Cost and Mortality Analysis of an Intermediate Respiratory Care Unit. Is It Really Efficient and Safe?

IntroductionHistorically, it has been assumed that Intermediate Respiratory Care Units (IRCU) were efficient, because they saved costs by reducing the number of admissions to intensive care units (ICU), and effective, because they specialized in respiratory diseases.MethodsThe number of IRCU admissions and mortality rate, historically and in 2016, were evaluated. For 2016, the grouped Related Diagnostic Groups (DRGs) were also described, and the savings achieved under all budgetary headings by avoiding UCI stays were calculated. A multivariate analysis was performed to associate costs with mean weights and complexity, and multiple logistic regression was performed on all patients admitted from 2004 to 2017 to describe the variables associated with mortality in our unit.ResultsAn IRCU generates savings of €500,000/year by reducing length of ICU stay. Analysis of the 2016 cohort shows that costs correlate with mean weight and mortality, and consequently complexity. The multivariate logistic regression analysis of the 2004–2017 cohort found respiratory frequency, leukopenia, anemia, hyperkalemia, and acidosis to be the variables best associated with mortality. The area under the curve for the logistic model was 0.75.ConclusionThe IRCU analyzed in our study was efficient in terms of ‘avoided costs’ and savings associated with complexity. Our results suggest that IRCUs have a lower mortality rate than other similar units, and are therefore a safe environment for patients.     

Asthma and obesity: a known association but unknown mechanism

The obese asthma phenotype is an increasingly common encounter in our clinical practice. Epidemiological data indicate that obesity increases the prevalence and incidence of asthma, and evidence that obesity precedes the development of asthma raises the possibility of a causal association. Obese patients with asthma experience more symptoms and increased morbidity compared with non-obese asthma patients. Despite more than a decade of research into this association, the exact mechanisms that underlie the interaction of obesity with asthma remain unclear. It is unlikely that the asthma-obesity association is simply due to comorbidities such as obstructive sleep apnoea or gastroesophageal reflux disease. Although inflammatory pathways are purported to play a role, there is scant direct evidence in humans that systemic inflammation modulates the behaviour of the asthmatic airway or the expression of symptoms in the obese. The role of non-eosinophilic airway inflammation also requires further study. Obesity results in important changes to the mechanical properties of the respiratory system, and these obesity-related factors appear to exert an additive effect to the asthma-related changes seen in the airways. An understanding of the various physiological perturbations that might be contributing to symptoms in obese patients with asthma will allow for a more targeted and rational treatment approach for these patients.     

Regulation of epithelial cell cytokine responses by the alpha3beta1 integrin

Epithelial cells (EC) from various tissues can produce important cytokines and chemokines when stimulated by proinflammatory cytokines. These EC also receive signals from cell surface integrins, like the alpha3beta1 integrin, which is important in cell migration and wound healing of epithelial monolayers. However, little is known of the effect of integrin signals on cytokine responses by EC. Colonic Caco-2 cells treated with an anti-alpha3 integrin antibody prior to stimulation with the proinflammatory cytokine interleukin (IL)-1 yielded suppressed levels of mRNA and secreted IL-6, IL-8 and monocyte chemoattractant protein-1 as compared to cells treated with normal mouse immunoglobulin G. Lung A549 cells also showed a similar suppression of cytokine secretion. Likewise, treatment of the Caco-2 cells with the same antibody suppressed tumour necrosis factor-alpha-stimulated IL-6 secretion. Fab fragments of the anti-alpha3 integrin antibody did not induce the suppressive effect but did block the suppressive effect of the whole antibody suggesting that the effect of the antibody required cross-linking of the integrins. Finally, culture of the Caco-2 cells on laminin type 5 (the major ligand for this integrin) yielded depressed levels of IL-1-induced IL-6 secretion as compared to cells on laminin type 1. These data are the first indication that the alpha3beta1 integrin may cause a suppression of cytokine responses by EC which may be important in regulating the capacity of EC to respond during inflammation or wound healing.     

Morbidity and immune response to natural schistosomiasis in baboons (<Emphasis Type="Italic">Papio anubis</Emphasis>)

The morbidity and immunological response to naturally acquired Schistosoma mansoni infection in a population of wild baboons (n=28) was investigated. Serum obtained from the baboons was assayed for adult worm (SWAP) and schistosome egg (SEA)-specific immunoglobulin (Ig)G and IgM antibodies. The animals were euthanised, perfused to recover adult schistosome worms and schistosome-related pathology was assessed. Nineteen animals (68%) had high serum levels of SWAP-specific IgG antibodies and 15 (54%) had high levels of SEA-specific IgG antibodies. Nine animals (32%) had high levels of SWAP-specific IgM antibodies and six (21%) had high levels of SEA-specific IgM antibodies. Mild schistosome-related pathology was noted in 18 animals (64%). However, adult schistosome worms were recovered from only three animals (10%). The results indicate a high exposure to schistosomiasis for free-ranging baboons inhabiting an endemic area, as evidenced by the high prevalence of parasite-specific humoral antibody response. However, this high exposure is associated with low worm recovery and mild pathology. In addition, parasite-specific IgM antibodies provided a good indicator of an active schistosome infection.     

Serum aminotransferase levels are associated with markers of hypoxia in patients with obstructive sleep apnea

STUDY OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is a disorder that often presents with elevated serum aminotransferase levels. Although it has classically been linked with the metabolic syndrome, recent studies suggest NAFLD may also be associated with obstructive sleep apnea (OSA). This study evaluates the association between serum aminotransferase levels and factors connected with: either the metabolic syndrome (elevated body mass index [BMI], lipid profile, blood pressure, fasting glucose), or with OSA severity (apnea hypopnea index, lowest oxygen saturation level, oxygen desaturation index, percent of time below 90% saturation [%T<90]). DESIGN: Retrospective case series. PATIENTS AND SETTING: 109 adult patients with OSA at a university hospital general clinical research center. MEASUREMENTS AND RESULTS: Markers of hypoxia (lowest oxygen saturation level and %T<90), correlated significantly with aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels (Pearson's r = -0.31 to -0.38, P <0.003), while apnea hypopnea index, body mass index, blood pressure, fasting glucose, triglyceride, and cholesterol levels did not. Hierarchical linear regression was then done to determine the best predictors of aminotransferase levels. Markers of metabolic syndrome were entered as one block and markers of sleep apnea as another. Regression analyses explained 16.3% of the variance in AST and 18.9% of the variance in ALT, with %T<90 playing the largest role. CONCLUSIONS: In patients with obstructive sleep apnea, serum aminotransferase levels are better predicted by markers of oxygen desaturation than by factors traditionally associated with the metabolic syndrome.     

Homozygous mutation in ELMO2 may cause Ramon syndrome

We report on a girl, born to first cousin Lebanese parents, with intellectual disability, seizures, repeated gingivorrhagia, enlarged lower and upper jaws, overgrowth of the gums, high arched and narrow palate, crowded teeth, hirsutism of the back, large abdomen and a small umbilical hernia. Cysts of the mandible, fibrous dysplasia of bones, and enlarged adenoids causing around 60% narrowing of the nasopharyngeal airways were noted at radiographic examination. Her brother presented with the same features in addition to a short stature, an ostium secundum, and more pronounced intellectual disability. He died at the age of 8 years from a severe pulmonary infection and repeated bleeding episodes. A clinical diagnosis of Ramon syndrome was made. Whole exome sequencing studies performed on the family revealed the presence of a novel homozygous missense mutation in ELMO2 gene, p.I606S in the affected individuals. Loss of function mutations in ELMO2 have been recently described in another clinically distinct condition: primary intraosseous vascular malformation or intraosseous hemangioma, called VMOS. Review of the literature and differential diagnoses are discussed.     

Factor Structure of the Urdu Version of the Spence Children's Anxiety Scale in Pakistan

Spence Children's Anxiety Scale (SCAS) is one of the most commonly used self-report questionnaires to measure symptoms of anxiety disorders in adolescents. Despite its common use, studies that examine the psychometric properties of SCAS in Pakistan is lacking. Therefore, the purpose of this study was to examine the psychometric properties of the Urdu translated version of the SCAS among adolescents in Pakistan. A total of 1277 students (708 boys and 569 girls), aged 13 to17 years, who had been recruited from 13 schools in Rawalpindi, Pakistan participated in the study. The mean overall anxiety score was significantly higher in girls than males on all the SCAS subscales except for obsessive compulsive disorder. The internal consistency of the Urdu SCAS was good. Confirmatory factor analyses supported six separate factor structures. Results of the study are discussed with reference to the sociocultural milieu of Pakistan and culture sensitive conceptualization of anxiety and its subtypes.     

The influence of maternal body composition on birth weight

Objective

To identify the maternal body composition parameters that independently influence birth weight.

Study design

A longitudinal prospective observational study in a large university teaching hospital. One hundred and eighty-four non-diabetic caucasian women with a singleton pregnancy were studied. In early pregnancy maternal weight and height were measured digitally in a standardised way and the body mass index (BMI) was calculated. At 28 and 37 weeks’ gestation maternal body composition was assessed using segmental multifrequency bioelectrical impedance analysis. At delivery the baby was weighed and the clinical details were recorded.

Results

Of the women studied, 29.2% were overweight and 34.8% were obese. Birth weight did not correlate with maternal weight or BMI in early pregnancy. Birth weight correlated with gestational weight gain (GWG) before the third trimester (r = 0.163, p = 0.027), but not with GWG in the third trimester. Birth weight correlated with maternal fat-free mass, and not fat mass at 28 and 37 weeks gestation. Birth weight did not correlate with increases in maternal fat and fat-free masses between 28 and 37 weeks.

Conclusions

Contrary to previous reports, we found that early pregnancy maternal BMI in a non-diabetic population does not influence birth weight. Interestingly, it was the GWG before the third trimester and not the GWG in the third trimester that influenced birth weight. Our findings have implications for the design of future intervention studies aimed at optimising gestational weight gain and birth weight.

Condensation

Maternal fat-free mass and gestational weight gain both influence birth weight.