Post-discharge Follow-up Visits Research Articles

Improvements in Transitional Care Among Medicaid-Insured Patients With Serious Mental Illness.

The Thrive program is an evidenced-based care model for Medicaid-insured adults in the hospital-to-home transition. A substantial portion of Thrive participants live with serious mental illness (SMI), yet Thrive's efficacy has not been tested among these patients. To compare 30-day postdischarge outcomes between Thrive participants with and without SMI and explore Thrive's appropriateness and acceptability among participants with SMI. We conducted a sequential explanatory mixed-methods study of 252 (62 with SMI) Thrive participants discharged from an academic medical center from February 2021 to August 2023. Interviews of participants with SMI were analyzed using rapid qualitative analysis. Participants with and without SMI experienced similar rates of 30-day readmissions, emergency room visits, and postdischarge follow-up visits, with these differences being nonsignificant. Participants with SMI were highly satisfied with Thrive's care coordination and attention to social needs, yet participants suggested stronger connections to behavioral health care. Participants with and without SMI benefit equitably from Thrive.

Outpatient Follow-Up Visits to Reduce 30-Day All-Cause Readmissions for Heart Failure, COPD, Myocardial Infarction, and Stroke: A Systematic Review and Meta-Analysis.

Hospital readmissions is an important public health problem that US hospitals are responsible for reducing. One strategy for preventing readmissions is to schedule an outpatient follow-up visit before discharge. The objective of this study was to determine whether outpatient follow-up visits are an effective method to reduce 30-day all-cause readmissions for patients discharged from US hospitals with heart failure, chronic obstructive pulmonary disease (COPD), acute myocardial infarction (AMI), or stroke. We conducted a systematic review and meta-analysis to identify relevant articles published from 2013 through 2023. We searched PubMed, CINAHL, and Cochrane. Eligible studies were those that assessed the effect of postdischarge outpatient follow-up visits on 30-day all-cause readmission. We used random effect meta-analyses to generate pooled adjusted effect estimates and 95% CIs. We initially identified 2,256 articles. Of these, 32 articles underwent full-text review and 15 met inclusion criteria. Seven studies addressed heart failure, 3 COPD, 2 AMI, and 3 stroke. Ten articles provided sufficient information for meta-analysis. The pooled adjusted effect measure was 0.79 (95% CI, 0.69-0.91), indicating that outpatient follow-up visits were associated with a 21% lower risk of readmission. However, we found a high degree of between-study heterogeneity (Q = 122.78; P < .001; I2 = 92.7%). Subgroup analyses indicated that study quality, disease condition, and particularly whether a time-dependent analysis method was used, explained much of the heterogeneity. Outpatient follow-up visits are a potentially effective way to reduce 30-day all-cause readmissions for patients discharged with heart failure or stroke, but evidence of benefit was lacking for COPD and we found no studies for assessing AMI. Our results emphasize the importance of study quality.

Risk of readmission and death after hospitalization for worsening heart failure: Role of post-discharge follow-up visits in a real-world study from the Grand Est Region of France.

Patients who experience hospitalizations due to heart failure (HF) face a significant risk of readmission and mortality. Our objective was to evaluate whether the risk of hospitalization and mortality following discharge from HF hospitalization differed based on adherence to the outpatient follow-up (FU) protocol comprising an appointment with a general practitioner (GP) within 15 days, a cardiologist within 2 months or both (termed combined FU). We studied all adults admitted for a first HF hospitalization from 2016 to 2020 in France's Grand Est region. Association between adherence to outpatient FU and outcomes were assessed with time-dependent survival analysis model. Among 67 476 admitted patients (mean age 80.3 ± 11.3 years, 53% women), 62 156 patients (92.2%) were discharged alive and followed for 723 (317-1276) days. Combined FU within 2 months was used in 21.1% of patients, with lower rates among >85 years, women, and those with higher comorbidity levels (p < 0.0001 for all). Combined FU was associated with a lower 1-year death or rehospitalization (adjusted hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.88-0.94, p < 0.0001) mostly related to lower mortality (adjusted HR 0.65, 95% CI 0.62-0.68, p < 0.0001) whereas HF readmission was higher (adjusted HR 1.19, 95% CI 1.15-1.24, p < 0.0001). When analysing components of combined FU separately, 1-year mortality was more related to cardiologist FU (HR 0.65, 95% CI 0.62-0.67, p < 0.0001), than GP FU (HR 0.87, 95% CI 0.85-0.90, p < 0.0001). Combined FU is carried out in a minority of patients following HF hospitalization, yet it is linked to a substantial reduction in 1-year mortality, albeit at the expense of an increase in HF hospitalizations.

National Patterns of Outpatient Follow-Up Visits After Emergency Care for Acute Bronchiolitis

This cohort study examines the frequency of postdischarge follow-up visits among US emergency department encounters for bronchiolitis and assesses whether follow-up was associated with decreased hospital reutilization or increased treatment with nonrecommended medications.

Changes in Lipoprotein(a) Levels in People after ST Elevation Myocardial Infarction-The STEMI-Lipids Study.

Lipoprotein(a) (Lp(a)) is considered an independent risk factor for cardiovascular diseases. The plasma concentration of Lp(a) is largely genetically determined but varies over a wide range within the population. This study investigated changes in Lp(a) levels after an acute myocardial infarction. Patients who underwent coronary angiography due to an ST elevation myocardial infarction were enrolled (n = 86), and Lp(a) levels were measured immediately after the intervention, one day, two days, and at a post-discharge follow-up visit at 3 to 6 months after the acute myocardial infarction. Median Lp(a) levels increased from a median of 7.9 mg/dL (3.8-37.1) at hospital admission to 8.4 mg/dL (3.9-35.4) on the following day, then to 9.3 mg/dL (3.7-39.1) on day two (p < 0.001), and to 11.2 mg/dL (4.4-59.6) at the post-discharge follow-up (p < 0.001). Lp(a) levels were the lowest during the acute myocardial infarction and started to increase significantly immediately thereafter, with the highest levels at the post-discharge follow-up. The moderate but significant increase in Lp(a) in people with acute myocardial infarction appears to be clinically relevant on an individual basis, especially when specific Lp(a) cut-off levels are supposed to determine the initiation of future treatment. Hence, a repeated measurement of Lp(a) after myocardial infarction should be performed.

Benign recurrent lymphocytic meningitis (Mollaret's meningitis) in Denmark: a nationwide cohort study.

Data on clinical features and outcomes of benign recurrent lymphocytic meningitis (BRLM) are limited. This was a nationwide population-based cohort study of all adults hospitalized for BRLM associated with herpes simplex virus type 2 (HSV-2) at the departments of infectious diseases in Denmark from 2015 to 2020. Patients with single-episode HSV-2 meningitis were included for comparison. Forty-seven patients with BRLM (mean annual incidence 1.2/1,000,000 adults) and 118 with single-episode HSV-2 meningitis were included. The progression risk from HSV-2 meningitis to BRLM was 22% (95% confidence interval [CI] 15%-30%). The proportion of patients with the triad of headache, neck stiffness and photophobia/hyperacusis was similar between BRLM and single-episode HSV-2 meningitis (16/43 [37%] vs. 46/103 [45%]; p = 0.41), whilst the median cerebrospinal fluid leukocyte count was lower in BRLM (221 cells vs. 398 cells; p = 0.02). Unfavourable functional outcomes (Glasgow Outcome Scale score of 1-4) were less frequent in BRLM at all post-discharge follow-up visits. During the study period, 10 (21%) patients with BRLM were hospitalized for an additional recurrence (annual rate 6%, 95% CI 3%-12%). The hazard ratio for an additional recurrence was 3.93 (95% CI 1.02-15.3) for patients with three or more previous episodes of meningitis. Clinical features of BRLM were similar to those of single-episode HSV-2 meningitis, whilst post-discharge outcomes were more favourable. Patients with three or more previous episodes of meningitis had higher risk of an additional recurrence.

Construction of a Nomogram predictive model for post-discharge psychosomatic review of psychiatric liaison consultation patients based on medical record data.

Epidemiological studies have shown that almost all physical illnesses coexist with psychiatric disorders or psychological problems, and the severity of mental illness is positively correlated with the duration and severity of physical illness. Liaison consultations are valuable in identifying and treating psychiatric disorders, but the rate of psychiatric follow-up after consultation is low in outpatients. This study aimed to investigate the factors influencing post-discharge psychosomatic follow-up visits in patients undergoing psychiatric liaison consultation in general hospitals and construct a Nomogram prediction model for patients' post-discharge psychosomatic follow-up visits. Medical record data of inpatients who received psychiatric liaison consultations at Xi'an International Medical Center Hospital in China from September 2019 to September 2020 were analyzed. Lasso regression and multivariate logistic regression analyses were conducted to screen independent influences on the occurrence of post-discharge psychosomatic follow-ups in patients undergoing psychiatric liaison consultations. Risk prediction column line graphs were constructed using R software, and the models were evaluated. Of the 494 inpatients who received psychiatric liaison consultations, 115 patients (23.279%) (mean age = 54.8 years) went for post-discharge psychosomatic follow-up, while 379 patients (mean age = 59.3 years) had no record of psychosomatic follow-up. Furthermore, occupation, interval.time, diagnosis, out.antipsychotics, and recommendations.followup were independent factors influencing post-discharge psychosomatic follow-up. The model accurately predicted post-discharge psychosomatic follow-up behavior of inpatients who received psychiatric liaison consultations. Lastly, the clinical decision curve analysis showed that the model had good validity for clinical application. Patients who received a psychiatric liaison consultation with a ≤ 10-day interval between admission to the hospital and application for consultation, were discharged with prescribed medication, and had a clear written medical order for a follow-up consultation had an increased probability of psychosomatic follow-up after discharge.

Improving compliance with post-hospitalization follow-up visits: A single community cancer center experience.

e13508 Background: Hospital discharge follow-up visits are crucial for the continuity of care and for reducing rehospitalizations. They prevent medication disruptions, missing opportunities for making a post-discharge treatment plan, and identifying complications. Our aim is: 1. To review the compliance of post-hospitalization follow-ups for a medical specialty. 2. To study the timeline from the discharge to the time they were seen in the hematology-oncology clinic. 3. To identify why patients seen in the hospital were lost to follow-up. 4. To improve compliance with post-discharge follow-up visits. Methods: This is a retrospective chart review of patients seen by our Hematology-oncologists at Einstein Medical Center Montgomery between January 2021 to December 2021. Data collected included: Specialty consulted- Hematology versus Oncology; if follow-up is indicated; if they have a Hematology Oncology provider elsewhere; if they were seen in the clinic and how long did it take for the patient to be seen after discharge; if they did not follow-up, the reason for failure to follow-up was reviewed. We defined “No contact from our office” when there was no documentation that our office staff tried to contact the patient to make a follow-up appointment. Results: Out of the total 526 inpatient consultations, 338 were for hematology, 169 were for oncology and 19 were for both hematology and oncology. Follow-up upon discharge was recommended for 429 patients (82%). Out of those 429 patients, 168 patients (39%) were seen in the clinic and 176 patients (41%) were not seen after discharge from the hospital. 85 patients (20%) had a Hematology Oncology provider in a different institution. 118 patients (68%) in this group of 168 patients were seen in less than 30 days. 41% of the patients that were not seen after discharge from the hospital had various reasons, which included 18% of patients who expired, and 10% of patients who chose to be on comfort care. 41% of the patients were lost to follow-up (unable to track after the discharge – data was limited due to this being a retrospective study), 2% of the patients were incarcerated, 23% of the patients had no contact from our office to make a follow-up appointment, 1% of the patients were subsequently hospitalized, and finally, 5% of the patients followed up in a different institution. Conclusions: Hematology was consulted more often than Oncology for the subspecialty in-hospital consultations. 41% of the patients were lost to follow-up due to reasons unknown who should have been seen in the Hematology/Oncology Clinic. Interventions that we recommend in improving this compliance are 1. Formulate a rapid discharge clinic – run by Hematology-Oncology fellows with attending oversight. 2. Involve the Oncology Nurse Navigator to help coordinate patient follow-up. 3. Provide better education for hospital staff about the importance of reviewing discharge instructions with the patients.

Improving Adolescent Violent Trauma Outcomes With a Hospital-Based Violence Prevention Initiative.

Violent trauma results in significant morbidity/mortality in Black/Hispanic males aged 15 to 24 years. Hospital- and community-level interventions may improve patient and community outcomes. To determine if a hospital-based violence prevention intervention using community outreach workers was associated with improved violent trauma patient postdischarge follow-up and reinjury rates. This is a retrospective, single-center, cohort study of admitted violent trauma patients to a public hospital in the Bronx, NY. Data were collected from a convenience sample of patients aged 15 to 24 years admitted with International Classification of Diseases, 10th Revision, codes for gunshot wound, stab wound, or physical assault from August 2014 to April 2018. The exposure variable was documentation of intervention team evaluation during admission. The outcome variables included attending >50% scheduled postdischarge follow-up visits, and subsequent violent reinjury (gunshot wound, stab wound, blunt assault) during the study time period. Multivariable regression models were used to determine the association between the exposure and outcome variables. A total of 535 patients were evaluated and were primarily male (92.5%), Black (54%)/Latino (36.4%), with mean age of 19.1 years. Patients in the exposure group had increased odds of attending >50% of scheduled clinic postdischarge follow-up visits (odds ratio, 2.29; 95% confidence interval 1.59-3.29) and decreased odds of subsequent violent reinjury presentation (odds ratio, 0.41; 95% confidence interval 0.22-0.75) 3 months after hospital discharge. A hospital-based violence prevention intervention may be associated with decreased odds of violent reinjury and increased odds of postdischarge scheduled appointment adherence in admitted pediatric violent trauma patients.

Prognostic implications of post-discharge hemodynamic congestion assessed by peripheral venous pressure among patients discharged from acute heart failure

BackgroundCongestion is a major cause of hospitalization for heart failure (HF). Peripheral venous pressure (PVP) strongly correlates with right atrial pressure. We recently reported that high PVP at discharge portends a poor prognosis in patients hospitalized for HF. In the same population, we aimed to analyze changes in PVP after discharge and to evaluate prognostic implications of post-discharge PVP. MethodsPVP was measured at the forearm vein of 163 patients in the 1-month post-discharge follow-up visit. The primary outcome was a composite of cardiovascular death or re-hospitalization for HF after the 1-month follow-up visit up to 1 year after discharge. ResultsPost-discharge PVP correlated with jugular venous pressure, the inferior vena cava diameter, and brain-type natriuretic peptide levels. The cumulative incidence of the primary outcome event was significantly higher in patients with PVP above the median (6 mmHg) than in those with median PVP or lower (39.8% versus 16.9%, Log-rank P = 0.04). Age- and sex-adjusted risk of PVP per 1 mmHg for the primary outcome measure was significant (hazard ratio: 1.12 [95% confidence interval 1.03–1.21]). 35% of patients who had PVP ≤6 mmHg at discharge had PVP >6 mmHg at the 1-month follow-up. PVP significantly decreased from discharge to 1-month follow-up in patients without the primary outcome event (from 6 [4–10] to 6 [4–8] mmHg, P=0.01), but remained high in those with the primary outcome event (from 8 [5–11] to 7 [5–10.5] mmHg, P = 0.9). ConclusionsPVP measurements during the early post-discharge period may be useful to identify high risk patients.Trial registration number: UMIN000034279.

Risk Factors for Readmission After Pulmonary Lobectomy: A Quality Collaborative Study

BackgroundPrevious studies have identified postoperative complications as being associated with readmission after lobectomy. However, these studies have not adequately accounted for the timing of complications or accounted for institutional effects. Our objectives were to examine readmission rates after lobectomy and identify factors associated with readmission. MethodsPatients aged >18 years undergoing lobectomy for lung cancer between 2015 and 2019 were identified from a statewide database. Patients with in-hospital mortality, missing data regarding discharge status, 30-day readmission status, and discharge location were excluded. Data regarding The Society of Thoracic Surgeons postoperative complications were abstracted by hospital data managers to determine the timing of occurrence (index admission vs readmission). Logistic mixed-model analysis, with hospitals as the random intercept to account for clustering data structure and assess hospital-specific effect on readmission, was performed. ResultsThe overall readmission rate was 6.9% (184 of 2686). The most common complication was air leak ≥5 days in 17.4% (467 of 2686). Variables significantly predictive of more readmission were predischarge postoperative complications and Zubrod score ≥1. Variables predictive of less readmission were increasing length of stay and having been operated on at institutions with higher cumulative volume or having postdischarge follow-up visit protocol ≤7 days from discharge. The C statistic for the final model was 0.80. ConclusionsPatients who experience postoperative complications are at increased risk for readmission, whereas follow-up ≤7 days was predictive of less risk for readmission. Efforts at reducing readmissions should focus on decreasing postoperative complication rates, the timing of discharge for patients experiencing complications, as well as decreasing length of time between discharge and clinic follow-up.

Patient Perspectives on Care Transitions From Hospital to Home

Understanding the patient's perspective of their care transition process from hospital or skilled nursing facility (SNF) to home may highlight gaps in care and inform system improvements. To gather data about patients' care transition experiences and factors associated with follow-up appointment completion. A survey tool was developed with input from patient advisors and organizations participating in a collaborative quality initiative. Seventeen hospitals, 12 practitioner organizations, and 6 SNFs in Michigan collaborated to identify shared patients who were aged 18 years and older, had a working telephone number, recently returned home or to an assisted living facility with a diagnosis of congestive heart failure or chronic obstructive pulmonary disease, or after an SNF stay. Using consecutive sampling, interviewers collected 5 telephone surveys per month. From October 2018 to December 2019, patients or caregivers were surveyed via telephone 8 to 12 days after discharge from a hospital or SNF. Data were analyzed from March 2020 to January 2022. Care transition experiences. The primary outcome was to identify patient-perceived gaps during care transition experiences, including postdischarge follow-up. On the basis of pilot data, the response rate was estimated at 34%, yielding 1257 surveys. Of 1257 survey respondents (mean [SD] age, 70 [12.94] years for 968 patients for whom age data was available), 654 (52%) were female; 829 (74%) were White, 250 (22%) were Black or African American, and 40 (4%) were another race. Eleven percent of patients reported not receiving a telephone number to call for postdischarge questions. Nearly 80% of patients (977 patients) received a follow-up telephone call, and most found it valuable. Twenty percent of patients (255 patients) reported at least 1 social determinant of health issue. Lack of transportation was associated with reduced likelihood of completing a follow-up visit, decreasing the odds of completing a follow-up by nearly 70% (odds ratio [OR], 0.31; 95% CI, 0.18-0.53; P < .001). Compared with other patient groups, Black patients were less likely to report completing a postdischarge follow-up visit (OR, 0.49; 95% CI, 0.36-0.67; P < .001) or to receive prescribed medical equipment (OR, 4.23; 95% CI, 1.30-13.83; P = .02). An examination of patient discharge experiences from a hospital or SNF identified inconsistencies in care transition processes, social determinants of health issues needing to be addressed after discharge, and racial disparities between patients who attend follow-up appointments. Physicians should be aware of these findings and their consequences for patient experiences.

Dose Response Relationship of RAS Blockers and Beta-Blockers in Patients with Acute Heart Failure Syndrome: A Nationwide Prospective Cohort Study, on Behalf of KorAHF Investigators

<h3>Purpose</h3> It remains unclear if patients with acute heart failure syndrome (AHFS) need to reach the maximally tolerated doses of renin-angiotensin system blockers (RASBs) or beta-blockers (BBs) to obtain a survival benefit. This study evaluated the dose-response relationship between RASBs or BBs and survival in AHFS patients. <h3>Methods</h3> In total, 5,331 patients in the Korean Acute Heart Failure registry were analyzed based on the doses of RASBs and BBs at discharge. Also, an additional analysis of 4,613 patients with dosage information at the first post-discharge follow-up visit was done. Survival curves were constructed using the Kaplan-Meier method and compared using the log-rank test, and independent predictors of mortality were identified with the multivariable Cox proportional hazards model. <h3>Results</h3> In patients hospitalized with AHFS, RASB use at discharge was associated with a significant reduction in the risk of all-cause mortality. This effect was dose dependent for heart failure with reduced ejection fraction (HFrEF) but did not attain statistical significance for heart failure with preserved ejection fraction (HFpEF). BB use at discharge was associated with a reduction in all-cause mortality in HFrEF but not for HFpEF patients, although this was not dose dependent. At the first post-discharge follow-up visit, a significantly higher risk of all-cause mortality was associated with the maintenance or withdrawal of RASBs compared to up-titration of dose in HFrEF patients. <h3>Conclusion</h3> Using RASBs or BBs at discharge was associated with improved survival. A dose-response relationship between RASB and all-cause mortality was evident in AHFS patients with a reduced ejection fraction but not BBs. It is important to initiate and up-titrate RASBs to the maximally tolerated dose in AHFS patients during the transition period, especially for patients with a reduced ejection fraction.

Caracterización clínica y terapéutica de la cardiopatía isquémica en España. Importancia de los programas de rehabilitación cardiaca

Introduction and objectivesThe objective of the study was to characterize the clinical and therapeutic profile of patients with ischemic cardiopathy (IC) in Spain in patients (group 1) at the time of hospital discharge after an acute coronary syndrome (ACS), (group 2) at the first post-discharge follow-up visit, and (group 3) after one year of the ACS. Patients and methodsObservational, multicenter, cross-sectional, nationwide, performed in conditions of routine clinical practice. ResultsA total of 1018 patients were included: 354 (34.8%) in the group 1, 326 (32.0%) in the 2, and 338 (33.2%) in the 3. Compared with group 3, a higher percentage of patients from group 1 were smokers (32.2% versus 10.9%), consumed alcohol (28.2% versus 19.5%), did not do any physical exercise (61.0% versus 38.2%) or followed a diet (57.1% versus 32.5%). Of patients in group 1, 65.4% were referred to a cardiac rehabilitation program (CRP). Of those in group 2, 53.1% had not a scheduled appointment to initiate a CRP. Regarding group 3, 58.3% did not receive the recommendation of doing a CRP. Absence of obesity and attendance to a CRP were variables associated with the control of cardiovascular risk factors. ConclusionsCurrently, less than 50% of patients with IC in Spain are remitted to a CRP despite being associated with an improved control of cardiovascular risk factors.

A dose-response relationship of renin-angiotensin system blockers and beta-blockers in patients with acute heart failure syndrome: a nationwide prospective cohort study.

It remains unclear if patients with acute heart failure syndrome (AHFS) need to reach the maximally tolerated doses of renin-angiotensin system blockers (RASBs) or beta-blockers (BBs) to obtain a survival benefit. This study evaluated the dose-response relationship between RASBs or BBs and survival in AHFS patients. In total, 5331 patients in the Korean Acute Heart Failure registry were analysed based on the doses of RASBs and BBs at discharge. In AHFS patients, RASB use at discharge was associated with a significant reduction in all-cause mortality risk. This effect was dose-dependent for heart failure with reduced ejection fraction (HFrEF) but did not attain statistical significance for heart failure with preserved ejection fraction (HFpEF). BB use at discharge was associated with reduced all-cause mortality in HFrEF patients but not in HFpEF patients. In an additional analysis of 4613 patients with dosage information at the first post-discharge follow-up visit, a significantly higher mortality risk was associated with the maintenance or withdrawal of RASBs compared with up-titrating the dose in HFrEF patients. Using RASBs or BBs at discharge was associated with improved survival. A dose-response relationship between RASBs and all-cause mortality was evident in AHFS patients with a reduced ejection fraction but not BBs. It is important to initiate and up-titrate RASBs to the maximally tolerated dose in AHFS patients during the transition period, especially for patients with a reduced ejection fraction.

Impact of a Pharmacy-Led Transitions of Care Program Within a Primary Care-Based Accountable Care Organization.

To assess the impact of pharmacist-led transitions of care program on 30-day readmission rates in the accountable care organization (ACO) primary care setting. Retrospective cohort study. Two primary care provider (PCP) offices with an ACO in South Florida. Adult Medicare patients who completed a post-discharge follow-up visit at two primary care offices within an ACO from July to December 2017. To supplement postdischarge visits with a PCP, the pharmacy services were also provided two days per week with a PCP. The comparator groups were patients who only saw a PCP or those who saw a PCP and pharmacist. The primary outcome was hospital readmission or emergency department visit within 30 days. A total of 190 subjects were included. There were 113 patients in the PCP group and 77 patients in the PCP/pharmacist group. There was a reduction in the primary outcome when comparing the PCP-only versus PCP/pharmacist groups (6.2% versus 3.9%; P = 0.74). Involving pharmacists in patient transitions of care in the primary care setting may be beneficial as previous studies have demonstrated. Further studies evaluating pharmacy services in emerging health care models are needed in order to most effectively utilize the expertise of the pharmacy team.

Living Donor Hepatectomy After Proven SARS-CoV-2 Infection: First Report of 9 Cases From 3 Centers

We read the report by Kute et al1 published in Transplantation regarding the safety of live kidney donation in 31 individuals with previous severe acute respiratory syndrome coronovirus-2 (SARS-CoV-2) infection. Liver transplantation (LT) has been severely restricted during the coronavirus disease 2019 (COVID-19) pandemic due to concerns of perioperative SARS-CoV-2 infection in donors and recipients.2,3 Unlike kidney transplantation that can be postponed for an extended duration, there is an element of urgency for patients awaiting LT. While there is general consensus that individuals with symptomatic SARS-CoV-2 infections should not proceed with living donor hepatectomy (LDH), there are no clear recommendations regarding the safety of LDH in individuals with recent asymptomatic infection. We had several instances of asymptomatic donors testing positive on preoperative screening. We set up a protocol of reassessing these donors for LDH if they satisfied the following 4 criteria: asymptomatic infection without abnormal inflammatory markers or liver function tests, have completed 2-wk isolation period, 2 negative real-time polymerase chain reaction (RT-PCR) tests 48 h apart—the second within 48 h of LDLT, and normal preoperative chest computed tomography scan. SARS-nCoV2 antibody levels were not routinely measured. Donors and recipients were managed in a COVID-19 free unit. All donors received perioperative deep venous thrombosis prophylaxis. Postdischarge follow-up visits were minimized and donors were followed by e-consultation with home blood sample collection.4 This is a retrospective report of living donors who tested positive for SARS-nCoV2 infection on routine RT-PCR screening. All clinical procedures were performed in accordance with the principles of the Istanbul Declaration. The study was exempt from ethics board approval as it was a retrospective review of deidentified data. Between July and December 2020, 9 potential living donors tested positive for SARS-nCoV2 infection on routine RT-PCR screening at 3 LT centers in India. There were 3 male and 6 female donors donating to 5 adult and 4 pediatric recipients (Table 1). Six tested positive during donor evaluation, while 3 tested positive during preoperative testing. None had computed tomography chest findings suggestive of SAR-nCoV2 infection. Two potential recipients also had positive testing with no symptoms. LT was postponed in all cases and donors and recipients were managed with strict home isolation for 2 wk. Repeat testing was performed after 2 wk, and donors proceeded with LDH once previously mentioned criteria were satisfied. TABLE 1. - Details of 9 donors who underwent LDH after asymptomatic SARS-CoV-2 infection Center number Donor age/sex Recipient age/sex Cause/MELD (PELD) Donor-patient relationship Graft type Time interval between first positive test and LDH (d) Total RT-PCR tests performed Peak postop serum bilirubin (mg%) Perioperative morbidity Hospital stay (d) Current status of donor Follow-up duration (mo) 1.1 24/M 41/M ALD/12 Uncle LL 92 4 2.1 Nil 7 Good 2.5 1.2 34/F 9/F Wilson’s/11 Mother LL 72 3 1.9 Ileus, NG 5 Good 1 1.3 35/F 47/M ALD/31 Spouse RL 64 3 3.4 Nil 6 Good 2 1.4 29/F 2/F EHBA/18 Mother LLS 53 3 1.6 Nil 6 Good 1 2.1 43/F 48/M ALD/24 Spouse RL 27 5 1.8 Pleural effusion 7 Good 4 2.2 33/F 8/F Wilson’s ACLF/28 Mother LL 15 3 1.3 Nil 7 Good 1 3.1 32/M 12/F BCS with HCC/20 Cousin RL 49 3 3.3 Nil 7 Good 1.5 3.2 30/F 35/M Cryptogenic CLD/22 Spouse RL 22 6 1.7 Nil 8 Good 1 3.3 46/M 3/M Abernathy syndrome Father LLS 87 4 1.0 Nil 7 Good 1 ACLF, acute on chronic liver failure; ALD, alcoholic liver disease; BCS, Budd-Chiari syndrome; CLD, chronic liver disease; EHBA, extrahepatic biliary atresia; F, female, HCC, hepatocellular carcinoma; LDH, living donor hepatectomy; LL, left lobe; LLS, left lateral segment graft; M, male; MELD, Model for End-stage Liver Disease; NG, nasogastric tube; PELD, pediatric end-stage liver disease; RL, right lobe; RT-PCR, real-time polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronovirus-2. Median interval between the first positive RT-PCR and LDH was 53 d. Three donors had positive RT-PCR tests even 3 wk after the initial positive test necessitating further delays in surgery until 2 consecutive negative tests were obtained. There were no major complications in any of the donors. One recipient needed reoperation for sepsis and developed early allograft dysfunction leading to prolonged hospital stay. All donors and recipients were discharged in stable condition. There were no COVID-19-related complications among the donors or recipients during the perioperative and follow-up period. Our report provides initial evidence for the safety of LDH after previous asymptomatic SARS-nCOV2 infection. Clarity is needed regarding the significance of repeat positive tests beyond 3 wk, role of antibody testing, and the benefit of preoperative vaccination for potential donors with previous asymptomatic SARS-nCOV2 infection.

Predictive value of biochemical and hematological markers in prognosis of asphyxic infants.

Background:Asphyxia is one of the main causes of infant mortality and long-term neurologic complications. This cohort study was aimed to compare the diagnostic value of the hematologic and biochemical factors in the prediction of prognosis of asphyxia according to the high prevalence of asphyxia and its complications.Methods:In this cohort with a two-year follow-up study with availability sampling, 196 term asphyxic infants were involved from 2009 to 2018. A researcher-designed questionnaire was used as the data collection tool containing infantile and maternal particulars as well as the clinical and laboratory assessments. Serum levels of interleukin-1β(IL-1β), IL-6, pro-oxidant/antioxidant balance (PAB), heat shock protein (HSP) and nucleated red blood cells (NRBC) were checked in infants with perinatal asphyxia. Denver II developmental screening test (DDST-II) was performed at 6, 12, 18, and 24 month post-discharge follow-up visits. Data analysis for comparison of infants with normal and abnormal outcomes was performed using student t- test, chi-square, ROC curve, and regression models.Results:IL-6, IL-1β, PAB, and NRBC count are among the most important predictors of abnormal complications in asphyxic newborns. PAB>22 (HK) showed sensitivity and specificity of 88.6% and 71.6%, respectively in the prediction of complications of asphyxia. The sensitivity and specificity of an IL-6 higher than 28 (pg/mL) in the prediction of complications of asphyxia were found to be 96.1% and 78.6%, respectively. Elevated levels of IL-6 and IL-1β were associated with increased unfavorable outcomes.Conclusion:Combinations of: IL-1β+ IL-6 + NRBC; IL-6 + HIE grade + PAB; and IL-6+ HIE grade + NRBC had the highest predictive value (100%) for prognosis of asphyxic infants.

Patient-specific versus Organisational Barriers to Program Adherence: A Multivariate Analysis.

Introduction:This article explores the influence of patient-specific and organisational factors on adherence to program guidelines in an integrated care program targeting older patients.Methods:The integrated care program aimed to offer post-discharge follow-up visits by a municipality nurse and the general practitioner to frail older patients after discharge from hospital. Adherence was measured as step 1) successful referral from the hospital and step 2) completed post-discharge follow-up visit. We followed a cohort of 1,659 patients who were selected to receive a post-discharge follow-up visit in 2014. We obtained unique data from hospitals, municipalities and from administrative registers.Results:We found substantial lack of adherence in both steps of the program: 69% adherence in step 1 and 54% adherence in step 2. In step 1, adherence was related to hospital, and receiving municipal home care prior to admission. In step 2, level of adherence varied according to municipality, the type of general practitioner and the patient’s gender.Conclusion:We found that adherence was strongly related to organisational factors. Adherence differed significantly at all organisational levels (hospital, municipality, general practice), thus indicating challenges in the vertical integration of care. Gender influenced adherence as the only patient-related factor.

Outcomes of common general surgery procedures for patients discharged over weekends at a tertiary care hospital in Saudi Arabia.

BACKGROUNDHospitals usually reduce staffing levels and services over weekends. This raises the question of whether patients discharged over a weekend may be inadequately prepared and possibly at higher risk of adverse events post-discharge.OBJECTIVESTo assess the outcomes of common general surgery procedures for patients discharged over weekends, and to identify the key predictors of early readmission.DESIGNRetrospective cohort study.SETTINGA tertiary care center.PATIENTS AND METHODSPatients discharged from general surgery services during the one-year period between January and December 2016 after cholecystectomy, appendectomy, or hernia repairs were included. Patient demographic information, comorbidities, and complications as well as admission and follow-up details were collected from electronic medical records.MAIN OUTCOME MEASURESOutcomes following weekend discharge, and the predictors of early readmission.SAMPLE SIZE743 patients.RESULTSThe operations performed: 361 patients (48.6%) underwent a cholecystectomy, 288 (38.8%) an appendectomy, and 94 (12.6%) hernia repairs. A significantly lower number of patients were discharged over the weekend (n=125) compared to those discharged on weekdays (n=618). Patients discharged during the weekend were younger, less likely to have chronic diseases, and had a significantly shorter average length of stay (LOS) (median 2 days, IQR: 1, 4 vs. median 3 days, IQR: 1, 5, P=.002). Overall, the 30-day readmission rate was 3.2% (n=24), and weekend discharge (OR=2.25, 95% CI 0.52–9.70) or any other variable did not predict readmission in 30 days. However, 14-day post-discharge follow-up visits were significantly lower in the weekend discharge subgroup (83.1% vs. 91.2%, P=.006).CONCLUSIONWeekend discharge was not associated with higher readmission rates. Physicians may consider discharging post-operative patients over a weekend without an increased risk to the patient. Day of discharge, length of stay and increased patient age are not predictors of early readmission.LIMITATIONSSingle-center study and retrospective.