Mortality,length of stay and costs associated with acute graft-versus-host disease during hospitalization for allogeneic hematopoietic stem cell transplantation

Objective: Acute graft-versus-host disease (aGVHD) is a common and life-threatening complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). The extent to which aGVHD increases inpatient costs associated with allo-HSCT has not been thoroughly evaluated. In this analysis, mortality, hospital length of stay (LOS) and costs associated with aGVHD during allo-HSCT admissions are evaluated.

Methods: This is a retrospective analysis of discharge records from the National Inpatient Sample database for patients receiving allo-HSCT between 1 January 2009 and 31 December 2013. Allo-HSCT discharges with an aGVHD diagnosis were included in the aGVHD group and those without any graft-versus-host disease (GVHD) diagnosis comprised the non-GVHD group. Mortality, LOS and costs were compared between the two groups, as well as within subgroups, including age (<18 vs. ≥18 years) and survival status (alive vs. deceased) at discharge.

Results: Overall, mortality (16.2% vs. 5.3%; p?<?.01), median hospital LOS (42.0 vs. 26.0 days; p?<?.01) and median total costs ($173,144 vs. $98,982; p?<?.01) were significantly increased in patients with aGVHD versus those without GVHD during hospitalizations for allo-HSCT, irrespective of age group. Patients with aGVHD who were <18 years of age had a lower mortality rate but greater hospital LOS and total costs versus patients aged ≥18 years. Patients who died during allo-HSCT hospitalization had longer LOS and incurred greater costs than those who survived in both the aGVHD and non-GVHD groups.

Conclusion: Occurrence of aGVHD during allo-HSCT admissions resulted in a tripling of the mortality rate and a near doubling of hospital LOS and total costs. In addition, death during allo-HSCT hospitalizations was associated with greater healthcare utilization and costs. Effectively mitigating aGVHD may improve survival and substantially reduce hospital LOS and costs for allo-HSCT.     

Rapid Progression of Native Renal Artery Fibromuscular Dysplasia Following Kidney Donation

Fibromuscular dysplasia is the second commonest anatomical abnormality apart from multiple renal arteries in the potential live donors. Pretransplant evaluation of the donors may include an angiography to evaluate the renal arteries, and failure to recognize renal arterial stenosis, particularly fibromuscular dysplasia, by noninvasive methods may eventually lead to hypertension and ischemic renal failure. We report a case of fibromuscular dysplasia that was undetected by computed tomographic angiography prior to donation. One year after kidney donation, it rapidly progressed to severe symptomatic stenosis with hypertension and acute renal failure. Following renal artery angioplasty, her blood pressure normalized over a period of 2 weeks without any need for antihypertensive medications and the serum creatinine returned to her baseline. The acceptability of renal donors with fibromuscular dysplasia depends on the age, race and the availability of the other suitable donors. Mild fibromuscular dysplasia in a normotensive potential renal donor cannot be considered a benign condition. Such donors need regular follow-up postdonation for timely detection and treatment.     

Auditory Evoked Potentials and Divided Attention

In a multi-channel divided attention task, 8 subjects listened to a sequence of tones delivered at one of two stimulation rates and at one of three spatial locations (channels): left ear, right ear, and an apparent position midway between left and right ears. Subjects were instructed to monitor one, two, or all three channels and detect slightly louder target tones in the monitored channel(s). Seven listening conditions were used, three in which subjects monitored one channel and ignored the others, another three in which two channels were simultaneously monitored and the third ignored, and a further condition in which all three channels were monitored. With a high stimulation rate, the N1 component of the vertex evoked potential (latency 70–130 msec) in both attended and unattended channels significantly decreased in amplitude with an increase in the number of monitored channels. At the same time, N1 was significantly larger when a channel was attended than when it was ignored. There were no significant effects under slow stimulation rate conditions. Like N1, target detectability (d') declined with increasing monitoring load only with a fast stimulation rate, but the correspondence between these two measures was not upheld in every condition. The results indicate that with a high “information load” in a multi-channel task, selective attention increases the vertex response in all attended channels, while divided attention decreases the response in both attended and unattended channels, thus suggesting that the N1 component of the auditory evoked potential reflects the apparent division of attentional capacity among competing auditory inputs.     

Costs of epilepsy in an intermediate care facility for persons with mental retardation

Epilepsy is a significant comorbid condition in institutionalized persons with developmental disabilities and may contribute significant additional costs. This study was conducted to provide an estimate of the costs of epilepsy from the institutional perspective. Costs were measured retrospectively for 50 persons with epilepsy and 50 persons without epilepsy matched by severity of developmental disability. A time and motion study was employed to assign opportunity costs to documented nursing and physician activities. Two separate methods of attribution were used and incremental costs attributable to epilepsy were found to be approximately $825 and $918 per person over a 6-month period. The following categories accounted for costs: personnel (47.0%), drug (39.6%), hospitalization (9.4%), and laboratories/procedures (4.0%). Results are useful for describing the economic burden of epilepsy.     

Electrochemical performance of nano-sized LiFePO4-embedded 3D-cubic ordered mesoporous carbon and nitrogenous carbon composites

Herein, we report a single-step synthesis, characterization, and electrochemical performance of nano-sized LiFePO₄ (LFP)-embedded 3D-cubic mesoporous carbon (CSI-809) and nitrogenous carbon (MNC-859) composites. Furthermore, in order to investigate the effects of both CSI-809 and MNC-859 on the electrochemical characteristics of LFP, a systematic study was performed on the morphology and microstructure of the composites, viz., LFP/CSI-809 and LFP/MNC-859, using XRD, FE-SEM, FT-Raman, and BET surface area analyses. Among these composites, LFP/MNC-859 exhibited better electrochemical performance with higher specific capacity and rate capability as compared to those of LFP/CSI-809. In addition, even after 100 cycles, LFP/MNC-859 retained 97% of its initial discharge capacity at 1C rate. The enhanced electrochemical performance of the nano-sized LFP-embedded MNC-859 can be attributed to the conductive nitrogenous carbon and mesoporosity, which facilitate electrolyte diffusion, and improved conductivity of the advanced LFP-nitrogenous porous carbon matrix.

Nano-sized LiFePO₄-embedded nitrogenous ordered mesoporous carbon composite cathode facilitate electronic conductivity and significantly enhances Li-ion diffusion and retains 97% of the initial discharge capacity at 1C rate even after 100 cycles.     

Acute Tubular Injury Is an Important Component in Type I Acute Antibody-Mediated Rejection

Background

“Acute tubular necrosis (ATN)-like” changes in type I acute antibody- mediated rejection (AAMR) have been proposed since 2005, but the presence of “ATN-like” injury in AAMR has not well been established. The aim of this study was to confirm the presence of acute tubular injury in type I AAMR, using the specific proximal tubular injury marker, kidney injury molecule-1 (KIM-1).

Design

The study included 3 groups of cases, namely, a negative control group (normal nontransplantation renal parenchyma as group 1, n = 11), a positive control group (transplant ATN with negative C4d staining as group 2, n = 12), and study cases (type 1 AAMR as group 3, n = 19). Biopsy specimens from all groups were stained immunohistochemically for KIM-1 (monoclonal antibody) and KIM-1 staining intensity in proximal tubules was graded from 0.5 to 3+. Clinical indices were also correlated and analyzed.

Results

Group 1 demonstrated significantly lower serum creatinine levels (1.02 ± 0.10 mg/dL) when compared with both group 2 and group 3. Both groups 2 and 3 showed similar serum creatinine levels (4.02 ± 0.59 mg/dL in group 2 and 3.24 ± 0.34 mg/dL in group 3). The negative control group demonstrated negative proximal tubule staining for KIM-1, whereas both groups 2 and 3 showed positive KIM-1 staining in proximal tubules (intensity ranging from 1+ to 3+ in group 2 and from 0.5 to 3+ in group 3).

Conclusion

Our results, using KIM-1 immunohistochemistry, demonstrated that acute tubular injury is an important component of type I AAMR.     

Simple organocatalyst component system for asymmetric hetero Diels–Alder reaction of isatins with enones

A simple two catalyst component system consisting of primary β-amino alcohols as a catalyst and amino acids as a co-catalyst put together works as an efficient organocatalyst system in the hetero Diels–Alder reaction of isatins with enones to afford the chiral spirooxindole–tetrahydropyranones in good chemical yields and stereoselectivities (up to 86%, up to 85 : 15 dr., up to 95% ee).

A simple two catalysts component system of β-amino alcohols (catalyst) and amino acids (co-catalyst) works as an efficient organocatalysts in hetero Diels–Alder reaction of isatins with enones to afford chiral spirooxindole-tetrahydropyranones.     

Study on the Prevalence of Leptospirosis among Fever Cases Reported from Private Clinics in the Urban areas of Villupuram District,Tamil Nadu,India

Objectives

To know the prevalence of leptospirosis cases reported in private clinics among fever cases in Villupuram District, Tamil Nadu, India to know its real magnitude of the problem and to diagnose Leptospirosis among fever cases from differential diagnosis.

Methods

1502 Blood serum samples collected from three urban towns namely Kallakurichi (Latitude: 11° 73′ N; Longitude: 78° 97′ E), Villupuram (Latitude: 11° 75′ N; Longitude: 79° 92′ E) and Thindivanam (Latitude: 12° 25′ N; Longitude: 79° 65′ E) in fifteen clinics based on case definition of leptospirosis delineated by the National Vector Borne Disease Control Programme (NVBDCP), Government of India. Samples were tested in the laboratory of the Zonal Entomological Team (ZET), Cuddalore with Macroscopic Slide Agglutination Test (MSAT) and Ig-M ELISA.

Result

There were 65 positive cases detected from 1502 blood serum samples in both MSAT and Ig-M ELISA. It could be known that there was 4% cases contributed from private clinics among fever cases. From this study, further it was known that all age groups of people affected irrespective of sexes based on their living condition associated with the environment prevailed of the disease.

Conclusion

From this study, it was quantified that 4% of cases reported in private clinics among fever cases and its findings ascertained both the importance of differential diagnosis as well as reports that should be included to the Government for knowing its real magnitude for planning.     

The high-cost,type 2 diabetes mellitus patient: an analysis of managed care administrative data

Background

Type 2 diabetes mellitus (T2DM) affects 25.8 million individuals in the United States and exerts a substantial economic burden on patients, health care systems, and society. Few studies have categorized costs and resource use at the patient level. The goals of this study were to assess predictors of being a high-cost (HC) patient and compare HC T2DM patients with not high-cost (NHC) T2DM patients.

Methods

Using managed care administrative claims data, patients with two or more T2DM diagnoses between 2005 and 2010 were selected. Patients were followed for 1 year after their first observed T2DM diagnosis; patients not continuously enrolled during this period were excluded from the study. Study measures included annual health care expenditures by component (i.e., inpatient, outpatient, pharmacy, total). Patients accruing total costs in the top 10% of the overall cost distribution (i.e., patients with costs > $20,528) were classified as HC a priori; all other patients were considered NHC. To assess predictors of being HC, a logistic regression model was estimated, accounting for demographics; underlying comorbidity burden (using the Charlson Comorbidity Index [CCI] score); diagnoses of renal impairment, obesity, or hypertension; and receipt of insulin, oral antidiabetics only, or no antidiabetics.

Results

A total of 1,720,041 patients met the inclusion criteria; 172,004 were HC. The mean (SD) CCI score for HC patients was 4.3 (3.0) versus 2.1 (1.7) for NHC patients. Mean (SD; upper 95% confidence interval-lower 95% confidence interval) annual per-patient costs were $56,468 ($65,604; $56,778-$56,157) among HC patients and $4,674 ($4,504; $4,695-$4,652) among NHC patients. Inpatient care and pharmacy costs were higher for HC patients than for NHC patients. The strongest predictor of being an HC patient was having a CCI score of 2 or greater (odds ratio [OR] = 4.896), followed by a diagnosis of obesity (OR = 2.106), renal impairment (OR = 2.368), and insulin use (OR = 2.098).

Conclusions

High-cost T2DM patients accrue approximately $52,000 more in total annual health care costs than not high-cost T2DM patients. Patients were significantly more likely to be high-cost if they had comorbid conditions, a diagnosis of obesity, or used insulin.