Management of inpatients with inflammatory bowel disease (IBD) requires increasing resources. We aimed to identify factors associated with hospital readmissions among individuals with IBD.
We ...collected data from the Healthcare Cost and Utilization Project Nationwide Readmissions Database 2013. We identified individuals with index hospitalizations for IBD. Patient-specific factors, comorbidities and hospitalization characteristics were extracted for the index hospitalization. We performed logistic regression modeling to create adjusted odds ratios (ORs) for 30-day hospital readmission. Subgroup analysis was performed based on disease type and performance of surgery.
We analyzed a total of 55,942 index hospital discharges; 3037 patients (7.0%) were readmitted to the hospital within 30 days. Increasing patient age (> 65: OR: 0.45; 95% CI 0.39-0.53) was associated with a decreased risk of readmission, while a diagnosis of Crohn's disease (OR: 1.09; 95% CI 1.00-1.18) and male sex (OR: 1.16; 95% CI 1.07-1.25) were associated with an increased risk of readmission. The comorbidities of smoking (OR: 1.09; 95% CI 1.00-1.19), anxiety (OR: 1.17; 95% CI 1.01-1.36) and opioid dependence (OR: 1.40; 95% CI 1.06-1.86) were associated with an increased risk of 30-day readmission. Individual hospitalization characteristics and disease complications were significantly associated with readmission. Performance of a surgery during the index admission was associated with a decreased risk of readmission (OR: 0.57; 95% CI 0.33-0.96).
Analyzing data from a US publicly available all-payer inpatient healthcare database, we identified patient and hospitalization risk factors associated with 30-day readmission. Identifying patients at high risk for readmission may allow for interventions during or after the index hospitalization to decrease this risk.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The introduction of new sedative agents as well as a desire for improved patient satisfaction and greater efficiency has changed the practice of endoscopic sedation. This survey was designed to ...provide national and regional data on endoscopic sedation and monitoring practices within the United States.
A 22-item survey regarding current practices of endoscopy and sedation was mailed to 5,000 American College of Gastroenterology physician members nationwide.
A total of 1,353 questionnaires (27.1%) were returned. Respondents performed an average of 12.3 esophagogastroduodenoscopies (EGDs) and 22.3 colonoscopies per wk. Endoscopic procedures were performed within a hospital setting (55.2) more often than at an ambulatory center (35.8%) or private office (8.8%). The vast majority of EGDs and colonoscopies (>98%) were performed with endoscopic sedation. Almost three quarters (74.3%) of the respondents used a narcotic and benzodiazepine for sedation, while propofol was preferred by 25.7%. Sedation practices varied considerably within different geographic regions of the United States. Respondents routinely monitored vital signs and pulse oximetry (99.2% and 98.6%, respectively), and supplemental oxygen was administered to all patients during EGD by 72.7% of endoscopists. Endoscopist satisfaction with sedation was greater among those using propofol than conventional sedation (10 vs 8, p < 0.0001).
During the past 15 yr, the volume of procedures performed by endoscopists in the United States has increased two- to fourfold. Propofol is currently being used for sedation in approximately one quarter of all endoscopies in the United States. The findings from this survey may help in the formulation of updated policies and practice guidelines pertaining to endoscopic sedation.
INTRODUCTION:The 2010 Affordable Care Act introduced the Hospital Readmissions Reduction Program to reduce health care utilization. Diverticular disease and its complications remain a leading cause ...of hospitalization among gastrointestinal disease. We sought to determine risk factors for 30-day hospital readmissions after hospitalization for diverticular bleeding.
MATERIALS AND METHODS:We utilized the 2013 National Readmission Database sponsored by the Agency for Healthcare Research and Quality focusing on hospitalizations with the primary or secondary discharge diagnosis of diverticular hemorrhage or diverticulitis with hemorrhage. We excluded repeat readmissions, index hospitalizations during December and those resulting in death. Our primary outcome was readmission within 30 days of index hospital discharge. Secondary outcomes of interest included medical and procedural comorbid risk factors. The data were analyzed using logistic regression analysis.
RESULTS:In total, 29,090 index hospitalizations for diverticular hemorrhage were included. There were 3484 (12%) 30-day readmissions with recurrent diverticular hemorrhage diagnosed in 896 (3%).Index admissions with renal failure odds ratio (OR), 1.31; 95% confidence interval (CI), 1.19-1.43, congestive heart failure (OR, 1.30; 95% CI, 1.17-1.43), chronic pulmonary disease (OR, 1.19; 95% CI, 1.09-1.29), coronary artery disease (OR, 1.12; 95% CI, 1.03-1.21), atrial fibrillation (OR, 1.12; 95% CI, 1.02-1.22) cirrhosis (OR, 1.95; 95% CI, 1.29-2.93, performance of blood transfusion (OR, 1.23; 95% CI, 1.15-1.33), and abdominal surgery (OR, 1.24; 95% CI, 1.03-1.49) had increased risk of 30-day readmission.
CONCLUSIONS:The 30-day readmission rate for diverticular hemorrhage was 12% with multiple identified comorbidities increasing readmission risk.
A small bowel source is suspected when evaluation of overt gastrointestinal (GI) bleeding with upper and lower endoscopy is negative. Video capsule endoscopy (VCE) is the recommended next diagnostic ...test for small bowel bleeding sources. However, clinical or endoscopic predictive factors for small bowel bleeding in the setting of an overt bleeding presentation are unknown. We aimed to define predictive factors for positive VCE among individuals presenting with overt bleeding and a suspected small bowel source.
We included consecutive inpatient VCE performed between September 1, 2012 to September 1, 2015 for melena or hematochezia at two tertiary centers. All patients had EGD and colonoscopy performed prior to VCE. Patient demographics, medication use, and endoscopic findings were retrospectively recorded. VCE findings were graded based on the P0-P2 grading system. The primary outcome of interest was a positive (P2) VCE. The secondary outcome of interest was the performance of a therapeutic intervention. Data were analyzed with the Fisher exact test for dichotomous variables and logistic regression.
Two hundred forty-three VCE were reviewed, and 117 were included in the final analysis. A positive VCE (P2) was identified in 35 (29.9%) cases. In univariate analysis, a positive VCE was inversely associated with presence of diverticula on preceding colonoscopy (OR: 0.44, 95% CI: 0.2-0.99), while identification of blood on terminal ileal examination was associated with a positive VCE (OR: 5.18, 95% CI: 1.51-17.76). In multivariate analysis, only blood identified on terminal ileal examination remained a significant risk factor for positive VCE (OR: 6.13, 95% CI: 1.57-23.81). Blood on terminal ileal examination was also predictive of therapeutic intervention in both univariate (OR: 4.46, 95% CI: 1.3-15.2) and multivariate analysis (OR: 5.04, 95% CI: 1.25-20.32).
Among patients presenting with overt bleeding but negative upper and lower endoscopy, the presence of blood on examination of the terminal ileum is strongly associated with a small bowel bleeding source as well as with small bowel therapeutic intervention. Presence of diverticula on colonoscopy is inversely associated with a positive VCE and therapeutic intervention in univariate analysis.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Greater understanding of the hepatitis C virus (HCV) genome and life cycle of the HCV virion allows for new targets for therapy that directly act on the viral machinery to inhibit replication. ...Numerous direct-acting antivirals are in development, and four have been brought to market. Simeprevir, a second-generation protease inhibitor, has been approved for HCV genotype 1 patients in combination with pegylated interferon-α and ribavirin. Sofosbuvir, a novel nucleotide analog, has pangenotypic coverage and has been approved for HCV genotype 1 patients with ribavirin and pegylated interferon-α. For HCV genotypes 2 and 3, an all-oral regimen of sofosbuvir with ribavirin has become the new gold standard for treatment. The efficacy and safety for these two novel therapies among various subpopulations of those infected with chronic hepatitis C are discussed in the following review. In addition, off-label and future therapeutic regimens are addressed, as well as the concerns about cost of current and future therapies.
Background and Aim:
The aim of this study is to assess paracentesis utilization and outcomes in hospitalized adults with cirrhosis and ascites.
Methods:
The 2011 Nationwide Inpatient Sample was used ...to identify adults, non‐electively admitted with diagnoses of cirrhosis and ascites. The primary endpoint was in‐hospital mortality. Variables included patient and hospital demographics, early (Day 0 or 1) or late (Day 2 or later) paracentesis, hepatic decompensation, and spontaneous bacterial peritonitis.
Results:
Out of 8 023 590 admissions, 31 614 met inclusion criteria. Among these hospitalizations, approximately 51% (16 133) underwent paracentesis. The overall in‐hospital mortality rate was 7.6%. There was a significantly increased mortality among patients who did not undergo paracentesis (8.9% vs 6.3%, P < 0.001). Patients who did not receive paracentesis died 1.83 times more often in the hospital than those patients who did receive paracentesis (95% confidence interval 1.66–2.02). Patients undergoing early paracentesis showed a trend towards reduction in mortality (5.5% vs 7.5%) compared with those undergoing late paracentesis. Patients admitted on a weekend demonstrated less frequent use of early paracentesis (50% weekend vs 62% weekday) and demonstrated increased mortality (adjusted odds ratio 1.12 95% confidence interval 1.01–1.25). Among patients diagnosed with spontaneous bacterial peritonitis, early paracentesis was associated with shorter length of stay (7.55 vs 11.45 days, P < 0.001) and decreased hospitalization cost ($61 624 vs $107 484, P < 0.001).
Conclusion:
Paracentesis is under‐utilized among cirrhotic patients presenting with ascites and is associated with decreased in‐hospital mortality. These data support the use of paracentesis as a key inpatient quality measure among hospitalized adults with cirrhosis. Future studies are needed to investigate the barriers to paracentesis use on admission.
Background
Within-breath oscillations in arterial oxygen tension (PaO
2
) can be detected using fast responding intra-arterial oxygen sensors in animal models. These PaO
2
signals, which rise in ...inspiration and fall in expiration, may represent cyclical recruitment/derecruitment and, therefore, a potential clinical monitor to allow titration of ventilator settings in lung injury. However, in hypovolaemia models, these oscillations have the potential to become inverted, such that they decline, rather than rise, in inspiration. This inversion suggests multiple aetiologies may underlie these oscillations. A correct interpretation of the various PaO
2
oscillation morphologies is essential to translate this signal into a monitoring tool for clinical practice. We present a pilot study to demonstrate the feasibility of a new analysis method to identify these morphologies.
Methods
Seven domestic pigs (average weight 31.1 kg) were studied under general anaesthesia with muscle relaxation and mechanical ventilation. Three underwent saline-lavage lung injury and four were uninjured. Variations in PEEP, tidal volume and presence/absence of lung injury were used to induce different morphologies of PaO
2
oscillation. Functional principal component analysis and
k
-means clustering were employed to separate PaO
2
oscillations into distinct morphologies, and the cardiorespiratory physiology associated with these PaO
2
morphologies was compared.
Results
PaO
2
oscillations from 73 ventilatory conditions were included. Five functional principal components were sufficient to explain ≥ 95% of the variance of the recorded PaO
2
signals. From these, five unique morphologies of PaO
2
oscillation were identified, ranging from those which increased in inspiration and decreased in expiration, through to those which decreased in inspiration and increased in expiration. This progression was associated with the estimates of the first functional principal component (
P
< 0.001,
R
2
= 0.88). Intermediate morphologies demonstrated waveforms with two peaks and troughs per breath. The progression towards inverted oscillations was associated with increased pulse pressure variation (
P
= 0.03).
Conclusions
Functional principal component analysis and
k
-means clustering are appropriate to identify unique morphologies of PaO
2
waveform associated with distinct cardiorespiratory physiology. We demonstrated novel intermediate morphologies of PaO
2
waveform, which may represent a development of zone 2 physiologies within the lung. Future studies of PaO
2
oscillations and modelling should aim to understand the aetiologies of these morphologies.
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