Development of an automated, real time surveillance tool for predicting readmissions at a community hospital

BACKGROUND

The Centers for Medicare and Medicaid Services' Readmissions Reduction Program adjusts payments to hospitals based on 30-day readmission rates for patients with acute myocardial infarction, heart failure, and pneumonia. This holds hospitals accountable for a complex phenomenon about which there is little evidence regarding effective interventions. Further study may benefit from a method for efficiently and inexpensively identifying patients at risk of readmission. Several models have been developed to assess this risk, many of which may not translate to a U.S. community hospital setting.

OBJECTIVE

To develop a real-time, automated tool to stratify risk of 30-day readmission at a semirural community hospital.

METHODS

A derivation cohort was created by extracting demographic and clinical variables from the data repository for adult discharges from calendar year 2010. Multivariate logistic regression identified variables that were significantly associated with 30-day hospital readmission. Those variables were incorporated into a formula to produce a Risk of Readmission Score (RRS). A validation cohort from 2011 assessed the predictive value of the RRS. A SQL stored procedure was created to calculate the RRS for any patient and publish its value, along with an estimate of readmission risk and other factors, to a secure intranet site.

RESULTS

Eleven variables were significantly associated with readmission in the multivariate analysis of each cohort. The RRS had an area under the receiver operating characteristic curve (c-statistic) of 0.74 (95% CI 0.73-0.75) in the derivation cohort and 0.70 (95% CI 0.69-0.71) in the validation cohort.

CONCLUSION

Clinical and administrative data available in a typical community hospital database can be used to create a validated, predictive scoring system that automatically assigns a probability of 30-day readmission to hospitalized patients. This does not require manual data extraction or manipulation and uses commonly available systems. Additional study is needed to refine and confirm the findings.

Parenting stress of caregivers of young children who are HIV Positive

OBJECTIVE

Paediatric HIV remains a major challenge in Sub-Saharan Africa. Paediatric HIV is a multi-generational disorder with far-reaching implications for the whole family. Parenting stress in caregivers of HIV infected children has been studied in developed countries but never in South Africa. The aim of this study was to determine the extent of parenting stress in caregivers of children infected with HIV in South Africa. Further objectives were to monitor the levels of stress over one year after caregivers started attending a paediatric HIV clinic and to ascertain what factors were predictive of a decrease in parenting stress over that time.

METHOD

One hundred and twenty two caregiver and children dyads were recruited into this study. Caregivers completed the Parenting Stress Index/ Short form at baseline and after six and 12 months. Demographic information was collected and the children's heights, weights and CD4 counts were recorded at each visit.

RESULTS

The families that participated in this study came from very poor socio-economic backgrounds. Eighty five percent of the children were still being cared for by their biological mothers. The parenting stress levels of the caregivers in this study were extremely high at baseline. Although the parenting stress levels did come down significantly over the study period (p< 0.001) they remained high and warrant further investigation and management. A better level of education, better housing facilities and fewer adults living in the household were the three most important factors predicting a decrease in parenting stress over a one year period.

CONCLUSION

Parenting stress of caregivers of young children infected with HIV is extremely high and warrants further investigation and long term management.

Purpura fulminans: recognition, diagnosis and management

Purpura fulminans (PF) is a haematological emergency in which there is skin necrosis and disseminated intravascular coagulation. This may progress rapidly to multi-organ failure caused by thrombotic occlusion of small and medium-sized blood vessels. PF may complicate severe sepsis or may occur as an autoimmune response to otherwise benign childhood infections. PF may also be the presenting symptom of severe heritable deficiency of the natural anticoagulants protein C or protein S. Early recognition and treatment of PF is essential to reduce mortality and to prevent major long-term health sequelae. However, management strategies require accurate identification of the underlying cause. This review focuses on the clinical features, differential diagnosis and laboratory features of the range of PF disorders and includes expert consensus opinion about immediate and on-going management.

Initial experience with a rapid access blackouts triage clinic

Transient loss of consciousness (T-LOC), or blackout, is common in acute medicine. Clinical skills are not done well, with at least 74,000 patients misdiagnosed and mistreated for epilepsy in England alone. The aim of this study was to provide a rapid, structured assessment and an electrocardiogram (ECG) for patients with blackouts, aiming to identify high risk, reduce misdiagnoses, reduce hospital admission rates for low-risk patients, diagnose and treat where appropriate, and also provide onward specialist referral. The majority of patients had syncope, and very few had epilepsy. A high proportion had an abnormal ECG. A specialist-nurse-led rapid access blackouts triage clinic (RABTC) provided rapid effective triage for risk, a comprehensive assessment format, direct treatment for many patients, and otherwise a prompt appropriate onward referral. Rapid assessment through a RABTC reduced re-admissions with blackouts. Widespread use of the web-based blackouts tool could provide the NHS with a performance map. The U.K. has low rates of pacing compared to Western Europe, which RABTCs might help correct. The RABTC sits between first responders and specialist referral, providing clinical assessment and ECG in all cases, and referral where appropriate.

Freeform surface filtering using the diffusion equation

The measurement of texture for geometric surfaces is well established for surfaces that are of a planar (Euclidean) nature. Gaussian filtering is the fundamental base for scale-limited surfaces used in surface texture, but cannot be applied to non-Euclidean surfaces without distortion of the results. A link exists between Gaussian filtering and solutions of the PDE that models linear isotropic diffusion. In particular, an analytical solution of this diffusion equation over a planar region at a time t is given by the continuous convolution of the initial distribution of the diffused quantity with a Gaussian function of standard deviation . A practical implementation of the standard Gaussian filter on sampled data can be viewed as a discretization of this process. On a non-Euclidean surface, the diffusion equation is formulated by using the Laplace–Beltrami operator. Using this generalization, a method of Gaussian filtering for freeform surface data is proposed by solving the diffusion equation for approximation residuals defined on a freeform least-squares approximation of the measurement surface data. Results of the application of these methods to simulated and experimental data are presented.

Maize nuclear background regulates the synthesis of a 22-kDa polypeptide in Zea luxurians mitochondria

When cytoplasm of the teosinte Zea luxurians is introduced into certain maize inbred nuclear backgrounds, the pattern of protein synthesis in the teosinte mitochondria is altered. Teosinte mitochondria purified from plants possessing a maize A619 nuclear background (Z.l.-A619 plants) synthesize a novel 22-kDa polypeptide that is associated exclusively with the membrane fraction of the organelle. Mitochondria from plants possessing a W23 nuclear background do not synthesize this protein. The F(1) hybrids Z.l.-A619 x W23 and Z.l.-W23 x A619 do not synthesize the protein. However, synthesis of the polypeptide was observed in 14 of 21 individual progeny from the backcross of the F(1) hybrid Z.l.-A619 x W23 to the pollen parent A619. These data suggest that a single nuclear gene controls the synthesis of the 22-kDa protein in mitochondria, with the recessive allele of the gene allowing expression of the polypeptide. Mitochondria from the F(1) hybrid Z.l.-A619 x Mo17 synthesize the 22-kDa protein, whereas mitochondria from Z.l.-A619 x B73 do not. Data from these outcrosses demonstrate that other maize lines also possess nuclear genes capable of regulating the synthesis of the 22-kDa Zea luxurians mitochondrial protein.

International variations in associations of allergic markers and diseases in children: ISAAC Phase Two

BACKGROUND

Circulating allergen-specific IgE (sIgE) and skin prick tests (SPT) are used to define atopy. Downregulation of local inflammatory responsiveness has been proposed to explain a low prevalence of positive SPTs in less affluent countries. We analysed the association between SPTs, total and allergen-specific IgE and their relationships to allergic symptoms in centres with diverse living conditions.

METHODS

Cross-sectional studies of stratified random samples of 8 to 12-year-old children (n = 7461) used the standardized methodology of Phase Two of the International Study of Asthma and Allergies in Childhood (ISAAC). Symptoms of asthma, rhinitis and eczema were ascertained by parental questionnaires. Skin examination, hypertonic saline bronchial challenge, six aeroallergen SPTs and measurements of serum total IgE and sIgE were performed.

RESULTS

In nonaffluent countries, a higher proportion of children with positive SPT had no detectable sIgE (range 37-61%) than in affluent countries (0-37%). Total serum IgE was associated with all disease outcomes among children with both positive SPT and sIgE (P < 0.001), but only with self-reported eczema in children with negative SPTs and negative sIgE.

CONCLUSIONS

The international pattern of discordance between SPT and sIgE results did not support the downregulation hypothesis. Among children with no evidence of sensitization to common aeroallergens, increased total IgE contributes little to the risk of wheeze and rhinitis in the general population but may play a role in eczema.