Related Admissions Research Articles

Vaccine-preventable diseases in hospitalized patients with heart failure: a nationwide cohort analysis

Abstract Introduction Infection related hospitalizations are common among patients with heart failure (HF), including those that could be prevented with appropriate vaccinations. Objective We aimed to determine the risk of vaccine preventable diseases (VPDs) in patients with HF. Methods We performed a population based retrospective cohort study using the United States- National Inpatient Sample (NIS) Database from 2010 to 2014. We identified patients who were admitted to the hospital with vaccine preventable diseases, namely influenza, varicella zoster infection (VZV), pneumococcal infection, meningococcal infection, diphtheria, pertussis, tetanus, hepatitis A (Hep A) and hepatitis B (Hep B) using international classification of diseases 9th revision clinical modification (ICD-9-CM) codes. In this cohort, we then identified patients with HF. Descriptive statistics were used to estimate the frequencies of various VPDs in patients with heart failure. A multivariate regression model adjusting for age, gender, race, immunosuppression (Diabetes, HIV, Organ transplantation, Malignancy) was employed to determine the risk of VPDs in patients with HF. Results Among a total of 11, 64,528 patients admitted with VPDs, HF was present in 1, 01,915 (8.8%).The most common VPD in patients with HF was VZV (30.7%), followed by influenza (28.2%), pneumococcal infection (20.9%) and Hep B (18.5%). Other VPDs were less common: Hep A (1.8%), diphtheria (0.4%), pertussis (0.2%), tetanus (10 patients) and meningococcal infection (0.1%). On multivariate analysis, patients with HF had increased risk of hospitalization due to influenza (aOR=1.20, 95% CI: 1.18–1.21; p<0.001) and pneumococcal infection (aOR=1.31, 95% CI: 1.29–1.33; p<0.001), but were at a lower risk of hospitalization due to VZV (aOR=0.81, 95% CI: 0.8–0.83; p<0.001), Hep B (aOR=0.78, 95% CI: 0.77- 0.8; p<0.001), Hep A (aOR=0.71, 95% CI: 0.67–0.74; p<0.001), Meningococcal infection (aOR=0.64, 95% CI: 0.52–0.78; p<0.001), diphtheria (aOR=0.79, 95% CI: 0.71–0.88; p<0.001) and tetanus (aOR=0.35, 95% CI: 0.19–0.65; p=0.001). No statistically significant association of HF was observed with pertussis (p=0.167). Conclusion In our study, patients with HF had a higher risk of hospital admissions secondary to influenza and pneumococcal infections and a lower risk of VZV, Hep B, Hep A, meningococcal infection, diphtheria, and tetanus related admissions when compared with non-HF patients. Funding Acknowledgement Type of funding source: None

Sacubitil/valsartan in systemic right ventricular failure

Abstract Background In patients with heart failure with low ejection fraction (EF) (≤35%) sacubitril/valsartan is proven to be beneficial. We aimed to assess the effects of sacubitril/valsartan in adult congenital heart disease patients with failing systemic right ventricle (sRV) in the setting of congenitally corrected transposition of the great arteries (TGA) or TGA after atrial switch. Purpose To evaluate the feasibility and effect of treatment with sacubitril/valsartan in patients with heart failure in the setting of a sRV on optimal medical heart failure treatment. Methods Data of patients with sRV failure (estimated RVEF ≤35%) treated with sacubitril/valsartan were analyzed. Patients were clinically evaluated at baseline and at six months after initiation of the highest tolerated dose. Results Fourteen patients completed six-month follow-up thus far, of which 6 female (42.8%) and 2 (14.3%) with congenitally corrected transposition of the great arteries (TGA). After 6 months, 9 patients (64.3%) were using the highest dose (97/103 mg twice daily) of sacubitril/valsartan. NT-proBNP was significantly lower after 3 months and after 6 months compared with baseline (64% of baseline, p=0.006 and 53% of baseline, p=0.001, respectively). The kidney function did not change significantly (creatinine at baseline 83.6±12.0 and at 6 months 88.5±13.87, p=0.141) and serum potassium remained within normal limits (4.28±0.36 and 4.49±0.30, p=0.007). There was no significant decrease in systolic blood pressure (p=0.960). The echocardiographic sRV fractional area change (FAC) improved (p=0.002) and Global Longitudinal Strain (GLS) showed a trend towards improvement (p=0.058). During the 6 months of treatment, the exercise capacity remained stable, there was no increase in diuretic use, no serious adverse events and no heart failure related admissions occurred. Conclusion Treatment of sRV heart failure patients with sacubitril/valsartan leads to a significant reduction in NT-proBNP and significant increase in FAC. All patients remained clinically stable and no heart failure related admissions or serious adverse events occurred. Changes after 6 months Funding Acknowledgement Type of funding source: None

Type 2 Diabetes and COVID-19-Related Mortality in the Critical Care Setting: A National Cohort Study in England, March-July 2020.

OBJECTIVETo describe the relationship between type 2 diabetes and all-cause mortality among adults with coronavirus disease 2019 (COVID-19) in the critical care setting.RESEARCH DESIGN AND METHODSThis was a nationwide retrospective cohort study in people admitted to hospital in England with COVID-19 requiring admission to a high dependency unit (HDU) or intensive care unit (ICU) between 1 March 2020 and 27 July 2020. Cox proportional hazards models were used to estimate 30-day in-hospital all-cause mortality associated with type 2 diabetes, with adjustment for age, sex, ethnicity, obesity, and other major comorbidities (chronic respiratory disease, asthma, chronic heart disease, hypertension, immunosuppression, chronic neurological disease, chronic renal disease, and chronic liver disease).RESULTSA total of 19,256 COVID-19–related HDU and ICU admissions were included in the primary analysis, including 13,809 HDU (mean age 70 years) and 5,447 ICU (mean age 58 years) admissions. Of those admitted, 3,524 (18.3%) had type 2 diabetes and 5,077 (26.4%) died during the study period. Patients with type 2 diabetes were at increased risk of death (adjusted hazard ratio [aHR] 1.23 [95% CI 1.14, 1.32]), and this result was consistent in HDU and ICU subsets. The relative mortality risk associated with type 2 diabetes decreased with higher age (age 18–49 years aHR 1.50 [95% CI 1.05, 2.15], age 50–64 years 1.29 [1.10, 1.51], and age ≥65 years 1.18 [1.09, 1.29]; P value for age–type 2 diabetes interaction = 0.002).CONCLUSIONSType 2 diabetes may be an independent prognostic factor for survival in people with severe COVID-19 requiring critical care treatment, and in this setting the risk increase associated with type 2 diabetes is greatest in younger people.

Decrease in Respiratory Related Hospitalizations in Tracheostomy-Dependent Children Who Tolerate Passy-Muir Valve Use.

To assess the effect of Passy-Muir® Valve (PMV) tolerance on respiratory illness and respiratory related hospital admissions in tracheostomy-dependent children. Retrospective cohort study of 262 patients who underwent tracheostomy placement between 2012 and 2018 at a tertiary free-standing children's hospital. Outcome measures studied were number of reported upper respiratory infections and respiratory related hospitalizations per year (RRH/year). About 135 (51.5%) tracheostomy-dependent children underwent PMV trials, and 106 (78.5%) of these children were able to tolerate PMV for at least 1 hour daily. When comparing children who tolerated PMV versus those who did not, the latter group had significantly higher rates of subglottic stenosis but no significant differences in RRH/year or average age. In those children who tolerated PMV and achieved routine use of PMV > 1 hour/day, an average of 1.14 RRH/year occurred prior to PMV tolerance, as compared with 0.57 RRH/year after PMV tolerance (P = .003). Multivariate analysis shows that in patients <2 years, there is a significant decrease in RRH/year after PMV tolerance is attained (1.53 vs 0.76, P = .001), independent of indication for tracheostomy. In tracheostomy-dependent children who tolerate PMV use routinely >1 hour/day there are decreased rates of respiratory related hospitalizations (RRH). Children <2 years of age have the most impact of RRH, with rates that are significantly lower with routine use of the PMV.

Coronavirus disease 2019 pregnancy outcomes in a racially and ethnically diverse population

BackgroundOlder age and medical comorbidities are identified risk factors for developing severe coronavirus disease 2019. However, there are limited data on risk stratification, clinical and laboratory course, and optimal management of coronavirus disease 2019 in pregnancy.ObjectiveOur study aimed to describe the clinical course of coronavirus disease 2019, effect of comorbidities on disease severity, laboratory trends, and pregnancy outcomes of symptomatic and asymptomatic severe acute respiratory syndrome coronavirus 2–positive pregnant women.Study DesignThis is a case series of pregnant and postpartum women who received positive test results for severe acute respiratory syndrome coronavirus 2 between March 3, 2020, and May 11, 2020, within 3 hospitals of the Yale New Haven Health delivery network. Charts were reviewed for basic sociodemographic and prepregnancy characteristics, coronavirus disease 2019 course, laboratory values, and pregnancy outcomes.ResultsOf the 1567 tested pregnant and postpartum women between March 3, 2020, and May 11, 2020, 9% (n=141) had a positive severe acute respiratory syndrome coronavirus 2 result. Hispanic women were overrepresented in the severe acute respiratory syndrome coronavirus 2–positive group (n=61; 43.8%). In addition, Hispanic ethnicity was associated with a higher rate of moderate and severe diseases than non-Hispanic (18% [11/61] vs 3.8% [3/78], respectively; odds ratio, 5.5; 95% confidence interval, 1.46–20.7; P=.01). Of note, 44 women (31.2%) were asymptomatic, 37 of whom (26.2%) were diagnosed on universal screening upon admission for delivery. Moreover, 59% (n=83) were diagnosed before delivery, 36% (n=51) upon presentation for childbirth, and 5% (n=7) after delivery. Severe disease was diagnosed in 6 cases (4.3%), and there was 1 maternal death. Obese women were more likely to develop moderate and severe diseases than nonobese women (16.4% [9/55] vs 3.8% [3/79]; odds ratio, 4.96; 95% confidence interval, 1.28–19.25; P=.02). Hypertensive disorders of pregnancy were diagnosed in 22.3% of women (17/77) who delivered after 20 weeks’ gestation. Higher levels of C-reactive protein during antepartum coronavirus disease 2019–related admission were more common in women with worse clinical course; however, this association did not reach statistical significance.ConclusionCoronavirus disease 2019 in pregnancy may result in severe disease and death. Hispanic women were more likely to receive a positive test result for severe acute respiratory syndrome 2 than other ethnic groups. Obesity and Hispanic ethnicity represent risk factors for moderate and severe diseases.

S3533 Indirect Impacts of COVID on Alcohol-Induced Liver Disease

INTRODUCTION: There is a paucity of COVID-19-negative patients who experienced alcohol-induced liver injury due to the disruption of daily activities and social isolation. CASE DESCRIPTION/METHODS: A 42-year-old male with history of alcohol induced liver cirrhosis (6 months prior MELD-Na 13, Child Pugh A, small esophageal varices and mild portal hypertensive gastropathy) presented to emergency room with 1 week of worsening abdominal pain and distension. For the last 1 month, he increased his alcohol intake to 12 beers a day (prior only 6 beers daily, last drink was 2 days ago); he states this increase was due to loss of employment and living alone. He denied any COVID-19 symptoms and tested negative. On admission, MELD-Na roughly tripled at 32 and Child Pugh now C. Labs were notable for severe hyponatremia (103 mEq/L), AST: ALT ratio ∼3:1 and acute kidney injury, concern for hepatorenal syndrome. He had tense ascites, no asterixis and A&Ox4. His hyponatremia resolved with appropriate therapy, paracentesis was negative for spontaneous bacterial peritonitis, kidney function improved on midodrine, octreotide and albumin. Yet, he developed multifactorial encephalopathy (alcohol withdrawal, ICU delirium and hepatic encephalopathy), not resolved with lactulose and rifaximin, which prolonged his hospitalization. His final days of admission were in MICU for presumed aspiration versus hospital acquired pneumonia, retest for COVID-19 were again negative. His family agreed to comfort care and the patient passed on hospital day 22. DISCUSSION: Our patient demonstrates the significant indirect effects of the COVID-19 pandemic on patients with alcohol induced liver disease. Recent publications predicted that relapses in alcohol abstinence, admissions, and new diagnoses of alcoholic liver disease would increase during quarantine.1-3 Future studies should investigate the increase in alcohol related relapses, admission, and mortality. Our patient is just one of many who, despite not contracting COVID-19, experienced negative health outcomes attributable to the pandemic.

EP09 COVID-19 and rheumatic disease clinical characteristics and outcomes of rheumatic disease patients hospitalised with COVID-19: a single centre experience

Case report - IntroductionThere is limited evidence on the outcomes of COVID-19 in patients with rheumatic diseases. Since severe COVID-19 is characterised by hyperinflammation, the effects of a pre-existing inflammatory state and immunomodulatory treatments on the disease’s course are of great interest. Even though patients in this group are perceived of being at higher risk for severe disease, most of the relevant observational studies have had controversial results. We aimed to investigate the clinical characteristics and outcomes of patients with a history of rheumatic disease and COVID-19 related admission in our centre. Case report - Case descriptionWe conducted a retrospective observational study of COVID-19 RT-PCR positive admissions of patients coded as having rheumatic disease in the Dudley Group NHS Foundation Trust between April 1st and June 24th, 2020. Data were extracted from the patient clinical notes and electronic medical records and were captured and analysed on MS Excel. Among 613 COVID-19 related admissions, 19 (3.1%) patients were coded as having comorbid rheumatic disease. 8 cases were excluded from further analysis as, upon records review, they had osteoarthritis or a history of gout. Thus, the true incidence of comorbid rheumatic disease among COVID-19 related hospitalisations was even lower at 11/613 (1.8%). The mean age of the patients was 80.5 ± 8.06 years, 9/11 (81.8%) were female and 8/11 (73%) were Caucasian. In the vast majority the diagnosis was that of Rheumatoid Arthritis (9/11, 81.8%), while one patient had Polymyalgia Rheumatica and another Systemic Lupus Erythematosus. Only a quarter of the patients had moderate (2, 18%) or high (1, 9%) disease activity on their most recent outpatient visit. In terms of antirheumatic medication, 5 (45%) patients were on regular Prednisolone (20% <5mg, 80% 5-10mg), 8 (72%) were on cs DMARDs and only 1 (9%) on bDMARDs. A substantial proportion of the patient cohort also suffered with other comorbidities. 8/11 (72.7%) patients had arterial hypertension, 5 (45.4%) had a history of cardiovascular disease, 3 (27.3%) obesity (BMI 30+), 3 (27.3%) previous history of cancer, 2 (18.2%) COPD, 2 (18.2%) CKD, 1 (9%) Interstitial lung disease, 1 (9%) Diabetes, 1 (9%) Cerebrovascular disease and 1 (9%) immunodeficiency. During their admission, 7 (63.6%) patients required supplemental oxygen therapy. Unfortunately, 5/11 (45.5%) patients had a fatal outcome.Case report - DiscussionIn our cohort, the percentage of patients with rheumatic diseases among inpatients with confirmed COVID-19 infection was low (∼1.8%). Potential explanations for this observation could be a beneficial effect of concomitant antirheumatic treatment (steroids and/or DMARDs) in controlling hyperinflammation, but also rheumatic disease patients’ increased risk awareness and thus increased compliance with viral spread mitigation measures (‘shielding’) as per Government guidelines. We also note the low rate of biologic DMARD use with only 1 (9%) inpatient having received Rituximab for RA.Case report - Key learning pointsThe incidence of rheumatic disease among COVID-19 related admissions in our centre was exceptionally low. Per recently published reports from worldwide registries, older age and multiple comorbidities appear to drive the risk for hospitalisation, need for oxygen supplementation and fatal outcome. Better understanding of the effect of DMARDs on COVID-19 severity requires further investigation, perhaps with SARS-CoV-2 antibody studies, but our observations appear to be reassuring.

S3219 Venous Thromboembolism Prophylaxis Adherence Rates in Hospitalized Inflammatory Bowel Patients at an Academic Medical Center

INTRODUCTION: Inflammatory Bowel Disease (IBD) is comprised of two distinct disorders: Crohn’s Disease (CD) and Ulcerative Colitis (UC). They are chronic inflammatory diseases that primarily affect the gastrointestinal (GI) tract, but they can also cause extraintestinal complications. Venous thromboembolism (VTE) is particularly prevalent in IBD patients (IBDP), especially during disease flares, and is associated with high risk of morbidity and mortality. However, IBDP also have a propensity for GI bleeding during IBD exacerbations. With risk for both VTE and GI bleed, the decision to start VTE prophylaxis (VTEP) in hospitalized IBD patients poses a conundrum. The American College of Chest Physicians currently recommends such patients receive VTEP as data from numerous randomized controlled trials demonstrates VTEP is not associated with major adverse events in IBDP. The goal of this study was to evaluate the rate of VTEP at our hospital. METHODS: A retrospective chart review was conducted following all IBDP admitted to Wake Forest Baptist Medical Center from 1/2019 to 6/2019. 150 patients were identified. Demographics, admission diagnosis, admission medications, presenting symptoms, and medical history were collected. RESULTS: Of the 150 IBDP, 57% received VTEP on admission. In admissions related to IBD (37%), 18.2% received VTEP, whereas in non-IBD related complaints 79% received VTEP. Among patients endorsing hematochezia on admission (15%), 22% received VTEP. Of the patients with a history of GI bleed (65%), 47% received VTEP. 50% of patients with a history of VTE (12%), received VTEP. Odds ratio estimates showed IBD related admissions, hematochezia, and history of GI bleed were negatively associated with VTEP. CONCLUSION: Our analysis demonstrated a statistically significant decrease in administration of VTEP in patients admitted for an IBD related complaint, patients endorsing hematochezia, and patients with a history of GI bleed. This shows a major deficit in our hospital’s adherence to the ACCP guidelines of VTEP administration to all IBDP admitted to the hospital. Future directions of these findings include implementation of a Best Practice Advisory (BPA) into the electronic medical record to encourage VTEP for IBDP. After a trial of this BPA, a similar analysis will be repeated to evaluate the efficacy of the measure.Figure 1

Prioritizing specialized children's surgery in Canada during the COVID-19 pandemic.

KEY POINTS On Mar. 11, 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19) a global pandemic, and our provincial and territorial governments began preparing hospitals for an expected surge of COVID-19–related hospital and intensive care unit admissions. This included

Proportion of Home and Leisure Accidents in mainland Portugal, in 2019

Abstract Unintentional injuries are recognized by the World Health Organization and the European Union as a preventable public health problem contributing to mortality and morbidity burden and expression in the emergency department (ED). According to EuroSafe injury is the fourth most common cause of death within the EU, being the leading cause of death in the youngest. Whereas injury related fatalities is only a part of the problem and more patients require hospital treatment it is essential measure the size of the injury problem and characteristics of these non-fatal injuries. Information from Injury Data-Base reveals that the majority of injury related ED attendances and hospital admissions result from accidents occur in home and during leisure times. So, the aim of this study it was to know the proportion of Home and Leisure Accidents (HLA) which needed attendance in the emergency rooms of the Hospitals National Health, in Portugal Mailand, in 2019. For the analysis were considered the total number of NHS health entities that have an ED, SONHO information system and National injury surveillance system - EVITA System. Based on hospital emergency records in 2019, was obtained the total number of victims by HLA who needed assistance in this health services. In 2019, there were 526 786 ED attendances due to HLA, so about 11,3% of hospital ED attendances in mainland Portugal were caused by HLA. Globally, it was observed a proportion of HLA with admission in ED higher in males (12,9%) than females (10,1%). Disaggregating the data by age group, it was possible to observe a preponderance of males in victims aged less than or equal to 54 years. On the other hand, females showed a higher proportion in individuals aged 55 and over. Additionally, victims aged 75 and over had the highest proportion of hospital admissions by HLA, both in females (15,5%) and males (13,1%). This study represented a relevant advance contributing to the revelation of the dimension of this problem in Portugal. Key messages The National Injury Surveillance System provides information that allows to know the dimension of this health problem in mainland Portugal. HLA represents 11,3 % of the total hospital ED attendances. HLA are the predominant cause of injury related ED attendances. Males and females have a different proportions of injury. Males aged 54 years and over have higher proportion of HLA than females.

Neighbourhood unemployment and other socio-demographic predictors of emergency hospitalisation for infectious intestinal disease in England: A longitudinal ecological study

Previous studies have observed that infectious intestinal disease (IID) related hospital admissions are higher in more deprived neighbourhoods. These studies have mainly focused on paediatric populations and are cross-sectional in nature. This study examines recent trends in emergency IID admission rates, and uses longitudinal methods to investigate the effects of unemployment (as a time varying measure of neighbourhood deprivation) and other socio-demographic characteristics on IID admissions for adults and children in England. A longitudinal ecological analysis was performed using Hospital Episode Statistics on emergency hospitalisations for IID, collected over the time period 2012-17 across England. Analysis was conducted at the neighbourhood (Lower-layer Super Output Area) level for three age groups (0-14; 15-64; 65+ years). Mixed-effect Poisson regression models were used to assess the relationship between trends in neighbourhood unemployment and emergency IID admission rates, whilst controlling for measures of primary and secondary care access, underlying morbidity and the ethnic composition of each neighbourhood. From 2012-17, declining trends in emergency IID admission rates were observed for children and older adults overall, while rates increased for some sub-groups in the population. Each 1 percentage point increase in unemployment was associated with a 6.3, 2.4 and 4% increase in the rate of IID admissions per year for children [IRR=1.06, 95%CI 1.06-1.07], adults [IRR=1.02, 95%CI 1.02-1.03] and older adults [IRR=1.04, 95%CI 1.036-1.043], respectively. Increases in poor primary care access, the percentage of people from a Pakistani ethnic background, and the prevalence of long-term health problems, in a neighbourhood, were also associated with increases in IID admission rates. Increasing trends in neighbourhood deprivation, as measured by unemployment, were associated with increases in emergency IID admission rates for children and adults in England, despite controlling for measures of healthcare access, underlying morbidity and ethnicity. Research is needed to improve understanding of the mechanisms that explain these inequalities, so that effective policies can be developed to reduce the higher emergency IID admission rates experienced by more disadvantaged communities.

CLINICAL OUTCOMES OF INFLUENZA INFECTION AMONG SOLID ORGAN TRANSPLANT RECIPIENTS IN ICU

Introduction: Influenza is usually a self-limited illness in healthy adults, but influenza virus infection can cause severe illness in certain high-risk groups like solid organ transplant recipients (SOTR). We aimed to evaluate the clinical results of SOTR with influenza admitted to the intensive care unit (ICU). Materials and Methods: Data of SOTR with influenza related ICU admission in a single center were analyzed between May 2016 to September 2019 retrospectively. Demographics, type of influenza virus, treatment duration, complications and mortality in ICU were assessed. Results: A total of 115 cases of influenza with SOTR were hospitalized. Out of these 17, %35 were female and 1 was a pediatric patient admitted to ICU due to acute respiratory failure. The median age of 17 patients consisting of 11 kidney and 6 liver recipients was 41 years (range 12-81years). Seven (41%) patients were in chronic rejection. Mean APACHE II and SOFA scores at ICU admission were 17±7.1 and 6.6±2.0 respectively. Except for one patient (<3 months), all were infected with influenza in the late period (>1 year) after transplantation. While real-time polymerase chain reaction (PCR) test was positive in 13 (76.5%) patients, other 4 (23.5%) were diagnosed with rapid antigen testing. The subtypes of influenza were revealed as: 2 (11.8%) influenza A, 13 (76.5%) influenza B, 2 (11.8%) influenza A and B. Simultaneous respiratory syncytial virus (RSV) positivity was seen in 9 SOTR (1 influenza A, 1 influenza A and B, 7 influenza B). Five patients were isolated due to extensively drug-resistant infections. Oseltamivir treatment was applied 5 or 10 days according to disease severity which was 58.8% and 41.2% respectively. Three (17.6%) patients received invasive mechanical ventilation and 10 (58.8%) high flow oxygen therapy for acute respiratory failure. Eight (47.0%) had vasopressor support due to shock and 7 (41.1%) patients received renal replacement therapy. The length of ICU and hospital stay were as 5.6±7.6 days and 18.2±19.0 days respectively. According to APACHE II scoring, mean predicted mortality was 17.0%, while 2 (11.7%) actual deaths were observed. Discussion: Most of the patients admitted to ICU for influenza were infected after the first year. Influenza B subtype was more common than A, and this was high in RSV accompaniment. Conclusion: Our study highlightes that, when the symptoms of influenza appear in high risk groups like solid organ transplant recipients, the early initiation of antiviral therapy can be a significantly lifesaving approach.

The Three-Year Effect of Medicaid Expansion on Emergency Department Visits and Admissions

We examine the effect of the Medicaid expansion in 2014 under in the Patient Protection and Affordable Care Act on emergency department (ED) utilization and ED admission rates (fraction of ED visits that lead to hospital admission) during the first 3 postexpansion years (2014 to 2016). We compared ED utilization and ED admission rates in 151 EDs in 14 expansion states with those in 376 EDs in 14 nonexpansion states, using difference-in-differences methods with data from 3 national emergency medicine groups from 2013 to2016. In expansion states, the volume of Medicaid-paid ED visits increased 49% (95% confidence interval 34% to 65%), and the volume of uninsured visits decreased 44% (95% confidence interval -52% to -34%) relative to that of nonexpansion states. Both effects on payer mix leveled off during 2015. There was no significant relative change in overall ED utilization or overall ED admission rates in expansion versus nonexpansion states during the study. However, relative ED admission rates for uninsured patients declined 8% (95% confidence interval -18% to -2%) in expansion states. Large changes in payer mix in expansion versus nonexpansion states were observed but leveled off during 2015, with more Medicaid-paid visits and fewer uninsured visits in expansion states. Despite these large changes, during this 3-year period, there was no evidence that expansion affected either overall ED visit volume or ED admission rates. The relative decline in ED admission rates in expansion states among the uninsured may reflect a selection effect in which, among newly Medicaid-eligible persons, sicker persons were more likely to enroll than healthier ones.

Neutropenic sepsis rates in patients receiving bleomycin, etoposide and cisplatin chemotherapy using olanzapine and reduced doses of dexamethasone compared to a standard antiemetic regimen.

To investigate whether the use of a steroid-sparing antiemetic protocol (substituting dexamethasone with olanzapine) affects the incidence of neutropenia and associated hospital admissions in patients receiving bleomycin, etoposide and cisplatin (BEP) chemotherapy. Records from 108 patients who received BEP at St Bartholomew's Hospital, London were divided into two groups according to antiemetic regimen. Group 1 (treated 2008-2013) were treated with a steroid-containing antiemetic protocol and group 2 (treated 2014-2017) were treated according to a steroid-sparing protocol, i.e. using olanzapine. Outcomes included incidence of neutropenia at nadir blood count, severity of neutropenia, hospital admissions attributable to febrile neutropenia (FN) and baseline risk factors associated with FN. Statistical analyses were performed using two-sided chi-squared tests. The baseline characteristics of the two groups were balanced with regard to age, gender, histology, and proportion of patients with International Germ Cell Cancer Collaborative Group poor-risk disease. The incidence of neutropenia of any grade (group 1, 96.2%; group 2, 98.1%) was similar, although group 2 had more patients with severe neutropenia than group 2 (77.7% vs 88.8%). There was a significant difference in FN incidence (group 1, 22%; group 2 7.5%; P=0.030). Most cases of FN occurred in cycle 1. Two baseline characteristics were over-represented in patients who developed FN: female sex and age ≥50years. By comparing two cohorts who received prophylactic antibiotics, our audit suggests that rates of FN-related admissions were lower in the cohort of patients in whom we employed a steroid-sparing antiemetic protocol.

Hospital Admission Trends for Bronchiolitis in Scotland, 2001-2016: A National Retrospective Observational Study.

Bronchiolitis is the commonest cause of respiratory related hospital admissions in young children. This study aimed to describe temporal trends in bronchiolitis admissions for children under 2 years of age in Scotland by patient characteristics, socioeconomic deprivation, and duration of admission. The national hospital admissions database for Scotland was used to extract data on all bronchiolitis admissions (International Classification of Disease, Tenth Revision, code J21) in children <2 years of age from 2001 to 2016. Deprivation quintiles were classified using the 2011 Scottish Index of Multiple Deprivation. Over the 15-year study period, admission rates for children under 2 years old increased 2.20-fold (95% confidence interval [CI], 1.4-3.6-fold) from 17.2 (15.9-18.5) to 37.7 (37.4-38.1) admissions per 1000 children per year. Admissions peaked in infants aged 1 month, and in those born in the 3 months preceding the peak bronchiolitis month-September, October, and November. Admissions from the most-deprived quintile had the highest overall rate of admission, at 40.5 per 1000 children per year (95% CI, 39.5-41.5) compared with the least-deprived quintile, at 23.0 admissions per 1000 children per year (22.1-23.9). The most-deprived quintile had the greatest increase in admissions over time, whereas the least-deprived quintile had the lowest increase. Zero-day admissions, defined as admission and discharge within the same calendar date, increased 5.3-fold (5.1-5.5) over the study period, with the highest increase in patients in the most-deprived quintile. This study provides baseline epidemiological data to aid policy makers in the strategic planning of preventative interventions. With the majority of bronchiolitis caused by respiratory syncytial virus (RSV), and several RSV vaccines and monoclonal antibodies currently in clinical trials, understanding national trends in bronchiolitis admissions is an important proxy for determining potential RSV vaccination strategies.

Reducing nosocomial transmission of COVID-19: implementation of a COVID-19 triage system

Nosocomial transmission of COVID-19 puts patients with other medical problems at risk of severe illness and death. Of 662 inpatients with COVID-19 at an NHS Trust in South London, 45 (6.8%) were likely to have acquired COVID-19 in hospital. These patients had no evidence of respiratory or influenza-like illness on admission and developed symptoms, with positive SARS-CoV-2 PCR test results, more than 7 days after admission (>14 days for 38 [5.7%] patients). Forty (88.9%) of these patients had shared a ward with a confirmed COVID-19 case prior to testing positive. Implementation of a triage system combining clinical assessment with rapid SARS-CoV-2 testing facilitated cohorting so that fewer susceptible patients were exposed to COVID-19 on shared wards. With hospital service resumption alongside the possibility of future waves of COVID-19 related admissions, strategies to prevent nosocomial transmission are essential. Point-of-care diagnostics can complement clinical assessment to rapidly identify patients with COVID-19 and reduce risk of transmission within hospitals.

The influence of a statewide “Stay-at-Home” order on trauma volume and patterns at a level 1 trauma center in the united states

The COVID pandemic of 2020 resulted in unprecedented restrictions of public life in most countries around the world, and many hospital systems experienced dramatic decreases in non-COVID related patient admissions. We aimed to compare trauma volumes, patient characteristics, and trauma mechanisms at a large, urban Level 1 trauma center in the United States during a state-wide “State of Emergency” and “stay-at-home” order to corresponding historic dates.All adult trauma activations from March 1 through April 30, 2020 and a historic control from March 1 through April 30, 2018 and 2019 were reviewed in the institution's trauma registry. Trauma volumes, patient characteristics, and trauma mechanisms were compared over time as increasingly stricter COVID-related restrictions were enacted in the Commonwealth of Virginia.After declaration of a state-wide “Public Health Emergency” on March 17, 2020, the daily number of trauma activations significantly declined to a mean of 4.7 (standard deviation, SD = 2.6), a decrease by 43% from a mean of 8.2 (SD = 0.3) for the same dates in 2018 and 2019. Trauma activations during COVID restrictions vs. historic control were characterized by significantly higher prevalence of chronic alcohol use (15.5% vs. 6.8%, p < 0.01), higher median (25th – 75th percentile) Injury Severity Score of 9 (5 – 16) vs. 6 (4 – 14), p = 0.01, and shorter median (25th – 75th percentile) length of hospital stay of 2 (1 – 6) days vs. 3 (1 – 7) days, p = 0.03.The COVID-related Public Health Emergency and “stay-at-home” order in the Commonwealth of Virginia dramatically reduced overall trauma volumes with minor but interesting changes in trauma patterns.

Self- Induced Medical Abortion: An Emerging Issue of Safety and Access

Introduction: Access to safe abortion services has been the need of the current era. Medical abortion (MA) is a simple, safe and effective method of induced abortion. MA drugs have been approved by Government of Nepal for termination of pregnancy up to 63 days of gestation in safe abortion service sites. But registered as well as unregistered MA drugs have been widely and easily available without prescription even in rural settings. This has led to a tremendous increase in self-induced medical abortions and its adverse consequences. Aim of our study was to find out incidence of abortion related admissions and description of self- induced MA presented to our institution.&#x0D; Methods: Descriptive study was conducted in Department of Obstetrics and Gynecology of KIST Medical College Teaching Hospital (KISTMCTH) from January 2015 to December 2016. Cases of complications of self-induced medical abortions were studied in detail which included age, parity, gestational age, address, type of complications and management.&#x0D; Results: Total number of Gynecology related admission over the period was 308. Among these, abortion related admission were 95 (30.84%). 44(46.3%) were spontaneous abortion and 51(53.7%) were induced abortion. 22(43.1%) were admitted due to complications of self- induced MA like incomplete abortion, bleeding, shock, sepsis and renal failure. Most of the patients were of age group 20-25 years and were multigravida and had done MA in first or second trimester.&#x0D; Conclusion: Self-induced medical abortion is still practiced even in urban area, landing to tertiary care hospital with complications. Thus MA should be provided by registered medical practitioner.

COVID-19 related admissions to a regional burn center: The impact of shelter-in-place mandate

The ramifications from the 2019 severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic caused by the novel corona virus will be felt globally for years to come. Mandates to shelter-in-place were called in nearly every state to limit viral exposure. The impact of the mandate on acute burn admissions was unknown. Our objective was to assess the impact of a shelter-in-place order on acute burn admissions at our burn center. All patients admitted to the burn center with burn injuries– including inhalation injury only– and desquamating skin disorders between March 10th to May 22nd, 2020 were eligible for inclusion. We compared all burn center admissions to a month-matched historical cohort from 2019, and summertime admissions for the last five years. Statistical significance was accepted as p < 0.05. There was a 9% increase in pediatric admissions after the shelter-in-place order. Compared to the 2019 cohort, there was a 28% increase in admissions of school aged children in 2020. This was not statistically significant. While the purpose of the “shelter-in-place” mandate was to reduce viral transmission of COVID-19, it consequently led to an increased percentage of admissions of school age children- comparable to our summertime numbers. More outreach and education are needed to provide safe resources for families during this pandemic.

Trends in Hospitalization for Human Immunodeficiency Virus in a Tertiary Hospital in Dar es Salaam, Tanzania: A Case study

Background:Reports on systematic evaluation of the impact of antiretroviral therapy(ART) on patients' hospitalisation in Sub Saharan Africa (SSA) and Tanzania in particular are scarce. We aimed at documenting the trends of hospital admissions at Muhimbili National Hospital (MNH) following scale up of free access to ART in Tanzania.Methods:Records for all admissions at MNH from June 2005 to June 2015 were reviewed. We extracted data from Hospital Information Management System as well as from patients' charts. Data extracted included diagnosis at discharge, reason for admission and thereafter assessed admission trends over the decade. We summarised the data as frequency and percentages. We compared proportions using Chi squared test, P<0.05 was deemed significant.Results:Overall there were 209,101 admissions during the study period (June 2005 to June 2015) and 7864/209,101 (3.8%) were due to HIV infection. Whereas 598/4,519 (13.2%) of all admissions in 2005 were due to HIV, only 345/13,119 (2.6%) of admissions in 2015 were HIV-related; showing a significant drop over time (P value for trend < .001). Generally, females 3887/6679 (58.2%) were more likely to be admitted than males (41.8%). Median CD4 count for admitted HIV patients was 143 cells/µl. Majority of admissions occured in the medical wards 3643/5310 (68.6%). Discharge diagnoses were Tuberculosis 1396/6482 (21.5%), anaemias 1016/6482 (15.6 %), malignancies 789/6482(12.2%), CNS infections 541/6482 (8.3%) and chronic kidney disease 308/6482 (4.8%). Three leading AIDS defining malignancies among hospitalised patients included Kaposi's sarcoma 380/789 (48.2%), carcinoma of the cervix 77/789 (9.8%), and Non-Hodgkin's lymphoma 44/789 (5.6%).Conclusion:Despite drastic drop of HIV related admissions at Muhimbili National Hospital over the years, the infection remains a problem of the adults, largely females suffering from medical conditions and presenting with severe immunosuppression. Tuberculosis remained the most common opportunistic infection among hospitalized HIV infected patients. Anaemia and cancers became more important causes of admission than was diarrhoea which had been the most common among HIV infected patients in pre- ART era.