Association between Birth Order and Emergency Room Visits and Acute Hospital Admissions following Pediatric Vaccination: A Self-Controlled Study

Objective

We investigated the association between a child''s birth order and emergency room (ER) visits and hospital admissions following 2-,4-,6- and 12-month pediatric vaccinations.

Methods

We included all children born in Ontario between April 1^st, 2006 and March 31^st, 2009 who received a qualifying vaccination. We identified vaccinations, ER visits and admissions using health administrative data housed at the Institute for Clinical Evaluative Sciences. We used the self-controlled case series design to compare the relative incidence (RI) of events among 1^st-born and later-born children using relative incidence ratios (RIR).

Results

For the 2-month vaccination, the RIR for 1^st-borns versus later-born children was 1.37 (95% CI: 1.19–1.57), which translates to 112 additional events/100,000 vaccinated. For the 4-month vaccination, the RIR for 1^st-borns vs. later-borns was 1.70 (95% CI: 1.45–1.99), representing 157 additional events/100,000 vaccinated. At 6 months, the RIR for 1^st vs. later-borns was 1.27 (95% CI: 1.09–1.48), or 77 excess events/100,000 vaccinated. At the 12-month vaccination, the RIR was 1.11 (95% CI: 1.02–1.21), or 249 excess events/100,000 vaccinated.

Conclusions

Birth order is associated with increased incidence of ER visits and hospitalizations following vaccination in infancy. 1^st-born children had significantly higher relative incidence of events compared to later-born children.     

Modes of Admission to Hospital: A Survey of Emergency Admissions to a General Medical Unit

In a survey of the modes of referral and disposal of “acute patients” to a general medical unit during the period 1 February 1968 to 31 July 1970 only 1,432 out of 3,455 were referred by general practitioners. There was a high incidence of self-referral to hospital, and this trend was on the increase. A large percentage of self-referred patients came from their homes, and 65-77% of these arrived by ambulance ordered by themselves.     

Liver Retransplantation in Adults: The Largest Multicenter Italian Study

This study is the largest Italian survey on liver retransplantations (RET). Data report on 167 adult patients who received 2 grafts, 16 who received 3 grafts, and one who received 4 grafts over a 11 yr period.There was no statistically significant difference in graft survival after the first or the second RET (52, 40, and 29% vs 44, 36, and 18% at 1,5,and 10 yr, respectively: Log-Rank test, p = 0.30).Survivals at 1, 5, and 10 years of patients who underwent 2 (n = 151) or 3 (n = 15) RETs, were 65, 48,and 39% vs 59, 44, and 30%, respectively (p = 0.59).Multivariate analysis of survival showed that only the type of graft (whole vs reduced) was associated with a statistically significant difference (HR = 3.77, Wald test p = 0. 05); the donor age appeared to be a relevant factor as well, although the difference was not statistically significant (HR = 1.91, Wald test p = 0.08).Though late RETs have better results on long term survival relative to early RETs, no statistically significant difference can be found in early results, till three years after RET.Considering late first RETs (interval>30 days from previous transplantation) with whole grafts the difference in graft survival in RETs due to HCV recurrence (n = 17) was not significantly different from RETs due to other causes (n = 53) (65–58 and 31% vs 66–57 and 28% respectively at 1–5 and 10 years, p = 0.66).     

Frequent Users of Hospital Emergency Departments in Korea Characterized by Claims Data from the National Health Insurance: A Cross Sectional Study

The Korean National Health Insurance, which provides universal coverage for the entire Korean population, is now facing financial instability. Frequent emergency department (ED) users may represent a medically vulnerable population who could benefit from interventions that both improve care and lower costs. To understand the nature of frequent ED users in Korea, we analyzed claims data from a population-based national representative sample. We performed both bivariate and multivariable analyses to investigate the association between patient characteristics and frequent ED use (4+ ED visits in a year) using claims data of a 1% random sample of the Korean population, collected in 2009. Among 156,246 total ED users, 4,835 (3.1%) were frequent ED users. These patients accounted for 14% of 209,326 total ED visits and 17.2% of $76,253,784 total medical expenses generated from all ED visits in the 1% data sample. Frequent ED users tended to be older, male, and of lower socio-economic status compared with occasional ED users (p < 0.001 for each). Moreover, frequent ED users had longer stays in the hospital when admitted, higher probability of undergoing an operative procedure, and increased mortality. Among 8,425 primary diagnoses, alcohol-related complaints and schizophrenia showed the strongest positive correlation with the number of ED visits. Among the frequent ED users, mortality and annual outpatient department visits were significantly lower in the alcohol-related patient subgroup compared with other frequent ED users; furthermore, the rate was even lower than that for non-frequent ED users. Our findings suggest that expanding mental health and alcohol treatment programs may be a reasonable strategy to decrease the dependence of these patients on the ED.     

Delays in Appropriate Antibiotic Therapy for Gram-Negative Bloodstream Infections: A Multicenter,Community Hospital Study

Background

Gram-negative bacterial bloodstream infection (BSI) is a serious condition with estimated 30% mortality. Clinical outcomes for patients with severe infections improve when antibiotics are appropriately chosen and given early. The objective of this study was to estimate the association of prior healthcare exposure on time to appropriate antibiotic therapy in patients with gram-negative BSI.

Method

We performed a multicenter cohort study of adult, hospitalized patients with gram-negative BSI using time to event analysis in nine community hospitals from 2003-2006. Event time was defined as the first administration of an antibiotic with in vitro activity against the infecting organism. Healthcare exposure status was categorized as community-acquired, healthcare-associated, or hospital-acquired. Time to appropriate therapy among groups of patients with differing healthcare exposure status was assessed using Kaplan-Meier analyses and multivariate Cox proportional hazards models.

Results

The cohort included 578 patients with gram-negative BSI, including 320 (55%) healthcare-associated, 217 (38%) community-acquired, and 41 (7%) hospital-acquired infections. 529 (92%) patients received an appropriate antibiotic during their hospitalization. Time to appropriate therapy was significantly different among the groups of healthcare exposure status (log-rank p=0.02). Time to first antibiotic administration regardless of drug appropriateness was not different between groups (p=0.3). The unadjusted hazard ratios (HR) (95% confidence interval) were 0.80 (0.65-0.98) for healthcare-associated and 0.72 (0.63-0.82) for hospital-acquired, relative to patients with community-acquired BSI. In multivariable analysis, interaction was found between the main effect and baseline Charlson comorbidity index. When Charlson index was 3, adjusted HRs were 0.66 (0.48-0.92) for healthcare-associated and 0.57 (0.44-0.75) for hospital-acquired, relative to patients with community-acquired infections.

Conclusions

Patients with healthcare-associated or hospital-acquired BSI experienced delays in receipt of appropriate antibiotics for gram-negative BSI compared to patients with community-acquired BSI. This difference was not due to delayed initiation of antibiotic therapy, but due to the inappropriate choice of antibiotic.     

Improving the Manchester Triage System for Pediatric Emergency Care: An International Multicenter Study

Objectives

This multicenter study examines the performance of the Manchester Triage System (MTS) after changing discriminators, and with the addition use of abnormal vital sign in patients presenting to pediatric emergency departments (EDs).

Design

International multicenter study

Settings

EDs of two hospitals in The Netherlands (2006–2009), one in Portugal (November–December 2010), and one in UK (June–November 2010).

Patients

Children (<16years) triaged with the MTS who presented at the ED.

Methods

Changes to discriminators (MTS 1) and the value of including abnormal vital signs (MTS 2) were studied to test if this would decrease the number of incorrect assignment. Admission to hospital using the new MTS was compared with those in the original MTS. Likelihood ratios, diagnostic odds ratios (DORs), and c-statistics were calculated as measures for performance and compared with the original MTS. To calculate likelihood ratios and DORs, the MTS had to be dichotomized in low urgent and high urgent.

Results

60,375 patients were included, of whom 13% were admitted. When MTS 1 was used, admission to hospital increased from 25% to 29% for MTS ‘very urgent’ patients and remained similar in lower MTS urgency levels. The diagnostic odds ratio improved from 4.8 (95%CI 4.5–5.1) to 6.2 (95%CI 5.9–6.6) and the c-statistic remained 0.74. MTS 2 did not improve the performance of the MTS.

Conclusions

MTS 1 performed slightly better than the original MTS. The use of vital signs (MTS 2) did not improve the MTS performance.     

Clinical Audit of COPD Patients Requiring Hospital Admissions in Spain: AUDIPOC Study

BACKGROUNDS: AUDIPOC is a nationwide clinical audit that describes the characteristics, interventions and outcomes of patients admitted to Spanish hospitals because of an exacerbation of chronic obstructive pulmonary disease (ECOPD), assessing the compliance of these parameters with current international guidelines. The present study describes hospital resources, hospital factors related to case recruitment variability, patients' characteristics, and adherence to guidelines. METHODOLOGY/PRINCIPAL FINDINGS: An organisational database was completed by all participant hospitals recording resources and organisation. Over an 8-week period 11,564 consecutive ECOPD admissions to 129 Spanish hospitals covering 70% of the Spanish population were prospectively identified. At hospital discharge, 5,178 patients (45% of eligible) were finally included, and thus constituted the audited population. Audited patients were reassessed 90 days after admission for survival and readmission rates. A wide variability was observed in relation to most variables, hospital adherence to guidelines, and readmissions and death. Median inpatient mortality was 5% (across-hospital range 0-35%). Among discharged patients, 37% required readmission (0-62%) and 6.5% died (0-35%). The overall mortality rate was 11.6% (0-50%). Hospital size and complexity and aspects related to hospital COPD awareness were significantly associated with case recruitment. Clinical management most often complied with diagnosis and treatment recommendations but rarely (<50%) addressed guidance on healthy life-styles. CONCLUSIONS/SIGNIFICANCE: The AUDIPOC study highlights the large across-hospital variability in resources and organization of hospitals, patient characteristics, process of care, and outcomes. The study also identifies resources and organizational characteristics associated with the admission of COPD cases, as well as aspects of daily clinical care amenable to improvement.     

Association between Air Pollutants and Asthma Emergency Room Visits and Hospital Admissions in Time Series Studies: A Systematic Review and Meta-Analysis

Background

Air pollution constitutes a significant stimulus of asthma exacerbations; however, the impacts of exposure to major air pollutants on asthma-related hospital admissions and emergency room visits (ERVs) have not been fully determined.

Objective

We sought to quantify the associations between short-term exposure to air pollutants [ozone (O₃), carbon monoxide (CO), nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and particulate matter ≤10μm (PM₁₀) and PM_2.5] and the asthma-related emergency room visits (ERV) and hospitalizations.

Methods

Systematic computerized searches without language limitation were performed. Pooled relative risks (RRs) and 95% confidence intervals (95%CIs) were estimated using the random-effect models. Sensitivity analyses and subgroup analyses were also performed.

Results

After screening of 246 studies, 87 were included in our analyses. Air pollutants were associated with significantly increased risks of asthma ERVs and hospitalizations [O₃: RR(95%CI), 1.009 (1.006, 1.011); I² = 87.8%, population-attributable fraction (PAF) (95%CI): 0.8 (0.6, 1.1); CO: RR(95%CI), 1.045 (1.029, 1.061); I² = 85.7%, PAF (95%CI): 4.3 (2.8, 5.7); NO₂: RR(95%CI), 1.018 (1.014, 1.022); I² = 87.6%, PAF (95%CI): 1.8 (1.4, 2.2); SO₂: RR(95%CI), 1.011 (1.007, 1.015); I² = 77.1%, PAF (95%CI): 1.1 (0.7, 1.5); PM₁₀: RR(95%CI), 1.010 (1.008, 1.013); I² = 69.1%, PAF (95%CI): 1.1 (0.8, 1.3); PM_2.5: RR(95%CI), 1.023 (1.015, 1.031); I² = 82.8%, PAF (95%CI): 2.3 (1.5, 3.1)]. Sensitivity analyses yielded compatible findings as compared with the overall analyses without publication bias. Stronger associations were found in hospitalized males, children and elderly patients in warm seasons with lag of 2 days or greater.

Conclusion

Short-term exposures to air pollutants account for increased risks of asthma-related ERVs and hospitalizations that constitute a considerable healthcare utilization and socioeconomic burden.     

Effects of Meteorological Factors on Daily Hospital Admissions for Asthma in Adults: A Time-Series Analysis

Background

There is limited evidence for the impacts of meteorological changes on asthma hospital admissions in adults in Shanghai, China.

Objectives

To quantitatively evaluate the short-term effects of daily mean temperature on asthma hospital admissions.

Methods

Daily hospital admissions for asthma and daily mean temperatures between January 2005 and December 2012 were analyzed. After controlling for secular and seasonal trends, weather, air pollution and other confounding factors, a Poisson generalized additive model (GAM) combined with a distributed lag non-linear model were used to explore the associations between temperature and hospital admissions for asthma.

Results

During the study periods, there were 15,678 hospital admissions for asthma by residents of Shanghai, an average 5.6 per day. Pearson correlation analysis found a significant negative correlation (r = −0.174, P<0.001) between asthma hospitalizations and daily mean temperature (DMT). The DMT effect on asthma increased below the median DMT, with lower temperatures associated with a higher risk of hospital admission for asthma. Generally, the cold effect appeared to be relatively acute, with duration lasting several weeks, while the hot effect was short-term. The relative risk of asthma hospital admissions associated with cold temperature (the 25^th percentile of temperature relative to the median temperature) was 1.20 (95% confidence interval [CI], 1.01∼1.41) at lag0-14. However, warmer temperatures were not associated with asthma hospital admissions.

Conclusions

Cold temperatures may trigger asthmatic attacks. Effective strategies are needed to protect populations at risk from the effects of cold.     

Radiological Findings of Sexual Intercourse Related Emergency Department Admissions: A First Overview

Objectives

Sexuality is an essential aspect of human function, well-being and quality of life. Many people have sex without complications. However, there are some people who need to seek emergency medical help for related health problems. The aim of this study was to present a first overview of patients who received a radiological examination related to sexual intercourse based emergency department admission.

Methods

Our centralized electronic patient record database was reviewed for patients who had been admitted to our emergency department with an emergency after sexual intercourse between 2000 and 2011. The database was scanned for the standardized key words ‘sexual intercourse’ or ‘coitus’ retrospectively. For all patients identified in the electronic patient record database the radiological examinations were searched for manually in our Radiology Information System, and reviewed by three independent radiologists.

Results

One hundred and twenty nine out of 445 (29,0%) patients received a radiological examination after immediate emergency department admission related to sexual intercourse. Fifty two out of 129 (40.3%) patients had positive radiological findings while 77 (59.7%) did not. Eighty point seven percent (n = 42) of the radiological findings were a sexual intercourse-associated pathology and 19.2% (n = 10) were considered to be incidental findings. Age and male sex positively correlated with radiological imaging workup (p<0.001, respectively p<0.037). The most common sexual intercourse-associated pathology was headache attributed to cerebrovascular insult (n = 21, 40.3%) followed by epididymitis (n = 7, 16.6%) and obstructive uropathy (n = 5, 11.6%). Of the patients with headache attributed to non-traumatic intracranial hemorrhage, subarachnoid hemorrhage (n = 14, 66.6%) was the most common, followed by intracerebral bleeding (n = 4, 19.0%) and one subdural hemorrhage.

Conclusions

Pathological findings are manifold. Cerebral imaging is the most common type of radiological imaging performed. Further prospective and standardized studies should be performed to better evaluate the significance of radiological imaging in this patient collective with the aim to gain better knowledge on what patients profit from what type of radiological imaging when presenting with a sexual intercourse related emergency.

Advances in Knowledge

The present study provides a first overview on radiological findings of sexual intercourse related emergency department admissions.     

Access to Primary Care and Visits to Emergency Departments in England: A Cross-Sectional,Population-Based Study

Background

The number of visits to hospital emergency departments (EDs) in England has increased by 20% since 2007-08, placing unsustainable pressure on the National Health Service (NHS). Some patients attend EDs because they are unable to access primary care services. This study examined the association between access to primary care and ED visits in England.

Methods

A cross-sectional, population-based analysis of patients registered with 7,856 general practices in England was conducted, for the time period April 2010 to March 2011. The outcome measure was the number of self-referred discharged ED visits by the registered population of a general practice. The predictor variables were measures of patient-reported access to general practice services; these were entered into a negative binomial regression model with variables to control for the characteristics of patient populations, supply of general practitioners and travel times to health services.

Main Result and Conclusion

General practices providing more timely access to primary care had fewer self-referred discharged ED visits per registered patient (for the most accessible quintile of practices, RR = 0.898; P<0.001). Policy makers should consider improving timely access to primary care when developing plans to reduce ED utilisation.     

Hospital Emergency Services for Children and Adolescents: A One-Year Review at the Vancouver General Hospital

The records of visits of children and adolescents to the emergency department of the Vancouver General Hospital were reviewed during the period July 1, 1965, to June 30, 1966, and the diagnostic and disposal data recorded. One-quarter of all visits were made by children and adolescents. Three-quarters of the visits were made for surgical conditions. There were more males than females in both surgical and medical groups, and the peaks in attendance were of those in the early preschool and late adolescent age groups. Three-quarters of the patients were referred to the family doctor and approximately one-sixth were admitted to the hospital. These findings suggested that while prompt medical attention was usually indicated, the majority of problems were not urgent and that the emergency department was becoming a substitute for the office of the family physician.     

Rising Obesity-Related Hospital Admissions among Children and Young People in England: National Time Trends Study

Objective

To describe the trends in hospital admissions associated with obesity as a primary diagnosis and comorbidity, and bariatric surgery procedures among children and young people in England.

Design

National time trends study of hospital admissions data between 2000 and 2009.

Participants

Children and young people aged 5 to 19 years who were admitted to hospital with any diagnosis of obesity.

Main outcome measures

Age- and sex-specific admission rates per million children.

Results

Between 2000 and 2009, age- and sex-specific hospital admission rates in 5–19 year olds for total obesity-related diagnoses increased more than four-fold from 93.0 (95% CI 86.0 to 100.0) per million children to 414.0 (95% CI 410.7 to 417.5) per million children, largely due to rising admissions where obesity was mentioned as a co-morbidity. The median age of admission to hospital over the study period was 14.0 years; 5,566 (26.7%) admissions were for obesity and 15,319 (73.3%) mentioned obesity as a comorbidity. Admissions were more common in girls than boys (56.2% v 43.8%). The most common reasons for admission where obesity was a comorbid condition were sleep apnoea, asthma, and complications of pregnancy. The number of bariatric surgery procedures has risen from 1 per year in 2000 to 31 in 2009, with the majority were performed in obese girls (75.6%) aged 13–19 years.

Conclusions

Hospital admission rates for obesity and related comorbid conditions have increased more than four-fold over the past decade amongst children and young people. Although some of the increase is likely to be due to improved case ascertainment, conditions associated with obesity in children and young people are imposing greater challenges for health care providers in English hospitals. Most inpatient care is directed at dealing with associated conditions rather than primary assessment and management of obesity itself.     

The Influence of Primary Care Quality on Hospital Admissions for People with Dementia in England: A Regression Analysis

Objectives

To test the impact of a UK pay-for-performance indicator, the Quality and Outcomes Framework (QOF) dementia review, on three types of hospital admission for people with dementia: emergency admissions where dementia was the primary diagnosis; emergency admissions for ambulatory care sensitive conditions (ACSCs); and elective admissions for cataract, hip replacement, hernia, prostate disease, or hearing loss.

Methods

Count data regression analyses of hospital admissions from 8,304 English general practices from 2006/7 to 2010/11. We identified relevant admissions from national Hospital Episode Statistics and aggregated them to practice level. We merged these with practice-level data on the QOF dementia review. In the base case, the exposure measure was the reported QOF register. As dementia is commonly under-diagnosed, we tested a predicted practice register based on consensus estimates. We adjusted for practice characteristics including measures of deprivation and uptake of a social benefit to purchase care services (Attendance Allowance).

Results

In the base case analysis, higher QOF achievement had no significant effect on any type of hospital admission. However, when the predicted register was used to account for under-diagnosis, a one-percentage point improvement in QOF achievement was associated with a small reduction in emergency admissions for both dementia (-0.1%; P=0.011) and ACSCs (-0.1%; P=0.001). In areas of greater deprivation, uptake of Attendance Allowance was consistently associated with significantly lower emergency admissions. In all analyses, practices with a higher proportion of nursing home patients had significantly lower admission rates for elective and emergency care.

Conclusion

In one of three analyses at practice level, the QOF review for dementia was associated with a small but significant reduction in unplanned hospital admissions. Given the rising prevalence of dementia, increasing pressures on acute hospital beds and poor outcomes associated with hospital stays for this patient group, this small change may be clinically and economically relevant.     

Survival in HIV-Infected Patients after a Cancer Diagnosis in the cART Era: Results of an Italian Multicenter Study

Objectives

We studied survival and associated risk factors in an Italian nationwide cohort of HIV-infected individuals after an AIDS-defining cancer (ADC) or non-AIDS-defining cancer (NADC) diagnosis in the modern cART era.

Methods

Multi-center, retrospective, observational study of HIV patients included in the MASTER Italian Cohort with a cancer diagnosis from January 1998 to September 2012. Malignancies were divided into ADC or NADC on the basis of the Centre for Disease Control-1993 classification. Recurrence of cancer and metastases were excluded. Survivals were estimated according to the Kaplan-Meier method and compared according to the log-rank test. Statistically significant variables at univariate analysis were entered in a multivariate Cox regression model.

Results

Eight hundred and sixty-six cancer diagnoses were recorded among 13,388 subjects in the MASTER Database after 1998: 435 (51%) were ADCs and 431 (49%) were NADCs. Survival was more favorable after an ADC diagnosis than a NADC diagnosis (10-year survival: 62.7%±2.9% vs. 46%±4.2%; p = 0.017). Non-Hodgkin lymphoma had lower survival rates than patients with Kaposi sarcoma or cervical cancer (10-year survival: 48.2%±4.3% vs. 72.8%±4.0% vs. 78.5%±9.9%; p<0.001). Regarding NADCs, breast cancer showed better survival (10-year survival: 65.1%±14%) than lung cancer (1-year survival: 28%±8.7%), liver cancer (5-year survival: 31.9%±6.4%) or Hodgkin lymphoma (10-year survival: 24.8%±11.2%). Lower CD4+ count and intravenous drug use were significantly associated with decreased survival after ADCs or NADCs diagnosis. Exposure to cART was found to be associated with prolonged survival only in the case of ADCs.

Conclusions

cART has improved survival in patients with an ADC diagnosis, whereas the prognosis after a diagnosis of NADCs is poor. Low CD4+ counts and intravenous drug use are risk factors for survival following a diagnosis of ADCs and Hodgkin lymphoma in the NADC group.     

Reference Equation for Respiratory Pressures in Pediatric Population: A Multicenter Study

Previous studies have proposed only one prediction equation for respiratory muscle strength without taking into consideration differences between ages in pediatric population. In addition, those researches were single-center studies. The objective of this study was to establish reference equations for maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax) in children and teenagers. In a multicenter study, 450 healthy volunteers were evaluated (aged 6–18yrs). There were included volunteers with normal lung function. We excluded volunteers who could not perform the tests; participated in physical activity more than twice a week; were born prematurely; smokers; chronic respiratory, cardiologic, and/or neurologic diseases; had acute respiratory disease during the prior three weeks. The volunteers were divided into two groups: Group 6–11 (6–11yrs) and Group 12–18 (12–18yrs). PImax and PEmax were measured according to statement. The mean PImax value was 85.6 (95%IC 83.6–87.6 cmH₂O), and PEmax 84.6 (95%IC 85.5–86.2 cmH₂O). The prediction equations for PImax and PEmax for Group 6–11 were 37.458–0.559 + (age * 3.253) + (BMI * 0.843) + (age * gender * 0.985); and 38.556 + 15.892 + (age * 3.023) + (BMI * 0.579) + (age * gender * 0.881), respectively (R² = 0.34 and 0.31, P<0.001). The equations for Group 12–18 were 92.472 + (gender * 9.894) + 7.103, (R² = 0.27, P = 0.006) for PImax; and 68.113 + (gender * 17.022) + 6.46 + (BMI * 0.927), (R² = 0.34, P<0.0001) for PEmax. This multicenter study determined the respiratory muscle strength prediction equations for children and teenagers.     

Hospital Admissions for Drug-Induced Liver Injury: Clinical Features, Therapy, and Outcomes

We investigated clinical features, therapy, and outcomes of patients hospitalized for drug-induced liver injury (DILI). DILI resolution was defined as liver biochemistry values back to normal or lower than CIOMS laboratory criteria; Chronicity was defined as persistent biochemical abnormality for >6?months after drugs?? withdrawal. Three-hundred cases were reviewed retrospectively; mean age 51 (13?C86) years, and 204 (68?%) were females. It included 267 (89?%) hepatocellular injury, 16 (5.3?%) cholestatic injury, and 17 (5.7?%) mixed injury cases. In hepatocellular injury group, 197 (73.8?%) patients with TBIL?<?10× ULN included 142 (72.1?%) females and 70 (26.2?%) patients with TBIL????10× ULN included 39 (55.7?%) females (P?=?0.012). Of 70 patients (TBIL????10× ULN), 20 were treated with steroid step-down therapy (79?±?26?days) and others with non-steroid therapy. The steroid therapy group showed higher DILI resolution rate (P?=?0.029) and shorter recovery time (P?=?0.012). Notably, 274/300 (91.3?%) patients resolved, 18/300 (6?%) developed chronic liver injury, 7/300 (2.3?%) died, and one patient received liver transplantation. In death group, TBIL, ALB, PT, and PTA revealed more severe abnormality than in recovery group. In 121/300 (40.3?%) patients, use of herbal medicines was the leading cause of liver injury, followed by antibiotics, cardiovascular drugs, and endocrine drugs. We concluded that step-down steroid therapy for DILI improved curative effect, shortened disease course, and was safe.     

Functional Changes during Hospital Stay in Older Patients Admitted to an Acute Care Ward: A Multicenter Observational Study

Objectives

Changes in physical performance during hospital stay have rarely been evaluated. In this study, we examined functional changes during hospital stay by assessing both physical performance and activities of daily living. Additionally, we investigated characteristics of older patients associated with meaningful in-hospital improvement in physical performance.

Methods

The CRiteria to assess appropriate Medication use among Elderly complex patients project recruited 1123 patients aged ≥65 years, consecutively admitted to geriatric or internal medicine acute care wards of seven Italian hospitals. We analyzed data from 639 participating participants with a Mini Mental State Examination score ≥18/30. Physical performance was assessed by walking speed and grip strength, and functional status by activities of daily living at hospital admission and at discharge. Meaningful improvement was defined as a measured change of at least 1 standard deviation. Multivariable logistic regression models predicting meaningful improvement, included age, gender, type of admission (through emergency room or elective), and physical performance at admission.

Results

Mean age of the study participants was 79 years (range 65–98), 52% were female. Overall, mean walking speed and grip strength performance improved during hospital stay (walking speed improvement: 0.04±0.20 m/s, p<0.001; grip strength improvement: 0.43±5.66 kg, p = 0.001), no significant change was observed in activities of daily living. Patients with poor physical performance at admission had higher odds for in-hospital improvement.

Conclusion

Overall, physical performance measurements show an improvement during hospital stay. The margin for meaningful functional improvement is larger in patients with poor physical function at admission. Nevertheless, most of these patients continue to have poor performance at discharge.     

Effect of Temperature on Hospital Admissions for Myocardial Infarction in a Subarctic Area

In a study of the effect of mean daily temperature on the admission and fatality rates of 771 patients with myocardial infarction the admission rate was found to be significantly higher on cold (temperature below 0°C.) than on warm (temperature above 0°C.) days. The fatality rate was almost equal in cold and warm weather. Thus the seasonal fluctuation in the admission rate of patients with myocardial infarction is probably due to a direct effect of environmental temperature.