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.

An outbreak of Serratia marcescens infection in a special-care baby unit of a community hospital in United Arab Emirates: the importance of the air conditioner duct as a nosocomial reservoir

We report an outbreak of Serratia marcescens infection in a special-care baby unit (SCBU) of a university-affiliated community hospital in the United Arab Emirates. The outbreak involved 36 infants and lasted for 20 weeks. Seven of the colonized infants developed invasive illnesses in the form of bacteraemia (four cases), bacteraemic meningitis (two) and clinical sepsis (one). Three other term infants had purulent conjunctivitis. There were five deaths with an overall mortality of 14%. S. marcescens was cultured from airflow samples from the air conditioning (AC) which was the reservoir of infection in this outbreak. Elimination of the nosocomial source and outbreak containment were eventually achieved by specialized robotic cleaning of the entire AC duct system of the SCBU. Strict adherence to the infection control policies was reinforced to prevent transmission of cross-infection.

Overweight, stature, and socioeconomic status among women--cause or effect: Israel National Women's Health Interview Survey, 1998

OBJECTIVE

To determine if short stature and overweight/obesity are predictors of low socioeconomic status (SES), measured by educational attainment.

DESIGN

A cross-sectional study on a random sample carried out through telephone interviews over a period of five months (March through August 1998).

SUBJECTS

A total of 1587 Jewish and Arab Israeli women--773 women age 20-44 years, and 814 women age 45-74 years.

METHODS

Two cross-sectional telephone surveys were conducted; both times, telephone numbers were drawn from the population registry. Multiple logistic regression analysis was used to determine significant predictors of body mass index (BMI), while controlling for population group, parity, smoking, and physical activity.

RESULTS

The level of one's education and one's stature were significantly, independently associated with BMI. Low stature and obesity were indicators of low educational attainment.

LIMITATIONS

The subjects of the study reported their own weight and height. The tendency to overestimate one's height and underestimate one's weight places the accuracy of data under question. However, as there is no reason to believe that the biases in the reports would vary with educational status, the results of the study remain valid.

CONCLUSIONS

Obesity/overweight is directly related to the level of education and inversely to stature. Together, one's level of education and stature may be determinants of low SES. Therefore, in subpopulations with high rates of obesity and short stature, comprehensive programs should include welfare in addition to dietary measures.

Workers' health in Israel

BACKGROUND

Occupational hazards are important causes of morbidity, mortality, and disability in the community. This article presents a review of workers' health in Israel.

METHODS

Data were collated from the Occupational Health Institute of the University of Tel Aviv, the National Insurance Institute, the Occupational Health Departments of the General Sick Fund, and the Institute of Safety and Hygiene of the Ministry of Labor and Welfare. International comparisons are based on data derived from the WHO Health for All database for the European region.

RESULTS

Levels of most biological and chemical exposures in 1996 were found to be in accordance with the standards, except for dust, gases, pesticides, and noise exposure. In 1996, 4.3% of the working population received injury compensation from the National Insurance Institute. 78% of workers' claims approved in 1992-1994 were for injuries to the back and spine. 93% of new cases of occupational diseases and injuries reported in 1996 by the occupational health service of the largest Health Fund were due to noise-induced hearing impairments. In 1996, there were 87 reported deaths following work accidents; about 50% of them were falls that occurred in the construction industry, and 26% of fatalities were among foreign workers. Rates of work accidents, average days of incapacity per accident, and fatalities have been increasing since 1991. Rates of occupational accidents and of occupational fatalities are higher than the European Community average.

CONCLUSIONS

Rates of occupational diseases and of injury compensation among workers are increasing, despite the efforts and resources invested in the prevention of work accidents and the promotion of workers' health. These findings indicate the necessity for further research and efforts toward the prevention of injuries and the promotion of occupational health in Israel.