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A pilot mobile integrated healthcare program for frequent utilizers of emergency department services

Hao Wang, MD - Sat, 05/13/2017 - 05:00

Am J Emerg Med. 2017 Nov;35(11):1702-1705. doi: 10.1016/j.ajem.2017.04.061. Epub 2017 Apr 27.

ABSTRACT

PURPOSE: To examine whether or not a mobile integrated health (MIH) program may improve health-related quality of life while reducing emergency department (ED) transports, ED admissions, and inpatient hospital admissions in frequent utilizers of ED services.

METHODS: A small retrospective evaluation assessing pre- and post-program quality of life, ED transports, ED admissions, and inpatient hospital admissions was conducted in patients who frequently used the ED for non-emergent or emergent/primary care treatable conditions.

RESULTS: Pre- and post-program data available on 64 program completers are reported. Of those with mobility problems (n=42), 38% improved; those with problems performing usual activities (N=45), 58% reported improvement; and of those experiencing moderate to extreme pain or discomfort (N=48), 42% reported no pain or discomfort after program completion. Frequency of ED transports decreased (5.34±6.0 vs. 2.08±3.3; p <0.000), as did ED admissions (9.66±10.2 vs. 3.30±4.6; p<0.000), and inpatient hospital admissions (3.11±5.5 vs. 1.38±2.5; p=0.003).

CONCLUSION: Results suggest that MIH participation is associated with improved quality of life, reduced ED transports, ED admissions, and inpatient hospital admissions. The MIH program may have potential to improve health outcomes in patients who are frequent ED users for non-emergent or emergent/primary care treatable conditions by teaching them how to proactively manage their health and adhere to therapeutic regimens. Programmatic reasons for these improvements may include psychosocial bonding with participants who received in-home care, health coaching, and the MIH team's 24/7 availability that provided immediate healthcare access.

PMID:28495031 | DOI:10.1016/j.ajem.2017.04.061

A Case-and-Control, Multisite, Positive Controlled, Prospective Study of the Safety and Effectiveness of Immediate Inferior Alveolar Nerve Processed Nerve Allograft Reconstruction With Ablation of the Mandible for Benign Pathology

Fayette C. Williams, DDS, MD, FACS - Sat, 05/13/2017 - 05:00

J Oral Maxillofac Surg. 2017 Dec;75(12):2669-2681. doi: 10.1016/j.joms.2017.04.002. Epub 2017 Apr 13.

ABSTRACT

PURPOSE: This study determined whether immediate reconstruction of the inferior alveolar nerve with a long (>4.5 cm) processed nerve allograft (PNA) in conjunction with simultaneous ablation and reconstruction of the mandible would be effective in safely restoring subjective sensation and achieving functional sensory recovery.

MATERIALS AND METHODS: Patients (5 to 70 yr old) requiring resection of the unilateral or bilateral mandible for benign pathology were included. The graft had to be longer than 4.5 cm. Results of sensory nerve tests and 3 different surveys (Direct Path, Numerical Rating Scale, Word Choice) were collected before surgery and at 3, 6, and 12 months after surgery. Safety data were recorded.

RESULTS: Twenty-six patients participated in this study. Three patients served as positive controls (no nerve repair). Five in the repair group and 1 in the positive control group were lost to follow-up. Data during a 1-year period were collected on 18 patients (7 male and 11 female; mean age, 26.4 yr; range, 10 to 64 yr). The mean length of the PNA was 62.7 mm (range, 45 to 70 mm). Seventeen of 18 patients had S4 sensory scores preoperatively and the postoperative score was S4 at 3 months in 3, at 6 months in 3, and at 1 year in 12. Scores for positive control patients never exceeded S2. Numerical rating scales and word choices were not statistically different from presurgical scores at 6 and 12 months. There were no adverse events.

CONCLUSIONS: The PNA is safe and effective when immediately inserted with resection and reconstruction of the mandible: 90% of patients achieved functional sensory recovery and reported similar sensations to preoperative subjective values.

PMID:28495410 | DOI:10.1016/j.joms.2017.04.002

Response to "Re-Thinking the Definition of Complicated Intra-Abdominal Infection"

Jeffrey Tessier, MD - Tue, 04/11/2017 - 05:00

Surg Infect (Larchmt). 2017 Apr;18(3):375-376. doi: 10.1089/sur.2017.057.

NO ABSTRACT

PMID:28394744 | DOI:10.1089/sur.2017.057

Traumatic Abdominal Solid Organ Injury Patients Might Benefit From Thromboelastography-Guided Blood Component Therapy

Richard Robinson, MD - Tue, 04/11/2017 - 05:00

J Clin Med Res. 2017 May;9(5):433-438. doi: 10.14740/jocmr3005w. Epub 2017 Apr 1.

ABSTRACT

BACKGROUND: Thromboelastography (TEG) has been utilized for the guidance of blood component therapy (BCT). We aimed to investigate the association between emergent TEG-guided BCT and clinical outcomes in patients with traumatic abdominal solid organ (liver and/or spleen) injuries.

METHODS: A single center retrospective study of patients who sustained traumatic liver and/or spleen injuries receiving emergent BCT was conducted. TEG was ordered in all these patients. Patient demographics, general injury information, outcomes, BCT, and TEG parameters were analyzed and compared in patients receiving TEG-guided BCT versus those without.

RESULTS: A total of 166 patients were enrolled, of whom 52% (86/166) received TEG-guided BCT. A mortality of 12% was noted among patients with TEG-guided BCT when compared with 19% of mortality in patients with non-TEG-guided BCT (P > 0.05). An average of 4 units of packed red blood cell (PRBC) was received in patients with TEG-guided BCT when compared to an average of 9 units of PRBC received in non-TEG-guided BCT patients (P < 0.01). A longer hospital length of stay (LOS, 19 ± 16 days) was found among non-TEG-guided BCT patients when compared to the TEG-guided BCT group (14 ± 12 days, P < 0.05). TEG-guided BCT showed as an independent factor associated with hospital LOS after other variables were adjusted (coefficiency: 5.44, 95% confidence interval: 0.69 - 10.18).

CONCLUSIONS: Traumatic abdominal solid organ injury patients receiving blood transfusions might benefit from TEG-guided BCT as indicated by less blood products needed and less hospitalization stay among the cohort.

PMID:28392864 | PMC:PMC5380177 | DOI:10.14740/jocmr3005w

Traumatic Abdominal Solid Organ Injury Patients Might Benefit From Thromboelastography-Guided Blood Component Therapy

Hao Wang, MD - Tue, 04/11/2017 - 05:00

J Clin Med Res. 2017 May;9(5):433-438. doi: 10.14740/jocmr3005w. Epub 2017 Apr 1.

ABSTRACT

BACKGROUND: Thromboelastography (TEG) has been utilized for the guidance of blood component therapy (BCT). We aimed to investigate the association between emergent TEG-guided BCT and clinical outcomes in patients with traumatic abdominal solid organ (liver and/or spleen) injuries.

METHODS: A single center retrospective study of patients who sustained traumatic liver and/or spleen injuries receiving emergent BCT was conducted. TEG was ordered in all these patients. Patient demographics, general injury information, outcomes, BCT, and TEG parameters were analyzed and compared in patients receiving TEG-guided BCT versus those without.

RESULTS: A total of 166 patients were enrolled, of whom 52% (86/166) received TEG-guided BCT. A mortality of 12% was noted among patients with TEG-guided BCT when compared with 19% of mortality in patients with non-TEG-guided BCT (P > 0.05). An average of 4 units of packed red blood cell (PRBC) was received in patients with TEG-guided BCT when compared to an average of 9 units of PRBC received in non-TEG-guided BCT patients (P < 0.01). A longer hospital length of stay (LOS, 19 ± 16 days) was found among non-TEG-guided BCT patients when compared to the TEG-guided BCT group (14 ± 12 days, P < 0.05). TEG-guided BCT showed as an independent factor associated with hospital LOS after other variables were adjusted (coefficiency: 5.44, 95% confidence interval: 0.69 - 10.18).

CONCLUSIONS: Traumatic abdominal solid organ injury patients receiving blood transfusions might benefit from TEG-guided BCT as indicated by less blood products needed and less hospitalization stay among the cohort.

PMID:28392864 | PMC:PMC5380177 | DOI:10.14740/jocmr3005w

Metastatic endometrial carcinoma invading bilateral total knee arthroplasties

Hugo Sanchez, MD - Thu, 03/23/2017 - 05:00

Arthroplast Today. 2015 Jun 23;1(2):31-35. doi: 10.1016/j.artd.2015.04.001. eCollection 2015 Jun.

ABSTRACT

We present a case of a 64-year old female with bilateral knee pain several months after undergoing staged bilateral TKA. Radiolucencies surrounding the keels of bilateral tibial components were found to represent metastatic poorly differentiated endometrial carcinoma. PET scan showed adrenal, pulmonary and tibial foci consistent with metastatic disease. No other cases of bilateral periprosthetic metastasis of endometrial carcinoma have been described in the literature. Metastases around orthopedic implants are a rare occurrence. The possibility of periprosthetic metastasis should remain in the differential diagnosis for any patient with a painful total joint arthroplasty, especially in the setting of a patient with a known diagnosis of cancer elsewhere in their body.

PMID:28326366 | PMC:PMC4926824 | DOI:10.1016/j.artd.2015.04.001

The Challenges of Measuring, Improving, and Reporting Quality in Primary Care

Richard Young, MD - Wed, 03/15/2017 - 05:00

Ann Fam Med. 2017 Mar;15(2):175-182. doi: 10.1370/afm.2014.

ABSTRACT

We propose a new set of priorities for quality management in primary care, acknowledging that payers and regulators likely will continue to insist on reporting numerical quality metrics. Primary care practices have been described as complex adaptive systems. Traditional quality improvement processes applied to linear mechanical systems, such as isolated single-disease care, are inappropriate for nonlinear, complex adaptive systems, such as primary care, because of differences in care processes, outcome goals, and the validity of summative quality scorecards. Our priorities for primary care quality management include patient-centered reporting; quality goals not based on rigid targets; metrics that capture avoidance of excessive testing or treatment; attributes of primary care associated with better outcomes and lower costs; less emphasis on patient satisfaction scores; patient-centered outcomes, such as days of avoidable disability; and peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.

PMID:28289120 | PMC:PMC5348238 | DOI:10.1370/afm.2014

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

Jeffrey Tessier, MD - Sat, 01/14/2017 - 05:00

Surg Infect (Larchmt). 2017 Jan;18(1):1-76. doi: 10.1089/sur.2016.261.

ABSTRACT

BACKGROUND: Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

METHODS: Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

RESULTS: This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

SUMMARY: The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

PMID:28085573 | DOI:10.1089/sur.2016.261

Maternity Care Services Provided by Family Physicians in Rural Hospitals

Richard Young, MD - Sun, 01/08/2017 - 05:00

J Am Board Fam Med. 2017 Jan 2;30(1):71-77. doi: 10.3122/jabfm.2017.01.160072.

ABSTRACT

BACKGROUND: The purpose of this study was to describe how many rural family physicians (FPs) and other types of providers currently provide maternity care services, and the requirements to obtain privileges.

METHODS: Chief executive officers of rural hospitals were purposively sampled in 15 geographically diverse states with significant rural areas in 2013 to 2014. Questions were asked about the provision of maternity care services, the physicians who perform them, and qualifications required to obtain maternity care privileges. Analysis used descriptive statistics, with comparisons between the states, community rurality, and hospital size.

RESULTS: The overall response rate was 51.2% (437/854). Among all identified hospitals, 44.9% provided maternity care services, which varied considerably by state (range, 17-83%; P < .001). In hospitals providing maternity care, a mean of 271 babies were delivered per year, 27% by cesarean delivery. A mean of 7.0 FPs had privileges in these hospitals, of which 2.8 provided maternity care and 1.8 performed cesarean deliveries. The percentage of FPs who provide maternity care (mean, 48%; range, 10-69%; P < .001), the percentage of FPs who do cesarean deliveries (mean, 66%; range, 0-100%; P < .001), and the percentage of all physicians who provide maternity care who are FPs (mean, 63%; range, 10-88%; P < .001) varied widely by state. Most hospitals (83%) had no firm numbers of procedures required to obtain privileges.

CONCLUSIONS: FPs continue to provide the majority of maternity care services in US rural hospitals, including cesarean deliveries. Some family medicine residencies should continue to train their residents to provide these services to keep replenishing this valuable workforce.

PMID:28062819 | DOI:10.3122/jabfm.2017.01.160072

Age and Its Impact on Outcomes with Intra-Abdominal Infection

Jeffrey Tessier, MD - Fri, 12/23/2016 - 05:00

Surg Infect (Larchmt). 2017 Feb/Mar;18(2):77-82. doi: 10.1089/sur.2016.184. Epub 2016 Dec 22.

ABSTRACT

BACKGROUND: Age has been shown to play a significant role in the etiology of complicated intra-abdominal infections (cIAIs), but the correlation between age and outcomes after therapy was not investigated in the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial.

PATIENTS AND METHODS: Data were obtained by post hoc analysis of the STOP-IT trial database. Patients were stratified by age <65 or ≥65 years. Primary outcomes were surgical site infection (SSI), recurrent IAI (recIAI), and death. Multivariable analysis was performed to identify independent predictors of outcomes.

RESULTS: There were 398 subjects <65 and 120 ≥ 65 years. Overall baseline characteristics of the two groups were similar. The site of infection was similar between groups except: Colon or rectum (48.3% vs. 29.9%, p = 0.0002) and biliary tree (16.7% vs. 9.1%, p = 0.02), which were more common in the older group, whereas small intestine (6.7% vs. 16.3%, p = 0.008) and appendix (4.2% vs.17.1%, p = 0.0004) were more common in the younger group. Among the primary outcomes, only death was significantly different between the age groups and was more prevalent in the ≥65 years group (4 [3.3%] vs. 1 [0.3%], p = 0.01). Surgical site infection (9.2% vs. 7.3%, p = 0.50), recIAI (15.8% vs. 14.4%, p = 0.69), and a composite outcome (26.7% vs. 20.4%, p = 0.14) were statistically similar between the age groups, and this remained true when controlling for other co-variables. Multivariable analyses did not reveal age as an independent predictor of the composite or individual outcomes.

CONCLUSION: Patients with a more advanced age demonstrated variable sources of infection relative to the younger cohort, yet received similar treatments. Patient age was not an independent predictor of the undesired cIAI outcomes. These findings suggest that advanced age itself does not play a significant role in predicting these adverse outcomes for cIAIs and does not necessitate an altered treatment tactic.

PMID:28005468 | DOI:10.1089/sur.2016.184

Lifelong Physical Activity Regardless of Dose Is Not Associated With Myocardial Fibrosis

Paul Bhella - Fri, 12/02/2016 - 05:00

Circ Cardiovasc Imaging. 2016 Nov;9(11):e005511. doi: 10.1161/CIRCIMAGING.116.005511.

ABSTRACT

BACKGROUND: Recent reports have suggested that long-term, intensive physical training may be associated with adverse cardiovascular effects, including the development of myocardial fibrosis. However, the dose-response association of different levels of lifelong physical activity on myocardial fibrosis has not been evaluated.

METHODS AND RESULTS: Seniors free of major chronic illnesses were recruited from predefined populations based on the consistent documentation of stable physical activity over >25 years and were classified into 4 groups by the number of sessions/week of aerobic activities ≥30 minutes: sedentary (group 1), <2 sessions; casual (group 2), 2 to 3 sessions; committed (group 3), 4 to 5 sessions; and Masters athletes (group 4), 6 to 7 sessions plus regular competitions. All subjects underwent cardiopulmonary exercise testing and cardiac magnetic resonance imaging, including late gadolinium enhancement assessment of fibrosis. Ninety-two subjects (mean age 69 years, 27% women) were enrolled. No significant differences in age or sex were seen between groups. Median peak oxygen uptake was 25, 26, 32, and 40 mL/kg/min for groups 1, 2, 3, and 4, respectively. Cardiac magnetic resonance imaging demonstrated increasing left ventricular end-diastolic volumes, end-systolic volumes, stroke volumes, and masses with increasing doses of lifelong physical activity. One subject in group 2 had late gadolinium enhancement in a noncoronary distribution, and no subjects in groups 3 and 4 had evidence of late gadolinium enhancement.

CONCLUSIONS: A lifelong history of consistent physical activity, regardless of dose ranging from sedentary to competitive marathon running, was not associated with the development of focal myocardial fibrosis.

PMID:27903541 | PMC:PMC5137797 | DOI:10.1161/CIRCIMAGING.116.005511

Chest Pain Risk Scores Can Reduce Emergent Cardiac Imaging Test Needs With Low Major Adverse Cardiac Events Occurrence in an Emergency Department Observation Unit

Richard Robinson, MD - Wed, 11/16/2016 - 05:00

Crit Pathw Cardiol. 2016 Dec;15(4):145-151. doi: 10.1097/HPC.0000000000000090.

ABSTRACT

OBJECTIVE: To compare and evaluate the performance of the HEART, Global Registry of Acute Coronary Events (GRACE), and Thrombolysis in Myocardial Infarction (TIMI) scores to predict major adverse cardiac event (MACE) rates after index placement in an emergency department observation unit (EDOU) and to determine the need for observation unit initiation of emergent cardiac imaging tests, that is, noninvasive cardiac stress tests and invasive coronary angiography.

METHODS: A prospective observational single center study was conducted from January 2014 through June 2015. EDOU chest pain patients were included. HEART, GRACE, and TIMI scores were categorized as low (HEART ≤ 3, GRACE ≤ 108, and TIMI ≤1) versus elevated based on thresholds suggested in prior studies. Patients were followed for 6 months postdischarge. The results of emergent cardiac imaging tests, EDOU length of stay (LOS), and MACE occurrences were compared. Student t test was used to compare groups with continuous data, and χ testing was used for categorical data analysis.

RESULTS: Of 986 patients, emergent cardiac imaging tests were performed on 62%. A majority of patients were scored as low risk by all tools (85% by HEART, 81% by GRACE, and 80% by TIMI, P < 0.05). The low-risk patients had few abnormal cardiac imaging test results as compared with patients scored as intermediate to high risk (1% vs. 11% in HEART, 1% vs. 9% in TIMI, and 2% vs. 4% in GRACE, P < 0.05). The average LOS was 33 hours for patients with emergent cardiac imaging tests performed and 25 hours for patients without (P < 0.05). MACE occurrence rate demonstrated no significant difference regardless of whether tests were performed emergently (0.31% vs. 0.97% in HEART, 0.27% vs. 0.95% in TIMI, and 0% vs. 0.81% in GRACE, P > 0.05).

CONCLUSIONS: Chest pain risk stratification via clinical decision tool scores can minimize the need for emergent cardiac imaging tests with less than 1% MACE occurrence, especially when the HEART score is used.

PMID:27846006 | DOI:10.1097/HPC.0000000000000090

Chest Pain Risk Scores Can Reduce Emergent Cardiac Imaging Test Needs With Low Major Adverse Cardiac Events Occurrence in an Emergency Department Observation Unit

Hao Wang, MD - Wed, 11/16/2016 - 05:00

Crit Pathw Cardiol. 2016 Dec;15(4):145-151. doi: 10.1097/HPC.0000000000000090.

ABSTRACT

OBJECTIVE: To compare and evaluate the performance of the HEART, Global Registry of Acute Coronary Events (GRACE), and Thrombolysis in Myocardial Infarction (TIMI) scores to predict major adverse cardiac event (MACE) rates after index placement in an emergency department observation unit (EDOU) and to determine the need for observation unit initiation of emergent cardiac imaging tests, that is, noninvasive cardiac stress tests and invasive coronary angiography.

METHODS: A prospective observational single center study was conducted from January 2014 through June 2015. EDOU chest pain patients were included. HEART, GRACE, and TIMI scores were categorized as low (HEART ≤ 3, GRACE ≤ 108, and TIMI ≤1) versus elevated based on thresholds suggested in prior studies. Patients were followed for 6 months postdischarge. The results of emergent cardiac imaging tests, EDOU length of stay (LOS), and MACE occurrences were compared. Student t test was used to compare groups with continuous data, and χ testing was used for categorical data analysis.

RESULTS: Of 986 patients, emergent cardiac imaging tests were performed on 62%. A majority of patients were scored as low risk by all tools (85% by HEART, 81% by GRACE, and 80% by TIMI, P < 0.05). The low-risk patients had few abnormal cardiac imaging test results as compared with patients scored as intermediate to high risk (1% vs. 11% in HEART, 1% vs. 9% in TIMI, and 2% vs. 4% in GRACE, P < 0.05). The average LOS was 33 hours for patients with emergent cardiac imaging tests performed and 25 hours for patients without (P < 0.05). MACE occurrence rate demonstrated no significant difference regardless of whether tests were performed emergently (0.31% vs. 0.97% in HEART, 0.27% vs. 0.95% in TIMI, and 0% vs. 0.81% in GRACE, P > 0.05).

CONCLUSIONS: Chest pain risk stratification via clinical decision tool scores can minimize the need for emergent cardiac imaging tests with less than 1% MACE occurrence, especially when the HEART score is used.

PMID:27846006 | DOI:10.1097/HPC.0000000000000090

Antimicrobial Stewardship: A Call to Action for Surgeons

Jeffrey Tessier, MD - Thu, 11/10/2016 - 05:00

Surg Infect (Larchmt). 2016 Dec;17(6):625-631. doi: 10.1089/sur.2016.187. Epub 2016 Nov 9.

ABSTRACT

Despite current antimicrobial stewardship programs (ASPs) being advocated by infectious disease specialists and discussed by national and international policy makers, ASPs coverage remains limited to only certain hospitals as well as specific service lines within hospitals. The ASPs incorporate a variety of strategies to optimize antimicrobial agent use in the hospital, yet the exact set of interventions essential to ASP success remains unknown. Promotion of ASPs across clinical practice is crucial to their success to ensure standardization of antimicrobial agent use within an institution. To effectively accomplish this standardization, providers who actively engage in antimicrobial agent prescribing should participate in the establishment and support of these programs. Hence, surgeons need to play a major role in these collaborations. Surgeons must be aware that judicious antibiotic utilization is an integral part of any stewardship program and necessary to maximize clinical cure and minimize emergence of antimicrobial resistance. The battle against antibiotic resistance should be fought by all healthcare professionals. If surgeons around the world participate in this global fight and demonstrate awareness of the major problem of antimicrobial resistance, they will be pivotal leaders. If surgeons fail to actively engage and use antibiotics judiciously, they will find themselves deprived of the autonomy to treat their patients.

PMID:27828764 | PMC:PMC5124748 | DOI:10.1089/sur.2016.187

Roles of disease severity and post-discharge outpatient visits as predictors of hospital readmissions

Richard Robinson, MD - Wed, 10/12/2016 - 05:00

BMC Health Serv Res. 2016 Oct 10;16(1):564. doi: 10.1186/s12913-016-1814-7.

ABSTRACT

BACKGROUND: Risks prediction models of 30-day all-cause hospital readmissions are multi-factorial. Severity of illness (SOI) and risk of mortality (ROM) categorized by All Patient Refined Diagnosis Related Groups (APR-DRG) seem to predict hospital readmission but lack large sample validation. Effects of risk reduction interventions including providing post-discharge outpatient visits remain uncertain. We aim to determine the accuracy of using SOI and ROM to predict readmission and further investigate the role of outpatient visits in association with hospital readmission.

METHODS: Hospital readmission data were reviewed retrospectively from September 2012 through June 2015. Patient demographics and clinical variables including insurance type, homeless status, substance abuse, psychiatric problems, length of stay, SOI, ROM, ICD-10 diagnoses and medications prescribed at discharge, and prescription ratio at discharge (number of medications prescribed divided by number of ICD-10 diagnoses) were analyzed using logistic regression. Relationships among SOI, type of hospital visits, time between hospital visits, and readmissions were also investigated.

RESULTS: A total of 6011 readmissions occurred from 55,532 index admissions. The adjusted odds ratios of SOI and ROM predicting readmissions were 1.31 (SOI: 95 % CI 1.25-1.38) and 1.09 (ROM: 95 % CI 1.05-1.14) separately. Ninety percent (5381/6011) of patients were readmitted from the Emergency Department (ED) or Urgent Care Center (UCC). Average time interval from index discharge date to ED/UCC visit was 9 days in both the no readmission and readmission groups (p > 0.05). Similar hospital readmission rates were noted during the first 10 days from index discharge regardless of whether post-index discharge patient clinic visits occurred when time-to-event analysis was performed.

CONCLUSIONS: SOI and ROM significantly predict hospital readmission risk in general. Most readmissions occurred among patients presenting for ED/UCC visits after index discharge. Simply providing early post-discharge follow-up clinic visits does not seem to prevent hospital readmissions.

PMID:27724889 | PMC:PMC5057382 | DOI:10.1186/s12913-016-1814-7

Roles of disease severity and post-discharge outpatient visits as predictors of hospital readmissions

Hao Wang, MD - Wed, 10/12/2016 - 05:00

BMC Health Serv Res. 2016 Oct 10;16(1):564. doi: 10.1186/s12913-016-1814-7.

ABSTRACT

BACKGROUND: Risks prediction models of 30-day all-cause hospital readmissions are multi-factorial. Severity of illness (SOI) and risk of mortality (ROM) categorized by All Patient Refined Diagnosis Related Groups (APR-DRG) seem to predict hospital readmission but lack large sample validation. Effects of risk reduction interventions including providing post-discharge outpatient visits remain uncertain. We aim to determine the accuracy of using SOI and ROM to predict readmission and further investigate the role of outpatient visits in association with hospital readmission.

METHODS: Hospital readmission data were reviewed retrospectively from September 2012 through June 2015. Patient demographics and clinical variables including insurance type, homeless status, substance abuse, psychiatric problems, length of stay, SOI, ROM, ICD-10 diagnoses and medications prescribed at discharge, and prescription ratio at discharge (number of medications prescribed divided by number of ICD-10 diagnoses) were analyzed using logistic regression. Relationships among SOI, type of hospital visits, time between hospital visits, and readmissions were also investigated.

RESULTS: A total of 6011 readmissions occurred from 55,532 index admissions. The adjusted odds ratios of SOI and ROM predicting readmissions were 1.31 (SOI: 95 % CI 1.25-1.38) and 1.09 (ROM: 95 % CI 1.05-1.14) separately. Ninety percent (5381/6011) of patients were readmitted from the Emergency Department (ED) or Urgent Care Center (UCC). Average time interval from index discharge date to ED/UCC visit was 9 days in both the no readmission and readmission groups (p > 0.05). Similar hospital readmission rates were noted during the first 10 days from index discharge regardless of whether post-index discharge patient clinic visits occurred when time-to-event analysis was performed.

CONCLUSIONS: SOI and ROM significantly predict hospital readmission risk in general. Most readmissions occurred among patients presenting for ED/UCC visits after index discharge. Simply providing early post-discharge follow-up clinic visits does not seem to prevent hospital readmissions.

PMID:27724889 | PMC:PMC5057382 | DOI:10.1186/s12913-016-1814-7

Heart Failure: Exercise-Based Cardiac Rehabilitation: Who, When, and How Intense?

Paul Bhella - Tue, 10/04/2016 - 05:00

Can J Cardiol. 2016 Oct;32(10 Suppl 2):S382-S387. doi: 10.1016/j.cjca.2016.06.001. Epub 2016 Jun 6.

ABSTRACT

The primary chronic symptom in patients with clinically stable heart failure (HF) is reduced exercise tolerance, measured as decreased peak aerobic power (peak oxygen consumption [Vo2]), and is associated with reduced quality of life and survival. Exercise-based cardiac rehabilitation (EBCR) is a safe and effective intervention to improve peak Vo2, muscle strength, physical functional performance, and quality of life and is associated with a reduction in overall and HF-specific hospitalization in clinically stable patients with HF. Despite these salient benefits, fewer than one-tenth of eligible patients with HF are referred for EBCR after hospitalization. In this review, selection for and timing of EBCR for patients with HF, as well as exercise prescription guidelines with special emphasis on the optimal exercise training intensity to improve peak Vo2, are discussed.

PMID:27692119 | DOI:10.1016/j.cjca.2016.06.001

Prophylactic Gentamicin Is Not Associated with Acute Kidney Injury in Patients with Open Fractures

Jeffrey Tessier, MD - Tue, 08/09/2016 - 05:00

Surg Infect (Larchmt). 2016 Dec;17(6):720-723. doi: 10.1089/sur.2015.086. Epub 2016 Aug 8.

ABSTRACT

BACKGROUND: Data on antimicrobial prophylaxis for open fractures is limited, with many protocols based on expert recommendations. These protocols include aminoglycosides (AGs) for fractures with significant soft tissue injury, but these drugs are associated with acute kidney injury (AKI) in other settings; this risk has not been defined for open fracture prophylaxis.

METHODS: We performed a retrospective study from May 2012 to October 2014 at our Level 1 trauma center. Patients with open fractures were evaluated for demographics, location/type of fracture, injury severity, and receipt of an AG. Outcomes included rates of AKI, infection, and mortality.

RESULTS: There were 167 patients with open fractures during the study period (119 males, mean age 42 ± 17 [standard deviation] years), with 80 (48%) receiving prophylactic gentamicin (AG+ group). The AG+ and AG- patients had similar fracture sites and Injury Severity Scores (ISSs) (12.6 ± 9.9 AG+ vs. 15.9 ± 13.2 AG-) but were more likely to have sustained blunt trauma (96% AG+ vs. 77%; p < 0.001) or received intravenous contrast medium ≤48 h from admission (75% AG+ vs. 56% AG-; p = 0.01). Gentamicin was not associated with AKI (odds ratio [OR] 0.22; 95% confidence interval [CI] 0.020-2.44; p = 0.22), whereas hypotension on admission (OR 10.7; 95% CI 1.42-80.93; p = 0.02) and ISS (OR 1.1; 95% CI 1.01-1.20; p = 0.02) were both associated with AKI. Only four fracture site infections were identified, three in the AG+ group and one in the AG- group (3.8% vs. 1.1%; p = 0.27). The mortality rate was greater in the AG- group (3.8% vs. 12.6%; p = 0.04).

CONCLUSIONS: Prophylactic gentamicin is not associated with AKI, whereas hypotension on admission and higher ISS were. The use of nephrotoxic agents, including aminoglycosides, should be restricted in open fracture patients presenting with hypotension or a high ISS.

PMID:27500970 | DOI:10.1089/sur.2015.086

Inclusion of Vancomycin as Part of Broad-Spectrum Coverage Does Not Improve Outcomes in Patients with Intra-Abdominal Infections: A Post Hoc Analysis

Jeffrey Tessier, MD - Wed, 08/03/2016 - 05:00

Surg Infect (Larchmt). 2016 Dec;17(6):694-699. doi: 10.1089/sur.2016.095. Epub 2016 Aug 2.

ABSTRACT

BACKGROUND: Management of complicated intra-abdominal infections (cIAIs) includes broad-spectrum antimicrobial coverage and commonly includes vancomycin for the empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA). Ideally, culture-guided de-escalation follows to promote robust antimicrobial stewardship. This study assessed the impact and necessity of vancomycin in cIAI treatment regimens.

PATIENTS AND METHODS: A post hoc analysis of the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial was performed. Patients receiving piperacillin-tazobactam (P/T) and/or a carbapenem were included with categorization based on use of vancomycin. Univariate and multivariable analyses evaluated effects of including vancomycin on individual and the composite of undesirable outcomes (recurrent IAI, surgical site infection [SSI], or death).

RESULTS: The study cohort included 344 patients with 110 (32%) patients receiving vancomycin. Isolation of MRSA occurred in only eight (2.3%) patients. Vancomycin use was associated with a similar composite outcome, 29.1%, vs. no vancomycin, 22.2% (p = 0.17). Patients receiving vancomycin had (mean [standard deviation]) higher Acute Physiology and Chronic Health Evaluation II scores (13.1 [6.6] vs. 9.4 [5.7], p < 0.0001), extended length of stay (12.6 [10.2] vs. 8.6 [8.0] d, p < 0.001), and prolonged antibiotic courses (9.1 [8.0] vs. 7.1 [4.9] d, p = 0.02). After risk adjustment in a multivariate model, no significant difference existed for the measured outcomes.

CONCLUSIONS: This post hoc analysis reveals that addition of vancomycin occurred in nearly one third of patients and more often in sicker patients. Despite this selection bias, no appreciable differences in undesired outcomes were demonstrated, suggesting limited utility for adding vancomycin to cIAI treatment regimens.

PMID:27483362 | DOI:10.1089/sur.2016.095

A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients

Richard Robinson, MD - Tue, 07/19/2016 - 05:00

J Clin Med Res. 2016 Aug;8(8):591-7. doi: 10.14740/jocmr2598w. Epub 2016 Jul 1.

ABSTRACT

BACKGROUND: There is no existing adequate blood transfusion needs determination tool that Emergency Medical Services (EMS) personnel can use for prehospital blood transfusion initiation. In this study, a simple and pragmatic prehospital blood transfusion needs scoring system was derived and validated.

METHODS: Local trauma registry data were reviewed retrospectively from 2004 through 2013. Patients were randomly assigned to derivation and validation cohorts. Multivariate logistic regression was used to identify the independent approachable risks associated with early blood transfusion needs in the derivation cohort in which a scoring system was derived. Sensitivity, specificity, and area under the receiver operational characteristic (AUC) were calculated and compared using both the derivation and validation data.

RESULTS: A total of 24,303 patients were included with 12,151 patients in the derivation and 12,152 patients in the validation cohorts. Age, penetrating injury, heart rate, systolic blood pressure, and Glasgow coma scale (GCS) were risks predictive of early blood transfusion needs. An early blood transfusion needs score was derived. A score > 5 indicated risk of early blood transfusion need with a sensitivity of 83% and a specificity of 80%. A sensitivity of 82% and a specificity of 80% were also found in the validation study and their AUC showed no statistically significant difference (AUC of the derivation = 0.87 versus AUC of the validation = 0.86, P > 0.05).

CONCLUSIONS: An early blood transfusion scoring system was derived and internally validated to predict severe trauma patients requiring blood transfusion during prehospital or initial emergency department resuscitation.

PMID:27429680 | PMC:PMC4931805 | DOI:10.14740/jocmr2598w

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