Influence of Admission Time on Health Care Quality and Utilization in Patients with Stroke: Analysis for a Possible July Effect and Weekend Effect

(1) Purpose: Undesirable health care outcomes could conceivably increase as a result of the entry of new, less experienced health care personnel into patient care during the month of July (the July effect) or as a result of the less balanced allocation of health care resources on weekends (the weekend effect). Whether these two effects were present in Taiwan’s National Health Insurance (NHI) system was investigated. (2) Methods: The current study data were acquired from the NHI Research Database. The research sample comprised ≥18-year-old patients diagnosed as having a stroke for the first time from 1 January 2006 to 30 September 2012. The mortality rate within 30 days after hospitalization and readmission rate within 14 days after hospital discharge were used as health care quality indicators, whereas health care utilization indicators were the total length and cost of initial hospitalization. (3) Results: The results revealed no sample-wide July effect with regard to the four indicators among patients with stroke. However, an unexpected July effect was present among in-patients in regional and public hospitals, in which the total lengths and costs of initial hospitalization for non-July admissions were higher than those for July admissions. Furthermore, the total hospitalization length for weekend admissions was 1.06–1.07 times higher than that for non-weekend admissions; the total hospitalization length for weekend admissions was also higher than that for weekday admissions during non-July months. Thus, weekend admission did not affect the health care quality of patients with stroke but extended their total hospitalization length. (4) Conclusions: Consistent with the NHI’s general effectiveness in ensuring fair, universally accessible, and high-quality health care services in Taiwan, the health care quality of patients examined in this study did not vary significantly overall between July and non-July months. However, a longer hospitalization length was observed for weekend admissions, possibly due to limitations in personnel and resource allocations during weekends. These results highlight the health care efficiency of hospitals during weekends as an area for further improvement.

Restoration of dysnatremia and acute kidney injury benefits outcomes of acute geriatric inpatients

Dysnatremia and dyskalemia are common problems in acutely hospitalized elderly patients. These disorders are associated with an increased risk of mortality and functional complications that often occur concomitantly with acute kidney injury in addition to multiple comorbidities. In a single-center prospective observational study, we recruited 401 acute geriatric inpatients. In-hospital outcomes included all-cause mortality, length of stay, and changes in functional status as determined by the Activities of Daily Living (ADL) scale, Eastern Cooperative Oncology Group (ECOG) performance, and Clinical Frailty Scale (CFS). The prevalence of dysnatremia alone, dyskalemia alone, and dysnatremia plus dyskalemia during initial hospitalization were 28.4%, 14.7% and 32.4%, respectively. Patients with electrolyte imbalance exhibited higher mortality rates and longer hospital stays than those without electrolyte imbalance. Those with initial dysnatremia, or dysnatremia plus dyskalemia were associated with worse ADL scores, ECOG performance and CFS scores at discharge. Subgroup analyses showed that resolution of dysnatremia was related to reduced mortality risk and improved CFS score, whereas recovery of renal function was associated with decreased mortality and better ECOG and CFS ratings. Our data suggest that restoration of initial dysnatremia and acute kidney injury during acute geriatric care may benefit in-hospital survival and functional status at discharge.

Adverse Events of Risperidone and Clozapine Combination Therapy on Schizophrenic Patients at Magelang Mental Hospital

The adverse drug effect of risperidone and clozapine combination therapy possibly increases the BMI, systolic and diastolic blood pressures of mental victims. This study aimed at determining the relationship between the duration of risperidone and clozapine combination therapy and increase in body mass index (BMI), systolic and diastolic blood pressures of schizophrenic patients. The correlation was obtained using the cohort retrospective method on 59 schizophrenic inpatients at Magelang Mental Hospital from February–May 2019. Participants were grouped into 2 categories, termed <8 and ≥8 weeks with 48 and 11 persons, respectively. Subsequently, patients’ BMI, systolic and diastolic blood pressures were measured during the first day of hospitalization and outpatient consultations, based on NCEP-ATP III cut off-point with the modification of Southeast Asian population’s BMI. Structured questionnaires were used to evaluate calory intake and physical activity as well as generate respondents’ medical records. The bivariate analysis results showed a significant relationship between BMI increase at initial hospitalization and during outpatient consultation on group ≥8 weeks therapy, 22.41±2.98 kg/m2 vs 25.2±6.80 kg/m2 (p=0.023, –2.75 (–5.12–(–0.39)). However, there is no major correlation occurred in systolic 117±11.73 mmHg vs 118±15.42 mmHg (p=0.797, 95%CI –1.07 (–9.41–7.26)) and diastolic blood pressures 76±7.86 mmHg vs 73±8.48 mmHg (p=0.192, 95% CI 3.52 (–1.81–8.86)) for both groups. Furthermore, age, gender, smoking status, dosage, co-medication, calory intake and physical activity indicated no substantial variations, in terms of the increase in BMI, systolic and diastolic blood pressures among two categories.

Multiple Primary Angiosarcomas of the Colon

Introduction. Gastrointestinal angiosarcomas are rare and represent less than 1% of all gastrointestinal tract malignancies, with most occurring in the stomach and small intestine. Occurrence in the colorectal segments is considered extremely rare. Case Report. We describe the case of a 61-year-old male with multiple primary angiosarcomas of the colon who presented with fever and abdominal pain. The patient was initially hospitalized and treated as having an infectious disease. A multislice computed tomography (MSCT) scan revealed multiple soft tissue tumors in the region of the left iliopsoas and gluteus medius muscles. After developing hematochezia, a colonoscopy was performed which found an ulcerated tumor in the sigmoid colon. The small tissue biopsy taken during the procedure presented diagnostic difficulties and was given a preliminary diagnosis of gastrointestinal stromal tumor (GIST). Examination of the resected colon segment and surrounding fat tissue revealed four separate tumors. Microscopically, the tumors were composed of solid sheets of spindle and epithelioid neoplastic cells with prominent nucleoli and numerous mitotic figures and immunohistochemically positive for ERG, CD31, CD34, vimentin, and CD117, while negative for CK7, CK20, CD20, CD3, CD45, TTF-1, PAN-CK, ALK, Mpox, S-100, and DOG1, leading to the final diagnosis of multiple colonic angiosarcomas. The patient’s condition declined rapidly and he passed away from multiple organ failures 60 days after initial hospitalization. Conclusion. Both clinical and pathological diagnoses of colorectal angiosarcoma are challenging. Patients are present with nonspecific symptoms leading to mismanagement and late diagnosis. A definitive pathological diagnosis relies on immunohistochemical staining for endothelial markers. Misdiagnosis as poorly differentiated adenocarcinoma or GIST is possible in limited tissue biopsies.

Different strategies, equivalent treatment approaches in terms of mortality in four university hospitals: a retrospective multicenter study of gastroschisis in Finland

Purpose Optimal treatment of gastroschisis is not determined. The aim of the present study was to investigate treatment methods of gastroschisis in four university hospitals in Finland. Methods The data of neonates with gastroschisis born between 1993 and 2015 were collected. The primary outcomes were short and long-term mortality and the length of stay (LOS). Statistical analyses consisted of uni- and multivariate models. Results Total of 154 patients were included (range from 31 to 52 in each hospital). There were no statistically significant differences in mortality or LOS between centers. Significant differences were observed between the hospitals in the duration of mechanical ventilation (p = 0.046), time to full enteral nutrition (p = 0.043), delay until full defect closure (p = 0.003), central line sepsis (p = 0.025), abdominal compartment syndrome (p = 0.018), number of abdominal operations during initial hospitalization (p = 0.000) and follow-up (p = 0.000), and ventral hernia at follow-up (p = 0.000). In a Cox multivariate analysis, the treating hospital was not associated with mortality. Conclusion There were no differences in short or long-term mortality between four university hospitals in Finland. However, some inter-hospital variation in postoperative outcomes was present. Level of evidence Level III.

MicroRNAs as Biomarkers for Predicting Complications following Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a high mortality hemorrhagic stroke that affects nearly 30,000 patients annually in the United States. Approximately 30% of aSAH patients die during initial hospitalization and those who survive often carry poor prognosis with one in five having permanent physical and/or cognitive disabilities. The poor outcome of aSAH can be the result of the initial catastrophic event or due to the many acute or delayed neurological complications, such as cerebral ischemia, hydrocephalus, and re-bleeding. Unfortunately, no effective biomarker exists to predict or diagnose these complications at a clinically relevant time point when neurologic injury can be effectively treated and managed. Recently, a number of studies have demonstrated that microRNAs (miRNAs) in extracellular biofluids are highly associated with aSAH and complications. Here we provide an overview of the current research on relevant human studies examining the correlation between miRNAs and aSAH complications and discuss the potential application of using miRNAs as biomarkers in aSAH management.

Case-control study of neuropsychiatric symptoms following COVID-19 hospitalization in 2 academic health systems

Neuropsychiatric symptoms may persist following acute COVID-19 illness, but the extent to which these symptoms are specific to COVID-19 has not been established. We utilized electronic health records across 6 hospitals in Massachusetts to characterize cohorts of individuals discharged following admission for COVID-19 between March 2020 and May 2021, and compared them to individuals hospitalized for other indications during this period. Natural language processing was applied to narrative clinical notes to identify neuropsychiatric symptom domains up to 150 days following hospitalization. Among 6,619 individuals hospitalized for COVID-19 drawn from a total of 42,961 hospital discharges, the most commonly documented symptom domains between 31 and 90 days after initial positive test were fatigue (13.4%), mood and anxiety symptoms (11.2%), and impaired cognition (8.0%). In models adjusted for sociodemographic features and hospital course, none of these were significantly more common among COVID-19 patients; indeed, mood and anxiety symptoms were less frequent (adjusted OR 0.72 95% CI 0.64-0.92). Between 91 and 150 days after positivity, most commonly-detected symptoms were fatigue (10.9%), mood and anxiety symptoms (8.2%), and sleep disruption (6.8%), with impaired cognition in 5.8%. Frequency was again similar among non-COVID-19 post-hospital patients, with mood and anxiety symptoms less common (aOR 0.63, 95% CI 0.52-0.75). Neuropsychiatric symptoms were common up to 150 days after initial hospitalization, but occurred at generally similar rates among individuals hospitalized for other indications during the same period. Post-acute sequelae of COVID-19 thus may benefit from standard if less-specific treatments developed for rehabilitation after hospitalization.

Ocorrência de readmissões hospitalares em um município de grande porte populacional

Objetivo: analisar as readmissões hospitalares em instituições públicas e privadas de um município de grande porte populacional. Método: Estudo observacional analítico das readmissões ocorridas em Ribeirão Preto, em 2011, em hospitais públicos e privados. Resultados: Identificou-se 16.123 readmissões hospitalares em 11 hospitais, com taxa média de readmissão de 14,2%. As readmissões mais frequentes ocorreram em pacientes em idade adulta, com no mínimo uma comorbidade associada. Predominaram as readmissões pelo Sistema Único de Saúde, em hospitais com mais de 100 leitos e elevada complexidade assistencial. A readmissão precoce está associada ao sexo, tipo de convênio e tempo de permanência na internação inicial. Conclusões: Os resultados sugerem que as readmissões estejam relacionadas à dinâmica da rede de serviços e à complexidade assistencial dos casos atendidos; seu monitoramento auxilia no processo de planejamento, programação e avaliação das ações em saúde; entretanto, a utilização desse indicador de desempenho deve acontecer em conjunto com outros indicadores, analisados de acordo com a realidade institucional e dos fatores intervenientes.Palavras-chave: Readmissão do Paciente; Indicadores de Qualidade em Assistência à Saúde; Acesso aos Serviços de Saúde. Occurrence of hospital readmissions in a large population municipalityABSTRACTObjective: to analyze hospital readmissions in public and private institutions in a large population size municipality. Method: Observational analytical study of readmissions in Ribeirão Preto in 2011, in public and private hospitals. Results: 16,123 hospital readmissions were identified in 11 hospitals, with a mean readmission rate of 14.2%. The most frequent readmissions occurred in adult patients, with at least one associated comorbidity. Readmissions were predominant in the Unified Health System, in hospitals with more than 100 beds and high complexity of care. Early readmission is associated with gender, type of health insurance plan and length of stay in the initial hospitalization. Conclusions: The results suggest that readmissions are related to the dynamics of the service network and to the complexity of care of the cases seen; its monitoring assists in the process of planning, programming and evaluating health actions; however, the use of this performance indicator should occur in conjunction with other indicators, analyzed according to the institutional reality and intervening factors.Keywords: Patient Readmission; Quality Indicators, Health Care; Health Services Accessibility.

Clinical Characteristics and Resistance Patterns of Pseudomonas aeruginosa Isolated From Combat Casualties

ABSTRACT Introduction Multidrug-resistant (MDR) Gram-negative infections complicate care of combat casualties. We describe the clinical characteristics, resistance patterns, and outcomes of Pseudomonas aeruginosa infections in combat casualties. Methods Combat casualties included in the Trauma Infectious Disease Outcomes Study with infections with and without P. aeruginosa isolation during initial hospitalization were compared. Pseudomonas aeruginosa from initial wound, blood, and serial isolates (≥7 days from previous isolate) collected from June 2009 through February 2014 was subjected to antimicrobial susceptibility testing, pulsed-field gel electrophoresis, and whole genome sequencing for assessing clonality. Multidrug resistance was determined using the CDC National Healthcare Safety Network definition. Results Of 829 combat casualties with infections diagnosed during initial hospitalization, 143 (17%) had P. aeruginosa isolated. Those with P. aeruginosa were more severely injured (median Injury Severity Score 33 [interquartile range (IQR) 27-45] vs 30 [IQR 18.5-42]; P &lt; .001), had longer hospitalizations (median 58.5 [IQR 43-95] vs 38 [IQR 26-56] days; P &lt; .001), and higher mortality (6.9% vs 1.5%; P &lt; .001) than those with other organisms. Thirty-nine patients had serial P. aeruginosa isolation (median 2 subsequent isolates; IQR: 1-5), with decreasing antimicrobial susceptibility. Ten percent of P. aeruginosa isolates were MDR, associated with prior exposure to antipseudomonal antibiotics (P = .002), with amikacin and colistin remaining the most effective antimicrobials. Novel antimicrobials targeting MDR Gram-negative organisms were also examined, and 100% of the MDR P. aeruginosa isolates were resistant to imipenem/relabactam, while ceftazidime/avibactam and ceftolozane/tazobactam were active against 35% and 56% of the isolates, respectively. We identified two previously unrecognized P. aeruginosa outbreaks involving 13 patients. Conclusions Pseudomonas aeruginosa continues to be a major cause of morbidity, affecting severely injured combat casualties, with emergent antimicrobial resistance upon serial isolation. Among MDR P. aeruginosa, active antimicrobials remain the oldest and most toxic. Despite ongoing efforts, outbreaks are still noted, reinforcing the crucial role of antimicrobial stewardship and infection control.

Home treatment compared to initial hospitalization in patients with acute pulmonary embolism in the Netherlands: a cost analysis

Background: Venous thromboembolism constitutes substantial healthcare costs amounting to about 60 million euros per year in the Netherlands. Compared to initial hospitalization, home treatment of pulmonary embolism (PE) is associated with a cost reduction. An accurate estimation of cost savings per patient treated at home is currently lacking. Aim: The aim of this study was to compare healthcare utilization and costs during the first 3 months after a PE diagnosis in patients who are treated at home versus those who are initially hospitalized. Methods: Patient-level data of the YEARS cohort study was used to estimate the proportion of patients treated at home, mean hospitalization duration in those who were hospitalized and rates of PE-related readmissions and complications. To correct for baseline differences within the two groups, regression analyses was performed. The primary outcome was the average total healthcare costs during a 3-month follow-up period for patients initially treated at home or in hospital. Results: Mean hospitalization duration for the initial treatment was 0.69 days for those treated initially at home (n=181) and 4.3 days for those initially treated in hospital (n=202). Total average costs per hospitalized patient were €3.204 and €1.507 per patient treated at home. The adjusted mean difference was €1.483 (95%CI €1.181 – 1.784). Conclusions: Home treatment of hemodynamically stable patients with acute PE was associated with an estimated net cost reduction of €1.483 per patient. This difference underlines the advantage of triage-based home treatment of these patients.