Why Should I Take My Medicine? A Review Of ED Visits For Seizures.

Study hypothesis The costs of anti-epileptic medication (AED) and poor care coordination result in increased Emergency Department (ED) visits for seizure events and produce both direct and indirect economic burdens on patients with frequent seizures. Methods A retrospective chart review study of ED visits with chief concern of seizure from two hospitals over a two-year period was performed; resulting in 152 visits recorded in this study. Data collected included demographic information, relevant seizure or past medical history (PMH), diagnostics performed in the ED, and the admission status of the patient along with the total charges per encounter. Data was analyzed descriptively and with logistic regression analysis. Results The results yielded by this study were generally in-line with the results of similar studies, indicating a higher relative rate of ED seizure visits for males, people of Black race, and infant and toddler populations. A high proportion of Medicaid/Medicare coverage and indiscernible employment status for most patients were also noted. Observed differences in average cost among patients with and without epilepsy and male versus female patients were not shown to be statistically significant. However, the increased likelihood of admission with increasing age was shown to be significant with an average age difference between admitted and discharged populations of approximately 10 years (p= 0.003). Conclusions The data provided here is not sufficient to examine the complex relationship between seizures, epilepsy, and costs among various other patient factors. Further study is necessary to minimize direct and indirect costs of seizures. Acknowledgments This project was funded, in part, with support from the Indiana Clinical and Translational Sciences Institute funded, in part by UL1TR002529 from the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Validation of an Online Calculator to Predict Short-term Postoperative Outcomes in Patients with Metastatic Brain Tumors

Introduction: Estimating the risk of extended length of stay (LOS) or non-routine discharge disposition is helpful in surgical decision-making for patients with brain metastases (BM). In 2020, an online calculator was introduced by Khalafallah et al. that stratified the risk of patients with brain tumors based on poor surgical outcomes. We applied the calculator to our population of BM patients to determine its generalizability and validity. Methods: We included BM patients who underwent a cranial procedure between 2015 and 2018 at a single academic institution. Patient age, race, marital status, admission status, KPS score, and medical co-morbidities (5-point modified frailty index (mFI-5)) were included in the analysis. We calculated the areas under the Receiver Operating Characteristics (ROC) curves to determine the validity of the model proposed in predicting extended LOS (>7 days) and need for specialty care at discharge (non-routine discharge disposition). Results: We analyzed 244 patients (mean age 61.2 years (SD 11.1), 57.0% female, and 78.1% Caucasian). The areas under the ROC curves were 0.8427 and 0.8422 for extended LOS and non-routine discharge disposition, suggesting high accuracy of the models for these outcomes. However, the (mFI-5) was not a significant predictor of either outcome in our multivariate analyses. Conclusions: We validated Khalafallah et al.’s predictive models of extended LOS and non-routine discharge disposition in our patient population, which included a broader range of surgical procedures. Further investigation of this model could clarify how the type of neurosurgical procedure influences outcomes, the role of the mFI-5, and its overall generalizability.

Establishing a sentinel surveillance system for the novel COVID-19 in a resource-limited country: methods, system attributes and early findings

ObjectivesTo establish a hospital-based platform to explore the epidemiological and clinical characteristics of patients screened for COVID-19.DesignHospital-based surveillance.SettingThis study was conducted in four selected hospitals in Bangladesh during 10 June–31 August 2020.ParticipantsIn total, 2345 patients of all age (68% male) attending the outpatient and inpatient departments of surveillance hospitals with any one or more of the following symptoms within last 7 days: fever, cough, sore throat and respiratory distress.Outcome measuresThe outcome measures were COVID-19 positivity and mortality rate among enrolled patients. Pearson’s χ2 test was used to compare the categorical variables (sign/symptoms, comorbidities, admission status and COVID-19 test results). Regression analysis was performed to determine the association between potential risk factors and death.ResultsCOVID-19 was detected among 922 (39%) enrolled patients. It was more common in outpatients with a peak positivity in second week of July (112, 54%). The median age of the confirmed COVID-19 cases was 38 years (IQR: 30–50), 654 (71%) were male and 83 (9%) were healthcare workers. Cough (615, 67%) was the most common symptom, followed by fever (493, 53%). Patients with diabetes were more likely to get COVID-19 than patients without diabetes (48% vs 38%; OR: 1.5; 95% CI: 1.2 to 1.9). The death rate among COVID-19 positive was 2.3%, n=21. Death was associated with age ≥60 years (adjusted OR (AOR): 13.9; 95% CI: 5.5 to 34), shortness of breath (AOR: 9.7; 95% CI: 3.0 to 30), comorbidity (AOR: 4.8; 95% CI: 1.1 to 21.7), smoking history (AOR: 2.2, 95% CI: 0.7 to 7.1), attending the hospital in <2 days of symptom onset due to critical illness (AOR: 4.7; 95% CI: 1.2 to 17.8) and hospital admission (AOR: 3.4; 95% CI: 1.2 to 9.8).ConclusionsCOVID-19 positivity was observed in more than one-third of patients with suspected COVID-19 attending selected hospitals. While managing such patients, the risk factors identified for higher death rates should be considered.

Urgent elective pathway service reconfiguration facilitates increased use of surgical adjuncts, improvement in survival trends, and reduced hospital stay for glioblastoma patients

Aims Glioblastomas (GB) are the most common and aggressive of intrinsic brain tumours. Median survival with maximal therapy is reported to be 14.6 months. Service reconfiguration at the Queen Elizabeth Hospital Birmingham (QEHB) has transformed the service for high grade brain cancer patients, including GB, from a predominantly emergency pathway based system to one of planned urgent-elective admissions consisting of: A. Patient-focused, consultant-led, research orientated “one stop shop” model of integrated outpatient neurosurgical oncology clinic B. Standardisation of urgent elective pathways C. Incorporation of neuro-surgical intra-operative adjuncts (neuro-monitoring, 5-ALA) into routine surgical practice for oncology. Using this model, we have reduced hospital length of stay (with associated financial savings), improved extent of resection and achieved a trend towards increased survival. Method We retrospectively identified patients with primary histological diagnoses of GB (WHO grade IV), who underwent surgery over a six year period, from 01/01/2014 to 31/12/2019, from the QEHB pathology database. Data was collected for demographics, surgical and oncological therapy, use of intra-operative adjuncts, emergency and elective admission status, year of admission, length of stay (LOS), and extent of resection (EOR) on first post-operative MRI scan from hospital databases. Survival was analysed using the Kaplan-Meier method and independent-samples median testing for survival. Proportion of patients undergoing resective surgery and admission status was calculated by year. Overall median survival was calculated and subgroup comparisons made of patients by: age, admission status, year of admission, biopsy or resection, oncology treatment. Hospital length of stay was calculated for patients by surgical procedure, admission pathways and compared across the year. Financial data taken from averages of inpatient episode costs were used to estimate cost savings. Results 610 patients underwent primary procedures for GB, of which 64 were still alive at time of analysis (02/02/2021). Median overall survival time was 9.53 months, this was greatest in patients who underwent resection with completion of Stupp protocol: 28.67 months (n=114). From 2014 to 2019, there has been an increase in elective admission rates (28.1% to 90.3%, p&lt;0.001) and increased proportion of resective surgery (68.4% to 81.9%, p&lt;0.001). There is a trend of improved survival from 2014 to 2019 (median 7.95 and 11.08 months, χ2=9.249, p=0.002). Increasing use of intra-operative adjuvants improved EOR (χ2 =31.064, p&lt;0.001). Through improved urgent-elective admission rates, hospital length of stay has decreased by five days for craniotomies and six days for biopsies. Cost analysis of three cases demonstrated that reducing the LOS by one night alone result in an average cost saving of approximately £750 per patient per night. Conclusion Switching to a system of planned and urgent elective based admission, with standardisation of neuro-oncology patient pathways, increased use of intra-operative adjuncts, earlier oncology multidisciplinary input and outpatient review, has improved the extent of GB resection, led to shorter length of hospital stay associated with significant financial savings and achieved a trend towards increased overall survival.

Acute phase clinical manifestation of COVID-19 is linked to long-COVID symptoms; A 9-month follow-up study

Background: The number of long-COVID is rising but it is not still clear which patients will develop long-covid and what will be the symptoms if they do.We followed up 95 patientswith confirmed COVID-19 after 9 months of the original study to delineate possible long COVID symptoms. Methods: The original study included 201 patients who were treated in a large referral center from March to May 2020. Ninty percent of the patients reported physical or psychological symptoms within 9 months post-COVID. Findings: Easy fatigability was the most common 51.04 % long-COVID symptoms followed by anxiety 38.54 %, dyspnea 38.54 %, and new headache 38.54%. There was no association between COVID-19 severity in the acute phase (admission status) and the number of long-COVID symptoms (F(1, 93) = 0.75, p = 0.45 (n.s.)), chronic fatigue syndrome (CFS) (F(1,93) = -0.49, p = 0.62 (n.s.), MOCA scores (F(1, 90) = 0.073, p = 0.787 (n.s.)) in the future. Being female (F(1, 92) = -2.27, p = 0.02), having a higher number of symptoms in the acute phase(F(1,93) = 2.76, p = 0.0068),and experiencing constitutional neuropsychiatric symptoms(F(1, 93)= 2.529, p = 0.01) in the acute phase were associated with higher occurance of CFS in follow up. Moreover, constitutional neuropsychiatric symptoms in acute phase were associated with cognitive dificits (lower MOCA score) (F(1, 93) = 10.84, p= 0.001) in the follow up. Conclusions: Severity of the acute disease does not seem to be related to long-COVID symptoms. However, specific clinical presentations might be predictors of distinct long-COVID symptoms. Constitutional neuropsychiatric symptoms in the acute phase are associated with important and debilitating chronic symptoms including chronic fatigue syndrome, and cognitive deficits. These results might pave the way for findingthe underlying mechanisms of long-COVID and provide additional insight into possible candidate treatments for COVID-19.

Pediatric Observational Priority Score and Early Warning Scoring System to Predict Admission Status in Pediatric Patients in Haji Adam Malik General Hospital

Background: Doctors must be able to quickly and accurately assess clinical condition of patients, especially in the emergency rooms. An easy scoring system but producing meaningful clinical conclusions is the reason for creating various scoring systems. Includes a scoring system for predicting the admission status of patients. Aim: To determine the diagnostic value of POPS and EWSS to predicting admission status of pediatric patients in the emergency department. Methods: Diagnostic tests for POPS and EWSS were done to predict the admission status of pediatric patients in the emergency department of Haji Adam Malik general hospital from May to October 2020. Subjects aged 1 month to 18 years were excluded if they left the emergency department prior to assessment, had trauma cases, died, inpatients due to social indications, and patients who came only to continue therapy were also excluded. POPS and EWSS assessments were carried out by the researcher and the admission status of the patients were determined by the doctor in charge in the emergency department. Results: There were 119 children meeting the inclusion and exclusion criteria. POPS score ≥3 had sensitivity 82.65%, specificity 85.71%, and AUC 0.88 (p <0.001). EWSS score ≥2 had sensitivity 83.67%, specificity 71.43%, and AUC 0.83 (p <0.001). Conclusion: POPS and EWSS had good diagnostic values in predicting the admission status of pediatric patients in the emergency department. POPS has a slightly higher diagnostic value than EWSS.

Descriptive Characterisation of Suspected Measles Cases in Sokoto State 2010 -2016: A Secondary Data Analysis

Background: Measles is a disease with worldwide distribution; however, control efforts have substantially altered the global distribution. The incidence has decreased considerably in regions where routine vaccination is strong; however, this is not the case in developing countries like Nigeria. This study aims to describe the distribution of measles cases in Sokoto state in time, place and person. Methods: Descriptive analyses of measles surveillance data between 2010 and 2016 was carried out to describe the epidemiology of measles in Sokoto State in Time, Place and Person. Microsoft Excel and IBM SPSS were used to analyse the data. We reported frequencies and proportions; cross-tabulations and chi-square tests were used to find associations between variables. Results: A total of 13974 suspected cases of measles were line-listed between January 2010 and June 2016. Overall, 11008 (78.8%) were below five years, and 7421 (53.1%) were males. A majority, 12896 (92%), of the suspected measles cases were reported in the first half of each year of evaluation. Gwadabawa Local Government Area (LGA) recorded the highest measles cases, 1881 (14%). Ten thousand and twenty-seven (71.8%) of suspected measles cases did not receive the measles vaccine. The overall Case Fatality Rate (CFR) was 0.9%. However, Bodinga LGA had the highest CFR of 4%. Only 605(4%) suspected measles cases were tested for Measles IgM. One hundred and twenty-five (0.9%) deaths were recorded. Factors significantly associated with deaths are measles vaccination status (p = 0.001) and admission status (p < 0.001). Conclusion: There is the persistence of measles over the period affecting primarily children below five years with a low CFR. However, a majority of the children did not receive their measles vaccine. Based on this finding, measles will remain a public health problem unless significant efforts are put into place to increase vaccination coverage.

The use of benzodiazepines and Z-drugs in the Acute Psychiatric Unit at Cavan General Hospital

AimsBenzodiazepines and Z-drugs are used frequently in acute psychiatric wards, however long-term administration can result in undesirable consequences. Guidelines recommend prescription of the lowest effective dose for the shortest period and if possible to prescribe “as required” rather than regularly. The 25-beded inpatient unit at Cavan General Hospital admits adult patients requiring acute care from the counties of Cavan and Monaghan. Admissions are accepted from four community mental health teams, two psychiatry of old age teams and the rehabilitation and mental health of intellectual disability teams. In order to evaluate the potential to improve our practice of prescribing benzodiazepine and Z-drugs, it was decided to evaluate current use.MethodThe NICE guidelines were consulted, and we retrospectively reviewed the use of these agents from mid-January to the end of May 2020. Demographic variables included age, gender, and county. Patients were stratified into three groups, the benzodiazepine group, the Z-drugs group, and the combined benzodiazepine and Z-drugs group. In each group therapeutic variables were recorded including the medication type, dose, frequency, prescriber, and duration of treatment. Other variables included psychiatric diagnoses, length of inpatient admission, status on admission, and recommendations on dischargeResultThere were 101admissions during that period, and 74 of them were prescribed these agents (n = 74; 73.3%). Fifty one (n = 51; 68.9%) received benzodiazepines only, twenty-three (n = 23; 31.1%) were prescribed Z-drugs, and twelve (n = 12; 16.2%) received both benzodiazepines and Z-drugs. Forty two patients (n = 42; 56.8%) were commenced on hypnotics in the APU, 23 patients (n = 23; 31.1%) already received hypnotics from the CMHTs, and the rest were prescribed by both. Thirty two patients (n = 32; 43.2%) were discharged on hypnotics. Patients admitted involuntarily and female patients had longer admissions (mean of 16.62 ± 3.26 days and 16.16 ± 2.89 days respectively). Schizophrenia and BPAD were the commonest diagnoses.ConclusionIt appears that large amounts of these agents are used in the Acute Hospital Setting which is not overly surprising given the severity of illness and clinical indications however improved awareness could still lead to more appropriate and hopefully reduced use. We therefore recommend:A formal audit including appropriate interventions i.e., educate staff and patients, highlight guidelines, and review subsequent practice.Train staff in safer prescribing practices including prn rather than regular use if appropriate.Regularly review discharge prescriptions indicating recommended duration of use.

The Berg Balance Scale at Admission Can Predict Community Ambulation at Discharge in Patients with Stroke

Background and Objectives: To regain the ability of community ambulation is a meaningful goal for stroke patients. Recent research recommended that the distance accomplished during the six-minute walk test (≥205 m in 6MWT) is the fittest for defining community ambulation. Until now, there are few studies that have used the updated definition to investigate the related predictors. The aim of this study was to investigate the association between the admission clinical parameters and community ambulation measured by the 6MWT at discharge. The other aim was to find the admission Berg Balance Scale (BBS) cut-off score to discriminate between household or community ambulators. Materials and Methods: This cohort study collected the data of patients who entered the post-acute Care Cerebrovascular Diseases program. Multivariate logistic regression was used to identify significant predictors measured at admission that are associated with community ambulation, and a receiver operating characteristic was adopted to calculate the cut-off value for admission status. There were 120 participants included in this study, and 25% (n = 30) of them regained the ability of community ambulation at discharge. The BBS on admission was identified as the only significant predictor for community ambulation (odds ratio 1.06). Results: The optimal cut-off score for the BBS at admission was 29, and the area under the curve for BBS scores on admission when discriminating between household and community ambulators at discharge was 0.74. Conclusions: The admission BBS scores could be used to predict household and community ambulators at discharge in stroke patients. The results of this study could help clinical physicians set appropriate discharge goals early.