Search

Aims The CONtrolling NUTritional status (CONUT) score represents the nutritional status of patients with heart failure (HF). Although high CONUT scores on admission are associated with increased risks of cardiovascular (CV) events in patients with HF, the impact of CONUT changes during hospitalization on their long‐term prognosis is unclear. This study aimed to investigate the impact of CONUT score changes on the clinical outcomes of patients with HF after discharge. Methods and results This observational study included 1705 patients hospitalized with HF who were discharged alive. The patients were categorized depending on their CONUT scores at admission and discharge into persistently high, high at admission and normal at discharge, normal at admission and high at discharge, and persistently normal CONUT groups. The primary endpoint was a composite of CV death and readmission for HF after discharge. The primary endpoint occurred in 652 patients (38%) during the median 525 day follow‐up period. Patients with persistently high CONUT scores had the highest composite endpoint rate (log‐rank trend test: P

BACKGROUND: The ventilatory ratio (VR) is a simple index of ventilatory efficiency and dead space. Because increased dead space and high ventilatory demands impose a limitation to unassisted ventilation, and may predispose patients to injurious strong efforts during assisted ventilation, evaluation of the VR could provide helpful information during weaning. We hypothesize that there is a threshold of VR associated with tolerance of unassisted breathing. METHODS: In a retrospective analysis, we included subjects ventilated in a control mode for at least 24 h, who were successfully liberated from mechanical ventilation, without use of noninvasive ventilation, and discharged alive from the ICU. We focused on the successful weaning attempts (the last, if more than one was performed) and evaluated the VR at the beginning and at the end of the assisted ventilation period. RESULTS: We examined 2,000 medical records and included in our analysis 572 subjects (age: 68 y, R(5-95) = 25–85, 68% male) with main admission diagnosis of respiratory failure (23%), sepsis (11%), brain injury (34%), and postoperative (14%). The VR at the beginning and the end of the assisted ventilation period was 1.5 (R(5-95) = 1–2.1) and 1.4 (R(5-95) = 1–2), respectively. The median duration of assisted ventilation in subjects with a VR ≥ 2 at the beginning of the assisted ventilation period was 3 d (R(5-95) = 0–14 d), significantly longer than in those with a VR < 2, 0.5 d (R(5-95) = 0–8 d, P < .001). CONCLUSIONS: Successful liberation from assisted ventilation was associated with a VR < 2. A VR > 2 was associated with longer duration of weaning. The VR could be used as an additional tool to facilitate the decision-making process during weaning.

Background Previous work has demonstrated that patients experience functional decline at 1–3 months post-discharge after COVID-19 hospitalization. Objective To determine whether symptoms persist further or improve over time, we followed patients discharged after hospitalization for severe COVID-19 to characterize their overall health status and their physical and mental health at 6 months post-hospital discharge. Design Prospective observational cohort study. Participants Patients ≥ 18 years hospitalized for COVID-19 at a single health system, who required at minimum 6 l of supplemental oxygen during admission, had intact baseline functional status, and were discharged alive. Main Measures Overall health status, physical health, mental health, and dyspnea were assessed with validated surveys: the PROMIS® Global Health-10 and PROMIS® Dyspnea Characteristics instruments. Key Results Of 152 patients who completed the 1 month post-discharge survey, 126 (83%) completed the 6-month survey. Median age of 6-month respondents was 62; 40% were female. Ninety-three (74%) patients reported that their health had not returned to baseline at 6 months, and endorsed a mean of 7.1 symptoms. Participants’ summary t-scores in both the physical health and mental health domains at 6 months (45.2, standard deviation [SD] 9.8; 47.4, SD 9.8, respectively) remained lower than their baseline (physical health 53.7, SD 9.4; mental health 54.2, SD 8.0; p

OBJECTIVE Shunt failure is common among patients undergoing ventriculoperitoneal shunting for treatment of hydrocephalus. The present study examined long-term shunt failure and associated risk factors in pediatric patients by using a national hospitalization database of Thailand. METHODS Patients 17 years or younger who had been admitted to 71 public hospitals in 2012–2017 for first-time ventriculoperitoneal shunting for diseases with known etiology and discharged alive were followed through 2019 to ascertain shunt failure. Shunt survivals were calculated using Kaplan-Meier estimates and time to failure was analyzed to identify risk factors for the first failure by using Cox proportional hazards regression. Differences in risks of subsequent failures with respect to place in the order of failures (i.e., first, second, third) were determined using a cumulative hazard function. RESULTS Over a median follow-up of 29.9 months, shunt failure occurred in 33.7% of 2072 patients (median age 8.8 months), with a higher proportion in patients < 1 year than in patients 1–17 years (37.8% vs 28.9%, p < 0.001), and ranged from 26.1% of those having posttraumatic hydrocephalus to 35.9% of those having infectious diseases. The shunt failure rates at 3, 6, and 12 months were 11.5%, 19.0%, and 25.2%, respectively. Patients < 1 year had a higher risk of the first failure than patients 1–17 years (hazard ratio 1.45, 95% CI 1.20–1.76). Among those with shunt failure, 35.8% had multiple failures and 52.9% failed within 180 days after the index shunting. The cumulative hazard of subsequent failure was consistently higher than that of an earlier failure regardless of age and etiology, and the cumulative hazard of the second failure in the patients with 180-day failure was higher than that in the patients in whom shunts failed beyond 180 days. CONCLUSIONS Shunt failure occurred more frequently in younger pediatric patients. Much attention should be placed on the initial shunt operation so as to mitigate the failure risk. Close follow-up was crucial once patients had developed the failure, because the risk of subsequent failure was more likely than an earlier one among those with multiple failures.

Summary Objective Our objective was to describe the characteristics of patients admitted, discharged and readmitted, due to COVID-19, to a central London acute-care hospital during the second peak, in particular in relation to corticosteroids use. Methods We reviewed patients admitted from the community to University College Hospital (UCH) with COVID-19 as their primary diagnosis between 1st-31st December 2020. Re-attendance and readmission data were collected for patients who re-presented within 10 days following discharge. Data were retrospectively collected. Results 196 patients were admitted from the community with a diagnosis of COVID-19 and discharged alive in December 2020. Corticosteroids were prescribed in hospital for a median of 5 days (IQR 3–8). 20 patients (10.2%) were readmitted within 10 days. 11/20 received corticosteroids in the first admission of which 10 had received 1–3 days of corticosteroids. Readmission rate in those receiving 1–3 days of corticosteroids was 25%. Conclusions Most international guidelines have recommended providing up to 10 days of corticosteroids for severe COVID-19 but stopping on discharge. Our findings show shorter courses of corticosteroids during admission are associated with an increased risk of being readmitted and support continuing the course of corticosteroids after hospital discharge monitored in the virtual ward setting.

Background Novel coronavirus disease 2019 (COVID-19) is frequently compared with influenza. The Hospitalized Adult Influenza Vaccine Effectiveness Network (HAIVEN) conducts studies on the etiology and characteristics of U.S. hospitalized adults with influenza. It began enrolling patients with COVID-19 hospitalizations in March 2020. Patients with influenza were compared with those with COVID-19 in the first months of the U.S. epidemic. Methods Adults aged ≥ 18 years admitted to hospitals in 4 sites with acute respiratory illness were tested by real-time reverse transcription polymerase chain reaction for influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing COVID-19. Demographic and illness characteristics were collected for influenza illnesses during 3 seasons 2016–2019. Similar data were collected on COVID-19 cases admitted before June 19, 2020. Results Age groups hospitalized with COVID-19 (n = 914) were similar to those admitted with influenza (n = 1937); 80% of patients with influenza and 75% of patients with COVID-19 were aged ≥50 years. Deaths from COVID-19 that occurred in younger patients were less often related to underlying conditions. White non-Hispanic persons were overrepresented in influenza (64%) compared with COVID-19 hospitalizations (37%). Greater severity and complications occurred with COVID-19 including more ICU admissions (AOR = 15.3 [95% CI: 11.6, 20.3]), ventilator use (AOR = 15.6 [95% CI: 10.7, 22.8]), 7 additional days of hospital stay in those discharged alive, and death during hospitalization (AOR = 19.8 [95% CI: 12.0, 32.7]). Conclusions While COVID-19 can cause a respiratory illness like influenza, it is associated with significantly greater severity of illness, longer hospital stays, and higher in-hospital deaths., COVID-19 is commonly compared with a “flu-like” illness; however, even during a high-burden influenza season, COVID-19 causes greater severity and complications in hospitalizations with increased ICU admissions, need for mechanical ventilation, and death.

Objective Current clinical guidelines have proposed heart failure (HF) with mid-range ejection fraction (HFmrEF), defined as a left ventricular ejection fraction (LVEF) of 40%-49%, but the proportion and prognosis of patients transitioning toward HF with a reduced LVEF (LVEF

espanolObjetivo. Nuestro estudio tiene como objetivo describir las caracteristicas clinicas y evolucion de los pacientes infectados por SARS-CoV-2 tratados con siltuximab, de acuerdo con el protocolo local, con objetivo de bloquear precozmente la actividad de la Interleukina-6 evitando la progresion de la cascada inflamatoria. Pacientes y metodos. Estudio retrospectivo de los primeros 31 pacientes con COVID-19 tratados con siltuximab en el Hospital Clinic de Barcelona y en el Hospital Universitario de Salamanca, en el periodo de marzo a abril, que tenian una PCR en frotis nasal positiva para SARS-CoV-2. Resultados. Fueron incluidos 31 pacientes tratados con siltuximab, con una mediana (RIC) de edad de 62 anos (56-71) y una prevalencia de varones del 71%. La comorbilidad mas frecuente fue la hipertension arterial (48%). La mediana de dosis administrada de siltuximab fue 800 mg con un rango de 785 mg a 900 mg. Siete pacientes recibieron siltuximab como terapia de rescate despues de una dosis de tocilizumab. Al final del estudio, un total de 26 (83.9) pacientes recibieron alta hospitalaria vivos. La tasa de mortalidad fue de 16.1%, sin embargo, solo 1 de los 24 pacientes que recibieron siltuximab como primera linea de tratamiento fallecio (4%). Conclusiones. Siltuximab es una alternativa bien tolerada al uso de tocilizumab como primera linea de tratamiento para pacientes con neumonia por COVID-19 dentro de los primeros 10 dias de sintomas y con proteina C-reactiva elevada. EnglishObjectives. The study aims to describe characteristics and clinical outcome of patients with SARS-CoV-2 infection that received siltuximab according to a protocol that aimed to early block the activity of IL-6 to avoid the progression of the inflammatory flare. Patients and methods. Retrospective review of the first 31 patients with SARS-CoV-2 treated with siltuximab, in Hospital Clinic of Barcelona or Hospital Universitario Salamanca, from March to April 2020 with positive polymerase-chain reaction (PCR) from a nasopharyngeal swab. Results. The cohort included 31 cases that received siltuximab with a median (IQR) age of 62 (56-71) and 71% were males. The most frequent comorbidity was hypertension (48%). The median dose of siltuximab was 800 mg ranging between 785 and 900 mg. 7 patients received siltuximab as a salvage therapy after one dose of tocilizumab. At the end of the study, a total of 26 (83.9) patients had been discharged alive and the mortality rate was 16.1% but only 1 out of 24 that received siltuximab as a first line option (4%). Conclusions. Siltuximab is a well-tolerated alternative to tocilizumab when administered as a first line option in patients with COVID-19 pneumonia within the first 10 days from symptoms onset and high C-reactive protein.

Anaemia is highly prevalent at the time of intensive care unit discharge and is persistent for a high proportion of intensive care unit survivors. Whether anaemia is a driver of impaired recovery after critical illness is uncertain. The aim of this study was to test the hypothesis that, in adult intensive care survivors, anaemia at the time of intensive care unit discharge independently predicts decreased days at home-90. This retrospective cohort study was conducted in a tertiary intensive care unit in Perth, Western Australia. All patients aged ≥ 16 years, discharged alive from their index intensive care unit admission and without documented treatment limitations were included. Median (IQR [range]) age of the 6358 participants was 61 (46-72 [16-95]) years and included 3385 (53.2%) unplanned admissions. Intensive care unit discharge with a haemoglobin concentration

Aims This study aims to investigate hospital readmissions and timing, as well as risk factors in a real world heart failure (HF) population. Methods and results All patients discharged alive in 2016 from Sahlgrenska University Hospital/Östra, Gothenburg, Sweden, with a primary diagnosis of HF were consecutively included. Patient characteristics, type of HF, treatment, and follow‐up were registered. Time to first all‐cause or HF readmission, as well as number of 1 year readmissions from discharge were recorded. In total, 448 patients were included: 273 patients (mean age 78 ± 11.8 years) were readmitted for any cause within 1 year (readmission rate of 60.9%), and 175 patients (mean age 76.6 ± 13.7) were never readmitted. Among readmissions, 60.1% occurred during the first quarter after index hospitalization, giving a 3 month all‐cause readmission rate of 36.6%. HF‐related 1 year readmission rate was 38.4%. Patients who were readmitted had significantly more renal dysfunction (52.4% vs. 36.6%, P = 0.001), pulmonary disease (25.6% vs. 15.4%, P = 0.010), and psychiatric illness (24.9% vs. 12.0%, P = 0.001). Number of co‐morbidities and readmissions were significantly associated (P

BACKGROUND There is little consensus on factors associated with survival in foals with septic arthritis and limited data on long-term racing performance of Thoroughbred foals treated for septic arthritis. A more thorough understanding of short- and long-term outcome is necessary to help inform owners, and subsequently guide treatment. OBJECTIVES To investigate factors associated with survival, and to analyse racing performance of foals with septic arthritis compared with their maternal siblings. STUDY DESIGN Retrospective cohort and a case-control study. METHODS Veterinary clinical records of Thoroughbred foals ≤180 days old that underwent arthroscopic, cannulae or through-and-through needle lavage for the treatment of septic arthritis between 2009 and 2015 were reviewed. Data included signalment, and clinicopathological information. The dam's foaling records were reviewed and the lifetime racing records were obtained for affected foals and two of their maternal siblings. Logistic regression analysis was used to determine factors associated with survival to discharge or racing. Comparisons between treated foals and their maternal siblings were made. RESULTS Ninety (78%) of 115 foals diagnosed with septic arthritis were discharged alive. Foals

The aim of this study was to investigate the procedural and short-term safety and efficacy of a new leaflet-based transcatheter mitral valve repair system.The PASCAL repair system has been recently approved for percutaneous treatment of mitral regurgitation (MR). Novel characteristics are broad paddles positioned around a central spacer and the ability for independent leaflet capture.Procedural and 30-day outcomes were investigated in the first 309 patients with symptomatic MR 3+/4+ treated with the PASCAL repair system at 10 sites. Primary efficacy endpoints were technical success and degree of residual MR at discharge. The primary safety endpoint was the rate of major adverse events (MAE).Among the 309 patients (mean age 77 ± 10 years, 42% women, mean European System for Cardiac Operative Risk Evaluation II score 5.8 ± 4.5%) included in this study, MR etiology was degenerative in 33%, functional in 52%, and mixed in 16%. Eighty-six percent of patients were in New York Heart Association functional class III or IV. The technical success rate was 96%. Of 308 patients discharged alive, MR was ≤2+ in 93.5%. At 30 days, the MAE rate was 4.1%, with an estimated all-cause mortality rate of 2.0%, and 72% of patients were in New York Heart Association functional class ≤II (p 0.001). Rates of device success and CLASP (Edwards PASCAL Transcatheter Mitral Valve Repair System Study) trial-defined clinical success were 81.9% and 86.9%, respectively. Single-leaflet device attachment occurred in 7 patients (2.3%).Mitral valve repair with the PASCAL system in the early post-approval phase was effective and safe, with high procedural success rates and low rates of MAE. MR was significantly reduced, accompanied by significant improvement in functional status.

International audience; Purpose: Mesenteric ischaemia after successfully resuscitated cardiac arrest (CA) has been insufficiently studied. We aimed to assess the frequency, risk factors, and outcomes of non-occlusive mesenteric ischaemia (NOMI) after CA. Methods: We retrospectively included patients admitted to a CA centre with sustained return of spontaneous circulation between 2007 and 2017. NOMI was suspected based on clinical symptoms and classified as possible if no tests were feasible or the only test was a negative abdominal computed tomography (CT) scan and as confirmed if diagnosed by endoscopy, CT, or surgery. Results: Of 1343 patients, 82 (6%) had suspected NOMI, including 33 (2.5%) with confirmed NOMI. Investigations for suspected NOMI were done in 47/82 (57%) patients (CT, n = 30; lower digestive endoscopy, n = 14; and upper digestive endoscopy, n = 12); 11 patients underwent surgery. By multivariate analysis, factors associated with suspected NOMI were female sex (OR, 1.8; 95%CI, 1.1–2.9, p = 0.02), cardiovascular comorbidities (OR, 1.6; 95%CI, 1.0–2.7; p = 0.047), admission lactate >5 mmol/L (OR, 2.0; 95%CI, 1.2–3.4; p = 0.01), low flow >17 min (OR, 2.2; 95%CI, 1.3–3.8; p = 0.003), and inotropic score >7 μg/kg/min (OR, 1.8; 95%CI, 1.1–3.2; p = 0.03). ICU mortality was 96% (79/82), with 61% of patients dying from multi-organ failure (MOF) and 35% from post-anoxic brain injury. Of the eight patients who regained consciousness, 5 finally died from MOF, leaving 3 patients discharged alive from the ICU with a good neurologic outcome. Conclusions: NOMI may affect 2.5–6% of patients after CA. Mortality was extremely high in patients, and very few survived with a good neurological outcome.

Aim We assessed the ability of the Out-of-Hospital Cardiac Arrest (OHCA) and the Cardiac Arrest Hospital Prognosis (CAHP) scores to predict neurological outcome following in-hospital cardiac arrest (IHCA). Methods Retrospective review of a seven-year French multicentric database including ten intensive care units. Primary endpoint was the outcome at hospital discharge using the Cerebral Performance Category score (CPC) in all IHCA patients. OHCA and CAHP scores, sequential organ failure assessment (SOFA) score and the simplified acute physiological score 2 (SAPS-2) were compared using area under ROC curves (AUROC) and Delong tests. Results Among 381 included patients, 125 (33%) were discharged alive with favourable outcome (CPC 1–2). Among 256 patients (77%) with unfavourable outcome (CPC 3–5), 10 were discharged alive with CPC 3 (4%), 130 died from withdrawal of life sustaining therapies because of severe neurological impairment (51%), 107 died from multiorgan failure (42%) and 9 died after discharge from complications and comorbidities (3%). OHCA and CAHP scores were independently associated with unfavourable outcome. The AUROCs to predict unfavourable outcome for OHCA, CAHP, SAPS-2 and SOFA scores were 0.76 [0.70–0.80], 0.74 [0.69–0.79], 0.72 [0.67–0.77], and 0.69 [0.64–0.74] respectively, with a significant difference observed only between OHCA and SOFA scores AUROCs (p = 0.04). Conclusion In parallel with CAHP score, OHCA score could be used to early predict outcome at hospital discharge after IHCA. However, prediction accuracy for all scores remains modest, suggesting the use of other dedicated means to early predict IHCA patients’ outcome.

Background Traumatic abdominal herniation with or without evisceration occurs with some regularity in dogs and cats, usually secondary to blunt force trauma or penetrating injuries. Sporadic peer-reviewed case reports have described herniorrhaphies in reptiles and amphibians, but none have described successful repair of acute traumatic eviscerations in companion lizards with long-term follow-up. Case descriptions One crested gecko (Correlophus ciliatus) and two leopard geckos (Eublepharis macularius) were presented for evaluation of traumatic coelomic eviscerations. Two of the animals were attacked by cats, while the third was presumptively attacked by its conspecific cagemate. Two animals eviscerated segments of their small intestines, while one animal eviscerated small intestines, stomach, spleen, and parts of a liver lobe and a fat pad. All eviscerated organs in all animals appeared viable at the time of their respective surgeries. All three animals had uncomplicated herniorrhaphies, recovered without complications, and were discharged alive from the hospital within 24 hours of their surgeries. Two of the animals were confirmed to be alive and doing well at the time of submission of this manuscript in June 2020 (one at approximately six months after surgery and one at approximately four years after surgery), whereas the final case was known to have survived at least three months postoperatively before being lost to follow-up. Conclusions and case relevance While limited to three cases, this case series demonstrates that coelomic herniorrhaphy can be a viable procedure in companion geckos to correct acute traumatic coelomic evisceration.

BackgroundIncidence, predictors, and prognostic impact of recurrent acute myocardial infarction (AMI) after initial AMI remain poorly understood. Data on recurrent AMI in China is unknown.MethodsUsing the China Patient-centred Evaluative Assessment of Cardiac Events (PEACE)-Prospective AMI Study, we studied 3387 patients admitted to 53 hospitals for AMI and discharged alive. The association of recurrent AMI with 1-year mortality was evaluated using time-dependent Cox regression. Recurrent AMI events were classified as early (1–30 days), late (31–180 days), and very late (181–365 days). Their impacts on 1-year mortality were estimated by Kaplan-Meier methodology and compared by the log-rank test. Multivariable modelling was used to identify factors associated with recurrent AMI.ResultsThe mean (SD) age was 60.7 (11.9) years and 783 (23.1%) were women. The observed 1-year recurrent AMI rate was 2.5% (95% CI 2.00 to 3.07) with 35.7% events occurring within the first 30 days. Recurrent AMI was associated with 1-year mortality with an adjusted HR of 25.42 (95% CI 15.27 to 42.34). Early recurrent AMI was associated with the highest 1-year mortality rate of 53.3% (log-rank p90 min/beats at initial admission, renal dysfunction, and not being prescribed any of guideline-based medications at discharge.ConclusionsOne-third of recurrent AMI events occurred early. Recurrent AMI is strongly associated with 1-year mortality, particularly if early. Heightened surveillance during this early period and improving prescription of recommended discharge medications may reduce recurrent AMI in China.

Background & Aims Although abnormal liver chemistries are linked to a higher risk of coronavirus disease 2019 (COVID‐19)‐related death, liver manifestations may be diverse and even confusing. Thus, we performed a meta‐analysis of published liver manifestations and described the liver damage in patients with COVID‐19 who died or discharged alive. Approach & Results We searched PubMed, Google Scholar, medRxiv, bioRxiv, the Cochrane Library, Embase, and three Chinese electronic databases through April 22, 2020. We analyzed pooled data on liver chemistries stratified by the main clinical outcome of COVID‐19, using a fixed or random‐effects model. In our meta‐analysis of 19 studies, which included a total of 4,103 patients, the pooled mean alanine aminotransferase and aspartate aminotransferase levels were respectively 31.7 and 51.0 IU/L in the patients with COVID‐19 who died and 27.7 and 32.9 IU/L in those discharged alive (both p < 0.0001). Compared with the patients discharged alive, those who died tended to have lower albumin levels but longer prothrombin time and higher international standardized ratio. Conclusions In this meta‐analysis, according to the main clinical outcome of COVID‐19, we comprehensively described three patterns of liver impairment related to COVID‐19, hepatocellular injury, cholestasis, and hepatocellular disfunction. The patients who died from COVID‐19 tended to have different liver chemistries from those discharged alive. Special caution should be given to the patients with relatively higher index of liver chemistries.

BackgroundInformation regarding the impact of cardiovascular disease (CVD) on disease progression among patients with mild coronavirus disease 2019 (COVID-19) is limited.MethodsThis study evaluated the association of underlying CVD with disease progression in patients with mild COVID-19. The primary outcome was the need to be transferred to intensive care due to disease progression. The patients were divided with and without CVD as well as stable and intensive care groups.ResultsOf 332 patients with mild COVID-19, median age was 51 years (IQR, 40-59 years), and 200 (61.2%) were female. Of 48 (14.5%) patients with CVD, 23 (47.9%) progressed to severe disease status and required intensive care. Compared with patients without CVD, patients with CVD were older, and more likely to have fatigue, chest tightness, and myalgia. The rate of requiring intensive care was significantly higher among patients with CVD than in patients without CVD (47.92% vs. 12.4%; PConclusionsPatients with mild COVID-19 complicating CVD in are susceptible to develop severe disease status and requirement for intensive care.Key PointsQuestionWhat is the impact of coexisting cardiovascular diseases (CVD) on disease progression in patients with mild COVID-19?FindingsAlthough most patients with mild COVID-19 were discharged alive from hospital, approximately 47.9% patients with coexisting CVD developed severe disease status and required intensive care. CVD is an independent risk factor of intensive care among patients with mild COVID-19.MeaningCoexisting CVD is associated with unfavorable outcomes among patients with mild COVID-19. Special monitoring is required for these patients to improve their outcome.

Objective:Methods that include the time-varying nature of healthcare-associated infections (HAIs) avoid biases when estimating increased risk of death and excess length of stay. We determined the excess mortality risk and length of stay associated with HAIs among inpatients in Singapore using a multistate model that accommodates the timing of key events.Design:Analysis of existing prospective cohort study data.Setting:Seven public acute-care hospitals in Singapore.Patients:Inpatients reviewed in a HAI point-prevalence survey (PPS) conducted between June 2015 and February 2016.Methods:We modeled each patient’s admission over time using 4 states: susceptible with no HAI, infected, died, and discharged alive. We estimated the excess mortality risk and length of stay associated with HAIs, with adjustment for the baseline characteristics between the groups for mortality risk.Results:We included 4,428 patients, of whom 469 had ≥1 HAI. Using a multistate model, the expected excess length of stay due to any HAI was 1.68 days (95% confidence interval [CI], 1.15–2.21 days). Surgical site infections were associated with the longest excess length of stay of 4.68 days (95% CI, 2.60–6.76 days). After adjusting for baseline differences, HAIs were associated with increased hazards of in-hospital mortality (adjusted hazard ratio [aHR], 1.32; 95% CI, 1.09–1.65) and decreased hazards in being discharged (aHR, 0.75; 95% CI, 0.67–0.84).Conclusions:HAIs are associated with increased length of hospital stay and mortality in hospitalized patients. Avoiding nosocomial infections can improve patient outcomes and free valuable bed days.

Hospice social workers face many challenges in attempts to replicate or supplement the holistic support and unique services hospice provides for individuals discharged alive. This discontinuity in care can impact the types of supports needed by individuals and caregivers, which may or may not be accessible within their community. Patients and families who have access to community-based palliative care programs following a discharge generally tend to navigate the process with fewer challenges. This qualitative study (N = 24) explored both the challenges of the live discharge process and the opportunities within social work practice in the US. Results from this study emphasize the need for a framework to better approach a live discharge to ensure appropriate supports are accessible for all patients and caregivers. Specifically, results highlight both the concrete and psychosocial challenges in live discharges as a result of tension between current eligibility requirements and individual feelings and needs. Social workers also provided suggestions to improve the live discharge process, including attention to communication and preparation. This paper outlines specific challenges of live discharge from hospice, a framework for understanding presented challenges, and implications for policy and practice.

Background: The use of implantable cardiac devices in patients with sudden cardiac arrest has contributed to their survival. Aim: To determine the survival rate at 30 days and one year after hospital discharge of patients who had a cardiac arrest with subsequent placement of an implantable cardiac device. Material and Methods: Twenty-three patients older than 18 years who presented sudden extra-institutional or intra-institutional death with subsequent implantation of an implantable cardiac device and whose survival was recorded at 30 days and one year, were included. A univariate analysis was performed. Results: Eighteen patients had an extra institutional cardiac arrest. All patients were discharged alive. We could not ascertain the health status of one patient at follow-up. Twenty-one patients had a Cerebral Performance Category (CPC) of 1 at discharge. One patient died of a stroke within 30 days and one patient died due to an arrhythmic electrical storm one year later. Twenty patients survived at least one year after hospital discharge. Conclusions: Survival at 30 days and one year, was high in patients with sudden death or cardiac arrest who required intracardiac devices.

Secondary overtriage (OT) is the unnecessary transfer of injured patients between facilities. In low- and middle-income countries (LMICs), which shoulder the greatest burden of trauma globally, the impact of wasted resources on an overburdened system is high. This study determined the rate and associated characteristics of OT at a Malawian central hospital. A retrospective analysis of prospectively collected data from January 2012 through July 2017 was performed at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. Patients were considered OT if they were discharged alive within 48 h without undergoing a procedure, and were not severely injured or in shock on arrival. Factors evaluated for association with OT included patient demographics, injury characteristics, and transferring facility information. Of 80,915 KCH trauma patients, 15,422 (19.1%) transferred from another facility. Of these, 8703 (56.2%) were OT. OT patients were younger (median 15, IQR: 6–31 versus median 26, IQR: 11–38, p

INTRODUCTION Extremely low birth weight (ELBW) children (birth weight ≤1000 g) are at risk of adverse neurodevelopmental outcome. The objectives of this study were to determine the prevalence of developmental disorders and disabilities among ELBW children born in Iceland during a 25 year period and to assess which clinical factors predict disability among these children. MATERIAL AND METHODS A retrospective study of all ELBW children born in Iceland 1988-2012 and discharged alive. The study group was found in the Children´s Hospital of Iceland NICU registry. Information was gathered from the NICU registry, the children´s and their mothers´ medical records and the State Diagnostic and Counselling Centre database. RESULTS Of 189 children 45 (24%) had developmental disorders, 13 (7%) had mild disorders and 32 (17%) had major disorders (disability) at 3-6 years. Risk factors for disability were multiple birth (RR 2.21; 95% CI: 1.19-4.09), Apgar < 5 after one minute (RR 2.40; 95% CI: 1.14-5.07), the initiation of enteral feeding more than four days after birth (RR 2.14; 95% CI: 1.11-4.11), full enteral feeding achieved after more then 21 days (RR 2.15; 95% CI: 1.11-4.15), neonatal pneumonia (RR 3.61; 95% CI: 1.98-6.57) and PVL (RR 4.84; 95% CI: 2.81-8.34). CONCLUSION The majority of ELBW children do not have major developmental disorders. The rate of disability in this study is similar to other studies. The study probably underestimates the rate of mild developmental disorders in the Icelandic population. Risk factors for disability in this study are comparable to previous studies.

IntroductionIt remains unclear if the development of health services, clinical management, and scientific evidence, during the pandemic is associated with better medical outcomes, sustained in the long term, for Covid-19 patients of each gender. This study presents the trends in mortality associated with Covid-19 for women and men during the first year of the pandemic.MethodsThis study was based in 17 Spanish hospitals. Sociodemographic, clinical, and mortality data from all patients with Covid-19, who had been discharged alive, or had died after being admitted, between March 2020 and February 2021, were used.The association between time of admission and mortality was examined with multivariate logistic regression models.Results3390 Covid-19 patients were included in the study, of which 1330 were women, the age was M(SD): 66.55(16.55) Death was reported for 451 patients. There was a significant decreasing trend in mortality by time of admission for the whole year with an OR: 0.86(0.77-0.96) p=0.005. No significant trend in mortality for women was observed OR: 1.00(0.85-1.19) p=0.959, while there was a significant decreasing trend for men OR: 0.78 (0.68-0.90) p=0.001DiscussionThe health policies put in place, the scientific evidence developed by researchers, and the experienced acquired by clinicians, are likely to explain this improvement in mortality. More epidemiological and clinical studies addressing trends of mortality in patients with different sociodemographic and clinical profile and the improvement of clinical outcomes are required. Future research may address the safety and efficacy of interventions specifically in female patients.

Background Type 2 myocardial infarction (T2MI) is common and associated with high cardiovascular event rates. However, the relationship between T2MI and heart failure (HF) is uncertain. Methods and Results We identified patients with T2MI at a large tertiary hospital between October 2017 and May 2018. Patient characteristics, causes of T2MI, and subsequent HF hospitalizations were determined by physician chart review. We identified 359 patients with T2MI over the study period; 184 patients had a history of HF. Among patients with ejection fraction (EF) assessment (N=180), the majority had preserved EF (N=107; 59.4%), followed by reduced EF (N=54; 30.0%), and mid‐range EF (N=19; 10.6%). Acute HF was the most common cause of T2MI (20.9%). Of those whose T2MI was precipitated by HF (N=75), the mean EF was 53.0±16.8% and 16 (21.3%) were de novo diagnoses of HF. Among patients with T2MI who were discharged alive with available follow‐up (N=289), 5.5% were hospitalized with acute HF within 30 days, 17.3% within 180 days, and 22.1% within 1 year. In subgroup analyses, among patients with T2MI with prevalent or new HF (N=161), the rate of HF hospitalization at 1 year was 34.2%, considerably higher than those with T2MI and no HF diagnosis at discharge (7.0%; N=9/128). Conclusions Index presentations of HF or worsening chronic HF represent the most common causes of T2MI. ≈1 in 5 patients with T2MI will be readmitted for HF within 1 year of their event. Strategies to prevent HF events after a T2MI are needed.

Background The coronavirus disease 2019 (COVID-19) pandemic may have affected the preventability of 30-day hospital revisits, including readmissions and emergency department (ED) visits without admission. This study was conducted to examine the preventability of 30-day revisits for patients admitted with COVID-19 in order to inform the design of interventions that may decrease preventable revisits in the future. Methods The study team retrospectively reviewed a cohort of adults admitted to an academic medical center with COVID-19 between March 21 and June 29, 2020, and discharged alive. Patients with a 30-day revisit following hospital discharge were identified. Two-physician review was used to determine revisit preventability, identify factors contributing to preventable revisits, assess potential preventive interventions, and establish the influence of pandemic-related conditions on the revisit. Results Seventy-six of 576 COVID-19 hospitalizations resulted in a 30-day revisit (13.2%), including 21 ED visits without admission (3.6%) and 55 readmissions (9.5%). Of these 76 revisits, 20 (26.3%) were potentially preventable. The most frequently identified factors contributing to preventable revisits were related to the choice of postdischarge location and to patient/caregiver understanding of the discharge medication regimen, each occurring in 25.0% of cases. The most frequently cited potentially preventive intervention was “improved self-management plan at discharge,” occurring in 65.0% of cases. Five of the 20 preventable revisits (25.0%) had contributing factors that were thought to be directly related to the COVID-19 pandemic. Conclusion Although only approximately one quarter of 30-day hospital revisits following admission with COVID-19 were potentially preventable, these results highlight opportunities for improvement to reduce revisits going forward.

Coronavirus disease 2019 (COVID-19) has spread across the globe with its consequent human and economic challenges. To achieve effective control of the pandemic, efforts need to be holistic and global. Understanding patients’ demographics and clinical characteristics will assist in the control of the infection. However, there is a paucity of studies on the clinical presentation of COVID-19 patients from Nigeria and indeed Africa. Thus, this retrospective case series evaluated the medical records of COVID-19 patients admitted in a tertiary hospital in Nigeria. Patients’ demographics, and other clinical variables were assessed and presented. Data of 14 patients with complete records were included in the study. Most of the patients (78.6%) were males and the mean age of the study participants is 63.5 years (SD; 11.5). The commonest presenting symptoms were fever (93%), cough (71.4%), and dyspnoea (57.1%). At presentation, 13 patients had coexisting diseases while 8 (57.0%) patients had moderate disease and the remaining 6 (43.0%) had severe cases. After management, 1 patient died, two were referred and 11 recovered and were discharged alive. Thus, this study has identified advanced age, male gender, and comorbidity as increased risk factors for hospitalisation. The patient survival outcome in this study was also good.

Context: Amid the COVID-19 surge in New York City, the need for palliative care was highlighted. Virtual consultation was introduced to expand specialist-level care to meet demand. Objectives: To examine the outcomes of COVID-19 patients who received virtual palliative care consultation from outside institutions. Design: This is a retrospective case series. Setting/Subjects: Subjects were 34 patients who received virtual palliative care consultation between April 13, 2020, and June 14, 2020. Measurements: Follow-up frequency and duration, code status change, withdrawal of life-sustaining treatment (LST), and multidisciplinary involvement. Results: Twenty-eight patients (82.3%) were in the intensive care unit and 29 patients (85.3%) were on at least two LSTs. Fifteen patients (44.1%) died in the hospital, 9 patients (26.4%) were discharged alive, and 10 patients (29.4%) were signed off. The median frequency of visits was 4.5 (IQR 6) over 11 days follow-up (IQR 17). Code status change was more frequent in deceased patients. LSTs were withdrawn in eight patients (23.5%). Conclusions: Virtual palliative care consultation was feasible during the height of the COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) has been shown to affect the cardiovascular system, and several cases of takotsubo syndrome (TTS) induced by COVID-19 have been reported. TTS predominantly affects postmenopausal women in western countries, but the prevalence in men is higher in Asian populations. It should be noted that male patients with either TTS or COVID-19 are associated with higher mortality. Despite the higher prevalence of TTS in Asian men, little is known about Asian men with TTS induced by COVID-19. This is a case report of a 60-year-old Asian male with biventricular TTS precipitated by COVID-19. He presented with acute respiratory distress syndrome, cardiogenic shock, and acute kidney injury. He required intubation, multiple vasopressors, and renal replacement therapy. The left ventricular ejection fraction was 15%, but it normalized in 5 weeks. The patient had a prolonged hospital stay in a critical condition, but was eventually discharged alive. The scarce literature about this condition in Asian male populations and the increasing number of COVID-19 cases in Asian countries highlight the rarity and importance of this case. Further studies are warranted to investigate the uneven sex distribution and outcomes of TTS triggered by COVID-19 in an Asian population. .

BACKGROUND/OBJECTIVE The aims of this study were to describe the rates and characteristics of nonelective 30-day readmission among adult patients hospitalized for acute gout and to assess predictors of readmission. METHODS We analyzed the 2017 Nationwide Readmission Database. Gout hospitalizations were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification code. Hospitalizations for adult patients were included. We excluded planned or elective readmissions. We utilized χ2 tests to compare baseline characteristics between readmissions and index hospitalizations. We used multivariate Cox regression to identify independent predictors of readmissions. RESULTS A total of 11,727 index adult hospitalizations with acute gout listed as the principal diagnosis were discharged alive and included. One thousand five hundred ninety-four (13.6%) readmissions occurred within 30 days. Acute gout was the most common reason for readmission. Readmissions had higher inpatient mortality (2.4% vs 0.1%, p < 0.0001), greater mean age (68.1 vs 67.0 years, p = 0.021), and longer hospital length of stay (5.9 vs 3.8 days, p < 0.0001) compared with index hospitalizations. Charlson Comorbidity Index scores of ≥2 (score 2: adjusted hazards ratio [AHR], 1.67; p = 0.001; score ≥3: AHR, 2.08; p < 0.0001), APR-DRG (All Patients Refined Diagnosis Related Groups) severity levels ≥2 (level 2: AHR, 1.43; p = 0.044; level 3: AHR, 1.83; p = 0.002; level 4: AHR, 2.38; p = 0.002), admission to metropolitan hospital (AHR, 1.83; p = 0.012), atrial fibrillation (AHR, 1.31; p = 0.004), and anemia (AHR, 1.30; p = 0.001) were significantly associated with 30-day readmissions. CONCLUSIONS Acute gout readmissions were associated with worse outcomes compared with index hospitalizations. Charlson Comorbidity Index scores ≥2, APR-DRG severity levels ≥2, admission to metropolitan hospital, atrial fibrillation, and anemia were significant predictors of readmission.

Objective We aimed to analyze trends of 30-day readmission and find high-risk patients associated with increased risk of mortality, resource use, and readmission after primary left ventricular assist device (LVAD) implantation. Limited data exist on the contemporary trends of readmission rates and patients at a higher risk of worse outcomes after LVAD implantation. Methods and Results This is a retrospective study of adults from the Nationwide Readmission Database who underwent primary durable LVAD implantation from 2010 to 2018. The main outcomes were 30-day readmission rates and their trends in patients with primary durable LVAD implantation from 2010 to 2018. This study also sought to identify patients at the highest risk for readmission, in-hospital mortality, and resource use. A total of 31,002 adults with primary durable LVAD implantation were included in the present analysis. Overall, 3808 patients (12.3%) died and 27,168 (87.6%) were discharged alive. Of those discharged alive, 8303 patients (30.6%) were readmitted within 30 days. The trend of 30-day all-cause readmission among LVAD implantation patients remained similar from 2010 to 2018 (P = .809). The in-hospital mortality rate during the index hospitalization decreased significantly (P = .014), and the mean cost of an index hospitalization increased (P = .031) during the study period. The patients with post-LVAD in-hospital cardiac, vascular, and thromboembolic complications (ie, high-risk patients) had the highest mortality, resource use, and readmission rates compared with patients without major complications. Conclusions This study found that the readmission rates associated with LVAD implantation did not change from 2010 to 2018 and identified high-risk patients who may benefit from closer monitoring after primary LVAD implantation.

International audience; As of today, little data is available on COVID-19 in African countries, where the case management relied mainly on a treatment by association between hydroxychloroquine (HCQ) and azithromycin (AZM). This study aimed to understand the main clinical outcomes of COVID-19 hospitalized patients in Senegal from March to October 20202. We described the clinical characteristics of patients and analysed clinical status (alive and discharged versus hospitalized or died) at 15 days after Isolation and Treatment Centres (ITC) admission among adult patients who received HCQ plus AZM and those who did not receive this combination. A total of 926 patients were included in this analysis. Six hundred seventy-four (674) (72.8%) patients received a combination of HCQ and AZM. Results showed that the proportion of patient discharge at D15 was significantly higher for patients receiving HCQ plus AZM (OR: 1.63, IC 95% (1.09–2.43)). Factors associated with a lower proportion of patients discharged alive were: age ≥ 60 years (OR: 0.55, IC 95% (0.36–0.83)), having of at least one pre-existing disorder (OR: 0.61, IC 95% (0.42–0.90)), and a high clinical risk at admission following NEWS score (OR: 0.49, IC 95% (0.28–0.83)). Few side effects were reported including 2 cases of cardiac rhythmic disorders in the HCQ and AZM group versus 13 in without HCQ + AZM. An improvement of clinical status at 15 days was found for patients exposed to HCQ plus AZM combination

Introduction: Psoriasis is known to increase the risk of type 1 diabetes mellites. This study aims to compare rates and outcomes of 30-day readmissions following admissions for type 1 diabetic ketoacidosis (T1DKA) in patients with and without psoriasis in the United States. Methods: We analyzed the 2018 National Readmission Database. We included index hospitalizations for all patients (aged≥18 years) with a principal diagnosis of T1DKA using ICD-10 codes. We further sub-stratified this group into those with and with a secondary diagnosis of psoriasis. Chi-square tests and regression analysis were used to compare 30-day readmission rates and readmission outcomes between both groups. We excluded elective and traumatic readmissions. Results: A total of 94,461 index hospitalizations for T1DKA, that were discharged alive, were included in the analysis. 357 (0.4%) of these, had co-existing psoriasis. 15,614 (16.5%) readmissions occurred within 30 days. Readmission rates were similar between psoriasis and non-psoriasis group (15.0% vs. 16.5%, p=0.663). The psoriasis group had a similar mean hospital length of stay (3.3 days vs. 2.9 days, p=0.077) and total hospital costs ($8,435 vs. $7,231, p=0.055) compared to the non-psoriasis group. Readmissions for T1DKA in psoriasis patients was associated with a total of 1,191 hospital days and $3,014,844 in-hospital costs. T1DKA without coma was the most common reason for readmission in both groups. Conclusion: Psoriasis patients admitted for T1DM have similar 30-day readmission rates and readmission outcomes compared to non-psoriasis patients admitted for TIDM. Disclosure E. Edigin: None. P. E. Ojemolon: None. H. Shaka: None. P. O. Eseaton: None. M. Almani: None. D. Jakhar: None. I. R. Asemota: None. E. Akuna: None.

ObjectiveThe objective of this study was to examine the impact of timely treatment and identification of sepsis on patient outcomes at Sutter Health, a mixed-payer healthcare system in northern California, US.MethodsThis observational, retrospective analysis considered electronic health record (EHR) data for individuals who presented with sepsis during 2016-17 at any of Sutter Health’s 22 emergency departments (ED). Impacts were assessed for the timing of broad-spectrum antibiotic and intravenous (IV) fluid initiation, first vital signs, sepsis screening, and lactate results. Outcomes were in-hospital mortality, hospital length of stay (LOS) and intensive care unit (ICU) hours for patients discharged alive.ResultsThe final sample size was 35,847 (N=9,638 severe sepsis, N=5,309 septic shock). Early fluid initiation had the largest estimated impacts: a mortality reduction of 2.85%[2.03%,3.68%] overall and 2.94%[1.44%,4.48%] for severe sepsis (within 1 hour of sepsis presentation), and 14.66%[9.23%,20.07%] for septic shock (within 3 hours); reduced LOS (days) 1.39[1.08,1.71] overall, 2.30[1.31,3.21] severe sepsis, 3.07[1.21,4.94] septic shock; and fewer ICU hours 25.93[16.95,34.66] overall, 35.06[14.7,56.99] severe sepsis, 41.99[15.70,70.68] septic shock (within 3 hours). Sepsis screening within 30 minutes was also associated with mortality reductions (3.88%[2.96%,4.90%] overall, 1.74%[0.08%,3.50%] severe sepsis, 6.78%[3.12%,10.33%] septic shock). The greatest improvement opportunity was estimated for joint initiation of antibiotics and IV fluids, with a modest additional mortality reduction of 0.80%[0.47%,1.17%] overall, 0.77%[0.34%,1.19%] severe sepsis, 2.94%[1.83%,3.97%] septic shock; LOS reduction of 0.37[0.28,0.46] overall, 0.29[0.17,0.43] severe sepsis, 0.25[0.01,0.51] septic shock (within 1 hour); ICU hours reduction of 4.85[3.26,6.57] overall, 5.07[2.55,7.67] severe sepsis, 3.85[1.69,6.24] septic shock (within 3 hours).

OBJECTIVE To describe the treatment of goats with urethral obstruction secondary to urolithiasis by combining tube cystostomy and urethrotomy. ANIMALS Eight male goats. STUDY DESIGN Short case series. METHODS Medical records (September 2012-September 2017) of male goats treated for obstruction secondary to urolithiasis with tube cystostomy and urethrotomy were reviewed. Data collected included signalment, history, physical examination findings, diagnostic results, perioperative treatments, operative details, hospitalization duration, intraoperative and postoperative complications, urolith analysis, and time to restoration of urethral patency. Long-term follow-up (>12 months) was obtained by email or telephone interviews of owners or by clinical examination. RESULTS Seven of eight goats were castrated males of various of breeds. All goats were tachycardic with urethral pulsation at admission. Uroliths were composed of calcium carbonate in four goats and silica in one goat. All goats regained urethral patency during hospitalization, and all were discharged alive from the hospital. Seven goats were alive at long-term follow-up. Postoperative complications included persistent urethral obstruction requiring a second urethrotomy 2 days postoperatively, premature dislodgement of the bladder catheter and jejunal obstruction secondary to adhesions, and recurrence of obstructive urolithiasis within the proximal perineal urethra requiring a second surgery 8 months later (1 each). Long-term outcome was good, with urethral patency beyond 12 months in six of eight goats. CONCLUSION Combining tube cystostomy and urethrotomy restored urethral patency in goats with urethral obstruction from uroliths. Although none of the complications seemed directly related to the urethrotomy, formation of abdominal adhesions and recurrence of urolithiasis affected long-term outcomes. CLINICAL SIGNIFICANCE Uroliths that do not dissolve in acidic urine may be more frequent in some practices. The combined approach of tube cystostomy and urethrotomy appears to successfully restore urethral patency with promising long-term outcomes.

Background The study aims to determine long-term survival, health-related quality of life (HRQoL) and functional and physical outcomes of adult extra corporeal membrane oxygenation (ECMO) patients as there are limited and conflicting data in this area. Methods All patients receiving ECMO from April 2009 until June 2014 at The Prince Charles Hospital, Brisbane had Kaplan Meier survival calculated. Quality of life (QoL) was assessed using the Short Form Health Survey (SF-36v2), EQ5D-5L, The Frenchay Activities Index (FAI) and a return to work survey. From December 2011, these measures and 6-minute walk distance (6MWD) were assessed at hospital discharge and 12 months post-discharge. Results Seventy-seven (77) patients (45 veno-arterial and 32 veno-venous) received ECMO of whom 47/77 (61%) survived to hospital discharge. There were no deaths recorded in those discharged alive from the intensive care unit at median follow-up time 1,011 days (range 227–2,014 days). Mean SF-36 scores (n = 33) and EQ5D were assessed at a median of 606 days after hospital discharge. SF-36 scores were significantly (p < 0.05) worse than age-matched norms in all domains except vitality, bodily pain and mental health. Thirteen (13) (39%) participants had persistent problems with mobility and usual activity as measured by EQ5D. At 12 months post-ECMO, 6MWD was 531(IQR:397.3–626.8)m; 72% (IQR:53.2–77.6%) predicted but had improved by 223 m (p = 0.002) when compared to baseline. Nineteen (19) of 20 participants who had been employed pre-ECMO had returned to work. Conclusions All ECMO patients discharged from hospital were alive at follow-up. Despite improvements in physical measures and HRQoL, long-term functional deficits persist when compared to that of aged- and sex-matched norms.

Aim Although survival from out-of-hospital cardiac arrest (OHCA) is improving, little is known about the long-term outcome of survivors. In this study, we assess the impact of sex on 12 month functional recovery and health-related quality-of-life (HRQoL) outcomes in OHCA survivors. Methods Between 2010 and 2016, consecutive adult OHCA survivors were invited to participate in structured telephone interviews using the Glasgow Outcome Scale–Extended (GOSE), the EuroQol-5D (EQ-5D), and 12-Item Short Form (SF-12) health survey. Results Of the 2300 patients discharged alive, 175 (7.6%) died during the follow-up period with the rate of death at 12 months being higher in women compared to men (10.4% vs. 6.4%; p = 0.002). Of the 2125 12 month survivors, 1752 (82.5%) participated in the interviews. Unadjusted outcomes were consistently poorer for females compared to males, with fewer women reporting good functional recovery (GOSE ≥ 7, 53.5% vs. 64.8%, p Conclusions Women report poorer functional recovery and HRQoL after OHCA. Further research is needed to better understand the reasons for these disparities.

AIMS: There are regional differences in the patient characteristics, management, and outcomes of hospitalized patients with heart failure (HF). The aim of this study was to evaluate the clinical characteristics and outcomes of Japanese patients who are hospitalized with HF on the basis of the left ventricular ejection fraction (LVEF) stratum. METHODS AND RESULTS: We retrospectively conducted a multicentre cohort study of 1245 hospitalized patients with decompensated HF between 2013 and 2014. Of these patients, 36% had an LVEF < 40% [HF with reduced ejection fraction (HFrEF), median age 72 years, 71% male], 21% had an LVEF 40-49% [HF with mid-range EF (HFmrEF), 77 years, 56% male], and 43% had an LVEF ≥ 50% [HF with preserved EF (HFpEF), 81 years, 44% male]. The primary outcome was death from any cause, and the secondary outcomes were cardiac death and re-hospitalization due to worsened HF after hospital discharge. There were high proportions of non-ischaemic cardiomyopathy (32%) in HFrEF patients, coronary artery disease (44%) in HFmrEF patients, and valvular disease (39%) in HFpEF patients. The frequencies of intravenous diuretic and natriuretic peptide administration during hospitalization were 66% and 30%, respectively. The median hospital stay for the overall population was 19 days, and the length of stay was >7 days for >90% of patients. In-hospital mortality was 7%, but was not different among the LVEF groups (HFrEF 7%, HFmrEF 6%, and HFpEF 8%). After a median follow-up of 19 months (range, 3-26 months), 192 (17%) of the 1156 patients who were discharged alive died, and 534 (46%) were re-hospitalized after hospital discharge. There were no significant differences in mortality after hospital discharge among the three LVEF groups (HFrEF 18%, HFmrEF 16%, and HFpEF 16%). There were no differences in cardiac death or re-hospitalization due to worsened HF after hospital discharge among the LVEF groups (cardiac death: HFrEF 8%, HFmrEF 7%, and HFpEF 7%; re-hospitalization due to worsened HF: HFrEF 19%, HFmrEF 16%, and HFpEF 17%). Multivariable-adjusted analyses showed that the HFmrEF and HFrEF groups, compared with the HFpEF group, were not associated with an increased risk for in-hospital death or death after hospital discharge. Non-cardiac causes of death and re-hospitalization after hospital discharge accounted for 35% and 38%, respectively. CONCLUSIONS: Our results revealed different clinical characteristics but similar mortality rates in the HFrEF, HFmrEF, and HFpEF groups. The most common cause of death and re-hospitalization after hospital discharge was HF, but non-cardiac causes also contributed to their prognosis. Integrated management approaches will be required for HF patients. peerReviewed

Aim Ongoing hepatitis A outbreaks among men who have sex with men (MSM) have been reported worldwide, mainly in Europe, since 2016. In Japan, there has been an increase in the number of notified hepatitis A cases since January 2018, most of which were suspected to have been transmitted through homosexual contact. In this paper, we describe the current outbreak situation of hepatitis A among MSM. Methods Between March and July 2018, 13 cases of hepatitis A were identified in our hospital. All cases were identified as MSM. Data on clinical and laboratory findings and therapies were collected from medical records. Serum or stool samples were obtained from 13 patients and subjected to sequence analysis. Results Of all patients, 12 reported to have male-to-male homosexual contact within 7 weeks prior to symptom onset, and 6 visited sex-on-premises venues in the same area. Furthermore, 12 patients were infected with HIV and consequently received antiretroviral therapy with sustained viral suppression. Ten patients received pulsed methylprednisolone therapy. Plasma exchange was additionally carried out in one patient. All patients received inpatient hospital care and were discharged alive. Sequence information, which was available in all cases, showed that the hepatitis A virus strain was identical to the EuroPride strain (RIVM-HAV16-090). Conclusions Results of sequence analysis suggest that the ongoing hepatitis A outbreak among MSM in Japan is linked to the 2016 European outbreaks. A vaccination program is urgently required for high-risk populations to control this ongoing outbreak.

Background: MERS-CoV emerged as a zoonotic disease in Saudi Arabia with 1437 cases as of July 2016. This study aimed at describing the epidemiology of MERS-CoV infection, clinical aspects of the disease and the determinants of survival. Methods: The medical records of Prince Mohamed Bin Abdulaziz Hospital were reviewed between April 2014 and December 2015 to identify admission and discharge with MERS-CoV. Patient’s characteristics, epidemiologic and clinical data and laboratory results were extracted and described. Logistic regression analyses were used to model the determinants of the survival of these patients. Significance of the results were judged at the 5% level. Results: 249 confirmed cases were admitted mostly in August (20.48%) and September (14.86%) of the year 2015. A third (39.36%) reported contact with an index case, developed the disease after 6.2 days and continued to shed the virus for 13.17 days on average. The case fatality rate was 20.08%. Independent predictors of being discharged alive among confirmed cases were younger age (ORA = 0.953), breathing ambient air (ORA = 8.981), not being transferred to the ICU (ORA = 24.240) and not receiving renal replacement therapy (ORA = 8.342). These variables explain 63.9% of the variability of patients’ status at discharge. Conclusion: MERS-CoV spread from human-to-human as community acquired and nosocomial infection. The study identified high risk patients in need for special medical attention in order to improve patients’ outcome. Keywords: MERS-CoV, Epidemiology, Determinants of survival, Saudi Arabia

Recently we developed and internally-validated the Soroka Acute Myocardial Infarction (SAMI) Score for prediction of all-cause long-term mortality (c-statistic 0.83-0.94) among hospital-survivors of AMI. We aimed to perform an external-validation of the SAMI score for long-term risk-stratification of STEMI patients undergoing PCI.A prospective registry of 1273 STEMI patients treated using primary PCI and discharged alive from Rabin Medical Center in Israel between 2004 and 2014 (age 60.8 ± 12.5 years, 83% males) was utilized for the validation. Chi-square test and logistic regression were used for calibration, and c-statistic (ROC procedure) for discrimination assessment of the SAMI score.All-cause mortality following one- and 5-years post-discharge was 3.8% and 8.1%, respectively. SAMI score values ranged between (-5) and (+15) points (median 2-points). In a univariate analysis the SAMI score variables were significantly associated with 1- and 5-years mortality. Higher SAMI score was associated with increased risk for dying: a one-point increase was associated with OR of 1.33 (95%CI: 1.24-1.42, p 0.001) and 1.37 (95%CI: 1.29-1.44, p 0.001) for 1- and 5-years mortality respectively. No statistically significant difference was found in the currently observed mortality rates by groups of SAMI score and the expected mortality rates as per the SAMI score index. The c-statistics were 0.82 and 0.83 for 1- and 5-year mortality, respectively.The SAMI score is a simple, robust and now also externally-validated prognostic tool for prediction of long-term all-cause mortality in hospital survivors of STEMI.

Hospice provides holistic support for individuals living with terminal illness and to their caregivers during the bereavement period. However, some individuals who enroll in hospice services are decertified as they do not experience a decline in health as quickly as required by current regulations, a practice referred to as a live discharge. The interruption in care can affect the physical and psychosocial care needs for individuals and caregivers and leave hospice clinicians with questions about how to best support them. However, there are no formal guidelines to support this process. This qualitative study (N = 24) explored the current practices of hospice social workers across the United States engaged in the live discharge process. Results from this study emphasize the need to bridge the gaps between policy and practice. Specifically, results highlight the challenges hospice social workers face to replicate or supplement the holistic support and unique services hospice provides for individuals discharged alive, and suggest further research to develop live discharge guidelines to identify appropriate support for patients and their caregivers who no longer meet hospice eligibility requirements.

Author(s): Goldstein, Sarah A; Mentz, Robert J; Hellkamp, Anne S; Randolph, Tiffany C; Fonarow, Gregg C; Hernandez, Adrian; Yancy, Clyde W; Al-Khatib, Sana M | Abstract: BackgroundWhen used in appropriately selected heart failure (HF) patients, cardiac resynchronization therapy (CRT) reduces mortality and hospitalization. It is not understood whether CRT implantation during hospitalization for HF is associated with similar benefits.HypothesisTiming of CRT implantation relative to hospitalization for HF is associated with clinical outcomes.MethodsThis analysis included patients eligible for CRT and discharged alive between January 2005 and December 2012 from 388 hospitals in Get With The Guidelines-HF. Participants were linked with Centers for Medicare and Medicaid Services data to evaluate outcomes of all-cause mortality and HF re-hospitalization based on CRT status (present on admission, placed during hospitalization, and prescribed at discharge; reference = no CRT).ResultsOf 15 619 CRT-eligible HF patients, 2408 (15%) had CRT on admission, 1269 (8%) underwent CRT implantation during hospitalization and 643 (4%) had CRT prescribed at discharge. Compared with patients without CRT, mortality was lower in those who received CRT implantation during HF hospitalization (adjusted hazard ratio [HR] 0.63; P l 0.0001) and those prescribed CRT at discharge (adjusted HR 0.78; P = 0.048). A reduction in HF re-hospitalization was observed in patients with CRT implanted during hospitalization (adjusted HR 0.64; P l 0.0001), but not in those who were prescribed CRT at discharge (adjusted HR 1.02; P = 0.77).ConclusionCRT implantation during HF hospitalization was associated with lower rates of mortality and HF re-hospitalization. These data suggest that a CRT utilization strategy that does not delay implantation to the post-discharge period may be appropriate. Randomized data are needed to definitively identify optimal timing of CRT implantation.

BACKGROUND AND OBJECTIVES Anaemia is common in the elderly and is recognized as a risk factor for several adverse outcomes in older adults, including hospitalization, morbidity and mortality. The study aims were to examine the prevalence of anaemia in elderly patients at discharge from the intensive care unit (ICU) and hospital. MATERIALS AND METHODS Patient randomized under the INFORM trial and with an ICU admission were included. Two cohorts, Cohort 1 patients who were alive on discharge from ICU and Cohort 2 patients who were discharged alive from hospital to home. Prevalence of significant anaemia defined as haemoglobin levels, less than 100 g/l was measured at ICU and hospital discharge. RESULTS Overall, 76·5% (683/893) of elderly admissions in Cohort 1 had a haemoglobin

Some patients with idiopathic pulmonary fibrosis (IPF) undergo recurrent acute exacerbations (AEs). This study aimed to elucidate the risk factors for recurrent AEs of IPF (AE-IPF). Consecutive patients with IPF admitted for their first AE-IPF between January 2008 and December 2018 were retrospectively recruited. Of 63 patients admitted for an AE-IPF and discharged alive, 9 (14.3%) developed a recurrence of AE within 1 year. The mean time to recurrence was 233 ± 103 days. Total doses (mg/month and mg/kg/month) of corticosteroids administered over day 1 to 30 after the AE were significantly higher in patients without recurrences of AE-IPF (5185 ± 2414 mg/month, 93.5 ± 44.0 mg/kg/month) than the doses in patients with recurrences (3133 ± 1990 mg/month, 57.2 ± 37.7 mg/kg/month) (p = 0.02 and p = 0.03, respectively). However, no differences were observed between the total doses of corticosteroids administered over days 31 to 60, 61 to 90, 91 to 120, and 151 to 180 after the AE. Furthermore, differences between the administration rates of immunosuppressive and antifibrotic treatments administered to the 2 patient groups were not significant. An increased total dose of corticosteroid administered over day 1 to 30 after an AE-IPF was associated with a decreased risk of subsequent recurrence of AE-IPF within 1 year after the first AE.

BackgroundAs the number of new cases and death due to COVID-19 is increasing, understanding the characteristics of severe COVID-19 patients and identifying characteristics that lead to death is a key to make an informed decision. In Ethiopia, as of September 27, 2020, a total of 72,700 cases and 1165 deaths were reported.ObjectiveThe study aimed to assess the determinants of death in Severe COVID-19 patients admitted to Millennium COVID-19 Care Center in Ethiopia.MethodsA case-control study of 147 Severe COVID-19 patients (49 deaths and 98 discharged alive cases) was conducted from August to September 2020. A comparison of underlying characteristics between cases (death) and controls (alive) was assessed using a chi-square test and an independent t-test with a p-value of ResultsHaving diabetes mellitus (AOR= 3.257, 95% CI= 1.348, 7.867, p-value=0.00), fever (AOR=0.328, 95% CI: 0.123, 0.878, p-value= 0.027) and Shortness of breath (AOR= 4.034, 95% CI= 1.481, 10.988, p-value=0.006) were found to be significant predictors of death in Severe COVID-19 patients.ConclusionsThe outcome of death in Severe COVID-19 patients is found to be associated with exposures to being diabetic and having SOB at admission. On the other hand, having a fever at admission was associated with a favorable outcome of being discharged alive.

OBJECTIVE: Interstitial lung diseases (ILDs) are associated with poor prognosis in the intensive care unit (ICU). We aimed to assess factors associated with hospital mortality in ILD patients admitted to the ICU and to investigate long-term outcome.MATERIAL AND METHODS: This was a retrospective study in a teaching hospital specialised in ILD management. Patients with ILD who were hospitalised in the ICU between 2000 and 2014 were included. Independent predictors of hospital mortality were identified using logistic regression.RESULTS: A total of 196 ILD patients were admitted to the ICU during the study period. Overall hospital mortality was 55%. Two years after ICU admission, 70 (36%) patients were still alive. Of the 196 patients, 108 (55%) required invasive mechanical ventilation, of whom 21 (20%) were discharged alive from hospital. Acute exacerbation of ILD and multi-organ failure were highly associated with hospital mortality (OR 5.4, 95% CI 1.9–15.5 and OR 12.6, 95% CI 4.9–32.5, respectively).CONCLUSION: Hospital mortality among ILD patients hospitalised in the ICU was high, but even where invasive mechanical ventilation was required, a substantial number of patients were discharged alive from hospital. Multi-organ failure could lead to major ethical concerns.

INTRODUCTION Improving patient outcomes after acute myocardial infarction (AMI) may be facilitated by identifying patients at a high risk of adverse events before hospital discharge. We aimed to determine the accuracy of the LACE (Length of stay, Acuity, Comorbidities, Emergency presentations within prior 6 months) index score (a prediction tool) for predicting 30-day all-cause mortality and readmission rates (independently and combined) in South Australian AMI patients who had an angiogram. METHODS All consecutive AMI patients enrolled in the Coronary Angiogram Database of South Australia Registry at two major tertiary hospitals and discharged alive between July 2016 to June 2017. A LACE score was calculated for each patient, and receiver operating characteristic curve analysis was performed. RESULTS Analysis of registry patients found a 30-day unplanned readmission rate of 11.8% and mortality rate of 0.7%. Moreover, the LACE index was a moderate predictor (C-statistic = 0.62) of readmissions in this cohort, and a score ≥10 indicated moderate discriminatory capacity to predict 30-day readmissions. CONCLUSION The LACE index shows moderate discriminatory capacity to predict 30-day readmissions and mortality. A cut-off score of nine to optimize sensitivity may assist clinicians in identifying patients at a high risk of adverse outcomes.