Genomic Characterization of SARS-CoV-2 Isolated from Patients with Distinct Disease Outcomes in Mexico.

The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has shown a wide spectrum of clinical manifestations ranging from asymptomatic infections to severe disease and death. Pre-existing medical conditions and age have been mainly linked to the development of severe disease; however, the potential association of viral genetic characteristics with different clinical conditions remains unclear. SARS-CoV-2 variants with increased transmissibility were detected early in the pandemics, and several variants with potential relevance for public health are currently circulating around the world. In this study, we characterized 57 complete SARS-CoV-2 genomes during the exponential growth phase of the early epidemiological curve in Mexico, in April 2020. Patients were categorized under distinct disease severity outcomes: mild disease or ambulatory care, severe disease or hospitalized, and deceased. To reduce bias related to risk factors, the patients were less than 60 years old and with no diagnosed comorbidities A trait-association phylogenomic approach was used to explore genotype-phenotype associations, represented by the co-occurrence of mutations, disease severity outcome categories, and clusters of Mexican sequences. Phylogenetic results revealed a higher genomic diversity compared to the initial viruses detected during the early stage of the local epidemic. We identified a total of 90 single nucleotide variants compared to the Wuhan-Hu-1 genome, including 54 nonsynonymous mutations. We did not find evidence for the co-occurrence of mutations associated with specific disease outcomes. Therefore, in the group of patients studied, disease severity was likely mainly driven by the host genetic background and other demographic factors. IMPORTANCE The genetic association of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) with different clinical conditions remains unclear and needs further investigation. In this study, we characterized 57 complete SARS-CoV-2 genomes from patients in Mexico with distinct disease severity outcomes: mild disease or ambulatory care, severe disease or hospitalized, and deceased. To reduce bias related to risk factors the patients were less than 60 years old and with no diagnosed comorbidities. We did not find evidence for the co-occurrence of mutations associated with specific disease outcomes. Therefore, in the group of patients studied, disease severity was likely mainly driven by the host genetic background and other demographic factors.

Characteristics of Deaths Among Individuals in US Immigration and Customs Enforcement Detention Facilities, 2011-2018.

Importance: Concerns have been raised that substandard medical care has contributed to deaths in US Immigration and Customs Enforcement (ICE) detention facilities. After each in-custody death, ICE produces detainee death reviews, which describe the circumstances of the death and determine whether ICE Performance-Based National Detention Standards (PBNDS) were violated. Objective: To describe factors associated with deaths in ICE detention facilities. Design, Setting, and Participants: This case series used data extracted from detainee death reviews of deaths among individuals detained in ICE facilities for whom these reviews were available from January 2011 to December 2018. Exposures: All individuals were in the custody of ICE at the time of death. Main Outcomes and Measures: Data including demographic information, medical histories, recorded medical data, and reported violations of PBNDS were systematically extracted and summarized. Results: Among 71 individuals who died in an ICE detention facility during the study period, detainee death reviews were available for 55 (77.5%). Most were male (47 [85.5%]), and the mean (SD) age at death was 42.7 (11.5) years. Individuals resided in the US for a mean (SD) of 15.8 (13.2) years before detention and were in ICE custody for a median of 39 days (interquartile range, 9-76 days) before death. Most had low burdens of preexisting disease, with 18 (32.7%) having a Charlson Comorbidity Index score of 0 and 15 (27.3%) having a score of 1 or 2. A total of 47 deaths (85.5%) were attributed to medical causes and 8 (14.5%) to suicide. Markedly abnormal vital signs were documented in the death reviews before 29 of 47 deaths from medical causes (61.7%), and 21 of these 29 deaths (72.4%) were preceded by abnormal vital signs during 2 or more encounters with ICE personnel before death or terminal hospital transfer. Overall, 43 detainee death reviews (78.2%) identified PBNDS violations related to medical care, with a mean (SD) of 3.2 (3.0) deficiencies per detainee death review. Conclusions and Relevance: In this case series, deaths in ICE detention facilities from 2011 to 2018 occurred primarily among young men with low burdens of preexisting disease. Markedly abnormal vital signs preceded death or hospital transfer for most nonsuicide deaths. The PBNDS were violated in most detainee death reviews. These results suggest that additional oversight and external evaluation of practices related to medical and psychiatric care within ICE facilities are needed.

Chronic anticoagulation is not associated with a reduced risk of acute kidney injury in hospitalised Covid-19 patients.

BACKGROUND: Coronavirus-19 (COVID-19) has been declared a global pandemic by the World Health Organisation. Severe disease typically presents with respiratory failure but Acute Kidney Injury (AKI) and a hypercoagulable state can also occur. Early reports suggest that thrombosis may be linked with AKI. We studied the development of AKI and outcomes of patients with COVID-19 taking chronic anticoagulation therapy. METHODS: Electronic records were reviewed for all adult patients admitted to Manchester University Foundation Trust Hospitals between March 10 and April 302,020 with a diagnosis of COVID-19. Patients with end-stage kidney disease were excluded. AKI was classified as per KDIGO criteria. RESULTS: Of the 1032 patients with COVID-19 studied,164 (15.9%) were taking anticoagulant therapy prior to admission. There were similar rates of AKI between those on anticoagulants and those not anticoagulated (23.8% versus 19.7%) with no difference in the severity of AKI or requirement of renal replacement therapy between groups (1.2% versus 3.5%). Risk factors for AKI included hypertension, pre-existing renal disease and male sex. There was a higher mortality in those taking anticoagulant therapy (40.2% versus 30%). Patients taking anticoagulants were less likely to be admitted to the Intensive Care Unit (8.5% versus 17.4%) and to receive mechanical ventilation (42.9% versus 78.1%). CONCLUSION: Patients on chronic anticoagulant therapy did not have a reduced incidence or severity of AKI suggesting that AKI is unlikely to be thrombotic in nature. Therapeutic anticoagulation is currently still under investigation in randomised controlled studies to determine whether it has a potential role in COVID-19 treatment.

Association of Sickle Cell Trait with Risk and Mortality of COVID-19: Results from the United Kingdom Biobank.

Sickle cell trait (SCT) carriers inherit one copy of the Glu6Val mutation in the hemoglobin gene and is particularly common in Black individuals (5-10%). Considering the roles of hemoglobin in immune responses and the higher risk for coronavirus disease (COVID-19) among Black individuals, we tested whether Black SCT carriers were at increased risk for COVID-19 infection and mortality according to the United Kingdom Biobank. Among Black individuals who were tested for COVID-19, we found similar infection rates among SCT carriers (14/72; 19.7%) and noncarriers (167/791; 21.1%), but higher COVID-19 mortality rates among SCT carriers (4/14; 28.6%) than among noncarriers (21/167; 12.6%) (odds ratio [OR], 3.04; 95% confidence interval [CI], 0.69-11.82; P = 0.12). Notably, SCT carriers with preexisting diabetes had significantly higher COVID-19 mortality (4/4; 100%) than those without diabetes (0/10; 0%; (OR, 90.71; 95% CI, 5.66-infinite; P = 0.0005). These findings suggest that Black SCT carriers with preexisting diabetes are at disproportionally higher risk for COVID-19 mortality. Confirmation by larger studies is warranted.

Biological Aging Predicts Vulnerability to COVID-19 Severity in UK Biobank Participants.

BACKGROUND: Age and disease prevalence are the 2 biggest risk factors for Coronavirus disease 2019 (COVID-19) symptom severity and death. We therefore hypothesized that increased biological age, beyond chronological age, may be driving disease-related trends in COVID-19 severity. METHODS: Using the UK Biobank England data, we tested whether a biological age estimate (PhenoAge) measured more than a decade prior to the COVID-19 pandemic was predictive of 2 COVID-19 severity outcomes (inpatient test positivity and COVID-19-related mortality with inpatient test-confirmed COVID-19). Logistic regression models were used with adjustment for age at the pandemic, sex, ethnicity, baseline assessment centers, and preexisting diseases/conditions. RESULTS: Six hundred and thirteen participants tested positive at inpatient settings between March 16 and April 27, 2020, 154 of whom succumbed to COVID-19. PhenoAge was associated with increased risks of inpatient test positivity and COVID-19-related mortality (ORMortality = 1.63 per 5 years, 95% CI: 1.43-1.86, p = 4.7 × 10-13) adjusting for demographics including age at the pandemic. Further adjustment for preexisting diseases/conditions at baseline (ORM = 1.50, 95% CI: 1.30-1.73 per 5 years, p = 3.1 × 10-8) and at the early pandemic (ORM = 1.21, 95% CI: 1.04-1.40 per 5 years, p = .011) decreased the association. CONCLUSIONS: PhenoAge measured in 2006-2010 was associated with COVID-19 severity outcomes more than 10 years later. These associations were partly accounted for by prevalent chronic diseases proximate to COVID-19 infection. Overall, our results suggest that aging biomarkers, like PhenoAge may capture long-term vulnerability to diseases like COVID-19, even before the accumulation of age-related comorbid conditions.

Left-Atrial Appendage Thrombosis in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation.

BACKGROUND: Data about the impact of left-atrial appendage thrombosis (LAAT) on early safety and mortality in patients undergoing transfemoral transcatheter aortic valve implantation (TF-TAVI) are scarce. We aimed to investigate the prevalence and predictors of LAAT and the outcome associated with this condition in patients treated by TF-TAVI. METHODS: Retrospective data analysis was derived from a prospective single-centre registry comparing patients with and without LAAT regarding early safety at 30 days, according to Valve Academic Research Consortium-2 (VARC-2) and 2-year mortality. RESULTS: LAAT was found in 7.6% of the whole cohort (n = 2527) and in 16.6% in those patients with known pre-existing atrial fibrillation (AF cohort, n = 1099). Compared with controls, patients with LAAT were sicker, indicated by a higher Society of Thoracic Surgeons (STS) score and burden of comorbidities. Neither VARC-2-defined early safety at 30 days nor the rate of stroke was different between LAAT and controls in both the whole (early safety: 29.2% vs 24.2%, P = 0.123; stroke: 5.9% vs 4.7%, P = 0.495) and AF cohort (early safety: 29.1% vs 22.9%, P = 0.072; stroke: 5.6% vs 3.3%, P = 0.142). Evaluating the whole cohort in a univariate analysis, the 2-year mortality was significantly higher in LAAT compared with controls (hazard ratio, 1.41; 95% confidence interval, 1.07-1.86; P = 0.014). However, multivariate analysis of the whole cohort and the AF cohort revealed no association between LAAT and 2-year mortality. CONCLUSIONS: LAAT was frequent in patients undergoing TF-TAVI- in particular, in patients with histories of AF-but it was not associated with an increase in periprocedural complications and did not predict 2-year mortality.

Primary De novo ductal adenocarcinoma of the lacrimal gland.

BACKGROUND: Primary ductal adenocarcinoma of the lacrimal gland is a rare and aggressive malignant epithelial lacrimal gland neoplasm, morphologically and phenotypically resembles salivary duct carcinoma, and both strongly resemble infiltrating ductal carcinoma of breast. METHOD: Retrospective Chart review of cases of malignant lacrimal gland tumors from 2013 July to 2020 July. Authors describe the clinico radiological, morphological and immunohistochemical features of primary ductal adenocarcinoma (PDA) of lacrimal gland. Extensive review of literature of PDA of lacrimal gland and salivary gland ductal carcinoma has been performed. RESULTS: Retrospective chart review of the last 7 years yielded 22 malignant lacrimal gland neoplasms of which 4 cases demonstrated features of primary ductal adenocarcinoma of lacrimal gland, 2/4 cases showed an evidence of a pre existing pleomorphic adenoma and 2 were found to be de novo ductal adenocarcinomas. PDA of lacrimal gland showed expression of CK7, CK19, AR, HER2, cyclin D1 and were negative for CK5/14, CK 20, ER, PR, PSA, TTF-1, S-100 and SMA. Expression of GCDFP-15 was noted in one case. The presence of multiple events of loco-regional recurrences and/or distant metastasis necessitated a multidisciplinary approach. CONCLUSIONS: Authors have expressed the need of clinical correlation; thorough tissue sampling and extensive immunohistochemical work up in identification of de novo PDA's and their molecular subtypes. A multi-institutional study might help in formulating the diagnostic criteria, identification of actionable targets, and thus study the role of targeted therapy in this rare and aggressive tumor which may result in better patient outcomes.

Decomposing Differences in Coronavirus disease 2019-related Case-Fatality Rates across Seventeen Nations.

As of 1 November 2020, estimated case-fatality rates associated with coronavirus disease 2019 are not uniformly patterned across the world and differ substantially in magnitude. Given the global spatial heterogeneity in case-fatality rates, we applied the Blinder-Oaxaca regression decomposition technique to identify how putative sociodemographic, structural, and environmental sources influence variation in case-fatality rates. We show that compositional and associational differences in country-level risk factors explain a substantial proportion of the coronavirus disease 2019-related case-fatality rate gap across nations. Asian countries fair better vis-à-vis case-fatality rate differences mainly due to variation in returns to sociodemographic, structural, and environmental sources among their citizens, relative to those who share similar attributes but live in Europe or North America. The variation in case-fatality rate is driven by Asian populations being better able to buffer the harmful effects of the very risk factors purported to exacerbate the risk of coronavirus disease 2019-related death. The dire circumstances in which we find ourselves demand better understanding of how preexisting conditions across countries contribute to observed disparities in case-fatality rates.

Preexisting Comorbidities Predicting COVID-19 and Mortality in the UK Biobank Community Cohort.

BACKGROUND: Hospitalized COVID-19 patients tend to be older and frequently have hypertension, diabetes, or coronary heart disease, but whether these comorbidities are true risk factors (ie, more common than in the general older population) is unclear. We estimated associations between preexisting diagnoses and hospitalized COVID-19 alone or with mortality, in a large community cohort. METHODS: UK Biobank (England) participants with baseline assessment 2006-2010, followed in hospital discharge records to 2017 and death records to 2020. Demographic and preexisting common diagnoses association tested with hospitalized laboratory-confirmed COVID-19 (March 16 to April 26, 2020), alone or with mortality, in logistic models. RESULTS: Of 269 070 participants aged older than 65, 507 (0.2%) became COVID-19 hospital inpatients, of which 141 (27.8%) died. Common comorbidities in hospitalized inpatients were hypertension (59.6%), history of fall or fragility fractures (29.4%), coronary heart disease (21.5%), type 2 diabetes (type 2, 19. 9%), and asthma (17.6%). However, in models adjusted for comorbidities, age group, sex, ethnicity, and education, preexisting diagnoses of dementia, type 2 diabetes, chronic obstructive pulmonary disease, pneumonia, depression, atrial fibrillation, and hypertension emerged as independent risk factors for COVID-19 hospitalization, the first 5 remaining statistically significant for related mortality. Chronic kidney disease and asthma were risk factors for COVID-19 hospitalization in women but not men. CONCLUSIONS: There are specific high-risk preexisting comorbidities for COVID-19 hospitalization and related deaths in community-based older men and women. These results do not support simple age-based targeting of the older population to prevent severe COVID-19 infections.

Variability of Care of Infants With Severe Respiratory Syncytial Virus Bronchiolitis: A Multicenter Study.

BACKGROUND: Viral bronchiolitis caused by respiratory syncytial virus (RSV) is a common childhood disease accounting for many hospitalizations worldwide. Some infants may clinically deteriorate, requiring admission to an intensive care unit. We aimed to describe diagnostic and therapeutic measures of bronchiolitis in Israeli pediatric intensive care units (PICUs) and evaluate intercenter variability of care. METHODS: Medical records of all RSV-infected infants admitted to 5 Israeli PICUs over 4 RSV seasons were retrospectively reviewed. RESULTS: Data on 276 infants with RSV-positive bronchiolitis, admitted to the participating PICUs were analyzed. Most of the infants were males with a mean admission age of 4.7 months. Approximately half of the infants had pre-existing conditions such as prematurity, cardiac disease or chronic lung disease. Respiratory distress was the most common symptom at presentation followed by hypoxemia and fever. There was significant variation in the methods used for RSV diagnosis, medical management and respiratory support of the infants. Furthermore, utilization of inhalational therapy and transfusion of blood products differed significantly between the centers. Although a bacterial pathogen was isolated in only 13.4% of the infants, 82.6% of the cohort was treated with antibiotics. CONCLUSIONS: Significant variation was found between the different PICUs regarding RSV bronchiolitis diagnosis, medical management and respiratory support, which may not be accounted for by the differences in baseline and clinical characteristics of the infants. Some of these differences may be explained by uneven resource allocations. This diversity and the documented routine use of medications with weak evidence of efficacy calls for national guidelines for bronchiolitis management.

Self-Inflicted Gun Violence Injuries Epidemic in the United States: A Closer Look at the Nation's Well-Being.

Gun-related injuries are a hotly debated sociopolitical topic in the United States. Annually, more than 33 million Americans seek heathcare services for mental health issues. These conditions are the leading cause of combined disability and death among women and the second highest among men. Our study's main objective was to identify cases of self-inflicted penetrating firearm injuries with reported pre-existing psychiatric conditions as defined in the 2013-2016 National Trauma Data Standard. The 2013-2016 Research Data Sets (RDSs) were reviewed. Cases were identified using the ICD-9 external cause codes 955-955.4, and ICD 10th Edition Clinical Modification external cause codes X72-X74. Odds ratios were calculated, and categorical data were analyzed by using the chi-squared test, with significance defined as P < 0.05. The 2013-2016 Research Data Set consists of 3,577,168 reported cases, with 15,535 observations of self-inflicted penetrating firearms injuries. Of those patients, 18.4 per cent had major psychiatric illnesses, 7.5 per cent had alcohol use disorder, 6.4 per cent had drug use disorder, and 0.6 per cent had dementia. An upward trend in the proportion of patients with major psychiatric illnesses was observed, from 15.5 per cent in 2013 to 18.6 per cent in 2016, peaking in 2015 at 20.9 per cent. Nearly one in three self-inflicted penetrating firearm injuries in the United States is associated with pre-existing behavioral health conditions. Advances in understanding the behavioral and social determinants leading to these conditions, and strategies to improve the diagnosis of mental illness and access to mental health care are required.

Physical activity, sedentary behavior and development of preeclampsia in women with preexisting diabetes.

AIMS: To explore the association between physical activity in early pregnancy and development of preeclampsia in women with preexisting diabetes. METHODS: In a prospective cohort study of 189 women with preexisting diabetes (110 type 1 and 79 type 2 diabetes), physical activity during pregnancy including sedentary behavior was evaluated with the Pregnancy Physical Activity Questionnaire. Primary outcome was preeclampsia. Secondary outcomes were preterm delivery, large and small for gestational age infants. RESULTS: Women developing preeclampsia (n = 23) had higher diastolic blood pressure in early pregnancy (mean 82 ± 9 SD vs. 77 ± 8, p = 0.004) and were more often nulliparous (91 vs. 52%, p < 0.001) compared with the remaining women (n = 166). Total physical activity in early pregnancy was similar between the groups (median 148 metabolic equivalent of task hours per week (MET-h/week) (interquartile range 118-227) versus 153 (121-205), p = 0.97). In early pregnancy, women developing preeclampsia reported a higher level of sedentary behavior (15 MET-h/week (7-18) versus 7 (4-15); p = 0.04); however, when adjusting for parity, diastolic blood pressure and smoking, the association attenuated (p = 0.13). Total physical activity and sedentary behavior in early pregnancy were not associated with preterm delivery, large or small for gestational age infants. CONCLUSIONS: Among women with diabetes, sedentary behavior was reported higher in early pregnancy in women developing preeclampsia compared with the remaining women, while total physical activity was similar. Sedentary behavior was a predictor of preeclampsia in the univariate analysis, but not in the multiple regression analysis, and larger studies are needed to evaluate this possible modifiable risk factor. Trial registration The study was registered at ClinicalTrials.gov (ID: NCT02890836).

Prevalence of Pre-existing Conditions Among Community Health Center Patients Before and After the Affordable Care Act.

OBJECTIVE: To assess the prevalence of pre-existing conditions for community health center (CHC) patients who gained insurance coverage post-Affordable Care Act (ACA). METHODS: We analyzed electronic health record data from 78,059 patients aged 19 to 64 uninsured at their last visit pre-ACA from 386 CHCs in 19 states. We compared the prevalence and types of pre-existing conditions pre-ACA (2012 to 2013) and post-ACA (2014 to 2015), by insurance status and race/ethnicity. RESULTS: Pre-ACA, >50% of patients in the cohort had ≥1 Pre-existing condition. Post-ACA, >70% of those who gained insurance coverage had ≥1 condition. Post-ACA, all racial/ethnic subgroups showed an increase in the number of pre-existing conditions, with non-Hispanic Black and Hispanic patients experiencing the largest increases (adjusted prevalence difference, 18.9; 95% CI, 18.2 to 19.6 and 18.3; 95% CI, 17.8 to 18.7, respectively). The most common conditions post-ACA were mental health disorders with the highest prevalence among patients who gained Medicaid (45.6%) and lowest among those who gained private coverage (30.5%). CONCLUSIONS: This study emphasizes the high prevalence of pre-existing conditions among CHC patients and the large increase in the proportion of patients with at least 1 of these diagnoses post-ACA. Given how common these conditions are, repealing pre-existing condition protections could be extremely harmful to millions of patients and would likely exacerbate health care and health disparities.

The effect of the Affordable Care Act preexisting conditions provision on marriage.

This paper investigates the effect of the Affordable Care Act preexisting conditions provision on marriage. The policy was implemented to prevent insurers from denying insurance coverage to individuals with preexisting health conditions. We test whether the implementation of the provision led to decreases in marriage among affected adults. We add to earlier work on how marital behavior is influenced by spousal health insurance and examine for the presence of "marriage lock," a situation in which individuals remain married primarily for insurance. Using longitudinal data from the Panel Study of Income Dynamics from 2009 to 2017 and estimating difference-in-differences models, we find that male household heads with preexisting conditions are 7.12 percentage points (8.9 percent) less likely to be married after the policy. Using information on insurance status prior to the policy change, we find significant reductions in marriage among individuals with preexisting conditions who were previously insured by spousal health insurance plans. The findings suggest that the inability to attain individual coverage and reliance on spousal insurance provided incentives to remain married before 2014.

Determining Physical and Mental Health Conditions Present in Older Adult Refugees: A Mini-Review.

In 2017, there were over 65 million displaced persons at the global level, with approximately 23 million of these people living as refugees around the world. In this same year, the US resettled 53,716 refugees, with the State of Utah receiving 954 of those refugees. Refugees, in general, often face health-related challenges upon resettlement. Since the health of aging refugee men and women is of growing concern, host communities face significant challenges in accommodating the health needs of a diverse refugee population. This study, a review of physical and mental health data from the Utah Department of Health, was undertaken in an effort to ascertain the prevalence of health conditions among refugee men and women 60 years and older arriving in Utah. Findings include information on diseases correlated with increasing age, such as hypertension, decreases in vision, arthritis, and low back pain, which are common among this population of refugees aged 60 years and older. Overall, most of the health conditions assessed affect women and men with a similar prevalence. Some notable exceptions are a history of torture and violence, and a propensity for tobacco use. When dealing with refugee men older than 60 years, providers should consider the psychological ramifications of having endured such atrocities, as well as introduction to evidence-based tobacco cessation programs. When working with refugee women of the same age, an increase in the prevalence of musculoskeletal pain and urinary tract infections should be considered.

How Would Americans' Out-of-Pocket Costs Change If Insurance Plans Were Allowed to Exclude Coverage for Preexisting Conditions?

Issue: A current Republican legislative proposal would permit insurers to offer plans that exclude coverage of treatment for preexisting health conditions, even while the bill would maintain the Affordable Care Act's rule prohibiting denial of coverage to people with a preexisting condition. Goal: Estimate patients' out-of-pocket costs for five common preexisting conditions if the bill were to become law and assess any additional impact on out-of-pocket expenditures if spending on care for preexisting conditions no longer counted against plan deductibles. Methods: Analysis of 2014­2016 Medical Expenditure Panel Survey data for the privately insured adult population under age 65; and the proposed Ensuring Coverage for Patients with Pre-Existing Conditions Act (S. 3388). Findings and Conclusion: If preexisting conditions were excluded from coverage, nearly all people with these conditions would see increased out-of-pocket costs. Average out-of-pocket costs for those with cancer or diabetes would triple, while costs for arthritis, asthma, and hypertension care would rise by 27 percent to 39 percent. Some individuals would see much larger increases: for example, 10 percent of diabetes patients could expect to incur over $9,200 annually in out-of-pocket costs. Many with preexisting conditions also would spend more on conditions that are not excluded, since out-of-pocket spending on their preexisting conditions would no longer count toward the deductible and out-of-pocket maximum.

Preexisting psychiatric illness worsens acute care outcomes after orthopaedic trauma in obese patients.

PURPOSE: Pre-existing psychiatric illness, illicit drug use, and alcohol abuse adversely impact patients with orthopaedic trauma injuries. Obesity is an independent factor associated with poorer clinical outcomes and discharge disposition, and higher hospital resource use. It is not known whether interactions exist between pre-existing illness, illicit drug use and obesity on acute trauma care outcomes. PATIENTS AND METHODS: This cohort study is from orthopaedic trauma patients prospectively measured over 10 years (N = 6353). Psychiatric illness, illicit drug use and alcohol were classified by presence or absence. Body mass index (BMI) was analyzed as both a continuous and categorical measure (<30 kg/m2 [non-obese], 30-39.9 kg/m2 [obese] and ≥40 kg/m2 [morbidly obese]). Main outcomes were the number of acute care services provided, length of stay (LOS), discharge home, hospital readmissions, and mortality in the hospital. RESULTS: Statistically significant BMI by pre-existing condition (psychiatric illness, illicit drug use) interactions existed for LOS and number of acute care services provided (ß values 0.012-0.098; all p < 0.05). The interaction between BMI and psychiatric illness was statistically significant for discharge to locations other than home (ß = 0.023; p = 0.001). DISCUSSION: Obese patients with orthopaedic trauma, particularly with preexisting mental health conditions, will require more hospital resources and longer care than patients without psychiatric illness. Early identification of these patients through screening for psychiatric illness and history of illicit drug use at admission is imperative to mobilize the resources and provide psychosocial support to facilitate the recovery trajectory of affected obese patients.

[Osteoporosis in private accident insurance]. / Osteoporose in der privaten Unfallversicherung.

Osteoporosis is a multifactorial disease resulting in reduced bone strength and increased bone fragility. The cause of osteoporosis is underexplored. The manifestation of osteoporosis makes a significant contribution to the development of bone fractures. In the medical assessment, the question arises to what extent osteoporosis is considered to be a previous disability or in particular as a contributory factor. In particular, there are some uncertainties relating to the degree of possible participation, as there are only insufficient scientific evaluation systems. From the authors' point of view no valid assessment of the degree of participation exists on the basis of technical examinations or even the severity of the trauma. At the current time there is no possibility to indicate the level of contribution in 10% or 20% steps. Taking the total picture, including clinical and radiological findings into consideration, it seems possible to assess the contribution only in larger percentage steps (e.g. 0%, 50% or ≥80%). The mere diagnosis of osteoporosis does not justify a participation rate unless its effects can be pathomorphologically proven.

Severe maternal morbidity: A population-based study of an expanded measure and associated factors.

Severe maternal morbidity conditions such as sepsis, embolism and cardiac arrest during the delivery hospitalization period can lead to extended length of hospital stays, life-long maternal health problems, and high medical costs. Most importantly, these conditions also contribute to the risk of maternal death. This population-based observational study proposed and evaluated the impact of expanding the Centers for Disease Control and Prevention (CDC) measure of severe maternal morbidity by including additional comorbidities and intensive care admissions during delivery hospitalizations and examined associated factors. A New York State linked hospitalization and birth record database was used. Study participants included all New York State female residents, ages 10 to 55 years, who delivered a live infant in a New York acute care hospital between 2008 and 2013, inclusive. Incidence trends for both severe maternal morbidity measures were evaluated longitudinally. Associations between covariates and the two severe maternal morbidity measures were examined with logistic regression models, solved using generalized estimating equations and stratified by method of delivery. The New York expanded severe maternal morbidity measure identified 34,478 cases among 1,352,600 hospital deliveries (estimated incidence 2.55%) representing a 3% increase in the number of cases compared to the CDC measure. Both estimates increased over the study period (p<0.001). Covariates with an odds ratio > 1.5 included most measured comorbidities (e.g., pregnancy-induced hypertension, placentation disorder), multiple births, preterm birth, no prenatal care, hospitalization prior to delivery, higher levels of perinatal care birthing facilities and race/ethnicity. Expanding the measure for severe maternal morbidity during delivery to capture intensive care admissions provides a more sensitive estimate of disease burden. Perinatal regionalization in New York appears effective in routing high risk pregnancies to higher levels of perinatal care birthing facilities.