospitalization.

PANDAS, a series of difficult decisions: a case report

BackgroundPediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS) is a controversial diagnosis with limited evidence-based treatment guidelines available, particularly for severe and treatment-resistant cases.Case presentation: This report describes a 9-year-old male presenting with sudden onset, severe obsessive-compulsive disorder (OCD) symptoms one month following a streptococcus infection. His symptoms included suicidality and recurrent self-injurious behaviors, which led to multiple inpatient hospitalizations. He was diagnosed with PANDAS and was treated with psychotropic medications, antibiotics, immunotherapy, and a tonsillectomy. Over the two years since initial admission, the patient’s condition improved, with a decrease in symptom severity and an increase in adaptive functioning, though symptom remission was slow to occur.ConclusionsThis paper explores the controversies surrounding the PANDAS diagnosis, reviews potential treatments, and discusses the dilemmas of medical decision-making in the setting of severe treatment-resistant symptoms and limited evidence-based guidelines. We hope that this case report will be valuable to healthcare providers facing similar presentations and inspire further investigation into this complex condition.