Significant Increase In Hospitalizations Research Articles

Heatwaves and diabetes in Brisbane, Australia: a population-based retrospective cohort study.

Available data on the effects of heatwaves on hospitalizations for diabetes and the post-discharge status of diabetics are scarce. This study aimed to assess the effects of heatwaves on hospitalizations and post-discharge deaths for diabetes, and to identify the individual- and community-level characteristics [i.e. age, gender, Socio-economic Indexes for Areas (SEIFA), and normalized difference vegetation index (NDVI)] that modified heatwave effects. Health data were extracted from a cohort study which included patients in Brisbane, Australia, who were hospitalized due to diabetes from 1st January 2005 to 31st December 2013, and died within 2 months after they were discharged. Data on community-level modifiers, including SEIFA and NDVI (i.e. urban vegetation), were obtained from Australian Bureau of Statistics and Australian Bureau of Meteorology, respectively. Case-crossover design was used to quantify the effects of heatwaves on hospitalizations and post-discharge deaths due to diabetes. Four heatwave definitions incorporating both intensity (i.e. 90th, 95th, 97th and 99th percentiles of mean temperature distribution) and duration (2 days), as well as excess heat factor (EHF), were used. A case-only design was adopted to identify the modifiers of heatwave effects. There were 10542 hospitalizations for diabetes, and 513 patients died due to diabetes within 2 months after discharge. During low-intensity heatwave days (i.e. 90th percentile & 2 days), we did not observe a significant increase in hospitalizations for diabetes [9% at lag 0; 95% confidence interval (CI): -3%, 23%; P = 0.146], but we observed a significant increase in post-discharge deaths (46% at lag 2; 95% CI: 3%, 107%; P = 0.036). During middle-intensity heatwave days (i.e. 95th percentile & 2 days), hospitalizations for diabetes increased by 19% at lag 0 (95% CI: 2%, 39%; P = 0.026), and post-discharge deaths increased by 64% at lag 0 (95% CI: 6%, 154%; P = 0.027). During high-intensity heatwave days (i.e. 97th percentile & 2 days), hospitalizations for diabetes increased by 37% at lag 1 (95% CI: 11%, 69%; P = 0.004) and post-discharge deaths increased by 137% at lag 1 (95% CI: 39%, 303%; P = 0.002). When heatwave intensity increased to 99th percentile, we did not observe a significant increase in hospitalizations (-1% at lag 0; 95% CI: -38%, 59%; P = 0.870) or post-discharge deaths (79% at lag 0; 95% CI: -39%, 431%; P = 0.301). When we used EHF to define heatwaves, we observed significant increases of hospitalizations (7%; 95% CI: 1%, 15%; P = 0.039) and post-discharge deaths (68%, 95% CI: 10%, 158%; P = 0.017) during heatwave days, compared with non-heatwave days. Children and male diabetics were particularly vulnerable to heatwave effects, but we did not find any significant modification effect of SEIFA or NDVI on the associations of heatwaves with hospitalizations and post-discharge deaths due to diabetes. Heatwaves may lead to hospitalizations of diabetics and their premature deaths. Heat-related diabetes burden in children may increase as climate warms and with increasing obesity rates in adolescents.

Predictive capability of the injury severity score versus the new injury severity score in the categorization of the severity of trauma patients: a cross-sectional observational study

The AIS scale is a measurement tool for single injuries. The ISS is considered the gold standard for determining the severity of injured patients, and the NISS was developed to improve the ISS with respect to loss of information, as well as to facilitate its calculation. The aim of this study was to analyse what injury severity measure, calculated according to the Abbreviated Injury Scale (AIS), 1998 and 2005 (update 2008) versions, performs better with mortality, cost and hospital length of stay healthcare indicators. This cross-sectional observational study was carried out between February 1st 2012 and February 1st 2013. Inclusion criteria were injured patients due to external causes admitted to trauma service through the emergency department. Manual coding of all injuries was performed and ISS and NISS scores were calculated for both versions of the AIS scale. Severity was then compared to mortality (in-hospital and at 30days), healthcare cost, and length of hospital stay. The index with the best predictive capability for in-hospital mortality was NISS 05 (AUC = 0.811). There was a significant increase in hospital stay and healthcare cost in the most severe patients in all indexes, except for ISS 05. NISS is found to be an index with higher predictive capability for in-hospital mortality and correlates better to length of hospital stay and healthcare cost.

Metformin associated lactic acidosis: a case series of 28 patients treated with sustained low-efficiency dialysis (SLED) and long-term follow-up

BackgroundMetformin associated lactic acidosis (MALA) is a well-known serious side effect of biguanides. However, the best treatment strategy remains a matter of debate. In the last 14 years, we observed a significant increase in hospitalizations for MALA to our Center. We report the outcomes of our clinical and therapeutic approach.MethodsThis is a single-center case series. Twenty-eight patients affected with MALA and acute kidney failure admitted between January 2000 and September 2014 were included. We analyzed comorbidities, laboratory tests and clinical parameters at admission, at 36 h and at discharge. All patients were treated with sustained low-efficiency dialysis (SLED) until normalization of serum lactate (≤ 3 mmol/L), bicarbonate (between 20 and 25 mmol/L) and potassium (between 4.0 and 5.1 mmol/L).ResultsThe mortality rate was 21.4%, with all of the events occurring within 24 h from admission, and before or during the first hemodialysis treatment. Precipitating causes included; acute dehydration (86.4%), systemic inflammatory response syndrome (SIRS) (57.1%), sepsis (10.7%), nephrolithiasis (14.6%) and exposure to iodinated contrast (7.1%). No further episodes of lactic acidosis were described after discontinuing the drug over a mean follow-up of 27.2 months. Furthermore, while in 2010, we had a peak incidence of MALA of 76.8 cases per 100,000 patients on metformin, this rate fell after an education campaign conducted by specialists on the proper usage of metformin in patients at risk of MALA. Although the fall in incidence after the educational program was not necessarily causal, in 2014 the incidence was 32.9/100,000.ConclusionsWe report an improved mortality rate in patients affected with MALA and acute kidney injury treated with SLED compared with other series published in literature. Rapid introduction of effective hemodialysis is critical in improving outcomes.

Lower glucocorticoid receptor gene expression and glucocorticoid receptor variants are associated with cocaine use and addiction

A new dengue vaccine was associated with increased risk of hospitalized virologically-confirmed disease during year 3 of follow-up among children age 2–5 years. Among hypotheses to explain this finding, we could not distinguish definitively between antibody dependent enhancement, waning immunity, or chance occurrence. However, any theory must account for the following: (a) the signal occurred mainly because of decreased dengue among controls rather than increased dengue among vaccinees; (b) among 48 data points, a statistically significant increase in hospitalization among vaccinated children occurred for only one age group, during one year, and in one region; (c) cumulative risk was similar for vaccinated vs. control children age 2–5 years at the end of year 5 and lower for vaccinated vs. control children among older age groups; (d) the protective effect of vaccine against hospitalization decreased from years 1–2 to years 3–5 of follow-up for all age groups and regions.

Dengue vaccine safety signal: Immune enhancement, waning immunity, or chance occurrence?

A new dengue vaccine was associated with increased risk of hospitalized virologically-confirmed disease during year 3 of follow-up among children age 2–5years. Among hypotheses to explain this finding, we could not distinguish definitively between antibody dependent enhancement, waning immunity, or chance occurrence. However, any theory must account for the following: (a) the signal occurred mainly because of decreased dengue among controls rather than increased dengue among vaccinees; (b) among 48 data points, a statistically significant increase in hospitalization among vaccinated children occurred for only one age group, during one year, and in one region; (c) cumulative risk was similar for vaccinated vs. control children age 2–5years at the end of year 5 and lower for vaccinated vs. control children among older age groups; (d) the protective effect of vaccine against hospitalization decreased from years 1–2 to years 3–5 of follow-up for all age groups and regions.

ANTIBACTERIAL THERAPY OF SEPTIC COMPLICATIONS IN RESISTANCE OF PATHOGENS TO CARBAPENEMS

Today, the resistance of Gram-negative bacteria to carbapenems becomes a global problem. Standard regimens of antibiotic treatments are noted to be ineffective in the development of diseases, caused by such pathogens, which resulted in a significant increase in hospital stay duration, cost of treatment and mortality rate. The review of literature describes therapeutic opportunities for treatment of diseases caused by pathogens resistant to carbapenems.

Citalopram dose reductions in response to safety warning increased hospitalization

A group of Department of Veterans Affairs (VA) patients who had their citalopram doses reduced after a federal safety communication about doses exceeding 40 mg/day experienced a significant increase in hospitalizations and deaths compared with patients whose doses were not reduced, a study has found. The study's authors suggested that the Food and Drug Administration's (FDA's) 2011 safety communication appears to have generated unintended clinical consequences. Study results were published online May 10 in the American Journal of Psychiatry.

Substitution and Complementary Effects of Hospitalizations in Jamaica: an Analysis of Spanish Town and Kingston Public Hospitals

Background and purpose: Despite significant medical and public health advances in Jamaica all too often health care planning lacks the flexibility to respond appropriately to the increased and varied demand of the population due to inadequate or inaccurate information. The accuracy of the information is pertinent to forward effective changes in the health care arena, which is instrumental in the coordination of care leading to cost reduction in health care management. This study sought to investigate: 1) Probabilities of hospitalization at two government hospitals in Jamaica; 2) Elasticities of hospitalization between two government hospitals in Jamaica; 3) Response-ability of patient-sharing between two government hospitals in Jamaica; and 4) The dual effect of patient-sharing in two government hospitals in Jamaica. Method: The data for this study were taken from a Jamaica Government Publication, the Ministry of Health, and, admission reports from the Jamaican national mental health public hospital for the 2006-2015 periods. Findings: During the 2011-2015 periods there was a 6.1% increase in hospitalization over two periods for Spanish Town Hospital compared to 14.0% for the Kingston Public Hospital. Although admissions at Kingston Public Hospital have shown signs of trending downwards in the last five years (2011-2015), there was a significant increase in hospitalization primarily due to the Chikungunya virus outbreak in 2014. Furthermore, the Spanish Town Hospital has seen a steady increase in hospitalization in the latter five years (2011-2015) compared to the former five years (2006-2010), with a marginal rise in 2014 over 2013. Conclusion: The study findings suggest that changes in the use of both major hospitals can be attributed to several factors inclusive of changed policy directives and the outbreak of viruses. Whenever there is an increase in patient load, there is a corresponding increase in staff workload, a strain on the already insufficient physical resources and an increase in patient dissatisfaction. More robust planning and collaboration between and across hospitals can therefore help to alleviate some of the issues unearthed by this study. Policy proposals that will have far reaching social and financial impact on the health sector must be bolstered with the necessary infrastructure and supporting policies if institutions are to respond effectively and efficiently to future demands which are as a direct consequence of the policy. The inability to respond to the needs of the patients increases patient dissatisfaction which proves counter-productive to the goals of the policy. To prevent this, decision makers are being urged to collaborate with researchers to project possible scenarios and determine the most effective pathways and processes for optimal care and response–ability by the institutions. Accurate methods of data collection, effective tracking and monitoring tools to enable the sharing of important health information within and across health care institutions are also needed.

Trends of Hospitalizations in the United States from 2000 to 2012 of Patients >60 Years With Aortic Valve Disease

In recent years, there has been an increased emphasis on the diagnosis and treatment of valvular heart disease and, in particular, aortic stenosis. This has been driven in part by the development of innovative therapeutic options and by an aging patient population. We hypothesized an increase in the number of hospitalizations and the economic burden associated with aortic valve disease (AVD). Using Nationwide Inpatient Sample from 2000 to 2012, AVD-related hospitalizations were identified using International Classification of Diseases, Ninth Revision, Clinical Modification, code 424.1, as the principal discharge diagnosis. Overall AVD hospitalizations increased by 59% from 2000 to 2012. This increase was most significant in patients >80 years and those with higher burden of co-morbidities. The most frequent coexisting conditions were hypertension, heart failure, renal failure, anemia, and diabetes. Overall inhospital mortality of patients hospitalized for AVD was 3.8%, which significantly decreased from 4.5% in 2000 to 3.5% in 2012 (p <0.001). The largest decrease in mortality was seen in the subgroup of patients who had heart failure (62% reduction), higher burden of co-morbidities (58% reduction), and who were >80 years (53% reduction). There was a substantial increase in the cost of hospitalization in the last decade from $31,909 to $38,172 (p <0.001). The total annual cost for AVD hospitalization in the United States increased from $1.3 billion in 2001 to $2.1 billion in 2011 and is expected to increase to nearly 3 billion by 2020. The last decade has witnessed a significant increase in hospitalizations for AVD in the United States. The associated decrease in inhospital mortality and increase in the cost of hospitalization have considerably increased the economic burden on the public health system.

Influence of hemodialysis on the plasma concentration of adenosine deaminase in patients with chronic kidney disease

Introduction: Over the past years there has been a significant increase in hospitalizations and treatments due to kidney complications that eventually resulted in the increased number of patients on dialysis. The adenosine deaminase (ADA) enzyme mediates the formation of some defense cells of the organism and is therefore a marker of inflammation. Objective: The objective of this study was to evaluate biomarkers of renal function and serum ADA of hemodialysis patients. Materials and methods: Blood samples were collected from 80 patients – 40 women and 40 men – between 19 and 60 years old, before and after the completion of hemodialysis. Results: There was a significant difference in levels of creatinine, urea and ADA in pre- and post-hemodialysis periods (p < 0.0001). There was a significant increase in post-dialysis ADA regardless of sex; however there was a significantly greater increase in men. Conclusion: The results showed a reduction in urea and creatinine parameters, evidencing the main purpose of hemodialysis. This study suggests that the determination of ADA activity could be used to monitor inflammation in hemodialysis patients, however wider and more specific studies are needed to show the effectiveness of serum ADA activity as an inflammatory marker in patients with chronic kidney disease.

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Introduction: Chylous effusions are a frequent complication after cardiac surgery in children and result in prolonged hospital stay and increase in other associated morbidities such as secondary immune deficiency and nutritional deficiencies. We sought to calculate the incidence and predictors of chylous effusion in children undergoing cardiac surgery at our center. Methods: We reviewed our hospital databases to identify cases with confirmed or suspected chylous effusions after undergoing surgery from January 1, 2009 to December 31st, 2011. Patients with documented chylous effusions in the medical record or those who were maintained on low-fat enteral formula were included as cases. Information on demographics, cardiac diagnosis, intra-operative course, and post-operative outcomes such as length of stay, days of chest tube retention, and infectious complications were collected. Results: During the study period, chylous effusions developed in 88 patients out of 995 who underwent cardiac surgery- an incidence of 9%. Chylous effusions occurred in younger patients (median age 4 days [0.0, 143.0 days- 25th, 75th percentile]) vs. median age of 434days [(59.0, 2697 days] in those with no chylous effusions {p<0.001}. Patients with chylous effusions had more complex cardiac lesions (highest Aristotle Score of 9 [7.0, 10.0] vs. 6.5 [6.0, 8.0]) {[p<0.001} and had longer cardiopulmonary bypass time (71 minutes [0.0, 124.0] vs. 149 minute [75.5, 235.0] {p<0.001}. Patients with chylous effusions had longer length of hospital stay (9.0 days [5.0, 24.8] vs. 64.5 days [30.8, 102.2 days] {p<0.001} and a higher incidence of positive blood, urine, respiratory and wound cultures (p<0.001 for each). A multivariable model shows age and highest Aristotle score to be predictive of development of chylous effusions. Conclusions: There is a significant incidence of chylous effusions in children undergoing cardiac surgery. These effusions are most likely to occur in young patients with more complex cardiac lesions. The occurrence of chylous effusions is associated with a significant increase in hospital stay and infectious complications.

Increased Reticulocytosis during Infancy Is Associated with Increased Hospitalizations in Sickle Cell Anemia Patients during the First Three Years of Life

ObjectiveAmong older children with sickle cell anemia, leukocyte counts, hemoglobin, and reticulocytosis have previously been suggested as disease severity markers. Here we explored whether these blood parameters may be useful to predict early childhood disease severity when tested in early infancy, defined as postnatal ages 60–180 days.Study DesignData from fifty-nine subjects who were followed at Children’s National Medical Center’s Sickle Cell Program for at least three years was retrospectively analyzed. Comparisons were made between white blood cell counts, hemoglobin and reticulocyte levels measured at ages 60–180 days and the clinical course of sickle cell anemia during infancy and childhood.ResultsA majority of subjects had demonstrable anemia with increased reticulocytosis. Only increased absolute reticulocyte levels during early infancy were associated with a significant increase in hospitalization during the first three years of life. Higher absolute reticulocyte counts were also associated with a markedly shorter time to first hospitalizations and a four-fold higher cumulative frequency of clinical manifestations over the first three years of life. No significant increase in white blood cell counts was identified among the infant subjects.ConclusionsThese data suggest that during early infancy, increased reticulocytosis among asymptomatic SCA subjects is associated with increased severity of disease in childhood.

Trends in surgery for upper urinary tract calculi in the USA using the Nationwide Inpatient Sample: 1999–2009

To determine trends in demographics and treatment for inpatient upper urinary tract calculi in the USA using a population-based cohort. All patients with a primary or secondary diagnosis of kidney or ureteric calculus between 1999 and 2009 in the US Nationwide Inpatient Sample were extracted and weighted. Temporal trend analyses were used to determine trends in gender, race and age presentation, as well as utilization rates of interventions. Temporal trends were quantified using the estimated annual percent change (EAPC) using least squares linear regression analysis. Overall, 2 109 455 patients were hospitalized with upper urinary tract calculi over the 11-year period. The majority of admissions were for ureteric calculi (63.4%). Admissions for renal calculus increased by 12.1% during the study period (EAPC + 0.92%, P = 0.039, 95% CI: 0.17-1.66), whilst discharges for ureteric calculus remained stable. A significant increase (25.4%) in hospitalizations for women was found (EAPC + 2.21%, P < 0.001, 95% CI: 1.40-3.03); by 2006, more women than men were admitted to hospital (95 953 vs. 94 556, respectively). There were significant increases in hospitalization for black, Hispanic and older patients. Significant changes in the use of all studied interventions were found except for ureteroscopy, extracorporeal shockwave lithotripsy and nephrectomy. In this nationally representative sample of inpatient discharges, significant increases were found in admissions for renal compared with ureteric calculi, and for black, Hispanic and older patients. With regard to surgical intervention, the largest increase was found in the use of procedures for kidney calculi. Women now comprise the majority in the inpatient management of stone disease.

Kidney Transplantation in the United States: Economic Burden and Recent Trends Analysis

As kidney transplant is the preferred mode of management of advanced kidney disease and economic trends for kidney transplant procedures are not well known, data were analyzed to assess these trends. Annual data for 1998 to 2008 from the Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality were used to analyze characteristics of patients discharged from hospitals in the United States with kidney transplant as the primary procedure. DATA SYNTHESIS/RESULTS: The population more than 65 years old had the most significant increase in hospitalizations for kidney transplant procedures (P< .01). The mean length of stay decreased by 2.8 days over the period studied (P= .02). Mean hospital charge increased despite a decrease in length of stay resulting in a 225% increase in charge per day of hospitalization, from $6907 in 1998 to $22 484 in 2008. The national aggregate hospital charges for kidney transplant procedures rose from $0.9 billion in 1998 to $3.1 billion in 2008. Kidney transplant was overall ranked sixth by mean cost per hospitalization and ranked seventh by mean charge per hospitalization among the Clinical Classification Software's Services and Procedures in this database in 2008. Despite shorter hospital stays, the economic burden of kidney transplants increased from 1998 to 2008.

Acute kidney injury: outcomes and quality of care

Deficiencies in management have been highlighted as contributory factors in the death of many patients with acute kidney injury (AKI). However, there is little evidence addressing the quality of care provided to patients with milder AKI. The aim of this study is to evaluate the quality of care provided to a non-select cohort of patients with AKI and evaluate discrepancies in causation, recognition and management. Retrospective inception cohort study. Demographic data were collected for all 1577 patients admitted to a University Teaching Hospital during a 1-month period. Baseline, admission and peak creatinine were correlated with mortality and length of hospital admission. AKI was classified according to Kidney Disease Improving Global Outcomes criteria. A retrospective case note review of all patients with AKI was carried out to evaluate quality of documentation and clinical management of AKI. Multivariate analysis was undertaken to determine risk factors for AKI. Incidence of AKI on admission was 4.6%. A further 10.3% developed AKI while in hospital. All cause mortality was 4-fold higher among patients with AKI compared with those without (19 vs. 3.8%; P < 0.001). Mortality was significantly higher in those patients who developed AKI while an in-patient compared with those with AKI on admission (27.3 vs. 11.8%; P < 0.001). Diabetes, clinician perception of frailty, age and treatment with angiotensin-converting enzyme inhibitor prior to admission were found to be independent risk factors for AKI. AKI was unrecognized in 23.5% of patients, two-thirds of whom were discharged without resolution of renal function. Significant weaknesses in management were poorly kept fluid balance charts (48.2%), failure to withhold nephrotoxic drugs (38.8%) and failure to act upon abnormal biochemistry (41%) in a timely fashion. AKI is common in hospitalized patients and associated with a significant increase in hospital stay and mortality. AKI is often found in conjunction with other organ failure and in many cases is not preventable. Nevertheless clinicians need to be more vigilant of small creatinine rises to permit early intervention particularly among elderly and frail patients.

Mechanisims of asthma and allergic disease – 1089. The effect of the gender of the fetus on the control of asthma during pregnancy

Background Studies suggest that the presence of a female fetus worsen maternal asthma by up regulating maternal inflammatory pathways. Unlike the presence of a male fetus that produces a flow of testosterone during the second trimester which is considered a protective factor against asthma. The secretion of testosterone influences b-adrenergicmediated relaxation of bronchial tissues and obstructs response to histamine, resulting in better improvement in asthma symptoms. Methods 476 pregnant women with physician-diagnosed asthma were enrolled during the first trimester of pregnancy and were followed up with a series of controlled maternal interviews throughout the pregnancy. The interviews assessed the level of asthma control using a 5-point scale. All medical records including information on hospitalization and unscheduled clinic visits for asthma since the last menstrual period were collected. Results A higher proportion of women carrying a girl had poor asthma symptom control during the first part of pregnancy (24.1%) compared with asthmatic women carrying a boy (11.6%; p =0 .003). There was almost no difference noticed in the asthma symptom control during the second or third trimesters between women carrying a female fetus versus womwn carrying a male fetus. female-bearing pregnancy was associated with a significant increase in hospitalizations for asthma exacerbations (22.6%) compared with male-bearing pregnancy (8.8%; p =0 .01). Also the presence of a female fetus was associated with a higher incidence of unscheduled asthma visits during pregnancy (p=0.041). Conclusions In conclusion, this study illustrated that the presence of a female fetus might increase asthma exacerbations during pregnancy compared to that of a male fetus. This evidence was supported by the number of unscheduled visits and hospitalizations in comparison to that in the case of a male fetus. However, the biological mechanism which could possibly defend the influence of fetal gender on the control of maternal asthma remains unstipulated. In this study we also noted the importance of early assessment and careful monitoring of all asthmatic pregnant women beside the major role of health education and environmental control when dealing with an asthmatic patient.

Association of partial adherence (PA) to antiretroviral therapy with hospitalizations and healthcare costs in an HIV population

PurposeOne intrinsic feature of once daily single tablet regimens (STR) in HIV treatment is to prevent missing part of a multi-drug regimen (i.e., partial adherence [PA]). We explored the frequency of PA among HIV patients (pts) treated with multi-pill protease inhibitor (PI), raltegravir (RAL), and non-nucleoside reverse transcriptase inhibitor (NNRTI) regimens and associations with hospitalizations and costs.MethodsWe analyzed healthcare claims from a US Medicaid population. Patients with an HIV diagnosis from 1/09 to 12/11 receiving complete ART (2 NRTIs plus a NNRTI, PI, or RAL) for ≥90 days as a STR or 2+ tablets daily were selected. Adherence and costs were observed from initiation until discontinuation of the entire regimen, switching third component classes, or database end. Adherence was reported as the percent of days (from pharmacy refill data) having a complete regimen, PA, or no medication. A logistic model assessed predictors of hospitalizations and a generalized linear model assessed healthcare costs with covariates for PA and complete non-adherence (CNA), third component, demographics, and prior ART use.ResultsN=1,878 STR, 729 RAL, 3,556 PI, and 775 NNRTI pts. CNA was similar across cohorts: 14.3% (46.4 days[d]) for STR, 14.0% (40.8 d) for RAL, 15.5% (53.0 d) for PI, and 13.5% (51.7 d) for multi pill NNRTI regimens. PA was seen in 12.1% (39.7 d) for RAL, 6.9% (31.7 d) for NNRTI, and 6.6% (26.7 d) for PI regimens. Thus, pts on STR had the highest percent of days (85.7%) with complete adherence to their regimen, vs. pts on multi pill RAL (73.9%), PI (77.9%), and NNRTI (79.6%) regimens. Likelihood of hospitalization significantly increased with both PA and CNA. Compared to <10 days of PA, the risk of hospitalization significantly increased (all p<0.05) with degree of incomplete adherence. For 20–30 days, the odds ratio [OR] was 1.34 for PA, and 1.45 for CNA. The OR was 1.74 for PA and 2.00 for >50 days CNA. Adjusted monthly healthcare costs were significantly greater for patients who were partially adherent for >5% of days (mean [SD] $5,108 [$1,315]) vs. ≤5% of days ($3,602[$894]).ConclusionsPatients on multi pill PI, RAL, and NNRTI regimens had significantly lower complete adherence vs. STR users, mainly due to PA to a multi-pill regimens. PA and CNA to multi-pill PI, RAL, and NNRTI regimens are independently associated with a significant increase in hospitalizations and healthcare cost.

Expanding the Armamentarium Against Respiratory Viral Infections: DAS181

Respiratory viral infections result in significant morbidity and mortality in adults and children globally. Influenza, alone, is responsible for seasonal epidemics resulting in 3–5 million severe infections and 250 000–500 00 deaths per year [1]. Additionally, influenza results in milder infections which significantly reduce productivity among otherwise healthy adults, resulting in approximately $26.7 billion in direct and indirect costs annually [2]. During the recent influenza A(H1N1) pandemic, influenza was associated with a significant increase in hospitalizations, particularly among individuals <65 years of age and those without co-morbidities, as compared with what is seen in interpandemic years [3]. Furthermore, the pandemic was associated with 284 400 (range, 151 700–575 400) excess deaths [4]. Data from randomized, placebo-controlled studies have documented that antiviral therapy with neuraminidase inhibitors (oseltamivir and zanamivir) and M2 inhibitors (amantadine and rimantadine) reduce the duration of illness attributable to influenza, speed clearance of virus from the host, and reduce infectious and noninfectious complications among otherwise healthy ambulatory adults and children [5, 6]. Furthermore, data from several retrospective studies prior to and during the pandemic consistently demonstrated that antiviral therapy, typically with oral oseltamivir, for adults hospitalized with influenza is associated with more rapid improvement in clinical symptoms, return to usual activity, clearance of viral shedding, and reduction in overall mortality; some studies have also shown a shorter duration of hospitalization and reduced progression to pneumonia and critical illness [7]. Unfortunately, development of antiviral resistance has significantly limited our options in the treatment of influenza. Early after the introduction of M2 inhibitors to clinical practice, emergence of resistance during therapy, as the result of mutations in 1 of 5 commonly recognized sites in the M2 gene, occurred frequently. More recently, M2 resistant variants of influenza A(H3N2) emerged and became established within the viruses circulating globally; in addition, the pandemic influenza A(H1N1) virus, which replaced the seasonal influenza A(H1N1) virus worldwide, is resistant to M2 inhibitors [8]. As a result, most guidelines now recommend against the use of M2 inhibitors for the prevention and treatment of influenza [9]. Resistance to the neuraminidase inhibitors may occur as the result of mutations in the neuraminidase gene, the hemagglutinin gene, or both [10]. Group 1 neuraminidases appear to be more susceptible to the development of oseltamivir resistance, as was seen with the global emergence of oseltamivir resistance in the previous seasonal influenza A(H1N1) virus in 2008–2009 [10]. Given our current reliance on neuraminidases for the management of influenza, oseltamivir resistance emerging globally in the background of M2 inhibitor resistance would greatly limit our options for treatment of influenza. As such, antiviral agents with novel mechanisms of action are clearly needed. DAS181 is a novel antiviral that consists of a sialidase from Actinomyces viscosus attached to a respiratory epitheliumanchoring domain that is critical for enhancing the efficacy and prolonging retention within the respiratory tract [11]. The drug cleaves the terminal sialic acid residues from the surface of human respiratory epithelial cells, thereby reducing the binding and, therefore, infectivity of influenza A and B viruses as well as parainfluenza viruses (PIV) [11]. Desialyation occurs rapidly and results in an inhibitory effect that lasts, ex vivo, for at least 2 days [11]. In addition, DAS181 appears to be potent against seasonal influenza A and B viruses, the 2009 pandemic influenza A(H1N1) virus, avian influenza A(H5N1) virus, and PIV types Received 27 August 2012; accepted 31 August 2012; electronically published 8 October 2012. Correspondence: Michael G. Ison, MD, MS, FIDSA, Divisions of Infectious Diseases, 645 N. Michigan Avenue Suite 900, Chicago, Illinois 60611, United States (mgison@ northwestern.edu). The Journal of Infectious Diseases 2012;206:1806–8 © The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com. DOI: 10.1093/infdis/jis623

Temporal trends in pre-surgical evaluations and epilepsy surgery in the U.S. from 1998 to 2009

To analyze trends in utilization of pre-surgical evaluations including video-EEG (VEEG) monitoring, intracranial EEG (IEEG) monitoring, and epilepsy surgery from 1998 to 2009 in the U.S. Data from the Nationwide Inpatient Sample were used to identify admissions for pre-surgical evaluations and surgery. Surgical treatment of epilepsy was identified by the presence of primary ICD-9-CM procedure codes 01.52 (hemispherectomy), 01.53 (lobectomy), or 01.59 (other excision of the brain, including amygdalohippocampectomy). We calculated annual rates of pre-surgical evaluations and surgery based on published estimates of prevalence of epilepsy in the U.S. In addition, we examined variations by region and hospital characteristics, and conducted multivariable analysis to detect temporal trends, adjusting for changes in the population. Sensitivity analysis was also conducted using different algorithms to identify the study population and outcomes. We detected an increase in the rate of hospitalizations related to intractable epilepsy. Similarly, we noted a significant increase in hospitalizations for VEEG monitoring, but not in IEEG monitoring or in surgery. Multivariable analysis and sensitivity analysis confirmed these results. In addition, there was a significant increase in the proportion of pre-surgical evaluations and surgery performed in non-teaching hospitals. Despite the increase in VEEG monitoring, the availability of guideline and evidences demonstrating benefits of epilepsy surgery was not associated with a greater employment of surgery over time. Nevertheless, access to pre-surgical evaluations and epilepsy surgery is no longer limited to large medical centers.

The post-pericardiotomy syndrome

The postpericardiotomy syndrome (PPS) is a relatively common complication following cardiac surgery, whose epidemiology is not well known because there are no standardized definitions. The aim of the present study is to review more recent updates on the diagnosis, therapy, prognosis, and especially prevention of the PPS. Recent studies suggest that it is time to develop standardized criteria for the diagnosis of the PPS to allow early recognition and treatment. Limited knowledge is still available on the pathogenesis of the syndrome, but it is now clear that the presumptive immune-mediated origin is not able to explain all cases. Treatment is largely empirical and based on antiinflammatory drugs either nonsteroidal or corticosteroids with the possible adjunct of colchicine, that has been demonstrated as a promising well tolerated and efficacious means to prevent several postoperative complications, including the PPS, pericardial and pleural effusions, and atrial fibrillation. Contemporary series of the PPS are scarce. About 20% of patients are affected by the syndrome after cardiac surgery with a significant increase in hospital stay, readmissions, and management costs. The overall short-term and middle-term prognosis is relatively good but constriction may develop in a long-term follow-up in a minority of patients. Therapeutic and preventive strategies, especially based on the use of colchicine, are worthy of further investigations to develop a more evidence-based approach to treatment and prevention.