Retrospective Case-cohort Study Research Articles

Open Partial Horizontal Laryngectomy in the Elderly: Oncological and Functional Outcomes.

The aim of the present study was to investigate the oncological and functional prognostic implication of perioperative risk factors in the elderly patient who underwent open partial horizontal laryngectomy (OPHL). A single institution, retrospective case-cohort study. The present study retrospectively reviewed the clinical charts of a cohort of 100 elderly laryngeal squamous cell carcinoma (LSCC) patients who underwent OPHL at our institution. Oncological and functional results were evaluated through univariate analysis. The overall recurrence rate was 19%. The 2 years overall and disease-specific survivals were 72% and 90%, respectively. No perioperative deaths were reported. A postoperative complication was reported in 20 cases (20%). Fifty-four patients (54%) were decannulated during the hospitalization. A percutaneous endoscopic gastrostomy procedure was performed in 12 patients (12%) due to persistent dysphagia. Twenty-six patients experienced postoperative late sequelae (26%), in terms of postoperative laryngeal obstruction (POLO) in 17 cases. A total of 80 patients (80%) were finally successfully decannulated. A functional total laryngectomy was performed in 6 cases. The indication to OPHL should be carefully evaluated in the elderly. In appropriately selected patient, OPHL represents a safe and effective therapeutic option. Cervical positive nodes and an incomplete resection of the tumor with positive surgical margins remain in such population the main prognostic factors for the oncological outcome, these factors have a negative impact on the functional outcome too, due to the need for adjuvant treatment. Hence, OPHL should be offered as a single-modality treatment especially in the elderly. 4 Laryngoscope, 2025.

Trends and determinants of time spent in the emergency department among Australian hospital presenting self-harm cases

AimsWaiting time (WT) and length of stay (LOS) are important metrics used to assess service delivery in emergency departments (EDs), and have been associated with subsequent re-presentations in EDs. This study investigated socio-demographic and health service determinants of WT and LOS among hospital treated self-harm (SH) cases presenting to EDs in Australian based hospitals. MethodsThis study employed a retrospective cohort study of all SH cases (N=6203) presenting to public hospital EDs in the Western Sydney catchment area from January 2016 to December 2022. Cox proportional hazard models were used to analyse demographic and service factors related to WT and LOS in Australian hospitals along with a description of secular trends in WT and LOS. ResultsLonger WT was evident for patients aged 15-64 than 0-14 years, non-admitted patients and patients arriving at the ED via transport other than ambulance whereas longer LOS was associated with older patients (65+ years). The inflow of non-SH cases to the ED did not have an impact on WT or LOS among SH cases. WT and LOS increased over time, particularly post the onset of the COVID-19 pandemic. The number of current self-harm cases receiving treatment in ED at the time of patient’s arrival also increased WT and LOS. ConclusionsWT and LOS have increased, especially post the onset of the COVID-19 pandemic. These findings necessitate the urgent need for updated strategies to manage ED resources, and suggest initiatives relating to ED diversion where appropriate for patients presenting to hospital following SH.

Prevalence and Outcomes of Emergency Presentations of Colorectal Cancer in Veterans Affairs Health Care System.

Colorectal cancer (CRC) diagnoses are frequently made through emergency presentations (EPs), a new cancer diagnosis following an emergency care episode or unplanned inpatient admission. The extent and implications of EPs are not well known in the Veterans Affairs (VA) health system, where robust CRC screening protocols exist. The impact of the COVID-19 pandemic on the route of CRC diagnosis also remains unclear. We conducted a retrospective cohort study of all incident CRC cases diagnosed nationally in the VA health care system from 2017 to 2021. We applied a previously validated algorithm to identify CRC EPs and used multivariable logistic regression and Cox proportional hazards models to examine the associations between EPs and CRC stage, treatment, and mortality. We identified 9,096 patients with CRC, 28.1% of whom had EPs, with the proportion of EPs increasing over the study period from 26.4% in 2017-2019 to 31.4% in 2020-2021. Patients with EPs were more likely to have advanced stage disease (adjusted OR 1.70; 95% CI 1.53-1.88) and less likely to receive cancer treatment (adjusted OR 0.65; 95% CI 0.56-0.75) than patients without EPs. Patients with EPs also had significantly higher mortality risk (adjusted HR 1.70; 95% CI 1.56-1.84). In a large cohort of patients diagnosed with CRC, we found EPs to be common and independently associated with worse cancer outcomes. EPs also increased during the COVID-19 pandemic. Interventions are needed to reduce potentially avoidable EPs and improve outcomes of patients with CRC diagnosis.

Abstract 4122486: Multicenter Study of Primary Fetal Cardiomyopathy: Clinical Outcomes And Genetic Etiologies, A Fetal Heart Society Research Collaborative Study

Background: Fetal cardiomyopathy (FCM) affects 8 per 100,000 live births, often with unknown etiology. Progress in fetal cardiac screening, genetic testing and management may have impacted historically poor outcomes. Aims: We sought to investigate genetic associations and clinical outcomes of FCM in the current era. Methods: This was a retrospective Fetal Heart Society Research Collaborative cohort study of FCM cases diagnosed from January 2017-December 2021 in 39 centers. Cases of fetal myocardial disease attributable to maternal diabetes, structural heart disease, arrhythmia or extra-cardiac conditions were excluded. Data including outcomes to 1 year after birth were collected. Significance of genetic testing results and FCM subtype were classified by each center. Results: There were 138 FCM cases diagnosed at a median gestational age of 27 +4 weeks (range 13-39 weeks). Suspected fetal heart disease (41%, 56/138) was the most common referral indication. There was a known family history of CM in 19% (26/138). FCM phenotypes included 38% (52/138) dilated, 24% (33/138) hypertrophic, 17% (24/138) non-compacted, 10% (14/138) mixed, 5% (7/138) restrictive, 3% (4/138) ventricular aneurysm, 3% (4/138) unspecified. Hydrops was present at diagnosis in 15% (20/138) and by delivery or at fetal demise in 26% (36/138). Of 128 continued pregnancies, 7% (9/128) had a fetal demise, 92% (118/128) a live birth and one was lost to follow-up. Among live births, 10% (12/118) received only palliative care. Of 106 actively treated, 75% (80/106) survived to 1 year; 7% (7/106) required ECMO, and 22% (23/106) were listed for transplant with 18 of these successfully transplanted. Of the cohort, a total of 80% (110/138) had genetic testing (including 30 with invasive prenatal testing), with 38% (52/138) having a confirmed genetic etiology and 28% (38/138) with a variant of uncertain significance (VUS) (Figure 1). Transplant-free survival to 1 year was similar for those with and without a genetic diagnosis (40%,21/52 vs 47%,40/86, p=0.48). Conclusion: Outcomes remain poor in FCM, with <50% 1-year survival overall. Confirmed genetic etiologies are now identified in nearly 40%, highlighting the importance of genetic testing.

Impact of inappropriate empirical antibiotic therapy on in-hospital mortality: a retrospective multicentre cohort study of patients with bloodstream infections in Chile, 2018–2022

IntroductionEmpirical antibiotic therapy is essential for treating bloodstream infections (BSI), yet there is limited evidence from resource-limited settings. We quantified the association of inappropriate empirical antibiotic therapy (IEAT) with in-hospital...

Abstract 308: Inpatient Optimization of Endovascular Therapy for Acute Ischemic Stroke in Patients with Active Malignancy

Introduction Landmark trials studying the efficacy of endovascular therapy for patients with large vessel occlusions generally excluded patients with active cancer. Of those with malignancy undergoing mechanical thrombectomy, they tend to have worse clinical outcomes despite technical success. Thus, implications of mechanical thrombectomy in this cohort remains debated. Our objective is to elucidate post thrombectomy outcomes in patients with active cancer to further optimize inpatient management. Methods We conducted a retrospective cohort study of stroke thrombectomy cases performed at our institution from January 2010 to March 2024. Pearson Chi‐square test and Fisher's exact test were used to analyze categorical variables, and Mann‐Whitney U tests were used for continuous variables. Multivariable logistic regression analyses were performed to evaluate for independent associations between baseline characteristics and study outcomes of interest, specifically, successful endovascular reperfusion (≥TICI 2b) and poor clinical outcome, defined as death or disposition to hospice. Results We identified 50 patients with active cancer who underwent mechanical thrombectomy (MT) for stroke. Mean age was 63.8 years (SD, 11.4), 48% were men, and 68% had stage IV cancer. Successful reperfusion was achieved in 78% of patients, and 50% ultimately had a poor clinical outcome, including 40% inpatient deaths. Of those that died inpatient, 46% of deaths were due to non‐neurological causes. 78% of patients undergoing MT were treated with optimal medical management post stroke with either anticoagulation or antiplatelet therapy. In total, 16% of patients went on to complete cancer treatment. While there were no pre‐EVT variables that were significantly associated with outcome change, the decision to initiate anticoagulation post‐EVT while inpatient was associated with more favorable outcomes (p=0.006). Only 6% of patients were found to have sICH, and the use of IV thrombolysis prior was not found to impact this rate. Conclusion In our study, we found that despite a high successful reperfusion rate, nearly half of cancer patients undergoing mechanical thrombectomy for large vessel occlusion strokes had a poor clinical outcome. We found that anticoagulation post thrombectomy independently correlated with a more favorable outcome. Future studies must further elucidate other factors that may influence outcomes to guide in optimal patient selection and maximize overall success of EVT in patients with cancer.

Unlike other medical conditions, type 2 diabetes is a risk factor for new-onset major depression after COVID-19

ObjectiveIt is unclear whether pre-COVID medical conditions are risk factors for post-COVID major depressive episode (MDE). We aimed to determine which pre-COVID medical conditions are risk factors for post-COVID MDE after a hospitalization for COVID-19. MethodsWe conducted a nested retrospective case-cohort study within a cohort of 650 patients evaluated six months after hospitalization for COVID-19 at Bicêtre hospital, France. Nine medical conditions present before COVID-19 (High blood pressure, obesity, type 2 diabetes, cardiac, respiratory and renal disease, immune deficiency, neoplasia and liver disease) were extracted from medical records. MDE was assessed using the Structured Clinical Interview for DSM-5 Disorders-Clinician Version (SCID-5-CV). Bivariate and multivariable analyses were performed to determine which pre-COVID medical conditions are independent risk factors for post-COVID new-onset MDE. ResultsPatients mean age was 62.8 (15.8), 258 (39.7 %) were women; 301 (46.3 %) had high blood pressure, 205 (32.4 %) had obesity, and 186 (28.6 %) had type 2 diabetes. Thirty-six (5.5 %) patients were diagnosed with a new-onset MDE. In contrast to other medical conditions, type 2 diabetes was significantly associated with new-onset MDE (OR = 2.51 [1.19–5.29]). ConclusionUnlike other pre-COVID medical conditions, type 2 diabetes is a risk factor for post-COVID MDE. Patients with type 2 diabetes should be screened for MDE after a hospitalization for COVID-19.

No difference in 6-month functional outcome between early and late decompressive craniectomies following acute ischaemic stroke in a national neurosurgical centre: a single-centre retrospective case-cohort study.

Decompressive craniectomies (DCs) are recommended for the treatment of raised intracranial pressure after acute ischaemic stroke. Some studies have demonstrated improved outcomes with early decompressive craniectomy (< 48h from onset) in patients with malignant cerebral oedema following middle cerebral artery infarction. Limited data is available on suboccipital decompressive craniectomy after cerebellar infarction. Our primary objective was to determine whether the timing of DCs influenced functional outcomes at 6months. Our secondary objectives were to analyse whether age, gender, the territory of stroke, or preceding thrombectomy impacts functional outcome post-DC. We conducted a retrospective study of patients admitted between January 2014 and December 2020 who had DCs post-acute ischaemic stroke. Data was collected from ICU electronic records, individual patient charts, and the stroke database. Twenty-six patients had early DC (19 anterior/7 posterior) and 21 patients had late DC (17 anterior/4 posterior). There was no difference in the modified Rankin Scale (mRS) score of the two groups at 90 (p = 0.318) and 180 (p = 0.333) days post early vs late DC. Overall outcomes were poor, with 5 out of 46 patients (10.9%) having a mRS score ≤ 3 at 6months. There was no difference in mRS scores between the patients who had hemicraniectomies for anterior circulation stroke (n = 35) and suboccipital DC for posterior circulation stroke (n = 11) (p = 0.594). In this single-centre retrospective study, we found no significant difference in functional outcomes between patients who had early or late DC after ischaemic stroke.

Association Between Oral Anticoagulant Adherence and Serious Clinical Outcomes in Patients With Atrial Fibrillation: A Long-Term Retrospective Cohort Study.

Patients with atrial fibrillation are frequently nonadherent to oral anticoagulants (OACs) prescribed for stroke and systemic embolism (SSE) prevention. We quantified the relationship between OAC adherence and atrial fibrillation clinical outcomes using methods not previously applied to this problem. Retrospective observational cohort study of incident cases of atrial fibrillation from population-based administrative data over 23 years. The exposure of interest was proportion of days covered during 90 days before an event or end of follow-up. Cox proportional hazard models were used to evaluate time to first SSE and the composite of SSE, transient ischemic attack, or death and several secondary outcomes. A total of 44 172 patients were included with median follow-up of 6.7 years. For direct OACs (DOACs), each 10% decrease in adherence was associated with a 14% increased hazard of SSE and 5% increased hazard of SSE, transient ischemic attack, or death. For vitamin K antagonist (VKA) the corresponding increase in SSE hazard was 3%. Receiving DOAC or VKA was associated with primary outcome hazard reduction across most the proportion of days covered spectrum. Differences between VKA and DOAC were statistically significant for all efficacy outcomes and at most adherence levels. Even small reductions in OAC adherence in patients with atrial fibrillation were associated with significant increases in risk of stroke, with greater magnitudes for DOAC than VKA. DOAC recipients may be more vulnerable than VKA recipients to increased risk of stroke and death even with small reductions in adherence. The worsening efficacy outcomes associated with decreasing adherence occurred without the benefit of major bleeding reduction.

Genomic characterization and cluster analysis of Carbapenem-resistant Klebsiella pneumoniae

To investigate the genomic features and perform cluster analysis of Carbapenem-resistant Klebsiella pneumoniae (CRKP) to provide an experimental basis for guiding the prevention and treatment of CRKP infections.A retrospective case-cohort study was conducted on 19 non-redundant CRKP strains isolated from the Tenth Affiliated Hospital of Southern Medical University between January and June 2023. Whole genome sequencing (WGS) and multilocus sequence typing (MLST) were performed to compare genomic features and analyze the resistance genes and homology of the strains.The results showed that the 19 CRKP strains were isolated from 8 different clinical departments, mainly from respiratory specimens. The whole genome sequencing revealed that the genomic lengths of CRKP ranged from 4.90 to 5.85 Mbp, with contigs N50 values>20 kb for each genome. The median overall GC content was 57.0% (50.4%-57.1%). Comparative genomic analysis identified three regions with high genomic variability. WGS detected 32 resistance genes across 11 categories. All 19 strains carried carbapenem resistance genes (blaKPC-2 and blaOXA-48), blaTEM-1B extended-spectrum β-lactamase resistance genes, qnrS1 quinolone resistance gene, and fosA fosfomycin resistance gene, with each strain carrying only one carbapenemase gene. The detection rate of blaKPC-2 was 94.7% (18/19). MLST identified three sequence types: ST11, ST437 and ST147, with ST11 being predominant (89.5%, 17/19). Clustering analysis based on acquired resistance genes revealed three clonal transmission patterns among strains 72 and 90, and strains 88, 84, 66 and 79.In conclusion, CRKP strains carry multiple resistance genes, and clustering analysis indicating that nosocomial clonal transmission is closely related to acquired resistance genes. The ST11-blaKPC-2 type strain is the predominant clone. Strengthened surveillance and effective control strategies are necessary to reduce nosocomial transmission of CRKP.

Long-term risk of right coronary artery injury after catheter ablation of cavotricuspid isthmus–dependent flutter

BackgroundRadiofrequency ablation (RFA) of cavotricuspid isthmus (CTI)–dependent atrial flutter requires ablation of the tricuspid annulus overlying the right coronary artery (RCA). Although it is considered safe, reports of acute and subacute RCA injury in human and animal studies raise the possibility of late RCA stenosis. ObjectiveThe objective of this study was to compare the incidence and severity of angiographic RCA stenoses in patients who have undergone CTI RFA with a control group to assess the long-term risk of RCA damage. MethodsA 2-center retrospective case-cohort study was performed including all patients from 2002 to 2018 undergoing atrial fibrillation (AF) with CTI ablation (CTI + AF) or AF ablation alone with subsequent coronary angiography (CAG). The AF alone group served as controls because of anticipated similarity of baseline characteristics. Coronary arteries that are anatomically remote to the CTI were examined as prespecified falsification end points. CAG was scored by a blinded observer. ResultsThere were 156 patients who underwent pulmonary vein isolation with subsequent CAG (CTI + AF, n = 81; AF alone, n = 75) with no difference in baseline characteristics including age, sex, comorbidities, and medications. Mean time from ablation to CAG was similar (CTI + AF, 5.0 ± 3.7 years; AF alone, 5.4 ± 3.9 years; P = .5). The mid and distal RCA showed no difference in the average number of angiographic stenoses or lesion severity. In regression analysis, CTI ablation was not a predictor of RCA stenosis severity (P = .6). There was no difference in coronary disease at sites remote to the CTI ablation (P = NS for all). ConclusionThere was no observed relationship between CTI RFA and the number or severity of angiographically apparent RCA stenoses in long-term follow-up.

Prophylactic cosyntropin after unintentional dural puncture and incidence of post-dural puncture headache and epidural blood patch use: A retrospective cohort study (2019–2022)

BackgroundCosyntropin has been suggested to decrease the incidence of post-dural puncture headache (PDPH) by increasing the production of cerebrospinal fluid. This study examined the association of prophylactic cosyntropin administration with the incidence of PDPH and its management with an epidural blood patch after an unintentional dural puncture (UDP). MethodsWe conducted a retrospective cohort study of cases with UDP during placement of neuraxial labor analgesia. Per institutional practice and at the discretion of the anesthesiologist, intravenous cosyntropin 1 mg may be administered for PDPH prophylaxis. PDPH, time from UDP to cosyntropin administration, time to development of PDPH, and management with epidural blood patch(es) were recorded. ResultsCosyntropin was administered in 164 of 234 (70%) cases with UDP. PDPH occurred 98/164 (60%) with cosyntropin and 45/70 (64%) without cosyntropin (p = 0.66). The PDPH adjusted incidence was 53% with cosyntropin and 62% without cosyntropin, difference 9% (95% CI −6% to 24%, p = 0.25). The adjusted epidural blood patch rate was 66% with cosyntropin and 78% without cosyntropin, difference of 12% (95% CI −5% to 28%, p = 0.17). ConclusionsProphylactic cosyntropin following UDP was not associated with a significant decrease in PDPH rate or use of epidural blood patch for management of PDPH. There was no significant difference in the rate of adverse hyperglycemic or hypertensive events amongst those who did or did not receive cosyntropin.

Progressive multifocal leukoencephalopathy and spectrum of predisposing conditions: a 20-year retrospective cohort study in a tertiary center in São Paulo, Brazil.

Epidemiological studies on predisposing conditions and outcomes of progressive multifocal leukoencephalopathy (PML) cases have been carried out exclusively in high-income countries. We aim to report and compare the main characteristics and outcomes of patients with PML and several underlying diseases in a referral center in a middle-income country. We performed a retrospective cohort study of PML cases admitted to a tertiary care hospital in São Paulo, Brazil during 2000-2022. Demographic and PML-specific variables were recorded. One-year case-fatality rate and factors associated with death were identified using a multivariate Cox proportional hazards regression model. Ninety-nine patients with PML were included. HIV infection (84.8%) and malignancy (14.1%) were the most prevalent underlying conditions. Other predisposing diseases were autoimmune/inflammatory diseases (5.1%) and solid organ transplantation (1.0%). One (1.0%) patient had liver cirrhosis and another (1.0%) patient was previously healthy. Focal motor deficits (64.2%) and gait instability (55.1%) were the most common signs. The one-year case-fatality rate was 52.5% (95% CI 42.2-62.7). The one-year case-fatality rate (95% CI) in patients with or without malignancy (85.7%, 95% CI 57.2-98.2% and 47.1%, 95% CI 36.1-58.2%, respectively) were statistically different (P = 0.009). Crude and adjusted Cox regression models identified malignancy as independently associated with death (adjusted HR = 3.92, 95% CI 1.76-8.73, P = 0.001). HIV/AIDS was the predisposing condition in 84.8% of PML cases. The one-year case-fatality rate was 52.5% and having a malignancy was independently associated with death. This study reports emerging data on the epidemiology and outcome of PML in a middle-income country.

Hazard of Failed Nonoperative Management for Symptomatic Accessory Navicular in Children and Adolescents: A Population-Based Case-Cohort Study.

The accessory navicular (AN) is an idiopathic condition of the foot present in 4% to 21% of the population. Most ANs remain asymptomatic, but children and adolescents who develop symptoms can have remarkably reduced quality of life. Although many respond to conservative measures, surgery is occasionally needed. Our purpose was to determine factors associated with the failure of nonoperative management. This single-institution retrospective case-cohort study included patients up to age 19 years presenting between 2000 and 2021 with symptomatic AN and treated with standard-of-care. All 298 surgical cases, indicating failed nonoperative treatment, were included. For the subcohort, 299 patients were randomly sampled from all eligible patients, regardless of treatment. Baseline characteristics were summarized for the surgical cases and subcohort. Proportional hazards assumptions were checked and stratification implemented when necessary. Marginal structural proportional hazard modeling was used to estimate hazard ratios with 95% confidence intervals via inverse probability and LinYing weighting methods. The 298 surgical cases failed nonoperative management at a median of 5.2 months (IQR, 2.0-11.6 mo). In the subcohort, 86 failures of nonoperative management and 213 nonfailures constituted a 28.8% surgery rate. In both cohorts, nearly all patients played sports. Univariate proportional hazard modeling found older age ( P =0.02) and activity limitation ( P <0.001) at presentation, female sex ( P =0.002), higher BMI ( P =0.01), AN on the right ( P <0.001), and bone marrow edema of the AN ( P <0.001) and navicular body ( P <0.001) on MRI were associated with increased hazard of nonoperative failure. Nearly all of the surgical cohort reported improvement in pain (278/296, 94%) and returned to their primary sport (236/253, 93%) after surgery. Most also experienced full resolution of symptoms (187/281, 67%). Symptomatic AN predominantly affects female athletes, leading to surgery in 28.8% of our subcohort. Conservative treatment may be less successful-and therefore surgery could be more strongly considered-in older age, activity limitation at presentation, female sex, higher BMI, right-sided AN, and bone marrow edema on MRI. Surgery is effective for symptomatic and functional improvement. Case-cohort-Level III.

Health care resource utilization and costs associated with psychiatric comorbidities in adult patients with attention-deficit/hyperactivity disorder.

Attention-deficit/hyperactivity disorder (ADHD) is a heterogeneous condition with extensive psychiatric comorbidities. ADHD has been associated with substantial clinical and economic burden; however, little is known about the incremental burden specifically attributable to psychiatric comorbidities of ADHD in adults. To assess the impact of psychiatric comorbidities, specifically anxiety and depression, on health care resource utilization (HRU) and costs in treated adults with ADHD in the United States. A retrospective case-cohort study was conducted. Adults with ADHD were identified in the IQVIA PharMetrics Plus database (10/01/2015-09/30/2021). The index date was defined as the date of initiation of a randomly selected ADHD treatment. The baseline period was defined as the 6 months prior to the index date, and the study period as the 12 months following the index date. Patients with at least 1 diagnosis for anxiety and/or depression during both the baseline and study periods were classified in the ADHD+anxiety/depression cohort, whereas those without diagnoses for anxiety or depression at any time were classified in the ADHD-only cohort. Entropy balancing was used to create reweighted cohorts with similar baseline characteristics. All-cause HRU and health care costs were assessed during the study period and compared between cohorts using regression analyses. Cost analyses were also conducted in subgroups stratified by comorbid conditions. After reweighting, patients in the ADHD-only cohort (N = 276,906) and ADHD+anxiety/depression cohort (N = 217,944) had similar characteristics (mean age 34.1 years; 54.8% male). All-cause HRU was higher in the ADHD+anxiety/depression cohort than the ADHD-only cohort (incidence rate ratios for inpatient admissions: 4.5, emergency department visits: 1.8, outpatient visits: 2.0, and psychotherapy visits: 6.4; all P < 0.01). All-cause health care costs were more than 2 times higher in the ADHD+anxiety/depression cohort than the ADHD-only cohort (mean per-patient per-year [PPPY] costs in ADHD-only vs ADHD+anxiety/depression cohort: $5,335 vs $11,315; P < 0.01). Among the ADHD+anxiety/depression cohort, average all-cause health care costs were $9,233, $10,651, and $15,610 PPPY among subgroup of patients with ADHD and only anxiety, only depression, and both anxiety and depression, respectively. Comorbid anxiety and depression is associated with additional HRU and costs burden in patients with ADHD. Comanagement of these conditions is important and has the potential to alleviate the burden experienced by patients and the health care system.

Critical Organ Dysfunction and Preoperative Mortality in Newborns with Hypoplastic Left Heart Syndrome.

Hypoplastic left heart syndrome (HLHS) is fatal without surgical intervention. An important subset of HLHS patients die prior to surgical intervention, but this population is underevaluated. The neonatal sequential organ failure assessment score (nSOFA) is an operational definition of organ dysfunction that can identify those with a high risk of mortality among neonatal intensive care unit (NICU) patients. The utility of the nSOFA to predict preoperative mortality in the unique HLHS population is unknown and could inform care, particularly care provided by neonatology staff. We performed a multicenter retrospective cohort study of HLHS cases across three level IV NICUs from January 1, 2009, to December 3, 2023. Patients were classified as either survived or died prior to surgical intervention. Demographic variables were curated from medical records including the maximum nSOFA (nSOFAmax) before surgical intervention or death. We identified 265 patients with HLHS over the study period. The nSOFAmax was greater in patients who died preoperatively (14/265; 5%) compared with survivors to surgical intervention (median 8 [interquartile range, 6, 12] vs. 2 [0, 4]; p < 0.001). The area under receiver operating characteristics curve for the nSOFAmax to discriminate for mortality was 0.93 (95% confidence interval, 0.88-0.98; p < 0.001). Compared with an nSOFAmax of 0, the likelihood ratio for preoperative death doubled at 2, tripled at 4, and was 10-fold at 9. This is the first demonstration of nSOFA utility in specific to congenital heart disease and HLHS. The nSOFAmax represents a novel, electronic health record-compatible, and generalizable method to identify patient-level organ dysfunction and risk for preoperative mortality in HLHS patients. KEY POINTS: · An important subset of HLHS patients die preoperatively.. · nSOFA can be used to measure preoperative HLHS severity.. · nSOFA predicts preoperative mortality risk in HLHS patients..

The predictive value of heart rate in determining clinical course after a bupropion overdose

Introduction Bupropion is a popular antidepressant due to its favorable side effect profile and indications for smoking cessation and weight loss. Due to the possibility of delayed onset seizure and other adverse outcomes after bupropion overdose, patients are often observed for periods of 12-24 hours following suspected ingestion. Tachycardia is a clinical predictor that holds promise in differentiating cases at risk for seizures from low-risk cases that do not require prolonged observation. This study assessed whether heart rate within the first eight hours of presentation can identify cases that do not require extended observation. Methods This is a retrospective cohort study of all supra-therapeutic bupropion cases from two hospital systems between 2010 and 2022. Results Data from 216 charts were included. Seizures, hypotension, and dysrhythmias occurred in 19 percent (n = 41), 1.4 percent (n = 3), 0.9 percent (n = 2) respectively. One patient died. Delayed adverse effects were rare (n = 4); they occurred from 14 hours to 28 hours post-ingestion. Maximum heart rate in eight hours was associated with a risk of adverse outcomes. (odds ratio, 1.07; 95 percent confidence interval: 1.05 to 1.09; P < 0.001). An eight hour maximum heart rate threshold of 104 beats/minute had a negative predictive value of 100 percent (95 percent confidence interval: 96.7 percent to 100 percent) for the occurrence of delayed adverse effects. All patients with delayed effects had tachycardia within five hours of emergency department arrival. Discussion Delayed adverse outcomes of seizures, hypotension, dysrhythmia, and death were uncommon in this cohort. Heart rate during the first eight hours of observation performs reliably as a screening test to identify patients at low risk for delayed adverse outcomes. This study is limited by its retrospective nature, the inability to ascertain time of ingestion for most cases and the lack of confirmatory laboratory testing. Conclusion This study supports the use of an eight hour observation period when there are no other clinical signs of toxicity to warrant admission and if no co-ingestion or administration of substances that mask tachycardia are present.

Correlation of Peripartum Acute Kidney Injury Severity With Obstetric Comorbidity Index Scores and Maternal Morbidity [ID 2683636

INTRODUCTION: Risk stratification systems are increasingly used to predict obstetric complications. The Obstetric Comorbidity Index (OB-CMI) is one validated prediction tool, applying weighted scores to maternal and obstetric conditions. Although acute kidney injury (AKI) is a severe maternal morbidity, there is limited information on predicting AKI severity. We aimed to investigate the utility of OB-CMI scores and its specific comorbidities in predicting obstetric AKI severity, and the relationship of AKI severity and other maternal morbidity outcomes. METHODS: This was an IRB-exempt, retrospective cohort study of AKI cases (ICD-10 code N17.0-17.9) between January 2018 and December 2022 at a single academic institution with ∼6,000 births annually. Information was extracted via chart review. Cases were stratified by those meeting American College of Obstetricians and Gynecologists (ACOG)/Society for Maternal-Fetal Medicine (SMFM) criteria for severe renal injury. Those with unknown baseline Cr were assigned 0.7 (the 95th percentile Cr value at 39–40 weeks). Groups were compared based on admission OB-CMI scores and comorbidities, and maternal morbidity events using independent t-tests, χ2, and Fisher's exact as appropriate. RESULTS: Two hundred thirty cases were reviewed: 8.3% (19 cases) met ACOG/SMFM AKI criteria. There was no significant difference in mean OB-CMI scores (mean 3.8 versus 4.1; P=.782) or incidence of individual comorbidities between groups. Regarding other maternal morbidity events, ACOG/SMFM criteria AKI was significantly associated with other severe morbidity events (47.4% versus 12.3%; P&lt;.001), including transfusion, disseminated intravascular coagulation, intubation, and intensive care unit admission. CONCLUSION: The OB-CMI score was poorly predictive of AKI severity; however, the occurrence of severe AKI by ACOG/SMFM criteria was associated with a 4-fold increased rate of co-occurring maternal morbidity events and a 2.5-fold increased rate of blood transfusion.

Clinical and Laboratory Profile, Management and Outcome of Pediatric SARS-CoV-2 Infection Admitted at the Philippine General Hospital.

The Philippines has recorded over 470,000 COVID-19 cases in children, with over 1,500 deaths during the same period. Although a Philippine online pediatric COVID-19 registry exists, this only relies on passive surveillance. This study determined the clinical and laboratory profile, risk factors for severe COVID-19, and mortality, management, and outcome of pediatric SARS-CoV-2 patients admitted at the Philippine General Hospital (PGH) from April 2020 to June 2022 to fill in knowledge gaps on the epidemiology of COVID-19 infection in children. This was a retrospective cohort study of pediatric COVID-19 cases admitted at the PGH, a designated COVID referral center during the study period. Demographic and clinical profile, risk factors, comorbidities, laboratory and radiologic findings, management, and outcomes across different disease severity states were gathered by chart review and the data were analyzed using STATA 17. There were 448 pediatric patients admitted and diagnosed with COVID-19 during the study period. Most patients belonged to the 1-5-year age group (25.9%), had no known exposure to a COVID-19 case (65.4%), were mild cases (37.3%%), and did not receive any dose of the COVID-19 vaccine (96.7%). The most common presenting symptoms across all disease categories were fever (44.4%), cough (28.6%), and shortness of breath (26.6%). Multisystem inflammatory syndrome in children (MIS-C) presented with fever (100%) and rash (53.9%). The risk factors for severe disease were the presence of a congenital anomaly lung disease, and elevated procalcitonin. Most patients with MIS-C were previously well with no comorbidities. Laboratory findings which were markedly elevated among severe and critical cases were ESR, CRP, D-dimer, LDH, and IL-6. Ferritin, procalcitonin (PCT) and IL-6 were elevated only in severe to critical COVID-19 cases and remained within normal for the other disease categories. As to treatment, asymptomatic, mild, and moderate cases were given supportive medications (zinc, vitamin D, and vitamin C), while investigational drugs particularly corticosteroids, IVIG, and remdesivir, were used in severe cases.Antibiotics were given to 71.7% of patients at the outset. As to the outcomes, 89% recovered, while 8.9% died. The case fatality rate from COVID-19 infection was at 2.2%. Admitted pediatric COVID-19 cases are generally mild but admission is due to underlying illness or comorbidities. Those with severe to critical cases have underlying comorbidities and had either progression or complications due to COVID disease. D-dimer, LDH, IL-6, ferritin and procalcitonin were elevated among severe and critical cases which can be utilized as inflammatory markers.

Tuberculosis in prison: What about after release? The example of French Guiana

ABSTRACT Introduction Tuberculosis is a major cause of mortality worldwide. Prisoners in Guiana have multiple risk factors. The primary objective of this study was to describe tuberculosis occurring in prison and after release in French Guiana between 2008 and 2020. Secondary objectives were to identify tuberculosis risk factors and determine annual incidences. Methods: A retrospective cohort study of tuberculosis cases was carried out at the Guiana prison between 2008 and 2020. Data were collected from prison registers and cross-referenced with the list of tuberculosis notifications in French Guiana. Results: A total of 36 cases of tuberculosis were studied. Incidence was high, at 263/100,000 per year, higher than elsewhere in France and comparable to that in Brazil. Despite visibly effective screening on entry, with little evidence of intra-prison circulation of tuberculosis, 39% of patients were diagnosed within two years of leaving prison (76% were symptomatic). This could be explained by the high prevalence of latent forms (LTI). Discussion Continued screening on entry, in combination with annual radiological and clinical screening, and reinforced follow-up on release seem indicated to improve patient management and the search for possible LTI.