Need For Rehospitalization Research Articles

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Neonatal visits to the pediatric emergency center and its implications on postnatal discharge practices in Qatar

Background:An early discharge from postnatal policy has been practiced at Women's Hospital, Hamad Medical Corporation.Aim:This observational cohort study was conducted to evaluate the effect of early postnatal discharge practice on neonatal morbidity in the State of Qatar.Setting and Design:This is a data-based cohort study. All neonates ≤28 days visiting the Pediatric Emergency Centers (PEC) were evaluated for the need for re-hospitalization, referral for clinic appointments, or observation at the PEC setting.Materials and Methods:Differences in outcome rates were compared in neonates who visited in the first 24 hours postnatal discharge (2-3 days of life) and those who visited after the third day of life.Statistical Analysis:Crude differences in incidence rate assessed by χ2 or Fisher exact test were applicable.Results:Of 3528 PEC visits for 1915 neonates, 1.7% required admission (3.1% of neonates), 8.4% were observed, 1.1% were referred to a clinic, and the remaining were discharged home. There was no significant difference in re-hospitalization rates of neonates visiting PEC in the first 3 days and those visiting at a later age (OR 0.78, 95% CL 0.19-3.23, P=1). However, early presentations to PEC was more likely to result in periods of observation (OR 1.88, 95% CL 1.17-3.04, P=0.01), or clinic referral (OR 4.96, 95% CL 2.16-11.38, P=0.001) when compared to older neonates. Moreover, those who presented early were significantly more likely to revisit any of the PECs with in the 28 days period (OR 3.20, 95% CL 2.17-4.97, P<0.0001).Conclusion:These results clearly demonstrate the need for a structured early post-discharge follow-up service that addresses the needs of all neonates and their families. The results, however, do not provide sufficient evidence that delaying postnatal discharges for apparently healthy neonates will provide significant health benefits to these neonates and their families.

The prevalence and risk factors of allergic and respiratory symptoms in a regional cohort of extremely low birth weight children (&lt;1000 g)

BackgroundChildren who were <1000 g (ELBW extremely low birth weight) at birth more frequently present with wheezing which is the most common reason that pediatric consultation is sought. Therefore asthma is diagnosed very often. However is the asthma that is diagnosed in ELBW subjects atopic in origin, or is there a different etiology?AimTo determine if ELBW infants are at higher risk for the development of allergic and respiratory symptoms and to establish if there were any specific risk factors for these symptoms.Methods81 children born with a mean birthweight of 845 g (91% of available cohort) were evaluated at the mean age 6.7 years. The control group included 40 full-term children. The children were examined for clinical signs of allergy, and were subjected to the following tests: serum total IgE, skin prick tests (SPT), exhaled nitric oxide measurement (FeNO) and spirometry.ResultsELBW children had wheezing episodes more often (64% vs. 25%; OR (odds ratio): 5.38; 95% CI (confidence interval): 2.14-13.8) and were diagnosed more frequently with asthma (32% vs. 7.5%; OR: 5.83, 95% CI: 1.52-26) than their term born peers. The most important risk factors for wheezing persistence were hospitalization and wheezing episodes in first 24 months of life. Mean serum tIgE level (geometric mean: 32+/−4 vs. 56+/−4 kU/L; p=0.002) was higher and the number of children with positive results of tIgE level (12% vs. 32%; p=0.02) were more frequent in the control group. Children from the control group also more frequently had SPT, however this data was not statistically significant (11% vs. 24%; p=0.09). All of the ELBW had normal FeNO level (<=20 ppb), but 5 children from the control group had abnormal results (p=0.02). There was no difference between the groups in the occurrence of allergic symptoms.ConclusionELBW children have more frequent respiratory, but not allergic problems at the age of 6–7 years compared to children born at term. The need for rehospitalization in the first 2 years of life, was a more important risk factor of future respiratory problems at the age of 7 than perinatal factors, the diagnosis of bronchopulmonary dysplasia or allergy.

Subsequent Infections in Survivors of Sepsis

Sepsis is a devastating condition with considerable mortality. The causes of long-term mortality are poorly understood. To test the hypothesis that patients with sepsis are more susceptible to recurrent infections and death due to infectious complications, we investigated the outcomes of patients who survived sepsis, with regard to the incidence of recurrent infections and mortality. A retrospective study of the patients admitted to the intensive care unit (ICU) for sepsis from 2001 to 2002 who achieved 30-day survival (sepsis survivors [SSs], N = 78) and a control group of patients admitted to the ICU for noninfectious conditions with a similar severity of illness (N = 50) was performed. The primary end point was the number of recurrent infections in the first year posthospitalization. The SSs group had higher rates of infections following hospital discharge compared to controls. Using a multivariable model, having survived sepsis was the strongest predictor of the development of subsequent infections (rate ratio [RR]: 2.83, P= .0006), the need for rehospitalization for infection in the year after the initial hospitalization (RR: 3.78, P = .0009), and postdischarge mortality (hazard ratio = 3.61, P = .003). Critically ill patients who survive sepsis have an increased risk of recurrent infections in the year following their septic episode that is associated with increased mortality.

Efficacy of Tamsulosin Oral Controlled Absorption System After Extracorporeal Shock Wave Lithotripsy to Treat Urolithiasis

To determine the efficacy of the tamsulosin oral controlled absorption system as an adjuvant therapy to extracorporeal shock wave lithotripsy (ESWL) for the expulsion of ureteral and renal stones. A consecutive sample of 248 patients with ureteral or renal stones who underwent ESWL in an academic hospital was included in a 12-week, prospective, open-label, randomized clinical trial. Of the 248 patients, 186, including 77 with ureteral stones (mean size 9 mm) and 109 with renal stones (mean size 13 mm) completed the study. After successful ESWL, the patients were randomized to standard medical care (corticosteroids and analgesics) or standard care plus the tamsulosin oral controlled absorption system 0.4 mg/d for 1 month. The stone clearance rate, interval to the elimination of stone fragments, incidence of renal colic, and the need for rehospitalization were assessed at 4, 8, and 12 weeks. The stone clearance rate was significantly greater for the patients treated with tamsulosin than for those in the standard care group at 4 (73.4% vs 55.9%, respectively; P < .001) and 12 (91.3% vs 74.6%, respectively; P < .05) weeks. Tamsulosin treatment was also associated with a significantly lower interval to the elimination of stone fragments (P < .001), a significantly lower rehospitalization rate (P < .001), and a significantly lower proportion of patients with acute renal colic (P < .05) than standard care alone. No severe adverse events leading to treatment discontinuation were observed. Adjuvant treatment with tamsulosin, in addition to standard treatment with steroids and analgesics, improved the outcome of ESWL.

Cost-effectiveness analysis on spinal anesthesia versus local anesthesia plus sedation for loop colostomy closure

Studies in the area of health economics are still poorly explored and it is known that the cost savings in this area is becoming more necessary, provided that strict criteria. To perform a cost-effectiveness analysis of spinal anesthesia versus local anesthesia plus sedation for loop colostomy closure. This was a randomized clinical trial with 50 patients undergoing loop colostomy closure either under spinal anesthesia (n = 25) or under local anesthesia plus sedation (n = 25). The duration of the operation, time spent in the post-anesthesia recovery room, pain, postoperative complications, length of hospital stay, laboratory and imaging examinations and need for rehospitalization and reoperation were analyzed. The direct medical costs were analyzed. A decision tree model was constructed. The outcome measures were mean cost and cost per local and systemic postoperative complications avoided. Incremental cost-effectiveness ratios were presented. Duration of operation: 146 +/- 111.5 min. vs 105 +/- 23.6 min. (P = 0.012); mean time spent in post-anesthesia recovery room: 145 +/- 110.8 min. vs 36.8 +/- 34.6 min. (P<0.001). Immediate postoperative pain was lower with local anesthesia plus sedation (P<0.05). Local and systemic complications were fewer with local anesthesia plus sedation (P = 0.209). Hospitalization + rehospitalization: 4.5 +/- 4.1 days vs 2.9 +/- 2.2 days (P<0.0001); mean spending per patient: R$ 5,038.05 vs 2,665.57 (P<0.001). Incremental cost-effectiveness ratio: R$ -474.78, indicating that the strategy with local anesthesia plus sedation is cost saving. In the present investigation, loop colostomy closure under local anesthesia plus sedation was effective and appeared to be a dominant strategy, compared with the same surgical procedure under spinal anesthesia.

250 Consecutive Unilateral Extravesical Ureteral Reimplantations in an Outpatient Setting

Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures and more effective than subureteral injection to resolve vesicoureteral reflux. Initial reports showed that the procedure could be feasibly done on an outpatient basis. We present further data on a large series of consecutive, planned, outpatient unilateral extravesical ureteral reimplantations. A total of 250 consecutive patients underwent scheduled outpatient unilateral extravesical ureteral reimplantation. We retrospectively reviewed their records. Patient data were collected on reflux laterality and grade, operative time, hospital stay, complications, need for rehospitalization and resolution rate on radiography 1 month postoperatively. A total of 209 females (84%) and 41 males (16%) underwent planned outpatient extravesical ureteral reimplantation, including on the left side in 158 (63%) and on the right side in 92 (37%). Mean reflux grade was 3.2 with grades II to V in 64 (26%), 96 (38%), 74 (30%) and 16 cases (7%), respectively. Average operative time was 63 minutes and average length of stay, defined as time from initial admission in to discharge home, was 6.2 hours (range 3 to 10 hours). Short-term and late complications occurred in 9 (3.6%) and 8 patients (3.2%), respectively. Extravesical ureteral reimplantation for unilateral vesicoureteral reflux may be consistently done on an outpatient basis with a reasonable complication rate and a low postoperative hospital admission rate.

Variability in Duration of Outpatient Diuretic Therapy in Bronchopulmonary Dysplasia: A Clinical Experience

We describe usual duration of outpatient diuretic therapy and duration of tapering of outpatient diuretics in infants with established bronchopulmonary dysplasia (BPD), and we identify factors associated with duration of diuretic taper. Infants with BPD discharged from the neonatal intensive care unit on diuretic therapy were identified and data were abstracted from clinical databases and medical records. BPD was defined as oxygen dependence at 28 days of life. Infants with chromosomal abnormalities or congenital heart disease and those requiring tracheostomy placement were excluded. Descriptive, univariate, and multivariate analyses were performed. Of 59 patients discharged on diuretic therapy, 10 were also discharged on oxygen. Median (25th, 75th percentiles) duration of outpatient diuretic therapy was 94 (69, 115) days and 30 (14, 84) days for duration of diuretic taper. Duration of therapy and duration of taper were significantly longer in infants discharged on oxygen. In Cox proportional hazards modeling, longer diuretic taper was associated with a higher dose of chlorothiazide at discharge, shorter interval to first outpatient visit, need for rehospitalization, and African-American race. Birth weight, gestational age, and various discharge therapies were not significantly associated with duration of taper after adjusting for these factors. In 58% of all patients, diuretics were tapered or discontinued at the first outpatient visit. This study demonstrated great variability in the duration of diuretic therapy and diuretic taper. Discharge on oxygen was associated with longer duration of diuretic therapy and taper. Active taper is successful in the majority of patients and should be considered in patients with stable BPD.

Staphylococcus aureus Bloodstream Infections in Older Adults: Clinical Outcomes and Risk Factors for In‐Hospital Mortality

To assess clinical outcomes and identify risk factors for mortality in older adults with Staphylococcus aureus bloodstream infection (SAB). Retrospective review. University of Michigan Health System, Ann Arbor. All patients aged 80 and older with SAB between January 2004 and July 2008. Clinical data, including comorbid conditions, SAB source, echocardiography results, Charlson Comorbidity Index, mortality (in-hospital and 6-month), and need for rehospitalization or chronic care after discharge. Seventy-six patients aged 80 and older (mean 85.5 +/- 4.2) with SAB were identified. Infection sources included 14 (18.4%) vascular catheter associated, 16 (21.1%) wound related, seven (9.2%) endocarditis, five (6.6%) intravascular, and 19 (25%) with unknown source; 46 (60.5%) patients had methicillin-resistant strains. Twenty-two (28.9%) patients underwent surgery or device placement within 30 days of developing SAB; 10 of these 22 had SAB associated with surgical site infection (SSI). Twenty two (28.9%) patients died in the hospital or were discharged to hospice care; at least 43 (56.6%) patients died within 6 months of presentation, and eight were lost to follow-up. Unknown source of bacteremia (odds ratio=5.2, P=.008) was independently associated with in-hospital death. Echocardiography was not pursued in 45% of patients. Of surviving patients, 40 (74.1%) required skilled care after discharge; eight (20%) required rehospitalization. SAB was associated with high mortality rates in patients aged 80 and older. The observed association between SAB and SSI may direct preventive strategies such as perioperative decolonization or antimicrobial prophylaxis. Interventions to optimize clinical care practices in elderly patients with SAB are essential given the associated morbidity and mortality.

A Randomized Controlled Trial of a Private-Sector Inpatient-Initiated Psychoeducation Program for Schizophrenia

A Randomized Controlled Trial of a Private-Sector Inpatient-Initiated Psychoeducation Program for Schizophrenia

The Role of Anemia in the Progression of Congestive Heart Failure: Is There a Place for Erythropoietin and Intravenous Iron?

SUMMARY Despite all the advances in congestive heart failure (CHF), the mortality, morbidity and the number of rehospitalizations in this condition is still very high, even if patients are given the recommended CHF medications in the recommended doses.We found that the majority of these refractory CHF patients were anemic, with hemoglobin concentrations less than 12 g/dL. In both uncontrolled and controlled studies, when we corrected their anemia with subcutaneous erythropoietin (EPO) and intravenous iron sucrose, we found that their cardiac functional status and cardiac function improved, their need for rehospitalization fell dramatically and their need for diuretics improved greatly. Their renal function, which had been deteriorating rapidly before correction of the anemia, generally stabilized or improved. Others subsequently found, in controlled studies using EPO, that cardiac function, as judged by oxygen utilization during peak exercise, also improved, as did exercise capacity and quality of life. Subsequently, many others have examined this relationship of anemia to the severity of CHF, the mortality rate and the hospitalization rate, and the great majority have confirmed our findings. A randomized controlled double-blind study is now being carried out on hundreds of severe, anemic CHF patients to ascertain the role of anemia correction is in CHF. If it verifies the preliminary optimistic results mentioned above, anemia management may become an important new therapy for the prevention of progression of CHF and the associated renal failure.

Smoking status and antithrombin therapy in patients with non–ST-segment elevation acute coronary syndrome

Smoking remains a major public health issue. We investigated the incidence of smoking and outcomes in high-risk patients with acute coronary syndromes. Differences in treatment effect of antithrombin therapies were also investigated. Using data from SYNERGY, patients were categorized by their self-reported smoking status. They were followed at 30 days and 6 months for death, nonfatal myocardial infarction (MI), revascularization procedures, stroke, and need for rehospitalization, and at 1 year for occurrences of death. Overall, 9,971 patients were evaluated, of whom 2,404 (24%) were current smokers, 3,491 (35%) were former smokers, and 4076 (41%) had never smoked. Current smokers were younger (median age 61 years, interquartile range [IQR] 52-67) than former smokers (median age 69 years, IQR 63-75) and never smokers (median age 70 years, IQR 64-77) and had fewer additional coronary artery disease risk factors (hypertension, diabetes, hypercholesterolemia). The 30-day death/MI rate was similar for former versus never smokers (15% vs 13.6%, P = .079) and for current versus never smokers (14% vs 13.6%, P = .585). Adjusted odds ratios for 30-day death/MI in patients receiving enoxaparin compared with those receiving unfractionated heparin were 1.065 (95% CI 0.883-1.283, P = .51) in never smokers, 1.034 (95% CI 0.853-1.254, P = .733) in former smokers, and 0.742 (95% CI 0.582-0.948, P = .017) in current smokers. A significant interaction for treatment and smoking status was found at 30 days (P = .0215), but not at 6 months (P = .1381) or 1 year (P = .1054). One-year unadjusted mortality rates were higher for former versus never smokers (9.1% vs 6.7%, P = .0002) but were similar for current versus never smokers (6.5% vs 6.7%, P = .7226). On follow-up at 30 days, 62.3% (n =1397) of current smokers reported not smoking. Smokers with non-ST-segment elevation acute coronary syndrome are generally younger and have fewer cardiac risk factors. A significant interaction of smoking and enoxaparin was seen at 30 days, but not sustained at 6 months and 1 year. More than 60% of smokers quit within 30 days of their cardiac event. There was little difference in outcomes from 30 days to 1 year for these smokers who quit versus those who did not.

Pharmacokinetic-Pharmacodynamic Crisis in the Elderly

Aging is characterized by a progressive loss of functional capacities of most if not all organs, a reduction in homeostatic mechanisms, and a response to receptor stimulation. Also, loss of water content and an increase of fat content in the body are reported. Therefore, understanding the influence of age-dependent changes in composition and function of the body on the pharmacokinetics and pharmacodynamics of drugs is important before prescribing drugs to elderly patients. In this study, a Medline search for articles published in the period between 1975 and June 2006 was conducted with use of the key words aging, pharmacokinetics, and pharmacodynamics to review data related to alteration in pharmacokinetics and pharmacodynamics in elderly patients. Analysis of data revealed that the most important pharmacokinetic changes in old age include a decrease in the excretory capacity of the kidney more than the decline in the rate of hepatic drug metabolism. On the other hand, pharmacodynamic changes in the elderly are frequent and commonly ascribed to alteration in the sensitivity to drugs, irrespective of changes in drug disposition. For instance, the sensitivity of the cardiovascular system to beta-adrenergic agonists and antagonists decreases in old age, and the incidence of orthostatic episodes in response to drugs that lower blood pressure increases. However, the central nervous system becomes vulnerable in the elderly to agents that affect brain function (eg, opioids, benzodiazepines, and psychotropic drugs). Therefore, these drugs must be used very cautiously in this age group. In conclusion, the complexity of the interactions between polypharmacy, comorbidity, altered pharmacodynamic sensitivity, and even modest changes in pharmacokinetics in elderly necessitate the medical approach "start low and go slow" for aged subjects, especially if drug therapy is considered beneficial or absolutely necessary for them.

Safe Transition to Home: Preparing the Near-term Infant for Discharge

Near-term infants, although often mature in appearance, are at risk for developing several complications, including hypothermia, hypoglycemia, infection, inadequate feeding, airway compromise, and hyperbilirubinemia. In many cases, these infants are discharged home with their mothers within 48 to 72 hours of delivery with similar discharge education and follow-up as full-term infants. This practice is not evidence-based and places these infants at risk for serious complications. In this article, the physiologic mechanisms that increase the risk of complications in this population are reviewed to provide the reader with an in-depth understanding of the importance of tailoring discharge education and follow-up to this specific population. Implications for practice are proposed and a near-term infant discharge checklist is introduced. The proposed changes in clinical practice aim at better meeting the needs of near-term infants and their families to promote the safe transition to home and prevent the development of complications and need for rehospitalization.

Poststroke Care

See related article, pages 1899–1904. “Thinking is easy, acting is difficult, and to put one’s thoughts into action is the most difficult thing in the world”. — —Goethe (1749–1832) Major advances in acute stroke management have been seen over the past decade, including the use of thrombolysis, antithrombotic therapy, and organized in-hospital stroke care. However, relatively few studies have evaluated the effectiveness of these interventions in routine clinical practice, or have assessed issues related to delivery of services, access to care, and long-term care after discharge from stroke. In this issue of Stroke , Bravata et al1 contribute to our understanding of outcomes after stroke by analyzing readmissions and deaths in the first 5 years after a hospitalization for stroke. The target population included stroke survivors aged over 65 years who were Medicare beneficiaries and who were discharged from Connecticut acute care hospitals in 1995. This population was followed from discharge in 1995 through 2000 using Medicare claims and Social Security Administration mortality data. Among 2603 patients discharged alive, 40% were readmitted at least once within the first year of discharge, 53% had died or been readmitted within 1 year and only 15% survived admission-free for 5 years. Leading causes for readmission included pneumonia (8.2% to 9.0%), stroke (3.9% to 6.1%) and acute myocardial infarction (4.2% to 6.0%). There was no apparent association between length of hospital stay and readmission rate (unreported data kindly provided by the authors, 2007), and no information was available on potential patient and system factors associated with higher hospital readmission rates. Lower readmission rates of 25% to 27% within 1 year have been previously reported.2,3 These studies found that the average number of days of rehospitalization was 23.2 Stroke was the single most frequent reason for readmission followed by cardiac disease, …

A review of levosimendan in the treatment of heart failure

Heart failure is a relatively important public health problem due to its increasing incidence, poor prognosis, and frequent need of re-hospitalization. Intravenous positive inotropic agents play an important role in treating acute decompensation of patients with heart failure due to left ventricular systolic dysfunction. Although frequently used, the inotropic agents beta-adrenergic agonists and phosphodiesterase inhibitors seem effective for improving symptoms in the short term; it has been shown that they increase morbidity and mortality by elevating intracellular cyclic adenosine monophosphate (cAMP) and calcium levels. Levosimendan is a new positive inotropic agent having ATP-dependent potassium-channel-opening and calcium-sensitizing effects. In studies on its effects without increasing intracellular calcium concentrations and on its effects that depend on available intracellular calcium levels, it has been shown to have favorable characteristics different from those of current inotropic agents, which exert their effects by increasing calcium concentrations. This study aims to review other important studies about levosimendan by revealing the underlying mechanisms of its activity, efficiency, and safety.

Patient-Provider Partnerships in Healthcare: Enhancing Knowledge Translation and Improving Outcomes

In the complex health arena, a key proposition is that no person acting alone is as effective as a team to drive best practices and outcomes. Another key factor supporting best outcomes is access to the best information to support best choices. Currently, stakeholders suffer from a paucity of real-world knowledge of actual practices and outcomes that allows care gaps to go undiscovered. A body of evidence indicates that measurement and timely feedback of actual practices can decrease the gaps between usual and best care. This is driven by the stakeholders' desire to be the best they can be, and it is enabled by the measured knowledge of where practices fall short of gold standards. The addition of patient partners to such communities of care offers promise of further acceleration and broader impact of knowledge translation and associated beneficial outcomes. For example, in the Improving Cardiac Outcomes in Nova Scotia (ICONS) community-based heart disease project, there was a marked decrease in rates of re-hospitalization over the five-year course of the project. This improvement was only very weakly, or not at all, related to traditional risk factors, such as the presence of multiple illnesses or older age, or to the use of efficacious medical therapies. However, ICONS provided an extensive and repeated multimedia communication among patients, families and providers of project goals, strategy and general news, as well as repeated measurements of practices and outcomes. One outcome of this shared knowledge may have been the reduced need for re-hospitalization. While exact cause-and-effect relationship remain uncertain, patient-provider integrated health networks appear feasible and offer promise for efficient knowledge creation and its population-effective translation. The model and its implementation may be improved by testing further locally responsive initiatives in innovative partnership clusters and by training more personnel resources in inter-professional settings.

Length of postnatal stay in healthy newborns and re-hospitalization following their early discharge

The present study was conducted prospectively to determine i) the length of postnatal hospital stay of healthy newborns and determine the factors facilitating their early discharge (< 48 h) and ii) the frequency and causes of re-hospitalization following early discharge, in a tertiary care hospital. Length of hospital stay was recorded for healthy newborns. Factors facilitating Early discharge were determined by both univariate and multivariate (multiple logistic regression) analyses. Of all newborns discharged within 48 h, every third case was called for a follow-up visit 72 hrs later and examined for any medical problem and need of re-hospitalization. A total of 1134 babies were enrolled, of which 861 (76.2%) were discharged at or before 48 hours. The overall mean (SD) length of hospital stay was 46.4 (45.8) h. Factors contributing to early discharge included vaginal delivery (RR: 30.2; 95% CI: 19.0, 47.9; P<0.001), absence of pre-existing maternal disease or obstetric complication (RR: 4.32; 95% CI: 2.27, 8.22; P < 0.001), and birth weight of > 2.5 kg (RR: 1.91; 95% CI: 1.27, 2.89; P = 0.002). Of the 280 neonates called for follow-up, 193 reported. Of these, 61 (31.6%) were normal. Neonatal jaundice was the most frequent problem seen in 105 (54.4%) children on follow-up. Only 16 (8.3%) newborns needed re-hospitalization; the most common indication being neonatal jaundice (n=9). Most of the children in our set-up are being discharged within 48 hrs. Early discharge is governed primarily by maternal indications. A follow-up visit after 72 hr is important to assess the need of re-hospitalization in healthy newborns discharged within 48 hrs of birth.

Growth in the Neonatal Intensive Care Unit Influences Neurodevelopmental and Growth Outcomes of Extremely Low Birth Weight Infants

The objectives of this study were to assess whether (1) in-hospital growth velocity is predictive of neurodevelopmental and growth outcomes at 18 to 22 months' corrected age among extremely low birth weight (ELBW) infants and (2) in-hospital growth velocity contributes to these outcomes after controlling for confounding demographic and clinical variables. Infants 501 to 1000 g birth weight from a multicenter cohort study were divided into quartiles of in-hospital growth velocity rates. Variables considered for the logistic-regression models included gender, race, gestational age, small for gestational age, mother's education, severe intraventricular hemorrhage, periventricular leukomalacia, age at regaining birth weight, necrotizing enterocolitis, late-onset infection, bronchopulmonary dysplasia, postnatal steroid therapy for pulmonary disease, and center. Of the 600 discharged infants, 495 (83%) were evaluated at 18 to 22 months' corrected age. As the rate of weight gain increased between quartile 1 and quartile 4, from 12.0 to 21.2 g/kg per day, the incidence of cerebral palsy, Bayley II Mental Developmental Index (MDI) <70 and Psychomotor Developmental Index (PDI) <70, abnormal neurologic examination, neurodevelopmental impairment, and need for rehospitalization fell significantly. Similar findings were observed as the rate of head circumference growth increased. The in-hospital rate of growth was associated with the likelihood of anthropometric measurements at 18 months' corrected age below the 10th percentile values of the Centers for Disease Control and Prevention 2000 growth curve. Logistic-regression analyses, controlling for potential demographic or clinical cofounders, and adjusted for center, identified a significant relationship between growth velocity and the likelihood of cerebral palsy, MDI and PDI scores of <70, and neurodevelopmental impairment. These analyses suggest that growth velocity during an ELBW infant's NICU hospitalization exerts a significant, and possibly independent, effect on neurodevelopmental and growth outcomes at 18 to 22 months' corrected age.

Rules for Predicting Safe Early Hospital Discharge for Patients with Upper Gastrointestinal Bleeding: A Phase I (Derivation Phase) Study

Backgrounds: Upper gastrointestinal bleeding (UGIB) is a common cause of hospitalization and resource utilization. The condition is often self-limiting in most patients. We aim to derive at decision rules to identify patients who may be discharged same day from the emergency rooms (ER) after endoscopic triage. Methods: Consecutive admissions of adult patients via ER with acute UGIB from April 2004 to April 2005 were prospectively entered into a database. We defined the high risk group as those requiring endoscopic therapy, those continued to bleed or developed re-bleeding, or the need for re-hospitalization, surgery and death within 30 days of admissions. Clinical and endoscopic parameters were analyzed using logistic regression model. Results: There were 432 admissions of adult patients for acute UGIB, and 99 (22.9%) were classified as the high risk group. Fresh hematemesis at presentation, systolic BP ≤ 100 mm Hg, low hematocrit ≤ 0.3, INR > 1.2, previous history of ulcer, ASA grade > 3 and presence of liver cirrhosis were independent factors that predicted events defined as above. These constituted a risk score. Those with a risk score ≤ 1 were categorized as low risk. The area under the ROC curve of our score was 0.71 (95% CI 0.65-0.77), which was significantly higher than that of Blatchford score (0.67 [0.61-0.74]), and the Rockall admission (0.60 [0.54-0.66]) and post-endoscopy scores (0.67 [0.61-0.73]) applied to the same cohort. Low risk patients may receive upper endoscopy at the level of ER, such that patients with high risk lesions warranting endoscopic therapy would be triaged to hospitalization, while others would be discharged. Screening with the risk score in combined with endoscopic triage at the ER allow 265/432 (61.3%) patients to be discharged on the same day. Conclusion: Our risk score is a simple method to identify low risk patients and to reduce admission when combined with endoscopic triage. It will be validated in another prospective cohort.