Association between inpatient palliative care encounter and 30-day all-cause readmissions after index hospitalization for chronic obstructive pulmonary disease.

BACKGROUND: Studies exist on the association between inpatient Palliative Care Encounter (iPCE) and 30-day rehospitalization among cancer and several non-cancer conditions but limited in persons with Chronic Obstructive Pulmonary Disease (COPD). OBJECTIVE: To assess the association between an iPCE with the risk of 30-day rehospitalization after an index hospitalization for COPD. METHODS: We conducted a cross-sectional analysis of the Nationwide Readmissions Database (2010-2014). Index hospitalizations were defined as persons ≥ 18 years of age, discharge destinations of either Home/Routine, Home with Home Care, or a Facility, and an index hospitalization with Diagnosis Related Group of COPD. The International Classification of Diseases, 9th revision codes were used to extract comorbidities and a Palliative Care Encounter (V66.7). RESULTS: There were 3,163,889 index hospitalizations and iPCE occurred in 21,330 (0.67%). There were 558,059 (17.63%) with a 30-day rehospitalization. An iPCE was associated with a significantly lower adjusted odds of 30-day readmission (Odds Ratio [OR], 0.50; 95% Confidence Interval [CI], 0.46 to 0.54).  By discharge destination, the odds of 30-day rehospitalization were for a discharged to a facility (OR, 0.37; 95% CI, 0.32 to 0.42), to home with home health (OR, 0.42; 95% CI, 0.37 to 0.47), and to home (OR, 0.98; 95% CI, 0.85 to 1.12) for those with relative to without iPCE. CONCLUSION: Inpatient PCE was associated with a 50% lower relative odds of 30-day rehospitalization after an index hospitalization for COPD. This association varied by discharge destination being statistically significant among those with a discharge destination of a facility (63%) and home with home care (58%).

Inpatient palliative care encounter and 30-day readmission among hospitalizations for heart failure.

Aim: To determine the association between inpatient palliative care encounter (PCE) and 30-day rehospitalization. Materials & methods: The Nationwide Readmission Database was used in a cross-sectional design study. Comorbidities and a palliative care encounter (PCE; V66.7) were defined using ICD-9 codes. Results: Overall, 21.28% of 3,534,480 index hospitalizations were readmitted. PCE occurred in 1.66% of index hospitalizations and was associated with a lower odds of 30-day rehospitalization (adjusted odds ratio, 0.38; 95% CI: 0.35-0.40). This association remained significant when assessed by discharge destination. Conclusion: PCE was associated with a lower relative odds of 30-day rehospitalization. A 73% decrease in the relative odds of 30-day rehospitalization among discharges to a facility, 64% for home with home health, and 22% for discharges to home.

A customized early warning score enhanced emergency department patient flow process and clinical outcomes in a COVID-19 pandemic.

Objective: Patient crowding and boarding in the emergency department (ED) is associated with adverse outcomes and has become increasingly problematic in recent years. We investigated the impact of an ED patient flow countermeasure using an early warning score. Methods: We conducted a cross-sectional analysis of observational data from patients who presented to the ED of a Level 1 Trauma Center in Pennsylvania. We implemented a modified version of the Modified Early Warning Score (MEWS), called mMEWS, to address patient flow. Patients aged ≥18 years old admitted to the adult hospital medicine service were included in the study. We compared the pre-mMEWS (February 19, 2017-February 18, 2019) to the post-mMEWS implementation period (February 19, 2019-June 30, 2020). During the intervention, low MEWS (0-1) scoring admissions went directly to the inpatient floor with expedited orders, the remainder waited in the ED until the hospital medicine admitting team evaluated the patient and then placed orders. We investigated the association between mMEWS, ED length of stay (LOS), and 24-hour rapid response team (24 hour-RRT) activation. RRT activation rates were used as a measure of adverse outcome for the new process and are a network team response for admitted patients who are rapidly decompensating. The association between mMEWS and the outcomes of ED length of stay in minutes and 24 hour-RRT activation was assessed using linear and logistic regression adjusting for a priori selected confounders, respectively. Results: Of the total 43,892 patients admitted, 19,962 (45.5%) were in the pre-mMEWS and 23,930 (54.5%) in the post-mMEWS implementation period. The median post-mMEWS ED LOS was shorter than the pre-mMEWS (376 vs 415 minutes; P < 0.01). After accounting for potential confounders, there was a 4.57% decrease in the ED LOS after implementing mMEWS (95% confidence interval [CI], 4.20-4.94; P < 0.01). The proportion of 24 hour-RRT did not differ significantly when comparing pre- and post-mMEWS (33.5% vs 34.4%; P = 0.83). Conclusion: The use of a modified MEWS enhanced admission process to the hospital medicine service, even during the COVID-19 pandemic, was associated with a significant decrease in ED LOS without a significant increase in 24 hour-RRT activation.

Enhanced expression and purification of membrane proteins by SUMO fusion in Escherichia coli.

Severe acute respiratory syndrome coronavirus (SARS-CoV) membrane protein and 5-lipoxygenase-activating protein (FLAP) are among a large number of membrane proteins that are poorly expressed when traditional expression systems and methods are employed. Therefore to efficiently express difficult membrane proteins, molecular biologists will have to develop novel or innovative expression systems. To this end, we have expressed the SARS-CoV M and FLAP proteins in Escherichia coli by utilizing a novel gene fusion expression system that takes advantage of the natural chaperoning properties of the SUMO (small ubiquitin-related modifier) tag. These chaperoning properties facilitate proper protein folding, which enhances the solubility and biological activity of the purified protein. In addition to these advantages, we found that SUMO Protease 1, can cleave the SUMO fusion high specificity to generate native protein. Herein, we demonstrate that the expression of FLAP and SARS-CoV membrane proteins are greatly enhanced by SUMO fusions in E. coli.

Expression and purification of SARS coronavirus proteins using SUMO-fusions.

Severe acute respiratory syndrome coronavirus (SARS-CoV) proteins belong to a large group of proteins that is difficult to express in traditional expression systems. The ability to express and purify SARS-CoV proteins in large quantities is critical for basic research and for development of pharmaceutical agents. The work reported here demonstrates: (1) fusion of SUMO (small ubiquitin-related modifier), a 100 amino acid polypeptide, to the N-termini of SARS-CoV proteins dramatically enhances expression in Escherichia coli cells and (2) 6x His-tagged SUMO-fusions facilitate rapid purification of the viral proteins on a large scale. We have exploited the natural chaperoning properties of SUMO to develop an expression system suitable for proteins that cannot be expressed by traditional methodologies. A unique feature of the system is the SUMO tag, which enhances expression, facilitates purification, and can be efficiently cleaved by a SUMO-specific protease to generate native protein with a desired N-terminus. We have purified various SARS-CoV proteins under either native or denaturing conditions. These purified proteins have been used to generate highly specific polyclonal antibodies. Our study suggests that the SUMO-fusion technology will be useful for enhancing expression and purification of the viral proteins for structural and functional studies as well as for therapeutic uses.