Social deprivation and hospital admission for respiratory infection: an ecological study

STUDY OBJECTIVE: To examine the relationship between social deprivation and risk of hospital admission for respiratory infection. METHODS AND SUBJECTS: Ecological study using hospital episode statistics and population census data. Cases were residents of the West Midlands Health Region admitted to hospital with a diagnosis of respiratory infection, acute respiratory infection, pneumonia or influenza over a 5-year period. Postcodes of cases were used to assign Townsend deprivation scores; these were then ranked and divided into five deprivation categories. Poisson regression analysis was used to estimate the magnitude of effect for associations between deprivation category and hospital admission by age and admitting diagnosis. MAIN RESULTS: There were 136755 admissions for respiratory infection, equivalent to an annual admission rate of 27.1 per 1000 population (95% CI = 26.9-27.2). Deprivation was associated with increased admission rates for all respiratory infection (P < 0.0001) and affected all age-groups. The greatest effect was in the 0-4 years age-group with admission rates 91% higher in the most deprived children compared to the least deprived. Hospital admissions for acute respiratory infection and pneumonia were both significantly associated with deprivation (P < 0.0001). CONCLUSIONS: Respiratory infection is associated with social inequalities in all age-groups, particularly in children. Prevention of respiratory infection could make an important contribution to reducing health inequalities.     

Patterns of hospitalisation in a paediatric diabetes clinic in Sydney

The hospital notes of all children with diabetes admitted to the Children's Hospital (both newly diagnosed and subsequent admissions) for the period 1985-1987 were examined. The information collected included basic demographic data, number of bed-days per admission, and reasons for admission. The direct cost of a bed-day and an admission for diabetes in this hospital were calculated. The median duration of an admission at diagnosis was 12 days, and of a subsequent admission 7 days. The proportion of total admissions to the Children's Hospital in 1987 which were due to diabetes (post diagnosis) was eight times the prevalence of IDDM in the 0-14-year population. In 1987, 5.5% of the diabetic patients (excluding new cases) aged 0-19 years and registered with this Diabetes Unit were admitted to hospital. Most of these admissions were for poor control, and were thus potentially preventable. The age group most at risk for admission due to ketoacidosis was the 10-14-year group. The cost of a diabetic bed-day was $Aust 295, average cost of an admission at diagnosis $Aust 3660, and of a post-diagnosis admission $Aust 2680. Thus, even in this young age group there is considerable morbidity due to diabetes, most of which can probably be prevented.     

Effect of cotrimoxazole on causes of death, hospital admissions and antibiotic use in HIV-infected children

BACKGROUND: Cotrimoxazole prophylaxis reduces morbidity and mortality in HIV-1-infected children, but mechanisms for these benefits are unclear. METHODS: CHAP was a randomized trial comparing cotrimoxazole prophylaxis with placebo in HIV-infected children in Zambia where background bacterial resistance to cotrimoxazole is high. We compared causes of mortality and hospital admissions, and antibiotic use between randomized groups. RESULTS: Of 534 children (median age, 4.4 years; 32% 1-2 years), 186 died and 166 had one or more hospital admissions not ending in death. Cotrimoxazole prophylaxis was associated with lower mortality, both outside hospital (P = 0.01) and following hospital admission (P = 0.005). The largest excess of hospital deaths in the placebo group was from respiratory infections [22/56 (39%) placebo versus 10/35 (29%) cotrimoxazole]. By 2 years, the cumulative probability of dying in hospital from a serious bacterial infection (predominantly pneumonia) was 7% on cotrimoxazole and 12% on placebo (P = 0.08). There was a trend towards lower admission rates for serious bacterial infections in the cotrimoxazole group (19.1 per 100 child-years at risk versus 28.5 in the placebo group, P = 0.09). Despite less total follow-up due to higher mortality, more antibiotics (particularly penicillin) were prescribed in the placebo group in year one [6083 compared to 4972 days in the cotrimoxazole group (P = 0.05)]. CONCLUSIONS: Cotrimoxazole prophylaxis appears to mainly reduce death and hospital admissions from respiratory infections, supported further by lower rates of antibiotic prescribing. As such infections occur at high CD4 cell counts and are common in Africa, the role of continuing cotrimoxazole prophylaxis after starting antiretroviral therapy requires investigation.     

Anti-HCV prevalence among diabetic and non-diabetic Egyptian children

Our aim was to determine the prevalence of the HCV infection among children with type 1 DM as compared to a group of non-diabetic children attending the general outpatient clinics of the same hospital and investigate the possible risk factors. The study was carried out on 692 children with type 1 DM attending the Pediatric Diabetes Unit at Cairo University Pediatric Hospital, Egypt, and 1042 non-diabetic children attending the general outpatient clinics of the same hospital. They were screened for HCV antibodies using third generation ELISA. Anti-HCV antibody prevalence in diabetic children below 9 years of age was comparable to that of non diabetic children (2.5% vs. 1.4%; p=0.25). Diabetic children had higher exposure to medical care (p=0.04); all diabetics were exposed to daily insulin injections and daily blood glucose monitoring. Non-diabetics had higher exposure to razors used by others (p=0.05) and higher rate of traditional hair cutting (p=0.05). To conclude, the prevalence of anti-HCV in diabetic children below 9 years of age was comparable to non diabetic children of the same age group. Application of standard precautions for infection control could successfully limit spread of HCV infection in our Pediatric Diabetes Unit, in a country with high HCV load as Egypt.     

Prevalence of diabetic retinopathy in children and adolescents with type-1 diabetes attending summer camps in France

OBJECTIVE: To evaluate, using fundus photography, the prevalence of diabetic retinopathy (DR) in young diabetic subjects attending summer camps run by the Aide aux Jeunes Diabétiques Association (Aid to Young Diabetics). RESEARCH DESIGN AND METHODS: Five hundred and four children and adolescents (250 boys and 254 girls), with type 1 diabetes mellitus, aged 10-18 years (mean:13+/-2), were screened for DR using non mydriatic photography, during their stay in a holiday camp. Demographic and clinical data recorded on subjects' arrival in the camp included date of birth, height, weight, treatment, blood pressure, and duration of diabetes. HbA(1c) was determined with a DCA 2000 kit. RESULTS: Mean diabetes duration was 4.8+/-3.4 years and mean HbA(1c) was 8.5+/-1.3%. Mild non proliferative DR was diagnosed in 23 children (4.6%). Compared to subjects without DR, those with DR were significantly older (P<10(-3)), had a longer duration of diabetes (P=0.001), higher systolic blood pressure (P=0.04), and had higher (but not significantly so) HbA(1c) (P=0.15). After adjustment for age, only longer duration remained significantly associated with DR (P=0.01). CONCLUSION: The prevalence of DR in these young patients was low compared to that reported in previous studies. The decrease may be due to modern diabetes care with multiple insulin injections. However, early detection of DR in adolescents, especially in their late teens, remains important, because it allows the identification of patients at high risk of progression towards severe stages of DR.     

Social deprivation and asthma

This study was conducted to see whether children living in socially deprived areas were more likely than other children to be admitted to hospital for asthma, and, if so, whether their excess risk was attributable to a higher prevalence of asthma or poorer treatment. Hospital admission rates for asthma were obtained for Cardiff electoral wards and compared with the Townsend indices of deprivation. A survey of respiratory symptoms was conducted in schoolchildren; prevalence of symptoms was compared with Townsend index and asthma admission rate for the schools' catchment areas.Asthma admissions were strongly correlated with Townsend indices at all ages. The prevalence of reported asthma and various degrees of wheeze in the schools was not significantly correlated with Townsend index or hospital admission rate in the corresponding areas. The presence of a smoker in the house was strongly associated with Townsend index and admission rate; children whose houses contained a smoker were more likely than others to have wheezed in the past year and to have disturbed nights due to wheezing. There was a non-significant negative association between Townsend index and regular use of inhaled steroids.The relationship between hospital admission for asthma and social deprivation is not explained by variations in prevalence, but it may be attributable to the aggravation of symptoms by active or passive smoking, and perhaps also to differences in management.     

Severe hypoglycemia in insulin-dependent diabetic children treated by multiple injection insulin regimen

The occurrence and risk factors of severe hypoglycemic attacks were analyzed during a 4-year study in a group of children and adolescents who received human insulin and followed a multiple daily injection regimen (three or four injections per day); 29 patients experienced severe hypoglycemia at least once in 4 years. Of these, 13 suffered recurrent episodes: 8 had two episodes, 4 had four episodes, and 1 patient had seven episodes. For comparative purposes, the nonhypoglycemic population (217 diabetic children) was used as a control group. The hypoglycemic children received insulin doses which were significantly higher than for nonhypoglycemic patients (1.05±0.6 U/kg daily vs 0.87±0.7;P<0.05). Moreover, the hypoglycemic group had a significantly higher mean number of previous episodes of severe hypoglycemia than the non-hypoglycemic group (0.98±1.2 vs 0.26±0.7;P<0.001). There was no significant difference in age, sex, duration of disease, and metabolic control between hypoglycemic and nonhypoglycemic children. There was no association between severe hypoglycemia and the presence of retinopathy, persistent microalbuminuria, or autonomic neuropathy. Severe hypoglycemia is a recurrent problem, not related to the quality of metabolic control nor to the presence of long-term microvascular complications, and diabetic children with a personal history of severe hypoglycemia are at risk for future episodes.     

Geographic and social factors are related to increased morbidity and mortality rates in diabetic patients.

AIMS: To investigate differences in metabolic control, access to healthcare, clinical outcomes and mortality rates in people from different cultural and ethnic backgrounds living in different geographical areas within central London. METHODS: Out of a cohort of 610 patients living within the Greater London boundary and having a first visit to St Thomas' hospital in 1982-1985, 332 patients (54%) were reviewed in 1995, 186 patients (30%) died between 1982 and 1995 and 92 patients (16%) were lost to follow-up. The patients' corresponding 'electoral wards' were ascertained in relation to postcodes of residence (Mapinfo). Each electoral ward has a Jarman 'Underprivileged Area Score' (UPA) so that patients can be clustered into prosperous, intermediate or deprived areas. RESULTS: Patients living in deprived areas (n = 181) were older (61.3 years (95% confidence interval (CI) 59.5-63.1) vs. 58.6 years (95% CI 55.1-62.1), P = 0.01) and had a higher body mass index (29.2 kg/m2 (95% CI 28.4-30.0) vs. 25.7 kg/m2 (95% CI 24.1-27.2), P = 0.003) and worse glycaemic control (HbA1 (%), 10.5 (95% CI 10.1-10.9) vs. 9.1 (95% CI 8.2-10.0), P = 0.003) than patients in prosperous areas (n = 59). Patients in deprived areas were more likely to be Caucasian (P < 0.005), and were less likely to be insulin-treated (P = 0.004). Smoking was more prevalent in deprived areas (P = 0.02). The prevalence of microvascular complications was related to geographical location and the age-sex adjusted mortality rate was significantly higher in deprived than prosperous areas (2.6 vs. 1.91 per 100 person-years). CONCLUSIONS: Environmental factors affect diabetes outcomes; increased morbidity and mortality rates in diabetic patients are related to socio-economic and ethnic status.     

Glycated hemoglobin, dyslipidemia and risk of atherosclerosis in type 1 diabetic patients

The aim of this study was to determine whether the dyslipidemia was associated with glycated hemoglobin (HbA1c) and to study the relationship of dyslipidemia and glycated hemoglobin with atherosclerosis as well as the gender difference in dyslipidemia. Twenty five clinically diagnosed type 1 diabetic children and adolescents in the age group of 7-18 years and 25 age and sex matched healthy children and adolescents constituted the study population. HbA1c was positively associated with total triglycerides, LDL, VLDL and HDL in diabetic cases as compared with controls. The gender differences were studied using chi-square test which showed that females were more prone to changes in lipid profiles as related to HbA1c levels. It was concluded that type 1 diabetes mellitus patients were at increased risk of premature atherosclerosis due to associated dyslipidemia that could be due to higher levels of glycated hemoglobin. Lower HDL levels, a possible risk of atherosclerosis showed inverse association with HbA1c levels, implying that elevated glycated hemoglobin was associated with multi-fold risk of atherosclerosis. Females were at increased risk of atherosclerosis than males because of higher prevalence of dyslipidemia among them.     

Hospital admissions of diabetic patients: information from hospital activity analysis

Hospital admissions data for 1981 reveal that, for the population of East Anglia, 1.6% of hospital bed days were attributed to diabetes mellitus as the principal cause for admission. Admissions for diabetes without complications or with ketoacidosis or other coma accounted for about 60% of bed days while the other specified complications of diabetes accounted for the remainder. Admissions with diabetes as a subsidiary diagnosis accounted for 2.6 times as many bed days as those for which the disease was the principal diagnosis. Ischaemic heart disease or cerebrovascular disease was recorded as principal diagnosis significantly more often than would be expected from the general population experience, particularly for female diabetics. On an average day, 5.6% of beds were occupied by diabetic patients. The diabetic population of East Anglia used, on average, 5.1 hospital bed days per person year compared with 1.1 days for the non-diabetic population.     

Association of self-reported alcohol use and hospitalization for an alcohol-related cause in Scotland: a record-linkage study of 23 183 individuals

Aims To investigate the extent to which self‐reported alcohol consumption level in the Scottish population is associated with first‐time hospital admission for an alcohol‐related cause. Design Observational record‐linkage study. Setting Scotland, 1995–2005. Participants A total of 23 183 respondents aged 16 and over who participated in the 1995, 1998 and 2003 Scottish Health Surveys, followed‐up via record‐linkage from interview date until 30 September 2005. Measurements Rate of first‐time hospital admission with at least one alcohol‐related diagnosis. Cox proportional hazards regression analysis was applied to estimate the relative risk of first‐time hospitalization with an alcohol‐related condition associated with usual alcohol consumption level (1–7, 8–14, 15–21, 22–35, 36–49, 50+ units/week and ex‐drinker, compared with <1 unit per week). Findings Of the SHS participants, 527 were hospitalized for an alcohol‐related cause during 135 313 person‐years of follow‐up [39 first admissions per 10 000 person‐years, 95% confidence interval (CI) 36–42]. Alcohol‐related hospitalization rates were considerably higher for males (61/10 000 person‐years, 95% CI 54–67) than for females (22/10 000 person‐years, 95% CI 18–26). Compared with the lowest alcohol consumption category (<1 unit per week), the relative risk of first‐time alcohol‐related admission increased with reported consumption: age‐adjusted hazard ratios ranged from 3 (1–5) for 1–7 units/week to 19 (10–37) for 50+ units/week (males); and from 2 (1–3) for 1–7 units/week to 28 (14–56) for 50+ units/week (females). After adjusting for age and usual alcohol consumption, the relative risk of first‐time alcohol‐related admission remained significantly higher for males reporting binge drinking and for both males and females residing in the most deprived localities. Conclusions Moderate and higher levels of usual alcohol consumption and binge drinking are serious risk factors for alcohol‐related hospitalization in the Scottish population. These findings contribute to our understanding of the relationship between alcohol intake and alcohol‐related morbidity.     

Non-diabetic relatives of Type 2 diabetic families: dietary intake contributes to the increased risk of diabetes.

AIMS: Non-diabetic first degree relatives of Type 2 diabetic patients are at increased risk of developing diabetes and cardiovascular disease. This is assumed to reflect a shared genetic predisposition. The aim of this study was to test the hypothesis that lifestyle factors, specifically dietary factors, are also important to the increased risk in non-diabetic relatives. METHODS: Dietary intake was assessed using a validated food frequency questionnaire in 149 non-diabetic first degree relatives (age 20-65 years) from families of North European extraction with two or more living Type 2 diabetic family members, and 143 age- and sex-matched control subjects from the background population with no family history of diabetes. RESULTS: Relatives reported higher absolute intakes of total fat (mean (95% confidence intervals) 83 (76-91) vs. 71 (66-76) g/day, P = 0.01), saturated fat (SFA; 39 (36-43) vs. 33 (30-36) g/day, P < 0.01) and cholesterol (391 (354-427) vs. 318 (287-349) mg/day, P < 0.01), and a lower intake of non-starch polysaccharide (P < 0.05). Considered as percentage of total daily energy intake, relatives had higher intakes of total fat (P < 0.01) and SFA (P < 0.02), and a lower intake of carbohydrate (P < 0.02). These differences remained after exclusion of suspected under- and over-reporters of dietary intake. CONCLUSIONS: Non-diabetic relatives of Type 2 diabetic patients were found to consume diets that will promote rather than prevent the development of diabetes and cardiovascular disease. This suggests that the increased risk to non-diabetic relatives is therefore not entirely genetic, and there is scope for decreasing the risk through lifestyle modification.     

Alerations of lymphocyte subsets in children of diabetic mothers

Summary To investigate the impact of diabetic mothers on the maturation of the immune system in their offspring, immunophenotypic markers of major lymphocyte subpopulations were evaluated by two-colour flow cytometric analysis in 160 healthy children of diabetic mothers (100 with insulin-dependent diabetes mellitus (IDDM); 48 with gestational diabetes), including 22 neonates, 45 infants aged 8–12 months, 46 children aged 1–2 years, 29 children aged 3–6 years and 18 children aged 7–17 years. Results were compared with 21 neonates of healthy mothers from our hospital and with 110 paediatric subjects of a reference population. In neonates of diabetic mothers, percentages of total lymphocytes (p=0.044), T and B lymphocytes (p=0.004, respectively) were significantly decreased compared to our neonates of healthy mothers. By subdividing the group of neonates in offspring of mothers with IDDM (n=15) or gestational diabetes (n=7), differences compared to normal neonates were mainly observed in neonates of mothers with IDDM (T lymphocytes: p=0.006; B lymphocytes: p=0.008). In cord blood, 45.5% of neonates had antibodies to islet cells, insulin or glutamic acid decarboxylase, most likely transmitted through the placenta of the diabetic mother. No association was found between alterations of lymphocyte subsets and antibody-positivity in cord blood, nor was there any correlation of lymphocyte counts and mean HbA₁ during pregnancy, maternal age at delivery, diabetes duration, or neonatal birth weight, respectively. Comparisons among age groups from newborn infants through adolescents revealed higher percentages of total lymphocytes and lower percentages of activated T cells in children of diabetic mothers compared to children of the reference population between the age of 1 to 6 years (67–73% of the cases above and 62–77% below the interquartiles of the reference range, respectively). No significant differences in lymphocyte subpopulations between children of mothers with IDDM diabetes and gestational diabetes have been detected. In addition, there were no abnormalities of lymphocyte subsets in children who are at high risk for the development of IDDM. In summary, we suggest that the observed changes in children of diabetic mothers may reflect a cellular immune reaction to the particular maternal environment, characterized by both an abnormal metabolic state and persisting autoimmunity in the affected mother.Abbreviations ICA Islet cell antibodies - IAA insulin auto-antibodies - GAD-ab antibodies to glutamic acid decarboxylase - IDDM insulin-dependent diabetes mellitus - FITC fluorescein isothiocyanate - PE phycoerythrin     

A mortality prediction model in diabetic ketoacidosis

AIM: To assess the value of clinical and laboratory parameters in predicting mortality in patients presenting with diabetic ketoacidosis (DKA). METHODS: The records of all DKA admissions within 10 years were reviewed. Eighteen variables were evaluated at initial presentation and 20 variables at 4, 12 and 24 h from admission. A scoring system derived from these variables was compared to the APACHE III scoring system. RESULTS: Among 154 patients (52 males, mean age 58 +/- 12 years), 20 (13%) died in hospital. Multivariate analysis yielded six variables as significant independent predictors (P < 0.05) of mortality: severe coexisting diseases (SCD) and pH < 7.0, at presentation; units of regular insulin required in the first 12 h > 50 and serum glucose > 16.7 mmo/l, after 12 h; depressed mental state and fever, after 24 h. An integer-based scoring system was derived, as follows: number of points = 6 (SCD at presentation) + 4 (pH < 7.0 at presentation) + 4 (regular insulin required > 50 IU after 12 h) + 4 (serum glucose > 16.7 mmo/l after 12 h) + 4 (depressed mental state after 24 h) + 3 (fever after 24 h). Patients with 0-14 points had 0.86% risk of death, whereas for those with 19-25 points the risk was 93.3%. Median APACHE III scores differed significantly (P < 0.001) among groups of patients stratified according to the above scoring system. CONCLUSIONS: Risk stratification of patients with diabetic ketoacidosis is possible from simple clinical and laboratory variables available during the first day of hospitalization.     

Advance care planning and hospital in the nursing home

BACKGROUND: the number of nursing home residents (NHRs) in hospital is increasing although hospital admission may be deleterious to their health. OBJECTIVE: to evaluate a system of educating residents, their families, staff and general practitioners about outcomes of dementia, advance care planning (ACP) and hospital in the home. METHODS: we employed one clinical nurse consultant, who utilised the 'Let Me Decide' Advance Care Directive. The intervention area consisted of two hospitals and the 21 nursing homes (NHs) around them compared with another, geographically separate, hospital and the 13 homes around it. We conducted a controlled evaluation monitoring emergency admissions to hospital. RESULTS: emergency calls to the ambulance service from intervention NHs decreased (intervention versus control; -1 versus +21%; P = 0.0019). The risk of a resident being in an intervention hospital bed for a day compared with in a control hospital bed, per NH bed, fell by a quarter from being initially similar [Relative Risk (RR) = 1.01; 95% confidence interval (CI) 0.98-1.04; P = 0.442] to being lower (RR = 0.74; 95% CI 0.72-0.77; P<0.0001). There was no significant change in mortality in the intervention homes, but in the control homes mortality rose in the third year to be 11.2 per 100 beds higher than in the intervention area (P<0.05). CONCLUSION: ACP and hospital in the home can result in decreased hospital admission and mortality of NHRs.     

Type 1 diabetes as a risk factor for stroke in men and women aged 15-49: a nationwide study from Sweden.

AIMS: The main objective was to determine premature stroke risk in men and women in Sweden with previous hospital admission for Type 1 diabetes or without previous hospital admission. METHODS: All individuals in Sweden aged 15-34 years at first hospital admission for Type 1 diabetes and aged 15-49 years at first hospital admission for stroke during the study period (1987-2001) were identified. Standardized incidence ratios (SIRs) were calculated to compare premature stroke risk between individuals admitted to hospital with Type 1 diabetes and individuals without hospital admission, after controlling for age, time period, occupation and geographical region. SIRs were also calculated for individuals with diabetic complications. RESULTS: The overall SIRs for premature stroke in men and women with hospital admission for Type 1 diabetes were 17.94 [95% confidence interval (CI) 12.87, 24.36] and 26.11 (95% CI 18.81, 35.32), respectively. Men and women with diabetic nephropathy had the highest significant SIRs of premature stroke: 48.87 and 73.53, respectively. CONCLUSIONS: Our data indicate that young to middle-aged individuals with Type 1 diabetes had a considerably higher risk of premature stroke than those without Type 1 diabetes. This underscores the need to implement vigorous interventions in healthcare settings in order to decrease the risk of premature stroke in individuals with Type 1 diabetes.     

Characteristics of diabetic ketoacidosis in older versus younger adults.

OBJECTIVE: To describe how diabetic ketoacidosis in those aged 65 or over differs from that in younger adults. DESIGN: Retrospective chart review of all adult patients with a primary or secondary discharge diagnosis of diabetic ketoacidosis (n = 338). SETTING: Three urban teaching hospitals in Milwaukee, WI from January 1, 1987 to May 31, 1990. PATIENTS: Two hundred twenty cases in 150 patients met our criteria for severity of illness to be included in the study. Twenty-seven cases were in patients > or = age 65; 193 cases were in patients < age 65. RESULTS: The older patients were less likely to have been using insulin before hospitalization (55.6% vs 80.2%, P = 0.004) and less likely to have had a prior episode of diabetic ketoacidosis (8.0% vs 51.4%, P = 0.001). The presenting laboratory data were not significantly different between older and younger subjects. There was a trend toward a higher mean insulin dosage to bring the patient's blood glucose to < or = 300 mg/dL for those age 65 or older; 69.1 units vs 44.9 units (P = 0.06). The time required to obtain a glucose < 300 mg/dL was greater in older patients (10.5 vs 7.7 hours, P = 0.01). The average length of stay for those age 65 or older was 12.4 days vs 6.7 days (P = 0.001). Thirdly, of those age 65 or older, 7% vs 29% of younger subjects had a blood glucose or Accucheck < or = 49 mg/dL at some time during their hospital course. The hypoglycemic episodes were more likely to be asymptomatic in older patients (P = 0.03). The mortality rate was 22% for those age 65 or older vs 2% for younger subjects (P = 0.001). The mortality rate for those in age groups 60-69 years, 70-79 years, and > or = 80 years was 8%, 27%, and 33%, respectively. In patients > or = 65, mortality was confined to those with coexisting renal disease or infection. CONCLUSION: Older patients with diabetic ketoacidosis are less likely to have been using insulin before hospitalization. They tend to receive more insulin therapy during their acute management, have a longer average length of hospital stay, and have a higher mortality rate.     

Increased overnight growth hormone concentrations in diabetic compared with normal adolescents

To determine the extent to which spontaneous plasma GH concentrations are abnormal in adolescents with insulin-dependent diabetes mellitus we performed 12-h overnight plasma GH profiles in 21 diabetic adolescents (11 males and 10 females; aged 9.8-16.5 yr; median, 13.6 yr) and 34 healthy adolescent controls (17 males and 17 females; aged 9.1-20.9 yr; median, 13.1 yr). Data were analyzed using the pulse detection program Pulsar and time series analysis, and are presented with respect to age and puberty stage. Mean and maximum GH concentrations, sum of the peak amplitudes, and mean calculated baseline concentrations in the normal children were higher during puberty; highest levels were seen in girls at puberty stages 2-3, and in boys at stages 4-5. A similar pattern was observed in the diabetic adolescents, but all measures of pulse height and mean calculated baseline concentrations were significantly greater than those in the normal subjects (multivariate analysis, P less than 0.001). Pulse frequency did not change during puberty in the normal or diabetic subjects, and the dominant pulse periodicity in both groups was about 180 min. We conclude that the predominant change in GH release during puberty is in pulse amplitude, and that this is increased in diabetes, whereas pulse frequency remains constant in both normal and diabetic adolescents.     

A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients

OBJECTIVE: to prove the effectiveness of geriatric evaluation and management for elderly, hospitalized patients, combined with post-discharge home intervention by an interdisciplinary team. DESIGN: randomized controlled trial with outcome and costs assessed for 12 months after the date of admission. SETTING: university-affiliated geriatric hospital and the homes of elderly patients. SUBJECTS: 545 patients with acute illnesses admitted from home to the geriatric hospital. INTERVENTIONS: patients were randomly assigned to receive either comprehensive geriatric assessment and post-discharge home intervention (intervention), comprehensive geriatric assessment alone (assessment) or usual care. MAIN OUTCOME MEASURES: survival, functional status, rehospitalization, nursing home placement and direct costs over 12 months. RESULTS: the intervention group showed a significant reduction in length of hospital stay (33.49 days vs 40.7 days in the assessment group and 42.7 days in the control group; P < 0.05) and rate of immediate nursing home placement (4.4% vs 7.3% and 8.1%; P < 0.05). There was no difference in survival, acute care hospital readmissions or new admissions to nursing homes but the intervention group had significantly shorter hospital readmissions (22.2 days vs 34.2 days and 35.7 days; P < 0.05) and nursing home placements (114.7 days vs 161.6 days and 170.0 days; P < 0.05). Direct costs were lower in the intervention group [about DM 7000 (US $4000) per person per year]. Functional capacities were significantly better in the intervention group. CONCLUSIONS: comprehensive geriatric assessment in combination with post-discharge home intervention does not improve survival, but does improve functional status and can reduce the length of the initial hospital stay and of subsequent readmissions. It can reduce the rate of immediate nursing home admissions and delay permanent nursing home placement. It may also substantially reduce direct costs of hospitalized patients.     

Length of stay is associated with incidence of in-hospital malnutrition in a group of low-income Brazilian children

OBJECTIVE: To test the hypothesis that increased length of stay and anthropometric status at admission are significant factors associated with in-hospital malnutrition (IHM). MATERIAL AND METHODS: Prospective study with two weight (admission and discharge) and one height (admission) measurements per child at the Instituto de Puericultura e Pediatria Martag?o Gesteira (IPPMG), Rio de Janeiro, Brazil. The study included 456 children of low socioeconomic status under 10 years of age admitted to the IPPMG during 1997. Statistical analysis involved calculation of in-hospital malnutrition (IHM) prevalence by covariates. The length of hospital stay varied from 1 to 69 days. Association of IHM with gender, age category, length of stay, presence of wasting, and stunting, was tested by calculating odds ratios using multivariate logistic regression. RESULTS: Logistic regression showed that after adjusting for gender, age category, and presence of stunting at admission, presence of wasting at admission (OR = 0.07, CI 95% 0.01-0.55) and length of stay from 17 to 69 days (OR = 4.68, CI 95% 2.00-10.95), were statistically associated with IHM in the final model. CONCLUSIONS: As intervention measures, the authors suggest implementation of an early identification system for children at risk of developing IHM, along with a review and implementation of in-hospital feeding protocols.