Primary Admission Research Articles

The significance of a concomitant clavicle fracture in flail chest patients: incidence, concomitant injuries, and outcome of 12,348 polytraumata from the TraumaRegister DGU®

PurposeIsolated clavicle fractures (CF) rarely show complications, but their influence in the thorax trauma of the seriously injured still remains unclear. Some authors associate CF with a higher degree of chest injuries; therefore, the clavicle is meant to be a gatekeeper of the thorax.MethodsA retrospective analysis of the TraumaRegister DGU® (project 2017-10) was carried out involving the years 2009–2016 (ISS ≥ 16, primary admission to a trauma center). Cohort formation: unilateral and bilateral flail chest injuries (FC), respectively, with and without a concomitant CF.Results73,141 patients (26.5% female) met the inclusion criteria and 12,348 had flail chest injuries (FC; 20.0% CF; 67.7% monolateral FC), 25,425 other rib fractures (17.7% CF), and 35,368 had no rib fractures (6.5% CF). On average, monolateral FC patients were 56.0 ± 17.9 years old and bilateral FC patients were 57.7 ± 19 years old. The ISS in unilateral and bilateral FC were 29.1 ± 11.7 and 42.2 ± 12.9 points, respectively. FC with a CF occurred more frequently with bicycle and motorbike injuries in monolateral FC and pedestrians in bilateral FC injuries and less frequently due to falls. Patients with a CF in addition to a FC had longer hospital and ICU stays, underwent artificially respiration for longer periods, and died less often than patients without a CF. The effects were highly significant in bilateral FC. CF indicates more relevant concomitant injuries of the lung, scapula, and spinal column. Moreover, CF was associated with more injuries of the extremities in monolateral CF.ConclusionDue to the relevance of a concomitant CF fracture in FC, diagnostics should focus on finding CFs or rule them out. Combined costoclavicular injuries are associated with a significantly higher degree of thoracic injuries and longer hospital stays.

How is patient activation related to healthcare service utilisation? Evidence from electronic patient records in England

BackgroundThere is increasing awareness of the importance of patient activation (knowledge, skills, and confidence for managing one’s health and health care) among clinicians and policy makers, with emerging evidence showing higher levels of patient activation are associated with better health outcomes and experiences of health care. This study aimed to examine the association between patient activation and a wide range of specific types of healthcare service utilisation in England, including GP and non-GP primary care, elective and emergency hospital admissions, outpatient visits, and attendances at the Accident and Emergency department.MethodsData were derived from linked electronic patient records collected by primary and secondary healthcare providers in North West London between January 2016 and November 2019. Our analyses focused on adults (18+) with a valid Patient Activation Measure (PAM). After excluding patients with missing data, we had an analytical sample of 15,877 patients. Data were analysed using negative binomial regression and logistic regression models depending on the outcome variable.ResultsPatients had a mean activation score of 55.1 and a standard deviation (SD) of 17.7 (range: 0–100). They had an average of 5.4 GP visits (SD = 8.0), 26.8 non-GP visits (SD = 23.4) and 6.0 outpatient attendances (SD = 7.9) within a one-year follow-up. About 24.7% patients had at least one elective admission, 24.2% had one or more emergency admissions, and 42.3% had one or more A&E attendance within the follow-up. After accounting for a number of demographic and health factors, we found a linear (or proximately linear) association between patient activation and the number of GP visits, emergency admissions and A&E attendance, but a non-linear relationship between patient activation and the number of non-GP visits, the number of outpatient attendance and elective inpatient admission.ConclusionsThis study has provided strong empirical evidence from England linking patient activation with healthcare service utilisation. It suggests the value of supporting patient activation as a potential pathway to ease the burden of healthcare system.

Drug prescriptions and dementia incidence: a medication-wide association study of 17000 dementia cases among half a million participants

BackgroundPrevious studies have suggested that some medications may influence dementia risk. We conducted a hypothesis-generating medication-wide association study to investigate systematically the association between all prescription medications and incident dementia.MethodsWe...

Developing evidence on social prescribing initiative in Lisbon: Challenges and insights for improving

Abstract Social prescribing is recent in Portugal and evidence is needed on the potential of this complex intervention to improve health and wellbeing outcomes but also to inform the commissioning of these programmes. In a collaborative approach, an evaluation protocol of the social prescribing in two primary healthcare units in Lisbon was developed, aiming to assess its implementation and impact at three levels: patients, health system and health-social sector intersection, within a mixed-methods approach. Exploring the social prescribing contribution to enhance patients' quality of life, well-being and activation involves assessing these outcomes throughout a longitudinal perspective. In an exploratory, prospective study, baseline data collection and three follow-ups are included. Secondary data comprise health status indicators collected from patients' medical records as well as referral and social responses elaborated within the intervention. Patients' experiences on the social prescribing activities performed, perceived changes in lifestyle, and perspectives about positive and negative aspects are assessed in semi-structured interviews. The need for further understanding the impact at the health system' level calls for an attentive look at the processes of change in patients' patterns of healthcare services use (appointments in primary healthcare units, hospital admissions and emergency episodes), but also changes in the services' reorganization to better integrative health care. At a broader level, insights will be obtained on the effects on the intersection between the health and social sectors and the experiences of networking, through focus group discussions with all the stakeholders involved. The social prescribing implementation process, barriers, facilitators and suggestions for improvement will also be explored. In this presentation, challenges will be debated, as well as insights for reflection about opportunities for improving evidence development.

Estimating population-based incidence of brain metastases – a comprehensive incident cohort study

Abstract Aims Brain metastases are the most common intracranial tumour and affect approximately 20% of adult cancer patients, most commonly from lung, breast, melanoma, and kidney cancer. However, the true incidence of brain metastasis is unknown. England’s cancer registration system only reliably captures brain metastases present at diagnosis (rather than those that develop later), and the same is true for US-based data. Although it is relatively easy to identify patients receiving some treatments for brain metastases (surgery, stereotactic radiosurgery (SRS) and whole-brain radiation therapy (WBRT)), identifying those receiving chemotherapy or no treatment is much harder. As a result, the existing literature is heavily biased towards reporting treated populations. This study attempts to find an unbiased estimate of the true number of patients developing brain metastases, based on data from a single centre. Method Cases of brain metastasis were retrospectively identified from the radiology information system database (SolitonTM). We performed a Boolean search for specific keywords in the radiology reports of all CT and MRI head scans performed at the trust between 1st January 2018 and 31st December 2019. The following keywords were searched for “metastases”, “metastatic“, “metastasis”, “mets”, “deposit”, “deposits”, “secondaries”, “secondary” and “disseminated”. Duplicate cases were then removed and the subsequent list was manually reviewed We identified all patients who received any treatment for brain metastases who were diagnosed at our centre. We only included patients with newly diagnosed brain metastases (included: leptomeningeal; excluded: skull-based metastases). We excluded patients who were diagnosed in other centres and treated here or diagnosed outside the study period. We then extracted data on primary diagnosis, admissions, and survival. Results 1192 patients had a CT or MRI of the head with a mention of “brain metastases” in the report; of these 305 were newly diagnosed with brain metastases during the study period (432 had metastases; 127 diagnosed earlier). Of these 305 patients, 217 (71.1%) were treated locally (SRS = 88; WBRT = 74; surgery = 88; systemic therapy = 16; multiple treatments = 45) and 10 (3.3%) were referred elsewhere. 78 (25.6%) patients received no treatment. Of the 217 treated patients, 124 were female, and the median age was 61. Of the 78 untreated patients, 38 were females, and the median age was 70 years old. The commonest primary diagnoses in both groups were lung (39%) and breast (21%) cancer. 16 (21%) of the untreated patients had an unbiopsied primary tumour. Median survival for patients having (any) treatment was 52 weeks compared to 5 weeks for those not having treatment. Conclusion We have presented an unbiased single-centre estimate of brain metastases occurrence. Unlike previous work, we manually reviewed all imaging reports that suggested metastasis, and included all patients diagnosed with brain metastases at any timepoint. We reduced the bias associated with being a tertiary centre by only including patients who were diagnosed here, rather than referred from other centres. 25% of our cohort received no treatment, and survival in this group is poor. This is broadly in line with the only other study on this topic (Bentley, 2019) that reported a large minority (39%) of untreated patients. Our key conclusions are: When assessing the incidence of brain metastases, studies that do not account for untreated patients are likely to significantly underestimate incidence, and over-estimate survival. Improving outcomes in patients with brain metastases might be best achieved by addressing earlier identification and intervention in those who currently receive no treatment

What happens to patients undergoing cancer surgery with psychiatric comorbidities?: A nationwide retrospective cohort study.

We aimed to describe the surgical outcomes and readmissions rates in patients with psychological comorbidities who underwent surgical intervention for cancer. The Hospital Readmission Reduction Program, a campaign by the Affordable Care Act, penalizes hospitals for greater readmission rates. One prevalent patient risk factor associated with hospital readmission is a comorbid psychiatric condition. Currently, no studies exist identifying psychiatric comorbidities and their effects on patients with cancer undergoing surgical intervention. A cross-sectional analysis was performed using the Nationwide Readmissions Database for 2010-2014 and included adult patients undergoing cancer resection operations. Multivariable logistic regression analyses were utilized to assess determinants of surgical outcomes and readmissions. Of 1 016 636 eligible patients, 11.6% had psychiatric comorbidities. Patients with psychiatric disorders had greater risks of mortality (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.18-1.25), complications (OR = 1.51, 95%CI = 1.50-1.52), extended length of stay (OR = 1.21, 95%CI = 1.20-1.22), and incurred healthcare expenditure at primary admission (OR = 1.16, 95% CI = 1.15-1.18). Psychiatric comorbidities were associated with an increased likelihood of readmission (OR = 1.13, 95%CI = 1.11-1.15). Concomitant psychiatric conditions were attributed to poor surgical outcomes and a higher risk of readmissions. Multidisciplinary care within the perioperative setting should be encouraged for patients with psychiatric disorders.

Digital signatures for early traumatic brain injury outcome prediction in the intensive care unit

Traumatic brain injury (TBI) is a leading neurological cause of death and disability across the world. Early characterization of TBI severity could provide a window for therapeutic intervention and contribute to improved outcome. We hypothesized that granular electronic health record data available in the first 24 h following admission to the intensive care unit (ICU) can be used to differentiate outcomes at discharge. Working from two ICU datasets we focused on patients with a primary admission diagnosis of TBI whose length of stay in ICU was ≥ 24 h (N = 1689 and 127). Features derived from clinical, laboratory, medication, and physiological time series data in the first 24 h after ICU admission were used to train elastic-net regularized Generalized Linear Models for the prediction of mortality and neurological function at ICU discharge. Model discrimination, determined by area under the receiver operating characteristic curve (AUC) analysis, was 0.903 and 0.874 for mortality and neurological function, respectively. Model performance was successfully validated in an external dataset (AUC 0.958 and 0.878 for mortality and neurological function, respectively). These results demonstrate that computational analysis of data routinely collected in the first 24 h after admission accurately and reliably predict discharge outcomes in ICU stratum TBI patients.

059 Atopic-eczema-associated fracture risk and oral corticosteroids: a population-based cohort study

Evidence suggests adults with atopic eczema have increased fracture risk. However, it is unclear whether oral corticosteroids explain the association. The objective of this study was to assess to what extent oral corticosteroids mediate the relationship between eczema and fracture risk. We performed a cohort study using English primary care (Clinical Practice Research Datalink) and hospital admissions (Hospital Episode Statistics) records (1998-2016). Participants were adults (18+) with eczema matched (on age, sex, and general practice) with up to five adults without eczema.

S3269 Common Presentations and Outcome of Eosinophilic Esophagitis in United States: Nationwide Inpatient Cohort Study

Introduction: Eosinophilic esophagitis (EoE) is a newly described disorder characterized by esophageal dysfunction and eosinophilic infiltration of the esophagus, once considered a rare entity, is becoming a commonly encountered gastroenterological condition. In addition to increased clinical recognition of EoE, rising EoE related hospitalization in the United States has been reported. We aimed to identify the most common presentations, medical and surgical outcomes Methods: A retrospective analysis utilizing the de-identified data from the National Inpatient Sample (NIS) was used to analyze patients hospitalized with Eosinophilic esophagitis as a primary admission diagnosis from 2004 through 2014. Hospital encounters for EoE were identified using the International Classification of Diseases (ICD-9) diagnostic codes; '53013'. The NIS is a component of the Healthcare Cost and Utilization Project, a national health care database developed through a partnership among federal and state governments and health care institutions sponsored by the Agency for Healthcare Research and Quality. We extracted the most common presentations, in-hospital diagnostic procedures, medical and surgical outcomes. Results: A total of 625,380 patients with a principal diagnosis of Eosinophilic Esophagitis were obtained through data analysis (2004 through 2014). The majority of the patients were between 35 and 79 years old, the most common presentations were: 49.6% presented with gastroesophageal reflux disease symptoms, 8.3% presented with dysphagia, 5.6% with atypical chest pain, 5.1% with vomiting, 4.1% with weight loss &failure to thrive, 3.7% with abdominal pain, and 1% with acute food impaction. Interesting associations with the EoE were asthma (4.7%), Food allergy (2.7%), and Atopic dermatitis (0.8%). 44.9% of the patients had Upper Endoscopy and Biopsy upon the same admission. The most common EGD findings were: Esophageal plaques or Candida (8.2%), Esophageal strictures (5%), Esophageal Furrows (4.7%), Steroid Use Induced infection (4.6%), Esophageal Ulceration (4 %), and esophageal rings (0.7%). Conclusion: In summary, national databases such as the NIS are handy tools to address questions surrounding low-frequency events like the EoE and outcomes that would otherwise escape study on a nationally representative level. However, caution must be used when interpreting results, as they are subject to several limitations.Table 1.: We Analyzed from the NIS data the most common presentations, in-hospital diagnostic procedures, medical and surgical outcomes between the years 2004 through 2014.

S3271 Impacts of Dysphagia Among Stroke Patients, Retrospective Nationwide Cohort Study

Introduction: Oropharyngeal dysphagia is frequent in hospitalized post-stroke patients; some studies suggest its presence in 37% to 78% of stroke survivors and are associated with increased catastrophic consequences related to this dysphagia, including; pneumonia, malnutrition, and longer hospitalization period. Methods: A retrospective analysis utilizing the de-identified data from the National Inpatient Sample (NIS) was used to analyze patients hospitalized with acute stroke as a primary admission diagnosis from 2004 through 2014. Hospital encounters for dysphagia were identified using the International Classification of Diseases (ICD-9) diagnostic codes'7872'. The NIS is a component of the Healthcare Cost and Utilization Project, a national health care database developed through a partnership among federal and state governments and health care institutions sponsored by the Agency for Healthcare Research and Quality. We extracted baseline medical and demographic data, including age, pneumonia, malnutrition, length of stay, and total charges. Categorical variables were compared using the chi-square test, and continuous variables were compared using the t-test. P-values less than 0.05 indicated a statistically significant association. The odds ratio and 95% confidence interval were also calculated. Data analysis was done using STATA Statistical Software, Release 16 (College Station, TX: StataCorp LLC.) Results: A total of 1979090 admissions for acute stroke were identified, of which 128065 patients with dysphagia. The average age is older for acute stroke patients with dysphagia (SWD) (75.81 vs 71.40; P < 0.001). Medical events were higher in SWD patients, including; pneumonia (7.7% vs 6.8%; P < 0.001), malnutrition (1.9% vs 0.7%; P < 0.001), sepsis (5.1% vs 3.7%; P < 0.001), dehydration (9.9% vs 7.4%; P < 0.001), acute kidney injury (10.3% vs 9.3%; P < 0.001), and atrial fibrillation (28.0 % vs 21.4%; P < 0.001). Length of stay is longer for SWD (9 vs 5.53 days; P < 0.001), and the total charges were significantly higher as well (55894.51 vs 38454.54 U.S. dollar; P < 0.001). Conclusion: Guidelines advocate screening all acute stroke patients for dysphagia. However, limited data are available regarding how many patients are screened and how failing a swallowing screen affects patient outcomes. Therefore, we sought to evaluate the impact of dysphagia on clinical outcomes: more frequent pneumonia, malnutrition, sepsis, acute kidney injury, length of stay, and costs were reported in this cohort.Table 1.: Comparison between hospital admission with and without dysphagia among stroke patients (n=1979090).

Signs of dysphagia and associated outcomes regarding mortality, length of hospital stay and readmissions in acute geriatric patients: Observational prospective study.

Dysphagia is a prevalent disorder in acute geriatric patients. This observational prospective study aimed at investigating adverse clinical outcomes linked to signs of dysphagia, including mortality, length of hospital stay (LOS), readmissions, among patients aged≥65 years at a Danish acute medical unit (AMU). Signs of dysphagia were assessed using bedside screening tools including the Eating Assessment Tool (EAT-10), a 30mL Water Swallowing Test (WST) and the Gugging Swallowing Screen tool (GUSS), as described in the preceding cross-sectional study. Data for the follow-up was twice retrieved from electronic medical charts 30 days and 90 days after the patients' primary admission to the hospital. Statistical analysis included non-parametric tests of independence and proportional hazards modelling. 444 patients were recruited, 334 of whom completed the dysphagia screening with 144 (43.1%) showing signs of dysphagia. Patients with signs of dysphagia, compared to those without, experienced higher mortality after 30 days (12.5% vs. 1.6%, p<0.001) and 90 days (21.5% vs. 5.8%, p<0.001), longer LOS (median [Q1; Q3]: 4 [2; 8] vs. 3 [1; 6] days, p=0.004), more total hospital days (THD) during both the 30-day and 90-day follow-up (for 90d: median [Q1; Q3]: 6 [2.25; 12] vs. 4 [2; 9] days, p=0.007), but no significant difference in frequency of readmissions. Multivariate proportional hazards modelling revealed signs of dysphagia, low performance status and high comorbidity to be independent risk factors for mortality. High comorbidity and low hemoglobin, but not signs of dysphagia, were revealed as independent risk factors for readmission. Dysphagia is a notable risk factor linked to increased mortality and length of hospital stay (LOS) for acute geriatric patients in general, not just those suffering from stroke, head and neck cancer or neurodegenerative diseases. Further research is needed to investigate the effectiveness and feasibility of systematic dysphagia screening within this population.

S3261 Eosinophilic Esophagitis Demographic Insight From National Inpatient Data 2004-2014

Introduction: Eosinophilic esophagitis (EoE) was first described in 1977. The increase in awareness and prevalence of EoE in the past two decades presents an increasing need for assessing the disease burden on the healthcare system. Therefore, this study used a retrospective strategy to examine the inpatient data from 11 years (2004 through 2014) to have a better insight Methods: A retrospective analysis utilizing the de-identified data from the National Inpatient Sample (NIS) was used to analyze patients hospitalized with Eosinophilic esophagitis as a primary admission diagnosis from 2004 through 2014. Hospital encounters for EoE were identified using the International Classification of Diseases (ICD-9) diagnostic codes; '53013'. The NIS is a component of the Healthcare Cost and Utilization Project, a national health care database developed through a partnership among federal and state governments and health care institutions sponsored by the Agency for Healthcare Research and Quality. We extracted baseline medical and demographic data, including age, race, income, insurance status, and hospital criteria Results: The total number of discharges with Eosinophilic Esophagitis obtained by reviewing NIS data from 2004 through 2014 was 625,380. The majority of the patients were between 35 and 79 years old, stratified according to age groups: 9.6% of patients were younger than 35 years, 16.5% (35-49 years old), 26.7% (50-64 years old), 27.8% (65-79 years old), and 19.5% of them were older than 79 years. The majority 51.0% (319123) of the patients were female, and white 72.0% (385744). Hospital characteristics revealed that: 40.5% of admissions were in the southern states’ hospitals, 61% large bed size hospitals, and 46.2% were urban non-teaching. The sources of payment among EoE patients were mostly Medicare (53.9%), while private insurance (25.1%), Medicaid (12%), and other sources (2.8%). The median length of stay (LOS) of EoE inpatient care was approximately 5.9 days. 44.9% of the patients had Upper Endoscopy and Biopsy upon the same admission Conclusion: EoE has transformed from a case-reportable phenomenon to an increasingly common diagnosis in recent years with the rise of more sensitive and specific tests. In addition to advancements in diagnostic tools, the prevalence of EoE has been steadily increasing within the last decades. Hereby, we did this preliminary data analysis as a small step in the process of getting better knowledge of EoE epidemiology.Table 1.: We extracted baseline medical and demographic data, including age, race, income, insurance status, and hospital criteria, using the ICD-9 diagnostic codes of Eosinophilic Esophagitis '53013',

Brief report: Cannabis and opioid use disorder among heart failure admissions, 2008-2018.

BackgroundIn the United States, both cannabis use disorder (CUD) and opioid use disorder (OUD) have increased in prevalence. The prevalence, demographics, and costs of CUD and OUD are not well known in heart failure (HF) admissions. This study aimed to use a national database to examine the prevalence, demographics, and costs associated with CUD and OUD in HF.MethodsThis study used the National Inpatient Sample from 2008 to 2018 to identify all primary HF admissions with and without the co-diagnosis of OUD or CUD using International Classification for Diagnosis, diagnosis codes. Demographics, costs, and trends were examined.ResultsBetween 2008 and 2018, we identified 11,692,995 admissions for HF of which 84,796 (0.8%) had a co-diagnosis of CUD only, and 67,137 (0.6%) had a co-diagnosis of OUD only. The proportion of HF admissions with CUD significantly increased from 0.3% in 2008 to 1.3% in 2018 (p<0.001). The proportion of HF admissions with OUD significantly increased from 0.2% in 2008 to 1.1% in 2018 (p<0.001). Patients admitted with HF and either CUD or OUD were younger, more likely to be Black, and from lower socioeconomic backgrounds (p<0.001, all). HF admissions with OUD or CUD had higher median costs compared to HF admissions without associated substance abuse diagnoses ($8,611 vs. $8,337 for CUD HF and $10,019 vs. $8,337 for OUD HF, p<0.001 for both).ConclusionsAmong discharge records for HF, CUD and OUD are increasing in prevalence, significantly affect underserved populations and are associated with higher costs of stay. Future research is essential to better delineate the cause of these increased costs and create interventions, particularly in underserved populations.

Primary admission and secondary transfer of trauma patients to Dutch level I and level II trauma centers: predictors and outcomes

PurposeThe importance and impact of determining which trauma patients need to be transferred between hospitals, especially considering prehospital triage systems, is evident. The objective of this study was to investigate the association between mortality and primary admission and secondary transfer of patients to level I and II trauma centers, and to identify predictors of primary and secondary admission to a designated level I trauma center.MethodsData from the Dutch Trauma Registry South West (DTR SW) was obtained. Patients ≥ 18 years who were admitted to a level I or level II trauma center were included. Patients with isolated burn injuries were excluded. In-hospital mortality was compared between patients that were primarily admitted to a level I trauma center, patients that were transferred to a level I trauma center, and patients that were primarily admitted to level II trauma centers. Logistic regression models were used to adjust for potential confounders. A subgroup analysis was done including major trauma (MT) patients (ISS > 15). Predictors determining whether patients were primarily admitted to level I or level II trauma centers or transferred to a level I trauma center were identified using logistic regression models.ResultsA total of 17,035 patients were included. Patients admitted primarily to a level I center, did not differ significantly in mortality from patients admitted primarily to level II trauma centers (Odds Ratio (OR): 0.73; 95% confidence interval (CI) 0.51–1.06) and patients transferred to level I centers (OR: 0.99; 95%CI 0.57–1.71). Subgroup analyses confirmed these findings for MT patients. Adjusted logistic regression analyses showed that age (OR: 0.96; 95%CI 0.94–0.97), GCS (OR: 0.81; 95%CI 0.77–0.86), AIS head (OR: 2.30; 95%CI 2.07–2.55), AIS neck (OR: 1.74; 95%CI 1.27–2.45) and AIS spine (OR: 3.22; 95%CI 2.87–3.61) are associated with increased odds of transfers to a level I trauma center.ConclusionsThis retrospective study showed no differences in in-hospital mortality between general trauma patients admitted primarily and secondarily to level I trauma centers. The most prominent predictors regarding transfer of trauma patients were age and neurotrauma. These findings could have practical implications regarding the triage protocols currently used.

Machine Learning Consensus Clustering Approach for Hospitalized Patients with Phosphate Derangements.

Background: The goal of this study was to categorize patients with abnormal serum phosphate upon hospital admission into distinct clusters utilizing an unsupervised machine learning approach, and to assess the mortality risk associated with these clusters. Methods: We utilized the consensus clustering approach on demographic information, comorbidities, principal diagnoses, and laboratory data of hypophosphatemia (serum phosphate ≤ 2.4 mg/dL) and hyperphosphatemia cohorts (serum phosphate ≥ 4.6 mg/dL). The standardized mean difference was applied to determine each cluster’s key features. We assessed the association of the clusters with mortality. Results: In the hypophosphatemia cohort (n = 3113), the consensus cluster analysis identified two clusters. The key features of patients in Cluster 2, compared with Cluster 1, included: older age; a higher comorbidity burden, particularly hypertension; diabetes mellitus; coronary artery disease; lower eGFR; and more acute kidney injury (AKI) at admission. Cluster 2 had a comparable hospital mortality (3.7% vs. 2.9%; p = 0.17), but a higher one-year mortality (26.8% vs. 14.0%; p < 0.001), and five-year mortality (20.2% vs. 44.3%; p < 0.001), compared to Cluster 1. In the hyperphosphatemia cohort (n = 7252), the analysis identified two clusters. The key features of patients in Cluster 2, compared with Cluster 1, included: older age; more primary admission for kidney disease; more history of hypertension; more end-stage kidney disease; more AKI at admission; and higher admission potassium, magnesium, and phosphate. Cluster 2 had a higher hospital (8.9% vs. 2.4%; p < 0.001) one-year mortality (32.9% vs. 14.8%; p < 0.001), and five-year mortality (24.5% vs. 51.1%; p < 0.001), compared with Cluster 1. Conclusion: Our cluster analysis classified clinically distinct phenotypes with different mortality risks among hospitalized patients with serum phosphate derangements. Age, comorbidities, and kidney function were the key features that differentiated the phenotypes.

Current status of thromboembolism risk assessment in patients hospitalized with non-valvular atrial fibrillation in tertiary hospitals in China

Objective: To analyze the current status, trend and predictors of thromboembolism risk assessment in patients hospitalized with non-valvular atrial fibrillation (NVAF) in tertiary hospitals in China. Methods: The study was based on data from the Improving Care for Cardiovascular disease in China (CCC)-Atrial Fibrillation (AF) project. About 10% of the tertiary hospitals in each geographic-economic stratum were recruited. Participating hospitals reported the first 10 to 20 patients with a discharge diagnosis of atrial fibrillation monthly. From February 2015 to December 2019, a total of 49 104 NVAF patients from 151 tertiary hospitals in 30 provinces, municipalities and autonomous regions were enrolled. Clinical data of the patients was collected. The proportion of NVAF patients receiving thromboembolism risk assessment, variations in the proportion between different hospitals, the time trend of the application of thromboembolism risk assessment, and the predictors of the application of thromboembolism risk assessment were analyzed. Results: The age of the NVAF patients was (68.7±12.1) years, 27 709 patients (56.4%) were male. Only 17 251 patients (35.1%) received thromboembolism risk assessment. The proportion varied substantially between hospitals with the lowest value of 0 and the highest value of 100%. Among the hospitals, which enrolled more than 30 patients, no patients received thromboembolism risk assessment in 18.4% (26/141) of the hospitals, more than 50% of the patients received thromboembolism risk assessment in 21.3% (30/141) of the hospitals, and all the patients received thromboembolism risk assessment in only 1 hospital. The proportion of NVAF patients receiving thromboembolism risk assessment was 16.2% (220/1 362) in the first quarter of 2015, and significantly increased to 67.1% (1 054/1 572) in the last quarter of 2019 (P<0.001). Patients' characteristics were associated with the application of thromboembolism risk assessment. The odds of receiving thromboembolism risk assessment was lower in male patients compared to female patients(OR=0.94,95%CI 0.89-0.99), lower in patients with acute coronary syndrome or other cardiovascular diseases compared to those with AF as the primary admission reason (OR=0.59, 95%CI 0.55-0.63, OR=0.52, 95%CI 0.45-0.61, respectively), and lower in patients with paroxysmal, persistent and long-standing/permanent AF compared to those with first detected AF (OR=0.62, 95%CI 0.57-0.67, OR=0.72, 95%CI 0.66-0.79, OR=0.57, 95%CI 0.52-0.64, respectively). The odds was higher in patients with a history of hypertension, heart failure, stroke/TIA, and previous anticoagulant therapy compared to those without the above conditions (OR=1.17, 95%CI 1.11-1.23, OR=1.18, 95%CI 1.07-1.30, OR=1.17, 95%CI 1.08-1.27, OR=1.28, 95%CI 1.19-1.37, respectively) (P all<0.05). Conclusion: Thromboembolism risk assessment was underused in patients hospitalized with NVAF in tertiary hospitals in China, and there were substantial variations between hospitals in the application of thromboembolism risk assessment. The application of thromboembolism risk assessment in tertiary hospitals has been improved in recent years, but there is still plenty of room for future improvement. Patients' characteristics could affect the application of thromboembolism risk assessment in China.

Impact of malignancy on In-hospital mortality, stratified by the cause of admission: An analysis of 67 million patients from the National Inpatient Sample.

To describe the patient characteristics and the reason for admission of patients with malignancy by malignancy, and to study mortality rates for the different causes of admissions among the different types of cancer. Using the nationwide Inpatient Sampling (2015-2017) we examined the cause of admission and associated in-hospital mortality, stratified by presence and type of malignancy. Multivariable logistic regression models were used to examine the association between in-hospital mortality and malignancy sites for different primary admission causes. Out of 67819693 inpatient admissions, 8.8% had malignancy. Amongst those with malignancy, haematological malignancy was the most common (20.2%). The most common cause of admission amongst all cancers were malignancy-related admissions, where up to 57% of all colorectal admissions were malignancy-related. The most common non-malignancy cause of admission was infectious causes, which were most frequent among patients with haematological malignancy (18.4%). Patients with malignancy had higher crude mortality rates (5.7% vs 1.9%). Mortality rates were highest among patients with lung cancer (8.7%). Among all admissions, the adjusted rates of mortality were higher for patients with lung (OR 3.65, 95% CI [3.59-3.71]), breast (OR 2.06, 95% CI [1.99-2.13]), haematological (OR 1.79, 95% CI [1.76-1.82]) and colorectal (OR 1.71, 95% CI [1.66-1.76]) malignancies compared with patients with no malignancy. Our work highlights the need to consider the burden of cancer on our hospital services and consider how the prognostic impact of different types of admissions may relate to the type of cancer diagnosis and understand whether these differences relate to disparities in clinical care/treatments.

Late Bleeding Following Cleft Palate Repair: An Under-Reported Finding?

The objective of this article is to assess the incidence of late bleeding following cleft palate repair (palatoplasty) in children. This is a retrospective review of a prospectively maintained database of patients treated for Cleft Lip and Palate in a tertiary academic pediatric hospital setting over 2 hospitals (Middlemore and Starship Hospitals) under the same multidisciplinary team of the Auckland Regional Cleft and Craniofacial Service, New Zealand. All patients with a diagnosis of Cleft Lip and/or Palate undergoing primary cleft palate repair over an 11 year period until March 2020 were included in the study. Our results found there were 482 patients with a new diagnosis of Cleft Lip and/or Palate from Jan 2009 through to March 2020. Three hundred sixty-six of those patients underwent primary palatoplasty at an average age of 10.5 months (range 8-18 months). The sub-types of cleft palate diagnoses were one-third Veau I, one-third Veau II, and the remaining one-third were Veau III, IV, and submucous cleft palate. One-third were syndromic. A total of 6 patients were re-admitted to hospital after discharge from their primary admission with bleeding from the cleft palate surgical site. Of the 6 patients re-admitted, 5 needed blood transfusions and 4 required an urgent return to the operating room. The authors found the rate of late bleeding following primary cleft palate repair in our unit is 1:61 operations or 1.6%. Late bleeding following cleft palate surgery is not well reported in the literature.

1250Grass pollen exposure and children’s asthma repeat admissions in Victoria, Australia

Abstract Background Paediatric asthma-related readmissions significantly challenge public health systems. As evidence suggests readmissions are possibly associated with ambient grass pollen levels, we sought to determine the relationship between grass pollen exposure and the risk of readmission for asthma among children in Victoria, Australia. Methods The Victorian Admitted Episodes Dataset 1st July 1997–30th June 2009 was used to identify primary admissions with a principal diagnosis of asthma for children aged 2-18 years. Total sample size was 48,068 admissions. Readmissions were defined as a subsequent admission within 28 days of index discharge. Multiple semi-parametric Poisson Generalized Additive Models were used to assess associations between the grass pollen season and daily grass pollen counts (lagged and cumulative) with repeat admissions, while controlling for meteorological factors and air pollutants. Results Readmissions totalled to 2,152 (4.47% of all admissions). Mean daily readmissions were 1.44 times higher during the grass pollen season (95%CI 1.03-2.02). Pollen season was associated with readmission only for the youngest age group (2-5), incident rate ratio 1.99 (95%CI 1.26-3.14). Daily readmission was non-linearly associated with same day pollen counts only for the 13-18-year age group. Lag 2 pollen counts were non-linearly associated with all daily readmissions for boys in gender-stratified and younger age groups (2-5, 6-12) in age-stratified analysis. Conclusions Grass pollen exposure was associated with higher readmission rates for paediatric asthma. Key messages Younger children and boys with severe or poorly controlled asthma need to be assessed for preventive therapies before the grass pollen season to reduce the repeat admissions.

Socioeconomic and Comorbid Factors Associated With Frostbite Injury in the United States.

Frostbite largely affects the extremities and often results in long-term disability due to amputation. More regions are experiencing extremes in temperature which increases the risk of frostbite injury. The aim of this study was to detail social and comorbid factors associated with frostbite injury compared to isolated hand or foot burns. We used the National Inpatient Sample from 2016 to 2018 to identify admissions included in this study. Weighted incidence and multivariable analysis assessed characteristics and outcomes of frostbite and isolated hand or foot burn injury. In the United States, the estimated incidence of frostbite injury in those aged 15 and older was 0.95 per 100,000 persons and 4.44 per 100,000 persons with isolated hand and foot burns. Homelessness, mental health disorder, drug or alcohol abuse, and peripheral vascular disease were all associated with the risk of frostbite injury when compared to burn injury. We found that other insurance was associated with amputation following burn injury, while black race and homelessness were associated with amputation during a nonelective primary admission following frostbite injury. The differing risk factors associated with early amputation in frostbite and burn patients warrant a multicenter study including burn centers in North America.