The Association Between Socioeconomic Status, Sex, Race / Ethnicity and In-Hospital Mortality Among Patients Hospitalized for Heart Failure.

BACKGROUND: The association between socioeconomic status (SES), sex, race / ethnicity and outcomes during hospitalization for heart failure (HF) has not previously been investigated. METHODS AND RESULTS: We analyzed HF hospitalizations in the United States National Inpatient Sample between 2015 and 2017. Using a hierarchical, multivariable Poisson regression model to adjust for hospital- and patient-level factors, we assessed the association between SES, sex, and race / ethnicity and all-cause in-hospital mortality. We estimated the direct costs (USD) across SES groups. Among 4,287,478 HF hospitalizations, 40.8% were in high SES, 48.7% in female, and 70.0% in White patients. Relative to these comparators, low SES (homelessness or lowest quartile of median neighborhood income) (relative risk [RR] 1.02, 95% confidence interval [CI] 1.00-1.05) and male sex (RR 1.09, 95% CI 1.07-1.11) were associated with increased risk, whereas Black (RR 0.79, 95% CI 0.76-0.81) and Hispanic (RR 0.90, 95% CI 0.86-0.93) race / ethnicity were associated with a decreased risk of in-hospital mortality (5.1% of all hospitalizations). There were significant interactions between race / ethnicity and both, SES (P < .01) and sex (P = .04), such that racial/ethnic differences in outcome were more pronounced in low SES groups and in male patients. The median direct cost of admission was lower in low vs high SES groups ($9324.60 vs $10,940.40), female vs male patients ($9866.60 vs $10,217.10), and Black vs White patients ($9077.20 vs $10,019.80). The median costs increased with SES in all demographic groups primarily related to greater procedural utilization. CONCLUSIONS: SES, sex, and race / ethnicity were independently associated with in-hospital mortality during HF hospitalization, highlighting possible care disparities. Racial/ethnic differences in outcome were more pronounced in low SES groups and in male patients.

Assessing the severity of Type 2 diabetes using clinical data-based measures: a systematic review.

AIMS: To identify and critically appraise measures that use clinical data to grade the severity of Type 2 diabetes. METHODS: We searched MEDLINE, Embase and PubMed between inception and June 2018. Studies reporting on clinical data-based diabetes-specific severity measures in adults with Type 2 diabetes were included. We excluded studies conducted solely in participants with other types of diabetes. After independent screening, the characteristics of the eligible measures including design and severity domains, the clinical utility of developed measures, and the relationship between severity levels and health-related outcomes were assessed. RESULTS: We identified 6798 studies, of which 17 studies reporting 18 different severity measures (32 314 participants in 17 countries) were included: a diabetes severity index (eight studies, 44%); severity categories (seven studies, 39%); complication count (two studies, 11%); and a severity checklist (one study, 6%). Nearly 89% of the measures included diabetes-related complications and/or glycaemic control indicators. Two of the severity measures were validated in a separate study population. More severe diabetes was associated with increased healthcare costs, poorer cognitive function and significantly greater risks of hospitalization and mortality. The identified measures differed greatly in terms of the included domains. One study reported on the use of a severity measure prospectively. CONCLUSIONS: Health records are suitable for assessment of diabetes severity; however, the clinical uptake of existing measures is limited. The need to advance this research area is fundamental as higher levels of diabetes severity are associated with greater risks of adverse outcomes. Diabetes severity assessment could help identify people requiring targeted and intensive therapies and provide a major benchmark for efficient healthcare services.

Meta-analysis of randomized and quasi-randomized clinical trials of topical antibiotics after primary closure for the prevention of surgical-site infection.

BACKGROUND: Surgical-site infections (SSIs) increase patient morbidity and costs. The aim was to identify and synthesize all RCTs evaluating the effect of topical antibiotics on SSI in wounds healing by primary intention. METHODS: The search included Ovid MEDLINE, Ovid Embase, the Cochrane Wounds Specialized Register, Central Register of Controlled Trials and EBSCO CINAHL from inception to May 2016. There was no restriction of language, date or setting. Two authors independently selected studies, extracted data and assessed risk of bias. When sufficient numbers of comparable trials were available, data were pooled in meta-analysis. RESULTS: Fourteen RCTs with 6466 participants met the inclusion criteria. Pooling of eight trials (5427 participants) showed that topical antibiotics probably reduced the risk of SSI compared with no topical antibiotic (risk ratio (RR) 0·61, 95 per cent c.i. 0·42 to 0·87; moderate-quality evidence), equating to 20 fewer SSIs per 1000 patients treated. Pooling of three trials (3012 participants) for risk of allergic contact dermatitis found no clear difference between antibiotics and no antibiotic (RR 3·94, 0·46 to 34·00; very low-quality evidence). Pooling of five trials (1299 participants) indicated that topical antibiotics probably reduce the risk of SSI compared with topical antiseptics (RR 0·49, 0·30 to 0·80; moderate-quality evidence); 43 fewer SSIs per 1000 patients treated. Pooling of two trials (541 participants) showed no clear difference in the risk of allergic contact dermatitis with antibiotics or antiseptic agents (RR 0·97, 0·52 to 1·82; very low-quality evidence). CONCLUSION: Topical antibiotics probably prevent SSI compared with no topical antibiotic or antiseptic. No conclusion can be drawn regarding whether they cause allergic contact dermatitis.

Incidence, prevalence and mortality of patients with psoriasis: a U.K. population-based cohort study.

BACKGROUND: The burden of psoriasis across many world regions is high and there is a recognized need to better understand the epidemiology of this common skin disorder. OBJECTIVES: To examine changes in the prevalence and incidence of psoriasis, and mortality rates over a 15-year period. METHODS: Cohort study involving analysis of longitudinal electronic health records between 1999 and 2013 using the U.K. Clinical Practice Research Datalink (CPRD). RESULTS: The prevalence of psoriasis increased steadily from 2·3% (2297 cases per 100 000) in 1999 to 2·8% (2815 per 100 000) in 2013, which does not appear to be attributable to changes in incidence rates. We observed peaks in age bands characteristic of early-onset (type I) and late-onset (type II) psoriasis, and changes in incidence and prevalence rates with increasing latitude in the U.K. All-cause mortality rates for the general population and for patients with psoriasis have decreased over the last 15 years. However, the risk of all-cause mortality for patients with psoriasis remains elevated compared with people without psoriasis (hazard ratio 1·21; 95% confidence interval 1·13-1·3) and we found no significant change in this relative excess mortality gap over time. CONCLUSIONS: We found an increasing population living longer with psoriasis in the U.K., which has important implications for healthcare service delivery and for resource allocation. Importantly, early mortality in patients with psoriasis remains elevated compared with the general population and we found no evidence of change in this premature mortality gap.

Suicide risk linked with clinical consultation frequency, psychiatric diagnoses and psychotropic medication prescribing in a national study of primary-care patients.

BACKGROUND: Little is known about the precursors of suicide risk among primary-care patients. This study aimed to examine suicide risk in relation to patterns of clinical consultation, psychotropic drug prescribing, and psychiatric diagnoses. METHOD: Nested case-control study in the Clinical Practice Research Datalink (CPRD), England. Patients aged ⩾16 years who died by suicide during 2002-2011 (N = 2384) were matched on gender, age and practice with up to 20 living control patients (N = 46 899). RESULTS: Risk was raised among non-consulting patients, and increased sharply with rising number of consultations in the preceding year [⩾12 consultations v. 1: unadjusted odds ratio (OR) 6.0, 95% confidence interval (CI) 4.9-7.3]. Markedly elevated risk was also associated with the prescribing of multiple psychotropic medication types (⩾5 types v. 0: OR 62.6, CI 44.3-88.4) and with having several psychiatric diagnoses (⩾4 diagnoses v. 0: OR 31.1, CI 19.3-50.1). Risk was also raised among patients living in more socially deprived localities. The confounding effect of multiple psychotropic drug types largely accounted for the rising risk gradient observed with increasing consultation frequency. CONCLUSIONS: A greater proportion of patients with several psychiatric diagnoses, those prescribed multiple psychotropic medication types, and those who consult at very high frequency might be considered for referral to mental health services by their general practitioners. Non-consulters are also at increased risk, which suggests that conventional models of primary care may not be effective in meeting the needs of all people in the community experiencing major psychosocial difficulties.

Influenza, influenza-like symptoms and their association with cardiovascular risks: a systematic review and meta-analysis of observational studies.

AIMS: To synthesise the evidence relating influenza and influenza-like symptoms to the risks of myocardial infarction (MI), heart failure (HF) and stroke. METHODS: We conducted a systematic review and meta-analysis of the evidence relating influenza and influenza-like symptoms to the risks of MI, HF and stroke. We systematically searched all MEDLINE and EMBASE entries up to August 2014 for studies of influenza vs. the cardiovascular outcomes above. We conducted random effects meta-analysis using inverse variance method for pooled odds ratios (OR) and evaluated statistical heterogeneity using the I(2) statistic. RESULTS: We identified 12 studies with a total of 84,003 participants. The pooled OR for risk of MI vs. influenza (serologically confirmed) was 1.27 (95% CI, confidence interval 0.54-2.95), I(2)  = 47%, which was significant for the only study that adjusted for confounders (OR 5.50, 95% CI 1.31-23.13). The pooled OR for risk of MI vs. influenza-like symptoms was 2.17 (95% CI 1.68-2.80), I(2)  = 0%, which was significant for both unadjusted (OR 2.23, 95% CI 1.65-3.01, five studies) and adjusted studies (OR 2.01, 95% CI 1.24-3.27, two studies). We found one study that evaluated stroke risk, one study in patients with HF, and one that evaluated mortality from MI - all of these studies suggested increased risks of events with influenza-like symptoms. CONCLUSIONS: There is an association between influenza-like illness and cardiovascular events, but the relationship is less clear with serologically diagnosed influenza. We recommend renewed efforts to apply current clinical guidelines and maximise the uptake of annual influenza immunisation among patients with cardiovascular diseases, to decrease their risks of MI and stroke.

Predicting multiple sclerosis following isolated optic neuritis in children.

BACKGROUND AND PURPOSE: Isolated optic neuritis (ON) is frequently the initial symptom of multiple sclerosis (MS). The aim of our study was to investigate the risk of conversion to MS in children following isolated ON and to evaluate the performance of current diagnostic methods such as cranial magnetic resonance imaging (cMRI), visual evoked potentials (VEPs) and oligoclonal bands in spinal fluid (OCB) as predictive factors for MS development. METHODS: Medical records of 159 patients presenting with acute ON between 2000 and 2010 at the Department of Pediatrics, University of Erlangen, were screened; 34 patients with isolated ON were identified. Progression to MS was defined according to the revised McDonald criteria 2005. Age, sex, VEPs, ON type, cMRI, OCB and visual recovery were assessed as predictors of progression to MS using simple logistic regressions. A multiple logistic regression model included variables found to be significant in univariate analyses. RESULTS: Abnormal cMRI was associated with an increase in the odds of MS development (odds ratio 20.57; 95% CI 2.16-196.10, P < 0.001), as was positive OCB (odds ratio 12.0; 95% CI 1.29-111.32, P = 0.001). However, only cMRI remained statistically significant in multiple regressions. CONCLUSIONS: Multiple sclerosis-like cMRI lesions and OCB are suitable for assessing the risk of progression to MS following isolated ON, as children with both cMRI abnormalities and positive OCB at onset of ON are at high risk of developing MS.

Development and preliminary validation of a risk prediction model for chemotherapy-related nausea and vomiting.

BACKGROUND: A number of risk factors have been implicated in the development of chemotherapy-induced nausea/vomiting (CINV). Our aim was to develop a risk prediction model and identify patients at high risk for developing CINV before their chemotherapy treatment. PATIENTS AND METHODS: A multisite, observational, prospective longitudinal design was used. Participants were 336 chemotherapy-naïve cancer patients providing 791 assessments. They completed measures to assess potential risk factors for CINV, including socio-demographic and clinical/treatment-related characteristics, symptom distress, expectations for CINV and state-trait anxiety. CINV was measured with the MASCC Antiemesis Tool. Participants were divided randomly to a training set (=286) and a test set (=50). Random-effects models were run to ascertain the contribution of risk factors in the development of CINV using the training sample. Specificity and sensitivity of the model were assessed in both sets of samples. RESULTS: Younger age, history of nausea/vomiting, trait anxiety and fatigue were linked with higher levels of CINV, and use of moderately and low emetogenic chemotherapy were linked with lower CINV. The model's specificity were 55.4 and 50.0 % and sensitivity were 80.3 and 79.0 % in the training and test sample, respectively. A dynamic web-based tool is freely available for use by clinicians. CONCLUSION: This model of risk prediction for CINV can be an aid to clinical decision-making and assist clinicians to rationalise antiemetic use with their patients.

Health checks in primary care for adults with intellectual disabilities: how extensive should they be?

BACKGROUND: Routine health checks have gained prominence as a way of detecting unmet need in primary care for adults with intellectual disabilities (ID) and general practitioners are being incentivised in the UK to carry out health checks for many conditions through an incentivisation scheme known as the Quality and Outcomes Framework (QOF). However, little is known about the data being routinely recorded in such health checks in relation to people with ID as practices are currently only incentivised to keep a register of people with ID. The aim of this study was to explore the additional value of a health check for people with ID compared with standard care provided through the current QOF structure. METHODS: Representative practices were recruited using a stratified sampling approach in four primary care trusts to carry out health checks over a 6-month period. The extracted data were divided into two aggregated informational domains for the purpose of multilevel regression analysis: 'ID-specific' (containing data on visual assessment, hearing assessment, behaviour assessment, bladder function, bowel function and feeding assessment) and financially incentivised QOF targets (blood pressure, smoking status, ethnicity, body mass index, urine analysis and carer details) which are incentivised processes. RESULTS: A total of 651 patients with ID were identified in 27 practices. Only nine practices undertook a health check on 92 of their patients with ID. Significant differences were found in the recorded information, between those who underwent a health check and those who did not (P < 0.001, chi(2) = 56.3). In the group that had health check, recorded information was on average higher for the 'QOF targets' domain, compared with the 'ID-specific' domain, by 58.7% (95% CI: 54.1, 63.3, P < 0.001). CONCLUSIONS: If incentives are to be used as a method for improving care for people with ID through health checks a more targeted approach focused on ID-specific health issues might be more appropriate than an extensive health check.

Impaired P600 in neuroleptic naive patients with first-episode schizophrenia.

Deficits of working memory (WM) are recognized as an important pathological feature in schizophrenia. Since the P600 component of event related potentials has been hypothesized that represents aspects of second-pass parsing processes of information processing, and is related to WM, the present study focuses on P600 elicited during a WM test in drug-naive first-episode schizophrenics (FES) compared to healthy controls. We examined 16 drug-naive first-episode schizophrenic patients and 23 healthy controls matched for age and sex. Compared with controls schizophrenic patients showed reduced P600 amplitude on left temporoparietal region and increased P600 amplitude on left occipital region. With regard to the latency, the patients exhibited significantly prolongation on right temporoparietal region. The obtained pattern of differences classified correctly 89.20% of patients. Memory performance of patients was also significantly impaired relative to controls. Our results suggest that second-pass parsing process of information processing, as indexed by P600, elicited during a WM test, is impaired in FES. Moreover, these findings lend support to the view that the auditory WM in schizophrenia involves or affects a circuitry including temporoparietal and occipital brain areas.