Causes and Predictors for 30-DAY Re-Admissions in Adult Patients with Diabetic Ketoacidosis in the United States: a Nationwide Analysis, 2010–2014

Objective: We aimed to determine the causes and predictors for 30-day re-admission following a hospitalization for diabetic ketoacidosis (DKA) in the United States.Methods: This retrospective cohort study analyzed data from the National Re-admission Database. We included adult patients with a primary discharge diagnosis of DKA, from 2010 to 2014. Our primary objective was to determine the frequency and causes for 30-day re-admission after an index hospitalization for DKA. We also performed multivariate regression analyses using covariates from the index admission to identify predictors for 30-day re-admissions.Results: Among 479,590 admissions for DKA, 58,961 (12.3%) were re-admitted within 30 days. Recurrent DKA represented 40.8% of all-cause re-admissions. In multivariate analysis, end-stage renal disease (odds ratio &lsqb;OR], 2.13; 95% confidence interval &lsqb;CI], 2.00 to 2.27; P<.001), Charlson Comorbidity Index ≥3 (OR, 2.49; 95% CI, 2.42 to 2.58; P<.001), discharge against medical advice (OR, 1.97; 95% CI, 1.86 to 2.09; P<.001), and drug use (OR, 1.78; 95% CI, 1.71 to 1.86; P<.001) were the most significant predictors for 30-day re-admission. About 50% of patients were re-admitted within 2 weeks after discharge.Conclusion: In the U.S., about one in every eight patients with DKA is re-admitted within 30 days, with 40.8% representing recurrent DKA episodes. Patients with end-stage renal disease, high comorbidity burden, drug use, and/or leaving against medical advice represented the highest risk group for re-admissions. Future studies with interventions focusing on high-risk population are critically needed.Abbreviations: AKI = acute kidney injury; BMI = body mass index; CCI = Charlson Comorbidity Index; CI = confidence interval; DKA = diabetic ketoacidosis; DM1 = type 1 diabetes mellitus; DM2 = type 2 diabetes mellitus; ESRD = end-stage renal disease; ICD-9-CM = International Classification of Diseases, Ninth Edition, Clinical Modification; IQR = interquartile range; LOS = length of stay; NRD = National Re-admission Database; OR = odds ratio     

The Effects of Perioperative Dexamethasone on Glycemic Control and Postoperative Outcomes

Objective: Perioperative glucocorticoids are commonly given to reduce pain and nausea in patients undergoing surgery. However, the glycemic effects of steroids and the potential effects on morbidity and mortality have not been systematically evaluated. This study investigated the association between perioperative dexamethasone and postoperative blood glucose, hospital length of stay (LOS), readmission rates, and 90-day survival.Methods: Data from 4,800 consecutive orthopedic surgery patients who underwent surgery between 2000 and 2016 within a single health system were analyzed retrospectively.Results: Patients with and without diabetes mellitus (DM) who were given a single dose of dexamethasone had higher rates of hyperglycemia during the first 24 hours after surgery as compared to those who did not receive dexamethasone (hazard ratio &lsqb;HR] was 1.81, and 95% confidence interval &lsqb;CI] was &lsqb;1.46, 2.24] for the DM cohort; HR 2.34, 95% CI &lsqb;1.66, 3.29] for the nonDM cohort). LOS was nearly 1 day shorter in patients who received dexamethasone (geometric mean ratio &lsqb;GMR] 0.79, 95% CI &lsqb;0.75, 0.83] for patients with DM; GMR 0.75, 95% CI &lsqb;0.72, 0.79] for patients without DM), and there was no difference in 90-day readmission rates. In patients without DM, dexamethasone was associated with a higher 90-day overall survival (99.07% versus 96.90%; P = .004).Conclusion: In patients with and without DM who undergo orthopedic surgery, perioperative dexamethasone was associated with a transiently higher risk of hyperglycemia. However, dexamethasone treatment was associated with a shorter LOS in patients with and without DM, and a higher overall 90-day survival rate in patients without DM, compared to patients who did not receive dexamethasone.Abbreviations: BMI = body mass index; CAD = coronary artery disease; CI = confidence interval; DM = diabetes mellitus; GMR = geometric mean ratio; HR = hazard ratio; IV = intravenous; LOS = length of stay; POD = postoperative day     

Frequency of Hypoglycemia and its Impact on Length of Stay,Mortality, and Short-Term Readmission in Patients with Diabetes Hospitalized In Internal Medicine Wards

ObjectiveTo evaluate whether hypoglycemia is associated with increases in length of stay (LOS), inpatient mortality, and readmission among patients with diabetes hospitalized in internal medicine wards.MethodsA retrospective cohort study was carried out using the Basic Minimum Data Set registry of the Spanish National Health System, which contains clinical and administrative information for every patient discharged from system hospitals. The analysis included patients discharged between January 2005 and December 2010 and had a primary (i.e., reason for the admission) or secondary diagnosis of diabetes and a secondary diagnosis of hypoglycemia. The associations between hypoglycemia and the study outcomes (mortality, readmission, and LOS) were evaluated using multivariate and multilinear regression models that included age, sex, and the Charlson index as covariates.ResultsDuring the study period, 3,361,104 patients were admitted to internal medicine wards in the National Health System. Of these, 921,306 (27.4%) had diagnoses of diabetes, and among these patients, 46,408 (5%) had secondary hypoglycemia. A total of 4,754 (10.2%) patients with secondary hypoglycemia died during their hospital stays, compared with 83,508 (9.5%) patients without hypoglycemia. The multivariate/multilinear regression models demonstrated significant associations between the presence of secondary hypoglycemia and greater inpatient mortality (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.20-1.28), a greater likelihood of readmission (OR 1.20, 95% CI 1.17-1.23), and an increased LOS (b 1.24, 95% CI 1.15-1.35).ConclusionHypoglycemia in patients with diabetes hospitalized in internal medicine wards is associated with increases in the LOS, inpatient mortality, and early readmission. (Endocr Pract. 2014;20:870-875)     

The Effects of a Comprehensive Multidisciplinary Outpatient Diabetes Program on Hospital Readmission Rates in Patients with Diabetes: A Randomized Controlled Prospective Study

Objective: The diagnosis of diabetes mellitus is associated with an increased risk of hospital readmissions. The goal of this study was to determine whether there was a difference in the rates of 30-day and 365-day hospital readmissions between diabetic patients who, upon their discharge, received diabetes care in a standard primary care setting and those who received their care in a specialized multidisciplinary diabetes program.Methods: This was a randomized controlled prospective study.Results: One hundred and ninety two consecutive patients were recruited into the study, 95 (49%) into standard care (control group) and 97 (51%) into a multidisciplinary diabetes program (intervention group). The 30-day overall hospital readmission rates (including both emergency department and hospital readmissions) were 19% in the control group and 7% in the intervention group (P = .02). The 365-day overall hospital readmission rates were 38% in the control group and 14% in the intervention group (P = .0002).Conclusion: Patients with diabetes who are assigned to a specialized multidisciplinary diabetes program upon their discharge exhibit significantly reduced hospital readmission rates at 30 days and 365 days after discharge.     

Evaluating the Use of Blood Cultures in the Management of Children Hospitalized for Community-Acquired Pneumonia

BackgroundBlood cultures are often recommended for the evaluation of community-acquired pneumonia (CAP). However, institutions vary in their use of blood cultures, and blood cultures have unclear utility in CAP management in hospitalized children.ObjectiveTo identify clinical factors associated with obtaining blood cultures in children hospitalized with CAP, and to estimate the association between blood culture obtainment and hospital length of stay (LOS).MethodsWe performed a multicenter retrospective cohort study of children admitted with a diagnosis of CAP to any of four pediatric hospitals in the United States from January 1, 2011-December 31, 2012. Demographics, medical history, diagnostic testing, and clinical outcomes were abstracted via manual chart review. Multivariable logistic regression evaluated patient and clinical factors for associations with obtaining blood cultures. Propensity score-matched Kaplan-Meier analysis compared patients with and without blood cultures for hospital LOS.ResultsSix hundred fourteen charts met inclusion criteria; 390 children had blood cultures obtained. Of children with blood cultures, six (1.5%) were positive for a pathogen and nine (2.3%) grew a contaminant. Factors associated with blood culture obtainment included presenting with symptoms of systemic inflammatory response syndrome (OR 1.78, 95% CI 1.10–2.89), receiving intravenous hydration (OR 3.94, 95% CI 3.22–4.83), receiving antibiotics before admission (OR 1.49, 95% CI 1.17–1.89), hospital admission from the ED (OR 1.65, 95% CI 1.05–2.60), and having health insurance (OR 0.42, 95% CI 0.30–0.60). In propensity score-matched analysis, patients with blood cultures had median 0.8 days longer LOS (2.0 vs 1.2 days, P < .0001) without increased odds of readmission (OR 0.94, 95% CI 0.45–1.97) or death (P = .25).ConclusionsObtaining blood cultures in children hospitalized with CAP rarely identifies a causative pathogen and is associated with increased LOS. Our results highlight the need to refine the role of obtaining blood cultures in children hospitalized with CAP.     

Development and Validation of a Novel Tool to Predict Hospital Readmission Risk Among Patients with Diabetes

Objective: To develop and validate a tool to predict the risk of all-cause readmission within 30 days (30-d readmission) among hospitalized patients with diabetes.Methods: A cohort of 44,203 discharges was retrospectively selected from the electronic records of adult patients with diabetes hospitalized at an urban academic medical center. Discharges of 60% of the patients (n = 26,402) were randomly selected as a training sample to develop the index. The remaining 40% (n = 17,801) were selected as a validation sample. Multivariable logistic regression with generalized estimating equations was used to develop the Diabetes Early Readmission Risk Indicator (DERRI™).Results: Ten statistically significant predictors were identified: employment status; living within 5 miles of the hospital; preadmission insulin use; burden of macrovascular diabetes complications; admission serum hematocrit, creatinine, and sodium; having a hospital discharge within 90 days before admission; most recent discharge status up to 1 year before admission; and a diagnosis of anemia. Discrimination of the model was acceptable (C statistic 0.70), and calibration was good. Characteristics of the validation and training samples were similar. Performance of the DERRI™ in the validation sample was essentially unchanged (C statistic 0.69). Mean predicted 30-d readmission risks were also similar between the training and validation samples (39.3% and 38.7% in the highest quintiles).Conclusion: The DERRI™ was found to be a valid tool to predict all-cause 30-d readmission risk of individual patients with diabetes. The identification of high-risk patients may encourage the use of interventions targeting those at greatest risk, potentially leading to better outcomes and lower healthcare costs.Abbreviations:DERRI™ = Diabetes Early Readmission Risk IndicatorICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical ModificationGEE = generalized estimating equationsROC = receiver operating characteristic     

External Validation of the Diabetes Early Re-Admission Risk Indicator (Derri™)

Objective: The Diabetes Early Re-admission Risk Indicator (DERRI™) was previously developed and internally validated as a tool to predict the risk of all-cause re-admission within 30 days of discharge (30-day re-admission) of hospitalized patients with diabetes. In this study, the predictive performance of the DERRI™ with and without additional predictors was assessed in an external sample.Methods: We conducted a retrospective cohort study of adult patients with diabetes discharged from two academic medical centers between January 1, 2000 and December 31, 2014. We applied the previously developed DERRI™, which includes admission laboratory results, sociodemographics, a diagnosis of certain comorbidities, and recent discharge information, and evaluated the effect of adding metabolic indicators on predictive performance using multivariable logistic regression. Total cholesterol and hemoglobin A1c (A1c) were selected based on clinical relevance and univariate association with 30-day re-admission.Results: Among 105,974 discharges, 19,032 (18.0%) were followed by 30-day re-admission for any cause. The DERRI™ had a C-statistic of 0.634 for 30-day re-admission. Total cholesterol was the lipid parameter most strongly associated with 30-day re-admission. The DERRI™ predictors A1c and total cholesterol were significantly associated with 30-day re-admission; however, their addition to the DERRI™ did not significantly change model performance (C-statistic, 0.643 &lsqb;95% confidence interval, 0.638 to 0.647]; P = .92).Conclusion: Performance of the DERRI™ in this external cohort was modest but comparable to other re-admission prediction models. Addition of A1c and total cholesterol to the DERRI™ did not significantly improve performance. Although the DERRI™ may be useful to direct resources toward diabetes patients at higher risk, better prediction is needed.Abbreviations: A1c = hemoglobin A1c; CI = confidence interval; DERRI™ = Diabetes Early Re-admission Risk Indicator; GEE = generalized estimating equation; HDL-C = high-density-lipoprotein cholesterol; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; LDL-C = low-density-lipoprotein cholesterol     

Risk factors for posttraumatic stress disorder following an industrial disaster in a residential area: A note on the origin of observed gender differences

Background: Studies indicate that differences in trait anxiety and trauma-related distress may mediate the gender differences observed in posttraumatic stress disorder (PTSD).Objective: We examined the contributions of gender, trait anxiety, and trauma-related distress to the development of PTSD after an industrial disaster.Methods: Three months after a massive explosion in a fireworks factory in Kolding, Denmark, in November 2004, residents in the surrounding area were asked to complete the Harvard Trauma Questionnaire, the General Health Questionnaire, and a questionaire designed for the present study. Using multivariable logistic regression with PTSD as the dependent variable, we examined 4 explanatory models: (1) gender; (2) gender and trait anxiety; (3) gender, trait anxiety, and perceived danger; and (4) gender, trait anxiety, perceived danger, perceived hostility, feeling isolated, depersonalization, and behavioral self-blame.Results: Fifty-one percent (N = 516; 265 women and 251 men) of the area residents participated in the study. The female-to-male ratio of PTSD was 2.4:1. Women experienced significantly more trait anxiety (P < 0.001), feelings of isolation (P < 0.005), and behavioral self-blame (P = 0.018), and less perceived danger (P = 0.034) than did men. In multivariable logistic regression analysis, gender alone predicted 3.7% of the variance in PTSD status (odds ratio [OR] = 2.40; 95% CI, 1.35-4.27; P < 0.005); however, in all other models, gender was not significant. The final model comprised trait anxiety (OR = 1.20; 95% CI, 1.11-1.30; P < 0.001), perceived danger (OR = 4.62; 95% Cl, 2.24-9.50; P < 0.001), perceived hostility (OR = 5.21; 95% CI, 1.93-14.09; P < 0.001), feeling isolated (OR = 3.34; 95% CI, 1.55-7.16; P < 0.002), depersonalization (OR = 2.49; 95% CI, 1.42-4.37; P < 0.001), and behavioral self-blame (OR = 0.46; 95% CI, 0.24-0.86; P = 0.015), explaining 48.9% of the variance in PTSD severity.Conclusion: This cross-sectional study found that gender was no longer associated with PTSD status when trait anxiety, perceived danger and hostility, feeling isolated, depersonalization, and behavioral selfblame were taken into account.     

ACUTE PANCREATITIS IN PATIENTS WITH SEVERE HYPERTRIGLYCERIDEMIA IN A MULTI-ETHNIC MINORITY POPULATION

Objective: To investigate the prevalence and predictors of hypertriglyceridemic acute pancreatitis (HTG-AP) in a multi-ethnic minority population.Methods: A retrospective, cross-sectional study from 2003 to 2013 of 1,157 adults with a serum triglyceride (TG) level =1,000 mg/dL comparing baseline characteristics and risk factors between those with and without HTG-AP.Results: Mean study population age was 49.2 ± 11.5 years; 75.6% were male, 31.6% African American, 38.4% Hispanic, 22.7% Caucasian, 5.7% Asian, and 1.6% Pacific Islander. Prevalence of HTG-AP was 9.2%. Patients with HTG-AP were significantly younger (41.3 years vs. 50.0 years; P<.001) than those without HTG-AP. Excessive alcohol intake (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.5 to 6.0; P<.001), gallstone disease (OR, 3.9; 95% CI, 1.4 to 10.8; P = .008), and TG >2,000 mg/dL (OR, 4.8; 95% CI, 3.1 to 7.4; P<.001) remained significant independent risk factors. TG levels for patients with HTG-AP were higher (median TG, 2,394 mg/dL; interquartile range [IQR], 1,152 to 4,339 mg/dL vs. median TG, 1,406 mg/dL; IQR, 1,180.7 to 1,876.5 mg/dL). TG levels >2,000 mg/dL were associated with higher incidence of AP (22% vs. 5%). Patients with TG levels <2,000 mg/dL and no risk factors had prevalence of 2% compared to 33.6% with one risk factor and TG >2,000 mg/dL. Patients with HTG-AP had higher incidence of diabetic ketoacidosis at admission (7.5% vs. 2.5%; P = .004).Conclusion: TG level =2,000 mg/dL is associated with higher HTG-AP prevalence in ethnic minorities. Presence of excessive alcohol intake and/or gallstones further accentuates risk.Abbreviations: AP = acute pancreatitis; CT = computed tomography; DM = diabetes mellitus; HbA1c = hemoglobin A1c; HIV = human immunodeficiency virus; HTG = hyper-triglyceridemia; HTG-AP = hypertriglyceridemic acute pancreatitis; ROC = receiver operating characteristic; TG = triglyceride     

Validation and Comparison of Two 30-Day Re-Admission Prediction Models in Patients with Diabetes

Objective: The objective was to evaluate the 30-day re-admission predictive performance of the HOSPITAL score and Diabetes Early Re-admission Risk Indicator (DERRI™) in hospitalized diabetes patients.Methods: This was a case-control study in an academic, tertiary center in the United States. Adult hospitalized diabetes patients were randomly identified between January 1, 2014, and September 30, 2017. Patients were categorized into two groups: (1) re-admitted within 30 days, and (2) not re-admitted within 30 days. Predictive performance of the HOSPITAL and DERRI™ scores was evaluated by calculating receiver operating characteristics curves (c-statistic), Hosmer-Lemeshow goodness-of-fit tests, and Brier scores.Results: A total of 200 patients were included (100 re-admitted, 100 non–re-admitted). The HOSPITAL score had a c-statistic of 0.731 (95% confidence interval &lsqb;CI], 0.661 to 0.800), Hosmer-Lemeshow test P = .211, and Brier score 0.212. The DERRI™ score had a c-statistic of 0.796 (95% CI, 0.734 to 0.857), Hosmer-Lemeshow test P = .114, and Brier score 0.212. The difference in receiver operating characteristic curves was not statistically significant between the two scores but showed a higher c-statistic with the DERRI™ score (P = .055).Conclusion: Both HOSPITAL and DERRI™ scores showed good predictive performance in 30-day re-admission of adult hospitalized diabetes patients. There was no significant difference in discrimination and calibration between the scores.Abbreviations: CI = confidence interval; DERRI™ = Diabetes Early Re-admission Risk Indicator; IQR = interquartile range     

Sex differences in intraventricular hemorrhage rates among very low birth weight newborns

Background: The influence of male or female sex on newborn outcomes has been recognized for >30 years. Several studies have observed higher mortality and morbidity in males than in females. It is not clear how this sex difference is sustained in postnatal complications such as intraventricular hemorrhage (IVH), especially in very low birth weight (VLBW) newborns.Objective: This study examined possible sex-related differences in IVH rates among VLBW neonates.Methods: In a retrospective observational study conducted in Hospital Privado, Córdoba, Argentina, data from 332 consecutive VLBW newborns in a 12-year period were reviewed. Maternal factors, labor and delivery characteristics, and neonatal parameters, including the results of cranial ultrasound examination to detect IVH, were compared for males and females. Bivariate and multivariate logistic regression analyses were performed.Results: A total of 322 VLBW newborns were included, 168 males and 154 females. Compared with female neonates, male neonates had a higher risk of overall IVH (26.8% vs 9.7%; odds ratio [OR] = 3.4 [95% CI, 1.8–6.4]; P < 0.001) and for grades III or IV on the Papile scale (16.1% vs 1.9%; OR = 9.6 [95% CI, 2.9–32.5]; P < 0.001). In the multivariate logistic regression model, male sex sustained the association with a greater risk of IVH (OR = 6.8 [95% CI, 3.8–12.0]).Conclusions: IVH was significantly associated with male sex in these VLBW newborns. Because other factors affect these differences, further research is required.     

Readmission for Acute Exacerbation within 30 Days of Discharge Is Associated with a Subsequent Progressive Increase in Mortality Risk in COPD Patients: A Long-Term Observational Study

Background and Objective

Twenty per cent of chronic obstructive pulmonary disease (COPD) patients are readmitted for acute exacerbation (AECOPD) within 30 days of discharge. The prognostic significance of early readmission is not fully understood. The objective of our study was to estimate the mortality risk associated with readmission for acute exacerbation within 30 days of discharge in COPD patients.

Methods

The cohort (n = 378) was divided into patients readmitted (n = 68) and not readmitted (n = 310) within 30 days of discharge. Clinical, laboratory, microbiological, and severity data were evaluated at admission and during hospital stay, and mortality data were recorded at four time points during follow-up: 30 days, 6 months, 1 year and 3 years.

Results

Patients readmitted within 30 days had poorer lung function, worse dyspnea perception and higher clinical severity. Two or more prior AECOPD (HR, 2.47; 95% CI, 1.51–4.05) was the only variable independently associated with 30-day readmission. The mortality risk during the follow-up period showed a progressive increase in patients readmitted within 30 days in comparison to patients not readmitted; moreover, 30-day readmission was an independent risk factor for mortality at 1 year (HR, 2.48; 95% CI, 1.10–5.59). In patients readmitted within 30 days, the estimated absolute increase in the mortality risk was 4% at 30 days (number needed to harm NNH, 25), 17% at 6-months (NNH, 6), 19% at 1-year (NNH, 6) and 24% at 3 years (NNH, 5).

Conclusion

In conclusion a readmission for AECOPD within 30 days is associated with a progressive increased long-term risk of death.     

Veralgemeende of selectieve screening voor dragerschap van methicilline resistente Staphylococcus aureus bij opname op een geriatrische dienst

Generalized or targeted screening for carriage of MRSA on admission to a geriatric hospital Objectives: to confirm previously risk factors for MRSA carriage in our geriatric patient population and to suggest a simplified risk score with a combination of these risk factors, to test the Novel Score and to check if a targeted MRSA screening on admission is possible to reduce the screening workload and cost. Design: a prospective in-hospital cohort study. Subjects: 1125 geriatric patients were screened for MRSA carriage within 24 hours after admission to a geriatric hospital. Methods: Risk factors, based on recently published risk scores (Preop Score and Ger Score) were determined. Results: Prevalence of MRSA carriage was 8,44%. In a multivariate analysis age ≥ 87 year (OR 1,864; 95% CI 1,145-3,035), presence of a long-term catheter (OR 2,813; 95% CI 1,562-5,065) and prior carriage of MRSA (OR 13,25; 95% CI 8,007-21,926) remained predictors of MRSA carriage. The Novel Score (cut-off ≥ 1) had a sensitivity of 73,7%, a specificity of 64%, PPV 15,9%, NPV 96,3% and AUC of 0,688. The Novel Score allows reduction of the screening load by 57,2%, but misses 26% of positive cases. 16% of MRSA carriers develop an infection that needs to be treated with vancomycin. Conclusion: With targeted MRSA screening on admission based on a risk score a substantial reduction of workload and costs is possible compared to generalized screening for MRSA. Because MRSA carriers can be missed with a risk score, the epidemiological context and the risk of transmission and infection with MRSA must be taken in to account when introducing a targeted screening. Tijdschr Gerontol Geriatr 2011; 42: 184-193     

Risk Factors for Central Lymph Node Metastases in Patients with Papillary Thyroid Microcarcinoma

Objectives: Papillary thyroid carcinoma with a maximum tumor diameter no more than 10 mm is defined as papillary thyroid microcarcinoma (PTMC). The proportion of newly diagnosed PTMCs has increased significantly in recent years. Different guidelines have different comments about optimal management of PTMC, especially on prophylactic central lymph node (CLN) dissection. The aim of the present study was to analyze the risk factors for CLN metastases in patients with PTMC.Methods: A total of 4,389 patients underwent thyroid surgery at our center from January 2017 to March 2018, and 2,129 patients with PTMC were selected and assessed retrospectively. The relationship between CLN metastases and clinicopathologic features of PTMC were analyzed by both univariate and multivariate analyses.Results: Of the 2,129 patients with PTMC, CLN metastases were confirmed by pathology in 923 patients. Univariate and multivariate analyses found several independent factors associated with CLN metastases. They were male gender (odds ratio [OR], 1.694; 95% confidence interval [CI], 1.386 to 2.071; P<.001), younger age (<45 years) (OR, 2.687; 95% CI, 2.196 to 3.288; P<.001), larger tumor size (>5 mm) (OR, 2.168; 95% CI, 1.782 to 2.636; P<.001), positive CLN metastases via ultrasound (OR, 4.939; 95% CI, 3.534 to 6.902; P<.001), and multifocality (OR, 1.424; 95% CI, 1.176 to 1.724; P<.001).Conclusion: CLN metastases are common in PTMC patients. Male gender, younger age (<45 years), larger tumor size (>5 mm), positive CLN metastases via ultrasound, and multifocality are independent risk factors for CLN metastases. Our data should be considered in the decision-making process related to performing CLN dissection.Abbreviations: CLN = central lymph node; PTC = papillary thyroid carcinoma; PTMC = papillary thyroid microcarcinoma     

Association Between Serum Uric Acid Level and Body Mass Index in Sex- and Age-Specific Groups in Southwestern China

Objective: To investigate the sex- and age-specific association between serum uric acid level and body mass index (BMI).Methods: A total of 144,856 subjects aged 20 to 79 years were enrolled in this cross-sectional study. Serum uric acid level, renal function, hepatic function, and lipid profile were investigated.Results: The prevalence of hyperuricemia decreased with age in men but increased in women. In men, the correlation coefficient between the serum urate level and BMI declined steadily with age. Underweight was associated with a 53 to 68% and a 66% lower prevalence of hyperuricemia in men aged 20 to 69 years and in women aged 20 to 29 years, respectively. Overweight and obesity were correlated with a higher odds ratio (OR) (95% confidence interval &lsqb;CI]) for hyperuricemia in both genders. In individuals with overweight or obesity, younger subjects had a higher OR (95% CI) for hyperuricemia than older subjects. Among subjects aged 20 to 59 years, as they gained weight, the OR (95% CI) for hyperuricemia increased faster in women than in men compared with their respective normal-weight controls.Conclusion: Underweight was associated with a lower prevalence of hyperuricemia in men aged ≤69 years. In individuals with overweight or obesity, younger subjects were more likely to develop hyperuricemia than older subjects. With active weight gain, the likelihood for developing hyperuricemia increased faster in women than in men compared with their respective normal-weight controls.Abbreviations: ALT = alanine aminotransferase; AST = aspartate aminotransferase; BMI = body mass index; CI = confidence interval; eGFR = estimated glomerular filtration rate; HDL-C = high-density-lipoprotein cholesterol; LDL-C = low-density-lipoprotein cholesterol; OR = odds ratio     

Side Effects of PTU and MMI in the Treatment of Hyperthyroidism: A Systematic Review and Meta-Analysis

Objective: The present study aimed to investigate the adverse effects of the antithyroid drugs propylthiouracil (PTU) and methimazole (MMI)/carbimazole (CMZ) in treating hyperthyroidism.Methods: Qualitative analysis was performed for studies identified in a literature search up to April 20, 2019, and 30 studies were selected for meta-analysis. The study designs included case-control, randomized controlled, and retrospective cohort. Patients were in four age groups: childhood, gestating mothers, older adults, and other ages, and all were receiving PTU or MMI/CMZ. Adverse reactions to MMI/CMZ and PTU were evaluated and compared.Results: Odds of liver function injury were higher in the PTU group than in the MMI/CMZ group (odds ratio &lsqb;OR], 2.40; 95% confidence interval &lsqb;CI], 1.16 to 4.96; P = .02). Odds of elevated transaminase were much higher in the PTU group than in the MMI/CMZ group (OR, 3.96; 95% CI, 2.49 to 6.28; P<.00001). No significant between-group differences were found in odds of elevated bilirubin, agranulocytosis, rash, or urticaria; incidence of other adverse events; or in children. Odds of birth defects during the first trimester of pregnancy were higher in the MMI/CMZ group than in the PTU group (OR, 1.29; 95% CI, 1.09 to 1.53; P = .003).Conclusion: The impact of PTU on liver injury and transaminase levels is greater than that of MMI/CMZ, but no significant between-group differences are found in the drugs' effects on bilirubin, agranulocytosis and rash, urticaria, or in children. In treating pregnancy-related hyperthyroidism, PTU should be used in the first trimester and MMI reserved for use in late pregnancy.Abbreviations: ALT = alanine aminotransferase; ATD = antithyroid drug; CI = confidence interval; CMZ = carbimazole; GD = Graves disease; MMI = methimazole; MTU = methylthiouracil; NOS = Newcastle-Ottawa Scale; OR = odds ratio; PTU = propylthiouracil; RAI = radioactive iodine     

Treatment of Diabetic Ketoacidosis and the Weekend Effect at an Urban Tertiary-Care Center

Objective: Weekend admission has been associated with higher morbidity and mortality, but the relationship between diabetic ketoacidosis (DKA) outcomes and this weekend effect is unclear. To better characterize it, we examined the outcomes of patients admitted with DKA to an urban tertiary-care center.Methods: This retrospective study included pediatric and adult patients admitted to Montefiore Health System from January 1, 2008, through December 31, 2018, with a primary or secondary diagnosis of DKA as identified by International Classification of Diseases (ICD)-9 and -10 codes; all ICD diagnoses were present on admission. Only the first admission for each patient was analyzed, and patients were excluded if their initial anion gap was less than 13 mEq/L. A subcohort comprised of patients with documented biochemical evidence of DKA resolution was also analyzed. The Friday-Saturday weekend was defined as the period between midnight on Friday and midnight on Sunday; the Saturday-Sunday weekend was similarly defined. The following outcomes were compared between weekday and weekend groups: length of stay; time to initiation of subcutaneous insulin; and time to each of the following: venous pH >7.3, blood glucose <200 mg/dL, and anion gap ≤12 mEq/L. Odds of 30-day all-cause mortality and 30-day all-cause and DKA-specific readmission were also examined.Results: Over 11 years, 4,703 patients were included in the overall cohort, and 648 were included in the subcohort. For both weekend definitions, weekend admission did not produce differences in any outcome for either study cohort.Conclusion: No weekend effect on DKA outcomes was detected at an urban tertiary-care center.Abbreviations: AG = anion gap; CCI = Charlson Comorbidity Index; DKA = diabetic ketoacidosis; ICD = International Classification of Diseases; IVI = intravenous insulin; LOS = length of stay; SCI = subcutaneous insulin     

Host Factors and Biomarkers Associated with Poor Outcomes in Adults with Invasive Pneumococcal Disease

BackgroundInvasive pneumococcal disease (IPD) causes considerable morbidity and mortality. We aimed to identify host factors and biomarkers associated with poor outcomes in adult patients with IPD in Japan, which has a rapidly-aging population.MethodsIn a large-scale surveillance study of 506 Japanese adults with IPD, we investigated the role of host factors, disease severity, biomarkers based on clinical laboratory data, treatment regimens, and bacterial factors on 28-day mortality.ResultsOverall mortality was 24.1%, and the mortality rate increased from 10.0% in patients aged ˂50 years to 33.1% in patients aged ≥80 years. Disease severity also increased 28-day mortality, from 12.5% among patients with bacteraemia without sepsis to 35.0% in patients with severe sepsis and 56.9% with septic shock. The death rate within 48 hours after admission was high at 54.9%. Risk factors for mortality identified by multivariate analysis were as follows: white blood cell (WBC) count <4000 cells/μL (odds ratio [OR], 6.9; 95% confidence interval [CI], 3.7–12.8, p < .001); age ≥80 years (OR, 6.5; 95% CI, 2.0–21.6, p = .002); serum creatinine ≥2.0 mg/dL (OR, 4.5; 95% CI, 2.5–8.1, p < .001); underlying liver disease (OR, 3.5; 95% CI, 1.6–7.8, p = .002); mechanical ventilation (OR, 3.0; 95% CI, 1.7–5.6, p < .001); and lactate dehydrogenase ≥300 IU/L (OR, 2.4; 95% CI, 1.4–4.0, p = .001). Pneumococcal serotype and drug resistance were not associated with poor outcomes.ConclusionsHost factors, disease severity, and biomarkers, especially WBC counts and serum creatinine, were more important determinants of mortality than bacterial factors.     

Predictors of depressive symptoms post-acute coronary syndrome

Objective: We examined the influence of gender on the prevalence of acute coronary syndrome (ACS) and the severity of depressive symptoms post-ACS.Methods: Patients received a Zung self-assessment questionnaire at hospital discharge for unstable angina (UA) or acute myocardial infarction (AMI) and returned it by mail. Major depressive symptoms were diagnosed based on a summed depressive symptoms (SDS) score of >50. Depressive symptomatology was modeled by stepwise multivariable logistic regression with the following predictors: gender, age, hypertension, diabetes mellitus, history of smoking, hypercholesterolemia, peripheral vascular disease, prior stroke, prior myocardial infarction (MI), and prior percutaneous coronary intervention or coronary artery bypass graft surgery. We also modeled severity of depressive symptoms via stepwise multiple linear regression with the same predictor variables.Results: A total of 944 patients were surveyed: 716 men and 228 women, mean (SD) age, 67 (13) years and 71 (12) years, respectively. Of these patients, 250 (35%) men and 103 (45%) women had depressive symptoms (P = 0.005). No significant difference was observed between men and women in rates of cardiac catheterization; severity of coronary artery disease; treatment with antiplatelet agents, β-blockers, angiotensin-converting enzyme inhibitors, or statins; or percutaneous or surgical revascularization rates during or post-ACS. Significant predictors of the presence of depressive symptoms were female gender (odds ratio [OR] = 1.64; 95% CI, 1.19-1.28), diabetes mellitus (OR = 1.42; 95% CI, 1.03-1.97), prior MI (OR = 1.56; 95% CI, 1.15-2.20), and smoking (OR = 1.41; 95% CI, 1.01-1.97). Variables significantly associated with a higher severity of depressive symptoms were female gender, prior MI, smoking, and stroke. Men with prior MI had significantly higher mean (SD) SDS scores than did men without prior MI in all age groups (48.4 [11] vs 44.6 [11], respectively; P < 0.001). In addition, significantly more men with prior MI had depressive symptoms compared with those without prior MI (45% vs 32%; P = 0.001). However, prior MI did not appear to affect SDS scores in women (49.1 [12] for prior MI vs 48.5 [12] for no prior MI; P = NS), and there was no significant difference in the percentage of women who had depressive symptoms with or without a history of prior MI. Depressive symptoms were much more severe in women with UA (SDS = 49.0 [12]) compared with women with AMI (SDS = 45.0 [12]; P = NS), or men with AMI (45.0 [12]; P = 0.004) or UA (46.0 [11]; P = 0.007) (analysis of variance, P = 0.003).Conclusions: Female gender is a significant independent predictor of depressive symptoms and their severity post-UA and post-AMI. History of prior MI is associated with a higher frequency and severity of depressive symptoms in men. These findings call for routine screening for depressive symptoms in men with prior MI and in women who present with ACS.