Predicting non-elective hospital readmissions: a multi-site study. Department of Veterans Affairs Cooperative Study Group on Primary Care and Readmissions.

OBJECTIVE: To determine clinical and patient-centered factors predicting non-elective hospital readmissions. DESIGN: Secondary analysis from a randomized clinical trial. CLINICAL SETTING: Nine VA medical centers. PARTICIPANTS: Patients discharged from the medical service with diabetes mellitus, congestive heart failure, and/or chronic obstructive pulmonary disease (COPD). MAIN OUTCOME MEASUREMENT: Non-elective readmission within 90 days. RESULTS: Of 1378 patients discharged, 23.3% were readmitted. After controlling for hospital and intervention status, risk of readmission was increased if the patient had more hospitalizations and emergency room visits in the prior 6 months, higher blood urea nitrogen, lower mental health function, a diagnosis of COPD, and increased satisfaction with access to emergency care assessed on the index hospitalization. CONCLUSIONS: Both clinical and patient-centered factors identifiable at discharge are related to non-elective readmission. These factors identify high-risk patients and provide guidance for future interventions. The relationship of patient satisfaction measures to readmission deserves further study.

Eosinophilia-myalgia syndrome and fasciitis with an active alveolitis.

This patient clearly had the EMS with eosinophilic fasciitis, apparently due to L-tryptophan. He also had an active alveolitis with a DIP-UIP-like picture. The lung findings were not similar to those reported in the Mayo series. It is perhaps most likely that his interstitial lung disease was of the cryptogenic variety and unrelated to the L-tryptophan. However, a more direct association cannot be ruled out until more cases with similar findings are thoroughly evaluated. We suggest that special consideration of pertinent studies for interstitial lung disease is merited in all patients with suspected EMS. These might include diffusing capacity, gallium scans of lungs, broncho-alveolar lavage and possibly lung biopsy.

Neutrophil life span in paroxysmal nocturnal hemoglobinuria.

We have studied neutrophil intravascular life span in six patients with paroxysmal nocturnal hemoglobinuria (PNH); four had normal neutrophil counts when studied and two were neutropenic. Five patients had enough circulating neutrophils to isolate for tests in vitro. Lysis of labeled neutrophils was greatly increased, compared to that of normal volunteers, when these neutrophils were incubated with acidified fresh serum as a source of active complement plus serum containing antineutrophil antibodies (from three different sources). Despite the in vitro lesion, however, each of these patients had a normal neutrophil intravascular life span as measured by the 32P-diisopropylfluorophosphate technique. One neutropenic patient, who had a normal neutrophil life span, had a shift of cells from the circulating to marginated pool of sufficient degree to cause the neutropenia. A second (severely) neutropenic patient was found to have developed extreme marrow hypoplasia, also explaining the neutropenia. Thus, in contrast to the shortened red cell life span, we have been unable to find a shortened neutrophil life span in PNH.

Hematology and immunology studies: the second manned Skylab mission.

The hematologic and immunologic functions of the Skylab 3 (second manned mission) astronauts were examined during the preflight, inflight, and postflight phases of the 59-d mission in order to evaluate the response to and/or the influence of the space flight environment. Most changes observed were subtle and did not represent a threat to the health and safety of the crewmen during orbital flight. Even the most significant change observed, a reduction in the circulating red cell mass, did not have a detrimental influence on the astronaut cardiovascular or exercise responses as evaluated by other experiment protocols. Considering the facts that the data were not collected under ideally controlled conditions and that the astronauts were in excellent physical condition, the results of these studies would seem to indicate that man can function quite well in the space flight environment of the Skylab orbiting workshop for extended periods of time.

Effect of hemodialysis on factors influencing oxygen transport.

Ten patients underwent 4 study hemodialyses, one with standard dialysis conditions, one with an isophosphate dialysate, one with simultaneous ammonium chloride loading, and other, after pretreatment, with sodium bicarbonate. Measurement of hemoglobin oxygen affinity (P-50), erythrocyte 2,3-DPG, blood-gasses, and serum chemistries revealed biochemically effective hemodialyses and slight changes in oxygen transport parameters. The P-50 (in vivo) values decreased slightly but significantly (p greater than 0.05) with dialysis. When corrected to pH 7.4, eliminating the Bohr effect, P-50 increased (p greater than 0.05). With unmodified dialysis elevated values of 2,3-DPG (in comparison to normal) decreased, a change that did not correlate with delta-p-50, delta-serum phosphate, or delta-serum creatinine. With standard and isophosphate dialyses Po-2 decreased significantly. The decrease correlated with delta-hydrogen ion concentration and did not occur with dialyses designed to maintain pH constant. Thus, hemodialysis influences many factors that affect oxygen transport in different and counterbalancing directions. These changes are not totally explained by alterations in 2,3-DPG, pH or serum phosphate. Maintenance of acidosis or hyperphosphatemia during dialysis is not recommended.

Influence of peritoneal dialysis on factors affecting oxygen transport.

To determine the effect of changing concentrations of uremic metabolites on factors affecting oxygen transport, without the effects of extracorporeal blood pumping, we studied five patients before, during and after peritoneal dialysis. Significant decreases in serum urea, creatinine and phosphate and increase in serum bicarbonate were not associated with changes in P50, a reflection of hemoglobin-oxygen affinity. High erythrocyte 2,3-DPG concentrations decreased only slightly. Arterial pO2 increased slightly as negative fluid balance was achieved. The slight changes in oxygen transport parameters with dialysis suggest an interplay of compensatory factors and do not warrant modifying dialysis to limit the correction on acidosis or hyperphosphatemia. Effects on hemoglobin and pO2 resulting from fluid loss can be the dominant influence of peritoneal dialysis on tissue oxygenation.

Skylab experiment results: hematology studies.

These studies were designed and coordinated to evaluate specific aspects of man's immunologic and hematologic systems which might be altered by or respond to the space flight environment. The biochemical functions investigated included cytogenetic damage to blood cells, immune resistance to disease, regulation of plasma and red cell volumes, metabolic processes of the red blood cell, and physical chemical aspects of red blood cell functions. Only minor changes were observed in the functional capacity of erythrocytes as determined by measuring the concentrations of selected intracellular enzymes and metabolites. Tests of red cell osmotic regulation indicated some elevation in the activity of the metabolic dependent Na-K pump, with no significant alterations in the cellular Na and K concentrations or osmotic fragility. A transient shift in red cell specific-gravity profile was observed on recovery, possibly related to changes in cellular water content. Measurements of hemoconcentration (hematocrit, hemoglobin concentration, red cell count) indicated significant fluctuations postflight, reflecting observed changes in red cell mass and plasma volume. There was no apparent reticulocytosis during the 18 days following the first manned Skylab mission in spite of a significant loss in red cell mass. However, the reticulocyte count and index did increase significantly 5 to 7 days after completion of the second, longer duration, flight. There were no significant changes in either the while blood cell count or differential. However, the capacity of lymphocytes to respond to an in vitro mitogenic challenge was repressed postflight, and appeared to be related to mission duration. The cause of this repression is unknown at this time. Only minor differences were observed in plasma protein patterns. In the second mission there were changes in the proteins involved in the coagulation process which suggested a hypercoagulative condition.