Febrile non-haemolytic transfusion reaction occurrence and potential risk factors among the U.S. elderly transfused in the inpatient setting, as recorded in Medicare databases during 2011-2012.

BACKGROUND AND OBJECTIVES: Febrile non-haemolytic transfusion reaction (FNHTR) is an acute transfusion complication resulting in fever, chills and/or rigours. Study's objective was to assess FNHTR occurrence and potential risk factors among inpatient U.S. elderly Medicare beneficiaries, ages 65 and older, during 2011-2012. MATERIALS AND METHODS: Our retrospective claims-based study utilized large Medicare administrative databases. FNHTR was ascertained via ICD-9-CM diagnosis code, and transfusions were identified by recorded procedure and revenue centre codes. The study ascertained FNHTR rates among the inpatient elderly overall and by age, gender, race, blood components and units transfused. Multivariate logistic regression analyses were used to assess potential risk factors. RESULTS: Among 4 336 338 inpatient transfusion stays for elderly during 2011-2012, 2517 had FNHTR diagnosis recorded, an overall rate of 58.0 per 100,000 stays. FNHTR rates (per 100,000 stays) varied by age, gender, number of units and blood components transfused. FNHTR rates were substantially higher for RBCs- and platelets-containing transfusions as compared to plasma only. Significantly higher odds of FNHTR were identified with greater number of units transfused (P < 0.01), for females vs. males (OR = 1.15, 95% CI 1.04-1.27), and with 1-year histories of transfusion (OR = 1.25, 95% CI 1.10-1.42), lymphoma (OR = 1.22, 95% CI 1.02-1.46), leukaemia (OR = 1.90, 95% CI 1.56-2.31) and other diseases. CONCLUSIONS: Our study shows increased FNHTR occurrence among elderly with greater number of units and with RBCs- and platelets-containing transfusions, suggesting need to evaluate effectiveness of prestorage leucoreduction in elderly. The study also suggests importance of prior recipient alloimmunization and underlying health conditions in the development of FNHTR.

Transfusion-associated circulatory overload (TACO) and potential risk factors among the inpatient US elderly as recorded in Medicare administrative databases during 2011.

BACKGROUND AND OBJECTIVES: Transfusion-associated circulatory overload (TACO) is a serious transfusion complication resulting in respiratory distress. The study's objective was to assess TACO occurrence and potential risk factors among elderly Medicare beneficiaries (ages 65 and older) in the inpatient setting during 2011. MATERIALS AND METHODS: This retrospective claims-based study utilized Medicare administrative databases in coordination with Centers for Medicare & Medicaid Services. Transfusions were identified by recorded procedure and revenue centre codes, while TACO was ascertained via ICD-9-CM diagnosis code. We evaluated TACO diagnosis code rates overall and by age, gender, race, number of units and blood components transfused. Multivariate logistic regression analyses were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Among 2,147,038 inpatient transfusion stays for elderly in 2011, 1340 had TACO diagnosis code, overall rate of 62·4 per 100,000 stays. TACO rates increased significantly with age and units transfused (P < 0·0001). After adjustment for confounding, significantly higher odds of TACO were found for women vs. men (OR = 1·40, 95% CI 1·26-1·60), White people vs. non-White people (OR = 1·38, 95% CI 1·20-1·62) and persons with congestive heart failure (OR = 1·61, 95% CI 1·44-1·88), chronic pulmonary disease (OR = 1·19, 95% CI 1·08-1·32) and different anaemias. CONCLUSION: Our study identified largest number of potential TACO cases to date and showed a substantial increase in TACO occurrence with age and number of units transfused. The study suggested increased TACO risk in elderly with congestive heart failure, chronic pulmonary disease and anaemias. Overall, study shows importance of large administrative databases as an additional epidemiological tool.

Surgical management of external auditory canal lesions.

BACKGROUND: Lesions arising in the external auditory canal that require surgical excision are uncommon. They are associated with a range of pathologies, including bony abnormalities, infections, benign and malignant neoplasms, and epithelial disorders. METHODS: This paper describes a 10-year personal case series of external auditory canal lesions with chart, imaging and histopathology review. RESULTS: In total, 48 lesions required surgical management, consisting of: 13 bony lesions; 14 infective lesions; 14 neoplasms with 11 histological types (including ceruminous adenoma and the extremely rare cavernous haemangioma); 3 epithelial abnormalities; and 4 other benign lesions. The surgical management is described. CONCLUSION: This study emphasises the diagnostic differences between exostoses and osteomas, and between external auditory canal cholesteatoma and keratosis obturans. It also discusses the management of aural polyps, and highlights the need to excise external auditory canal masses for histology in order to guide subsequent treatment.

Masses and disease entities of the external auditory canal: radiological and clinical correlation.

A wide spectrum of disease entities can affect the external auditory canal (EAC). This review describes the normal anatomy of the EAC. Congenital abnormalities, infections, neoplasms, and miscellaneous conditions, such as cholesteatoma and acquired stenosis, are shown with reference to clinical relevance and management. Cases have been histologically confirmed, where relevant. The EAC is frequently imaged - for example, on cross-sectional imaging of the brain - and this review should stimulate radiologists to include it as an important area for review.

Xylometazoline hydrochloride 0.1 per cent versus physiological saline in nasal surgical aftercare: a randomised, single-blinded, comparative clinical trial.

OBJECTIVES: A variety of topical preparations are used for symptomatic relief following nasal surgery. The aim of this study was to compare the effect of two commonly used products on patient symptom scores following nasal surgery. DESIGN: Randomised, single-blinded, comparative clinical trial. SETTING: A single, secondary otorhinolaryngology centre. PARTICIPANTS: One hundred and twenty patients undergoing septoplasty or functional endoscopic sinus surgery as an isolated procedure between November 2003 and January 2006. Patients undergoing additional nasal procedures were excluded, as were those requiring additional post-operative medications other than standardised analgesia. METHODS: Following nasal surgery, patients were randomised to receive either xylometazoline hydrochloride 0.1 per cent nasal spray or a sterile physiological saline aerosol. MAIN OUTCOME MEASURES: Visual analogue scale symptom scores for nasal obstruction, rhinorrhoea, pain, loss of sense of smell and bleeding were assessed at day 10 post-operatively. RESULTS: Post-operative symptom scores were compared between treatment groups. Overall, median pain scores were significantly higher in the xylometazoline group (p = 0.03, chi-square test). When analysed by procedure, median pain scores were significantly higher in septoplasty patients using xylometazoline (p = 0.019, chi-square test). CONCLUSION: There is no evidence to support the use of xylometazoline hydrochloride 0.1 per cent nasal spray over aerosolised physiological saline alone, following nasal surgery. Furthermore, there may be more pain associated with the post-operative use of xylometazoline.

Use of intravenous steroids at induction of anaesthesia for adult tonsillectomy to reduce post-operative nausea and vomiting and pain: a double-blind randomized controlled trial.

OBJECTIVE: To assess the effectiveness of intravenous steroids at induction of anaesthetic to reduce post-operative nausea and vomiting and pain after adult tonsillectomy. DESIGN: Prospective, double-blind, randomized, placebo controlled trial, with ethical approval, following Consolidated Standards of Reporting Trials guidelines. SETTING: District General Hospital in Scotland, UK. PARTICIPANTS: Seventy-two adults between 16 and 70 years, American Association of Anaethetists (ASA) 1, listed for elective tonsillectomy. INTERVENTION: Single dose of either 10 mg of dexamethasone or 2 mL of saline after induction with a consistent anaesthetic technique. MAIN OUTCOME MEASURES: Patients filled in a visual analogue scale relating to pain and post-operative nausea and vomiting for the day of operation and 7 days after operation. The time to first ingestion of food and drink after operation was also noted. RESULTS: Data completion rate of 64% (46 of 72 patients enrolled). Statistically significant relative decrease (62%P = 0.001) in the incidence of post-operative nausea and vomiting was seen in those treated with dexamethasone. Statistically significant relative decrease (23%P = 0.016) in post-operative pain scores for the day of operation was seen in those treated with dexamethasone. Significant decrease (17.5%, P < 0.001) in mean pain score for seven post-operative days was seen in those treated with dexamethasone. No adverse effects were seen. CONCLUSIONS: Dexamethasone given as a single dose of 10 mg at induction of anaesthesia for adult tonsillectomy is an effective, safe and inexpensive method for reducing morbidity in adult tonsillectomy.

The impact of an inpatient physician program on quality, utilization, and satisfaction.

OBJECTIVE: To evaluate an inpatient physician system initiated in June 1996 for all patients of a health maintenance organization admitted to the general medicine service of an urban teaching hospital. In the new program, attending physician duties were transferred from the patient's own general internist to another internist serving on a hospital-based rotation. STUDY DESIGN: Cohort with historical controls. PARTICIPANTS AND METHODS: We compared the following measures before and after the new inpatient physician program began: (1) hospital length of stay and total charges, (2) outcomes related to quality of care, (3) primary care physician satisfaction, and (4) housestaff satisfaction. Differences before and after initiation of the inpatient physician program were evaluated using multivariate analyses to adjust for patient differences and secular trends. RESULTS: There were 2265 patients discharged from the general medical service in the year following implementation of the inpatient physician program. Postintervention average length of stay decreased from 3.5 to 3.0 days (P < .001). In multivariate analyses, average length of stay was reduced by 0.3 days (P = .008), and total hospital charges were reduced an average of $426 per admission (P = .001). In-hospital mortality rates, percentage of patients discharged home directly, and 30-day readmission rates did not change significantly in the postintervention period. Satisfaction among primary care physicians was high, with 90% of those answering a survey responding that they would recommend a similar program to other primary care groups. Medical housestaff satisfaction with their educational experience also increased. CONCLUSIONS: Implementation of an inpatient physician program at this institution significantly decreased resource utilization while maintaining or improving quality of care. Satisfaction with the program was high among primary care internists and housestaff.

Reversal of epidermal hyperproliferation in psoriasis by insulin-like growth factor I receptor antisense oligonucleotides.

Epidermal hyperplasia is a key feature of the common skin disorder psoriasis. Stimulation of epidermal keratinocytes by insulin-like growth factor I (IGF-I) is essential for cell division, and increased sensitivity to IGF-I may occur in psoriasis. We hypothesized that inhibition of IGF-I receptor expression in the psoriasis lesion would reverse psoriatic epidermal hyperplasia by slowing the rate of keratinocyte cell division. Here we report the use of C5-propynyl-dU,dC-phosphorothioate antisense oligonucleotides to inhibit IGF-I receptor expression in keratinocytes. We identified several inhibitory antisense oligonucleotides and demonstrated IGF-I receptor inhibition in vitro through an mRNA targeting mechanism. Repeated injection of these oligonucleotides into human psoriasis lesions, grafted onto nude mice, caused a dramatic normalization of the hyperplastic epidermis. The findings indicate that IGF-I receptor stimulation is a rate-limiting step in psoriatic epidermal hyperplasia and that IGF-I receptor targeting by cutaneous administration of antisense oligonucleotides forms the basis of a potential new psoriasis therapy.

Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan.

PURPOSE: Unplanned hospital readmission within 30 days of discharge is considered a "sentinel event" for poor quality. Patients at high risk for this adverse event could be targeted for interventions designed to reduce their risk of readmission. The purpose of this study was to identify patient characteristics and risk factors at discharge associated with unplanned readmission within 30 days of hospital discharge. SUBJECTS AND METHODS: We performed a matched case-control study among patients in a Medicare managed care plan who had been admitted to an academic hospital. The cases were patients aged 65 years or older who were urgently or emergently readmitted to the hospital within 30 days of discharge. One control patient who was not readmitted within 30 days was matched to each case by principal diagnosis. The medical records of the first admission of the cases and the admission of the controls underwent review (blinded to case-control status) to determine the patient's baseline demographic characteristics, comorbid conditions, previous health care utilization, and functional status. The records were also reviewed to assess risk factors on discharge, including clinical instability, inability to ambulate and feed, mental status changes, number of discharge medications, and discharge disposition. RESULTS: Five factors were independently associated (P < 0.05) with unplanned readmission within 30 days. These included four baseline patient characteristics: age 80 years or older [odds ratio = 1.8; 95% confidence interval (CI), 1.02-3.2], previous admission within 30 days (odds ratio = 2.3; 95% CI, 1.2-4.6), five or more medical comorbidities (odds ratio = 2.6; 95% CI, 1.5-4.7), and history of depression (odds ratio = 3.2; 95% CI, 1.4-7.9); and one discharge factor: lack of documented patient or family education (odds ratio = 2.3; 95% CI, 1.2-4.5). CONCLUSIONS: If validated, these factors may identify patients at high risk of readmission. They suggest that interventions, such as improved discharge education programs, may reduce unplanned readmission.

Oligonucleotide uptake in cultured keratinocytes: influence of confluence, cationic liposomes, and keratinocyte cell type.

The success of anti-sense strategies has been limited, at least in part, by the poor uptake of these agents into the target cells. In keratinocytes, there is conflicting evidence as to the amount and location of oligonucleotide uptake into these cells, with variable proportions of cells reported to take up oligodeoxynucleotide, and also cytoplasmic and nuclear localization reported. In this study, the uptake of oligodeoxynucleotides in cultured normal human keratinocytes and the HaCaT cell line was quantitated in the presence of various lipids designed to enhance uptake and in varying culture conditions. About 12% of cells in a confluent normal human keratinocyte culture showed nuclear uptake, with a small and variable proportion showing cytoplasmic localization after 24 h incubation with 1 microM oligodeoxynucleotide. Uptake of oligodeoxynucleotide was found to be increased by liposome encapsulation (to a maximum of 28.1% +/- 2.1% of cells), low confluence (39.5% +/- 2.5%), and further increased by a combination of the two conditions (55.4% +/- 4.3%). HaCaT cell populations showed sparse but consistent uptake of oligodeoxynucleotide, with about 1% of cells showing nuclear localization in the presence of 1 microM oligodeoxynucleotide, increasing to 13.5% +/- 4.9% in the presence of cationic lipid (Tfx-50) in low confluence HaCaT monolayers. We conclude that normal keratinocytes exhibit reliable, substantial uptake of oligonucleotides in conditions controlled for confluence and aided by liposome encapsulation.

An outpatient program to treat deep venous thrombosis with low-molecular-weight heparin.

CONTEXT: Although recent trials have demonstrated the safety and efficacy of low-molecular-weight (LMW) heparin, clinicians may need help incorporating this drug into routine practice. OBJECTIVE: To describe the development, implementation, and early results of an outpatient LMW heparin program for acute deep venous thrombosis (DVT). DESIGN: Before-after study. SETTING: Eight health centers of Harvard Vanguard Medical Associates, a multispecialty group practice in Boston. PATIENTS: Patients with confirmed acute, lower-extremity DVT before (40 patients given a diagnosis from January to August 1996) and after (67 patients given a diagnosis from September 1996 to April 1997) implementation of the LMW heparin program. INTERVENTION: A centrally coordinated outpatient LMW heparin program. DATA SOURCES: Hospital and HMO financial databases; electronic patient medical records. OUTCOME MEASURES: Costs of care for 2-week episodes and short-term clinical outcomes. RESULTS: The proportion of patients with DVT treated in the hospital decreased from 90% to 46% after the introduction of the LMW heparin program. The mean cost of treatment for all patients with DVT decreased from $5465 to $3719 per patient. For the subset of patients actually treated in the outpatient program, the average cost was $1402 per patient. There were no deaths, no clinically recognized pulmonary emboli, and no cases of significant bleeding among patients treated in the program, although 3 patients were subsequently hospitalized for worsening leg pain. CONCLUSIONS: The cost of caring for patients with DVT decreased after introduction of the outpatient LMW heparin program. Given explicit selection criteria, short-term clinical outcomes after outpatient management have been excellent. This program may serve as a model for physicians and health plans interested in establishing a program for treating acute DVT in the outpatient setting.

Importance of valvular incompetence after acute deep venous thrombosis.

The color Doppler scanner was used to analyze acute deep venous thrombosis in 14 patients. A thrombus was found in the superficial femoral vein in 4 patients and in the superficial femoral and popliteal veins in 6 patients; a popliteal occlusion was found in 4 patients. All 14 patients were treated with intravenous heparin followed by at least 3 months of warfarin therapy. Patients were re-examined between 24 and 48 months. Six patients were symptomatic; 8 were asymptomatic. Five patients had occluding thrombus in the distal popliteal vein; major competent collateral channels developed from the proximal superficial femoral vein, and they remained asymptomatic. Three patients whose superficial femoral veins recanalized without valvular incompetence were asymptomatic. Valvular incompetence was observed in all of the symptomatic patients. Patients with persistent popliteal occlusion and collateral channels have fewer symptoms than patients with valvular incompetence in the superficial femoral and popliteal veins.

Preoperative evaluation of patients with peripheral vascular disease.

Coronary artery disease is the leading cause of death after revascularization procedures for abdominal aortic aneurysms and peripheral vascular disease. Late survival after vascular procedures is substantially reduced, largely by the high incidence of subsequent cardiac events. At the Lahey Clinic, it is not our practice to perform routine coronary angiography before elective revascularization. Thallium myocardial perfusion imaging should be performed in all patients before operation. Abnormal results on thallium exercise scanning showing multiple perfusion abnormalities or lung uptake at peak exercise identify patients who are candidates for preoperative cardiac catheterization. When severe correctable coronary artery disease is identified, these patients should be considered for coronary artery bypass surgery before vascular operation.