The Early HOSPITAL Score to Predict 30-Day Readmission Soon After Hospitalization: a Prospective Multicenter Study.

BACKGROUND: The simplified HOSPITAL score is an easy-to-use prediction model to identify patients at high risk of 30-day readmission before hospital discharge. An earlier stratification of this risk would allow more preparation time for transitional care interventions. OBJECTIVE: To assess whether the simplified HOSPITAL score would perform similarly by using hemoglobin and sodium level at the time of admission instead of discharge. DESIGN: Prospective national multicentric cohort study. PARTICIPANTS: In total, 934 consecutively discharged medical inpatients from internal general services. MAIN MEASURES: We measured the composite of the first unplanned readmission or death within 30 days after discharge of index admission and compared the performance of the simplified score with lab at discharge (simplified HOSPITAL score) and lab at admission (early HOSPITAL score) according to their discriminatory power (Area Under the Receiver Operating characteristic Curve (AUROC)) and the Net Reclassification Improvement (NRI). KEY RESULTS: During the study period, a total of 3239 patients were screened and 934 included. In total, 122 (13.2%) of them had a 30-day unplanned readmission or death. The simplified and the early versions of the HOSPITAL score both showed very good accuracy (Brier score 0.11, 95%CI 0.10-0.13). Their AUROC were 0.66 (95%CI 0.60-0.71), and 0.66 (95%CI 0.61-0.71), respectively, without a statistical difference (p value 0.79). Compared with the model at discharge, the model with lab at admission showed improvement in classification based on the continuous NRI (0.28; 95%CI 0.08 to 0.48; p value 0.004). CONCLUSION: The early HOSPITAL score performs, at least similarly, in identifying patients at high risk for 30-day unplanned readmission and allows a readmission risk stratification early during the hospital stay. Therefore, this new version offers a timely preparation of transition care interventions to the patients who may benefit the most.

Urinary incontinence in systemic sclerosis: a prospective multicentre cohort study.

Investigate the natural history of urinary incontinence (UI) in systemic sclerosis (SSc) and assess its impact on quality of life (QoL). A longitudinal, international observational study followed 189 patients with SSc for a median duration of 5 years (IQR: 4.8-5.3). Presence, subtype and severity of UI, hospital admission and QoL were assessed using serial self-administered questionnaires. Mortality data came from national death registries. Multilevel mixed-effect logistic regressions explored factors associated with UI. Cox models adjusted the effects of UI on hospitalization and death for age, sex and subtype of SSc. Mean annual rates of new-onset UI and remission were 16.3% (95%CI 8.3%-24.2%) and 20.8% (95%CI 12.6-29.1), respectively. Among UI patients, 57.9% (95%CI 51.8-64.0) changed from one UI subtype to another. Between annual questionnaires, the severity of UI was the same in 51.1% (95%CI 40.8-61.4), milder or resolved in 35.2% (95%CI 25.3-44.9), and worse in 13.8% (95%CI 6.7-20.9). Anti-centromere antibodies, digestive symptoms, sex, age, neurological or urological comorbidities, diuretics and puffy fingers were all associated with UI. The two strongest predictors of UI and UI subtypes were a recent UI episode and the subtype of previous leakage episodes. UI at inclusion was not associated with hospital admission (adjusted HR: 1.86; 95%CI 0.88-3.93), time to death (aHR: 0.84; 95%CI 0.41-1.73) or change in QoL over time. Self-reported UI among SSc patients is highly dynamic: it waxes and wanes, changing from one subtype to another over time.

Development of the AL-O-A Score for Delirium Screening in Acute Internal Medicine: a Monocentric Prospective Study.

BACKGROUND: Delirium occurs frequently in acute internal medicine wards and may worsen the patient's prognosis; it deserves a fast, systematic screening tool. OBJECTIVE: Develop a delirium screening score for inpatients admitted to acute internal medicine wards. DESIGN: A monocentric prospective study between November 2019 and January 2020. PARTICIPANTS: Two hundred and seventeen adult inpatients. MAIN MEASURES: Within 48 h of hospital admission, physicians administered an index test to participants which explored potential predictors associated with the fluctuation of mental state, inattention, disorganised thinking and altered level of consciousness. On the same day, patients underwent a neuropsychological evaluation (reference standard) to assess for delirium. The score was constructed using a backward stepwise logistic regression strategy. Areas under the receiver operating curves (AUC) and calibration curves were drawn to calculate the score's performance. The score was tested on subgroups determined by age, sex and cognitive status. RESULTS: The AL-O-A score ("abnormal or fluctuating ALertness, temporospatial Orientation and off-target Answers") showed excellent apparent (AUC 0.95 (95% CI 0.91-0.99)) and optimism-corrected discrimination (AUC 0.92 (95% CI 0.89-0.96)). It performed equally well in subgroups with and without cognitive impairment (AUC 0.93 (95% CI 0.88-0.99) vs 0.92 (95% CI 0.80-0.99)); in men and women (AUC 0.96 (95% CI 0.94-0.99) vs 0.95 (95% CI 0.89-0.99)); and in patients younger and older than 75 years old (AUC 0.98 (95% CI 0.95-0.99) vs 0.93 (95% CI 0.87-0.99)). CONCLUSIONS: A simple, 1-min screening test (AL-O-A score), even administered by an untrained professional, can identify delirium in internal medicine patients.

Unprovoked internal jugular vein thrombosis: a case report and literature review.

BACKGROUND: Managing thrombosis in rare sites is challenging. Existing studies and guidelines provide detailed explanations on how to overcome lower-limb thromboses and pulmonary embolisms, but few studies have examined thrombosis in rare sites. Lack of data makes clinical practice heterogeneous. Recommendations for diagnosing, treating, and following-up internal jugular vein thrombosis are not clearly defined and mostly based on adapted guidelines for lower-limb thrombosis. CASE PRESENTATION: A 52-year-old Caucasian woman came to the Emergency Department with chest, neck, and left arm pain. Computed tomography imagery showed a left internal jugular vein thrombosis. An extensive workup revealed a heterozygous factor V Leiden gene. Therapy was initiated with intravenous unfractionated heparin, then switched to oral acenocoumarol, which resolved the symptoms. Based on this case presentation and a literature review, we summarize the causes, treatment options, and prognosis of unprovoked internal jugular vein thrombosis. CONCLUSIONS: Managing internal jugular vein thrombosis lacks scientific data from large randomized clinical trials, partly because such thromboses are rare. Our literature review suggested that clinical treatments for internal jugular vein thrombosis often followed recommendations for treating lower-limb thrombosis. Future specific studies are required to guide clinicians on the modalities of diagnosis, screening for thrombophilia or oncologic disease, treatment duration, and follow-up.

Acute cytokine release syndrome after a first dose of pembrolizumab as second-line treatment for metastatic, programmed death-ligand 1-positive, non-small-cell lung cancer.

INTRODUCTION: The use of programmed death-ligand 1 (PD-L1) checkpoint inhibitor therapy is expanding, although its adverse effects are not completely known. We report on a rare case of acute cytokine release syndrome related to pembrolizumab use in a patient with lung cancer. CASE REPORT: A 79-year-old man with metastatic, PD-L1-positive, non-small-cell lung cancer developed a febrile condition associated with a systemic inflammatory response syndrome and suffered haemodynamic compromise four hours after the first intravenous administration of pembrolizumab. A thorough medical workup found no alternative cause and a grade 2 cytokine release syndrome (CRS) was diagnosed.Management and outcome: Aggressive fluid resuscitation and supportive therapy led to restitutio ad integrum. DISCUSSION: Acute CRS after the administration of a PD-L1 inhibitor is infrequent but could be a fatal condition. Supportive treatment and, if necessary, corticosteroids should be considered.

Urinary incontinence and cardiovascular disease: a narrative review.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) has recently been associated with increased mortality. This observation deserves consideration, since UI is a frequent condition. Shared risk with cardiovascular disease and UI could offer part of the explanation. METHODS: In this narrative review, we explore the association between UI and some cardiovascular risk factors: obesity, diabetes, high blood pressure, tobacco smoking, alcohol, and caffeine intake. We also review the benefit of cardiovascular risk management on bladder health. RESULTS: Bladder function is affected by many cardiovascular risk factors. They can be protective or detrimental. Obesity, diabetes, and, to a lesser extent, high blood pressure and cigarette smoking have been associated with UI in different settings, precede new onset UI in longitudinal studies, have a dose effect, and have a biologic mechanism linked with UI. Thus, UI could be considered a possible consequence of metabolic syndrome. Furthermore, prevention programs aimed at decreasing weight, quitting smoking, healthy diet, and increasing physical activity have resulted in a decreased incidence, prevalence, and severity of UI. CONCLUSIONS: Knowing the association among UI, cardiovascular risk factors, and mortality should encourage UI screening in the population as well as cardiovascular risk factor screening among patients with UI. The secondary benefit for UI could be an important motivator for increasing adherence to cardiovascular prevention programs.

Urinary Incontinence and Indwelling Urinary Catheters as Predictors of Death after New-Onset Stroke: A Report of the South London Stroke Register.

OBJECTIVE: To explore the relationship between indwelling urinary catheters (IUCs), urinary incontinence (UI), and death in the poststroke period and to determine when, after the neurological event, UI has the best ability to predict 1-year mortality. METHODS: In a prospective observational study, 4477 patients were followed up for 1 year after a first-ever stroke. The impact of UI or urinary catheters on time to death was adjusted in a Cox model for age, sex, Glasgow Coma Scale, prestroke and poststroke Barthel Index, swallow test, motor deficit, diabetes, and year of inclusion. The predictive values of UI assessed at the maximal deficit or 7 days after a stroke were compared using receiver-operating curves. RESULTS: UI at the maximal neurological deficit and urinary catheters within the first week after the stroke were present in 43.9% and 31.2% patients, respectively. They were both associated with 1-year mortality in unadjusted and adjusted analysis (hazard ratio [HR], 1.78, 95% confidence interval [CI], 1.46-2.19, and HR, 1.84, 95% CI 1.54-2.19). Patients with UI and urinary catheters had twice the mortality rate of incontinent patients without urinary catheters (HR, 10.24; 95% CI, 8.72-12.03 versus HR, 4.70; 95% CI, 3.88-5.70; P < .001). UI assessed after 1 week performed better at predicting 1-year mortality than UI assessed at the maximal neurological deficit. CONCLUSION: IUCs in the poststroke period is associated with death, especially among incontinent patients. UI assessed at 1 week after the neurological event has the best predictive ability.

[Epidemiology and strategy to prevent urinary catheters related complications]. / Epidémiologie et stratégies de prévention des complications liées au sondage urinaire.

Indwelling urinary catheter (IUC) is encountered in every four admitted in-patients. The risk of bacteriuria increases by 3­7 % every day and is almost universal at 30 days. Of these, 10 % will develop symptomatic infection, bacteremia, septic choc or death. Traumatic complications of IUC are seldom studied, but are at least as frequent as the infectious complications of IUC, with similar impact on LOS or morbidity. Prevention should focus on finding alternatives to IUC (for example, use of condom for men, assess the non-hourly diuresis), a strict compliance on known indication for IUC and hygiene, as well as to ask every day the possibility to withdraw the catheter.

Une sonde urinaire (SU) est posée à un quart des patients hospitalisés. La bactériurie est inéluctable, augmentant de 3 à 7 % par jour et affectant virtuellement tous les patients à un mois. De ces patients, 10 % vont devenir symptomatiques, avec à l'extrémité du spectre, la bactériémie, le choc septique et le décès. Les complications non infectieuses des SU sont moins étudiées mais tout aussi fréquentes, avec un impact similaire sur la durée de séjour et la morbidité. La prévention des complications des SU passe par la recherche d'autres possibilités (par exemple, étuis péniens, contrôle de la diurèse non horaire), un respect strict des indications aux SU et des règles d'hygiène lors de la manipulation du système, ainsi que par un souci quotidien d'effectuer le retrait des SU dont l'indication n'est plus justifiée.

The limited cutaneous form of systemic sclerosis is associated with urinary incontinence: an international multicentre study.

Objectives: The aim of this study was to explore the association between urinary incontinence (UI) and the main clinical and serological subsets of SSc, to assess risk factors for UI and its impact on quality of life (QoL). Methods: UI and QoL were assessed through self-administered questionnaires in 334 patients with SSc from five European tertiary centres. Logistic regressions were performed to test the association between clinical forms, serological status and UI and to adjust for confounders. Further independent predefined SSc risk factors for UI were tested through a multivariable logistic model. Results: The prevalence of UI was 63% (95% CI: 60, 68%). lcSSc and ACAs were both significantly associated with UI even after adjusting for age, sex, disability, diabetes, BMI, caffeine consumption, dyspnoea, faecal incontinence, abnormal bowel movement, presence of overlapping rheumatological disease and pulmonary hypertension [adjusted odds ratio (OR) = 2.4; 95% CI: 1.2, 4.7]. ACA and lcSSc doubled the risk of frequent and heavy urinary leaks. Factors independently associated with UI were as follows: lcSSc (OR = 2.2; 95% CI: 1.1, 3.2), ACA (OR = 2.8; 95% CI: 1.4, 5.8), female sex (OR = 10.8; 95% CI: 2.8, 41.3), worsening of dyspnoea (OR = 6.8; 95% CI: 1.2, 36.7), higher HAQ-DI (OR = 3.2; 95% CI: 1.5, 6.7), BMI (OR = 1.1; 95% CI: 1.0, 1.1) and active finger ulceration (OR = 0.3; 95% CI: 0.1, 0.7). Patients suffering from UI had decreased QoL. Conclusion: Self-reported UI is frequent in SSc and disproportionally affects the limited cutaneous form of the disease and patients positive for ACA. Trial registration: ClinicalTrials.gov, http://clinicaltrials.gov, NCT01971294.

A case report of CT-diagnosed renal infarct secondary to syphilitic aortitis.

BACKGROUND: Even though reported cases of syphilis have been increasing, cases of tertiary syphilis remain extremely rare. The majority of our knowledge with regard to complications of syphilis such as aortitis was acquired before the advent of relatively modern technologies such as CT, MRI and PET. This case report presents a rare case of syphilitic aortitis associated with a renal infarct caused by a peripheral arterial embolism diagnosed by CT. CASE PRESENTATION: We present a young man with sudden abdominal pain and flank tenderness without fever. Blood tests showed acute kidney failure. Computed tomography showed a right renal infarct and a non-circular thickening of the descending thoracic aortic wall with intra-luminal thrombus. Serology confirmed the diagnosis of syphilis. Treatment with anticoagulant and penicillin resulted in a good outcome. Follow-up PET-MRI showed resolution of the thrombus with a metabolically inactive atheromatous plaque. CONCLUSION: Technologies, such as CT, PET-CT and PET-MRI, that were not present during the pre-antibiotic era, can provide new insights into rare presentations of tertiary syphilis such as aortitis. These imaging modalities show promise for early radiological diagnosis of aortitis in syphilis and may be useful for determining the response to treatment in specific cases.

Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis.

AIM: Thrombolytic therapy induces faster clot dissolution than anticoagulation in patients with acute pulmonary embolism (PE) but is associated with an increased risk of haemorrhage. We reviewed the risks and benefits of thrombolytic therapy in the management of patients with acute PE. METHODS AND RESULTS: We systematically reviewed randomized controlled studies comparing systemic thrombolytic therapy plus anticoagulation with anticoagulation alone in patients with acute PE. Fifteen trials involving 2057 patients were included in our meta-analysis. Compared with heparin, thrombolytic therapy was associated with a significant reduction of overall mortality (OR; 0.59, 95% CI: 0.36-0.96). This reduction was not statistically significant after exclusion of studies including high-risk PE (OR; 0.64, 95% CI: 0.35-1.17). Thrombolytic therapy was associated with a significant reduction in the combined endpoint of death or treatment escalation (OR: 0.34, 95% CI: 0.22-0.53), PE-related mortality (OR: 0.29; 95% CI: 0.14-0.60) and PE recurrence (OR: 0.50; 95% CI: 0.27-0.94). Major haemorrhage (OR; 2.91, 95% CI: 1.95-4.36) and fatal or intracranial bleeding (OR: 3.18, 95% CI: 1.25-8.11) were significantly more frequent among patients receiving thrombolysis. CONCLUSIONS: Thrombolytic therapy reduces total mortality, PE recurrence, and PE-related mortality in patients with acute PE. The decrease in overall mortality is, however, not significant in haemodynamically stable patients with acute PE. Thrombolytic therapy is associated with an increase of major and fatal or intracranial haemorrhage.

Urinary incontinence as a marker of higher mortality in patients receiving home care services.

OBJECTIVE: To evaluate urinary incontinence (UI) as a predictor of nursing home admission, hospitalization or death in patients receiving home care services. SUBJECTS AND METHODS: A total of 699 community-dwelling participants receiving home care services in Geneva were evaluated in Autumn 2004 using the Minimal Data Set-Home Care, a validated instrument that includes grading of UI. Data on death, hospitalization and nursing home admission were collected up until June 2007. The impact of UI on time-dependent outcomes was analysed using survival analysis and multivariate regression Cox models to adjust for age, gender, body mass index, cardiac failure, cognitive impairment, delirium, depression, disability, alcohol and tobacco use, self-rated health, faecal incontinence and number of medications. RESULTS: We found that UI was present in 193 participants (27.8%). After adjustment for confounding factors, UI was associated with a longer length of hospital stay: +36.7 days, (95% confidence interval [CI]: 1.2-72.3) and a higher mortality rate (hazard ratio [HR] 1.6; 95% CI: 1.1-2.6). The HR for death was 1.5 (95% CI: 0.9-2.5) for participants complaining of one episode of urinary leakage per week at most, 2.0 (95% CI: 1.2-3.5) for those presenting with two or more episodes per week and 4.2 (95% CI: 2.3-7.7; P for trend: <0.001) for daily UI compared with participants without UI. Institutionalization (HR 1.1; 95% CI: 0.6-2.2) and hospitalization rates (HR 1.0; 95% CI: 0.7-1.3) were not different between patients with or without UI. CONCLUSION: In a cohort of patients receiving home care services, UI was a strong predictor of length of hospital stay and mortality, increasing with UI severity.

[A review of hospital based internal medicine in 2013]. / Médecine interne hospitalière: l'année 2013 en revue.

The last few years have seen many studies, pharmacological molecules, and procedures addressing frequent clinical presentations and scenarios. The multiplicity of therapeutic options for, as examples, anticoagulation, the treatment of anaemia, glycemic control, closure of cardiac defects, nevertheless require validation so that medical practice can be based on clear therapeutic objectives, evidence of its effectiveness, and a certain economic viability. This selective review of the literature summarizes certain studies published this year.

Neurological diagnostic tests for patients with and without delirium: a prospective observational study.

Since most of the precipitating factors of delirium are not due to neurological disorders, neurological diagnostic tests (NDTs) may be of limited value. We hypothesized that delirium has a high burden of NDTs with a low diagnostic yield. All patients admitted to the internal medicine wards of a single secondary teaching hospital between November 2019 and January 2020 were eligible. Within the first 48 h of their admission, they had a formal evaluation by a neuropsychologist to screen for presence of delirium. NDTs (brain MRI, brain CT, electroencephalography (EEG), and lumbar puncture) performed during the hospital stay were compared between patients with and without delirium using a logistic regression model stratified by a propensity score. The proportions of diagnostic yield (acute anomalies that changed the treatment management) provided by each type of examination were compared. Of 217 patients included, 19/32 patients (61%) with delirium had one or more NDTs, compared to 48/185 (26%) without delirium (adjusted OR 2.7; 95%CI 1.1-6.7; p = 0.027). The proportions of NDT results affecting management for patients with and without delirium were 13 and 20% for brain CT scans (p = 0.71), 29 and 38% for brain MRI (p = 0.99), and 20 and 10% for EEGs (p = 0.99), respectively. The higher proportion of NDTs performed on patients with delirium was associated with a low diagnostic yield, although not statistically different from those performed among inpatients without delirium. There is a need for restrictive, evidence-based guidelines to help with the work-up for patients with delirium.

Radiological Explorations of Patients with Upper or Febrile Urinary Tract Infection.

Recent European Association of Urology (EAU) guidelines and a clinical prediction rule developed by Van Nieuwkoop et al. suggest simple criteria for performing radiological imaging for patients with a febrile urinary tract infection (UTI). We analysed the records of patients with a UTI from four hospitals in Switzerland. Of 107 UTI patients, 58% underwent imaging and 69% (95%CI: 59-77%) and 64% (95%CI: 54-73%) of them were adequately managed according to Van Nieuwkoop's clinical rule and EAU guidelines, respectively. However, only 47% (95%CI: 33-61%) and 57% (95%CI: 44-69%) of the imaging performed would have been recommended according to their respective rules. Clinically significant imaging findings were associated with a history of urolithiasis (OR = 11.8; 95%CI: 3.0-46.5), gross haematuria (OR = 5.9; 95%CI: 1.6-22.1) and known urogenital anomalies (OR = 5.7; 95%CI: 1.8-18.2). Moreover, six of 16 (38%) patients with a clinically relevant abnormality displayed none of the criteria requiring imaging according to Van Nieuwkoop's rule or EAU guidelines. Thus, adherence to imaging guidelines was suboptimal, especially when imaging was not recommended. However, additional factors associated with clinically significant findings suggest the need for a new, efficient clinical prediction rule.

Factors associated with one-year mortality after hospital discharge: A multicenter prospective cohort study.

OBJECTIVES: 1) To identify predictors of one-year mortality in hospitalized medical patients using factors available during their hospital stay. 2) To evaluate whether healthcare system use within 30 days of hospital discharge is associated with one-year mortality. STUDY DESIGN AND SETTING: This prospective, observational study included adult patients from four mid-sized hospital general internal medicine units. During index hospitalization, we retrieved patient characteristics, including demographic and socioeconomic indicators, diagnoses, and early simplified HOSPITAL scores from electronic health records and patient interviews. Data on healthcare system use was collected using telephone interviews 30 days after discharge. Survival status at one year was collected by telephone and from health records. We used a univariable analysis including variables available from the hospitalization and 30-day post-discharge periods. We then performed multivariable analyses with one model using index hospitalization data and one using 30-day post-discharge data. RESULTS: Of 934 patients, 123 (13.2%; 95% CI 11.0-15.4%) were readmitted or died within 30 days. Of 814 patients whose primary outcome was available, 108 died (13.3%) within one year. Using factors obtained during hospitalization, the early simplified HOSPITAL score (OR 1.50; 95% CI 1.31-1.71; P < 0.001) and not living at home (OR 4.0; 95% CI 1.8-8.3; P < 0.001) were predictors of one-year mortality. Using 30-day post-discharge predictors, hospital readmission was significantly associated with one-year mortality (OR 4.81; 95% CI 2.77-8.33; P < 0.001). SIGNIFICANCE: Factors predicting one-year mortality were a high early simplified HOSPITAL score, not living at home, and a 30-day unplanned readmission.

Effects of a Multimodal Transitional Care Intervention in Patients at High Risk of Readmission: The TARGET-READ Randomized Clinical Trial.

Importance: Hospital readmissions are frequent, costly, and sometimes preventable. Although these issues have been well publicized and incentives to reduce them introduced, the best interventions for reducing readmissions remain unclear. Objectives: To evaluate the effects of a multimodal transitional care intervention targeting patients at high risk of hospital readmission on the composite outcome of 30-day unplanned readmission or death. Design, Setting, and Participants: A single-blinded, multicenter randomized clinical trial was conducted from April 2018 to January 2020, with a 30-day follow-up in 4 medium-to-large-sized teaching hospitals in Switzerland. Participants were consecutive patients discharged from general internal medicine wards and at higher risk of unplanned readmission based on their simplified HOSPITAL score (≥4 points). Data were analyzed between April and September 2022. Interventions: The intervention group underwent systematic medication reconciliation, a 15-minute patient education session with teach-back, a planned first follow-up visit with their primary care physician, and postdischarge follow-up telephone calls from the study team at 3 and 14 days. The control group received usual care from their hospitalist, plus a 1-page standard study information sheet. Main Outcomes and Measures: Thirty-day postdischarge unplanned readmission or death. Results: A total of 1386 patients were included with a mean (SD) age of 72 (14) years; 712 (51%) were male. The composite outcome of 30-day unplanned readmission or death was 21% (95% CI, 18% to 24%) in the intervention group and 19% (95% CI, 17% to 22%) in the control group. The intention-to-treat analysis risk difference was 1.7% (95% CI, -2.5% to 5.9%; P = .44). There was no evidence of any intervention effects on time to unplanned readmission or death, postdischarge health care use, patient satisfaction with the quality of their care transition, or readmission costs. Conclusions and Relevance: In this randomized clinical trial, use of a standardized multimodal care transition intervention targeting higher-risk patients did not significantly decrease the risks of 30-day postdischarge unplanned readmission or death; it demonstrated the difficulties in preventing hospital readmissions, even when multimodal interventions specifically target higher-risk patients. Trial Registration: ClinicalTrials.gov Identifier: NCT03496896.

Effectiveness of Transition Care Intervention Targeted to High-Risk Patients to Reduce Readmissions: Study Protocol for the TARGET-READ Multicenter Randomized-Controlled Trial.

Hospital readmissions within 30 days represent a burden for the patients and the entire health care system. Improving the care around hospital discharge period could decrease the risk of avoidable readmissions. We describe the methods of a trial that aims to evaluate the effect of a structured multimodal transitional care intervention targeted to higher-risk medical patients on 30-day unplanned readmissions and death. The TARGET-READ study is an investigator-initiated, pragmatic single-blinded randomized multicenter controlled trial with two parallel groups. We include all adult patients at risk of hospital readmission based on a simplified HOSPITAL score of ≥4 who are discharged home or nursing home after a hospital stay of one day or more in the department of medicine of the four participating hospitals. The patients randomized to the intervention group will receive a pre-discharge intervention by a study nurse with patient education, medication reconciliation, and follow-up appointment with their referring physician. They will receive short follow-up phone calls at 3 and 14 days after discharge to ensure medication adherence and follow-up by the ambulatory care physician. A blind study nurse will collect outcomes at 1 month by phone call interview. The control group will receive usual care. The TARGET-READ study aims to increase the knowledge about the efficacy of a bundled intervention aimed at reducing 30-day hospital readmission or death in higher-risk medical patients.

Associations between post-discharge medical consultations and 30-day unplanned hospital readmission: A prospective observational cohort study.

BACKGROUND: The period following hospital discharge is one of significant vulnerability. Little is known about the relationship between post-discharge healthcare use and the risk of readmission. OBJECTIVES: To explore associations between medical consultations and other healthcare use parameters and the risk of 30-day unplanned hospital readmission. METHODS: Between July 2017 and March 2018, we monitored all adult internal medicine patients for 30 days after their discharge from four mid-sized hospitals. Using follow-up telephone calls, we assessed their post-discharge healthcare use: consultations with general practitioners (GPs) and specialist physicians, emergency room (ER) visits, and home visits by nurses. The binary outcome was defined as any unplanned hospital readmission within 30 days of discharge, and this was analyzed using logistic regression. RESULTS: Of 934 patients discharged, 111 (12%) experienced at least one unplanned hospital readmission within 30 days. Attending at least one GP consultation decreased the odds of readmission by half (adjusted OR: 0.5; 95%CI: 0.3-0.7), whereas attending at least one specialist consultation doubled those odds (aOR: 2.0; 95%CI: 1.2-3.3). GP consultations also reduced the odds of the combined risk of an ER visit or unplanned hospital readmission (aOR: 0.5; 95%CI: 0.3-0.7). ER visits were also associated with a higher readmission risk after adjusting for confounding factors (aOR: 10.0; 95%CI: 6.0-16.8). CONCLUSION: GP consultations were associated with fewer ER visits and unplanned hospital readmissions.

Risks and benefits of urinary catheterisation during inpatient diuretic therapy for acute heart failure: a retrospective, non-inferiority, cohort study.

OBJECTIVES: Patients with acute congestive heart failure (HF) regularly undergo urinary catheterisation (UC) at hospital admission. We hypothesised that UC has no clinical benefits with regard to weight loss during inpatient diuretic therapy for acute congestive HF and increases the risk of urinary tract infection (UTI). DESIGN: Retrospective, non-inferiority study. SETTING: Geneva University Hospitals' Department of Medicine, a tertiary centre. PARTICIPANTS: In a cohort of HF patients, those catheterised within 24 hours of diuretic therapy (n=113) were compared with non-catheterised patients (n=346). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary endpoint was weight loss 48 hours after starting diuretic therapy. Secondary endpoints were time needed to reach target weight, discontinuation of intravenous diuretics and resolution of respiratory failure. Complications included the time to a first UTI, first hospital readmission and death. RESULTS: A total of 48-hour weight loss was not statistically different between groups and the adjusted difference was below the non-inferiority boundary of 1 kg (0.43 kg (95% CI: -0.03 to 0.88) in favour of UC, p<0.01 for non-inferiority). UC was not associated with time to reaching target weight (adjusted HR 1.0; 95% CI: 0.7 to 1.5), discontinuation of intravenous diuretics (aHR 0.9; 95% CI: 0.7 to 1.2) or resolution of respiratory failure (aHR 1.1; 95% CI: 0.5 to 2.4). UC increased the risk of UTI (aHR 2.5; 95% CI: 1.5 to 4.2) but was not associated with hospital readmission (aHR 1.1; 95% CI: 0.8 to 1.4) or 1-year mortality (aHR 1.4; 95% CI: 1.0 to 2.1). CONCLUSION: In this retrospective study, with no obvious hourly diuresis-based diuretic adjustment strategy, weight loss without UC was not inferior to weight loss after UC within 24 hours of initiating diuretic treatment. UC had no impact on clinical improvement and increased the risk of UTI. This evidence, therefore, argues against the systematic use of UC during a diuretic therapy for HF.