Previous Hospital Admissions Research Articles

Factors Associated With Early Readmission Among Patients Discharged to Post‐Acute Care Facilities

Over a quarter of Medicare patients admitted to the hospital are discharged to post-acute care (PAC) facilities, but face high rates of readmission. Timing of readmission may be an important factor in identifying both risk for and preventability of future readmissions. This study aims to define factors associated with readmission within the first week of discharge to PAC facilities following hospitalization. This was a secondary analysis of the 2011 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for California, Massachusetts, and Florida. The primary outcome was all-cause readmission within 7 days after hospital discharge, compared to readmission on days 8-30, for patients aged 65 and older who were discharged from the hospital to a PAC facility. Predictor variables included patient, index hospitalization, and hospital characteristics; multivariable logistic regression was used to identify significant predictors of readmission within 7 days. There were 81,173 hospital readmissions from PAC facilities in the first 30 days after hospital discharge. Patients readmitted within the first week were older, white, urban, had fewer comorbid illnesses, had a higher number of previous hospital admissions, and less commonly had Medicare as a payer. Longer index hospital length of stay (LOS) was associated with decreased risk of early readmission (OR 0.74; 95% CI 0.70-0.74 for LOS 4-7 days and 0.60; 95% CI 0.56-0.64 for LOS ≥8 days). Shorter length of index hospital stay is associated with earlier readmission and suggests that for this comorbid, older population, a shorter hospital stay may be detrimental. Readmission after 1 week is associated with increased chronic disease burden, suggesting they may be associated with factors that are less modifiable.

Long-term Exposure to PM2.5 and Mortality Among Older Adults in the Southeastern US.

Little is known about what factors modify the effect of long-term exposure to PM2.5 on mortality, in part because in most previous studies certain groups such as rural residents and individuals with lower socioeconomic status (SES) are under-represented. We studied 13.1 million Medicare beneficiaries (age ≥65) residing in seven southeastern US states during 2000-2013 with 95 million person-years of follow-up. We predicted annual average of PM2.5 in each zip code tabulation area (ZCTA) using a hybrid spatiotemporal model. We fit Cox proportional hazards models to estimate the association between long-term PM2.5 and mortality. We tested effect modification by individual-level covariates (race, sex, eligibility for both Medicare and Medicaid, and medical history), neighborhood-level covariates (urbanicity, percentage below poverty level, lower education, median income, and median home value), mean summer temperature, and mass fraction of 11 PM2.5 components. The hazard ratio (HR) for death was 1.021 (95% confidence interval: 1.019, 1.022) per 1 μg m increase in annual PM2.5. The HR decreased with age. It was higher among males, non-whites, dual-eligible individuals, and beneficiaries with previous hospital admissions. It was higher in neighborhoods with lower SES or higher urbanicity. The HR increased with mean summer temperature. The risk associated with PM2.5 increased with relative concentration of elemental carbon, vanadium, copper, calcium, and iron and decreased with nitrate, organic carbon, and sulfate. Associations between long-term PM2.5 exposure and death were modified by individual-level, neighborhood-level variables, temperature, and chemical compositions.

Antimicrobial-Resistant Bacteremia in the Elderly: Risk of Previous Hospitalization

Summary Background Studies have shown a positive correlation between hospital admission and antimicrobial-resistant bacteria (ARB)-related community-acquired bacteremia (CAB), however, the definition regarding the duration from prior hospitalization as having risks for such infections varies between literatures. Therefore, we conducted a retrospective analysis to determine the time-effect of recent hospitalization on the risk of CAB due to extended-spectrum beta-lactamases (ESBLs)-producing Enterobacteriaceae in elderly patients. Methods From 2006 to 2008, all consecutive episodes of documented bacteremia developed within first 48 h of hospital admission due to E. coli and K. pneumoniae in patient age of 65 or greater were retrospectively enrolled. Results Out of 494 non-duplicated CAB episodes, 9.5% were due to ESBLs-producing E. coli/K. pneumoniae . Age, history of previous hospital admission, and nursing home residents were independently associated with the risk for CAB due to ESBLs-producing E. coli/K. pneumoniae . History of previous hospitalization was the most significant one among these risks and the effect was time-dependent: within 2∼30 days (OR 8.8; 95% CI 1.9 to 41.2), 31∼90 days (OR 9.0; 95% CI 1.9 to 41.2), 91∼180 days (OR 5.6; 95% CI 1.1 to 29.1), 181∼360 days (OR 5.5; 95% CI 1.0 to 29.1) and over 360 days (OR 3.5; 95% CI 0.5 to 22.7). Conclusion Our study showed that the risk of CAB in elderly due to ESBLs-producing E. coli/K. pneumoniae was highly associated with history of recent hospital admissions, and the effect can be prolonged up to 360 days after discharge.

Mental Distress among Patients Admitted in Gondar University Hospital: A Cross Sectional Institution Based Study

Background: Mental distress is a state that manifests from anxiety, depression or unexplained somatic symptoms and is typically encountered in community and health care settings. Methods: Institution based, cross-sectional study was conducted among 418 hospital patients at Gondar University Hospital from April 15 to May 15 in 2013. Participants were selected using a systematic randomsampling technique. Semi-structured questionnaires were used to collect social, demographic and clinical data. Mental distress was measured with a Self-Reporting Questionnaire (SRQ-25). Binary logistic regression analysis was performed to identify factors associated with distress. Results: Prevalence of mental distress was 58.6% among hospital admitted patients. In the group, 237 (56.7%) were male. Individuals with a history of previous hospital admission, we used an adjusted odds ratio (AOR) and a confidence interval (CI) [AOR=1.7, 95% CI (1.11, 2.73)]. These patients also tended to be female [AOR=2, 95% CI (1.26, 3.12)] and were more likely to have distress (than those without previous hospital admissions). Widowers [AOR=2.8, 95% CI (1.1, 7.20)] who used tobacco [AOR=4, 95% CI (1.1, 15.28), alcohol [AOR=3, 95% CI (1.82, 4.69)] or had hospital stays of one to two weeks [AOR=2.3, 95% CI (1.4, 3.8)] also had more distress. When hospital stays three to four weeks [AOR=2, 95%, CI (1.18, 3.93)], distress levels significantly increased compared to those who were single (and did not use tobacco or alcohol or have shorter hospital stays, lasting less than a week). Patients who went to primary school [AOR=0.5, 95% CI (0.26, 0.93)] and secondary school [AOR=0.4, 95% CI (0.26, 0.85)] were less likely to experience distress than those unable to read and write. Conclusion: Prevalence of mental distress was quite high among patients admitted to a hospital. Factors included being female, being widowed and having a history of previous hospital admissions. Individuals who were illiterate, had substance abuse, or concerned about the length of their hospital stay encountered even greater distress levels.

Effectiveness of Social Skills Training Program on Social Functioning and Severity of Symptoms Among Patients with Schizophrenia

This study aimed at evaluating the effectiveness of socials kills training program on social functioning and severity of symptoms among newly admitted schizophrenic Patients. Quasi-experimental design (pre-posttest-groups) was utilized in this study. The present study was conducted at Al-Abbassia hospital for mental health. Purposive random sample consisted of 40 schizophrenic patients which were selected from six inpatient wards of newly admitted patients. Three tools were used to collect the data for the current study, Personal and medical data sheet, social functioning questionnaire and positive & negative symptoms scale (PANSS). A constructed social skills training Program was designed to help patients to develop and promote necessary skills for effective communication and interaction with others that needed for improved his/her functioning and independent living. This program was implemented over 15 sessions, three sessions per week and each session lasted about 60-90 minutes. Pre, and post assessment were carried out for the same group (self-control group). The current study results revealed that, overall significant effects of social skills training program regarding improving patients’ social functioning and decreasing severity of symptoms. There was statistically significant difference between pre, and post assessment regarding dependent variables. A statistically significant positive correlation were detected between dependent variables and patients’ related variables such as age, compliance with medication, with whom the patient stays, and numbers of previous hospital admissions. So, the study concluded that, the social skills training program was effective with newly admitted schizophrenics’ patients concerning enhancing patients, social functioning and reducing severity of symptoms. The study recommended that, social skill training program should be integrated as an intervention in conjunction with pharmacological therapy without contraindications and it can maximize the effect.

Childhood trauma and factors associated with depression among inpatients with cardiovascular disease.

AIMTo identify factors associated with depressive symptoms among inpatients with cardiovascular disease (CVD).METHODSThis is a cross-sectional study performed in a subsample of a large cross-sectional research that investigated affective disorders and suicide behaviour among inpatients hospitalized in non-surgical wards of the University Hospital of the Federal University of Minas Gerais from November 2013 to October 2015. Sociodemographic and clinical data were obtained through a structured interview and medical record review. Depression was assessed by the depression subscale of the Hospital Anxiety and Depression Scale, with scores ≥ 8 considered as positive screening for depression. We used the Fageström Test for Nicotine Dependence to characterize nicotine dependence. For assessing resilience and early-life trauma, we used the raw scores of the Wagnild and Young Resilience Scale and Childhood Trauma Questionnaire, respectively.RESULTSAt endpoint, we included 137 subjects. Thirty-eight (27.7%) subjects presented depressive symptoms and nine (23.7%) of those were receiving antidepressant treatment during hospitalization. The female sex; a lower mean educational level; a greater prevalence of previous suicide attempts; a higher level of pain; a higher prevalence of family antecedents of mental disorders; a lower resilience score; and higher childhood trauma score were the factors significantly associated with screening positive for major depression (P < 0.05). Multivariate analysis demonstrated that the factors independently associated with the depressive symptoms were a higher childhood trauma severity (OR = 1.06; P = 0.004); moderate to severe nicotine dependence (OR = 8.58; P = 0.008); and the number of previous hospital admissions (OR = 1.11; P = 0.034). The obtained logistic model was considered valid, indicating that the three factors together distinguished between having or not depressive symptoms, and correctly classified 74.6% of individuals in the sample.CONCLUSIONOur results demonstrate that inpatients presenting both CVD and a positive screening for depression are more prone to have antecedents of childhood trauma, nicotine dependence and a higher number of previous hospitalizations.

Risk Factors of Poor Outcomes after Admission for a COPD Exacerbation: Multivariate Logistic Predictive Models

ABSTRACTThe aim of this study was to identify a multivariate model to predict poor outcomes after admission for exacerbation of chronic obstructive pulmonary disease (COPD). We performed a multicenter, observational, prospective study. Patients admitted to hospital for COPD were followed up for 3 months. Relevant clinical variables at admission were selected. For each variable, the best cut-offs for the risk of poor outcome were identified using receiver operating characteristic (ROC) curves. Finally, a stepwise logistic regression model was performed. A total of 106 patients with a mean age of 71.1 (9.8) years were included. The mean maximum expiratory volume in the first second (FEV1)(%) was 45.2%, and the mean COPD assessment test (CAT) score at admission was 24.8 (7.1). At 3 months, 39 (36.8%) patients demonstrated poor outcomes: death (2.8%), readmission (20.8%) or new exacerbation (13.2%). Variables included in the logistic model were: previous hospital admission, FEV1 < 45%, Charlson ≥ 3, hemoglobin (Hb)<13 g/L, PCO2 ≥ 46 mmHg, fibrinogen ≥ 554 g/L, C-reactive protein (CRP)≥45 mg/L, leukocyte count < 9810 × 109/L, purulent sputum, long-term oxygen therapy (LTOT) and CAT ≥ 31 at admission. The final model showed that Hb < 13 g/L (OR = 2.46, 95%CI 1.09–6.36), CRP ≥ 45 mg/L (OR = 2.91, 95%CI: 1.11–7.49) and LTOT (3.07, 95%CI: 1.07–8.82) increased the probability of poor outcome up to 82.4%. Adding a CAT ≥ 31 at admission increased the probability to 91.6% (AUC = 0.75; p = 0.001). Up to 36.8% of COPD patients had a poor outcome within 3 months after hospital discharge, with low hemoglobin and high CRP levels being the risk factors for poor outcome. A high CAT at admission increased the predictive value of the model.

Readmissions at Royal Oldham Hospital AMU

Background This paper contributes to the developing body of literature that explores the theme of hospital readmissions. Interest in this area has grown since a policy of non-payment for 30-day readmissions was introduced by the Department of Health. This has moved hospitals to seek out ways of reducing their readmission rates. Aim The goal of this study was to investigate the drivers of readmissions at the Royal Oldham Hospital of the Pennine Acute Trust, by identifying patterns existing within a sample of readmitted patients. Methodology A random sample of 55 patients readmitted to the Acute Medical Unit (AMU) within 30 days of a previous discharge during December 2013 was used. Factors frequently implicated in readmissions were selected as variables for analysis. Results The findings were largely concurrent with previous observations that old age, male gender, previous hospital admissions and existing comorbid conditions increase the risk of readmission. The findings were consistent with reports that diagnoses at the times of admission and readmission are typically different, and that common causes of readmission are infection and complications relating to co-morbid conditions. Conclusion This study forms solid foundations upon which more expansive auditing can take place, and specific recommendations are made for the reduction of readmission rates on AMU.

Can continuity of primary care decrease emergency care use? A nested case-control study

BackgroundNational Health Service emergency departments have been under considerable pressure. Many patients presenting to emergency departments could be managed in primary care, suggesting that aspects of general practice might be associated with unplanned hospital admission. Recently a government scheme introduced the concept of a named GP (general practitioner) responsible for the care of patients aged 75 and older to reduce unplanned hospital admission. We aimed to investigate whether better continuity of care is associated with lower risk of emergency hospital admission. MethodsWe used records from 10 000 patients aged 65 years and over randomly selected from the Clinical Practice Research Datalink, linked with Hospital Episode Statistics. Using a nested-case control approach, we identified 769 patients with an emergency hospital admission between April 1, 2012, and March 31, 2014, and at least two GP consultations in the previous 2 years, of which the last was within 30 days before hospital admission. 2123 controls were matched on age group, last consultation within the same time-period as the case, and GP practice to account for practice composition, deprivation level, and services such as out-of-hours. For both cases and controls we calculated two longitudinal measures of continuity of care—namely, Bice and Boxerman's index, which quantifies the extent to which the patient saw the same GP, and proportion of times seen by an index GP (ie, last GP seen before admission). Conditional logistic regression models were applied to estimate the odds ratio (OR) associated with continuity of care, adjusting for sex, number of consultations, previous hospital admission, and a range of comorbidities. FindingsBoth the Bice and Boxerman and the appointed index GP measures showed a graded inverse association between lower continuity of care and higher risk of emergency hospital admission (OR for those experiencing the least continuity of care 2·1 [95% CI 1·3–3·2] and 2·3 [1·6–2·9], respectively, compared with those who always saw the same GP). InterpretationBetter continuity of care might reduce emergency hospital admission. More research is needed to understand this association including distinguishing between GP-referred emergency hospital admissions and admissions through the emergency department. Such an analysis requires a bigger data set. FundingNational Institute for Health Research School of Primary Care Research grant (round 9, project number 246).

Association Between Short-Term Exposure to PM2.5 and PM10 and Mortality in Susceptible Subgroups: A Multisite Case-Crossover Analysis of Individual Effect Modifiers.

We performed a multisite study to evaluate demographic and clinical conditions as potential modifiers of the particulate matter (PM)-mortality association. We selected 228,619 natural deaths of elderly persons (ages ≥65 years) that occurred in 12 Italian cities during the period 2006-2010. Individual data on causes of death, age, sex, location of death, and preexisting chronic and acute conditions from the previous 5 years' hospitalizations were collected. City-specific conditional logistic regression models were applied within the case-crossover "time-stratified" framework, followed by random-effects meta-analysis. Particulate matter less than or equal to 2.5 µm in aerodynamic diameter (PM2.5) and particulate matter less than or equal to 10 µm in aerodynamic diameter (PM10) were positively associated with natural mortality (1.05% and 0.74% increases in mortality risk for increments of 10 µg/m3 and 14.4 µg/m3, respectively), with greater effects being seen among older people, those dying out-of-hospital or during the warm season, and those affected by 2 or more chronic diseases. Limited associations were found among persons with no previous hospital admissions. Diabetes (1.98%, 95% confidence interval (CI): 0.54, 3.44) and cardiac arrhythmia (1.65%, 95% CI: 0.37, 2.95) increased risk of PM2.5-related mortality, while heart conduction disorders increased risk of mortality related to both PM2.5 (4.22%, 95% CI: 0.15, 8.46) and PM10 (4.19%, 95% CI: 0.38, 8.14). Among acute conditions, recent hospital discharge for heart failure modified the PM10-mortality association. The study found increases in natural mortality from PM exposure among people with chronic morbidity; diabetes and cardiac disorders were the main susceptibility factors.

The relapse rate and predictors of relapse in patients with first-episode psychosis following discontinuation of antipsychotic medication.

To determine the "real world" relapse rate in patients with first-episode psychosis (FEP) who had discontinued antipsychotic medication and identify socio-demographic and clinical factors associated with the risk of relapse. Quantitative data were obtained via case-note review on 63 patients with FEP who had discontinued antipsychotic medication from Birmingham Early Intervention Service between 2012 and 2015. The follow-up period was until either: an occurrence of a relapse; end of 12-month study period; end of patient's case-note record. Relapse was defined as a return of symptoms requiring one of the following: home treatment, hospital admission or was based on clinical teams' decision as having a relapse. A pro-forma targeted pre-defined socio-demographic and clinical factors. Survival analysis was undertaken to estimate the 12-month relapse rate following discontinuation of antipsychotics and Cox regression performed to identify relapse predictors. The Kaplan-Meier 12-month relapse estimate was 67% (95% confidence interval, 54%, 80%). Significant factors (P < .05) independently associated with an increased risk of relapse following discontinuation of antipsychotic medication were: male gender, not being in education, employment or training (NEET) and number of previous psychiatric hospital admissions. Relapse is common after discontinuation of antipsychotic medication following recovery from a FEP. It is important that patients who wish to discontinue their medication are informed of the high relapse rates and the associated risks. Furthermore, male patients, patients with NEET status and those who have had previous hospital admissions may require closer monitoring.

Discharge Planning: Screening Older Patients for Multidisciplinary Team Referral.

The objective was to determine whether the Elders Risk Assessment Index can predict multi-disciplinary team referral of older patients (≥ 65 years) in Emergency Department same-day discharges.The study identified 1,376 qualifying individuals from a regional New Zealand hospital database. Of these, 12.7 % were referred to the multi-disciplinary team. Univariate and multivariate analyses were used to explore associations between the Index, its components, and other demographic factors with referral. With every unit increase in the Index there was a 9% increase in the odds of being referred. When the components of the Index were analysed separately, an increased likelihood of being referred was associated with not being married, having had a previous hospital admission of more than five days, having chronic obstructive pulmonary disease, and being older. Conversely, a decreased likelihood was associated with having diabetes. When non-Index items were analysed it was found that females were more likely to be referred than males and that Māori were less likely to be referred than New Zealand Europeans.With adaptation, the Elders Risk Assessment Index may provide a simple, cost-effective, and timely tool to assist in determining the need for multi-disciplinary team referral for older people who present to the Emergency Department.

Mechanisms underlying increased mortality risk in patients with heart failure and reduced ejection fraction randomly assigned to adaptive servoventilation in the SERVE-HF study: results of a secondary multistate modelling analysis

A large randomised treatment trial (SERVE-HF) showed that treatment of central sleep apnoea with adaptive servoventilation in patients with heart failure and reduced ejection fraction (HFREF) increased mortality, although the analysis of the composite primary endpoint (time to first event of death from any cause, life-saving cardiovascular intervention, or unplanned hospital admission for worsening heart failure) was neutral. This secondary multistate modelling analysis of SERVE-HF data investigated associations between adaptive servoventilation and individual components of the primary endpoint to try to better understand the mechanisms underlying the observed increased mortality. In SERVE-HF, participants were randomly assigned to receive either optimum medical treatment for heart failure alone (control group), or in combination with adaptive servoventilation. We analysed individual components of the primary SERVE-HF endpoint separately in a multistate model, with and without three covariates suggested for effect modification (implantable cardioverter defibrillator at baseline, left ventricular ejection fraction [LVEF], and proportion of Cheyne-Stokes Respiration [CSR]). The SERVE-HF study is registered with ClinicalTrials.gov, number NCT00733343. Univariate analysis showed an increased risk of both cardiovascular death without previous hospital admission (hazard ratio [HR] 2·59, 95% CI 1·54-4·37, p<0·001) and cardiovascular death after a life-saving event (1·57, 1·01-2·44, p=0·045) in the group receiving adaptive servoventilation versus the control group. Adjusted analysis showed that the increased risk attributed to adaptive servoventilation of cardiovascular death without previous hospital admission for worsening heart failure varied with LVEF and that the risk attributed to adaptive servoventilation of hospital admission for worsening heart failure varied with LVEF and CSR. In patients with LVEF less than or equal to 30%, use of adaptive servoventilation markedly increased the risk of cardiovascular death without previous hospital admission (HR 5·21, 95% CI 2·11-12·89, p=0·026). Adaptive servoventilation is associated with an increased risk of cardiovascular death in patients with heart failure and reduced ejection fraction (LVEF ≤45%) treated for predominant central sleep apnoea. This multistate modelling analysis shows that this risk is increased for cardiovascular death in patients not previously admitted to hospital, presumably due to sudden death, and in patients with poor left ventricular function. ResMed.

Predictors of Hospital Readmission in Patients Receiving Outpatient Parenteral Antimicrobial Therapy

Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used, and unfortunately, readmissions during OPAT are common. The purpose of this study was to identify predictors of hospital readmission among patients receiving OPAT. Retrospective cohort study. Large academic tertiary care hospital. A total of 216 adults who were discharged and received OPAT through a peripherally inserted central catheter for at least 2 days for treatment of an active infection, excluding patients with cystic fibrosis, between January 2012 and August 2013. Of these patients, 43 had hospital readmissions and 173 did not. The median age of all study patients was 56 years. Common infections included bone and joint (32%), genital/urinary tract (16%), endocarditis (14%), central nervous system (9.7%), and pneumonia (9.7%). For the 43 patients (20%) who had readmissions, reasons for readmission were infection recurrence or progression (33%), adverse drug reactions (24%), central catheter-associated issues (16%), or non-OPAT-related reasons (27%). In the multivariate analysis, patients assigned to a primary care physician were less likely to be readmitted (odds ratio [OR] 0.286, 95% confidence interval [CI] 0.115-0.711), whereas factors independently associated with an increased readmission rate included previous hospital admission in the past 12 months (OR 2.588, 95% CI 1.159-5.778), medical history of malignant lymphoma (OR 25.172, 95% CI 2.311-272.209), and increased planned OPAT duration (OR 1.058, 95% CI 1.034-1.082). Readmissions while patients received OPAT were common. Therefore, proactive interventions including primary care physician assignment to facilitate follow-up and communication should be implemented to decrease the risk of readmission, particularly in the identified high-risk populations.

Targeting, Monitoring and Effect of Oral Iron Therapy on Haemoglobin Levels in Older Patients Discharged to Primary Care from Inpatient Rehabilitation: A Cohort Study Using Routinely Collected Data.

Oral iron is commonly prescribed to older patients with suspected or confirmed iron-deficiency anaemia; however, few studies have examined the effectiveness of oral iron therapy in the real world in this population. We therefore determined the prevalence of iron deficiency in older people prescribed oral iron, examined the response mounted to therapy and ascertained predictors of response to oral iron. We analysed a routinely collected, linked dataset from older patients who had undergone inpatient rehabilitation between 1999 and 2011. An initial analysis examined patients within this cohort who were prescribed iron after rehabilitation and derived three groups based upon their ferritin and transferrin indices: probably, possibly and not iron deficient. A second analysis compared pre- and post-treatment haemoglobin to determine the degree of response to iron therapy across each category of deficiency. Finally, patient demographics, linked biochemistry data and comorbid disease based on International Classification of Disease (ICD-10) codes from previous hospital admissions were used in regression modelling to evaluate factors affecting response to therapy. A total of 490 patients were prescribed oral iron within 90 days of rehabilitation discharge. Of these, 413 (84%) had iron indices performed; 94 (23%) were possibly deficient, 224 (54%) were probably deficient, and 95 (23%) were not deficient. Of the 490 patients, 360 had both pre- and post-treatment haemoglobin data and iron indices; probably deficient patients mounted a slightly greater response to oral iron (17 vs. 12g/L for not deficient; p<0.05). Only pre-treatment haemoglobin, mean cell volume and lower gastrointestinal pathology were significant predictors of a response to oral iron therapy. Notably, acid-suppressant use was not a predictor of response. We conclude that many older patients are exposed to oral iron without good evidence of either iron deficiency or a significant response to therapy.

Medical and Social Determinants of Health Associated with Intensive Care Admission for Asthma in Children.

Risk factors for severe asthma exacerbations in children requiring admission to the intensive care unit (ICU) may occur in variety of medical, environmental, economic, and socioeconomic domains. We sought to characterize medical and sociodemographic risk factors among children who required admission to the intensive care unit for asthma. Data were obtained from the Greater Cincinnati Asthma Risk Study, a population-based, prospective, observational cohort of children admitted for treatment of acute asthma or bronchodilator-responsive wheezing. Data collected on 774 children included race, socioeconomic status, allergen sensitization, environmental exposures, psychosocial strain, and financial hardship. Analyses compared children admitted to the ICU to those admitted to a medical inpatient unit. One hundred sixty-one (20.9%) children required admission to intensive care. There was no difference in sex, race, insurance status, caregiver educational level, income, financial strain, psychological distress, or marital status between the ICU and non-ICU cohorts. Risk for medication nonadherence assessed by parent report was not different between groups. Although previous hospital admission or emergency department visit history did not differ between the groups, prior ICU admission was more common among those admitted to the ICU at the index admission (27 vs. 16%, P = 0.002). Children requiring intensive care admission were more likely to be sensitized to multiple aeroallergens. Exposure to cigarette smoke (measured as salivary cotinine), although a risk factor for hospital admission, was negatively associated with risk of ICU admission. Social and economic risk factors typically predictive of increased asthma morbidity, including exposure to tobacco smoke, were not associated with ICU admission among a population of children admitted to the hospital for treatment of acute asthma. Intrinsic disease factors, including allergic sensitization, may be more important predictors of ICU admission.

Characteristics of patients contacting a center for undiagnosed and rare diseases.

BackgroundLittle is known about the characteristics of patients seeking help from dedicated centers for undiagnosed and rare diseases. However, information about their demographics, symptoms, prior diagnoses and medical specialty is crucial to optimize these centers’ processes and infrastructure.MethodsUsing a questionnaire, structured information from 522 adult patients contacting a center for undiagnosed and rare diseases was obtained. The information included basic sociodemographic data (age, gender, insurance status), previous hospital admissions, primary symptoms of complaint and previously determined diagnosis.ResultsThe majority of patients completing the questionnaire were female, 300 (57 %) vs. 222 men (43 %). The median age was 52 years (range 18–92). More than half, 309 (59 %), of our patients had never been admitted to a university hospital. Common diagnoses included other soft tissue disorders, not classified elsewhere (ICD M79, n = 63, 15.3 %), somatoform disorders (ICD F45, n = 51, 12.3 %) and other polyneuropathies (ICD G62, n=36, 8.7 %). The most frequent symptoms were general weakness (n = 180, 36.6 %) followed by arthralgia (n = 124, 25.2 %) and abdominal discomfort (n = 113, 23.0 %). The majority of patients had either internal medicine (81.3 %) and/or neurologic (37.6 %) health problems.ConclusionsPain-associated diagnoses and the typical “unexplained” medical conditions (chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome) are frequent among people contacting a center dedicated to undiagnosed diseases. The chief symptoms are mostly unspecific. An interdisciplinary organizational approach involving mainly internal medicine, neurology and psychiatry/psychosomatic care is needed.

Asthma-specific health-related quality of life of people in Great Britain: A national survey

Background: Although the ultimate goal of asthma treatment is to improve asthma-specific Health-Related Quality-Of-Life (HRQOL), in the UK population this is insufficiently studied. National asthma-specific HRQOL data is needed to inform strategies to address this condition. Aims and objectives: To benchmark asthma-specific HRQOL in a national survey of adults with asthma, and explore differences in this measure within subsections of the population. Methods: We analysed answers to the Marks Asthma Quality-of-Life Questionnaire (AQLQ-M) from a representative sample of 658 adults with asthma. Respondents answered asthma-specific questions to assess control, previous hospital admissions, asthma attacks and an indicator of severity. Higher scores indicate poorer HRQOL (maximum = 60). The highest quintile formed a subgroup ‘Poor HRQOL’. Data were weighted to correct for any biases caused by differential non-response. Chi-square analyses were used to determine differences between good and poor quality of life and regression analyses performed to determine what factors are associated with poor HRQOL. Results: The response rate was 49%. AQLQ-M median (IQR) scores were 5 (2–13) for the total sample (poor HRQOL = 21, good HRQOL = 3). Significant differences between good and poor HRQOL were observed in smoking status, SES, employment status and co-morbidities, but no differences were found between age groups. Those with poorly controlled asthma were significantly more likely to have poor HRQOL, ≥1 breathing related hospital admission or ≥1 asthma attack. Conclusions: This article provides benchmarking data on asthma-specific HRQOL. Improved strategies are needed to target interventions towards people experiencing poor HRQOL.

Violence and mental disorders. A retrospective study of people in charge of a community mental health center

BackgroundNumerous studies conducted in inpatient settings have highlighted how mental disorders are associated with an increased risk of violence, particularly during acute phases. However, to date a more limited number of studies have been performed to assess the risk of violence in outpatients, particularly in Italy. The present study aims to evaluate the prevalence of violent events in a sample of patients in charge of a community mental health center in Italy. MethodsBased on data obtained from standardized clinical records, a retrospective study was undertaken to investigate acts of violence (physical aggression only) in a total of 678 patients (Males=308, 45.4%) in charge of a university mental health center; patients were mainly affected by anxiety disorders (30.7%), depressive disorder (17.2%), bipolar disorder (18.3%) and schizophrenia or other psychotic disorders (25.0%). Results27.6% of the sample had committed at least one act of violence during their lifetime, 10.5% over the previous year. 56.7% of those who committed violence acts had acted violently twice or more during their lifetime. A significant association of lifetime violence was found with gender (male), younger age, low education, unemployment, living with parents. With regard to diagnosis, a significant association was found with schizophrenia and other psychotic disorders, personality disorders, mental retardation, and comorbidity between two or more psychiatric disorders. Violence was moreover associated with early age at onset and at first psychiatric treatment, longer duration of the disorder, previous hospital admissions, previous violent events. ConclusionViolent behavior is relatively common among outpatients.

Low dose oestrogen combined oral contraception and risk of pulmonary embolism, stroke, and myocardial infarction in five million French women: cohort study

Objective To assess the risk of pulmonary embolism, ischaemic stroke, and myocardial infarction associated with combined oral contraceptives according to dose of oestrogen (ethinylestradiol) and progestogen.Design Observational cohort study.Setting Data...