Hospital volume and other risk factors for in-hospital mortality among diverticulitis patients: A nationwide analysis

BACKGROUND:

Previous studies have found that a higher volume of colorectal surgery was associated with lower mortality rates. While diverticulitis is an increasingly common condition, the effect of hospital volume on outcomes among diverticulitis patients is unknown.

OBJECTIVE:

To evaluate the relationship between hospital volume and other factors on in-hospital mortality among patients admitted for diverticulitis.

METHODS:

Data from the Nationwide Inpatient Sample (years 1993 to 2008) were analyzed to identify 822,865 patients representing 4,108,726 admissions for diverticulitis. Hospitals were divided into quartiles based on the volume of diverticulitis cases admitted over the study period, adjusted for years contributed to the dataset. Mortality according to hospital volume was modelled using logistic regression adjusting for age, sex, race, comorbidities, health care insurance, admission type, calendar year, colectomy, disease severity and clustering. Risk estimates were expressed as adjusted ORs with 95% CIs.

RESULTS:

Patients at high-volume hospitals were more likely to be admitted emergently, undergo surgical treatment and have more severe disease. In-hospital mortality was higher among the lowest quartile of hospital volume compared with the highest volume (OR 1.13 [95% CI 1.05 to 1.21]). In-hospital mortality was increased among patients admitted emergently (OR 2.58 [95% CI 2.40 to 2.78]) as well as those receiving surgical treatment (OR 3.60 [95% CI 3.42 to 3.78]).

CONCLUSIONS:

Diverticulitis patients admitted to hospitals with a low volume of diverticulitis cases had an increased risk for death compared with those admitted to high-volume centres.     

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

Background

Evidence-based interventions to reduce hospital readmissions may not generalize to resource-constrained safety-net hospitals.

Objective

To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients.

Design

Randomized controlled trial.

Participants

General medicine inpatients having at least one of the following readmission risk factors: (1) age ≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay ≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls.

Interventions

PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management.

Main Measures

The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls).

Key Results

Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1 % decrease [95 % CI: −8.0 %, -0.2 %] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8 % increase [95 % CI: 4.4 %, 19.0 %] in readmission with no change in 30-day outpatient follow-up.

Conclusions

A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3185-x) contains supplementary material, which is available to authorized users.KEY WORDS: care transitions, continuity of care, health care delivery, patient safety, underserved populations     

Impact of Age on Transcatheter Aortic Valve Implantation Outcomes: Comparison Between Patients Aged ≤80 Years versus Patients >80 Years

Objective To investigate the procedural outcomes and the long-term survival of patients undergoing transcatheter aortic valve implantation (TAVI) and compare study results of patients ≤ 80 years and patients > 80 years old. Methods A total of 240 patients treated with TAVI were divided into two groups according to age ≤ 80 years (n = 105; 43.8%) and > 80 years (n = 135; 56.2%). The baseline characteristics and the procedural outcomes were compared between these two groups of patients. Results With the exception of peripheral artery disease and hypercholesterolemia, which were more frequently observed in the older age group, baseline characteristics were comparable between groups. Complication rates did not differ significantly between patients ≤ 80 years and patients > 80 years. There were no differences in 30-day mortality rates between patients aged ≤ 80 years and patients > 80 years old (9.5% vs. 7.4%, respectively; P = 0.557). After a median follow-up of 28 months (interquartile range: 16–42 months), 50 (47.6%) patients aged ≤ 80 years died compared to 57 (42%) deaths in the group of patients > 80 years old (P = 0.404). Conclusion The results of the present single center study showed that age didn't significantly impact the outcomes of TAVI.     

It’s a man’s world: Does orthotopic liver transplantation in the elderly male confer an additional risk on survival?

BACKGROUND:

Orthotopic liver transplantation (OLT) in a well-selected population is a highly successful procedure, with one-year survival rates reported to be as high as 90%. Advanced age is considered to be a contraindication. Survival rates in patients >60 years of age appear to be comparable with those of younger patients. However, little objective data exist on the outcomes of patients >65 years of age undergoing OLT.

OBJECTIVE:

To review the outcomes of OLT in the Irish National Transplant Unit in patients >65 years of age and to compare outcomes with patients ≤65 years of age. Second, to identify any factors that may provide valuable prognostic information regarding outcomes.

METHOD:

Patients >65 years of age who underwent OLT since the inception of the National Liver Unit in 1993 were identified from a prospectively maintained database. Medical records were reviewed. Survival was compared with the overall cohort using the Kaplan-Meier technique. Independent variables between the two groups were assessed using logistic regression analysis.

RESULTS:

Between January 1993 and December 2009, 551 patients underwent 639 transplants in the Irish National Liver Transplant Unit. Forty-three transplants were performed in 40 patients >65 years of age. Unadjusted one- and three-year survival rates for the elderly cohort were 77.8% and 64.5%, respectively. This compared with 93% and 85%, respectively, in the unselected cohort. Using Kaplan-Meier analysis, a significant benefit in survival was observed in patients ≤65 years of age (P=0.017). Similarly, when adjusted for sex, a significant difference was noted between the groups. Male patients >65 years of age had poorer survival compared with their female counterparts >65 years of age and all patients ≤65 years of age (P=0.02). There was no significant difference between the groups with respect to preoperative variables such as bilirubin, creatinine and sodium levels, and Model for End-stage Liver Disease score. A significant difference was seen in male patients >65 years of age with more than one comorbidity, compared with female patients and male patients ≤65 years of age.

CONCLUSION:

Male sex was associated with poorer survival in patients >65 years of age undergoing OLT. Multiple comorbidities in elderly male patients should be considered a relative contraindication in patients being assessed for OLT.     

The clinical factors for predicting severe diverticulitis in Korea: a comparison with Western countries

Background/Aims

It is unclear whether the risk factors associated with complicated diverticulitis in Asian and Western countries are the same. We evaluated the risk factors associated with severe diverticulitis (SD) in Korea and compared the clinical characteristics of diverticulitis according to location.

Methods

A retrospective review of 190 patients hospitalized with acute diverticulitis from January 2005 to June 2010 was conducted. SD was defined as one of the following: perforation, abscess, obstruction, sepsis, or peritonitis that required an urgent operation.

Results

Twenty-four patients (12.6%) were diagnosed with SD. SD was significantly associated with older age, a fever over 38℃, changes in bowel habits and a high visceral adipose tissue (VAT)/total adipose tissue (TAT) ratio. Multivariate analysis showed that the risk factors for developing SD were an age of 40 years or more (odds ratio [OR], 3.2; p=0.032), male gender (OR, 4.0; p=0.021) and left-sided diverticulitis (OR, 6.2; p=0.017). Right-sided diverticulitis (n=175, 92.1%) was significantly associated with younger ages, fewer changes in bowel habits, fewer comorbidities and non-SD.

Conclusions

This study suggests that the risk factors for developing SD in Korea, where right-sided diverticulitis is predominant, are the male gender, an age of more than 40 years old, and left-sided diverticulitis. Given that there are different risk factors for developing SD in Western countries, different strategies for the treatment of diverticulitis in the Korean population seem to be needed.     

Risk Factors for Severe Diverticulitis in Computed Tomography-Confirmed Acute Diverticulitis in Korea

Background/Aims

Acute complicated diverticulitis can be subdivided into moderate diverticulitis and severe diverticulitis. Although there have been numerous studies on the risk factors for complicated diverticulitis, little research has focused on severe diverticulitis. This study was designed to identify the risk factors for severe diverticulitis in an acute diverticulitis attack using the modified Hinchey classification.

Methods

Patients were included if they had any evidence of acute diverticulitis detected by computed tomography. The patients were subdivided into severe diverticulitis (Hinchey class ≥Ib; abscesses or peritonitis) and moderate diverticulitis (Hinchey class Ia; pericolic inflammation) groups.

Results

Of the 128 patients, 25 exhibited severe diverticulitis, and 103 exhibited moderate diverticulitis. In a multivariate analysis, age >50 years (odds ratio [OR], 5.27; p=0.017), smoking (OR, 3.61; p=0.044), comorbidity (OR, 4.98; p=0.045), leukocytosis (OR, 7.70; p=0.003), recurrence (OR, 4.95; p=0.032), and left-sided diverticulitis (OR, 6.92; p=0.006) were significantly associated with severe diverticulitis.

Conclusions

This study suggests that the risk factors for severe diverticulitis are age >50 years, smoking, comorbidity, leukocytosis, recurrent episodes, and left-sided diverticulitis.     

Type 2 Diabetes Phenotype and Progression Is Significantly Different if Diagnosed before versus after 65 Years of Age

Background

The incidence of type 2 diabetes is increasing disproportionately in individuals <65 years of age. It is not known whether disease characteristics in these younger patients are similar to “classic” late-onset type 2 diabetes.

Methods

In the epidemiological cohort study entitled “Retrolective Study: Self-Monitoring of Blood Glucose and Outcome in Patients with Type 2 Diabetes,” a total of 3268 patients from randomly contacted primary care practices were documented during a mean follow-up period of 6.5 years. All newly diagnosed patients of these practices were included.

Results

At diagnosis, 64.2% of the patients were aged ≤65 years. Thereof, 57.2% were male, whereas in the age group >65 years only 35.0% were male (p < 0.001). The younger group exhibited more severe metabolic deterioration at diagnosis and in the following years than the older group. Conversely, the older group presented at diagnosis with a higher prevalence of cardiovascular risk factors. Self-monitoring of blood glucose (SMBG) was more prominent in the younger group. In both age groups, the use of SMBG was associated with a significantly lower risk (p = 0.003) of a combined end point (severe diabetic complication or all-cause mortality).

Conclusions

There are considerable differences in disease characteristics between people diagnosed with type 2 diabetes during 45–65 years of age versus diagnosis at a later age. Type 2 diabetes diagnosed before the age of 65 years disproportionately affected men and exhibited a more severe disease course, but was characterized by significantly less cardiovascular risk factors in comparison to type 2 diabetes diagnosed at a later age. The use of SMBG was associated with a better clinical outcome in both age groups.     

Visceral Obesity as a Risk Factor for Left-Sided Diverticulitis in Japan: A Multicenter Retrospective Study

Background/Aims

Left-sided diverticulitis is increasing in Japan, and many studies report that left-sided diverticulitis is more likely to be severe. Therefore, it is important to identify the features and risk factors for left-sided diverticulitis. We hypothesized that left-sided diverticulitis in Japan is related to obesity and conducted a study of the features and risk factors for this disorder in Japan.

Methods

Right-sided diverticulitis and left-sided diverticulitis patients (total of 215) were compared with respect to background, particularly obesity-related factors to identify risk factors for diverticulitis.

Results

There were 166 (77.2%) right-sided diverticulitis patients and 49 (22.8%) left-sided diverticulitis patients. The proportions of obese patients (body mass index ≥25 kg/m², p=0.0349), viscerally obese patients (visceral fat area ≥100 cm², p=0.0019), patients of mean age (p=0.0003), and elderly patients (age ≥65 years, p=0.0177) were significantly higher in the left-sided-diverticulitis group than in the right-sided-diverticulitis group. The proportion of viscerally obese patients was significantly higher in the left-sided-diverticulitis group than in the left-sided-diverticulosis group (p=0.0390).

Conclusions

This study showed that obesity, particularly visceral obesity, was a risk factor for left-sided diverticulitis in Japan.     

Ulcerative colitis-associated hospitalization costs: A population-based study

BACKGROUND:

Hospitalization costs for ulcerative colitis (UC) following the introduction of infliximab have not been evaluated.

OBJECTIVE:

To study predictors of costs for UC patients who were hospitalized for a flare or colectomy.

METHODS:

Population-based surveillance identified adults (≥18 years of age) admitted to hospital for UC flare or colectomy between 2001 and 2009 in the Calgary Health Zone (Alberta). Medical charts were reviewed and patients stratified into three admission types: responsive to inpatient medical therapy (n=307); emergent colectomy (n=227); and elective colectomy (n=208). The annual median cost with interquartile range (IQR) was calculated. Linear regression determined the effect of admission type on hospital charges after adjusting for age, sex, smoking, comorbidities, disease extent, medication use (eg, infliximab) and year. The adjusted cost increase was presented as the percent increase with 95% CIs. Joinpoint analysis assessed for an inflection point in hospital cost after the introduction of infliximab.

RESULTS:

Median hospitalization cost for UC flare, emergent colectomy and elective colectomy, respectively, were: $5,499 (IQR $3,374 to $8,904), $23,698 (IQR $17,981 to $32,385) and $14,316 (IQR $11,932 to $18,331). Adjusted hospitalization costs increased approximately 6.0% annually (95% CI 4.5% to 7.5%). Adjusted costs were higher for patients who underwent an elective colectomy (percent increase cost 179.8% [95% CI 151.6% to 211.1%]) or an emergent colectomy (percent increase cost 211.1% [95% CI 183.2% to 241.6%]) than medically responsive patients. Infliximab in hospital was an independent predictor of increased costs (percent increase cost 69.5% [95% CI 49.2% to 92.5%]). No inflection points were identified.

CONCLUSION:

Hospitalization costs for UC increased due to colectomy and infliximab.     

Practice patterns and outcomes in patients presenting to the emergency department with acute heart failure

BACKGROUND:

Heart failure (HF) is a common emergency department (ED) presentation and a leading reason for hospitalization. Canadian practice patterns for the management of acute HF have not been well described.

OBJECTIVE:

To describe current treatment patterns of patients presenting to the ED with acute HF and investigate whether these treatments influenced outcomes.

METHODS:

A health record review was performed in a 30% random sample of all patients who presented to six EDs in the Capital Health Region (Edmonton, Alberta) with a most responsible diagnosis of acute HF from April 2002, to March 2003.

RESULTS:

A total of 448 patients (45% women) with a mean (± SD) age of 75.3±11.2 years were included. Comorbidities included hypertension (55%), coronary artery disease (39%) and previous myocardial infarction (38%). In the first 72 h, patients were most commonly treated with intravenous furosemide (48%), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (45%), oral furosemide (42%) and salbutamol (38%). Fifty-four per cent of patients were admitted to the hospital, and 20% died or were readmitted within 30 days. Multivariate logistic regression analysis revealed age, history of HF, history of angioplasty and oxygen administration in the ED as independent predictors of death or readmission at 30 days. No medications were associated with decreased readmission or death.

CONCLUSIONS:

The current treatment patterns for acute HF are mostly symptomatic. Proven efficacious HF therapies remain underused. Future research should focus on the integration of disease management, identifying predictors of admission and readmission, and treatments to reduce rehospitalization.     

Survival and Predictive Factors of Lethality in Hemodyalisis: D/I Polymorphism of The Angiotensin I-Converting Enzyme and of the Angiotensinogen M235T Genes

Background

End-stage kidney disease patients continue to have markedly increased cardiovascular disease morbidity and mortality. Analysis of genetic factors connected with the renin-angiotensin system that influences the survival of the patients with end-stage kidney disease supports the ongoing search for improved outcomes.

Objective

To assess survival and its association with the polymorphism of renin-angiotensin system genes: angiotensin I-converting enzyme insertion/deletion and angiotensinogen M235T in patients undergoing hemodialysis.

Methods

Our study was designed to examine the role of renin-angiotensin system genes. It was an observational study. We analyzed 473 chronic hemodialysis patients in four dialysis units in the state of Rio de Janeiro. Survival rates were calculated by the Kaplan-Meier method and the differences between the curves were evaluated by Tarone-Ware, Peto-Prentice, and log rank tests. We also used logistic regression analysis and the multinomial model. A p value ≤ 0.05 was considered to be statistically significant. The local medical ethics committee gave their approval to this study.

Results

The mean age of patients was 45.8 years old. The overall survival rate was 48% at 11 years. The major causes of death were cardiovascular diseases (34%) and infections (15%). Logistic regression analysis found statistical significance for the following variables: age (p = 0.000038), TT angiotensinogen (p = 0.08261), and family income greater than five times the minimum wage (p = 0.03089), the latter being a protective factor.

Conclusions

The survival of hemodialysis patients is likely to be influenced by the TT of the angiotensinogen M235T gene.     

Acute exacerbation of chronic obstructive pulmonary disease: Influence of social factors in determining length of hospital stay and readmission rates

BACKGROUND:

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is the leading reason for hospitalization in Canada and a significant financial burden on hospital resources. Identifying factors that influence the time a patient spends in the hospital and readmission rates will allow for better use of scarce hospital resources.

OBJECTIVES:

To determine the factors that influence length of stay (LOS) in the hospital and readmission for patients with AECOPD in an inner-city hospital.

METHODS:

Using the Providence Health Records, a retrospective review of patients admitted to St Paul’s Hospital (Vancouver, British Columbia) during the winter of 2006 to 2007 (six months) with a diagnosis of AECOPD, was conducted. Exacerbations were classified according to Anthonisen criteria to determine the severity of exacerbation on admission. Severity of COPD was scored using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. For comparative analysis, severity of disease (GOLD criteria), age, sex and smoking history were matched.

RESULTS:

Of 109 admissions reviewed, 66 were single admissions (61%) and 43 were readmissions (39%). The number of readmissions ranged from two to nine (mean of 3.3 readmissions). More than 85% of admissions had the severity of COPD equal to or greater than GOLD stage 3. The significant indicators for readmission were GOLD status (P<0.001), number of related comorbidities (OR 1.47, 95% CI 1.10 to 1.97; P<0.009) and marital status (single) (OR 4.18, 95% CI 1.03 to 17.02; P<0.046). The requirement for social work involvement during hospital admission was associated with a prolonged LOS (P<0.05).

CONCLUSIONS:

The results of the present study show that disease severity (GOLD status) and number of comorbidities are associated with readmission rates of patients with AECOPD. Interestingly, social factors such as marital status and the need for social work intervention are also linked to readmission rates and LOS, respectively, in patients with AECOPD.     

Sex differences in coronary catheterization and revascularization following acute myocardial infarction: Time trends from 1994 to 2003 in British Columbia

BACKGROUND:

Studies before the turn of the century reported sex differences in procedure rates. It is unknown whether these differences persist.

OBJECTIVES:

To examine time trends and sex differences in coronary catheterization and revascularization following acute myocardial infarction (AMI).

METHODS:

A retrospective analysis was performed of all patients 20 years of age or older who were admitted to hospital in British Columbia with an AMI between April 1, 1994, and March 31, 2003. Segmented regression analysis was used to examine the inflection point of the time trend in 90-day catheterization rates post-AMI. Multivariable Cox regression modelling was used to evaluate sex differences in receiving catheterization and revascularization following AMI.

RESULTS:

Ninety-day coronary catheterization rates increased significantly over the study period for both men and women (P<0.0001 for trend), with a steeper increase beginning in September 2000. Women were less likely to undergo catheterization than men, even after adjustment for baseline differences; this sex effect was modified by age and care in the intensive care unit or cardiac care unit (ICU/CCU). Specifically, ICU/CCU admission eliminated the sex difference among patients who were younger than 65 years of age. Conditional on receiving cardiac catheterization post-AMI, female sex was not associated with a lower likelihood of receiving revascularization within one year (HR 0.96; 95% CI 0.91 to 1.02).

CONCLUSIONS:

Despite recent increases in catheterization rates post-AMI, women were less likely to undergo catheterization than men. Interestingly, access to ICU/CCU care removed the sex difference in catheterization access in patients younger than 65 years of age.     

Predictors of mortality among patients undergoing colectomy for ischemic colitis: A population-based,United States study

BACKGROUND:

Ischemic colitis is a potentially life-threatening condition that can require colectomy for management.

OBJECTIVE:

To assess independent predictors of mortality following colectomy for ischemic colitis using a nationally representative sample of hospitals in the United States.

METHODS:

The Nationwide Inpatient Sample was used to identify all patients with a primary diagnosis of acute vascular insufficiency of the colon (International Classification of Diseases, Ninth Revision codes 557.0 and 557.9) who underwent a colectomy between 1993 and 2008. Incidence and mortality are described; multivariate logistic regression analysis was performed to determine predictors of mortality.

RESULTS:

The incidence of colectomy for ischemic colitis was 1.43 cases (95% CI 1.40 cases to 1.47 cases) per 100,000. The incidence of colectomy for ischemic colitis increased by 3.1% per year (95% CI 2.3% to 3.9%) from 1993 to 2003, and stabilized thereafter. The postoperative mortality rate was 21.0% (95% CI 20.2% to 21.8%). After 1997, the mortality rate significantly decreased at an estimated annual rate of 4.5% (95% CI −6.3% to −2.7%). Mortality was associated with older age, 65 to 84 years (OR 5.45 [95% CI 2.91 to 10.22]) versus 18 to 34 years; health insurance, Medicaid (OR 1.69 [95% CI 1.29 to 2.21]) and Medicare (OR 1.33 [95% CI 1.12 to 1.58]) versus private health insurance; and comorbidities such as liver disease (OR 3.54 [95% CI 2.79 to 4.50]). Patients who underwent colonoscopy or sigmoidoscopy (OR 0.78 [95% CI 0.65 to 0.93]) had lower mortality.

CONCLUSIONS:

Colectomy for ischemic colitis was associated with considerable mortality. The explanation for the stable incidence and decreasing mortality rates observed in the latter part of the present study should be explored in future studies.     

Readmission within 30 days of Hospital Discharge among Children Receiving Chronic Dialysis

Background and objectives

The hospital admission rate for children receiving chronic dialysis has been increasing over the last decade. Approximately one third of patients with ESRD age 0–19 years are readmitted to the hospital within 30 days of discharge. The objective of this study was to examine hospital readmissions among a cohort of children receiving chronic dialysis to identify factors associated with higher rates of 30-day readmission.

Design, settings, participants, & measurements

A retrospective cohort of index admissions was developed among chronic dialysis patients age 3 months to 17 years at free-standing children’s hospitals reporting information to the Pediatric Hospital Information System between January 2006 and November 30, 2010, and followed until December 31, 2010. The primary outcome was any-cause 30-day readmission, and the secondary outcome was 30-day readmission for a cause similar to that of the index hospitalization.

Results

In this cohort, 25% of hospital admissions were followed by a readmission within 30 days. Children older than 2 years of age had a lower odds of readmission (odds ratio [OR], 0.6; 95% confidence interval [95% CI], 0.5 to 0.8). Those receiving hemodialysis had a higher risk of readmission (OR, 1.2; 95% CI, 1.0 to 1.4), and admissions >14 days were also more likely to be followed by a readmission (OR, 1.5; 95% CI, 1.1 to 2.0). Approximately 50% of the readmissions were for a similar diagnosis as the index admission; however, the specific admitting diagnosis was not associated with readmission.

Conclusions

A significant number of admissions among children receiving long-term dialysis are followed by readmission within 30 days. Further investigation is required to reduce the high rate of readmissions in these children.     

Risk factors and outcomes associated with chronic obstructive pulmonary disease exacerbations requiring hospitalization

BACKGROUND:

Acute respiratory exacerbations are the most frequent cause of medical visits, hospitalization and death for chronic obstructive pulmonary disease (COPD) patients and, thus, exert a significant social and economic burden on society.

OBJECTIVE:

To identify the risk factors associated with hospital readmission(s) for acute exacerbation(s) of COPD (AECOPD).

METHODS:

A review of admission records from three large urban hospitals in Vancouver, British Columbia, identified 310 consecutive patients admitted for an AECOPD between April 1, 2001, and December 31, 2002. Logistic regression analysis was performed to identify risk factors for readmissions following an AECOPD.

RESULTS:

During the study period, 38% of subjects were readmitted at least once. The mean (± SD) duration from the index admission to the first readmission was 5±4.08 months. Comparative analysis among the three hospitals identified a significant difference in readmission rates (54%, 36% and 18%, respectively). Logistic regression analysis revealed that preadmission home oxygen use (OR 2.55; 95%CI 1.45 to 4.42; P=0.001), history of a lung infection within the previous year (OR 1.73; 95% CI 1.01 to 2.97; P=0.048), other chronic respiratory disease (OR 1.78; 95% CI 1.06 to 2.99; P=0.03) and shorter length of hospital stay (OR 0.97; 95% CI 0.945 to 0.995; P=0.021) were independently associated with frequent readmissions for an AECOPD.

CONCLUSIONS:

Hospital readmission rates for AECOPD were high. Only four clinical factors were found to be independently associated with COPD readmission. There was significant variability in the readmission rate among hospitals. This variability may be a result of differences in the patient populations that each hospital serves or may reflect variability in health care delivery at different institutions.     

Liver retransplantation in adults: a single-centre, 25-year experience

Background:

Retransplantation is the only form of treatment for patients with irreversible graft failure. The aim of this study was to analyse a single centre''s experience of the indications for and outcomes of retransplantation.

Methods:

A total of 196 patients who underwent liver retransplantation using 225 grafts, between January 1982 and July 2007, were included in the study. The following parameters were analysed: patient demographics; primary diagnosis; distribution of retransplantation over different time periods; indications for retransplantation; time interval to retransplantation, and overall patient and graft survival.

Results:

Of the 2437 primary orthotopic liver transplantations, 196 patients (8%) required a first regraft, 23 patients (1%) a second regraft and six patients (0.25%) a third regraft. Autoimmune hepatitis was the most common primary diagnosis for which retransplantation was required (12.7% of primary transplantations). The retransplantation rate declined from 12% at the beginning of our programme to 7.6% at the end of the study period. The most common indication for retransplantation was hepatic artery thrombosis (31.6%). Nearly two-thirds of the retransplantations were performed within 6 months of the primary transplantation. The 1-, 3-, 5- and 10-year patient survival rates following first retransplantation were 66%, 61%, 57% and 47%, respectively. Five-year survival after second retransplantation was 40%. None of the patients have yet survived 3 years after a third regraft. Donor age of ≤55 years and a MELD (Model for End-stage Liver Disease) score of ≤23 were associated with better outcome following retransplantation.

Conclusions:

First retransplantation was associated with good longterm survival. There was no survival benefit following second and third retransplantations. A MELD score of ≤23 and donor age of ≤55 years correlated with better outcome following retransplantation.     

Predictors of medication adherence in pediatric inflammatory bowel disease patients at the Stollery Children’s Hospital

BACKGROUND:

Patients with inflammatory bowel disease (IBD) often do not take their medications as prescribed.

OBJECTIVE:

To examine self-reported adherence rates in IBD patients at the Stollery Children’s Hospital (Edmonton, Alberta) and to determine predictors of medication adherence.

METHODS:

A survey was mailed to 212 pediatric IBD patients of the Stollery Children’s Hospital. A chart review was completed for those who returned the survey.

RESULTS:

A total of 119 patients completed the survey. The nonresponders were significantly older than responders (14.5 years versus 13.2 years; P=0.032). The overall adherence rate was 80%. Nonadherence was associated with older age (14.6 years versus 13.0 years; P=0.04), longer disease duration (5.0 years versus 3.1 years; P=0.004) and reported use of herbal medications (40.0% versus 13.6%; P=0.029). The most common reasons reported for missing medications were forgetfulness, feeling better and too many medications. In addition, patients reported being more likely to take anti-inflammatory medications and less likely to take herbal medicines.

CONCLUSION:

Identified predictors of nonadherence such as age, disease duration and use of herbal treatments may enable the development of specific strategies to improve adherence in adolescents with IBD.     

ECG Manifestations of the Biggest Outbreak of Chagas Disease due to Oral Infection in Latin-America

Background

Chagas disease affects more than 15 million people worldwide. Although vector-borne transmission has decreased, oral transmission has become important. Recently, our group published the clinical and epidemiological characteristics of the largest outbreak of orally transmitted Chagas disease reported till date. Objective: To describe electrocardiographic changes occurring in the study population during the outbreak caused by ingestion of contaminated guava juice.

Methods

We evaluated 103 positive cases, of which 76 (74%) were aged ≤ 18 years (average age: 9.1 ± 3.1 years) and 27 (26%) were aged > 18 years (average age: 46 ± 11.8 years). All patients underwent clinical evaluations and ECG. If the patients had palpitations or evident alterations of rhythm at baseline, ambulatory ECG monitoring was performed.

Results

A total of 68 cases (66%; 53 children and 15 adults) had ECG abnormalities. Further, 69.7% (53/76) of those aged ≤ 18 years and 56% (15/27) of those aged >18 years showed some ECG alteration (p = ns). ST-T abnormalities were observed in 37.86% cases (39/103) and arrhythmias were evident in 28.16% cases (29/103). ST alterations occurred in 72% of those aged ≤18 years compared with 19% of th ose aged >18 years (p < 0.0001).

Conclusion

This study reports the largest number of cases in the same outbreak of acute Chagas disease caused by oral contamination, with recorded ECGs. ECG changes suggestive of acute myocarditis and arrhythmias were the most frequent abnormalities found.