Quantitative Analysis of Characteristics Associated with Patient-Directed Discharges, Representations, and Readmissions: a Safety-Net Hospital Experience.

BACKGROUND: No clinical tools currently exist to stratify patients' risks of patient-directed discharge (PDD). OBJECTIVE: This study aims to identify trends and factors associated with PDD, representation, and readmission. DESIGN: This was an IRB-approved, single-centered, retrospective study. PARTICIPANTS: Patients aged > 18, admitted to medicine service, were included from January 1st through December 31st, 2019. Patients admitted to ICU or surgical services were excluded. MAIN MEASURES: Demographics, insurance information, medical history, social history, rates of events occurrences, and discharge disposition were obtained. KEY RESULTS: Of the 16,889 encounters, there were 776 (4.6%) PDDs, 4312 (25.5%) representations, and 2924 (17.3%) readmissions. Of those who completed PDDs, 42.1% represented and 26.4% were readmitted. Male sex, age ≤ 45, insurance type, homelessness, and substance use disorders had higher rates of PDD (OR = 2.0; 4.2; 4.5; 6.2; 5.2; p < 0.0001, respectively). Patients with homelessness, substance use disorders, mental health disorders, or prior history of PDD were more likely to represent (OR = 3.6; 2.0; 2.0; 1.5; p < 0.0001, respectively) and be readmitted (OR = 2.2; 1.6; 1.9; 1.5; p < 0.0001, respectively). Patients aged 30-35 had the highest PDD rate at 16%, but this was not associated with representations or readmissions. Between July and September, the PDD rate peaked at 5.5% and similarly representation and readmission rates followed. The rates of subsequent readmissions after PDDs were nearly two-fold compared to non-PDD patients in later half of the year. 51% of all subsequent readmissions occur within 7 days of PDD, compared to 34% in the non-PDD group (OR = 2.0; p < 0.0001). Patients with primary diagnosis of abscess had 16% PDDs. CONCLUSIONS: Factors associated with PDD include male, younger age, insurance type, substance use, homelessness, and primary diagnosis of abscess. Factors associated with representation and readmission are homelessness, substance use disorders, mental health disorders, and prior history of PDD. Further research is needed to develop a risk stratification tool to identify at-risk patients.

Oil droplet cataracts can mimic retinal disease.

PURPOSE: Oil Droplet Cataracts in adults is an elusive diagnosis for ophthalmologist. It is difficult to diagnose, and patients can suffer for years with increasingly debilitating symptoms for what is a surgically curable condition. Additionally, patients often undergo difficult and costly medical testing as well as occasionally receive improper treatment. This case series goal is to highlight this condition, showing that with careful slit lamp examination and index of suspicion one is able to appropriately diagnose this condition and avoid unnecessary testing and harm to a patient's quality of life. METHODS: Nine cases of this diagnostically challenging condition seen by one of the authors of this paper (JSS) are included. All were referred for electrophysiological or careful testing for unexplained visual loss, by neuroophthalmologists and/or retina specialists. Three were suspected of having a retinal dystrophy. Many had already undergone MRI and extensive evaluations. RESULTS: All patients were women. The average age was 45.5 years old with a range of 32-52 years of age on at their initial visit. The average length of symptoms prior to the initial visit was 3.2 years with a range of 3 months-11 years and a median of 4 years. Six had uniocular oil droplet cataracts, and three had binocular involvement. At diagnosis of the affected eyes, visual acuity ranged from 20/30-1 to 20/160 with a median of 20/65 in the affected eyes. Five patients had monocular diplopia or triplopia. Four had myopic shifts. Six patients had cataract surgery with resolution of their symptoms and restoration of good visual acuity. One patient who had been prescribed a low vision telescope for her presumed retinal dystrophy recovered to 20/20- ou, and had normalization of her electroretinogram after cataract surgery. CONCLUSIONS: This case series shows the diagnostic difficulty of this condition and the years it could take before a definitive diagnosis is made. Slit lamp examination was able to successfully diagnose this condition, although sometimes the oil droplet cataract was not seen until a later visit. Oil droplet cataracts should be considered in the differential diagnosis for a patient presenting with unexplained visual loss or acute worsening visual difficulties, and may mimic a retinal dystrophy. Once diagnosed, cataract surgery can cure this condition.(Abraham Ifrah, Janet S Sunness; Oil Drop Cataracts Mimicking Retinal Disease. Invest. Ophthalmol. Vis. Sci. 2020;61(7):3851).

Abnormal Visual Function Outside the Area of Atrophy Defined by Short-Wavelength Fundus Autofluorescence in Stargardt Disease.

Purpose: To examine the extent of visual function abnormality outside the dark lesion on short-wavelength fundus autofluorescence (SW-AF), and its correlation with background SW-AF features and optical coherence tomography (OCT) in recessive Stargardt disease (STGD1). Methods: Forty-nine eyes of 25 participants in the ProgStar (the Natural History of the Progression of Atrophy Secondary to Stargardt Disease) study at our center were included. Patients underwent microperimetry (both threshold and dense scotoma mapping), OCT, SW-AF, and visual acuity testing. The Fisher's exact test, the χ2 test, and unpaired t-tests were used to analyze the data. Results: Of 40 eyes without central fixation, 33 (82%) placed fixation remote (most ≥5°) from the dense scotoma edge, despite good intervening retinal sensitivity. OCT findings accounted for the remote fixation in 75%. Eighteen (37%) of all 49 eyes had dense scotoma extending past the dark lesion border. OCT was not adequate to define the edge of the scotoma. Of the 49 eyes, 28 (57%) had the mottled background pattern, 10 (20%) had the uniform pattern, and 11 (22%) had the other pattern, with >75% of eyes in each pattern having remote fixation. The dense scotoma exceeded the dark lesion primarily in the mottled pattern. The two eyes of each patient were concordant in all features. Conclusions: Functional abnormalities in STGD1 extend past the SW-AF dark lesion. The disruption of the ellipsoid zone shows that photoreceptor abnormality extends peripheral to the dark lesion, and it explains in part the remote fixation pattern and the dense scotoma exceeding the dark lesion. This has implications for clinical trials for STGD1.