Impact of Obesity in Hospitalized Patients with Heart Failure: A Nationwide Cohort Study.

OBJECTIVES: Obesity and cardiovascular disease remain significant burdens on the overall provision of health care in the United States. Obesity has been shown to be a direct risk factor for heart failure (HF). We conducted a nationwide cohort study to assess the short-term impact of obesity in hospitalized patients with HF. METHODS: We identified 1,520,871 encounters with a primary diagnosis of HF in the 2013-2014 Nationwide Readmission Database. We excluded patients younger than 18 years (n = 2755), hospitalized patients discharged in December (n = 126,137), patients with missing mortality information (n = 477), missing length of stay (LOS; n = 91), patients who were transferred to another hospital (n = 38,489), and patients with conflicting body weight information (n = 7757). Multivariable logistic regression was used to evaluate the association between baseline characteristics (including the presence of obesity) and in-hospital mortality, as well as 30-day readmission rates. RESULTS: The overall in-patient mortality rate was 2.8% (n = 37,927). Obese patients had numerically a lower mortality (1.8%) compared with the nonobese patients (3.1%); however, the difference in risk was not significant on multivariable analysis (hazard ratio 0.97, 95% confidence interval 0.94-1.01). In the overall cohort, 20.6% (n = 269,988) were readmitted within 30 days. The risk of 30-day readmission was significantly lower in obese patients (19.4%) compared with nonobese patients (20.9%) (odds ratio 0.85, 95% confidence interval 0.84-0.86). Obese patients had longer LOSs (median of 5 days [3-7] vs 4 days [2-6], P < 0.001) and higher costs of index admission (median of $27,206 [$16,027-$48,316] vs $23,339 [$13,698-$41,982], P < 0.001) compared with nonobese patients. CONCLUSIONS: In this cross-sectional study of patients hospitalized for HF in the United States, obesity was not associated with a higher risk of inpatient mortality, but it was associated with a lower 30-day readmission rate. Obese patients with HF, however, had longer LOSs and higher costs of index admission. Our findings support the obesity paradox seen in patients with HF.

Effect of Citalopram for the Treatment of Neurocardiogenic Syncope.

BACKGROUND: Neurocardiogenic syncope (NCS) is a common form of syncope. Although selective serotonin reuptake inhibitors and other medications have been used to treat NCS with variable success, there is no consensus regarding a first-line therapy. STUDY QUESTION: To assess the effects of citalopram in NCS and to examine the effect of diagnostic use of the head-up tilt table (HUTT) versus empirical diagnosis on patient outcome. STUDY DESIGN: A retrospective case series of 1000 consecutive patients who were diagnosed with NCS and treated with citalopram. MEASURES AND OUTCOMES: The primary outcome measure was well-being score (WS) recorded at each outpatient visit. RESULTS: After excluding patients who had other comorbidities, were taking daily medication, or did not attend a follow-up visit within 1 month after treatment initiation, data from 186 patients were included. Thirty-five patients were diagnosed empirically, and 151 patients were diagnosed with the HUTT. All 186 patients were followed up within 1 month (early follow-up); of these, 92 patients attended a second follow-up after 1 month (late follow-up). The early follow-up group showed a significant improvement in mean WS (7.35 vs. 4.46, P < 0.001) and only 5 patients discontinued therapy because of intolerability. The late follow-up group also showed significant improvements in mean WS at the early follow-up (7.42 vs. 4.43, P < 0.001) and late follow-up (7.42 vs. 4.26, P < 0.001). Of 186 patients who were treated with citalopram, only 11 reported the development of undesirable side effects. There was no significant difference in the outcome of patients who were diagnosed empirically versus those who were diagnosed with the HUTT. CONCLUSIONS: Citalopram seems to have desirable effects on NCS and patient well-being. Diagnostic use of the HUTT is useful for confirming diagnoses of NCS but is not likely to improve patient outcome.

Pneumothorax prevalence and mortality per gestational age in the newborn.

OBJECTIVES: Pneumothorax (PTX) in newborns is a life-threatening condition associated with high morbidity and mortality especially in premature infants. The frequency of PTX in neonates at different gestational ages (GA) and its impact on neonatal mortality have not been quantified. We aimed to determine: (1) the prevalence of PTX in neonates at different GA from ≤24 to ≥37 weeks, (2) the impact of PTX on mortality per GA, and (3) the impact of PTX on the length of stay (LOS) per GA. METHODS: The national Kids' Inpatient Database for the years of 2006-2012 were used. We included all infants admitted to the hospital with a documented GA and International Classification of Disease 9 code of PTX. Bivariate and multivariate analyses were conducted and odds ratios (OR) were calculated. RESULTS: A total of 10,625,036 infants were included; of them 3665 infants (0.034%) had a diagnosis of PTX, with highest prevalence at ≤24 weeks GA (0.67%), and lowest at term (0.02%). The overall mortality rate of patients with PTX was 8.8%, and greater in preterm (16.3%) versus term infants (2.7%). The association of mortality with PTX was greatest at GA of 29-32 weeks (OR = 8.55; 95% confidence interval: 6.56-11.13). Infants who survived until discharge had a median of 2-12 days longer LOS depending on GA category. CONCLUSIONS: The prevalence of PTX peaks in infants less than 24 weeks, however, its impact on mortality is greatest at 29-32 weeks. PTX is associated with longer LOS in survivors.

National Trends of Tobacco, Alcohol, and Drug Use in Patients Admitted With Acute Myocardial Infarction.

BACKGROUND: Acute myocardial infarction (AMI) is a significant health and economic burden in the US. Tobacco, alcohol, and drug use are established risk factors. We sought to evaluate the national trend of use of each substance in patients admitted with AMI. METHODS: We used the National Inpatient Sample between 2005 and 2017. We included adult patients hospitalized with AMI. International Classification of Diseases, Ninth and Tenth Revisions codes were used to define tobacco, alcohol, cocaine, opioid, cannabis and other drug use. Trends of each substance use were assessed using multivariable Poisson regression, and were expressed as annual percent change (APC) with their 95% confidence intervals (CIs). RESULTS: A total of 10,796,844 hospitalizations with AMI were included. Among all substances used, tobacco was the most common (32.7%), followed by alcohol (3.2%). Between 2005 and 2017, the prevalence ratio of tobacco use increased from 21.5% to 44.5% with an APC +6.2% (95%CI 6.2%-6.2%). Tobacco users had more percutaneous coronary intervention (41%vs25%) and coronary artery bypass surgery (6.9%vs4.9%), p < 0.001. Further, there were positive trends in alcohol (APC +3.1%; 95%CI 3.0%-3.2%), opioid (APC +9.0%; 95%CI 8.7%-9.2%), cannabis (APC + 7.2; 95% CI 7%-7.4%), and combined all drug use (+7.1%; 95%CI 7%-7.2%). Meanwhile, there was a slight negative trend in cocaine use. CONCLUSIONS: This analysis outlines the national trends of substance use in patients admitted with AMI and reveals an increasing prevalence of tobacco use, alcohol and drug use. More effective cessation measures are necessary to reduce the risk for AMI and its burden on the healthcare system and economy.

Prevalence of venous thromboembolism in admissions and readmissions with and without syncope: a nationwide cohort study.

AIMS: The Pulmonary Embolism in Syncope Italian Trial reported 17.3% prevalence of pulmonary embolism (PE) in patients admitted with syncope. We investigated the prevalence of venous thromboembolism [VTE, including PE and deep vein thrombosis (DVT)] in syncope vs. non-syncope admissions and readmissions, and if syncope is an independent predictor of VTE. METHODS AND RESULTS: We conducted an observational study of index admissions of the 2013-14 Nationwide Readmission Database. We excluded patients <18 years, December discharges, died during hospitalization, hospital transfers, and missing length of stay. Encounters were stratified by the presence or absence of DVT/PE and syncope diagnoses. Multivariable logistic regression analysis was used to evaluate the association between syncope and VTE. There were 38 655 570 admissions, of whom 285 511 had syncope. In the overall cohort, syncope occurred in 1.6% of VTE and 1.8% in non-VTE admissions. In a multivariable model, syncope was associated with a lower prevalence of VTE [odds ratio (OR) 0.76, 95% confidence interval (CI) 0.75-0.78; P < 0.001]. In index syncope vs. non-syncope admissions, the prevalence of DVT, PE, and VTE were 0.4 ± 0.06% vs. 1.3 ± 0.12%, 0.2 ± 0.04% vs. 1.2 ± 0.11%, and 0.5 ± 0.07% vs. 2.1 ± 0.14% (all P < 0.001), respectively. At 30 days, the prevalence of DVT, PE, and VTE in syncope vs. non-syncope were 2.2 ± 0.14% vs. 2.1 ± 0.14% (P = 0.38), 1.4 ± 0.12% vs. 1.2 ± 0.11% (P = 0.01), and 2.6 ± 0.17% vs. 3.0 ± 0.17% (P = 0.99), respectively. CONCLUSION: Syncope admissions were associated with a lower prevalence of VTE as compared to non-syncope admissions. Syncope should not trigger an automatic PE workup, rather, should be put into context of patient presentation.

Neonatal seizures in the U.S. National Inpatient Population: Prevalence and outcomes.

BACKGROUND: Seizures are the most frequent neurological manifestation in neonates. Prevalence of neonatal seizures has not been well described in relationship with gestational age (GA). Also, the impact of seizures on neonatal mortality has not been quantified. This study aims to determine 1) prevalence of neonatal seizures in all GA groups, 2) associated mortality in each GA group and 3) impact of seizures on length of stay (LOS) of survivors in each GA group. METHODS: Data from the national Kids' Inpatient Database (KID) for the years 2006, 2009 and 2012 was used in the study. All admitted infants with a documented GA were included in the study. All categorical variables were analyzed using Chi-square test, continuous variables were analyzed using t-test, and logistic regression analysis used to calculate odds ratio (OR) and 95% confidence intervals (CI). RESULTS: A total of 10, 572,209 infants were included, of whom 4400 infants (0.04%) had seizures. The highest prevalence was at 24 weeks (0.12%). Overall mortality rate of patients with seizures was 4% with OR = 2.24 (95% CI = 1.90-2.65, p < 0.001). The correlation of seizure with mortality was significant after 33 weeks GA with greatest impact at 33-36 weeks GA (OR = 46.38 (95% CI = 26.86-80.08, p < 0.001). Seizures were associated with increased median LOS from 2 to 4 days (p < 0.001). CONCLUSION: The prevalence of seizures varies according to gestational age ranging from 0.02% to 0.12%. The highest prevalence is at 24 weeks GA. The greatest impact for seizures on mortality is at 33-36 weeks GA.

Effects of Probiotics on Intestinal Failure-Associated Liver Disease in Adult Patients Receiving Prolonged Parenteral Support: A Tertiary Care Center Experience.

BACKGROUND: It has been hypothesized that dysbiosis plays a significant role in the pathogenesis of intestinal failure-associated liver disease (IFALD). Therefore, we aimed to investigate the effect of probiotics on IFALD in patients receiving parenteral support, namely home parenteral nutrition (HPN) and home intravenous fluids (HIVFs). METHODS: We retrospectively reviewed charts of patients with intestinal failure who received HPN or HIVF for >2 weeks at our tertiary center between January 2005 and August 2016. We excluded patients <18 years of age, patients with other causes of liver disease, patients who used probiotics for <30 days, patients with <6 months' follow-up, and those who had long-term antibiotic use (>30 days). Bivariable and multivariable logistic regression analyses were used in this study. RESULTS: A total of 282 patients who received parenteral support were included. Eighty-five percent of our sample received PN. A total of 78 (27.7%) patients used probiotics. The prevalence of IFALD in patients who used probiotics was 35.9% vs 54.4% in patients who did not use probiotics, P = .005. In multivariable analysis, only small-bowel length of 10-90 cm and HPN use showed a significant impact on IFALD, odds ratio (OR) = 4.394 (95% confidence interval [CI], 1.635-11.814; P = .003) and OR = 4.502 (95% CI 1.412-14.351; P = .011), respectively. CONCLUSION: Our study revealed that the prevalence of IFALD was comparable among the probiotic users and nonusers. Only small bowel length of 1090 cm and HPN use showed a significant impact on IFALD.

Impact of Tricuspid Regurgitation in Patients With Heart Failure and Mitral Valve Disease from a Nationwide Cohort Study.

Concomitant heart failure (HF) and mitral valve disease (MVD) portend significant morbidity and mortality. Although associated Tricuspid regurgitation (TR) is a common occurrence in this scenario, it is not well known whether there are additional prognostic implications. We sought to assess whether coexistent TR is associated with higher readmission rates or increased mortality in patients with HF and MVD. We identified 1,520,871 encounters with a primary diagnosis of HF in the 2013 to 2014 Nationwide Readmission Database. We excluded patients without MVD, patients <18 years old, those with rheumatic heart disease and infective endocarditis. We also excluded patients who were discharged in December, hospital transfers, and cases where follow-up or outcomes were missing. Logistic regression was used to evaluate the association between baseline characteristics (including the presence of tricuspid valve disease), mortality as well as 30-day readmission rates. A total of 221,127 admissions with HF and MVD were identified. Median age was 79 years (IQR, 67 to 87), 55% were female, 2.7% died during hospitalization, and the 30-day readmission rate was 20.3%. Nearly 1/3 had concomitant TR (n = 78,356, 35%). The presence of TR was neither associated with elevated risk of mortality (hazard ratio 0.98, 95% confidence interval 0.93 to 1.04) nor 30-day readmission rate (odds ratio 1.01, 95% confidence interval 0.98 to 1.03). HF accounted for 33% of 30-day readmissions, while combined cardiac causes accounted for 54%. In conclusion concomitant TR in patients with HF and MVD was not associated with worse short-term outcomes in terms of inpatient hospital mortality and 30-day readmission rates.

Outcomes of patients with severe tricuspid regurgitation and congestive heart failure.

OBJECTIVES: A substantial number of patients with severe tricuspid regurgitation (TR) and congestive heart failure (CHF) are medically managed without undergoing corrective surgery. We sought to assess the characteristics and outcomes of CHF patients who underwent tricuspid valve surgery (TVS), compared with those who did not. METHODS: Retrospective observational study involving 2556 consecutive patients with severe TR from the Cleveland Clinic Echocardiographic Database. Cardiac transplant patients or those without CHF were excluded. Survival difference between patients who were medically managed versus those who underwent TVS was compared using Kaplan-Meier survival curves. Multivariate analysis was performed to identify variables associated with poor outcomes. RESULTS: Among a total of 534 patients with severe TR and CHF, only 55 (10.3%) patients underwent TVS. Among the non-surgical patients (n=479), 30% (n=143) had an identifiable indication for TVS. At 38 months, patients who underwent TVS had better survival than those who were medically managed (62% vs 35%; p<0.001). On multivariate analysis, advancing age (HR: 1.23; 95% CI 1.12 to 1.35 per 10-year increase in age), moderate (HR: 1.39; 95% CI 1.01 to 1.90) and severe (HR: 2; 95% CI 1.40 to 2.80) right ventricular dysfunction were associated with higher mortality. TVS was associated with lower mortality (HR: 0.44; 95% CI 0.27 to 0.71). CONCLUSION: Although corrective TVS is associated with better outcomes in patients with severe TR and CHF, a substantial number of them continue to be medically managed. However, since the reasons for patients not being referred to surgery could not be ascertained, further randomised studies are needed to validate our findings before clinicians can consider surgical referral for these patients.

Causes and Predictors of 30-Day Readmission in Patients With Syncope/Collapse: A Nationwide Cohort Study.

Background Syncope accounts for 0.6% to 1.5% of hospitalizations in the United States. We sought to determine the causes and predictors of 30-day readmission in patients with syncope. Methods and Results We identified 323 250 encounters with a primary diagnosis of syncope/collapse in the 2013-2014 Nationwide Readmissions Database. We excluded patients younger than 18 years, those discharged in December, those who died during hospitalization, hospital transfers, and those whose length of stay was missing. We used multivariable logistic regression analysis to evaluate the association between baseline characteristics and 30-day readmission. A total of 282 311 syncope admissions were included. The median age was 72 years (interquartile range, 58-83), 53.9% were women, and 9.3% had 30-day readmission. The most common cause of 30-day readmissions was syncope/collapse, followed by cardiac, neurological, and infectious causes. Characteristics associated with 30-day readmissions were age 65 years and older (odds ratio [OR], 0.7; 95% confidence interval [ CI ], 0.6-0.7), female sex (OR, 0.9; 95% CI, 0.8-0.9), congestive heart failure (OR, 1.5; 95% CI, 1.2-1.9), atrial fibrillation/flutter (OR, 1.3; 95% CI, 1.3-1.4), diabetes mellitus (OR, 1.2; 95% CI, 1.2-1.3), coronary artery disease (OR, 1.2; 95% CI, 1.2-1.3), anemia (OR, 1.4; 95% CI, 1.4-1.5), chronic obstructive pulmonary disease (OR, 1.4; 95% CI, 1.3-1.4), home with home healthcare disposition (OR, 1.5; 95% CI, 1.5-1.6), leaving against medical advice (OR, 1.7; 95% CI, 1.6-1.9), length of stay of 3 to 5 days (OR, 1.5; 95% CI, 1.4-1.6) or >5 days (OR, 2; 95% CI, 1.8-2), and having private insurance (OR, 0.6; 95% CI, 0.6-0.7). Conclusions The 30-day readmission rate after syncope/collapse was 9.3%. We identified causes and risk factors associated with readmission. Future prospective studies are needed to derive risk-stratification models to reduce the high burden of readmissions.