Early Readmissions after Esophagectomy for Esophageal Adenocarcinoma: Does Facility Case-Volume Matter?

Increased esophagectomy procedures over the past four decades have correlated with the rise in incidence of esophageal adenocarcinoma. Despite advances in technology and procedural expertise, esophagectomy remains a high-risk surgical procedure. Higher volume facilities have more experience with esophagectomy and would be expected to have a lower incidence of surgical complications and attendant morbidity and mortality. By analyzing information from a nationwide United States hospital database, we sought to find out if there is a significant difference between facilities stratified by case volume, with regards to 30-day readmission after esophagectomy. The findings of this study indicated that even with a large applied differential, early readmissions did not differ significantly between high- and low-volume centers. Also, analyzed and discussed were any associated demographic and comorbidity factors as they relate to early readmissions after esophagectomy for esophageal adenocarcinoma across the country. This is the first study to specifically address these variables.

Readmissions related to short bowel syndrome: a study from a national database.

While short bowel syndrome (SBS) is the leading cause of intestinal failure in children, little objective data are available regarding hospital readmissions for children with SBS. This study sought to investigate rehospitalizations related to SBS in young children. Data for study were obtained from the 2013 Nationwide Readmissions Database (NRD). Using data from the 2013 NRD, we identified a total of 1898 hospitalizations in children with SBS aged 1-4 years. A total of 901 index cases and 997 rehospitalizations were noted. Of these, 425 children (47.2%) underwent rehospitalizations. The most frequent diagnoses and procedures associated with readmission of children with SBS were related to infections and intravenous catheter placement. This is the first study to use US nationwide data to report on the incidence of readmissions in children with SBS. The results from this study indicate that improving central line care and providing home healthcare resources to families at discharge may help in preventing SBS-related rehospitalizations.

Risk factors for Clostridium difficile infection in pediatric inpatients: A meta-analysis and systematic review.

OBJECTIVE: To summarize risk factors for Clostridioides (formerly Clostridium) difficile infection (CDI) in hospitalized pediatric patients as determined by previous observational studies. DESIGN: Meta-analysis and systematic review. PATIENTS: Studies evaluating risk factors for CDI in pediatric inpatients were eligible for inclusion. METHOD: We systematically searched MEDLINE, Web of Science, Scopus, and EMBASE for subject headings and text words related to CDI and pediatrics from 1975 to 2017. Two of the investigators independently screened studies, extracted and compiled data, assessed study quality, and performed the meta-analysis. RESULTS: Of the 2,033 articles screened, 14 studies reporting 10,531,669 children met the inclusion criteria. Prior antibiotic exposure (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.31-3.52) and proton pump inhibitor (PPI) use (OR, 1.33; 95% CI, 1.07-1.64) were associated with an increased risk of CDI in children. Subgroup analyses using studies reporting only adjusted results suggested that prior antibiotic exposure is not a significant risk factor for CDI. H2 receptor antagonist (H2RA) use (OR, 1.36; 95% CI, 0.31-5.98) and that female gender (OR, 0.87; 95% CI, 0.74-1.03) did not play a significant role as a risk factor for developing CDI. CONCLUSION: Prior antibiotic exposure appears to be an important risk factor for CDI based on the combined analysis but not significant using adjusted studies. PPI use was associated with an increased risk of CDI. Judicious and appropriate use of antibiotics and PPIs may help reduce the risk of CDI in this vulnerable population.

Hospital readmissions related to Clostridium difficile infection in the United States.

Using a national readmissions database, we report a significant burden of Clostridium difficile-associated readmissions in the United States manifested as a high rate of rehospitalizations and substantial hospital stays and costs.

Mortality associated with gastrointestinal bleeding in children: A retrospective cohort study.

AIM: To determine the clinical characteristics of children with gastrointestinal bleeding (GIB) who died during the course of their admission. METHODS: We interrogated the Pediatric Hospital Information System database, including International Classification of Diseases, Current Procedural Terminology and Clinical Transaction Classification coding from 47 pediatric tertiary centers extracting the population of patients (1-21 years of age) admitted (inpatient or observation) with acute, upper or indeterminate GIB (1/2007-9/2015). Descriptive statistics, unadjusted univariate and adjusted multivariate analysis of the associations between patient characteristics and treatment course with mortality was performed with mortality as primary and endoscopy a secondary outcome of interest. All analyses were performed using the R statistical package, v.3.2.3. RESULTS: The population with GIB was 19528; 54.6% were male, overall mortality was 2.07%; (0.37% in patients with the principal diagnosis of GIB). When considering only the mortalities in which GIB was the principal diagnosis, 48% (12 of 25 principal diagnosis GIB mortalities) died within the first 3 d of admission, whereas 19.8% of secondary diagnosis GIB patients died with 3 d of admission. Patients who died were more likely to have received octreotide (19.8% c.f. 4.04%) but tended to have not received proton pump inhibitor therapy in the first 48 h, and far less likely to have undergone endoscopy during their admission (OR = 0.489, P < 0.0001). Chronic liver disease associated with a greater likelihood of endoscopy. Mortalities were significantly more likely to have multiple complex chronic conditions. CONCLUSION: GIB associated mortality in children is highest within 7 d of admission. Multiple comorbidities are a risk factor whereas early endoscopy during the admission is protective.

Readmission after Gastrointestinal Bleeding in Children: A Retrospective Cohort Study.

INTRODUCTION: To compare the demographic, clinical, and therapeutic characteristics in a cohort of patients discharged following acute gastrointestinal bleeding, representing to the emergency department (ED) and readmitted within 30 days of discharge with the characteristics of non-readmitted patients. STUDY DESIGN: Hospitalization data was obtained from the Pediatric Hospital Information System including 49 tertiary children's hospitals in the US. Children 1-21 years of age diagnosed with acute gastrointestinal bleeding, admitted between January 2007 and September 2015 were included. The primary outcomes in this study were 30-day inpatient readmission through the ED and 30-day return to the ED only. Unadjusted, univariate followed by multivariable analysis of the associations between patient characteristics and treatment course at the index encounter using the R statistical package, v. 3.2.3. RESULTS: During the study period, 9902 patients were admitted with acute gastrointestinal bleeding; in the following month, 1460 (16.1%) represented to the ED and 932 (9%) were readmitted; 68.7% within 14 days from discharge. Readmission was most frequently associated with portal hypertension or esophageal variceal hemorrhage. There was a decreased likelihood of readmission with endoscopy (OR 0.77, 95% CI, 0.661, 0.906) and with Meckel scan (OR 0.513, 95% CI 0.362, 0.727) during the initial admission. Multiple comorbidities, longer initial stay and the early proton pump inhibitor therapy were associated with higher likelihood of readmission. DISCUSSION: Readmission following acute gastrointestinal bleeding is common and is more likely following variceal hemorrhage, long initial admission, and chronic comorbidities.

Impact of sustained virological response to chronic hepatitic C antiviral therapy on new onset diabetes mellitus type 2 after controlling for metabolic syndrome.

The high cost associated with antiviral treatment for chronic hepatitis C virus (HCV) infection mandates further investigation in the context of preventing complications such as type 2 diabetes mellitus (DM2). We determined the cumulative incidence of DM2 in subjects with chronic HCV infection who received concomitant pegylated interferon (Peg-IFN) and ribavirin. We conducted a retrospective analysis of data obtained from Veterans Administrations Informatics and Computing Infrastructure (VINCI) to identify an adult cohort of patients without diabetes with chronic HCV infection who received Peg-IFN-based therapy between October 2001 and December 2011. Patients with history of HIV, hepatitis B infection, hepatocellular cancer (HCC), non-HCC cancers, and history of transplantation were excluded. Sustained virological response (SVR) was defined as negative HCV RNA 3 months after completion of therapy. Using Cox proportional hazards regression for multivariable analysis, we determined that patients who achieved SVR were at a significantly less risk of developing DM2. Adjusted survival rates showed that the responders' group was significantly less likely to develop DM2 over time (HR 0.60, CI 0.48 to 0.74, p<0.001). Peg-IFN-based therapy in chronic HCV patients that resulted in SVR significantly decreased the risk of developing DM2 and independently predicts the development of new onset disease after controlling for correlates of metabolic syndrome.

Emergency department visits related to functional abdominal pain in the pediatric age group.

To analyze visits to and admissions from the emergency department (ED) in children with a primary diagnosis of functional abdominal pain (FAP). This was a cross-sectional study using data from the Nationwide Emergency Department Sample (HCUP-NEDS 2008-2012). FAP-related ED visits were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. The most frequent secondary diagnoses associated with FAP-related ED visits were also extracted. In 2012, a total of 796,665 children presented to the ED with a primary diagnosis of FAP. This correlated to a rate of 11.5 ED visits/1000 population. The highest incidence of ED visits was observed for children in the 10-14-year age group; median (IQR) age of 11 (8) years. In analyzing the temporal trends associated with FAP-related ED visits, we observed an increase in both the overall number of visits (14.0%) as well as the population-adjusted incidence (16.0%) during the period 2008-2012. This coincided with a decreasing trend in hospital admissions from the ED; from 1.4% in 2008 to 1.0% in 2012 (-28.5%). The overwhelming majority (96.7%) of patients with FAP who presented to the ED were treated and released. On multivariate analysis, the leading factor associated with an increased likelihood of admission from the ED was teaching hospital status (aOR 2.07; 95% CI 1.97 to 2.18). The secondary diagnosis most commonly associated with FAP-related ED visits was nausea and/or emesis (19.8%). Pediatric FAP-related ED visits increased significantly from the period 2008 to 2012. However, the incidence of hospital admissions from the ED declined during the same period.

Epidemiology and Healthcare Resource Utilization Associated With Children With Short Bowel Syndrome in the United States.

BACKGROUND: There is a lack of large database research relating to the epidemiology and health resource utilization associated with short bowel syndrome (SBS) in the United States. METHODS: We analyzed the Kids' Inpatient Database for the year 2012 and utilized International Classification of Diseases, Ninth Revision, and Clinical Modification ( ICD-9-CM) diagnosis codes to identify patients 0-3 years of age with SBS, who were matched by age and sex to children without SBS. The study variables included patient and hospital demographics, All Patient Refined Diagnosis Related Groups, in-hospital mortality, hospital length of stay, and hospitalization costs. We also determined the most frequent ICD-9-CM diagnostic and procedural codes associated with SBS. RESULTS: Children with SBS demonstrated a higher rate of mortality than that of children without SBS (1.6% vs 0.7%; P < .001). Children with SBS also experienced a longer length of stay (median days [interquartile range]: 8 [15] vs 2 [3]; P < .001) and higher hospital costs ($17,000 [$34,000] vs $3000 [$5000]; P < .001). The most frequent medical diagnoses associated with SBS were infection (62%), anemia (29%), and liver disease (17%). Children with SBS also demonstrated more severe illness as assessed by an All Patient Refined Diagnosis Related Group score of 3 or 4 (94.30% vs 16.20%; P < .001). CONCLUSIONS: Children hospitalized with SBS have a high severity of illness and experience complicated inpatient courses related to their disease. Our study represents the first use of national U.S. data to study the epidemiology and health resource utilization associated with SBS.

Pediatric hospitalizations for inflammatory bowel disease based on annual case volume: results from the Kids' Inpatient Database 2012.

To study differences related to pediatric inflammatory bowel disease (IBD) care among hospitals that were stratified based on annual case volume. This is a cross-sectional study using data from the United States Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). IBD-related hospitalizations were identified using International Classification of Diseases-9-Clinical Modification codes. Hospital volume was divided into low or high by assigning cut-off values of 1-20 and >20 annual IBD hospitalizations. We assessed a total of 8647 pediatric IBD discharges during 2012 from 660 hospitals in the USA. 107 of these hospitals were classified as high-volume centers (HVCs) for pediatric IBD care and 553 low-volume centers (LVCs). HVCs were more likely to be associated with an academic teaching status compared to LVCs (97.1% vs 67.6%, p<0.001). The incidence of transfer of medical care from LVCs to other hospitals was 5.5% but only 0.7% for HVCs (p<0.001). The median number of procedures (medical and surgical) performed on children admitted with IBD was higher at HVCs (2 vs 1, p<0.001). IBD admissions at HVCs were more likely to undergo surgical procedures compared to LVCs (17% vs 10%, p<0.001). The incidence of postoperative complications was not significantly different. There were significantly greater hospital costs (median US$11,000 vs US$6,000, p<0.001) and lengths of stay (median 5 days vs 4 days, p<0.001) associated with HVCs compared to LVCs. Pediatric admissions to HVCs for IBD undergo a greater number of medical and surgical procedures and are associated with higher costs and lengthier hospital stays.

Rising Incidence of Clostridium difficile Related Discharges among Hospitalized Children in the United States.

Using a national database, we report an increasing trend in Clostridium difficile incidence among hospitalized children in the United States from 2003 to 2012. The incidence rate of CDI increased from 24.0 to 58.0 per 10,000 discharges per year (P<0.001) across all age groups, with the greatest increase in children 15 years and older. Infect. Control Hosp. Epidemiol. 2015;37(1):104-106.

Acute Recurrent Pancreatitis in Children: A Study From the Pediatric Health Information System.

We investigated acute recurrent pancreatitis (ARP) in children using a national health care database. From 2002 to 2014, 26,435 children had a diagnosis of acute pancreatitis (AP); 10,648 discharges were index hospitalizations. A total of 6159 children had a single hospitalization for AP, whereas 4489 (42%) children underwent 15,787 rehospitalizations. Children experienced a median of 2 ARP-related hospitalizations with a median time between admissions of 86 days. Younger patients with a more severe index episode of AP were at a higher risk of ARP. ARP-related hospitalizations had an increased requirement for intensive care unit care compared with an index episode of AP.

Emergency Department Visits and Hospitalizations in Children With Chronic Pancreatitis in the United States.

We analyzed 2 national databases to assess the use of health care resources by children with chronic pancreatitis (CP). In 2012, the hospital discharge rate for pediatric CP was 2.73/100,000 children. Patients with CP were sicker with a greater burden of illness than age- and sex-matched counterparts. Acute pancreatitis occurred frequently in hospitalized children with CP. Abdominal pain and nausea, and vomiting were the most common gastrointestinal symptoms associated with emergency department visits in children with CP. A significant proportion of these visits resulted in a hospitalization. These findings add to our understanding of the epidemiology of CP in the United States.

Esophageal variceal bleeding in hospitalized patients with cirrhosis.

Esophageal variceal bleeding (EVB) is a frequent complication in cirrhotic patients resulting in considerable mortality and morbidity. The aim of this study was to investigate the occurrence, impact, and trends of EVB in hospitalized cirrhotic patients on a nationwide level in the United States. We interrogated data from the Nationwide Inpatient Sample from 2002 to 2012. Utilizing International Classification of Diseases, Ninth Revision, Clinical Modification codes, we analyzed hospital discharges for cirrhosis and related EVB in adult patients. EVB in cirrhotic patients was independently associated with overall worse outcomes with respect to in-hospital mortality (10% vs 5%; P < 0.01) and hospital charges (median $41,000 vs $26,000; P < 0.01). In the period from 2002 to 2012, the number of cirrhosis-related hospitalizations increased from 337,956 to 570,220 (P < 0.01). Concurrently, the incidence of EVB in hospitalized cirrhotic patients declined from 8.60% to 5.78%, with an overall decreased trend (P < 0.01). The decline in the rate of EVB in hospitalized cirrhotic patients from 2002 to 2012 likely reflects the effectiveness of primary and secondary prophylaxis.

Emergency Department Visits Related to Inflammatory Bowel Disease: Results From Nationwide Emergency Department Sample.

We analyzed a national US database to study the presentation of children with inflammatory bowel disease (IBD) to the emergency department (ED). Our results indicate that from 2006 to 2010, there was a significant increase in the number of ED visits related to children with IBD accompanied by a contemporaneous decline in the rate of hospitalization that followed these ED visits. Earlier published results have highlighted an increased overall rate of hospitalizations in the United States related to children with IBD. In this context, our results support the evidence for an increased prevalence of pediatric IBD in the United States in recent years.

Accuracy of loop-mediated isothermal amplification for the diagnosis of Clostridium difficile infection: a systematic review.

Loop-mediated isothermal DNA amplification (LAMP) is currently used as standalone diagnostic test for C. difficile infection (CDI). We assessed the diagnostic accuracy of LAMP for the diagnosis of CDI. We searched 5 databases to identify studies that compared LAMP with culture cytotoxicity neutralization assay or anaerobic toxigenic culture (TC) of C. difficile. We used the random-effects model to calculate pooled sensitivities, specificities, diagnostic odds ratios, and their 95% confidence intervals (CIs). The search of the databases yielded 16 studies (6979 samples) that met inclusion criteria. When TC was used as the gold standard (6572 samples), bivariate analysis yielded a mean sensitivity of 0.95 (95% CI, 0.93-0.97; I(2)=67.4) and a mean specificity of 0.99 (95% CI, 0.96-1.00; I(2)=97.0). LAMP is a useful diagnostic tool with high sensitivity and specificity for detecting CDI. The results should, however, be interpreted only in the presence of clinical suspicion and symptoms of CDI.

Emergency department visits for acute pancreatitis in children: results from the Nationwide Emergency Department Sample 2006-2011.

OBJECTIVE: The objective of this study was to describe the epidemiology and trends in pediatric acute pancreatitis (AP)-associated emergency department (ED) visits in the United States. METHODS: Estimates of AP-associated ED visits were calculated in children from birth to 19 years of age using the Nationwide Emergency Department Sample. RESULTS: From 2006 to 2011, there were an estimated total of 78,787 ED visits associated with the diagnosis of AP. The greatest number of ED visits occurred in children 15 to 19 years of age (67.0%). A majority of patients were subsequently admitted to the hospital for further care (74.1%). Risk factors independently associated with an increased rate of hospital admission included 3 or more comorbid conditions (adjusted odds ratio [aOR] 12.81; 95% confidence interval [CI], 11.29-14.56), children younger than 5 years (aOR, 1.73; 95% CI, 1.58-1.89), presentation to a teaching hospital (aOR, 1.68; 95% CI, 1.62-1.74) or a hospital in the Western region of the United States (aOR, 1.48; 95% 1.42-1.54), and health coverage with Medicaid (aOR, 1.23; 95% CI, 1.17-1.29). Acute pancreatitis-associated ED visits increased from 14.5 per 100,000 children in 2006 to 16.1 per 100,000 children in 2011 (11.42% increase; P < 0.01). CONCLUSION: There has been an increasing incidence of AP-associated ED visits in children from 2006 to 2011.

Emergency department visits related to cirrhosis: a retrospective study of the nationwide emergency department sample 2006 to 2011.

There is scant literature about cirrhosis and its associated complications in a non-hospitalized population.To study the epidemiology of cirrhosis-associated Emergency Department visits in the US.Estimates were calculated in patients' ≥18 years using the Nationwide Emergency Department Sample.The number of visits associated with an International Classification of Diseases-9 diagnosis code of cirrhosis increased non-significantly from 23.81/10,000 population (2006) to 23.9/10,000 population (2011; P = 0.05). A majority of these patients (75.30%) underwent hospital admission, the greatest risk factor for this was the presence of ≥3 comorbidities (adjusted odds ratio 30.8; 95% Confidence Interval 30.4-31.2). Infection was the most frequent concurrent complicating diagnosis associated with cirrhosis (20.1%). There was a decreased incidence in most of the complicating conditions except for hepatorenal syndrome and spontaneous bacterial peritonitis.Our results indicate a stable trend for cirrhosis-associated Emergency Department visits from 2006 to 2011. Further studies are required to investigate the increased incidence of spontaneous bacterial peritonitis and hepatorenal renal syndrome in the cirrhotic population.

Risk factors for recurrent Clostridium difficile infection: a systematic review and meta-analysis.

OBJECTIVE: An estimated 20-30% of patients with primary Clostridium difficile infection (CDI) develop recurrent CDI (rCDI) within 2 weeks of completion of therapy. While the actual mechanism of recurrence remains unknown, a variety of risk factors have been suggested and studied. The aim of this systematic review and meta-analysis was to evaluate current evidence on the risk factors for rCDI. DESIGN: We searched MEDLINE and 5 other databases for subject headings and text related to rCDI. All studies investigating risk factors of rCDI in a multivariate model were eligible. Information on study design, patient population, and assessed risk factors were collected. Data were combined using a random-effects model and pooled relative risk ratios (RRs) were calculated. RESULTS: A total of 33 studies (n=18,530) met the inclusion criteria. The most frequent independent risk factors associated with rCDI were age≥65 years (risk ratio [RR], 1.63; 95% confidence interval [CI], 1.24-2.14; P=.0005), additional antibiotics during follow-up (RR, 1.76; 95% CI, 1.52-2.05; P<.00001), use of proton-pump inhibitors (PPIs) (RR, 1.58; 95% CI, 1.13-2.21; P=.008), and renal insufficiency (RR, 1.59; 95% CI, 1.14-2.23; P=.007). The risk was also greater in patients previously on fluoroquinolones (RR, 1.42; 95% CI, 1.28-1.57; P<.00001). CONCLUSIONS: Multiple risk factors are associated with the development of rCDI. Identification of modifiable risk factors and judicious use of antibiotics and PPI can play an important role in the prevention of rCDI.