Patients With Acute-on-Chronic Liver Failure Have Greater Healthcare Resource Utilization After Liver Transplantation.

BACKGROUND & AIMS: Although liver transplantation (LT) has been demonstrated to provide survival benefit for patients with acute-on-chronic liver failure (ACLF), data are lacking regarding resource utilization for this population after LT. METHODS: We retrospectively reviewed data from 10 centers in North America of patients transplanted between 2018 and 2019. ACLF was identified by using the European Association for the Study of the Liver-Chronic Liver Failure criteria. RESULTS: We studied 318 patients of whom 106 patients (33.3%) had no ACLF, 61 (19.1%) had ACLF-1, 74 (23.2%) had ACLF-2, and 77 (24.2%) had ACLF-3 at transplantation. Healthcare resource utilization after LT was greater among recipients with ACLF compared with patients without ACLF regarding median post-LT length of hospital stay (LOS) (P < .001), length of post-LT dialysis (P < .001), discharge to a rehabilitation center (P < .001), and 30-day readmission rates (P = .042). Multivariable negative binomial regression analysis demonstrated a significantly longer LOS for patients with ACLF-1 (1.9 days; 95% confidence interval [CI], 0.82-7.51), ACLF-2 (6.7 days; 95% CI, 2.5-24.3), and ACLF-3 (19.3 days; 95% CI, 1.2-39.7), compared with recipients without ACLF. Presence of ACLF-3 at LT was also associated with longer length of dialysis after LT (9.7 days; 95% CI, 4.6-48.8) relative to lower grades. Multivariable logistic regression analysis revealed greater likelihood of discharge to a rehabilitation center among recipients with ACLF-1 (odds ratio [OR], 1.79; 95% CI, 1.09-4.54), ACLF-2 (OR, 2.23; 95% CI, 1.12-5.01), and ACLF-3 (OR, 2.23; 95% CI, 1.40-5.73). Development of bacterial infection after LT also predicted LOS (20.9 days; 95% CI, 6.1-38.5) and 30-day readmissions (OR, 1.39; 95% CI, 1.17-2.25). CONCLUSIONS: Patients with ACLF at LT, particularly ACLF-3, have greater post-transplant healthcare resource utilization.

Understanding current and projected emergency department presentations and associated healthcare costs in a changing thermal climate in Adelaide, South Australia.

BACKGROUND: Exposure to extreme temperatures is associated with increased emergency department (ED) presentations. The resulting burden on health service costs and the potential impact of climate change is largely unknown. This study examines the temperature-EDs/cost relationships in Adelaide, South Australia and how this may be impacted by increasing temperatures. METHODS: A time series analysis using a distributed lag nonlinear model was used to explore the exposure-response relationships. The net-attributable, cold-attributable and heat-attributable ED presentations for temperature-related diseases and costs were calculated for the baseline (2014-2017) and future periods (2034-2037 and 2054-2057) under three climate representative concentration pathways (RCPs). RESULTS: The baseline heat-attributable ED presentations were estimated to be 3600 (95% empirical CI (eCI) 700 to 6500) with associated cost of $A4.7 million (95% eCI 1.8 to 7.5). Heat-attributable ED presentations and costs were projected to increase during 2030s and 2050s with no change in the cold-attributable burden. Under RCP8.5 and population growth, the increase in heat-attributable burden would be 1.9% (95% eCI 0.8% to 3.0%) for ED presentations and 2.5% (95% eCI 1.3% to 3.7%) for ED costs during 2030s. Under the same conditions, the heat effect is expected to increase by 3.7% (95% eCI 1.7% to 5.6%) for ED presentations and 5.0% (95% eCI 2.6% to 7.1%) for ED costs during 2050s. CONCLUSIONS: Projected climate change is likely to increase heat-attributable emergency presentations and the associated costs in Adelaide. Planning health service resources to meet these changes will be necessary as part of broader risk mitigation strategies and public health adaptation actions.

Risk Factors for Posttransplantation Mortality in Recipients With Grade 3 Acute-on-Chronic Liver Failure: Analysis of a North American Consortium.

Although liver transplantation (LT) yields survival benefit for patients with acute-on-chronic liver failure grade 3 (ACLF-3), knowledge gaps remain regarding risk factors for post-LT mortality. We retrospectively reviewed data from 10 centers in the United States and Canada for patients transplanted between 2018 and 2019 and who required care in the intensive care unit prior to LT. ACLF was identified using the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) criteria. A total of 318 patients were studied, of whom 106 (33.3%) had no ACLF, 61 (19.1%) had ACLF-1, 74 (23.2%) had ACLF-2, and 77 (24.2%) had ACLF-3 at transplantation. Survival probability 1 year after LT was significantly higher in patients without ACLF (94.3%) compared with patients with ACLF (87.3%; P = 0.02), but similar between ACLF-1 (88.5%), ACLF-2 (87.8%), and ACLF-3 (85.7%; P = 0.26). Recipients with ACLF-3 and circulatory failure (n = 29) had similar 1-year post-LT survival (82.3%) compared with patients with ACLF-3 without circulatory failure (89.6%; P = 0.32), including those requiring multiple vasopressors. For patients transplanted with ACLF-3 including respiratory failure (n = 20), there was a trend toward significantly lower post-LT survival (P =  0.07) among those with respiratory failure (74.1%) compared with those without (91.0%). The presence of portal vein thrombosis (PVT) at LT for patients with ACLF-3 (n = 15), however, yielded significantly lower survival (91.9% versus 57.1%; P < 0.001). Multivariable logistic regression analysis revealed that PVT was significantly associated with post-LT mortality within 1 year (odds ratio, 7.3; 95% confidence interval, 1.9-28.3). No correlation was found between survival after LT and the location or extent of PVT, presence of transjugular intrahepatic portosystemic shunt, or anticoagulation. LT in patients with ACLF-3 requiring vasopressors yields excellent 1-year survival. LT should be approached cautiously among candidates with ACLF-3 and PVT.

Increasing impacts of temperature on hospital admissions, length of stay, and related healthcare costs in the context of climate change in Adelaide, South Australia.

BACKGROUND: A growing number of studies have investigated the effect of increasing temperatures on morbidity and health service use. However, there is a lack of studies investigating the temperature-attributable cost burden. OBJECTIVES: This study examines the relationship of daily mean temperature with hospital admissions, length of hospital stay (LoS), and costs; and estimates the baseline temperature-attributable hospital admissions, and costs and in relation to warmer climate scenarios in Adelaide, South Australia. METHOD: A daily time series analysis using distributed lag non-linear models (DLNM) was used to explore exposure-response relationships and to estimate the aggregated burden of hospital admissions for conditions associated with temperatures (i.e. renal diseases, mental health, diabetes, ischaemic heart diseases and heat-related illnesses) as well as the associated LoS and costs, for the baseline period (2010-2015) and different future climate scenarios in Adelaide, South Australia. RESULTS: During the six-year baseline period, the overall temperature-attributable hospital admissions, LoS, and associated costs were estimated to be 3915 cases (95% empirical confidence interval (eCI): 235, 7295), 99,766 days (95% eCI: 14,484, 168,457), and AU$159 million (95% eCI: 18.8, 269.0), respectively. A climate scenario consistent with RCP8.5 emissions, and including projected demographic change, is estimated to lead to increases in heat-attributable hospital admissions, LoS, and costs of 2.2% (95% eCI: 0.5, 3.9), 8.4% (95% eCI: 1.1, 14.3), and 7.7% (95% eCI: 0.3, 13.3), respectively by mid-century. CONCLUSIONS: There is already a substantial temperature-attributable impact on hospital admissions, LoS, and costs which are estimated to increase due to climate change and an increasing aged population. Unless effective climate and public health interventions are put into action, the costs of treating temperature-related admissions will be high.

Mechanical prostheses for right ventricular outflow tract reconstruction: a systematic review and meta-analysis.

It remains unclear as to whether mechanical valves have a role in pulmonary valve replacement. A systematic review and meta-analysis was performed to answer this question. Nineteen observational studies, including 299 pediatric and adult patients with a mean follow-up of 73 months, were analyzed. Nonstructural valve deterioration and valve thrombosis occurred in 1.5% and 2.2% of patients, respectively. Surgical reintervention was required in 0.9% of cases and thrombolysis was required in 0.5%. Mechanical valves in the pulmonary position are associated with a low incidence of valve deterioration and thrombosis, as well as freedom from reoperation and thrombolysis.