Assessment of early morning serum cortisol levels in adult male patients with alcohol-related disorders.

BACKGROUND: Alcohol-related disorders are a major health problem among Indian male professionals because of the unique nature of socioeconomic and demographic conditions. Various studies have highlighted the association between alcohol-related disorders and hypothalamic-pituitary-adrenal (HPA) axis dysfunction, but the evidence accrued so far is inconclusive. In our study, we have assessed early morning serum total cortisol concentration among Indian adult male population affected with alcohol-related disorder. METHODS: A case-based cross-sectional study in which all consecutive patients admitted in the psychiatry ward of a tertiary care hospital with diagnosis of 'alcohol-related disorders', who were meeting all the inclusion criteria, and who had none of the exclusion criteria were part of the study. Diseased controls and healthy controls were chosen by applying strict inclusion and exclusion criteria. Serum early morning (0400 h) total cortisol levels were estimated using automated quantitative enzyme-linked fluorescent assay technique. RESULTS: 98 psychiatric patients and 50 healthy controls were evaluated. Out of these 98 patients 66 patients were diagnosed cases of alcohol-related disorder. Morning serum total cortisol levels in patients with alcohol-related disorders was found to be significantly different from healthy controls. CONCLUSION: Our study suggests that alcohol-related disorders are associated with chronic changes in HPA axis and significant alteration of early morning serum total cortisol levels were demonstrated in this group of patients.

Burden of Readmissions Among Patients With Critical Limb Ischemia.

BACKGROUND: Readmissions constitute a major health care burden among critical limb ischemia (CLI) patients. OBJECTIVES: This study aimed to determine the incidence of readmission and factors affecting readmission in CLI patients. METHODS: All adult hospitalizations with a diagnosis code for CLI were included from State Inpatient Databases from Florida (2009 to 2013), New York (2010 to 2013), and California (2009 to 2011). Data were merged with the directory available from the American Hospital Association to obtain detailed information on hospital-related characteristics. Geographic and routing analysis was performed to evaluate the effect of travel time to the hospital on readmission rate. RESULTS: Overall, 695,782 admissions from 212,241 patients were analyzed. Of these, 284,189 were admissions with a principal diagnosis of CLI (primary CLI admissions). All-cause readmission rates at 30 days and 6 months were 27.1% and 56.6%, respectively. The majority of these were unplanned readmissions. Unplanned readmission rates at 30 days and 6 months were 23.6% and 47.7%, respectively. The major predictors of 6-month unplanned readmissions included age, female sex, black/Hispanic race, prior amputation, Charlson comorbidity index, and need for home health care or rehabilitation facility upon discharge. Patients covered by private insurance were least likely to have a readmission compared with Medicaid/no insurance and Medicare populations. Travel time to the hospital was inversely associated with 6-month unplanned readmission rates. There was a significant interaction between travel time and major amputation as well as travel time and revascularization strategy; however, the inverse association between travel time and unplanned readmission rate was evident in all subgroups. Furthermore, length of stay during index hospitalization was directly associated with the likelihood of 6-month unplanned readmission (odds ratio for log-transformed length of stay: 2.39 [99% confidence interval: 2.31 to 2.47]). CONCLUSIONS: Readmission among patients with CLI is high, the majority of them being unplanned readmissions. Several demographic, clinical, and socioeconomic factors play important roles in predicting readmissions.

Degenerative Mitral Stenosis: Unmet Need for Percutaneous Interventions.

Degenerative mitral stenosis (DMS) is an important cause of mitral stenosis, developing secondary to severe mitral annular calcification. With the increase in life expectancy and improved access to health care, more patients with DMS are likely to be encountered in developed nations. These patients are generally elderly with multiple comorbidities and often are high-risk candidates for surgery. The mainstay of therapy in DMS patients is medical management with heart rate control and diuretic therapy. Surgical intervention might be delayed until symptoms are severely limiting and cannot be managed by medical therapy. Mitral valve surgery is also challenging in these patients because of the presence of extensive calcification. Hence, there is a need to develop an alternative percutaneous treatment approach for patients with DMS who are otherwise inoperable or at high risk for surgery. In this review, we summarize the available data on the epidemiology of DMS and diagnostic considerations and current treatment strategies for these patients.

Trends in the Burden of Adult Congenital Heart Disease in US Emergency Departments.

BACKGROUND: We assessed trends in incidence, in-hospital mortality, and admission among patients with adult congenital heart disease (ACHD) presenting to the emergency department (ED) from 2006 to 2012. HYPOTHESIS: There is a considerable burden of ACHD in the US EDs. METHODS: We used the 2006-2012 US Nationwide Emergency Department Sample. All ED visits with ACHD were identified using standard International Classification of Diseases, Ninth Edition, Clinical Modification codes. RESULTS: The number of patients presenting to the ED with simple (40.6%) as well as complex (37.6%) ACHD across 2006-2012 increased significantly. Also, there was a considerable increase in prevalence of traditional cardiovascular risk factors among ACHD patients, including hypertension, diabetes, smoking, obesity, and chronic kidney disease. Besides miscellaneous noncardiovascular conditions, nonspecific chest pain (15.9%) and respiratory disorders (15.0%) were the most common reasons for ED visits among patients with simple and complex ACHD, respectively. Although there was a trend toward decrease in admissions across 2006-2012 (Ptrend < 0.001), the proportion of patients with ACHD presenting to ED requiring admission remained substantial (63.4%). Finally, there was significant variation in admission trends across different geographic locations, hospital types, insurance status, and ED volume among ACHD patients presenting to the ED. CONCLUSIONS: There has been a progressive increase in number of ED visits among ACHD patients across 2006-2012 in the United States. Moreover, the cardiovascular risk-factor profile of ACHD patients has changed, adding to complexity in management. Current health care delivery to ACHD patients also shows significant geographical, hospital-based, and insurance status-based disparities.

Nationwide Hospitalization Trends in Adult Congenital Heart Disease Across 2003-2012.

BACKGROUND: We aimed to assess trends in hospitalization, outcomes, and resource utilization among patients admitted with adult congenital heart disease (ACHD). METHODS AND RESULTS: We used the 2003-2012 US Nationwide Inpatient Sample for this study. All admissions with an ACHD were identified using standard ICD codes. Resource utilization was assessed using length of stay, invasive procedure utilization, and cost of hospitalization. There was a significant increase in the number of both simple (101%) as well as complex congenital heart disease (53%)-related admissions across 2003-2012. In addition, there was a considerable increase in the prevalence of traditional cardiovascular risk factors including older age, along with a higher prevalence of hypertension, diabetes, smoking, obesity, chronic kidney disease, and peripheral arterial disease. Besides miscellaneous causes, congestive heart failure (11.8%), valve disease (15.5%), and cerebrovascular accident (26.1%) were the top causes of admission to the hospital among patients with complex ACHD, simple ACHD without atrial septal defects/patent foramen ovale and simple atrial septal defects/patent foramen ovale patients, respectively. In-hospital mortality has been relatively constant among patients with complex ACHD as well as simple ACHD without atrial septal defects/patent foramen ovale. However, there has been considerable increase in the average length of stay and cost of hospitalization among the ACHD patients during 2003-2012. CONCLUSIONS: There has been a progressive increase in ACHD admissions across 2003-2012 in the United States, with increasing healthcare resource utilization among these patients. Moreover, there has been a change in the cardiovascular comorbidities of these patients, adding a layer of complexity in management of ACHD patients.

Gender Disparities in Outcomes and Resource Utilization for Acute Pulmonary Embolism Hospitalizations in the United States.

Current data regarding gender disparities in outcomes after acute pulmonary embolism (PE) are limited and controversial. We sought to assess the gender-specific rates and trends in treatment, outcomes, and complications after acute PE. We used the 2003 to 2011 Nationwide Inpatient Sample database for this analysis. All hospital admissions with a principal diagnosis of acute PE were identified using the International Classification of Diseases, Ninth Edition, codes. Inhospital mortality and discharge to nursing facility were co-primary outcomes of our study. Secondary outcomes included shock, transfusion of blood products, utilization of thrombolysis, inferior vena cava filter placement, and cost of hospitalization. Over a 9-year period, a total of 276,484 discharges with acute PE were identified. Compared with men, there was significantly higher inhospital mortality in women admitted with acute PE (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.03 to 1.15). In addition, there was a significantly higher need for discharge to nursing facility among women compared with men (OR 1.30, 95% CI 1.27 to 1.34). Besides this, women experienced a higher need for transfusion (OR 1.38, 95% CI 1.33 to 1.44) and occurrence of shock (OR 1.10, 95% CI 1.01 to 1.18) during hospitalization. Furthermore, there was a significantly lower utilization of vena cava filters (OR 0.86, 95% CI 0.84 to 0.89) in women compared with men. Among patients in shock who were eligible for thrombolysis (age <75 years, no previous stroke, no bleeding on presentation, and not pregnant), the utilization of thrombolysis was similar between men and women (OR 1.19, 95% CI 0.93 to 1.53). Lastly, the cost of hospitalization after acute PE was significantly higher in men than women (adjusted mean difference $425, 95% CI $304 to $546). In conclusion, among patients admitted with acute PE, women tend to have more adverse outcomes and higher incidence of complications compared with men.

Renin-Angiotensin System Antagonists in Patients Without Left Ventricular Dysfunction After Percutaneous Intervention for ST-Segment Elevation Myocardial Infarction.

There is a paucity of evidence on the impact of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) on long-term outcomes in patients with ejection fraction (EF) >40% after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI). We compared long-term all-cause mortality between patients with left ventricular ejection fraction (LVEF) >40% discharged on ACEi/ARB with patients who were discharged on neither of these agents. Patients discharged after percutaneous intervention for STEMI from our catheterization laboratories from January 2002 to December 2011 were considered for inclusion. Patients were excluded if they had LVEF <40% or chronic kidney disease or hypotension (systolic blood pressure <90 mm Hg any time after the procedure). Long-term mortality and discharge medications were determined using the Social Security Death Index and electronic medical record review, respectively. A total of 988 patients were included. The median follow-up duration was 4.6 years. Kaplan-Meier analysis showed no significant difference in long-term all-cause mortality in patients discharged on ACEi/ARB compared with those who were not discharged on these medications. The number needed to treat to prevent 1 death at 1 year was 714. In addition, multivariable Cox proportional hazard modeling failed to demonstrate any beneficial effect of ACEi/ARB similar to Kaplan-Meir analysis (hazard ratio 0.88, 95% confidence interval 0.57 to 1.36). In conclusion, we found no significant benefit in long-term mortality using ACEi/ARB in patients with LVEF >40% after primary percutaneous coronary intervention for STEMI.