Potentially Preventable Hospitalizations Among Adults With Pediatric-Onset Disabilities

ObjectiveTo examine the risk of any and specific potentially preventable hospitalizations (PPHs) for adults with cerebral palsy (CP) or spina bifida (SB). We hypothesize that PPH risk is greater among adults with CP/SB compared with the general population.Patients and MethodsUsing January 1, 2007, to December 31, 2017, national private administrative claims data (OptumInsight) in the United States, we identified adults with CP/SB (n=10,617). Adults without CP/SB were included as controls (n=1,443,716). To ensure a similar proportion in basic demographics, we propensity-matched our controls with cases in age and sex (n=10,617). Generalized estimating equation models were applied to examine the risk of CP/SB on PPHs. All models were adjusted for age, sex, race/ethnicity, health indicators, US Census Division data, and socioeconomic variables. Adjusted odds ratios were compared within a 4-year follow-up.ResultsAdults with CP/SB had higher risk for any PPH (odds ratio [OR], 4.10; 95% CI, 2.31 to 7.31), and PPHs due to chronic obstructive pulmonary disease/asthma (OR, 1.85; CI, 1.23 to 2.76), pneumonia (OR, 3.01; 95% CI, 2.06 to 4.39), and urinary tract infection (OR, 6.48; 95% CI, 3.91 to 10.75). Cases and controls who had an annual wellness visit had lower PPH risk (OR, 0.52; 95% CI, 0.41 to 0.67); similarly, adults with CP/SB who had an annual wellness visit compared with adults with CP/SB who did not had lower odds of PPH (OR, 0.75; 95% CI, 0.60 to 0.94).ConclusionAdults with pediatric-onset disabilities are at a greater risk for PPHs. Providing better access to preventive care and health-promoting services, especially for respiratory and urinary outcomes, may reduce PPH risk among this patient population.     

Traumatic Spinal Cord Injury and Risk of Early and Late Onset Alzheimer’s Disease and Related Dementia: Large Longitudinal Study

ObjectiveTraumatic spinal cord injury (TSCI) is a life altering event most often causing permanent physical disability. Little is known about the risk of developing Alzheimer disease and related dementia (ADRD) among middle-aged and older adults living with TSCI. Time to diagnosis of and adjusted hazard for ADRD was assessed.DesignCohort study.SettingUsing 2007-2017 claims data from the Optum Clinformatics Data Mart, we identified adults (45+) with diagnosis of TSCI (n=7019). Adults without TSCI diagnosis were included as comparators (n=916,516). Using age, sex, race/ethnicity, cardiometabolic, psychological, and musculoskeletal chronic conditions, US Census division, and socioeconomic variables, we propensity score matched persons with and without TSCI (n=6083). Incidence estimates of ADRD were compared at 4 years of enrollment. Survival models were used to quantify unadjusted, fully adjusted, and propensity-matched unadjusted and adjusted hazard ratios (HRs) for incident ADRD.ParticipantsAdults with and without TSCI (N=6083).InterventionNot applicable.Main Outcomes MeasuresDiagnosis of ADRD.ResultsBoth middle-aged and older adults with TSCI had higher incident ADRD compared to those without TSCI (0.5% vs 0.2% and 11.7% vs 3.3% among 45-64 and 65+ y old unmatched cohorts, respectively) (0.5% vs 0.3% and 10.6% vs 6.2% among 45-64 and 65+ y old matched cohorts, respectively). Fully adjusted survival models indicated that adults with TSCI had a greater hazard for ADRD (among 45-64y old: unmatched HR: 3.19 [95% confidence interval, 95% CI, 2.30-4.44], matched HR: 1.93 [95% CI, 1.06-3.51]; among 65+ years old: unmatched HR: 1.90 [95% CI, 1.77-2.04], matched HR: 1.77 [1.55-2.02]).ConclusionsAdults with TSCI are at a heightened risk for ADRD. Improved clinical screening and early interventions aiming to preserve cognitive function are of paramount importance for this patient cohort.     

Disability Among Persons With Chronic Severe Back Pain: Results From a Nationally Representative Population-based Sample

We evaluated the association between the chronic severe back pain with disability and participation, in U.S. Adults using data from the US 2019 National Health Interview Survey. In our sample of 2,925 adults (weighted n: 20,468,134) who reported having chronic severe back pain, 60% reported mobility disability, 60% had work limitations, 34% were limited for social participation and 16% had self-care limitations. Older age (65+) was associated with mobility difficulties (OR 1.99, 95% CI 1.28,6.09) and work limitation (OR 2.21, 95% CI 1.61,3.05). Lower socioeconomic status was associated with increasing odds of disability across the 4 categories. Being obese was only associated with mobility difficulties (OR 1.95, 95% CI 1.41,2.71), while not working in the past week was associated with difficulties in mobility (OR 3.55, 95% CI 2.64,4.75), self-care (OR 3.34, 95% CI 2.20,5.08), and social participation (OR 3.20, 95% CI 2.13,4.80). Comorbidities were highly associated with limitations in all 4 categories. Those deeming their ability to manage their pain ineffective were twice as likely to have limitations in self-care, social and work participation but not mobility. Identifying factors associated with disability and limitation may help target appropriate management for persons with chronic pain at high risk for disability.PerspectiveWe evaluated the association between the chronic severe back pain with disability and participation, in a representative sample of Americans. Identifying factors associated with a likelihood of disability may help target appropriate pain management for persons at high risk for disability due to chronic severe back pain.     

Prehospital Use of Inhaled Corticosteroids and Point Prevalence of Pneumonia at the Time of Hospital Admission: Secondary Analysis of a Multicenter Cohort Study

ObjectiveTo address clinical concern regarding the use of inhaled corticosteroids (ICSs) and the risk for pneumonia, particularly among patients with chronic obstructive pulmonary disease (COPD) and asthma.Patients and MethodsA multicentered prospective cohort of patients admitted to the hospital from March 1, 2009, through August 31, 2009, with pneumonia or another risk factor for acute respiratory distress syndrome was analyzed to determine the risk for pneumonia requiring hospitalization among patients taking ICSs. The adjusted risk (odds ratio [OR]) for developing pneumonia because of ICSs was determined in a multiple logistic regression model.ResultsOf the 5584 patients in the cohort, 495 (9%) were taking ICSs and 1234 (22%) had pneumonia requiring hospitalization. In univariate analyses, pneumonia occurred in 222 (45%) of the patients on ICSs vs 1012 (20%) in those who were not (OR, 3.28; 95% CI, 2.71-3.96; P<.001). After adjusting in the logistic regression model, prehospital ICS use was not significantly associated with pneumonia in the whole cohort (OR, 1.20; 95% CI, 0.93-1.53; P=.162), among the subset of 589 patients with COPD (OR, 1.40; 95% CI, 0.95-2.09; P=.093), among the 440 patients with asthma (OR, 1.07; 95% CI, 0.61-1.87; P=.81), nor among the remaining 4629 patients without COPD or asthma (OR, 1.32; 95% CI, 0.88-1.97; P=.179).ConclusionWhen adjusted for multiple confounding variables, ICS use was not substantially associated with an increased risk for pneumonia requiring admission in our cohort.     

Contributing factors to diaper dermatitis and NICU length of stay

ObjectiveDiaper dermatitis (DD) among NICU infants is preventable and under-recognized. The role of clinical characteristics (CC) on DD is also poorly described. This study examined the: 1) prevalence of DD in NICU; 2) relationship of factors including CC and DD; and 3) contribution of DD and CC factors on NICU Length of stay (LOS).MethodRetrospective chart review data was collected on all infants admitted to the NICU. Analyses included bivariate and multivariable logistic regression for DD outcome and negative binomial regression model for predicting infants’ NICU LOS.ResultsDD prevalence in the NICU sample was 34% (n = 180), 70% White, 56% male, 72% infants born at higher gestational age, and 62.2% born vaginally. Logistic regression results showed that Black infants have lower AOR of DD, whereas, NICU LOS (OR 1.02; 95% CI 1.01, 1.03), number of skin injuries (OR 1.22; 95% CI 1.01–1.47), and older gestational age (OR 3.73; 95%CI 0.83–0.95) increased the odds of DD. Significant interaction of gestational age group and days to full feed was identified.ConclusionDD is common among NICU infants and several CC play an integral role as risk and moderating factors for DD. Routine collection of infant skin integrity data is currently lacking in large collaborative databases, which limits better understanding of DD in NICU. Improvements in preventative measures could benefit from continued study of the impact nutrition and LOS have on DD development. Better systems of collecting and analyzing DD data and its impact on NICU LOS are needed.     

Relationship Between the Exposure to Occupation-related Psychosocial and Physical Exertion and Upper Body Musculoskeletal Diseases in Hospital Nurses: A Systematic Review and Meta-analysis

PurposeNurses’ musculoskeletal diseases (MSDs) are worldwide prevalent and are considered to be a costly occupational injury. This study aims to investigate the relationship between exposure to occupation-related psychosocial factors, physical workload, and upper body musculoskeletal diseases among hospital nurses.MethodsAn electronic search was implemented using nine databases with June 2019 as the latest search date. English and Chinese studies were chosen, and data were independently and separately extracted by two investigators. Pooled odds ratio (OR) and its 95% confidence interval (CI) were estimated for each subset, using the fixed or random-effects model, following heterogeneity between studies for research synthesis. The source of heterogeneity was explored through subgroup, sensitivity, and meta-analyses.ResultsEighteen studies were included in the meta-analysis. Most participants were women (51.4%–100.0%), aged between 20 and 60. A correlation was found between high job demand and the prevalence of low back pain (OR = 1.41; 95% CI = 1.23-1.62). Total job strain was related to the risk of low back pain (OR = 1.71; 95% CI = 1.15-2.55), neck pain (OR = 1.67; 95% CI = 1.26-2.20), shoulder pain (OR = 1.62; 95% CI = 1.06-2.48) and back pain (OR = 1.45; 95% CI = 1.10-1.91). Furthermore, the physical workload was significantly associated with the prevalence of low back pain (OR = 1.76; 95% CI = 1.32-2.35), neck pain (OR = 1.17; 95% CI = 1.08-1.27), shoulder pain (OR = 1.59; 95% CI = 1.37-1.85) and back pain (OR = 1.66; 95% CI = 1.45-1.90).ConclusionThere were significant associations between occupational strain, more physical workload and upper body MSDs, but the evidence advocating a growth risk in MSDs due to low levels of social support is quite weak.     

Risk factors for methicillin-resistant Staphylococcus aureus colonization and infection in patients with human immunodeficiency virus infection: A systematic review and meta-analysis

ObjectiveTo investigate the potential factors affecting methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in patients with human immunodeficiency virus (HIV) infection.MethodsA systematic search of publications listed in electronic from inception up to August 2020 was conducted. A random-effects model was used to calculate odds ratio (OR) with 95% confidence interval (CI).ResultsA total of 31 studies reporting 1410 MRSA events in 17 427 patients with HIV infection were included. Previous hospitalization (OR 1.80; 95% CI 1.37, 2.36), previous antibiotic therapy (OR 2.69; 95% CI 2.09, 3.45), CD4+ count (OR 1.79; 95% CI 1.41, 2.28), Centers for Disease Control and Prevention classification of stage C (OR 2.66; 95% CI 1.80, 3.93), skin lesions (OR 2.02; 95% CI 1.15, 3.55), intravenous device use (OR 2.61; 95% CI 1.59, 4.29) and an MRSA colonization history (OR 6.30; 95% CI 2.50, 15.90) were significantly associated with an increased risk of MRSA colonization and infection. Antiretroviral therapy (OR 0.71; 95% CI 0.50, 0.99) and current antibiotic use (OR 0.13; 95% CI 0.05, 0.32) were significantly associated with a reduced risk of MRSA colonization and infection.ConclusionMRSA colonization and infection in HIV-infected patients is associated with a number of risk factors.     

Risks and Outcomes of Perioperative Pulmonary Embolism in Major Surgeries: A Population-Based Study

PurposePerioperative pulmonary embolism (PE) is a significant cardiovascular complication in many surgeries. This study aimed to investigate the risks and outcomes of perioperative PE in major surgery.MethodsDischarge records of the Nationwide Readmission Database from 2010 to 2015 were extracted and analyzed. Length of stay, charges, death, and 30-day hospital readmission rate were compared for patients with and without perioperative PE. In addition, surgery-specific risk factors and therapies associated with PE were explored in a multivariable model.FindingsA total of 12,376,153 hospitalizations for major surgeries were involved, and perioperative PE occurred in 22,676 hospitalizations (0.18%). The length of stay, charges, rate of death, and 30-day hospital readmission were higher in patients with perioperative PE than in those without perioperative PE. Respiratory (odds ratios [OR], 2.09; 95% CI, 1.89–2.3), cardiovascular (OR, 1.62; 95% CI, 1.51–1.73), and musculoskeletal (OR, 1.22; 95% CI, 1.1–1.29) surgeries were risk factors for the occurrence of perioperative PE. In patients with perioperative PE, respiratory surgery was a risk factor for death (OR, 1.48; 95% CI, 1.10–2.00), whereas gynecologic/obstetric surgery was a protective factor for 30-day readmission (OR, 0.30; 95% CI, 0.10–0.88). Regarding therapy for perioperative PE, thrombolytic therapy (OR, 1.74; 95% CI, 1.26–2.42) and embolectomy (OR, 3.60; 95% CI, 2.35–5.51) were risk factors for death.ImplicationsRespiratory, cardiovascular, and musculoskeletal surgeries were risk factors for the occurrence of perioperative PE and death. Future research on precise models to predict PE in major surgeries is needed for appropriate interventions to improve outcomes of perioperative PE.     

Impact of Dementia on Patterns of Home Care After Inpatient Rehabilitation Discharge for Older Adults After Hip Fractures

ObjectiveTo describe differences in home care use in the 30 days after discharge from inpatient rehabilitation after a hip fracture among older adults with dementia compared with those without dementia.DesignRetrospective cohort study of individually linked health administrative data.SettingCommunity-dwelling older adults after discharge from inpatient rehabilitation facilities in Ontario, Canada.ParticipantsA total of 17,263 older adults (N=17,263), of whom 2489 had dementia (14.4%), who were treated for hip fracture in acute care and then admitted to inpatient rehabilitation facilities between January 1, 2011 and March 31, 2017.InterventionsNot applicable.Main Outcome MeasuresThe proportion receiving home care services and number of visits (physiotherapy, occupational therapy, nursing, personal/homemaking) in the 30 days after discharge were compared by dementia status with multivariate models, stratified by sex.ResultsCompared with those without dementia, adults with dementia were older, had lower functional scores, and were more likely to receive home care services in the 30 days after discharge from inpatient rehabilitation (87.0% vs 79.0%, P<.001), including personal/homemaking services (66.1% vs 46.4%, P<.001) and occupational therapy (45.3% vs 37.4, P<.001) but not physiotherapy (55.8% vs 56.2%, P=.677) or nursing (19.6% vs 18.7%, P=.268). After adjustment, older adults with dementia were more likely to receive home care in both men (odds ratio [OR] =2.01; 95% confidence interval [CI], 1.57-2.57) and women (OR=1.50; 95% CI, 1.30-1.74) as well as more services (rate ratio men=1.60; 95% CI, 1.44-1.79; rate ratio women=1.50; 95% CI, 1.41-1.60).ConclusionsAmong older adults discharged from inpatient rehabilitation, older adults with dementia received home care services more often than older adults without dementia. However, irrespective of sex and dementia status, almost half of this population (44%) did not receive physiotherapy. We recommend that, resources permitting, all older adults receive physiotherapy to facilitate recovery.     

Systemic Lupus Erythematosus and Increased Prevalence of Atherosclerotic Cardiovascular Disease in Hospitalized Patients

ObjectiveTo assess the prevalence of atherosclerotic cardiovascular disease (ASCVD) and its individual phenotypes of coronary artery disease (CAD), peripheral artery disease (PAD), and cerebrovascular disease by age and sex in a large US cohort of hospitalized patients with systemic lupus erythematosus (SLE).MethodsA nested case-control study of adults with and without SLE was conducted from the January 1, 2008, through December 31, 2014, National Inpatient Sample. Hospitalized patients with SLE were matched (1:3) by age, sex, race, and calendar year to hospitalized patients without SLE. The prevalences of CAD, PAD, and cerebrovascular disease were evaluated, and associations with SLE were determined after adjustment for common cardiovascular risk factors.ResultsAmong the 252,676 patients with SLE and 758,034 matched patients without SLE, the mean age was 51 years, 89% were women, and 49% were white. Patients with SLE had a higher prevalence of ASCVD vs those without SLE (25.6% vs 19.2%; OR, 1.45; 95% CI, 1.44-1.47; P<.001). After multivariable adjustment, SLE was associated with a greater odds of ASCVD (adjusted odds ratio [aOR], 1.46; 95% CI, 1.41-1.51). The association between SLE and ASCVD was observed in women and men and was attenuated with increasing age. Also, SLE was associated with increased odds of CAD (aOR, 1.42; 95% CI, 1.40-1.44), PAD (aOR, 1.25; 95% CI, 1.22-1.28), and cerebrovascular disease (aOR, 1.68; 95% CI, 1.65-1.71).ConclusionIn hospitalized US patients, SLE was associated with increased ASCVD prevalence, which was observed in both sexes and was greatest in younger patients.     

Patient-Reported Cognitive and Functional Impairments Among Older Canadians With Cancer: a Population-Based Study

ContextCancer is estimated to affect one out of two Canadians throughout their lifetime and to be the cause of death of one out of four Canadians. Although it can affect virtually patients of any age, it disproportionately affects older adults.ObjectivesThe objective of the present study is to assess the prevalence of self-reported cognitive and functional impairments among older adults with cancer vs. older adults without cancer; and to evaluate the factors associated with self-reported cognitive impairment among older adults with cancer.MethodsCanadian Community Health Survey data sets (2007–2016) were accessed, and participants 65 years wand older who answered the question Do you have cancer? and who have complete information about participant-reported cognitive function (assessed through health utilities index) were included. Differences in participant-reported functional status (including cognition, vision, hearing, speech, ambulation, dexterity, and emotion) between older adults with or without cancer were evaluated through Chi-squared testing. Multivariable logistic regression analysis was conducted to assess factors associated with participant-reported cognitive impairment among older adults with cancer.ResultsA total of 73,110 participants 65 years and older were included: 4342 participants with an active cancer diagnosis and 68,768 participants without an active cancer diagnosis (at the time of survey completion). Participants with cancer were more likely to report impairment in cognition (participants with cancer who can remember and think: 62.3%, whereas participants without cancer who can remember and think: 67.3%; P < 0.001), hearing (participants with cancer who can hear well: 82.2%, whereas participants without cancer who can hear well: 86.7%; P < 0.001), and mobility (participants with cancer who can walk without difficulty: 77.3%, whereas participants without cancer who can walk without difficulty: 84%; P < 0.001). The following factors were associated with participant-reported cognitive impairment among older adults with cancer: older age (odds ratio [OR] for age 65–69 years vs. age 80 years and older: 0.54; 95% CI: 0.35–0.84), lower income (OR: 2.12; 95% CI: 1.14–3.92), poor self-perceived health (OR for excellent vs. poor health: 0.38; 95% CI: 0.17–0.81), poor self-perceived mental health (OR for excellent vs. poor health: 0.08; 95% CI: 0.02–0.28), and illicit drug use (OR: 2.04; 95% CI: 1.31–3.18).ConclusionOlder adults with an active cancer diagnosis are more likely to report impaired cognitive and functional status compared with older adults without an active cancer diagnosis. More efforts are needed to ensure the integration of validated geriatric assessment tools (incorporating patient-reported elements) in the care of older adults with cancer.     

Gender-specific associations between activities of daily living disability and depressive symptoms among older adults in China: Evidence from the China Health and Retirement Longitudinal Study

PurposeTo evaluate the associations between BADL/IADL disability and depressive symptoms from the perspective of gender among older adults in China.MethodsThis cross-sectional study used the data from the second wave of the China Health and Retirement Longitudinal Study (CHARLS). The sample included 3463 older adults aged 60 years and older across China. Multivariable logistic regression models were conducted.ResultsAmong 3463 older adults, 1240 (35.8%) were classified as depressed, the prevalence of BADL and IADL disabilities were 756 (21.8%) and 1194 (34.5%), respectively. After controlling for covariates, BADL/IADL disability was significantly associated with an increased risk of depression prevalence both in men and women among older adults. Compared with IADL independent, IADL disability was about two times more likely to develop depressive symptoms in men (OR = 2.165, 95% CI = 1.661–2.822), which was much higher than that in women (OR = 1.748, 95% CI = 1.415–2.160). In contrast, the odds of being depressed for women with BADL disability (OR = 1.824, 95% CI = 1.447–2.299) were much higher than the odds for men with BADL disability (OR = 1.791, 95% CI = 1.348–2.379).ConclusionsOlder adults with BADL/IADL disability were more likely to have depressive symptoms both for men and women. However, the associations between depressive symptoms and BADL/IADL disability were different in gender. Our results suggest that differential institutional care service and appropriate strategies for improvement in mental health are required.     

Early Predictors of Near-Shore Spinal Injuries Among Emergency Department Patients

BackgroundSpinal injuries (SIs) can pose a significant burden to patients and family; delayed surgical intervention, associated with interhospital transfer, results in worse outcomes.ObjectiveThis study aimed to identify early patient-centered factors associated with risk for near-shore SIs to assist clinicians with expeditious medical decision-making.MethodsWe performed a multicenter retrospective study of all adults transported from Ocean City, Maryland to two emergency departments (EDs) and one regional trauma center for evaluation of suspected SIs from 2006 to 2017. Outcomes were any SI and any spinal cord injury (SCI). Multivariable logistic regression was performed for association of environmental and clinical factors with outcomes.ResultsWe analyzed 278 records, 102 patients (37%) were diagnosed with any SI and 41 (15%) were diagnosed with SCIs. Compared with patients without SI, patients with SI were more likely to be older (48 vs. 39 years), male (90% vs. 70%), with pre-existing spinal condition (62% vs. 33%), and injury caused by diving (11% vs. 2%). Multivariable logistic regression showed age (odd ratio [OR] 1.07; 95% confidence interval [CI] 1.04–1.11), diving (OR 3.5; 95% CI 3–100+), and wave height (OR 4.5; 95% CI 1.35–15.2) were associated with any SI, and a chief complaint of extremity numbness or tingling (OR 5.73; 95% CI 1.2–27.9) was associated with SCI.ConclusionsWe identified older age, diving, and higher wave height as risk factors for any SI and symptoms of numbness and tingling were associated with SCIs. Clinicians should consider expediting these patients’ transfers to a trauma center with neurosurgical capability.     

Current trends in venous thromboembolism among persons hospitalized with acute traumatic spinal cord injury: does early access to rehabilitation matter?

Selassie AW, Varma A, Saunders LL. Current trends in venous thromboembolism among persons hospitalized with acute traumatic spinal cord injury: does early access to rehabilitation matter?

Objective

To determine the incidence of venous thromboembolism (VTE) among patients with traumatic spinal cord injury (TSCI) in acute care settings that is attributable to extended length of stay (LOS), insurance status, and access to rehabilitation.

Design

Population-based, retrospective cohort study.

Setting

Levels I through III and undesignated trauma centers.

Participants

Patients with acute TSCI (N=3389) discharged from all acute care hospitals in South Carolina from 1998 through 2009, and a representative sample of patients with TSCI (n=186) interviewed 1 year later.

Interventions

Not applicable.

Main Outcome Measure

VTE while in acute care.

Results

Annual incidence of TSCI is 67.2 per million in the state of South Carolina, while the cumulative incidence of VTE is 4.1%. Patients with TSCI who developed VTE were nearly 4 times more likely (odds ratio [OR], 3.98; 95% confidence interval [CI], 2.57–6.17) to have been those who stayed 12 days or longer in acute care after adjusting for covariates. The adjusted mean LOS in acute care was 32.0 days (95% CI, 27.7–37.2) for patients with TSCI who had indigent insurance versus 11.3 days (95% CI, 4.9–17.6) for Medicare, and 18.5 days (95% CI, 14.5–22.5) for commercial insurance after adjusting for VTE, disposition, and year of discharge. Only 20% of the persons under indigent care received rehabilitation from accredited rehabilitation facilities in contrast to 60% under commercial insurance.

Conclusions

Fewer patients with TSCI under indigent care received postacute rehabilitation compared with Medicare or commercial insurance. Insurance status remains a major barrier to timely transfer to rehabilitation, leading to protracted LOS in acute care with increased risk of VTE.     

Hemolyzed Laboratory Specimens in the Emergency Department: An Underappreciated,but Frequent Problem

IntroductionHemolysis of blood samples from emergency department (ED) patients leads to delays in treatment and disposition. The aim of this study is to determine the frequency of hemolysis and variables predictive of hemolysis.MethodsThis observational cohort study was conducted among three institutions: academic tertiary care center and two suburban community EDs, with an annual census of over 270,000 ED visits. Data were obtained from the electronic health record. Adults requiring laboratory analysis with at least one peripheral intravenous catheter (PIVC) inserted within the ED were eligible. Primary outcome was hemolysis of lab samples and secondary outcomes included variables related to PIVC failure.ResultsBetween January 8, 2021 and May 9, 2022, 141,609 patient encounters met inclusion criteria. The average age was 55.5 and 57.5% of patients were female. Hemolysis occurred in 24,359 (17.2%) samples. In a multivariate analysis, when compared to 20-gauge catheters, smaller 22-gauge catheters had an increased odds of hemolysis (OR 1.78, 95% confidence interval (CI) 1.65-1.91; P < .001), while larger 18-gauge catheters had a lower odds of hemolysis (OR 0.94; 95% CI 0.90-0.98; P = .0046). Additionally, when compared to antecubital placement, hand/wrist placement demonstrated increased odds of hemolysis (OR 2.06; 95% CI 1.97-2.15; P < .001). Finally, hemolysis was associated with a higher rate of PIVC failure (OR 1.06; 95%CI 1.00-1.13; P = 0.043).DiscussionThis large observational analysis demonstrates that lab hemolysis of is a frequent occurrence among ED patients. Given the added risk of hemolysis with certain placement variables, clinicians should consider catheter gauge/placement location to avoid hemolysis that may result in patient care delays and prolonged hospital stays.     

Outcomes Following Percutaneous Coronary Intervention in Renal Transplant Recipients: A Binational Collaborative Analysis

ObjectiveTo investigate the clinical and procedural characteristics in patients with a history of renal transplant (RT) and compare the outcomes with patients without RT in 2 national cohorts of patients undergoing percutaneous coronary intervention (PCI).Patients and MethodsData from the National Inpatient Sample (NIS) and British Cardiovascular Intervention Society (BCIS) were used to compare the clinical and procedural characteristics and outcomes of patients undergoing PCI who had RT with those who did not have RT. The primary outcome of interest was in-hospital mortality.ResultsOf the PCI procedures performed in 2004-2014 (NIS) and 2007-2014 (BCIS), 12,529 of 6,601,526 (0.2%) and 1521 of 512,356 (0.3%), respectively, were undertaken in patients with a history of RT. Patients with RT were younger and had a higher prevalence of congestive cardiac failure, hypertension, and diabetes but similar use of drug-eluting stents, intracoronary imaging, and pressure wire studies compared with patients who did not have RT. In the adjusted analysis, patients with RT had increased odds of in-hospital mortality (NIS: odds ratio [OR], 1.90; 95% CI, 1.41-2.57; BCIS: OR, 1.60; 95% CI, 1.05-2.46) compared with patients who did not have RT but no difference in vascular or bleeding events. Meta-analysis of the 2 data sets suggested an increase in in-hospital mortality (OR, 1.79; 95% CI, 1.40-2.29) but no difference in vascular (OR, 1.24; 95% CI, 0.77-2.00) or bleeding (OR, 1.21; 95% CI, 0.86-1.68) events.ConclusionThis large collaborative analysis of 2 national databases revealed that patients with RT undergoing PCI are younger, have more comorbidities, and have increased mortality risk compared with the general population undergoing PCI.     

Out-of-Hospital Pediatric Patient Safety Events: Results of the CSI Chart Review

Objective: Studies of adult hospital patients have identified medical errors as a significant cause of morbidity and mortality. Little is known about the frequency and nature of pediatric patient safety events in the out-of-hospital setting. We sought to quantify pediatric patient safety events in EMS and identify patient, call, and care characteristics associated with potentially severe events. Methods: As part of the Children's Safety Initiative -EMS, expert panels independently reviewed charts of pediatric critical ambulance transports in a metropolitan area over a three-year period. Regression models were used to identify factors associated with increased risk of potentially severe safety events. Patient safety events were categorized as: Unintended injury; Near miss; Suboptimal action; Error; or Management complication (“UNSEMs”) and their severity and potential preventability were assessed. Results: Overall, 265 of 378 (70.1%) unique charts contained at least one UNSEM, including 146 (32.8%) errors and 199 (44.7%) suboptimal actions. Sixty-one UNSEMs were categorized as potentially severe (23.3% of UNSEMs) and nearly half (45.3%) were rated entirely preventable. Two factors were associated with heightened risk for a severe UNSEM: (1) age 29 days to 11 months (OR 3.3, 95% CI 1.25-8.68); (2) cases requiring resuscitation (OR 3.1, 95% CI 1.16-8.28). Severe UNSEMs were disproportionately higher among cardiopulmonary arrests (8.5% of cases, 34.4% of severe UNSEMs). Conclusions: During high-risk out-of-hospital care of pediatric patients, safety events are common, potentially severe, and largely preventable. Infants and those requiring resuscitation are important areas of focus to reduce out-of-hospital pediatric patient safety events.     

Adults With Tetralogy of Fallot: Early Postoperative Outcomes and Risk Factors for Complications

ObjectiveTo report the early postoperative outcomes in adults with tetralogy of Fallot (TOF) undergoing cardiac surgery and to identify patient factors associated with complications.Patients and MethodsWe performed a single-institution retrospective review of adults with TOF who underwent cardiac surgery from January 8, 2008, through June 21, 2018. Patients’ characteristics, preoperative imaging, surgical interventions, outcomes, and complications were analyzed.ResultsThere were 219 adults with TOF (mean age, 40 years; range, 18-83 years; 88 [40%] female) in the study. Surgical interventions included repair or replacement of the pulmonary valve (n=199 [91%]), tricuspid valve (n=70 [32%]), mitral valve (n=13 [5.9%]), and aortic valve (n=8 [3.7%]). Three patients (1.4%) underwent first-time TOF repair. The 30-day mortality rate was 1.4% (n=3). Early postoperative complications occurred in 66 (30%) and included arrhythmias requiring treatment, dialysis requirement, liver dysfunction, respiratory failure, infection, reoperation, cardiac arrest, mechanical circulatory support, and death. Multivariate analysis found older age at current surgery (odds ratio [OR], 1.04 per year; 95% CI, 1.01 to 1.06; P<.001), longer cardiopulmonary bypass time (OR, 1.01 per minute; 95% CI, 1.01 to 1.02; P<.001), right ventricular systolic dysfunction (OR, 1.31; 95%, CI 1.02 to 1.69; P=.03), diabetes mellitus (OR, 3.50; 95% CI, 1.20 to 10.2; P=.02), and history of initial palliative surgery (OR, 1.99; 95% CI, 1.01 to 3.91; P=.05) as independent predictors of complications.ConclusionSurgical interventions for adult patients with TOF can be performed with low early morbidity and mortality. Clinical characteristics and preoperative testing parameters can predict risk for complications in the postoperative period.     

Age-dependent impact of the major common genetic risk factor for COVID-19 on severity and mortality

BackgroundThere is considerable variability in COVID-19 outcomes among younger adults, and some of this variation may be due to genetic predisposition.MethodsWe combined individual level data from 13,888 COVID-19 patients (n = 7185 hospitalized) from 17 cohorts in 9 countries to assess the association of the major common COVID-19 genetic risk factor (chromosome 3 locus tagged by rs10490770) with mortality, COVID-19-related complications, and laboratory values. We next performed metaanalyses using FinnGen and the Columbia University COVID-19 Biobank.ResultsWe found that rs10490770 risk allele carriers experienced an increased risk of all-cause mortality (HR, 1.4; 95% CI, 1.2–1.7). Risk allele carriers had increased odds of several COVID-19 complications: severe respiratory failure (OR, 2.1; 95% CI, 1.6–2.6), venous thromboembolism (OR, 1.7; 95% CI, 1.2–2.4), and hepatic injury (OR, 1.5; 95% CI, 1.2–2.0). Risk allele carriers age 60 years and younger had higher odds of death or severe respiratory failure (OR, 2.7; 95% CI, 1.8–3.9) compared with those of more than 60 years (OR, 1.5; 95% CI, 1.2–1.8; interaction, P = 0.038). Among individuals 60 years and younger who died or experienced severe respiratory failure, 32.3% were risk-variant carriers compared with 13.9% of those not experiencing these outcomes. This risk variant improved the prediction of death or severe respiratory failure similarly to, or better than, most established clinical risk factors.ConclusionsThe major common COVID-19 genetic risk factor is associated with increased risks of morbidity and mortality, which are more pronounced among individuals 60 years or younger. The effect was similar in magnitude and more common than most established clinical risk factors, suggesting potential implications for future clinical risk management.