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CONTEXTE: Les caracteristiques des patients, les soins cliniques, l'utilisation des ressources et les issues cliniques des personnes atteintes de la maladie a coronavirus 2019 (COVID-19) hospitalisees au Canada ne sont pas bien connus. METHODES: Nous avons recueilli des donnees sur tous les adultes hospitalises atteints de la COVID-19 ou de l'influenza ayant obtenu leur conge d'unites medicales ou d'unites de soins intensifs medicaux et chirurgicaux entre le 1er novembre 2019 et le 30 juin 2020 dans 7 centres hospitaliers de Toronto et de Mississauga (Ontario). Nous avons compare les issues cliniques des patients a l'aide de modeles de regression multivariee, en tenant compte des facteurs sociodemographiques et de l'intensite des comorbidites. Nous avons valide le degre d'exactitude de 7 scores de risque mis au point a l'externe pour determiner leur capacite a predire le risque de deces chez les patients atteints de la COVID-19. RESULTATS: Parmi les hospitalisations retenues, 1027 patients etaient atteints de la COVID-19 (age median de 65 ans, 59,1% d'hommes) et 783 etaient atteints de l'influenza (age median de 68 ans, 50,8% d'hommes). Les patients ages de moins de 50 ans comptaient pour 21,2% de toutes les hospitalisations dues a la COVID-19 et 24,0% des sejours aux soins intensifs. Com pa rativement aux patients atteints de l'influenza, les patients atteints de la COVID-19 presentaient un taux de mortalite perhospitaliere (mortalite non ajustee 19,9% c. 6,1%; risque relatif [RR] ajuste 3,46%, intervalle de confiance [IC] a 95% 2,56-4,68) et un taux d'utilisation des ressources des unites de soins intensifs (taux non ajuste 26,4% c. 18,0%; RR ajuste 1,50, IC a 95% 1,25-1,80) significativemen t plus eleves, ainsi qu'une duree d'hospitalisation (duree mediane non ajustee 8,7 jours c. 4,8 jours; rapport des taux d'incidence ajuste 1,45; IC a 95% 1,25-1,69) significativement plus longue. Le taux de rehospitalisation dans les 30 jours n'etait pas significativement different (taux non ajuste 9,3% c. 9,6%; RR ajuste 0,98%, IC a 95% 0,70-1,39). Trois scores de risque utilisant un pointage pour predire la mortalite perhospitaliere ont montre une bonne discrimination (aire sous la courbe [ASC] de la fonction d'efficacite du recepteur [ROC] 0,72-0,81) et une bonne calibration. INTERPRETATION: Durant la premiere vague de la pandemie, l'hospitalisation des patients atteints de la COVID-19 etait associee a des taux de mortalite et d'utilisation des ressources des unites de soins intensifs et a une duree d'hospitalisation significativement plus importants que les hospitalisations des patients atteints de l'influenza. De simples scores de risque peuvent predire avec une bonne exactitude le risque de mortalite perhospitaliere des patients atteints de la COVID-19., Des etudes internationales ont rapporte que les patients hospitalises en raison de la maladie a coronavirus 2019 (COVID-19) presentaient des taux eleves de maladie grave et de mortalite (1-5). Deux [...]

The COVID-19 pandemic has revealed weaknesses in global manufacturing and distribution of medications, exacerbating many pre-existing limitations and inequities in drug supply and creating new shortages. (1-3) Supply chains have [...]

BACKGROUND: Patient characteristics, clinical care, resource use and outcomes associated with admission to hospital for coronavirus disease 2019 (COVID-19) in Canada are not well described. METHODS: We described all adults with COVID-19 or influenza discharged from inpatient medical services and medical-surgical intensive care units (ICUs) between Nov. 1, 2019, and June 30, 2020, at 7 hospitals in Toronto and Mississauga, Ontario. We compared patient outcomes using multivariable regression models, controlling for patient sociodemographic factors and comorbidity level. We validated the accuracy of 7 externally developed risk scores to predict mortality among patients with COVID-19. RESULTS: There were 1027 hospital admissions with COVID-19 (median age 65 yr, 59.1% male) and 783 with influenza (median age 68 yr, 50.8% male). Patients younger than 50 years accounted for 21.2% of all admissions for COVID-19 and 24.0% of ICU admissions. Compared with influenza, patients with COVID-19 had significantly greater in-hospital mortality (unadjusted 19.9% v. 6.1%, adjusted relative risk [RR] 3.46, 95% confidence interval [CI] 2.56-4.68), ICU use (unadjusted 26.4% v. 18.0%, adjusted RR 1.50, 95% CI 1.25-1.80) and hospital length of stay (unadjusted median 8.7 d v. 4.8 d, adjusted rate ratio 1.45, 95% CI 1.25-1.69). Thirty-day readmission was not significantly different (unadjusted 9.3% v. 9.6%, adjusted RR 0.98, 95% CI 0.70-1.39). Three points-based risk scores for predicting in-hospital mortality showed good discrimination (area under the receiver operating characteristic curve [AUC] ranging from 0.72 to 0.81) and calibration. INTERPRETATION: During the first wave of the pandemic, admission to hospital for COVID-19 was associated with significantly greater mortality, ICU use and hospital length of stay than influenza. Simple risk scores can predict in-hospital mortality in patients with COVID-19 with good accuracy., International studies report that patients admitted to hospital with coronavirus disease 2019 (COVID-19) have high rates of critical illness and mortality. (1-5) Two small Canadian case series have described care [...]

BACKGROUND: Timely follow-up after hospital discharge may decrease readmission to hospital. Financial incentives to improve follow-up have been introduced in the United States and Canada, but it is unknown whether they are effective. Our objective was to evaluate the impact of an incentive program on timely physician follow-up after hospital discharge. METHODS: We conducted an interventional time series analysis of all medical and surgical patients who were discharged home from hospital between Apr. 1, 2002, and Jan. 30, 2015, in Ontario, Canada. The intervention was a supplemental billing code for physician follow-up within 14 days of discharge from hospital, introduced in 2006. The primary outcome was an outpatient visit within 14 days of discharge. Secondary outcomes were 7-day follow-up and a composite of emergency department visits, nonelective hospital readmission and death within 14 days. RESULTS: We included 8 008934 patient discharge records. The incentive code was claimed in 31% of eligible visits by 51% of eligible physicians, and cost $17.5 million over the study period. There was no change in the average monthly rate of outcomes in the year before the incentive was introduced compared with the year following introduction: 14-day follow-up (66.5% v. 67.0%, overall p = 0.5), 7-day follow-up (44.9% v. 44.9%, overall p = 0.5) and composite outcome (16.7% v. 16.9%, overall p = 0.2). INTERPRETATION: Despite uptake by physicians, a financial incentive did not alter follow-up after hospital discharge. This lack of effect may be explained by features of the incentive or by extra-physician barriers to follow-up. These barriers should be considered by policymakers before introducing similar initiatives., Readmissions after hospital discharge are common, occurring for about 14% of patients in the United States at 30 days after discharge and costing $41 billion annually. (1) How much hospital [...]

IMPORTANCE: Recognizing and preventing patient deterioration is important for hospital safety. OBJECTIVE: To investigate whether critical illness events (in-hospital death or intensive care unit [ICU] transfer) are associated with greater risk of subsequent critical illness events for other patients on the same medical ward. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study in 5 hospitals in Toronto, Canada, including 118 529 hospitalizations. Patients were admitted to general internal medicine wards between April 1, 2010, and October 31, 2017. Data were analyzed between January 1, 2020, and April 10, 2023. EXPOSURES: Critical illness events (in-hospital death or ICU transfer). MAIN OUTCOMES AND MEASURES: The primary outcome was the composite of in-hospital death or ICU transfer. The association between critical illness events on the same ward across 6-hour intervals was studied using discrete-time survival analysis, adjusting for patient and situational factors. The association between critical illness events on different comparable wards in the same hospital was measured as a negative control. RESULTS: The cohort included 118 529 hospitalizations (median age, 72 years [IQR, 56-83 years]; 50.7% male). Death or ICU transfer occurred in 8785 hospitalizations (7.4%). Patients were more likely to experience the primary outcome after exposure to 1 prior event (adjusted odds ratio [AOR], 1.39; 95% CI, 1.30-1.48) and more than 1 prior event (AOR, 1.49; 95% CI, 1.33-1.68) in the prior 6-hour interval compared with no exposure. The exposure was associated with increased odds of subsequent ICU transfer (1 event: AOR, 1.67; 95% CI, 1.54-1.81; >1 event: AOR, 2.05; 95% CI, 1.79-2.36) but not death alone (1 event: AOR, 1.08; 95% CI, 0.97-1.19; >1 event: AOR, 0.88; 95% CI, 0.71-1.09). There was no significant association between critical illness events on different wards within the same hospital. CONCLUSIONS AND RELEVANCE: Findings of this cohort study suggest that patients are more likely to be transferred to the ICU in the hours after another patient’s critical illness event on the same ward. This phenomenon could have several explanations, including increased recognition of critical illness and preemptive ICU transfers, resource diversion to the first event, or fluctuations in ward or ICU capacity. Patient safety may be improved by better understanding the clustering of ICU transfers on medical wards.

IMPORTANCE: People who survive hospitalization for COVID-19 are at risk for developing new cardiovascular, neurological, mental health, and inflammatory autoimmune conditions. It is unclear how posthospitalization risks for COVID-19 compare with those for other serious infectious illnesses. OBJECTIVE: To compare risks of incident cardiovascular, neurological, and mental health conditions and rheumatoid arthritis in 1 year following COVID-19 hospitalization against 3 comparator groups: prepandemic hospitalization for influenza and hospitalization for sepsis before and during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study included all adults hospitalized for COVID-19 between April 1, 2020, and October 31, 2021, historical comparator groups of people hospitalized for influenza or sepsis, and a contemporary comparator group of people hospitalized for sepsis in Ontario, Canada. EXPOSURE: Hospitalization for COVID-19, influenza, or sepsis. MAIN OUTCOME AND MEASURES: New occurrence of 13 prespecified conditions, including cardiovascular, neurological, and mental health conditions and rheumatoid arthritis, within 1 year of hospitalization. RESULTS: Of 379 366 included adults (median [IQR] age, 75 [63-85] years; 54% female), there were 26 499 people who survived hospitalization for COVID-19, 299 989 historical controls (17 516 for influenza and 282 473 for sepsis), and 52 878 contemporary controls hospitalized for sepsis. Hospitalization for COVID-19 was associated with an increased 1-year risk of venous thromboembolic disease compared with influenza (adjusted hazard ratio, 1.77; 95% CI, 1.36-2.31) but with no increased risks of developing selected ischemic and nonischemic cerebrovascular and cardiovascular disorders, neurological disorders, rheumatoid arthritis, or mental health conditions compared with influenza or sepsis cohorts. CONCLUSIONS AND RELEVANCE: In this cohort study, apart from an elevated risk of venous thromboembolism within 1 year, the burden of postacute medical and mental health conditions among those who survived hospitalization for COVID-19 was comparable with other acute infectious illnesses. This suggests that many of the postacute consequences of COVID-19 may be related to the severity of infectious illness necessitating hospitalization rather than being direct consequences of infection with SARS-CoV-2.

Objectives: In summer 2021, the number of COVID-19–associated hospitalizations in the United States increased with the surge of the SARS-CoV-2 Delta variant. We assessed how COVID-19 vaccine initiation and dose completion changed during the Delta variant surge, based on jurisdictional vaccination coverage before the surge.Methods: We analyzed COVID-19 vaccination data reported to the Centers for Disease Control and Prevention. We classified jurisdictions (50 states and the District of Columbia) into quartiles ranging from high to low first-dose vaccination coverage among people aged ≥12 years as of June 30, 2021. We calculated first-dose vaccination coverage as of June 30 and October 31, 2021, and stratified coverage by quartile, age (12-17, 18-64, ≥65 years), and sex. We assessed dose completion among those who initiated a 2-dose vaccine series.Results: Of 51 jurisdictions, 15 reached at least 70% vaccination coverage before the Delta variant surge (ie, as of June 30, 2021), while 35 reached that goal as of October 31, 2021. Jurisdictions in the lowest quartile of vaccination coverage (44.9%-54.9%) had the greatest absolute (9.7%-17.9%) and relative (18.1%-39.8%) percentage increase in vaccination coverage during July 1–October 31, 2021. Of those who received the first dose during this period across all jurisdictions, nearly 1 in 5 missed the second dose.Conclusions: Although COVID-19 vaccination initiation increased during July 1–October 31, 2021, in jurisdictions in the lowest quartile of vaccination coverage, coverage remained below that of jurisdictions in the highest quartile of vaccination coverage before the Delta variant surge. Efforts are needed to improve access to and increase confidence in COVID-19 vaccines, especially in low-coverage areas.

What is the cost of an adverse event? This question, which now underpins many quality improvement efforts, initially interested only medical tort litigators and their clients. In 1991, the Harvard [...]

Universal immune receptors represent a rapidly emerging form of adoptive T-cell therapy with the potential to overcome safety and antigen escape challenges faced by conventional chimeric antigen receptor (CAR) T-cell therapy. By decoupling antigen recognition and T-cell signaling domains via bifunctional antigen-specific targeting ligands, universal immune receptors can regulate T-cell effector function and target multiple antigens with a single receptor. Here, we describe the development of the SpyCatcher immune receptor, the first universal immune receptor that allows for the post-translational covalent attachment of targeting ligands at the T-cell surface through the application of SpyCatcher-SpyTag chemistry. The SpyCatcher immune receptor redirected primary human T cells against a variety of tumor antigens via the addition of SpyTag-labeled targeting ligands, both in vitro and in vivo. SpyCatcher T-cell activity relied upon the presence of both target antigen and SpyTag-labeled targeting ligand, allowing for dose-dependent control of function. The mutational disruption of covalent bond formation between the receptor and the targeting ligand still permitted redirected T-cell function but significantly compromised antitumor function. Thus, the SpyCatcher immune receptor allows for rapid antigen-specific receptor assembly, multiantigen targeting, and controllable T-cell activity.

BACKGROUND:Transthoracic echocardiography is routinely performed in patients with stroke or transient ischemic attack (TIA) to help plan secondary stroke management, but recent data evaluating its usefulness in this context are lacking. We sought to evaluate the value of echocardiography for identifying clinically actionable findings for secondary stroke prevention.METHODS:We conducted a multicentre cohort study of patients admitted to hospital with stroke or TIA between 2010 and 2015 at 2 academic hospitals in Toronto, Ontario, Canada. Clinically actionable echocardiographic findings for secondary stroke prevention included cardiac thrombus, patent foramen ovale, atrial myxoma or valvular vegetation. We identified patient characteristics associated with clinically actionable findings using logistic regression.RESULTS:Of the 1862 patients with stroke or TIA we identified, 1272 (68%) had at least 1 echocardiogram. Nearly all echocardiograms were transthoracic; 1097 (86%) were normal, 1 (0.08%) had an atrial myxoma, 2 (0.2%) had a valvular vegetation, 11 (0.9%) had a cardiac thrombus and 66 (5.2%) had a PFO. Patent foramen ovale was less likely among patients older than 60 years (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.20–0.57), with prior stroke or TIA (adjusted OR 0.31, 95% CI 0.09–0.76) or with dyslipidemia (adjusted OR 0.39, 95% CI 0.15–0.84). Among the 130 patients with cryptogenic stroke who had an echocardiogram (n= 110), a PFO was detected in 19 (17%) on transthoracic echocardiogram.INTERPRETATION:Most patients with stroke or TIA had a normal echocardiogram, with few having clinically actionable findings for secondary stroke prevention. Clinically actionable findings, specifically PFO, were more common in patients with cryptogenic stroke.

IMPORTANCE: Trauma of hospitalization refers to the depersonalizing and stressful experience of a hospital admission and is hypothesized to increase the risk of readmission after discharge. OBJECTIVES: To characterize the trauma of hospitalization by measuring patient-reported disturbances in sleep, mobility, nutrition, and mood among medical inpatients, and to examine the association between these disturbances and the risk of unplanned return to hospital after discharge. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study enrolled participants between September 1, 2016, and September 1, 2017, at 2 academic hospitals in Toronto, Canada. Participants were adults admitted to the internal medicine ward for more than 48 hours. Participants were interviewed before discharge using a standardized questionnaire to assess sleep, mobility, nutrition, and mood. Responses for each domain were dichotomized as disturbance or no disturbance. Disturbance in 3 or 4 domains (the upper tertile) was considered high trauma of hospitalization, and disturbance in 0 to 2 domains (the lower 2 tertiles) was considered low trauma. MAIN OUTCOME AND MEASURES: The primary outcome was readmission or emergency department visit within 30 days of discharge. The association between trauma of hospitalization and the primary outcome was examined using logistic regression, adjusted for age; sex; length of stay; Charlson Comorbidity Index Score; Laboratory-Based Acute Physiology Score; and baseline disturbances in sleep, mobility, nutrition, and mood. RESULTS: A total of 207 patients participated, of whom 82 (39.6%) were women and 125 (60.4%) were men, with a mean (SD) age of 60.3 (16.8) years. Among the 207 participants, 75 (36.2%) reported sleep disturbance, 162 (78.3%) reported mobility disturbance, 114 (55.1%) reported nutrition disturbance, and 48 (23.2%) reported mood disturbance. Nearly all participants (192 [92.8%]) described a disturbance in at least 1 domain, and 61 participants (29.5%) had high trauma exposure. A statistically significant 15.8% greater absolute risk of readmission or emergency department visit was found in participants with high trauma (37.7%; 95% CI, 25.9%-51.1%) compared with those with low trauma (21.9%; 95% CI, 15.7%-29.7%), which remained statistically significant after adjusting for baseline characteristics (adjusted odds ratio, 2.52; 95% CI, 1.24-5.17; P = .01) and propensity score matching (odds ratio, 2.47; 95% CI, 1.11-5.73; P = .03). CONCLUSIONS AND RELEVANCE: Disturbances in sleep, mobility, nutrition, and mood were common in medical inpatients; such trauma of hospitalization may be associated with a greater risk of 30-day readmission or emergency department visit after hospital discharge.

AbstractObjectivesLong bone fractures (LBFs) are among the most frequent traumatic injuries seen in emergency departments. Reduction and immobilization is the most common form of treatment for displaced fractures. Point-of-care ultrasound (PoCUS) is a promising technique for diagnosing LBFs and assessing the success of reduction attempts. This article offers a comprehensive review of the use of PoCUS for the diagnosis and reduction of LBFs.Data sourceMEDLINE and EMBASE databases were searched through July 19, 2015.Study selectionWe included prospective studies that assessed test characteristics of PoCUS in 1) the diagnosis or 2) the reduction of LBFs. The methodological quality of the included studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.Data extractionThirty studies met inclusion criteria (n=3,506; overall fracture rate 48.0%). Test characteristics of PoCUS for the diagnosis of LBFs were as follows: sensitivity 64.7%–100%, specificity 79.2%–100%, positive likelihood ratio (LR) 3.11–infinity, and negative LR zero–0.45. Sensitivity and specificity for the adequate reduction of LBFs with PoCUS were 94%–100% and 56%–100%, respectively. PoCUS diagnosis of pediatric forearm fractures in 10 studies showed a pooled sensitivity of 93.1% (95% confidence interval [CI], 87.2%–96.4%) and specificity of 92.9% (95% CI, 86.6%–96.4%), and PoCUS diagnosis of adult ankle fractures in four studies showed a pooled sensitivity of 89.5% (95% CI, 77.0%–95.6%) and specificity of 94.2% (95% CI, 86.1%–97.7%).ConclusionPoCUS demonstrates good diagnostic accuracy in all LBFs studied, especially in pooled results of diagnosis of pediatric forearm and adult ankle fractures. PoCUS is an appropriate adjunct to plain radiographs for LBFs.

Diabetes has been reported to be associated with an increased risk of death among patients with COVID-19. However, available studies lack detail on COVID illness severity and measurement of relevant comorbidities.

Why psychiatrists choose a particular dose of antipsychotic for an individual patient with schizophrenia is unknown. This study aimed to investigate consultant psychiatrists' perspectives on the dose titration and their attitudes towards therapeutic drug monitoring (TDM) for antipsychotics.

Peripheral T-cell lymphomas (PTCLs) are a heterogeneous group of lymphoid malignancies associated with poor prognosis due to ineffective treatment options and high rates of relapse. The success of chimeric antigen receptor T-cell (CART) therapy for certain hematologic malignancies makes it an attractive treatment option for PTCLs. However, shared expression of potential target antigens by both malignant and healthy T cells poses a challenge. Current prospective CART approaches cause a high degree of on-target, off-tumor activity, resulting in fratricide during CART expansion, depletion of healthy T cells in vivo, and immune compromise in the patient. To limit off-tumor targeting, we sought to develop a CART platform specific for a given T-cell receptor vβ (TCRvβ) family that would endow CAR-modified T cells with the ability to mediate lysis of the clonal malignant population while preserving the majority of healthy T cells. Here, CAR constructs specific for multiple TCRvβ family members were designed and validated. Our results demonstrate that TCRvβ-family–specific CARTs (TCRvβ-CARTs) recognize and kill TCRvβ-expressing target cells. This includes specific self-depletion of the targeted cell subpopulation in the CART product and lysis of cell lines engineered to express a target TCRvβ family. Furthermore, TCRvβ-CARTs eliminated the dominant malignant TCRvβ clone in 2 patient samples. Finally, in immunodeficient mice, TCRvβ-CARTs eradicated malignant cells in a TCRvβ-dependent manner. Importantly, the nontargeted TCRvβ families were spared in all cases. Thus, TCRvβ-CART therapy provides a potential option for high-precision treatment of PTCL with limited healthy T-cell depletion.

Schuster: Novartis, Genentech, Inc./ F. Hoffmann-La Roche: Research Funding; AlloGene, AstraZeneca, BeiGene, Genentech, Inc./ F. Hoffmann-La Roche, Juno/Celgene, Loxo Oncology, Nordic Nanovector, Novartis, Tessa Therapeutics: Consultancy, Honoraria.

Background Certain sociodemographic subgroups of HIV-infected patients may experience more chronic disease than others due to behavioural risk factors, advanced HIV disease or complications from extended use of combination antiretroviral therapy (cART), but recent comparative data are limited.Methods We studied HIV-infected adult patients in care during 2006–2010 who had been prescribed =6 months of cART. We analysed the prevalence of selected key chronic conditions and polymorbidity (having 2 or more out of 10 key conditions) by gender and race/ethnicity.Results Of the 3,166 HIV-infected patients (median age 47 years, CD4+T-cell count 496 cells/mm3, duration of cART use 6.8 years), 21% were female, 57% were non-Hispanic White and over half were current or former tobacco smokers. The five most frequent conditions among women (median age 45 years) were dyslipidaemia (67.3%), hypertension (57.4%), obesity (31.7%), viral hepatitis B or C coinfection (29.0%) and low high-density lipoprotein cholesterol (HDLc; 27.3%). The five most frequent conditions in men (median age 47 years) were dyslipidaemia (81.2%), hypertension (54.4%), low HDLc (41.1%), elevated triglycerides (32.3%) and elevated non-HDLc (26.8%). In multivariable analyses, Hispanic patients had higher prevalence of obesity and diabetes than White patients; Black patients had higher prevalence of obesity and hypertension but lower rates of lipid abnormalities. Of all patients, 73.7% of women and 66.8% of men had polymorbidity, with no evidence of disparities by race/ethnicity.Conclusions Among contemporary cART-treated HIV-infected adults, chronic conditions and polymorbidity were common, underscoring the importance of chronic disease prevention and management among ageing HIV-infected patients.

ObjectiveTo determine whether patients discharged from hospital during the December holiday period have fewer outpatient follow-ups and higher rates of death or readmission than patients discharged at other times.DesignPopulation based retrospective cohort study.SettingAcute care hospitals in Ontario, Canada, 1 April 2002 to 31 January 2016.Participants217 305 children and adults discharged home after an urgent admission, during the two week December holiday period, compared with 453 641 children and adults discharged during two control periods in late November and January.Main outcome measuresThe primary outcome was death or readmission, defined as a visit to an emergency department or urgent rehospitalisation, within 30 days. Secondary outcomes were death or readmission and outpatient follow-up with a physician within seven and 14 days after discharge. Multivariable logistic regression with generalised estimating equations was used to adjust for characteristics of patients, admissions, and hospital.Results217 305 (32.4%) patients discharged during the holiday period and 453 641 (67.6%) discharged during control periods had similar baseline characteristics and previous healthcare utilisation. Patients who were discharged during the holiday period were less likely to have follow-up with a physician within seven days (36.3% v47.8%, adjusted odds ratio 0.61, 95% confidence interval 0.60 to 0.62) and 14 days (59.5% v68.7%, 0.65, 0.64 to 0.66) after discharge. Patients discharged during the holiday period were also at higher risk of 30 day death or readmission (25.9% v24.7%, 1.09, 1.07 to 1.10). This relative increase was also seen at seven days (13.2% v11.7%, 1.16, 1.14 to 1.18) and 14 days (18.6% v17.0%, 1.14, 1.12 to 1.15). Per 100 000 patients, there were 2999 fewer follow-up appointments within 14 days, 26 excess deaths, 188 excess hospital admissions, and 483 excess emergency department visits attributable to hospital discharge during the holiday period.ConclusionsPatients discharged from hospital during the December holiday period are less likely to have prompt outpatient follow-up and are at higher risk of death or readmission within 30 days.

Several letters to the editor are presented in response to various topics including the match between France and Italy in the Six Nations rugby football tournament, the disappointment of fans about the postponement of the game between France and Ireland and the job of a coach in rugby football.

Several letters to the editor are presented in response to articles published in previous issues, including "Kevin Hart's Funny Business," by Jonah Weiner, "The Point of No Return," by Eric Holthaus, and "Yemen's Hidden War," by Matthieu Aikins.