Search

Purpose: The advent of laparoscopy has revolutionized surgical practice within the last 30 years. Conversion to open surgery, however, remains necessary at times, even for the most experienced laparoscopic surgeon., Methods: The kids' inpatient database was analyzed for 2006, 2009, and 2012 for patients who underwent laparoscopic appendectomy and conversion to open (CPT 470.1 and V64.41, respectively). Variables included in multivariable analysis were determined based on those variables found to have significance on univariate analysis., Results: A total of 104,865 patients, ages 0-17 years, underwent laparoscopic appendectomy during the three study periods. Of these, 2370 (2.2%) laparoscopic surgeries were converted to open appendectomy. Multivariable logistic regression showed significantly higher rates of conversion amongst patients with peritonitis (OR 6.7, p < 0.001) or abscess (OR 14.3, p < 0.001), obesity (OR 2.02, p < 0.001), age > 13 years (OR 1.53 for ages 13-15, OR 1.77 for ages 16-17, p < 0.001 for both), or cared for at rural hospitals (OR 1.55, p = 0.002). Rates of conversion decreased over time for children at adult hospitals and at urban hospitals, regardless of teaching status (p < 0.001 for both)., Conclusion: Risk factors for conversion from laparoscopic to open appendectomy included abscess, peritonitis, increased age, obesity, male gender, socioeconomic status and treatment at a non-pediatric-specific hospital, and the overall rate is decreasing over time.

Objectives: High ambient temperatures are associated with significant health risk in the United States. The risk to children has been minimally explored, and often young children are considered as a single age group despite marked physiologic and social variation among this population from infancy through preschool. This study explored the heterogeneity of risk of heat among young children., Study Design: Using a time-stratified, case-crossover design, we evaluated associations between maximum daily temperature (Tmax) and ED visits (n = 1,002,951) to New York City (NYC) metropolitan area hospitals for children aged 0-4 years in May-September, 2005-2011., Methods: Conditional logistic regression analysis estimated risks for an interquartile range of Tmax for 0-6 lag days. Stratified analyses explored age strata by year, race/ethnic groups, and diagnostic codes. Sensitivity analyses controlled for same day ambient ozone, particulate matter <2.5 microns, and relative humidity and, separately, explored race groups without ethnicity and different diagnostic code groupings., Results: Children ages 0-4 years had increased risk of emergency department visits with increased Tmax on lag days 0, 1, and 3. The association was strongest on lag day 0, when an increase in Tmax of 13 °F conferred an excess risk of 2.6% (95% confidence interval [CI]: 2.2-3.0). Stratifying by age, we observed significant positive associations for same-day exposures, for 1-4 year olds. Children less than 1 year of age showed a significant positive association with Tmax only on lag day 3. The race/ethnicity stratified analysis revealed a similar lag pattern for all subgroups. The diagnostic group analysis showed percent excess risk for heat-specific diagnoses (16.6% [95% CI: 3.0-31.9]); general symptoms (10.1% [95% CI: 8.2-11.9]); infectious (4.9% [95% CI: 3.9-5.9]); and injury (5.1% [95% CI: 3.8-6.4]) diagnoses., Conclusion: We found a significant risk of ED visits in young children with elevated Tmax. Risk patterns vary based on age with infants showing delayed risk and toddlers and preschoolers with same day risk. In addition, the finding of increased risk of injury associated with higher temperatures is novel. Altogether, these findings suggest a need for a tailored public health response, such as different messages to caregivers of different age children, to protect children from the effects of heat. Next steps include examining specific subcategories of diagnoses to develop protective strategies and better anticipate the needs of population health in future scenarios of climate change., (Copyright © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Previous studies have identified drug and alcohol use as risk factors for readmission using claims data, but not by using substance use screening scores. This preliminary study tested the hypothesis that prevalence of 30-day readmission would be higher among patients screening positive on the 10-item Alcohol Use Disorders Identification Test (AUDIT-10) or the 10-item Drug Abuse Screening Test (DAST-10) tools at intake than among the general patient population. Social workers screened 4708 adult inpatients using prescreening questions followed by the AUDIT-10 and/or DAST-10. Patients with positive screens were followed for readmissions within 30 days of discharge. A positive screening score on the AUDIT-10 or DAST-10 instrument at intake was associated with higher risk of readmission to the general medicine wards within 30 days; this relationship appears complex and subject to mediation. Post hoc chart review found that the majority of readmissions among patients with positive screens were not immediately attributable to substance use. Further study is needed to verify these preliminary findings.

Introduction: Many patients transported by emergency medical services (EMS) may require advanced cardiac care but do not have ST-segment elevation (STEMI) on the initial prehospital EKG. We sought to identify factors associated with the need for advanced cardiac care in undifferentiated EMS patients reporting chest pain in the absence of STEMI on EKG., Methods: We performed a retrospective analysis of all adult patients, reporting atraumatic chest pain from a single EMS agency, presenting to a single, urban hospital over a 10-year period. Patients with STEMI on prehospital electrocardiogram were excluded. Patient demographics, chest pain characteristics and prehospital factors were abstracted for all patients. We identified those patients that required advanced cardiac care and performed regression analysis to determine associated factors., Results: A total of 956 charts were analyzed. Of this total, 193 patients (20.2%) met the primary composite outcome. Of the outcome group, 185 patients (95.9%) had coronary artery disease documented on cardiac catheterization, 22 patients (11.4%) underwent CABG, and seven patients (3.6%) died in the hospital. Most significant variables (multivariable IRR) included age (1.02), male gender (1.65), history of MI (1.47), PCI (1.66), hyperlipidemia (1.40), diaphoresis (1.51), home aspirin (1.53), and improvement with EMS treatment (1.60)., Conclusion: We have identified several factors that could be considered when risk stratifying prehospital patients reporting chest pain. While potentially predictive, the factors are broad and support the need for other objective factors that could augment prediction of patients who may benefit from early advanced cardiac care., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: This study examined the patterns of direct observation of patients by nursing staff ('nurse specials') and compared those required for mental health/drug health (MH/DH)-related presentations to other patient groups in different care settings., Methods: A retrospective review of nurse special shifts requested during the 2014 calendar year at an urban teaching hospital., Results: Hospital-wide 14,021 8-hour nursing shifts were ordered for special observation of patients, an average of 39 per day. Of these, 30% were requested for MH/DH-related presentations, with the majority (70%) required for medically unstable patients. However, of the 1917 shifts required in the emergency department, 1841 (96%) were for MH/DH presentations compared to 76 (4%) for patients with unrelated medical conditions (odds ratio 98.2; 95% confidence interval 77.71-124.06, P<0.0001)., Conclusions: In contrast to the rest of the hospital, emergency department-based nurse special requests were significantly more likely to be for MH/DH presentations. This figure represents a considerable staff and financial burden and may be reduced by diversion or more rapid transfer of such presentations to an appropriate inpatient ward.

User participation has become an increasingly important principle in health care over the last few decades. Healthcare professionals are expected to involve patients in treatment decisions. Clear guidance as to what this should entail for professionals in clinical work is not accounted for in legislation. In this study, we explore how healthcare professionals in a Municipal Acute Ward perceived, experienced and performed user participation. The ward represents a new short-time service model for emergency assistance in Norway. We focused on the challenges the professionals faced in clinical work and how they dealt with these. Data were drawn from qualitative interviews with 11 healthcare professionals and from 10 observations in relation to previsits and physician's rounds in the ward. Transcripts of interviews and observations were analysed using a method for systematic text condensation. In the analysis, we applied Lipsky's perspective on dilemmas of street-level bureaucrats. The results show that that the professionals perceived user participation as an important and natural part of their work. They experienced difficulties related to collaboration with patients, caregivers, and professionals in other services, and with framework conditions that caused conflicting expectations, responsibility, and priorities. The professionals seemed to take a pragmatic approach to user participation, managing it within narrow perspectives. Our study indicates that the participants dealt with the dilemmas at the cost of user participation. The results demonstrate that there is a gap between the outlined health policy and the professionals' opportunities to fulfil this policy in clinical work regarding user participation. The policy decision-makers should recognise the balancing work required of healthcare professionals to deal with difficulties in clinical work. The knowledge that professionals possess as performers of services and the need for valuing in policy processes should be acknowledged., (© 2017 Nordic College of Caring Science.)

Background: The 30-day readmission rate for patients with a left ventricular assist device implantation at a large, urban, Midwest hospital system (from October 2013 to September 2014) was estimated at 32.1%., Problem Statement: Readmission rates were a concern at this facility. Review of the readmissions, change in practice, and home expectations of patients and families have identified an opportunity to improve the transitions of care for this left ventricular assist device (LVAD) program. Therefore, the purpose of this project was to evaluate the effectiveness and feasibility of a transitional care model (TCM) for care of patients with left ventricular devices., Methods: Ten patients were enrolled in the pilot that was implemented in June 2015. A transitional care nurse trained to support patients with ventricular assist devices was used to facilitate patient flow. The goal was to create an individualized plan for the development or improvement of self-management skills to decrease readmission rates. The transitional care nurse collaborated with the ventricular device team., Outcomes: The 30-day readmission rate during the pilot was 14.3% compared to the previous annual overall rate of 42.6%., Implications for Practice: Based on these results, further research is recommended into interventions consistent with the TCM to advance care coordination and to facilitate care transition in the this fragile patient population.

Introduction and Objective: The last years an increase of severe cases of invasive disease (ID) due to Streptococcus pyogenes or streptococcus b-hemolytic group A (SGA) had been detected. The aim of this study was to analyze the epidemiology and the clinical features of ID due to SGA in a tertiary Pediatric Hospital., Material and Methods: Retrospective study in a Pediatric hospital, of all in-patients with final diagnosis of ID due to SGA during 6 years (2009-2014). To consider ID, SGA had to be isolated in sterile samples; in patients with fascitis necroticans in skin samples or in any sample in patients with the diagnostic of Streptococcal Toxic Shock Syndrome (STSS). The SSTS was defined as hypotension and at least 2 of these criteria: renal failure, hepatic failure, acute respiratory distress, tissue necrosis or desquamative erythematous rash. Demographic data, type of infection, risk factors, clinical presentation, analytical data at admission, treatment, need for admission to a pediatric intensive care unit, microbiological data, hospital stay and evolution were collected., Results: Fifty-two (52) cases were included (12/10,000 of all inpatients); 3 years-old was the medium age (p25-75: 1.4-6.9 years); 28 (53.8%) were boys. Fourteen patients (26.9%) had risk factors. Fever was the major symptom (51 patients, 98.1%). The skin lesions were the most frequent clinical manifestations found (21; 40.4%). In 50 (96%) cases, SGA was isolated in at least one sterile sample. Skin and soft tissue infections were diagnosed in 14 patients (26.9%), 14 (26.9%) pneumonias, 12 (23.1%) bones and joints infections, 10 (19.2%) SSTS, 6 (11.5%) occult bacteremia, 4 (7.7%) meningitis and 2 (3.8%) sepsis. Surgery was required in 18 cases (34.6%) and 17 patients (32.7%) needed intensive care. The medium hospital stay was 9.5 days (p25-75: 8-15 days). Three patients presented sequels and one patient died., Conclusion: The ID due to SGA was a rare but serious reason for hospital admission. Skin and soft tissue infections, and pleuroneumonia were the most common forms of ID. The mortality of our sample was low despite the serious clinical manifestations., (Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.)

Background: Failure in the timely follow-up of test results has been widely documented, contributing to delayed medical care. Yet, the impact of delay in reviewing test results on hospital length of stay (LOS) has not been studied. We examine the relationship between laboratory tests review time and hospital LOS., Methods: A retrospective cohort study of inpatients admitted to a metropolitan teaching hospital in Sydney, Australia, between 2011 and 2012 (n = 5804). Generalized linear models were developed to examine the relationship between hospital LOS and cumulative clinician read time (CRT), defined as the time taken by clinicians to review laboratory test results performed during an inpatient stay after they were reported in the computerized test reporting system. The models were adjusted for patients' age, sex, and disease severity (measured by the Charlson Comorbidity index), the number of test panels performed, the number of unreviewed tests pre-discharge, and the cumulative laboratory turnaround time (LTAT) of tests performed during an inpatient stay., Results: Cumulative CRT is significantly associated with prolonged LOS, with each day of delay in reviewing test results increasing the likelihood of prolonged LOS by 13.2% (p < 0.0001). Restricting the analysis to tests with abnormal results strengthened the relationship between cumulative CRT and prolonged LOS, with each day of delay in reviewing test results increasing the likelihood of delayed discharge by 33.6% (p < 0.0001). Increasing age, disease severity and total number of tests were also significantly associated with prolonged LOS. Increasing number of unreviewed tests was negatively associated with prolonged LOS., Conclusions: Reducing unnecessary hospital LOS has become a critical health policy goal as healthcare costs escalate. Preventing delay in reviewing test results represents an important opportunity to address potentially avoidable hospital stays and unnecessary resource utilization.

Objectives: Nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) has been accounted as one of the main risk factors for the development of complicated nosocomial infections. The present study aimed to determine nasal carriage rate, antimicrobial susceptibility pattern and molecular characteristics of MRSA isolates., Methods: This cross-sectional study was performed within 6 months period from July 2015 at 3 hospitals of Isfahan, Iran. Totally, 326 nasal samples were collected by cotton sterile swab from the nasal cavity of participants. Standard microbiological methods were used for identification S. aurues and MRSA isolates. Antibiotic susceptibility pattern was determined by the disc diffusion method according to the CLSI recommendation. Determination of SCCmec typing, agr groups, and virulence genes were performed by PCR method., Results: Overall, 23.6% of cases were S. aureus carriers including, 23.4% (25/107) of HCWs and 23.7% (52/219) of patients. The rate of MRSA nasal carriages among patients was found to be 51.9% and 16% in HCWs. The highest levels of resistance among MRSA isolates were against ampicillin (93.5%) and tetracycline (83.4%); while, the most effective antibiotics were vancomycin and co-trimoxazole with 100% and 71%, susceptibility. The presence of hla and pvl genes was detected in 80.6% and 3.2% of MRSA isolates, respectively. SCCmec types I, III, IV and V were found in 16.1%, 25.8%, 25.8%, and 16.1% of isolates, respectively. Moreover, agr group I was the predominant type with 43.3., Conclusion: Our results showed a high rate of MRSA colonization in hospitalized patients which remains a significant healthcare problem in our region.

Objectives: This study sought to determine whether the likelihood of receiving primary intensive care unit (ICU) care by a cardiologist versus a noncardiologist was greater for Caucasians than for African Americans admitted to an ICU for heart failure (HF). The authors further evaluated whether primary ICU care by a cardiologist is associated with higher in-hospital survival, irrespective of race., Background: Increasing data demonstrate an association between better HF outcomes and care by a cardiologist. It is unclear if previously noted racial differences in cardiology care persist in an ICU setting., Methods: Using the Premier database, adult patients admitted to an ICU with a primary discharge diagnosis of HF from 2010 to 2014 were included. Hierarchical logistic regression models were used to determine the association between race and primary ICU care by a cardiologist, adjusting for patient and hospital variables. Cox regression with inverse probability weighting was used to assess the association between cardiology care and in-hospital mortality., Results: Among 104,835 patients (80.3% Caucasians, 19.7% African Americans), Caucasians had higher odds of care by a cardiologist than African Americans (adjusted odds ratio: 1.42; 95% confidence interval: 1.34 to 1.51). Compared with a noncardiologist, primary ICU care by a cardiologist was associated with higher in-hospital survival (adjusted hazard ratio: 1.20, 95% confidence interval: 1.11 to 1.28). The higher likelihood of survival did not differ by patient race (interaction p = 0.32)., Conclusions: Among patients admitted to an ICU for HF, African Americans were less likely than Caucasians to receive primary care by a cardiologist. Primary care by a cardiologist was associated with higher survival for both Caucasians and African Americans., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Demands made on nursing staff are expanding and changing, requiring a broad set of competencies that require evaluation and enhancement in places. This study used the Nurse Competence Scale to measure self-assessed competence among nurses working in three municipal health-care services in Norway. Results indicate that nurses perceive their competence as being satisfactory overall, but there are areas that would benefit from improvement: providing patients' family members with education and guidance, quality assurance, and using research to evaluate and develop services. These competencies could be the focus of departments' future competence plans. The Nurse Competence Scale can be used to assess the impact of training and the efficacy of competence-enhancing actions.

Objective: To investigate factors predictive of short hospital admissions and appropriate placement to inpatient versus clinical decision units (CDUs)., Method: This is a retrospective analysis of attendance and discharge data from an inner-city ED in England for December 2013. The primary outcome was admission for less than 48 hours either to an inpatient unit or CDU. Variables included: age, gender, ethnicity, deprivation score, arrival date and time, arrival method, admission outcome and discharge diagnosis. Analysis was performed by cross-tabulation followed by binary logistic regression in three models using the outcome measures above and seeking to identify factors associated with short-stay admission., Results: There were 2119 (24%) admissions during the study period and 458 were admitted for less than 24 hours. Those who were admitted in the middle of the week or with ambulatory care sensitive conditions (ACSCs) were significantly more likely to experience short-stays. Older patients and those who arrived by ambulance were significantly more likely to have a longer hospital stay. There was no association of length of inpatient stay with being admitted in the last 10 min of a 4 hours ED stay., Conclusion: Only a few factors were independently predictive of short stays. Patients with ACSCs were more likely to have short stays, regardless of whether they were admitted to CDU or an inpatient ward. This may be a group of patients that could be targeted for dedicated outpatient management pathways or CDU if they need admission., Competing Interests: Competing interests: SAI, IP, DM, BB, GJ and TH have support from Barts Health NHS Trust for the submitted work, (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Study Objective: We describe ketamine procedural sedations and associated adverse events in low-acuity and high-acuity patients in a resource-limited ED., Methods: This was a prospective observational study of ketamine procedural sedations at the Emergency Medical Department at the Muhimbili National Hospital in Dar es Salaam, Tanzania. We observed consecutive procedural sedations and recorded patient demographics, medications, vital signs, pulse oximetry, capnography and a priori defined adverse events (using standard definitions in emergency medicine sedation guidelines). All treatment decisions were at the discretion of the treating providers who were blinded to study measurements to simulate usual care. Data collection was unblinded if predefined safety parameters were met. For all significant adverse and unblinding events, ketamine causality was determined via review protocol. Additionally, providers and patients were assessed for sedation satisfaction., Results: We observed 54 children (median 3 years, range 11 days-15 years) and 45 adults (median 33 years, range 18-79 years). The most common indications for ketamine were burn management in children (55.6%) and orthopaedic procedures in adults (68.9%). Minor adverse events included nausea/vomiting (12%), recovery excitation (11%) and one case of transient hypertension. There were nine (9%) patients who had decreased saturation readings (SpO 2 ≤92%). There were three deaths, all in severely injured patients. After review protocol, none of the desaturations or patient deaths were thought to be caused by ketamine. No patient experienced ketamine-related laryngospasm, apnoea or permanent complications. Overall, ketamine was well tolerated and resulted in high patient and provider satisfaction., Conclusion: In this series of ketamine sedations in an urban, resource-limited ED, there were no serious adverse events attributable to ketamine., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: There is limited research on metabolic abnormalities in psychotropic-naïve patients with serious mental illness (SMI). Our study examined metabolic conditions in a large, ethnically diverse sample of psychotropic-naïve and non-naïve adults with SMI at an urban public hospital., Methods: In this cross-sectional study of 923 subjects, the prevalences of hyperglycemia meeting criteria for type 2 diabetes mellitus (T2DM) based on fasting plasma glucose and obesity defined by BMI and abdominal girth were compared across duration of psychotropic medication exposure. Multiple logistic regression models used hyperglycemia and obesity as dependent variables and age, sex, race/ethnicity, and years on psychotropics as independent variables., Results: Psychotropic-naïve patients, including both schizophrenia and non-psychotic subgroups, showed an elevated prevalence of hyperglycemia meeting criteria for T2DM and a decreased prevalence of obesity compared to the general population. Obesity rates significantly increased for those on psychotropic medications more than 5 years, particularly for patients without psychosis (BMI: aOR = 5.23 CI = 1.44-19.07; abdominal girth: aOR = 6.40 CI = 1.98-20.69). Women had a significantly higher obesity rate than men (BMI: aOR = 1.63 CI = 1.17-2.28; abdominal girth: aOR = 3.86 CI = 2.75-5.44). Asians had twice the prevalence of hyperglycemia as whites (aOR = 2.29 CI = 1.43-3.67), despite having significantly less obesity (BMI: aOR = .39 CI = .20-.76; abdominal girth: aOR = .34 CI = .20-.60). Hispanics had a higher rate of obesity by BMI than whites (aOR = 1.91 CI = 1.22-2.99)., Conclusions: This study showed disparities between obesity and T2DM in psychotropic-naïve patients with SMI, suggesting separate risk pathways for these two metabolic conditions., (Copyright © 2018. Published by Elsevier Ltd.)

Objective: To analyse routinely collected data from a hospital database of drug health consultation-liaison (CL) assessments. We aimed to investigate changes in psychostimulant-related health service demand in an inner-city hospital to inform the development of locally appropriate models of care., Methods: We used de-identified drug health CL service data from 2012 to 2015. Psychostimulant-related consultations and admissions were compared with opioid-related consultations and admissions over time, by sex and by ward type (medical units, mental health units or emergency department)., Results: The CL service collected information on 8800 consultations and 4405 hospital admissions from 2012 to 2015. Psychostimulant use was responsible for 684 (7.8%) consultations and 372 (8.4%) admissions. Opioids were related to 1914 (21.8%) consultations and 864 (19.6%) admissions. Psychostimulants were the subject of three times more consultations in 2015 than in 2012, and more than twice as many admissions. Time trend analysis showed a significant time effect for consultations and admissions relating to psychostimulants. Conversely, no significant changes were observed in consultations and admissions relating to opioids., Conclusion: This study identified a rapid rise in the demand for psychostimulant-related inpatient assessments, suggesting the use of these drugs has increased locally. Because of the impact on the public health system, there is a need to invest in and implement new treatment strategies and services for psychostimulant users., Competing Interests: None declared

The aim of this study was to describe the management of severe blunt renal injuries at a Level I trauma hospital. Data were collected through a record review of patients admitted from January 1, 2000, to December 31, 2011. These data were compiled as part of our hospital's participation in the Nonoperative Management of Grade IV and V Blunt Renal Injuries: A Research Consortium of New England Centers for Trauma Study. Thirty-six patients with severe blunt renal injuries were identified. Twenty-nine (80.6%) underwent nonoperative management (NOM) for their injuries. Seven (19.4%) received an immediate operation because of hemodynamic instability or CT findings of large hemoperitoneum or extravasation. No significant differences were observed on Injury Severity Score, Glasgow Coma Scale, injury grade, or systolic blood pressure on arrival to the emergency department. On arrival, the operative patients had higher heart rates and lower hematocrit and hemoglobin values relative to the NOM patients. The kidney was salvaged in three of the seven operative patients and was either saved or partially saved in all except one NOM patient. Three NOM patients died; none because of renal injuries. All other patients were successfully managed. None of the operative patients died. NOM management of high-grade renal injury was successful for these patients and should be considered in the management of grade IV and V blunt renal trauma.

Introduction: The patient's request for urgent care in ophthalmology (PRUCO) at health care centers is constantly growing. In France, university hospitals are managing 75% of these cases. We sought to quantify PRUCO referred to French university hospital emergency units as well as to approach the structure and the territorial distribution of emergency eye care provided by French university hospitals., Methods: We conducted a quick cross-sectional survey sent to the 32 metropolitan and overseas French university hospitals. It inquired for each hospital whether emergency eye care units were available, whether ophthalmologists were on duty or on call overnight and how many PRUCO were managed in 2016., Results: The 32 university hospitals completed the survey. A total of 398650 PRUCO were managed in French university hospitals in 2016. The emergency unit was exclusively dedicated to eye care for 70% of the hospitals, with 47% (15/32) of them employing an ophthalmologist on duty overnight. Every hospital but one had at least one ophthalmologist on call. The city of Paris set aside, university hospitals took care of an annual mean of 9000 PRUCO (min=500; max=32,250)., Conclusion: The 32 French university hospitals are actively responding to patient's requests for urgent care in ophthalmology with very heterogeneous patient volumes and organizational systems. Half of them employ ophthalmologists on duty., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Aim: Our objectives were to assess the management of patients with major thalassemia and identify the various complications and monitoring means., Patients and Methods: A retrospective study was conducted on 26 β-thalassemic patients in the department of paediatrics, Hédi Chaker hospital, Sfax, Tunisia during a period of 25 years (from 1 January 1990 to 31 December 2014)., Results: The mean age of the beginning of transfusion was 11.5 months. That was with phenotyped red blood cells but not leukodepleted blood. Twenty-three patients received chelation. Before 2001, all patients received deferoxamine, poor adherence to this treatment was observed in 66% of cases. It was replaced by deferiprone since 2006 and deferasirox since 2009. A combination of 2 or 3 chelators was indicated for four patients. A total splenectomy was performed in 10 cases patients; it was due to hypersplenism. The bone marrow transplant was performed for one patient at the age of 9 year but it was rejected. Many complications were detected: endocrine complications (19 cases), immune complications (9 cases), gallbladder stones (5 cases), cardiac complications (4 cases), osteoporosis (3 cases), infectious complications (3 cases) and thromboembolic complications (2 cases). We noted some side effects related to chelation therapy in twelve cases. Four patients were dead., Conclusion: Improving the medical care of homozygous β-thalassemic children requires adherence to transfusion regimen and chelation therapy. Bone marrow transplantation remains the only possible curative therapy, which must be promoted in our country., (Copyright © 2017. Published by Elsevier SAS.)

Objective: This study tests the feasibility of using a large (big) clinical data set to test the ability to extract time-referenced data related to medication administration to identify late doses and as-needed (PRN) administration patterns by RNs in an inpatient setting., Methods: The study is a secondary analysis of a set of data using bar-code medication administration time stamps (n = 3043812) for 50883 patients admitted to a single, urban, 525-bed hospital in 11 inpatient units by 714 nurses between April 1, 2013, and March 31, 2015., Results: The large majority of scheduled medications (43.3%) were administered between 9 to 10 AM and 9 to 10 PM accounting for the most amount of delayed doses. On average, patients received 8.9 medications per day, and nurses administered 19.7 medications per shift. The average full-time nurse administered 3414 medications per year., Conclusions: The findings support use of time-referenced data to identify clinical processes and performance in administering scheduled and PRN medications.

Introduction: Stroke is one of the leading causes of death in Canada. While stroke care has improved dramatically over the last decade, outcomes following stroke among patients treated in rural hospitals have not yet been reported in Canada., Objectives: To describe variation in 30-day post-stroke in-hospital mortality rates between rural and urban academic hospitals in Canada. We also examined 24/7 in-hospital access to CT scanners and selected services in rural hospitals., Materials and Methods: We included Canadian Institute for Health Information (CIHI) data on adjusted 30-day in-hospital mortality following stroke from 2007 to 2011 for all acute care hospitals in Canada excluding Quebec and the Territories. We categorized rural hospitals as those located in rural small towns providing 24/7 emergency physician coverage with inpatient beds. Urban hospitals were academic centres designated as Level 1 or 2 trauma centres. We computed descriptive data on local access to a CT scanner and other services and compared mean 30-day adjusted post-stroke mortality rates for rural and urban hospitals to the overall Canadian rate., Results: A total of 286 rural hospitals (3.4 million emergency department (ED) visits/year) and 24 urban hospitals (1.5 million ED visits/year) met inclusion criteria. From 2007 to 2011, 30-day in-hospital mortality rates following stroke were significantly higher in rural than in urban hospitals and higher than the Canadian average for every year except 2008 (rural average range = 18.26 to 21.04 and urban average range = 14.11 to 16.78). Only 11% of rural hospitals had a CT-scanner, 1% had MRI, 21% had in-hospital ICU, 94% had laboratory and 92% had basic x-ray facilities., Conclusion: Rural hospitals in Canada had higher 30-day in-hospital mortality rates following stroke than urban academic hospitals and the Canadian average. Rural hospitals also have very limited local access to CT scanners and ICUs. These rural/urban discrepancies are cause for concern in the context of Canada's universal health care system.

Background: Successful tuberculosis (TB) treatment is essential to effective TB control. TB-HIV coinfection, social determinants and access to services influenced by rural residence can affect treatment outcome. We examined the separate and joint effects of rural residence and HIV infection on poor treatment outcome among patients enrolled in a large TB treatment centre in Kano, Nigeria., Methods: We retrospectively analysed a cohort of patients with TB enrolled in a large urban TB clinic in northern Nigeria, from January 2010 to December 2014. Poor treatment outcome was defined as death, default or treatment failure. We used Poisson regression to model rates and determine the relative risks (and 95% confidence intervals, CI) of poor treatment outcomes., Results: Among 1381 patients included in the analysis, 28.4% were rural residents; 39.8% were HIV-positive; and 46.1% had a poor treatment outcome. Approximately 65 and 38% of rural and urban residents, respectively, had a poor treatment outcome. Rural residents had 2.74 times (95% CI: 2.27-3.29) the risk of having a poor treatment outcome compared to urban residents. HIV-positive patients had 1.4 times (95% CI: 1.16-1.69) the risk of poor treatment outcome compared to HIV-negative patients. The proportion of poor treatment outcome attributable to rural residence (population attributable fraction, PAF) was 25.6%. The PAF for HIV infection was 11.9%. The effect of rural residence on poor treatment outcome among HIV-negative patients (aRR:4.07; 95%CI:3.15-5.25) was more than twice that among HIV-positive patients (aRR:1.99; 95%CI:1.49-2.64)., Conclusion: Rural residents attending a large Nigerian TB clinic are at increased risk of having poor treatment outcomes, and this risk is amplified among those that are HIV-negative. Our findings indicate that rural coverage of HIV services may be better than TB services. These findings highlight the importance of expanding coverage of TB services to ensure prompt diagnosis and commencement of treatment, especially among rural-dwellers in resource-limited settings.

Background: The identification of patients at high risk of unplanned readmission is an important component of discharge planning strategies aimed at preventing unwanted returns to hospital. The aim of this study was to investigate the factors associated with unplanned readmission in a Sydney hospital. We developed and compared validated readmission risk scores using routinely collected hospital data to predict 7-day, 30-day and 60-day all-cause unplanned readmission., Methods: A combination of gradient boosted tree algorithms for variable selection and logistic regression models was used to build and validate readmission risk scores using medical records from 62,235 live discharges from a metropolitan hospital in Sydney, Australia., Results: The scores had good calibration and fair discriminative performance with c-statistic of 0.71 for 7-day and for 30-day readmission, and 0.74 for 60-day. Previous history of healthcare utilization, urgency of the index admission, old age, comorbidities related to cancer, psychosis, and drug-abuse, abnormal pathology results at discharge, and being unmarried and a public patient were found to be important predictors in all models. Unplanned readmissions beyond 7 days were more strongly associated with longer hospital stays and older patients with higher number of comorbidities and higher use of acute care in the past year., Conclusions: This study demonstrates similar predictors and performance to previous risk scores of 30-day unplanned readmission. Shorter-term readmissions may have different causal pathways than 30-day readmission, and may, therefore, require different screening tools and interventions. This study also re-iterates the need to include more informative data elements to ensure the appropriateness of these risk scores in clinical practice.

Background: Research exploring patient experience of palliative care in the hospital setting has previously been limited to negative aspects of care. However, recent studies have shown that patients with palliative care needs experience benefits being in hospital. Little is known about how experiences of benefit and burden vary according to socio-demographic and illness-related factors and how these experiences influence patient preferences to return to hospital., Aim: To identify factors influencing experiences of benefit and burden and the predictors associated with a preference to return to hospital in palliative care., Design: Cross-sectional design using a questionnaire survey., Setting/participants: In total, 116 hospital inpatients admitted with palliative care needs in an urban hospital in New Zealand. Recruitment was from an oncology ward, four general medical wards and a respiratory ward., Results: Those living in more deprived areas experienced more benefit being in hospital ( F(4, 109) = 3.15, p = 0.017), while younger people ( F(4, 109) = 4.44, p = 0.00) and those from Asian or Pacific cultures ( F(2, 111) = 7.78, p = 0.000) experienced more burden. Those with a non-cancer diagnosis felt less safe in hospital ( p = 0.04). 'Feeling safe' was a significant ( B = 0.14, p = 0.03) predictor for a preference to return to hospital., Conclusion: Deprivation, diagnosis, age and ethnicity influenced experiences of benefit and burden in hospital. 'Feeling safe' was a significant predictor for a preference to return to hospital. Further research is needed to understand why certain patient factors influence experiences of hospitalisation and how 'feeling safe' can be replicated in other care environments.

Point of care (POC) laboratory testing is used to improve emergency department (ED) throughput but often overuses resources by duplicating formal laboratory testing. This study sought to evaluate the effect of a multimodal intervention on duplicate chemistry testing. This pre-post analysis included all visits to 2 urban EDs between June 2014 and June 2016. The multimodal intervention including provider education, signage, electronic health record redesign, and audit and feedback focused on reducing duplicate chemistry testing. The primary outcome was the number of duplicate chemistry tests per 100 visits. Autoregressive integrated moving-average models were used to account for secular changes. A total of 299 701 ED visits were included. The daily number of duplicate chemistry and POC chemistry tests significantly decreased following the intervention (3.3 fewer duplicates and 10.2 fewer POC per 100 ED visits, P < .0001). This implementation of a multimodal quality improvement intervention yielded substantial reductions in the overuse of blood chemistry testing in the ED.

Purpose: The traditional technique of placing a peripheral intravenous (IV) catheter is successful in most cases on inpatient wards. However, when the traditional method fails, a central venous catheter may be placed to maintain IV access. These catheters are associated with risks including central line-associated bloodstream infection., Methods: We evaluated the effectiveness and acceptability of an ultrasound-guided peripheral IV service to reduce the number of newly placed central venous catheters on an inpatient ward. Central venous catheters were counted daily on intervention and control wards using a standard protocol, and rates of newly placed catheters were compared using a Poisson regression model. Nurses were surveyed to assess acceptability and perceived benefit., Results: We found a reduction in the rate of newly placed central venous catheters on the intervention unit compared with the control unit at 90 days: mean 0.47 versus 0.67 newly placed central venous catheters/day, but the difference was not significant (P = .08). Nurses were in favor of the ultrasound-guided IV service, with perceived benefit to their patients., Conclusion: Ultrasound-guided peripheral IV might reduce unnecessary central venous catheters on general inpatient wards. A portable ultrasound used for this purpose was found to be acceptable by nursing staff.

Background: Patients with repeated hospitalizations represent a group with potentially avoidable utilization. Recent publications have begun to highlight the heterogeneity of this group. Latent class analysis provides a novel methodological approach to utilizing administrative data to identify clinically meaningful subgroups of patients to inform tailored intervention efforts., Objective: The objective of the study was to identify clinically distinct subgroups of adult superutilizers., Research Design: Retrospective cohort analysis., Subjects: Adult patients who had an admission at an urban safety-net hospital in 2014 and 2 or more admissions within the preceding 12 months., Measures: Patient-level medical, mental health (MH) and substance use diagnoses, social characteristics, demographics, utilization and charges were obtained from administrative data. Latent class analyses were used to determine the number and characteristics of latent subgroups that best represented these data., Results: In this cohort (N=1515), a 5-class model was preferred based on model fit indices, clinical interpretability and class size: class 1 (16%) characterized by alcohol use disorder and homelessness; class 2 (14%) characterized by medical conditions, MH/substance use disorders and homelessness; class 3 (25%) characterized primarily by medical conditions; class 4 (13%) characterized by more serious MH disorders, drug use disorder and homelessness; and class 5 (32%) characterized by medical conditions with some MH and substance use. Patient demographics, utilization, charges and mortality also varied by class., Conclusions: The overall cohort had high rates of multiple chronic medical conditions, MH, substance use disorders, and homelessness. However, the patterns of these conditions were different between subgroups, providing important information for tailoring interventions.

Background: Cryptococcosis is still a life-threatening mycosis that continues to be of serious concern in Latin American countries, especially among HIV+positive population. However, there is not any reliable information about the prevalence of this disease in this region., Aims: The aim of this study is to report data of 2041 patients with cryptococcosis that were attended at the Infectious Diseases Hospital F. J. Muñiz over a 30 year-period., Methods: Information about demographic and clinical data, survival time and the applied treatment, was taken from the Mycology Unit database. Mycological exams from different clinical samples were performed. Cryptococcal capsular antigen in serum and cerebrospinal fluid was detected through the latex agglutination technique. Cryptococcus isolates were phenotypically identified and the genotype was determined in some of them. Susceptibility tests were carried out following M27-A3 document., Results: Seventy five percent of HIV+positive patients and 50% of the HIV-negative population were males. Mean ages were 34.1 in HIV+positive patients and 44.8 in the HIV-negative. Cryptococcosis was associated with AIDS in 98% of the cases. Meningeal compromise was seen in 90% of the patients. Although cerebrospinal fluid rendered more positive results, blood culture was the first diagnostic finding in some cases. Cryptococcal antigen showed positive results in 96.2% of the sera samples and in the 93.1% of the cerebrospinal fluid samples. Most of the isolates were Cryptococcus neoformans and belonged to genotype VNI. Minimal inhibitory concentration values were mostly below the epidemiological cutoff values., Conclusions: We observed that thanks to a high level of clinical suspicion, early diagnosis, combined therapy and intracranial pressure control by daily lumbar punctures, the global mortality rate has markedly decreased through the years in the analyzed period., (Copyright © 2017 Asociación Española de Micología. Publicado por Elsevier España, S.L.U. All rights reserved.)

Context: Evidence suggests an association between rurality and decreased life expectancy., Objective: To determine whether rural hospitals have higher hospital mortality, given that very sick patients may be transferred to regional hospitals., Design: In this ecologic study, we combined Medicare hospital mortality ratings (N = 1267) with US census data, critical access hospital classification, and National Center for Health Statistics urban-rural county classifications. Ratings included mortality for coronary artery bypass grafting, stroke, chronic obstructive pulmonary disease, heart attack, heart failure, and pneumonia across 277 California hospitals between July 2011 and June 2014. We used generalized estimating equations to evaluate the association of urban-rural county classifications on mortality ratings., Main Outcome Measures: Unfavorable Medicare hospital mortality rating "worse than the national rate" compared with "better" or "same.", Results: Compared with large central "metro" (metropolitan) counties, hospitals in medium-sized metro counties had 6.4 times the odds of rating "worse than the national rate" for hospital mortality (95% confidence interval = 2.8-14.8, p < 0.001). For hospitals in small metro counties, the odds of having such a rating were 3.7 times greater (95% confidence interval = 0.7-23.4, p = 0.12), although not statistically significant. Few ratings were provided for rural counties, and analysis of rural counties was underpowered., Conclusion: Hospitals in medium-sized metro counties are associated with unfavorable Medicare mortality ratings, but current methods to assign mortality ratings may hinder fair comparisons. Patient transfers from rural locations to regional medical centers may contribute to these results, a potential factor that future research should examine.

Introduction: Animal bite injuries to the head and neck regions are an important public health problem. Most of these bites are from dogs. A 10-year retrospective study was undertaken to determine the prevalence of animal and human bites., Materials and Methods: This retrospective study was done from January 2011 to December 2016 and included 387 patients with a mean age of 21.51 years. Data collection included age, sex, days of hospitalization, lesion type, and clinical management., Results: Majority of patients were in age group of 21-29 years, followed by 31-55 years. Out of the total 281 patients, 42 patients (51.60%) were males and 34 patients (48.40%) were females. Mean hospital stay was 7.2 days with a minimum of 5 days and a maximum of 12 days. Surgical management included cleansing and primary closure of the wound., Conclusions: We concluded that the use of empiric antibiotic prophylaxis is essential for management of facial animal bite, and the antibiotic of first choice is amoxicillin-clavulanic acid. The aim of immediate surgical repair (< 6 h) is to avoid infections. The persistence of dog bite is public health problem in Venezuela.

Few qualitative studies have explored the relationship between substance use and self-harm. We employed a multiple-case study research design to analyze data from 80 patients who were admitted to a hospital in South Africa following self-harm. Our analysis revealed, from the perspective of patients, a number of distinct ways in which substance use is implicated in self-harm. Some patients reported that substance intoxication resulted in poor decision making and impulsivity, which led to self-harm. Others said substance use facilitated their self-harm. Some participants detailed how in the past their chronic substance use had served an adaptive function helping them to cope with distress, but more recently, this coping mechanism had failed which precipitated their self-harm. Some participants reported that substance use by someone else triggered their self-harm. Findings suggest that there are multiple pathways and a host of variables which mediate the relationship between substance use and self-harm.

This study describes in detail the burden of caring for patients aged ≥ 50 years seen in one year with a fragility fracture in a large urban environment and shows that these fractures result in a long length of stay and significant mortality. Intervention to prevent further fracture was poorly done., Purpose: To examine the epidemiology of fragility fracture in patients over age 50 years and record the number who received appropriate secondary prevention treatment., Methods: All patients aged ≥ 50 years presenting with a fracture during the 12 months following July 1 st 2011, to Auckland City Hospital or residing in central Auckland at the time of their fracture, were identified from hospital and Accident Compensation Corporation records. A random sample of 55% of these patient's records were reviewed to establish the type of fracture, prior fracture and falls history, and use of bisphosphonates in the 12 months before presentation. Their length of stay (LOS) by type of fracture was recorded. The use of bisphosphonate drugs in the following 12 months was obtained from centralised national records of prescriptions., Results: 2729 patients aged ≥ 50 years presented with a fragility fracture in the central Auckland region in one year. Fifty-six percent of these patients were seen at Auckland Hospital and of these, 82% patients required admission with a mean LOS of 20 days (SD ± 24 days).The remaining 44% of patients were looked after in the private outpatient sector. Approximately 30% of the admissions were for hip fracture. Sixty-four percent of patients with a fragility fracture did not receive a potent bisphosphonate, 12% were considered not appropriate for treatment, and 24% received a potent bisphosphonate during their admission or in the next 12 months., Conclusions: Approximately 1 in 18 people aged ≥ 50 years presented in one year with a fragility fracture.Secondary prevention strategies were poorly implemented. Additional resources for identifying and initiating secondary fracture prevention care such as a Fracture Liaison Service are urgently needed.

Aim: Medical comorbidities are a major cause of death among patients with mental illness. The purpose of this study was to clarify the risk factors for mortality among psychiatric patients with medical comorbidities., Methods: We retrospectively reviewed the clinical files of patients transferred to Tokyo Metropolitan Matsuzawa Hospital from a psychiatric hospital to treat medical comorbidities during the 3-year period from January 2014 to December 2016. We analyzed the clinical differences between the expired and alive patients., Results: Of the 287 patients included, 29 (10.1%) had expired at the time of hospital discharge, while 258 (89.9%) were living. A multivariable analysis to determine the prognostic factors related to mortality from medical comorbidities showed that body mass index <18.5 had the highest odds ratio among the predictive factors (5.1; 95% confidence interval, 1.5-17.1; P < 0.05), followed by a serum albumin level < 3.0 mg/dL (3.0; 95% confidence interval, 1.1-8.1; P < 0.05)., Conclusion: We found that underweight and hypoalbuminemia were risk factors for mortality among psychiatric patients with medical comorbidities. Physicians at psychiatric hospitals should consider transferring patients with medical comorbidities to a general medical hospital in the presence of underweight and/or hypoalbuminemia., (© 2017 The Authors. Psychiatry and Clinical Neurosciences © 2017 Japanese Society of Psychiatry and Neurology.)

Objectives: In 2011, the AHA recommended risk stratification of patients with acute pulmonary embolism (PE). Failure to risk stratify may cause under recognition of intermediate-risk PE and its attendant short- and long-term consequences. We sought to determine if patients hospitalized with acute PE were appropriately risk stratified according to the 2011 AHA Scientific Statement within our hospital system and whether differences exist in adherence to risk stratification by hospital or treating hospital service. We also wished to know the frequency of in-hospital consultations for acute PE which might assist in the risk stratification process., Methods: This is a retrospective chart audit of all patients hospitalized with a diagnosis of acute PE between January 2011 and December 2013 at our 937-bed metropolitan, three hospital system comprised of academic University, neuroscience Specialty, and teaching Community hospitals. We evaluated the presence of imaging, laboratory tests, and specialty consultation within 72 h of PE diagnosis by hospital., Results: 701 patients with acute PE were admitted to our hospital system during the study period. 308 patients (43.9%) met criteria for intermediate-risk PE. 347 patients (49.5%) were considered 'Low-Risk - At Risk', patients defined in a low-risk category not having undergone all recommended risk stratification testing and so truly may have been in a higher risk category. No specialty consultations were utilized for 265 patients (37.8%)., Conclusions: Our large metropolitan hospital system inadequately risk stratifies hospitalized patients with acute PE. Because nearly one-half of patients with acute PE did not have all recommended testing, clinicians may be under recognizing patients with intermediate-risk PE and their risk for long-term morbidity. Specialty consultations were underutilized and may help guide medical decision-making.

Objective: To identify key organizational approaches associated with underuse of breast cancer care., Setting: Nine New York City area safety-net hospitals., Study Design: Mixed qualitative-quantitative, cross-sectional cohort., Methods: We used qualitative comparative analysis (QCA) of key stakeholder interviews, defined organizational "conditions," calibrated conditions, and identified solution pathways. We defined underuse as no radiation after lumpectomy in women <75 years or mastectomy in women with ≥4 positive nodes, or no systemic therapy in women with tumors ≥1 cm. We used hierarchical models to assess organizational and patient factors' impact on underuse., Principal Findings: Underuse varied by hospital (8-29 percent). QCA found lower underuse sites designated individuals to track and follow-up no-shows; shared clinical information during handoffs; had fully integrated electronic medical records enabling transfer of responsibility across specialties; had strong system support; allocated resources to cancer clinics; had a patient-centered culture paying close organizational attention to clinic patients. High underuse sites lacked these characteristics. Multivariate modeling found that hospitals with strong approaches to follow-up had low underuse rates (RR = 0.28; 0.08-0.95); individual patient characteristics were not significant., Conclusions: At safety-net hospitals, underuse of needed cancer therapies is associated with organizational approaches to track and follow-up treatment. Findings provide varying approaches to safety nets to improve cancer care delivery., (© Health Research and Educational Trust.)

Background and Objectives: The use of palliative care in AKI is not well described. We sought to better understand palliative care practice patterns for hospitalized patients with AKI requiring dialysis in the United States., Design, Setting, Participants, & Measurements: Using the 2012 National Inpatient Sample, we identified patients with AKI and palliative care encounters using validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. We compared palliative care encounters in patients with AKI requiring dialysis, patients with AKI not requiring dialysis, and patients without AKI. We described the provision of palliative care in patients with AKI requiring dialysis and compared the frequency of palliative care encounters for patients with AKI requiring dialysis with that for patients with other illnesses with similarly poor prognoses. We used logistic regression to determine factors associated with the provision of palliative care, adjusting for demographics, hospital-level variables, and patient comorbidities., Results: We identified 3,031,036 patients with AKI, of whom 91,850 (3%) received dialysis. We observed significant patient- and hospital-level differences in the provision of palliative care for patients with AKI requiring dialysis; adjusted odds were 26% (95% confidence interval, 12% to 38%) lower in blacks and 23% (95% confidence interval, 3% to 39%) lower in Hispanics relative to whites. Lower provision of palliative care was observed for rural and urban nonteaching hospitals relative to urban teaching hospitals, small and medium hospitals relative to large hospitals, and hospitals in the Northeast compared with the South. After adjusting for age and sex, there was low utilization of palliative care services for patients with AKI requiring dialysis (8%)-comparable with rates of utilization by patients with other illnesses with poor prognosis, including cardiogenic shock (9%), intracranial hemorrhage (10%), and acute respiratory distress syndrome (10%)., Conclusions: The provision of palliative care varied widely by patient and facility characteristics. Palliative care was infrequently used in hospitalized patients with AKI requiring dialysis, despite its poor prognosis and the regular application of life-sustaining therapy., (Copyright © 2017 by the American Society of Nephrology.)

Background: Traumatic injuries represent a major burden of disease worldwide. Haiti lacks statistics on the epidemiology of traumatic injuries, as there is no formal injury surveillance program. This study will assess the burden of traumatic injuries in an urban trauma center in the capital city of Port-au-Prince, Haiti., Methods: A retrospective, cross-sectional chart review study at an urban trauma hospital was carried out for the period December 1, 2015, to January 31, 2016. Data were obtained through the hospital's main patient logbook, medical charts, and trauma registry forms. Data on medical documentation, demographics, and injury characteristics were collected and analyzed using descriptive statistics., Results: A total of 410 patients were evaluated for treatment of traumatic injuries during the 2-month study. The mean age in years was 30, with 66.3% male and 78.4% less than 41 years of age. There were 6.6 injuries per day and no correlation between frequency of injury and day of the week. Road traffic accidents accounted for 43.0% of trauma modes. The mean and median length of stay were 6.6 and 3.0 days. 9.0% of patients suffered severe trauma (ISS ≥ 16). 21.0% of patients with traumatic brain injury suffered severe head injuries. Extremity trauma was the most frequently injured anatomical region (50.0%). 22.7% of patients were admitted, and 15.1% patients underwent at least one surgical procedure., Conclusions: Road traffic accidents are the primary reason for injury; thus, prevention initiatives and improved trauma care may provide substantial public health benefits.

Background: In response to urban-rural disparities in healthcare resources, China recently launched a healthcare reform with a focus on improving rural care during the past decade. However, nationally representative studies comparing medical care and patient outcomes between urban and rural areas in China during this period are not available., Methods and Results: We created a nationally representative sample of patients in China admitted for ST-segment-elevation myocardial infarction in 2001, 2006, and 2011, using a 2-stage random sampling design in 2 urban and 3 rural strata. In China, evidence-based treatments were provided less often in 2001 in rural hospitals, which had lower volume and less availability of advanced cardiac facilities. However, these differences diminished by 2011 for reperfusion therapy (54% in urban versus 57% in rural; P =0.1) and reversed for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (66% versus 68%; P =0.04) and early β-blockers (56% versus 60%; P =0.01). The risk-adjusted rate of in-hospital death or withdrawal from treatment was not significantly different between urban and rural hospitals in any study year, with an adjusted odds ratio of 1.13 (0.77-1.65) in 2001, 0.99 (0.77-1.27) in 2006, and 0.94 (0.74-1.19) in 2011., Conclusions: Although urban-rural disparities in evidence-based treatment for myocardial infarction in China have largely been eliminated, substantial gaps in quality of care persist in both settings. In addition, urban hospitals providing more resource-intensive care did not achieve better outcomes., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01624883., (© 2017 American Heart Association, Inc.)

Purpose: This policy brief provides data assessing effects of Medicaid Disproportionate Share Hospital (DSH) payment on rural hospitals in 47 states. While the allocation of DSH funds to the state is determined by federal legislation utilizing a formula developed by the Centers for Medicare & Medicaid Services (CMS), each state determines distribution to hospitals using an approved State Plan Amendment (SPA) that meets minimum federal requirements. Our findings suggest that distribution to rural hospitals, and critical access hospitals (CAHs) in particular, varies considerably across states. Data presented in this document helps ground any changes to either federal requirements or to SPAs by showing the impact of DSH payment from the most recent data available., Key Findings: (1) Medicaid DSH payment methodology and distribution to hospitals varies considerably across states. (2) The percentage of rural hospitals in a state receiving any Medicaid DSH payment ranged from 0 percent to 100 percent. (3) For rural hospitals receiving Medicaid DSH payments, the impact on total patient revenue ranged from less than 0.5 percent to 8.8 percent.

Aims HIV-infected persons may have elevated risks for heart failure, but factors associated with heart failure in the modern era of HIV therapy are insufficiently understood. Despite substantial disagreement between physician-adjudicated heart failure and heart failure diagnosis codes, few studies of HIV cohorts have evaluated adjudicated heart failure. We evaluated associations of HIV viremia, immunosuppression, and cardiovascular risk factors with physician-adjudicated heart failure. Methods and results We analyzed clinical characteristics associated with heart failure in a cohort of 5041 HIV-infected patients receiving care at an urban hospital system between 2000 and 2016. We also evaluated characteristics of HIV-infected patients who screened negative for heart failure, screened positive for possible heart failure but did not have heart failure after adjudication, and had adjudicated heart failure. HIV-infected patients with heart failure ( N = 216) were older and more likely to be black, hypertensive, and have diabetes than HIV-infected patients without heart failure; heart failure with reduced ejection fraction was more common than heart failure with preserved ejection fraction. In our primary analyses restricted to HIV-infected patients whose heart failure diagnoses did not precede their HIV diagnoses ( N = 149), peak HIV viral load ≥100,000 copies/mL (odds ratio (OR) 2.12, 1.28-3.52) and nadir CD4 T-cell count <200 cells/mm 3 (OR 2.35, 1.04-5.31) were associated with significantly elevated odds of heart failure. Overall, 30.6% of patients with any diagnosis code of heart failure had adjudicated heart failure. Conclusion Higher peak HIV viremia and lower CD4 cell nadir are associated with significantly elevated odds of heart failure for HIV-infected persons. Physician adjudication of heart failure may be helpful in HIV cohorts.

Background: Hip and knee prosthetic replacements have proven to be the most appropriate treatment in the joints that do not benefit from medical or arthroscopic interventions; however, infections are the most feared complication. It is recommended that the incidence of infection should not exceed 2%., Material and Methods: This was an observational, prospective, longitudinal and observational study conducted in patients fitted with a prosthetic joint from August 2011 to July 2012. Patients were followed up pre and post-surgery for one year to identify a prosthetic infection, diagnosed using international parameters. We calculated the incidence of prosthetic infection, as well as the incidence density., Results: A total of 339 patients (179 hip and 160 knee) were included. Variations in the time of pre-operative antibiotics' administration were observed. Six prosthetic infections were identified with an incidence rate of 1.79/339 arthroplasties, 2.2/179 hip procedures, and 1.25/160 knee arthroplasties. An incidence density of 0.02/year for hip arthroplasties and 0.11/year for knee procedures was identified. There were 4 infections of hip and 2 of knee. Five infections were acute and one chronic. The isolated microorganisms were E. faecalis, S. epidermidis (2), S. mitis, S. aureus and P. stomatis., Conclusions: The incidence of prosthetic joint infection in the first year of follow-up at our centre is within the recommended parameters. Surgical techniques and organizational practices influence the results., (Copyright © 2016 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.)

Objective: Approximately 20% of patients admitted to hospital with drug overdose will require intensive care unit (ICU) admission. An understanding of the characteristics of these patients may assist with their management and identify those patients at risk of multiple hospital presentations due to drug overdose. Our aim was to examine the characteristics of patients admitted to ICU following drug overdoses and identify the predictors of multiple hospital presentations due to drug overdose., Methods: Patients admitted to a metropolitan ICU over a three-year period following drug overdoses were identified using ICU patient databases, and their medical records., Results: There were 254 admissions due to drug overdoses. The majority of overdoses were intentional (82.7%) and included multiple agents (68.1%). Two-thirds of patients had psychiatric diagnosis, and 54% had documented history of substance use disorders. In-hospital mortality was 2.8%. Over half of patients admitted had documented history of prior hospital presentation due to overdoses. Personality disorder and schizophrenia were independent predictors of multiple hospital presentations due to overdoses., Conclusion: Personality disorders or schizophrenia were independent predictors of patients with multiple overdose presentations. Preventative strategies focusing on these patients may reduce the incidence of their hospital presentations and ICU admissions.

Diabetic foot ulcer (DFU) is a common complication observed in diabetic patients and affects diabetic patients in multiple ways. Severe DFU even leads to amputation in many cases. Early detection and intervention of DFU in diabetic patients can significantly relieve the pain caused by the ulcer and also keep patients from losing limbs in severe cases. In this study, the risks of diabetic patients getting DFU were estimated through a hospital-based survey. This survey collected information from hospitalized diabetic patients in Wuhan City, Hubei Province, China, using a questionnaire. This investigation includes studies from two stages with 502 diabetic patients from 20 hospitals in Wuhan City. The results suggested that patients with a long history of diabetes are often associated with a high risk of DFU (χ 2  = 11.428, p = 0.0007), smoking (χ 2  = 8.386, p = 0.0007), diabetic complications (χ 2  = 13.484, p < 0.0001), and especially patients with diabetic foot complications (χ 2  = 57.6621, p < 0.0001). Foot lesions appeared to be important attributors to DFU since our data demonstrated close correlations between DFU and patients with calluses/corns (χ 2  = 4.584, p = 0.0323), tinea pedis (χ 2  = 4.030, p = 0.0447), and cracked skin (χ 2  = 8.712, p = 0.0032). Only a small number of patients seek for the assistance from specialists, such as trimming toenails (3.4%), removing corn or calluses (1.4%) or treating wounds (11.78%), when they are suffering from foot problems. The findings of this study can potentially be utilized to develop an early DFU diagnostic method in diabetic patients and can provide objective evidence for suggesting that patients who are suffering from foot problems should seek professional help., (© 2017 by the Wound Healing Society.)

Background and Objectives: Early stage lung cancer is generally treated with surgical resection. The objective of the study was to identify patient and hospital characteristics associated with the type of lung cancer surgical approach utilized in New York State (NYS), and to assess in-hospital adverse events., Methods: A total of 33 960 lung cancer patients who underwent limited resection (LR) or lobectomy (L) were selected from the NYS Statewide Planning and Research Cooperative System database (1995-2012)., Results: LR patients were more likely to be older (adjusted odds ratio OR adj and [95% confidence interval]: 1.01 [1.01-1.02]), female (OR adj : 1.11 [1.06-1.16]), Black (OR adj : 1.17 [1.08-1.27]), with comorbidities (OR adj : 1.08 [1.03-1.14]), and treated in more recent years than L patients. Length of stay and complications were significantly less after LR than L (OR adj : 0.56 [0.53-0.58] and 0.65 [0.62-0.69]); in-hospital mortality was similar (OR adj : 0.93 [0.81-1.07]), and was positively associated with age and urgent/emergency admission, but inversely associated with female gender, private insurance, recent admission year, and surgery volume., Conclusions: There was a growing trend toward LR, which was more likely to be performed in older patients with comorbidities. In-hospital outcomes were better after LR than L, and were affected by patient and hospital characteristics., (© 2017 Wiley Periodicals, Inc.)

Background: A small proportion of patients utilizes a disproportionately large amount of emergency department (ED) resources. Being able to properly identify chronic frequent ED users, i.e. frequent ED users over a multiple-year period, would allow healthcare professionals to intervene before it occurs and, if possible, redirect these patients to more appropriate health services. The objective of this study was to explore the factors associated with chronic frequent ED utilization in a population with diabetes., Methods: A population-based retrospective cohort study using administrative data was conducted on 62,316 patients with diabetes living in metropolitan areas of Quebec (Canada), having visited an ED during 2006, and still alive in 31 December 2009. The dependant variable was being a chronic frequent ED user, defined as having at least 3 ED visits per year during three consecutive years (2007-2009). Independent variables, measured during 2006, included age, sex, neighbourhood deprivation, affiliation to a general practitioner, and number of physical and mental health comorbidities. Logistic regression and tree-based method were used to identify factors associated with chronic frequent ED use., Results: A total of 2.6% of the cohort (patients with diabetes and at least one ED visit in 2006) was identified as chronic frequent ED users. These patients accounted for 16% of all ED visits made by the cohort during follow-up. The cumulative effect of a high illness burden combined with mental health disorders was associated with an increased risk of chronic frequent ED use., Conclusions: Interventions must target the population at higher risk of becoming chronic frequent ED users and should be designed to manage the complex interaction between high illness burden and mental health.

Colorectal cancer (CRC) remains a leading cause of morbidity and mortality in the U.S. Disparities in access to care contribute to advanced CRC stage at diagnosis, and these disparities are most pronounced among underserved populations and ethnic minorities. We aim to evaluate race/ethnicity-specific disparities in CRC stage at diagnosis among an ethnically diverse, urban safety-net hospital. We retrospectively evaluated all adult CRC patients diagnosed from January 1, 2009 to October 1, 2015. CRC cases were confirmed by histopathology specimens from biopsies and/or surgical resection. CRC staging utilized American Joint Committee on Cancer (AJCC) staging systems and were stratified by race/ethnicity. Multivariate logistic regression models were utilized to evaluate disparities in AJCC stage at presentation (stage 3-4 vs. stage 0-2). Among 311 patients with CRC [51.5% male, 25.3% black, 18.7% Hispanic, 32.0% Asian, and mean age at diagnosis 58.1 years (SD 10.3)] 61.4% had advanced ACC stage 3-4 CRC at diagnosis. Among black patients with CRC, 73.3% had AJCC stage 3-4 cancer at time of diagnosis. On multivariate regression, blacks were nearly four times more likely to have advanced AJCC stage 3-4 CRC at diagnosis compared to whites (OR 3.70; 95% CI 0.97-14.11; p = 0.055). Among a diverse underserved population, over 60% of CRC were AJCC stage 3-4 at diagnosis, and nearly 75% of blacks with CRC had AJCC stage 3-4 at diagnosis. Advanced stage CRC at diagnosis limits options for potentially curative therapies, and increases the risk for cancer recurrence and mortality.

Background: Improvement of quality of life in old age and prevention of age-associated diseases have become the main focus of research into aging; however, information regarding the skin health status of geriatric patients still remains sparse., Goal: To investigate the extent of dermatological diseases in hospitalized geriatric patients, map the most prevalent ones, check for any gender differences and document any correlations with duration of hospitalization and results of geriatric assessments., Patients and Methods: A total of 110 hospitalized geriatric patients underwent a complete dermatological examination at the Evangelical Geriatric Hospital (Evangelisches Geriatriezentrum) Berlin. The collected information was stratified according to dermatological diagnosis, results of geriatric assessments, duration of hospitalization, age and gender of the patients., Results: The average number of diagnosed skin diseases per patient was 3.7 ± 1.8 for the female population and 4.3 ± 2.0 for the male population. After categorizing all diagnosed skin diseases, infectious diseases were found to be most common in both female and male patients (55 % and 58 %, respectively) followed by vascular diseases (46.7 % and 54 %, respectively). Precancerous skin lesions and epithelial skin cancer were more frequent in men than in women (20 % vs. 6.7 %, p < 0.037 and 34 % vs. 13.3 %, p < 0.010, respectively). Pruritus showed a positive correlation with the duration of hospitalization and a negative correlation with the Barthel index and Tinetti score on the day of discharge, indicating that pruritus may have a significant impact on the physical condition of elderly multimorbid patients and on the static and dynamic balance abilities., Conclusion: Our results demonstrate that skin health in the elderly is compromised and disregarded and this should constitute one of the top priorities of healthcare specialists and physicians in the future.

Background: Delays in patient transfers are associated with worse outcomes for some neurosurgical conditions. One of the primary causes of transfer delay is lack of neurosurgery intensive care unit bed availability. In the present study, we characterize the results of implementing an interhospital transfer protocol to reduce unnecessary transfers and improve bed availability., Methods: A transfer protocol was implemented in July 2012 at the Bellevue Hospital Department of Neurosurgery that screened for and prevented transfer of low-risk patients who were unlikely to require specialized inpatient neurosurgical care. The impact of this protocol was assessed with prospectively recorded data on all potential interhospital transfers from May 2011 through June 2016., Results: Of the 1978 calls (regarding 1886 individual patients), 402 occurred before the implementation of the transfer protocol and 1576 occurred after. Before the protocol, 84.1% of transfer requests were accepted, but 15.2% were subsequently denied for bed unavailability. After the protocol, a smaller share of transfer requests were accepted after protocol screening (71.8%, P < 0.001), but only 1.9% (P < 0.001) were subsequently denied because of bed unavailability. The diagnosis demographics changed significantly (P < 0.001), with a larger share of arriving transfers suffering from aneurysms or tumors after the protocol and a smaller share suffering from stenosis/disc disease without neurological symptoms., Conclusions: The transfer protocol implemented in the present study allowed transfer determination based on the need for specialized neurosurgical care rather than chance unavailability of beds. Developing interhospital transfer protocols may be an effective strategy to efficiently allocate limited hospital resources and improve transfer systems., (Copyright © 2017 Elsevier Inc. All rights reserved.)