Recurrent Hospitalizations Research Articles

62 Unrecognized fentanyl use in an adolescent with seizure-like episodes and recurrent hospitalizations

62 Unrecognized fentanyl use in an adolescent with seizure-like episodes and recurrent hospitalizations

Investigation of neurogenic dysphagia in commonly seen neurological diseases

Neurological disorders lead to varying degrees of impairment in the functions of vital swallowing structures, such as the cortex, cerebellum, brainstem, cranial nerves, and muscles. Neurogenic dysphagia is observed in approximately 50% of common neurological disorders such as stroke, multiple sclerosis, and Parkinson’s disease. Although the pathophysiology and course of the disease vary, dysphagia may occur at any stage of swallowing, including oral preparation, oral, pharyngeal, and esophageal phases. Neurogenic dysphagia ranks among the top symptoms that restrict patients’ independence in daily life activities, reduce their quality of life and increase morbidity and mortality rates. Despite being a prevalent and highly impactful symptom among patients, neurogenic dysphagia can go unnoticed among the multiple symptoms experienced by neurological disorders due to their nature. It is important to be aware of disease-specific risk factors for the early detection of neurogenic dysphagia. Overlooked dysphagia can lead to complications such as aspiration pneumonia, dehydration, malnutrition, and weight loss. Among these complications, aspiration pneumonia is the most common, requiring attention due to its recurrent hospitalizations, inpatient treatment, and high healthcare costs. Many patients exhibit common neurogenic dysphagia symptoms such as drinking liquids in small sips, cutting solid foods into small pieces, decreased appetite, and prolonged meal times. The aim of this study is to examine various aspects of neurogenic dysphagia in different neurological disorders, including its etiology, risk factors, symptoms, and prevalence.

P-222. Emergence and dissemination of Clostridioides difficile isolates with reduced fidaxomicin susceptibility in an acute care hospital

Abstract Background Despite increasing use of fidaxomicin for Clostridioides difficile infection (CDI), isolates with reduced susceptibility (minimum-inhibitory concentration [MIC] >2 ug/mL) have been rare in surveillance studies. However, there has been recent reports of clinical isolates with reduced susceptibility associated with mutations in the RpoB and RpoC genes coding for the RNA polymerase target of fidaxomicin. The clinical implications of reduced susceptibility are uncertain because fidaxomicin achieves high concentrations in the intestinal tract. Whole genome sequencing analysis demonstrating that isolates from 3 patients (patients 1, 3, and 4) infected with ribotype 097 strains (sequence type [ST] 21) are genetically related (<2 single nucleotide polymorphism differences) suggesting patient-to-patient transmission ST21 = Ribotype 097; ST2 = Ribotype 014-020 Methods During a 3-year period, patients treated for CDI in an acute care hospital were assessed for recurrence and fidaxomicin treatment failure, defined as persistent symptoms and culture positivity after >10 days of fidaxomicin treatment without an alternative explanation. Serial stool samples from these patients were cultured for C. difficile confirmed by MALDI-TOF. Susceptibility testing was performed by agar dilution. Whole genome sequencing (WGS) was performed to determine relatedness of the isolates (genetically related: <2 single nucleotide polymorphism differences) and to identify mutations associated with reduced fidaxomicin susceptibility. Results Among 115 patients treated with fidaxomicin, there were 20 (17%) recurrences and 3 (2.6%) treatment failures. In 2 of the patients with treatment failure, initial C. difficile isolates were susceptible to fidaxomicin but genetically related isolates with reduced susceptibility (MIC >16ug/mL) associated with distinct mutations in rpoB (V1143G) and rpoC (R89G) emerged. The patient with the rpoC mutation had recurrent hospital admissions and maintained carriage of the isolate with reduced susceptibility over a 3-year period. Three additional patients were infected with C. difficile isolates with fidaxomicin MICs >8 ug/mL, including 2 patients with sequence type 21 (ribotype 097) isolates genetically related to the treatment failure isolate with the rpoC mutation (Figure). Conclusion Emergence of C. difficile isolates with reduced fidaxomicin susceptibility may play a role in some cases of fidaxomicin treatment failure. Our findings suggest that patient-to-patient transmission could lead to dissemination of isolates with reduced fidaxomicin susceptibility. Disclosures Curtis Donskey, MD, Clorox: Grant/Research Support|Pfizer: Grant/Research Support

Evaluating the use of Uromune® autovaccine in recurrent urinary tract infections: a pilot unicenter retrospective study in Reus, Spain

BackgroundUrinary tract infections (UTIs) are a significant global health issue, especially among women, with growing concerns related to antibiotic resistance and adverse effects. The Uromune®, a sublingual, heat-inactivated, polybacterial vaccine, represents a promising therapeutic alternative by enhancing immune responses against uropathogens.MethodsThis pilot retrospective study, conducted at Hospital Universitari de Sant Joan de Reus from January 2018 to August 2022, assessed the association between Uromune® administration and changes in recurrent UTIs. Patients received personalized autovaccines administered as two sublingual puffs daily for three months. Clinical, microbiological, and demographic data were analyzed to assess treatment outcomes and identify recurrence-associated factors.ResultsForty-nine patients (mean age, 61 years, and 59.2% women) were included in the study. Uromune® treatment decreased UTI episodes from 3.73 ± 0.97 the year before to 0.98 ± 1.36 (p < 0.001) the year after its administration. The number of patients who suffered three or more episodes per year dropped from 43 (87.7%) before the intervention to 7 (14.3%) afterwards. The maximum effectiveness of the autovaccine was observed three months post-administration, with 44 patients not experiencing any UTI episodes. Regression analysis identified having had a urostomy, chronic kidney disease, and being immunosuppressed as predictors of recurrence.ConclusionUromune® autovaccine was associated with a significant reduction in the frequency of recurrent UTIs and related hospitalizations, offering substantial relief to patients. These findings suggest that Uromune® may be a promising option for managing recurrent UTIs, though controlled studies are needed to confirm its efficacy compared to standard treatments.

The effect of azithromycin treatment on respiratory morbidity in children with down syndrome

BackgroundChildren with Down syndrome (DS) often experience recurrent and prolonged hospitalizations from respiratory infections. While Azithromycin has been increasingly used for lower-respiratory tract infections (LRTIs) in children, its potential benefits for DS patients are unexplored. This study evaluates the effect of chronic azithromycin treatment on respiratory morbidity in children with DS.MethodsIn this retrospective cohort study, we analyzed data from children with DS aged 0–6 years treated with Azithromycin for at least 6 weeks (10 mg/kg, thrice weekly). Respiratory morbidity indicators, such as primary care visits, medication consumption, emergency department visits, hospitalizations, and hospital length of stay (LOS), were assessed and compared six months before and after the Azithromycin treatment.ResultsTwenty-three episodes of Azithromycin treatment (≥ 6 weeks) in eighteen children with DS (mean age of 2.3 years, 78% males) during 2016–2023 were included. A significant reduction in mean respiratory LOS was observed (13.6 vs. 4.7 days, p = 0.05) when comparing pre to post-Azithromycin treatment. Other secondary respiratory outcomes showed no significant differences.ConclusionThe significant reduction in respiratory LOS suggests the potential benefits of Azithromycin in children with DS, and emphasizes the need for larger clinical trials to determine optimal use and long-term effects in this vulnerable population.

Optimizing haemodialysis outcomes: A pilot study on the effectiveness of multidisciplinary clinics in enhancing vascular access and improving patient outcomes

Background Patients with kidney failure face increased health risks during early haemodialysis due to physical and emotional challenges. Most patients begin haemodialysis using catheters, which increases mortality and complication risks. This study evaluates the impact of multidisciplinary clinics on vascular access and patient outcomes on haemodialysis. Objectives To compare the influence of multidisciplinary clinics with conventional clinics on the utilisation of definitive vascular access for haemodialysis. Methods This is a single-centre, retrospective cohort study included 145 patients newly started on haemodialysis. Patients were evaluated over a 12-month follow-up period (July 2018 to December 2020). The primary outcome was definitive vascular access for haemodialysis. Secondary outcomes included the frequencies of catheter-related bloodstream infections, intensive care unit admissions, and recurrent hospitalizations. Results The study analysed 53 and 92 participants in the multidisciplinary clinics and conventional groups, respectively. Although only 10% of patients started haemodialysis with definitive access, the multidisciplinary clinics group exhibited significantly higher utilisation of definitive vascular access after 6 months (OR = 2.44, 95% CI 1.16-5.26, p = .039). The multidisciplinary clinics group had lower risks of intensive care unit admission (OR 0.92, 95% CI 1.03-1.15, p = .026) and recurrent hospitalization (OR 0.13, 95% CI 2.06-26.68, p = .001). Although not statistically significant (OR 0.34, 95% CI 0.47-18.46, p = .709), the multidisciplinary clinics group had a lower incidence of catheter-related infections. Conclusions Multidisciplinary care significantly increases the use of definitive vascular access, reduces intensive care unit admissions, and hospitalization rates, demonstrating the effectiveness of comprehensive, coordinated care in managing patients on haemodialysis.

Cholestyramine: an inexpensive but overlooked treatment for long-acting anticoagulant rodenticide (LAAR) poisoning

Treatment of long-acting, anticoagulant rodenticides (LAAR)-poisoned patients with high-dose oral vitamin K1 (VK1) is expensive and requires several months. The long duration can result in non-adherence leading to recurrent severe coagulopathy, bleeding, and hospitalizations. Cholestyramine (CSA) is an inexpensive, safe, and effective gut-restricted resin used to treat primary hypercholesterolemia or pruritus, and to accelerate clearance of teriflunomide. We propose using inexpensive CSA therapy in LAAR-poisoned patients while administering daily high-dose oral VK1 and periodically monitoring plasma LAAR concentrations until declining to a safe concentration. We suggest that this regimen should be available to public health clinics responding to outbreaks of LAAR poisoning. CSA treatment could improve patient adherence, shorten duration of high dose oral VK1 therapy, and reduce healthcare expenditures.

FRAILTY STATUS AND CATHETER ABLATION THERAPY FOR ATRIAL FIBRILLATION IN REAL-AF: A MULTICENTER CLINICAL REGISTRY

Abstract There has been increasing interest in understanding if frailty assessment could improve clinical decision-making related to catheter ablation therapy (CAT) for atrial fibrillation (AF) patients. This prospective study assessed acute hospital complications, AF recurrence and AF-related hospitalization within 12 months after CAT according to frailty status pre-CAT. Study subjects (n=3,406) were patients in Real-AF, a multicenter clinical registry in the US, who underwent CAT with 12-month outcome data (2018-2022). Frailty scores were derived using the cumulative health deficit approach (deficits count divided by the total number of health indicators), and categorized: Fit (≤.12), Intermediate (.12–.24), and Frail (≥0.25). Cross-tabulations, trend tests, and logistic regression were performed. Mean age± SD of study subjects was 65.2± 11.0; males were 59.0%. Among patients who underwent CAT, 24.5% met criteria for Frail (score≥0.25). Frailty scores were correlated weakly with age (r=0.09; p&amp;lt;.01). Fit (1.2%) and Frail (1.3%) had similar acute in-hospital complication rates. Increasingly higher probability of AF recurrence (18.2% vs. 19.8% vs. 22.6%; p=.02), and AF-related hospital admission (2.1% vs. 3.4% vs. 4.6% vs. 5.4%, p=.02) within 12 months after CAT were observed across increasing frailty severity categories. Frailty remained associated with AF recurrence and hospitalization in age- and sex-adjusted models; e.g., odds of hospitalization post-CAT were 2.3 (95%CI: 1.0-5.0, p=.039) times higher in Frail than in Fit. Despite adverse trends with frailty, absolute 12-month risks after CAT, even among Frail, was low. Implementation research is warranted to establish the clinical value of frailty assessment for CAT-related decision-making in AF patients.

Low triiodothyronine syndrome as a factor of an unfavorable course of heart failure in patients with ischemic heart disease and COVID-19 history

Objective — to establish the association of low triiodothyronine syndrome (LT3S) with the risk of an unfavorable course of heart failure (HF) in patients with ischemic heart disease who have had COVID‑19, taking into account some clinical, pharmacogenetic, and biomarker indicators. Materials and methods. The study included 352 patients with ischemic origin of HF arising in individuals with ischemic heart disease. Of these, 128 (36.4%) patients had a history of COVID‑19 with lung involvement, and 224 (63.6%) without lung involvement. The patients were followed up for 24 months to study the impact of the presence of LT3S, levels of tumor necrosis factor α (TNF‑α), interleukin‑6 (IL‑6), and polymorphisms of the β‑adrenergic receptor system genes on the course of HF, taking into account the frequency of hospitalizations due to HF decompensation. Results. The frequency of recurrent hospitalizations of HF patients without lung involvement in COVID‑19 was 20.6%, while in patients with lung involvement — 45.3% (χ2=24.505; p=0.0001). There is a tendency to the increase in the frequency of recurrent hospitalizations in HF patients with established LT3S compared to those without this syndrome (31.7% vs. 22.9%, χ2=3.326; p=0.068). It was found that the risk of LT3S increased in homozygous carriers of CC polymorphism at the Ser275 site of the G‑protein β3 subunit gene: the odds ratio (OR) was 1.75 (95% confidence interval (CI) 0.99—3.07; p=0.054). The risk of increasing concentration of TNF‑α and IL‑6 in HF patients was higher in homozygous carriers of CC polymorphism at the Ser275 site of the G‑protein β3 subunit gene: OR=4.55 (95% CI 1.27—16.34); p=0.028) and OR=5.86 (95% CI 1.81—19.00; p=0.003). The risk of recurrent hospitalizations in HF patients with lung involvement in COVID‑19 was associated with the heterozygous C/T polymorphism at the Ser275 site of the G‑protein β3 subunit gene (OR=4.36 (95% CI 1.85—10.27; p=0.022). Conclusions. In patients with ischemic HF low T3 blood serum level can be a predictor of unfavorable prognosis. LT3S in such patients is associated with more severe course of COVID­­19. The inducer of LT3S development may be proinflammatory cytokines that affect the conversion of T4 to T3. The risk of LT3S development in patients with IHD and COVID­­19 history is associated with b­­adrenoreceptor system gene polymorphism. Measuring T3 level in blood serum is a simple instrument for the risk stratification in patients with severe form of COVID­­19 on the background of HF syndrome.

Differences in microorganism profile in periprosthetic joint infections of the hip in patients affected by chronic kidney disease

BackgroundPatients affected by chronic kidney disease (CKD) are at increased risk of periprosthetic joint infection (PJI) after total hip arthroplasty (THA). This patient population has a higher risk of recurrent infections and hospitalization. The aim of this study is to compare the profile of microorganisms in patients with CKD and PJI of the hip versus controls and to individuate potentially unusual and drug-resistant microorganisms among the causative bacteria.Materials and methodsA total of 4261 patients affected by PJI of the hip were retrospectively studied. Patients affected by CKD in this population were identified and compared with a control group of patients with PJI but without CKD. Data on patient characteristics and comorbidities were collected. The microorganisms responsible for PJI were identified and compared between both groups.ResultsThe CKD group included 409 patients, 54.3% male, mean age of 73.8 ± 8.9 years, a higher body mass index (BMI) than the general population (29.88 ± 5.90 kg/m2), and higher age-adjusted CCI of 6.15 ± 2.35. Overall, 70 different isolates of microorganisms were identified, including 52 Gram-positive spp., 28 Gram-negative spp., 3 fungi, and 1 mycobacterium. Polymicrobial infections were more common in CKD group than controls (47.9% versus 30.9%; p < 0.0001). Staphylococcus spp. were the most common bacteria in both groups, followed by Gram-negative Enterobacteriaceae and Streptococcus spp. CKD group showed a higher risk of developing infections caused by Staphylococcus aureus (p = 0.003), Gram-negative bacteria, and Candida (p = 0.035).ConclusionsRenal failure exposes patients who undergo THA to PJI caused by microorganisms that are potentially more drug resistant, leading to a higher risk of treatment failure. Knowing in advance the different microorganism profiles could help to plan a different surgical strategy.Level of Evidence III.

Catheter Ablation in Atrial Fibrillation: Recent Advances.

Atrial fibrillation (AF) is the leading cause of arrhythmia-related morbidity and mortality. Recurrent symptoms, hospitalizations, and cost burden to patients have necessitated treatments beyond antiarrhythmic drugs (AADs) for patients with AF. Catheter ablation has proven to be effective over medical therapy alone; however the recurrence rates for atrial tachyarrhythmias post-ablation remain significant, particularly in patients with persistent and long-standing persistent AF. Hence, new techniques for catheter ablation have arisen, such as non-thermal energy sources, novel catheters, electroanatomical mapping, and ablation of additional targets. In this review, we discuss the recent advances in the field of catheter ablation, including newer modalities for the prevention of adverse events and future perspectives.

A study of nutritional assessment in paediatric patients with congenital heart disease in a tertiary care centre

: Congenital heart disease refers to any anatomical defect in the heart or major blood vessels present in children at birth. CHD (congenital heart disease) occurs in round about 1% of live births in developed countries. In developing countries due to poor resources, delayed diagnosis and surgery for CHD leads to a vicious cycle of congestive heart failure and respiratory infections, resulting in a high prevalence of preoperative malnutrition in patients with CHD. The incidence of congenital heart disease at birth is variable, incidence figures use to range between 5-8/1000 live births before the introduction of echocardiography but due to better diagnosis in today’s era many more milder forms are being detected, so the current estimates range from 8-12/1000 live births.: To assess the nutritional status in patients with CHD using clinical evaluation, anthropometry.: It is a cross-sectional observational stud. In our study a total of 75 cases of congenital heart disease were examined in a period of 18 months: Out of 75 patients 56 (74.66%) were &amp;#60;=5years and male predominance were seen. Most of the patient were having Acyanotic CHD: That there are multiple factors that are responsible for malnutrition in children with CHD including, poor socioeconomic strata, already poor health conditions in the general population, recurrent hospitalizations and recurrent lower respiratory tract infections.

Association between visual impairment and recurrent hospitalizations in older US adults.

Visual impairment (VI) is common in older adults and is associated with adverse health outcomes. However, the association between objectively assessed VI and recurrent hospitalization remains unclear. To investigate the association of different domains of visual function with recurrent hospitalization in older adults in the United States. We used data from Round 11 of the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries, which included objective measures of distance and near visual acuity and contrast sensitivity. Using multivariable logistic regression models, we analyzed the association between VI (distance and near acuity <20/40, contrast sensitivity <1 SD below the sample mean) and prior year hospitalization and estimated marginal predicted probabilities of any (≥1) and recurrent (>1) hospitalization. Models were adjusted for demographic factors and comorbid medical conditions and accounted for NHATS complex survey design. The sample included 2960 respondents aged 71 and older (median age 81 years; 45% male, 82% non-Hispanic White). The predicted probability of hospitalization for those with any type of VI was 19.2% (15.9-22.6) versus 16.7% (14.9-18.6) for those without VI. The predicted probability of recurrent hospitalization for those with any type of VI was 7.2% (4.8-9.7) versus 4.1% (3.1-5.2) for those without VI. Near VI was significantly associated with recurrent hospitalization (OR = 2.04 [1.6, 3.61], p = 0.02), independent of other visual function measures, while other types of VI were not. Near VI is significantly associated with recurrent hospitalization in older US adults. Future studies should determine whether improving near vision affects the likelihood of recurrent hospitalization.

P09 Characterizing the burden of generalized pustular psoriasis in the United Kingdom: insights from the SCRIPTOR study

Abstract Generalized pustular psoriasis (GPP) is a heterogeneous, systemic, neutrophilic, inflammatory disease with chronic symptoms and periods of flaring that negatively impact a patient’s quality of life (QoL). The goal of the international, non-interventional SCRIPTOR study is to understand the clinical burden of GPP, including flare frequency, treatment patterns and healthcare resource utilization. Between December 2022 and May 2023, data were collected from five dermatology centres in the UK using medical charts of patients diagnosed with GPP (2011 onwards). Patients diagnosed with acute generalized exanthematous pustulosis without a history of GPP were not included. Twenty-seven patients (n = 18; 67% female), with a mean [standard deviation (SD)] age at GPP diagnosis of 53.1 (19.7) years (range: 18.0–86.0 years) were included. Most patients were Caucasian (n = 21; 78%), followed by Asian (n = 4; 15%) and mixed/unknown ethnicity (n = 2; 7%). Most patients (74%) had ≥1 GPP risk factor, the most common being a previous diagnosis of plaque psoriasis (plaque PsO; 65%), medication use (55%) and comorbidities (50%). Common comorbidities were plaque PsO (58%), hypertension (46%) and psychiatric conditions (29%). Diagnosis of GPP predominantly occurred in an inpatient setting (74%), with guideline diagnostic criteria used in ∼80% of cases. At GPP diagnosis, 95% of patients had pustules. Prior to diagnosis of GPP, seven patients (26%) had a flare. Among patients with a follow-up duration of ≥1 year (n = 13), mean (SD) flare episodes per year was 0.9 (0.6). GPP flare triggers (infections and medication use/withdrawal) were documented in six patients (43% of post-diagnosis cases). Physical examination and laboratory testing were commonly used in the assessment of GPP flares. Psoriasis area and severity index and dermatology life quality index were used in ∼30% of routine follow-ups and ∼20% of documented flare cases. At diagnosis, there were 17 all-cause (median/mean duration: 17.0/22.1 days) and 3 flare-related (27.0/29.0 days) hospitalizations documented. Post-diagnosis, 11 patients had ≥1 hospital/emergency room admission due to: GPP flare (n = 14, 74%), complications, comorbidity management and adverse events (n = 3, 16% each). The most prescribed medications for flare treatment (n = 39) were topical corticosteroids (n = 9), retinoids (n = 7), methotrexate and ciclosporin (n = 4 each). Methotrexate (n = 23), retinoids (n = 14) and ciclosporin (n = 8) were often prescribed for long-term treatment (n = 74). From pre-diagnosis onwards, GPP exerts a significant burden, with recurrent flare episodes, hospitalizations and complications. The use of guideline diagnostic criteria varies, and disease severity and QoL assessment tools are underutilized. There are different approaches used for the treatment of GPP flares and long-term treatment. Overall, these findings emphasize the need for continuous treatment and comprehensive guidelines for GPP in the UK.

Prognostic Factors of Flap Complications After Carbon-ion Radiotherapy for Head and Neck Cancer With Reconstruction.

The incidence of flap complications after carbon-ion (C-ion) radiotherapy (RT) for head and neck cancer with reconstruction is unknown. This study investigated the incidence and risk factors of flap complications following C-ion RT for head and neck cancer with reconstruction. We retrospectively analyzed 24 cases, excluding cases of re-irradiation, treated with C-ion RT at QST Hospital for loco-regional recurrence after reconstructive surgery for head and neck cancers from April 1997 to March 2020. We evaluated flap complications as anastomosis-related (flap loss and necrosis) and flap bed-related (wound dehiscence) complications. Wound dehiscence was assessed using Common Terminology Criteria for Adverse Events version 5.0. The correlation between clinical factors, dosimetric parameters, and flap complication was analyzed retrospectively. The median follow-up period was 42.2 months (range=6.7-155.9 months). None of the 24 enrolled patients experienced flap loss and flap necrosis, and two (8.3%) patients had grade 1 wound dehiscence; grade 2 or greater toxicities were not recorded. The median interval between C-ion RT and wound dehiscence of the flap was 6.8 (6.5 and 7.0) months. Univariate analysis to identify clinical and dose-volume histogram parameters associated with the occurrence of grade 1 wound dehiscence after C-ion RT revealed that the minimum dose (Dmin) ≥5.9 Gy for flap was a statistically significant risk factor (p=0.017). C-ion RT for head and neck cancers after reconstructive surgery is safe, with no serious flap complications. Dmin was an independent risk factor for the development of wound dehiscence.

Rifaximin discontinuation during broad-spectrum antibiotic treatment in critically ill patients with hepatic encephalopathy

Hepatic encephalopathy (HE) is one of the main complications of cirrhosis, characterized by a wide spectrum of neuropsychiatric alterations that lead to an increase in mortality, morbidity and recurrent hospitalizations. Due to the central role in HE pathogenesis of ammonia and other neurotoxins primarily produced by the gut microbiota, the main therapeutic approaches for the treatment of HE are based on the modulation of the gut microbiota. Rifaximin is a non-absorbable broad-spectrum antibiotic, that is effective against ammonia-producing gram-positive, gram-negative, and anaerobic species, approved for the treatment of HE in secondary prophylaxis. The chronic administration of rifaximin in this setting is associated with a lower risk of HE recurrence and mortality, while the role of rifaximin for the treatment of an overt-HE episode in inpatients is still unclear. Limited data exist about the coadministration of rifaximin and broad-spectrum antibiotics commonly used to treat concomitant infections, as patients receiving or recently treated with antibiotics were frequently excluded from clinical trials. In this editorial we comment on the article by Ward et al published in the recent issue of the World Journal of Hepatology . It is a single center, retrospective, quasi-experimental, pharmacist-driven protocol, with the aim to evaluate the feasibility and safety of rifaximin discontinuation in critically ill patients with HE and chronic liver disease receiving broad-spectrum antibiotic therapies in intensive care units. The study revealed no differences between the protocol and control group in terms of primary outcome (days alive and free of delirium and coma to day 14) and secondary outcomes which include: Intensive care mortality, intensive care length of stay, intravenous vasopressor requirement changes and adverse effects rate. Therefore, rifaximin discontinuation during broad-spectrum antibiotic therapy does not appear to negatively impact the clinical status of critically ill liver patients, with a similar safety profile and significant cost savings, as compared to the coadministration of rifaximin and broad-spectrum antibiotics. In agreement with Ward et al , a recently published double-blind, randomized controlled trial provided additional evidence to support the feasibility of withholding rifaximin during broad-spectrum antibiotic therapy in critically ill cirrhotic patients. However, given the limitations of these studies, further multicentric and prospective clinical trials, enrolling a larger sample of non-critically ill patients, are needed to better establish the role of rifaximin in this setting.

Late diagnosis of sickle cell disease in adults still a challenge in developing countries: a case report

BackgroundSickle cell disease is a genetic disease with multisystem involvement. More than 300,000 children are born with sickle cell disease globally, with the majority of cases being in Sub-Saharan Africa. In Uganda, about 20,000 children are born with sickle cell disease annually, with more than three-quarters dying before the age of 5 years. Those who live beyond 5 years tend to have poor health-related quality of life, numerous complications, and recurrent hospitalizations. In developing countries, most symptomatic patients are diagnosed early in childhood. Few of those not screened in childhood tend to present in adulthood with variable symptoms.Case presentationThis case reports a 22-year-old African male patient of Toro tribe who presented with paroxysms of multiple joint pain associated with generalized body malaise for about 6 months. He presented as a referral from a lower facility with an unestablished cause of symptoms. Physical examination revealed conjunctival pallor, icterus, and tenderness of joints. Cell counts showed anemia and hemoglobin electrophoresis revealed 87% of sickled hemoglobin.ConclusionThis case report pinpoints the importance of considering the diagnosis of sickle cell disease even in adults presenting with symptoms of sickle cell disease. It also adds to the relevance of screening at all age groups, especially in high-endemic regions such as Africa and Asia.

Posttraumatic Stress Disorder and the Risk of Heart Failure Hospitalizations Among Individuals With Coronary Artery Disease.

Posttraumatic stress disorder (PTSD) is associated with maladaptive dysregulation of stress response systems, which could lead to an increased risk of heart failure. We investigated whether PTSD was independently associated with first and recurrent heart failure hospitalizations in the setting of coronary artery disease. Individuals with stable coronary artery disease and without heart failure at baseline were enrolled in 2 parallel prospective cohort studies in metropolitan Atlanta, GA. Participants underwent a structured clinical interview to assess their lifetime history of PTSD. Current PTSD symptoms were assessed using the PTSD symptom checklist. Participants were followed up for a median time of 4.9 years. The primary end point was first or recurrent hospitalization for heart failure. Secondary end points included cardiovascular death and nonfatal myocardial infarction with and without hospitalization for heart failure. Survival analysis for repeated events was used to assess the association of PTSD with adverse events. We studied 736 individuals with a mean age of 60±10 years; 36% were Black, and 35% were women. In total, 69 (9.4%) patients met the criteria for PTSD. Having a PTSD diagnosis was associated with the primary end point of first or recurrent heart failure hospitalizations, with a hazard ratio of 4.4 (95% CI, 2.6-7.3). The results were minimally attenuated after adjusting for demographic and clinical factors (hazard ratio, 3.7 [95% CI, 2.1-6.3]). Similarly, a 10-point increase in the PTSD symptom checklist score was associated with a 30% (95% CI, 10%-50%) increase in heart failure hospitalizations. PTSD was not associated with an end point of cardiovascular death or nonfatal myocardial infarction, which excluded hospitalizations due to heart failure. Among patients with coronary artery disease, PTSD is associated with incident and recurrent heart failure hospitalizations. Future research is needed to investigate whether PTSD management can reduce the risk of heart failure.

Statistical Inference for Counting Processes Under Shape Heterogeneity.

Proportional rate models are among the most popular methods for analyzing recurrent event data. Although providing a straightforward rate-ratio interpretation of covariate effects, the proportional rate assumption implies that covariates do not modify the shape of the rate function. When the proportionality assumption fails to hold, we propose to characterize covariate effects on the rate function through two types of parameters: the shape parameters and the size parameters. The former allows the covariates to flexibly affect the shape of the rate function, and the latter retains the interpretability of covariate effects on the magnitude of the rate function. To overcome the challenges in simultaneously estimating the two sets of parameters, we propose a conditional pseudolikelihood approach to eliminate the size parameters in shape estimation, followed by an event count projection approach for size estimation. The proposed estimators are asymptotically normal with a root- convergence rate. Simulation studies and an analysis of recurrent hospitalizations using SEER-Medicare data are conducted to illustrate the proposed methods.

Sleep in hospitalized children with cancer: relationship with psychiatric disorders and hospital conditions.

Children with cancer often undergo prolonged and recurrent hospitalization, which leads to an increased incidence of sleep disruptions and psychiatric disorders. This study aimed to objectively quantify the prevalence of sleep disruptions in hospitalized pediatric oncology patients and to determine the effects of psychiatric disorders, treatment regimens, and hospital conditions on sleep patterns. This cross-sectional study included 39 children who were undergoing treatment and monitoring in the pediatric oncology inpatient service. Parents completed questionnaires providing information about their child's sleep patterns, quality of life, and hospital conditions. The children were monitored for five days using actigraphy to record sleep parameters. They were evaluated with a semi-structured interview form (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version-DSM 5-Turkish Adaptation) for psychiatric diagnoses. Sleep disruptions were identified in 27 (69.2%) children with cancer. In addition to adjustment disorder and anxiety disorder psychiatric diagnoses, behavioral problems and emotional symptoms were more common in the group with sleep disruptions. Actigraphy measurements indicated that poor sleep was associated with younger age, recent cancer diagnosis, specific phobias, depression, daytime napping, and frequent vital sign assessments. Sleep problems in hospitalized children with cancer are linked to psychiatric comorbidities, treatment routines, and hospital conditions. By recognizing psychiatric symptoms and optimizing hospital conditions that affect sleep, healthcare providers can enhance the quality of sleep for these children.